A Guide to Implementing the Theory of
“Here is Edward Bear, coming
downstairs now, bump, bump, bump, on the back of his head. It is, as far as he knows, the only way of
coming downstairs, but sometimes he feels that there really is another way,
if only he could stop bumping for a moment and think of it. And then he feels that perhaps there
isn't.” ‑‑ A. A. Milne.
How many Edward
Bears are there here I wonder? How
many people, like Edward Bear, are dissatisfied with the current situation,
wonder if there can’t be something better, and then doubt that there is? Probably quite a few I suspect. Well, the following pages were written with
the Edward Bears of healthcare in mind.
However, for these pages to be of any benefit, we will have to stop
bumping the back of our head for more than just a moment – there is quite a
bit to think about; things that we might not have thought about before.
If you have
just “landed” on this page as the consequence of some frustrated internet
search on healthcare and improvement and Lean, or some other such facet, then
don’t push the “back button” yet. Hold
on for a moment and I will provide some rationale.
You may feel
uneasy seeing headings above such as “production” and “supply chain” and
“projects,” as this indicates some operational bias to this website. But this is exactly as it should be; most
of the problems in healthcare are operational. Most of the problems in any modern
enterprise of more than one department are operational. Why is this? Well, operations are full of people, and
with that there are a few challenges that we need to learn to overcome. We are going to do that by invoking a
management philosophy known as Theory of Constraints. If you suffer from improvement fad fatigue,
then you have my sympathy (which is of no use to you), and you also have my
understanding. We are going to look at
why several of the current and past fads have failed to yield the necessary
results and also look at the hugely valuable and more fundamental aspects
that do yield results. Outside of the
Toyota Production System, Theory of Constraints is the only consistent and
fundamental approach to process improvement.
I am going to
make an assumption that many people in healthcare are very busy – after all
everyone else is, so I doubt that healthcare is much different, and maybe it
is somewhat worse. Therefore, this
page will not only serve as an introduction but also as a directory to other
parts of the website where there is material that you may need to follow
up. As we learn to bump our heads less
often, we will find that we have more time.
have visited this website before will know that I have left healthcare until
after production, supply chain, and projects – the three major logistical
arms that Theory of Constraints applies to.
However, my interest in healthcare predates all of these. It was my interest in service operations
that sent me in search of better approaches to the very real chaos that
prevails throughout professional consultancies. After all, if seemingly clever
professionals such as engineers and scientists are in this state – and a rather
permanent state at that – what then of other forms of business? Were we missing something? Could we learn? And I rather picked that of all the service
operations, surely modern healthcare services must be the most complex of the
lot, surely anything “new” must stand or fall in this environment – hence
part of the attraction. I’ve since
learnt that nothing is too complex, but most things are simply made way too
complicated, complicated beyond belief.
The world is not a complicated place, but we certainly force it to
behave in a very complicated manner.
Much of the
problem in modern healthcare – like so much else in the modern world – has to
do with the dynamics of our organizations, not the detail, after all we are
all expert in the day-to-day detail of our profession or area or what have
you. In fact, from the start we have
used two terms here from systems thinking; “dynamic complexity,” and “detail
complexity.” Somewhere along the way
we have asserted that; “dynamic complexity isn’t.” And indeed dynamic complexity isn’t complex
at all. It is our psychology and our
failure to understand what has gone on in the past 100 years that is the
cause of our current situation and the source of the apparent complexity.
So, take a
step back for a moment and think.
Think how little removed we are from the discovery of modern
antibiotics, how little removed we are from anesthetic via a chloroform mask,
indeed how little removed we are from formerly complicated surgery such as
appendectomy that used to require an incision that seemed to extend from the
pelvis to the arm.
All of this,
of course, is detail complexity. There
is so much we can do today that was unimaginable 10 or 20 or 30 years
ago. Relative expectations right
around the world are also so much greater as a consequence. But this is true of any aspect of human
endeavor. People are unlikely to forgo
their Ipods for 78’s (a 78 was a flat plastic disk with music recorded as
analogue grooves that could be played back using a needle – strange but true),
so too with healthcare. What is missing
is an effective approach to dynamic complexity.
again for a minute. Think back again
to hospitalization in the time of our parents or our grandparents. Was it different? Of course it was. It was vastly different. It was much simpler. It doesn’t matter what industry you run
this test on, it will be the same. It
was simpler in that there were less dependencies with which to deal with, and
less choice in any case when such a dependency was brought to bear. I guess that we all long for a former
simpler experience that we seem to have lost, but at the same time we don’t
want to forgo the improved detail that we have gained since.
isn’t a win-lose situation. It is
win-win, if only we are willing to learn how.
And in order to be willing to learn how, we must be willing to suspend
some of the things that we have learnt in the past and still hold to be
true. There is a fundamental paradox
in that what we have learnt through personal experience is exactly what we
don’t need if we are to successfully operate a modern healthcare system.
damn word “system” again, it will undoubtedly keep popping up. The peculiarities of the dynamic complexity
systems that we are going to look at is that they are composed of tasks or
steps or stages that are strongly linear, serial, and dependent. Many stages have a specialist staff that
only do one or two particular things (and very well at that). The trouble is that all of “this” has only
happened in the last 100 years or so, barely a couple of generations. We don’t teach people how to manage this
situation because we fail to recognize that it is different. We “know” how to manage each task or step
or stage – or so we think, if they existed in isolation – and we extrapolate
that out to the belief that competent management of the whole system is
simply the sum of the competent management of each and every task along the
webpages we have consistently called this the Reductionist/local
But there is
another approach that we must use, the
Systemic/global optimum approach.
healthcare from a dynamical point of view is like a chain, and a chain as we
know is only as strong as its weakest link.
We must seek out the dynamical weakest link and strengthen it and
protect it, and once strengthened and protected, we must search for the next,
and so forth, in a process of on-going and continual improvement. It is not just the detail of healthcare
solutions that must improve, it is the dynamics of the delivery that must
improve as well – and we are starting from behind.
here before, many times before, since modern hospitalization first occurred;
scratch the surface and many things that we now take for granted have their
origins in Scientific Management from the early 1900’s. At the moment Lean is the lead mechanism
for healthcare process improvement.
That healthcare professionals are receptive to Lean methodologies
indicates only too well the underlying desire to do better with the limited
resources that we currently do have.
After all, everybody wants to do their best – right?
But Lean is an
amalgam of a number of previous attempts at system improvement. These older strands weave in and out of the
current approach, however, one or two important strands that ought to be in
the mix have been dropped out, and one or two that ought not to be in the mix
have been added in. Let’s address
essentially an explicit Western academic interpretation of a tacit Eastern
industrial reality that we know today as the Toyota Production System. The Toyota Production System isn’t a recent
development, the philosophical roots go back to the late 1880’s within the
Toyoda family, the intent to manufacture cars extends back to 1911, and the
actuality of beginning to build cars dates from the early 1930’s (1).
pillars of the system are;
§ Autonomation (automation with a human touch).
from the silk spinning & weaving origins of the company and the Toyoda
family. Integral within this is a
focus on the absolute minimization of waste.
This major thread, the absolute minimization of waste comes via the
contemporaneous work of Frederick Taylor and Frank and Lillian Gilbreth in
North America in the late 1890’s and early 1900’s (2). Lillian Gilbreth visited Japan on a number
of occasions and Taylor’s work was translated and vigorously advocated by
Japanese nationals at the time. Not
only has the elimination of waste had a pedigree extending back to North
American industrialization in the 1900’s, it has also reappeared under the
auspices of; Kaizen, Total Quality Management, and World Class Manufacturing
– each of these being an attempt to describe key Japanese industrial
expertise. As I said, we have been
here many times before.
A strand that
has been left out of the Lean mix is the impact that W. Edwards Deming’s
methods had on Toyota from 1960 onwards, and many other major Japanese
industries since 1950. Deming’s work
is based upon the foundations established by Walter Shewhart at Bell Labs in
the mid-1920’s (3). These days the
work of Deming is pretty much bastardized under the banner of Six Sigma and
we are all the poorer for it. And this
is why people have to talk about Lean and Six Sigma as a pair within
the same breath and within the same sentence.
approaches; the Toyoda’s, Taylor, and Deming/Shewhart were concomitant with the
development of modern industrialization and the needs that arose out of
that. By the mid-1920’s we had the
essentials of what we require except for one thing – an understanding that we
have only had since the mid-1980’s. We will come back to that soon enough.
that is left out of the Lean mix is the logistical backbone of Just-In-Time,
either the use of Kanban logistics or Tact time. The reason for this is two-fold. Firstly Kanban and Tact time really are
best suited for repetitive manufacturing.
There are nevertheless places in healthcare where they could be used –
drug and consumable resupply for instance – but generally they are not. This is because of the second reason, the
West’s predilection for data (detail complexity) and computer information
systems, especially those known as material resource planning (MRP II) or
enterprise resource planning (ERP). It
seems to be poorly understood is that Kanban logistics has the essential
function of stopping the waste of over-production.
critically, Kanban is the focusing mechanism
or driver for process improvement within the Toyota Production System. A common enough analogy is a boat floating
over hidden rocks. The rocks (our
problems) are hidden in a sea of work-in-process. In healthcare we call these queues, and
they contain people called patients.
The Kanban system functions by reducing the sea of work-in-process
step-by-step until it uncovers a new problem.
The new problem is then addressed using various techniques and improvements
are made until there is no longer a problem.
The cycle then continues.
Without a focusing system for the whole process we are left with only local initiatives, and that unfortunately is how Lean
in healthcare functions at the present.
What then of the
threads that have been added to Lean that ought not to have been? Well, the predominant one is value stream
mapping. The Toyota Production System
is recognized as a new sociotechnical system (4); it is characterized by
people who work within the system all of their working lives, it is
characterized by people who move around within the system, 6 months here, 2
years there, learning how the process works.
In the West where, to paraphrase Deming, we don’t have such constancy
of purpose, people don’t actual know the entire stream of their process, and
if we bring in consultants, which isn’t such an unusual occurrence, the
matter is made even worse.
We can’t blame
our people, after all our whole management system is built around local
efficiency and departmental optimization, and if that wasn’t enough, our
career progression is determined by individual achievement, not group
achievement. That, however, isn’t a
good reason to adopt value stream mapping.
With focus, you can bring
about real improvement in the time that most people are still trying to work
out how to map their value stream.
In the section
called “& More ...”
we discussed in some detail; Deming, Taylor, and Toyota – in
fact a page for each. The point of
this was to illustrate how they have each been systematically
mis-understood. They have been
systematically mis-understood because we operate under a paradox or a “cloud”
whereby our personal experience as individuals stops us from learning from
our everyday experience in industry.
We called this the fundamental cloud.
You can find two files in the PowerPoint section that address this in general terms.
Lean and the
predecessors such as Kaizen, Total Quality Management, and World Class
Manufacturing will not help us because they are bereft of context. And the context must be systemic. The original work of Deming, Taylor, and
Toyota had the context embedded within it.
Descriptions of the derivatives lack this aspect. They are, as Taylor described it in 1911,
mechanisms without the essence. You
can see the problem isn’t a new one.
Well, it is a
both a curious and fortunate thing that healthcare professionals are actually
exposed to this context, the essence, within their professional lives. Healthcare professionals do understand
systems – albeit a plethora of sub-systems – in the form of the human
body. And each of these systems has
some rate limiting factor, a weakest link.
So too with our healthcare processes.
Indeed the healthcare process is best viewed as a patient.
Lets take a look.
professionals know about rate limiting steps.
Rate limiting steps are of course a dynamic entity, however, we are
going to take a step back for a moment and use a simple static analogy – a
The weakest link in our static chain is analogous to the rate limiting
step in a dynamic system. A static
chain should not be our preferred analogy, but let’s continue to work with it
for a short while. It has its
advantages – for instance, you can go and cut a plastic chain and use it as a
What about this
Where is the weakest link? It
clearly has to have one. If we were to
pull the chain it would eventually break at one of the links, but which one? This is often very much closer to peoples’
real experience. The analogy makes
sense but the location of the weakest link is no longer so clear – or it is
clear in so much as everyone’s own department is “probably” the weakest
link. But that won’t do. There is only one. This brings us to the next point.
Unfortunately in Western management we break the system down into
pieces and seek overall efficiency and optimization from every link – that’s
why it feels as though “our” link is always the weakest. If we don’t believe that, then we just need
to go and look at the KPI’s that people are expected to perform to, or go and
look at the management accounting figures – the subdivision and allocation of
costs across the system as though each link is independent. Either of these approaches ignores the
serial dependency, in fact interdependency, between the various links.
replace this with a different paradigm;
The key to this quest is the identification of the weakest link, the
rate limiting step in our process.
Once we know where this is, it then offers us huge leveragability.
But let’s now
change our analogy; change it away from a physical chain to one of a “group
of groups” of people. Let’s have a
is a group of people.
They might be a department or a team, we don’t need to know exactly
what, they are after all just an analogy.
And here we
have a group of groups of people.
Well that’s nice. And in our
local efficiency/departmentalize view of the world we might accept this
diagram at face value. But the chain
analogy begs the question, what are the links? There are links, let’s have a look.