I am finally back from vacation and able to post a new discussion. In the past several postings I have been discussing how hospitals can utilize the teachings of the Theory of Constraints (TOC). TOC’s in its most simplistic form is based upon how well we can execute Dr. Goldratt’s Five Focusing Steps.
1. Identify the System Constraint. The system constraint is that part of the process that limits the flow of any system or process. If you consider the overall flow of patients throughout the entire hospital, it can be found in the discharge process thus freeing up beds for new patients or at a lower level, passage of patients through an Emergency Department (ED) or a Surgical Unit (SU). The key point is, there will always be a constraint within any system or process so you must locate it. One of the best techniques for identifying the constraint is to map out the entire process from patient entry to treatment to discharge.
2. Decide how to exploit the system constraint. Once the constraint has been identified, we must decide why it is the system constraint and take the necessary actions to reduce its impact. If, for example, we have discovered that the discharge process is the overall system constraint, we must focus our improvement efforts on the discharge process. It makes no sense to improve the flow and throughput of ED patients if the discharge process isn’t freeing up hospital beds. If that were the case, we would have a backlog of patients waiting for available beds. This would be an example of a localized improvement which would not improve the overall system throughput. In fact, all it would do is move the system constraint to the discharge process so all of your efforts would be wasted. Yes, you would improve the throughput and flow through the ED, but patient satisfaction would deteriorate.
3. Subordinate everything else to the exploitation decision. Subordination in this context simply means that you should never out-pace your true system constraint. In our ED example, there would be an automatic subordination of the ED to the pace of the discharge process. Think about it…..if you increased the throughput of the ED without increasing the throughput of the discharge process, where would you place the influx of the ED patients? In the hallways? This is why it is so important to consider the “total” system before improvement efforts are initiated. Subordination is by far and away the most difficult step to achieve because in most cases people seen as being idle is viewed as a negative. When the capacity of one step in the process is greater than the capacity of the receiving process, the supplying process must “slow down” or a build-up or queue of patients will occur in front of the true system constraint.
4. If necessary, elevate the system constraint. If, after improvement efforts, the capacity of the true system constraint is still not able to handle the patient capacity, you may need to spend money, but most of the time Step 2, Exploitation, will alleviate the system constraint. As an example, in one hospital I assisted, the hospital had no problems with the discharge process, but the time it took to free up a bed for an incoming patient had been identified as the constraint. The team created a simple process map and found the constraint to be the time it took to clean and prepare a room for the incoming patient. When we looked at the cleaning/preparation step in this process we discovered that only one cleaner was assigned to prepare the room. My suggestion was to add a second cleaner to essentially cut the cleaning time in half. The team immediately pushed back and said that they were not permitted to hire any additional staff. But when they looked at the availability of cleaners they discovered that there was ample capacity to better utilize their pool of cleaners. So for ED admissions, they were able to “double-up” the housekeeping staff and break the constraint and flow improved immediately without spending any money.
On the other hand, suppose they didn’t have additional capacity, what could they have done to break this constraint? I explained to them that the cost of an additional cleaner would have been far less than the revenue increase they would have achieved. This type of constraint would have been classified as an “artificial constraint” because the profitability improvement would have been such that it would have been justified.
5. Return to Step 1, but don’t let inertia cause a new constraint. Once the constraint has been broken, a new constraint will appear automatically and when it does, a review of the policies and procedures that were implemented to break the constraint must be reviewed to make sure that they will not impede the new constraint.
The lesson here is that by simply using Goldratt’s Five Focusing steps the flow of patients through a healthcare system can be dramatically improved. The starting point should always be a system level mapping exercise to identify the true system constraint. This most effective way of mapping the system is to actually become the object (i.e. patient, blood sample, etc.) moving through the process. Once that is completed, Goldratt’s focusing steps can be implemented and you’re on your way.