In this posting I want to demonstrate how to create and use one of the Thinking Process (TP) tools to identify the reasons why patient wait times are excessively long in this clinic.
One of the primary tools in our arsenal was
the Current Reality Tree (CRT) and it is this tool that I will focus on for the
remainder of this blog posting. I do so
because the CRT clearly articulated the problems within this clinic, especially
as it relates to overbooking. This CRT
was actually created as a result of a conference call with the Process Owner
and Champion prior to a Rapid Process Improvement Workshop (RPIW), but was
later updated based upon new facts and assumptions discovered during the actual
RPIW. In reality, I don’t recommend
using a phone call to develop CRT’s, but in this case, since I was a thousand
miles away and pressed for time, I elected to do so.
If you are new to my blog, let me briefly
explain a bit about CRT’s, how they are developed and how they are used. CRT’s are part of a larger body of knowledge
in TOC known as the Thinking Process (TP)
tools. CRT’s are used to identify,
visualize and link the Undesirable
Effects (UDE’s) that exist within any organization. UDE’s are all of the “things” you don’t like about the way the
organization is currently operating. The method I used to create a CRT was to
first, list all of the negative or “undesirable effects (UDE’s)” that I heard
during our conference call. I then
proceeded to connect the UDE’s using sufficiency based logic (i.e. a series of
“if-then” causal relationships). That is,
if “x” exists, then “y” will be observed.
In reality, there is a logical order that connects these UDE’s to each
other and when the CRT is completed, the lower level UDE’s usually become the
root cause or core problem(s) causing many of the others.
In the case of this clinic, there were
initially 10 UDE’s that I picked up by listening to the various conference call
participants. In the CRT below I have
highlighted the original list of UDE’s in orange. I then began the “effect-cause-effect”
linkage process which is done by arranging the UDE’s in a logical order to
arrive at the final order that you see in the figure below. I construct the CRT from top to bottom and
then read it from bottom to top using the sufficiency
logic I referred to earlier (i.e. “if A, then B”). In constructing the CRT I added additional
UDE’s (shaded in white) to complete the cause and effect connections. These add-on UDE’s were ones that I learned
about during our actual RPIW.
It is clear that all of the UDE’s listed in
this CRT are contributing to the most important UDE of all, “Patient wait times are excessively long.” In the CRT that was created, there were three
primary causes for this most important UDE as follows:
1. The clinic is over-booked most of the time.
2. Attending physicians do not have time to see patients in a timely manner
3. There is no synchronized patient flow in the clinic
Upon completion of
the CRT I discovered something very compelling.
That is, there were five different causes for the clinic being
over-booked. If we could come up with
the right injection(s) to eliminate most of these UDE’s, then much of our
problem could be resolved. The ellipse
beneath the UDE, “The clinic is over-booked most of the time” is the logical
“and” statement used when developing the CRT.
This “and” statement simply means that all five of these UDE’s
contribute to the problem of over-booking.
In reality, I probably shouldn’t have used this symbol since each of
these UDE’s by themselves could have created an over-booked state, but I
elected to use it to demonstrate the conditions that are working together to
create the over-booked state.
In my next posting I will demonstrate how to turn the CRT into a Future Reality Tree (FRT) and discuss how this will help create improvement actions to reduce the excessive patient waiting times,
Bob Sproull
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