Monday, November 18, 2013

Focus and Leverage Part 278

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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