With all of the recent news reports about how poorly the VA Healthcare system is being run, many people have developed some very negative opinions of the VA and the people who work there. I have been fortunate enough to have spent time working with a VA hospital in the Northeast and I want to give the VA employees a pat on the back. The VA employees that I have worked with are all very dedicated to the veterans they serve, so please don't blame them for what the VA leadership at the highest levels are doing. For the most part, the employees care very much about their patients, but in many cases their hands are tied. I've spent the last two weeks working with a private, religious-based hospital and the employees there are also very dedicated to their patients. There is so much caring and love in the air at this hospital...a genuine caring for their patients. So with such dedicated employees, why are many hospitals getting such negative press?
Healthcare is really no different than industries like manufacturing in that the behaviors we see and read about are usually the direct result of the performance metrics that are in place. Eli Goldratt's famous quote, "You show me how you measure me and I'll show you how I'll behave" really tells the story about what's happening at the VA. There is a policy at the VA that states that all patients needing care must be seen within 14 days. So think about the negative behaviors that a metric like this might induce, especially if the systems within the VA healthcare system are broken.....which they are in many cases. It doesn't surprise me that some of the leaders/managers at the various VA hospitals around the country have created a bogus list of patient wait time that simply isn't factual. They did it to protect their livelihoods. That doesn't make it right, but it does help explain why these bogus lists exist.
Another behavior that exists in other VA facilities is that, because the metric tells these facilities that they must "see" patients within 14 days, they do just that. They schedule patients in their allotted time, but the healthcare that they provide is minimal at best. That is, it's one thing to just "see" their patients, but it's a completely different thing to provide healthcare that diagnoses what's wrong with the patients and then provides an adequate treatment. By just scheduling and seeing their patients, they have met the requirement of the performance metric. So what's the solution to this problem?
The real problem is the VA's inability to serve the volume of patients seeking treatment for what ails them. Most VA facilities have a very active and on-going Lean initiative with many employees engaged in removing waste from their processes, but, for me, these same facilities lack the necessary focus on the right part of the various processes. As I have written about many times on this blog, unless and until improvement efforts are focused on the right part of the process, the throughput of patients through these processes will not improve. Most places I have observed attempt to remove waste from every step in their processes without identifying the leverage point. The leverage point is the constraint or bottleneck operation. The flow or throughput of patients through a healthcare process is dictated by the constraint. Let's look at an example.
Suppose we're looking at improving a surgical process such as the process in the figure below.
Suppose an improvement team is formed and a member of the team has this great idea that will reduce the time to complete Step 1 from 15 minutes to 10 minutes. Ask yourself, how many more patients can we get through this process as a result of this change? The answer is zero. Now suppose there is another idea from a team member that will reduce Step 2's time from 20 minutes to 12 minutes. Ask you self this same question and you will arrive at the same number, zero. But you may be saying, we removed time, so why aren't more patients passing through our process.
The late Dr. Eli Goldratt provided us with the answer to this question when he taught us that we must first identify the constraint and then exploit it. Since Step 3 is the system constraint or bottleneck, only reductions in time at this step will increase the throughput of patients through this process. It's really that simple. What if we were able to reduce Step 3 from 90 minutes down to 45 minutes? The answer is very simple.....we have effectively doubled the capacity of this process. Instead of one patient every 90 minutes, we can now process patients every 45 minutes.
My suggestion to the VA and private hospitals everywhere is to learn everything they can about the Theory of Constraints and then practice what you've learned.
Bob Sproull
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