TOC offers a number of different ways to identify the core problem of a system, all of which can achieve the same result of arriving at a core problem that, on further analysis, can be expressed as a core conflict.

While it is possible to identify an organizational core conflict through one of the more direct TOC analytical process, such as the Three Cloud7 analysis, this process may not provide the breadth of analysis needed to fulfill the need of a system-wide platform to air problems. It is necessary to provide the staff with a broad-brush relational map to show from where their own experiences emanate and how the subsequent behaviors they are forced to exhibit are the result of the way the system is structured and operating.

When the system being analyzed is more heavily dependent on people as opposed to mechanical processes and process units, it is necessary to take a more detailed approach to finding the core problem.

At this stage of the process, the staff has neither the time nor the skills to identify their own facility's core problem; therefore, it is necessary to provide both the platform and mechanism for them.

Each facility's personnel must understand what it needs to change8 before plans can be made to facilitate change. Few people, if any, in any given facility have a clear picture of how their current activities generate problems and what magnitude of impact these problems have throughout the system. Therefore, it is necessary to find a way to gather evidence of the problems in the most effective way possible, with the least detrimental impact possible on the treatment of patients.

The problems need to be stated in such a way as to clearly explain the effect the problems are having on the system. To expect the staff to know how to do this without training is unreasonable. Therefore, the best way to collect the statements that will contribute to the eventual UDE statements that will be used in the subsequent TOC analysis is for trained TOC practitioners to conduct short interviews with the staff on an individual basis.

Twenty- to thirty-minute interviews should be conducted in a safe, private environment and the interviewees should be assured that their contributing statements will not be attributed to them personally and that the final analysis will not include the names of the contributors.

Prior to the interviews, the participants should be told that their contribution is not forming a witch hunt, that it is not a process intended to place blame on them or their colleagues. This obstacle can be addressed effectively by giving the interviewee a brief description of three of the basic assumptions of TOC.

1. All systems are simple, if understood correctly.

2. There are no conflicts in reality, just different perspectives of reality.

3. People want to do good; this is especially true in healthcare and it is often the system or people's perspective of the system that forces them to behave in ways that are counterintuitive.

By briefly explaining that these are the assumptions of the process in which they are participating and that their contribution will be confidential, most participants readily agree to participate. They intuitively know that the system should and can be improved, and when that is done, they will be able to provide better, quicker services to more patients. Furthermore, the participants also agree that in order to change the system they recognize their need to participate and support the proposed process.

The participants are then asked to tell the interviewers about the problems (UDEs) they experience in their work lives. These statements are noted by the interviewers.

At this stage of the analysis, time is the current constraint of the interviewees. Therefore, it is necessary for the TOC practitioners to subordinate the interview schedule to the needs of the facility.

It is also necessary to interview a range of staff from executives and physicians, to nurses, technicians, and administrative and service support staff. As well as capturing statements from the vertical structure, it is also necessary to collect statements across disciplines. Many of the interviewees will represent both aspects of a facility.

Building the Current Reality Tree 9 (CRT) of a Facility

The purpose of the CRT is to determine the core problem of a specific system, which in this case is a single facility. A facility-wide CRT offers a comprehensive and very detailed "snapshot in time," clearly showing the interconnectedness of the problems that are being experienced by the staff and patients.

Because words are used as the primary source of "data," a CRT easily incorporates details of behaviors, operational issues, policies, and protocols. Numbers can be included if they are needed to substantiate certain points, but the product of a CRT is written explanation of the existence of everyday problems and their source.

The process of building a CRT starts with writing the cause-and-effect logical relationship between closely related UDEs. Continuing to incorporate all UDEs in this way offers the readers a unique, revealing overview of their organization and a chance to recognize systemic patterns of behavior being exhibited by the staff, and understand why they exist.

Converting the Interviewees' Statements into UDEs

Many of the statements collected during the interview process will be duplicates. These are easily collated and represented as a single UDE. Some statements appear to be standalone comments. Often, these take the form of a direct quote from a participant and, whenever possible, should not be generalized.

No statements should be dismissed at this stage, as they may be critical to the analysis, no matter how far-fetched they may appear. Some statements may even appear to describe a positive rather than a negative, but if the contributor considered it a negative, it should be included in the next step of the analysis to verify its orientation.

Constructing the CRT

Using rigorous cause-and-effect logic and the Categories of Legitimate Reservation (CLR),10 the UDEs are connected to reveal the core problem, which can then be expressed in the form of a Cloud to describe the core conflict 11 of the facility.

During this process, it is necessary to have ongoing contact with a champion at the facility who is used to verify the logic used to construct the CRT, the core problem, and the core conflict.

Sphere of Influence

Constructed correctly, the CRT will identify both internal and external constraints. During the reporting process, and after the CRT, the core problem and its underlying core conflict have been verified, it is necessary to make staff at the facility aware of the need to plan to work within its current sphere of influence, the recognized bounded areas of activity over which the staff, including the executives, have the authority to make autonomous changes. A facility may be suffering from a legislative or corporate constraint that its staff has no current ability to influence. To try to do so at this stage will be a waste of effort and time that is needed to treat patients.

However, the ability to address corporate constraints will improve once the facility's executives are able to demonstrate that its ability to improve further is being blocked by corporate policies, by which time the head office will be keen to understand how the facility has been able to produce marked improvements in patient Throughput.

Most facility CRTs will expose many erroneous behavioral issues that are being driven by behaviors, policies, and procedures 12 that eventually will need to be addressed. The danger at this stage of the process is that the staff will want to address these issues in isolation-in effect, reverting back to addressing symptoms as opposed to the core problem.

How to Cause the Change

Training the Process Units

Once the core problem and its underlying conflict and their causal relationships to the numerous isolated UDEs have been identified and verified by the contacts (the champion and key staff) at the facility, it is time to begin to train the employees (managers, clinicians, and support personnel) to prepare them to overcome the facility's core problem.

The training needs to include an overview of TOC and how it addresses problems. The people who need to be trained are those working at the facility who will be needed to introduce the changes necessary to overcome the systemic conflict. Often this will require people from all levels of the facility to be trained as the CRT will clearly show the far-reaching effects of the deep-rooted core problem.

To this end, the training needs to offer trainees opportunities to work on existing problems through guided practice using the three basic behavioral TOC tools:13 1. The Evaporating Cloud14 2. The Negative Branch15 3. The Ambitious Target16-a derivative of the Prerequisite Tree17 developed by TOC for Education The repeated use of these three tools will increase the ability of the staff to overcome many of the nonsystemic and interpersonal problems they encounter during their working day.

The Process of Ongoing Improvement

Providing a Knowledge Base for Achieving the Goal Now

The Cloud

The Cloud will give them the critical thinking skills they need to: Make effective win-win decisions.

Understand and facilitate their own and other people's understanding of situations.

FIGURE 32-3 A nurse's dilemma.

Resolve dilemmas and conflicts on many levels-personal, departmental, etc.

Be receptive and willing participants in other people's or department's problems.

In Fig. 32-3, we see an example of a typical problem in large-scale healthcare systems that many nurses experience.

When nurses are allocated patients, they are responsible for their care and are often expected to attend to many of their patients' needs. However, when the needs of two patients clash, they are often caught in the dilemma of who to take care of and are often forced to resolve this by delaying care for one patient in favor of another.

This cloud reads: In order to [A] provide the best care I can for my patients, I need to [B] complete patient X's discharge, and in order to [B] complete patient X's discharge, I want to [D] accompany him to his transportation when it arrives at 10 a.m.

On the other hand, in order to [A] provide the best care I can for my patients, I need to [C] support patient Y during the consultation with his doctor, and in order to [C] support patient Y during the consultation with his doctor, I want to [D'] be with patient Y during the consultation at 10 a.m.

Obviously, the nurse cannot be in two places at once.

Table 32-2 shows some of the assumptions between the nurses' needs, B and C, and wants, D and D'.

TABLE 32-2 Assumptions for Attending to Patient X or Patient Y By sharing this cloud, it became evident that this dilemma was a common occurrence at this particular facility. Most nurses said that they had resolved this cloud by challenging the assumption of "because the transportation is booked" between B and D by spending time rescheduling the booked transportation until after patient Y's consultation with his doctor. That way they could fulfill all of their duties-meet all of their needs and take the best care they could of their two patients.

However, on hearing about this the patient transportation service was eager to share how this particular resolution affected them.

The Negative Branch

The Negative Branch will give them a predictive tool to: Provide a process by which proposed solutions can be effectively critiqued.

Differentiate and address the weak parts of proposed plans, thereby removing the need to reject them completely and improving on the original idea.

Act as a communication tool for needed buy-in.

In Fig. 32-4, we see a simplified example of how the transportation service used the Negative Branch to communicate its perspective of the problem of rescheduling patient transport times on short notice.

When the nursing staff read this Negative Branch and realized why there had been recent price increases for the services, they challenged the transportation providers need to increase the number of crews (the point at which the NBR turned negative) and therefore their charges. When it was explained to the nursing staff that approximately 20 percent of all of the discharge bookings from that particular facility had to be rescheduled, the nurses began to realize that an occasional change request from each of them was costing the facility more than they had budgeted for.

The nurses revisited their dilemma and decided to see if it was possible to find an alternative solution to rescheduling transportation on the day of the patient's discharge, especially as patients were usually disappointed when their return home was delayed.

The Ambitious Target Tool

The Ambitious Target Tool will provide a basic sequencing tool to: Offer a means to investigate the reasoning behind proposed actions.

Bring a greater understanding of the need to sequence and protect the time to complete critical tasks.

Give the staff a basis with which to plan their personal contribution to large projects.

Table 32-3 is a simplified version of the Ambitious Target Tool that the nurses decided to use to take a closer look at the activities that take place during the discharge process.