They decided to challenge the assumption from the cloud of "accompanying patients off of the premises is part of my duties."

When the nurses shared this information with the transportation managers, they were able to suggest that their crews were already qualified to bring patients into the hospital, which should mean that they were qualified to take them out.

Once this had been verified by the Legal Department, the transport crews collected patients from their beds and the nurses were able to say goodbye to their charges at their bedsides and use the time gained to take care of their other patients.

FIGURE 32-4 The problem of scheduling patient transport.

TABLE 32-3 PRT Results Challenge the Assumption from the Cloud of "Accompanying Patients Off of the Premises is Part of My Duties"

The overall results were: A reduction in the cost of patient discharge transport.

Extra time for the nurses to take care of their patients.

Far fewer delays in planned patient discharges due to transportation.

Far fewer patients and relatives being disappointed by unnecessary delays in discharges.

An improved working relationship between the nurses and transportation crews.

Earlier and more predictable bed availability.

Providing the Knowledge Base for Achieving the Goal in the Future

Each TOC student needs to use these three tools a sufficient number of times to integrate them into their everyday thinking skills to become comfortable with their use and for the tools to become each student's preferred tool of choice when they encounter problems.

Once this has been achieved, they will be ready to participate in the construction of the systemic plan that will address the core problem of the facility. The students will be ready to assist in the production of desirable effects (DE) 18-the antithesis of the original UDEs used to construct the CRT-which will be used to build the lower, facility-specific levels of the Strategy and Tactic Tree (S&T). 19

Addressing the New Core Problem

By using some of the problems included in the CRT as worked examples in the workshops, the students will have become very familiar with both the CRT and their own facility's core conflict.

In order to move the facility as a whole, it is necessary to produce a systemic S&T using this knowledge to populate the lower levels of the tree, the actions of which will address the systemic core conflict and move the facility into a position where the champion and the staff will be ready to address the facility's higher aims of the tree including: Recognizing the need to protect the time of the staff that will be used effectively to improve patient Throughput.

How the facility will be able to identify and release latent capacity.

How to support the staff to introduce productive behaviors.

How the application of scientific thinking can be applied successfully to soft systems.

The facility specific S&T will also include, in the higher levels, the identification and incorporation within the facility of the knowledge of the higher level TOC applications that will be needed to bring about systemic Throughput improvements.

Five Focusing Steps

The Five Focusing Steps(5FS) (Goldratt 1990, Chapter 11(is a systematic five-step approach used to improve a system's ability continually to obtain goal units. The steps are as listed in the following: 1. IDENTIFY the system's constraints.

2. Decide how to EXPLOIT the system's constraints.

3. SUBORDINATE everything else to the above decision.

4. ELEVATE the system's constraints.

5. WARNING!!!! If in the previous steps a constraint has been broken, go back to Step 1, but do not allow INERTIA to cause a system's constraint.

Critical Chain Project Management (CCPM)20

CCPM is the TOC solution for planning, scheduling, and managing performance in a project environment. It is applied in two very different environments-single project environments and multi-project environments where resources are shared across several different projects concurrently.

TOC Synchronized Supply Chain Application21

The TOC Distribution/Replenishment solution is a pull distribution method that involves setting stock buffer sizes and then monitoring and replenishing inventory within a supply chain based on the actual consumption of the end user, rather than a forecast. Each link in the supply chain holds the maximum expected demand within the average replenishment time, factored by the level of unreliability in replenishment time. Each link generally receives what was used, although this amount is adjusted up or down when buffer management detects changes in the demand pattern.

Drum-Buffer Rope (DBR)22

DBR is the TOC method for scheduling and managing sequential process steps.

Buffer Management (BM)23

BM is the TOC method of identifying the current status of items with respect to arriving at the bottleneck and causes of lateness in items of arriving at the bottleneck. This tool is used to focus both expediting and local improvement efforts, which results in global improvement.

The TOC Thinking Processes (TP)24

The TP is a set of logic tools that can be used independently or in combination to address the three questions in the change sequence, namely, What to change? What to change to? and How to cause the change?

Leaving a TOC Legacy

The aim of this program is for the TOC experts to leave each participating facility with the knowledge to be able to maintain the process of ongoing improvement, through repeated application of the 5FS and the in-house knowledge and confidence to use the TOC applications until they are able to position and manage their constraint in such a way that it maximizes their ability to strive for the goal of treating more patients, better, sooner, now and in the future.

Summary

Contrary to common belief, the quality and cost of healthcare delivery is far more dependent on the people delivering the service than the infrastructures in which they operate. Excellent medical prevention and treatment can take place in the most basic of settings if the people delivering it are well trained, knowledgeable, and have access to the supplies they need. However, expensive and well-designed large-scale healthcare facilities, infrastructures, and buildings can fail in their purpose to deliver good quality, affordable, and timely care if the people working within it are hampered by the way the internal systems operate. By failing to meet the needs of their patients and their staff, these organizations can stagnate and lose the ability to make effective improvements.

All too often improvement projects in large-scale healthcare systems fail to yield the expected results. More often than not this is not due to a lack of efficacy on the part of the methodology used, or a lack of the intent by the people trying to improve matters, but rather a lack of understanding of the underlying issues that need to be addressed to unlock the stalemate generated by so many failed attempts to progress matters. In addition to breaking the "improvement stalemate," there is the added obstacle of the day-to-day business of the hospitals and clinics, which cannot and should not be interrupted. Unlike a production line, it is not possible to shut down a clinic for a refit if the demand for its services cannot be satisfied elsewhere. Healthcare is a continually traveling carousel of activity onto which improvement programs have to leap and be successful without disrupting the daily business of providing care.

In order to provide the improved levels of care their patients need, operational health-care improvement efforts need to be subordinate to the day jobs of caregivers. The people working in healthcare have to be able to integrate changes that will bring about real gains with a minimum of disruption to patients and services. However, even before changes are attempted, the people expected to implement them need to be able to voice any concerns they have and contribute their own expertise and experiences about any proposed changes in the processes they perform each day. All too often, the operational knowledge and intuition of the staff is not sought or offered. However, giving people the opportunity to participate in the planning of improvement projects is insufficient.

In any Emergency Room, a team of well-trained, experienced medical and nonmedical support staff can treat multiple patients with incredible speed, accuracy, and high quality of care. Charge the same team with improving patient Throughput management in the Emergency Room and they will likely suggest as many ways to improve matters as there are people in the discussion. Furthermore, if there are physicians present the number of suggestions will likely double as they attempt to consider the merits of their own opposing views! So, what is missing? Why is it so difficult to gain consensus and implement successful improvement initiatives in healthcare settings? There certainly is not a lack of methodologies, intelligence, or ability. Quite simply, it is due to a lack of a common language and processes to resolve issues in a way that will bring all of the participants to agreement without having to compromise any of the important needs of the stakeholders.

By producing a factual, system-wide analysis of how the prevailing problems are affecting the system as a whole and how these interactions produce ripple effects throughout the system, it is easy for the staff to recognize why certain difficulties arise out of the interactions between departments, divisions, and personnel. With this level of analysis, it is a simple task, often for the first time ever in the life of a facility, to demonstrate the way internal systems, policies, and procedures have evolved and why some of them are outdated or inappropriate for current needs, forcing people to behave in ways that are often counterintuitive and sometimes badly. Furthermore, this analysis can begin to open new lines of communication and repair those that are failing or have broken down. The provision of this platform and mechanism at the outset of a TOC improvement program in a large-scale healthcare system provides a very powerful demonstration25 of how the TOC tools provide a mechanism to begin to effectively address UDEs experienced by the staff.

With such a high dependency on the behavior of people, the initial core problems of individual facilities are highly unlikely to be operational issues, but rather they will be behavioral. Of course, operational issues will exist in every facility, but addressing the deepest problem of a lack of platform and mechanism by which negatives can be raised and effectively addressed will yield far greater benefits when the constraint becomes an operational issue.

In partnership with the system-wide CRT, training the people in the three basic TOC tools provides the staff with the mindset they need to be receptive, decisive, and willing to participate in the development of new solutions to longstanding problems. Practicing these tools on small everyday issues clears much of the "noise" out of the system to reveal the "skeleton" of operational issues residing in the original CRT analysis that need to be addressed.

By cycling through the 5FS and training trainers to disseminate the knowledge of the three tools within the facility, it is possible to rapidly achieve exponential improvements in all of the necessary measures that are desirable in large-scale healthcare systems-Throughput, cost, quality, and waiting times to be able to treat more patients, better, sooner, now and in the future.

Proof of Concept

The author of this chapter was able to apply these principals to a large not-for-profit health-care system that was able to: Triple patient Throughput with: Only a 5 percent increase in resources A sustained increase in service quality to over 96 percent A sustained increase in patient satisfaction to over 96 percent And achieved: Third-year operating profit (margin) equal to first year revenue The organization had no difficulty in recruiting clinical staff and establishing a waiting list of professionals ready to work for the organization. It continues to provide the margin needed to achieve its mission today.

References

Goldratt, E. M. 1990. The Haystack Syndrome: Sifting Information out of the Data Ocean. Crotonon-Hudson, NY: North River Press.