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A Guide to Implementing the Theory of
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Caring
About Healthcare “Here is Edward Bear, coming
downstairs now, bump, bump, bump, on the back of his head. It is, as far as he knows, the only way of
coming downstairs, but sometimes he feels that there really is another way,
if only he could stop bumping for a moment and think of it. And then he feels that perhaps there
isn't.” ‑‑ A. A. Milne. How many Edward
Bears are there here I wonder? How
many people, like Edward Bear, are dissatisfied with the current situation,
wonder if there can’t be something better, and then doubt that there is? Probably quite a few I suspect. Well, the following pages were written with
the Edward Bears of healthcare in mind.
However, for these pages to be of any benefit, we will have to stop
bumping the back of our head for more than just a moment – there is quite a
bit to think about; things that we might not have thought about before. If you have
just “landed” on this page as the consequence of some frustrated internet
search on healthcare and improvement and Lean, or some other such facet, then
don’t push the “back button” yet. Hold
on for a moment and I will provide some rationale. You may feel
uneasy seeing headings above such as “production” and “supply chain” and
“projects,” as this indicates some operational bias to this website. But this is exactly as it should be; most
of the problems in healthcare are operational. Most of the problems in any modern
enterprise of more than one department are operational. Why is this? Well, operations are full of people, and
with that there are a few challenges that we need to learn to overcome. We are going to do that by invoking a
management philosophy known as Theory of Constraints. If you suffer from improvement fad fatigue,
then you have my sympathy (which is of no use to you), and you also have my
understanding. We are going to look at
why several of the current and past fads have failed to yield the necessary
results and also look at the hugely valuable and more fundamental aspects
that do yield results. Outside of the
Toyota Production System, Theory of Constraints is the only consistent and
fundamental approach to process improvement. I am going to
make an assumption that many people in healthcare are very busy – after all
everyone else is, so I doubt that healthcare is much different, and maybe it
is somewhat worse. Therefore, this
page will not only serve as an introduction but also as a directory to other
parts of the website where there is material that you may need to follow
up. As we learn to bump our heads less
often, we will find that we have more time. People who
have visited this website before will know that I have left healthcare until
after production, supply chain, and projects – the three major logistical
arms that Theory of Constraints applies to.
However, my interest in healthcare predates all of these. It was my interest in service operations
that sent me in search of better approaches to the very real chaos that
prevails throughout professional consultancies. After all, if seemingly clever
professionals such as engineers and scientists are in this state – and a rather
permanent state at that – what then of other forms of business? Were we missing something? Could we learn? And I rather picked that of all the service
operations, surely modern healthcare services must be the most complex of the
lot, surely anything “new” must stand or fall in this environment – hence
part of the attraction. I’ve since
learnt that nothing is too complex, but most things are simply made way too
complicated, complicated beyond belief.
The world is not a complicated place, but we certainly force it to
behave in a very complicated manner. Much of the
problem in modern healthcare – like so much else in the modern world – has to
do with the dynamics of our organizations, not the detail, after all we are
all expert in the day-to-day detail of our profession or area or what have
you. In fact, from the start we have
used two terms here from systems thinking; “dynamic complexity,” and “detail
complexity.” Somewhere along the way
we have asserted that; “dynamic complexity isn’t.” And indeed dynamic complexity isn’t complex
at all. It is our psychology and our
failure to understand what has gone on in the past 100 years that is the
cause of our current situation and the source of the apparent complexity. So, take a
step back for a moment and think.
Think how little removed we are from the discovery of modern
antibiotics, how little removed we are from anesthetic via a chloroform mask,
indeed how little removed we are from formerly complicated surgery such as
appendectomy that used to require an incision that seemed to extend from the
pelvis to the arm. All of this,
of course, is detail complexity. There
is so much we can do today that was unimaginable 10 or 20 or 30 years
ago. Relative expectations right
around the world are also so much greater as a consequence. But this is true of any aspect of human
endeavor. People are unlikely to forgo
their Ipods for 78’s (a 78 was a flat plastic disk with music recorded as
analogue grooves that could be played back using a needle – strange but true),
so too with healthcare. What is missing
is an effective approach to dynamic complexity. Think back
again for a minute. Think back again
to hospitalization in the time of our parents or our grandparents. Was it different? Of course it was. It was vastly different. It was much simpler. It doesn’t matter what industry you run
this test on, it will be the same. It
was simpler in that there were less dependencies with which to deal with, and
less choice in any case when such a dependency was brought to bear. I guess that we all long for a former
simpler experience that we seem to have lost, but at the same time we don’t
want to forgo the improved detail that we have gained since. However this
isn’t a win-lose situation. It is
win-win, if only we are willing to learn how.
And in order to be willing to learn how, we must be willing to suspend
some of the things that we have learnt in the past and still hold to be
true. There is a fundamental paradox
in that what we have learnt through personal experience is exactly what we
don’t need if we are to successfully operate a modern healthcare system. There’s that
damn word “system” again, it will undoubtedly keep popping up. The peculiarities of the dynamic complexity
systems that we are going to look at is that they are composed of tasks or
steps or stages that are strongly linear, serial, and dependent. Many stages have a specialist staff that
only do one or two particular things (and very well at that). The trouble is that all of “this” has only
happened in the last 100 years or so, barely a couple of generations. We don’t teach people how to manage this
situation because we fail to recognize that it is different. We “know” how to manage each task or step
or stage – or so we think, if they existed in isolation – and we extrapolate
that out to the belief that competent management of the whole system is
simply the sum of the competent management of each and every task along the
way. In these
webpages we have consistently called this the Reductionist/local
optima approach. But there is
another approach that we must use, the
Systemic/global optimum approach. You see,
healthcare from a dynamical point of view is like a chain, and a chain as we
know is only as strong as its weakest link.
We must seek out the dynamical weakest link and strengthen it and
protect it, and once strengthened and protected, we must search for the next,
and so forth, in a process of on-going and continual improvement. It is not just the detail of healthcare
solutions that must improve, it is the dynamics of the delivery that must
improve as well – and we are starting from behind. We’ve been
here before, many times before, since modern hospitalization first occurred;
scratch the surface and many things that we now take for granted have their
origins in Scientific Management from the early 1900’s. At the moment Lean is the lead mechanism
for healthcare process improvement.
That healthcare professionals are receptive to Lean methodologies
indicates only too well the underlying desire to do better with the limited
resources that we currently do have.
After all, everybody wants to do their best – right? But Lean is an
amalgam of a number of previous attempts at system improvement. These older strands weave in and out of the
current approach, however, one or two important strands that ought to be in
the mix have been dropped out, and one or two that ought not to be in the mix
have been added in. Let’s address
these briefly. Lean is
essentially an explicit Western academic interpretation of a tacit Eastern
industrial reality that we know today as the Toyota Production System. The Toyota Production System isn’t a recent
development, the philosophical roots go back to the late 1880’s within the
Toyoda family, the intent to manufacture cars extends back to 1911, and the
actuality of beginning to build cars dates from the early 1930’s (1). The two
pillars of the system are; § Just-in-time. § Autonomation (automation with a human touch). These come
from the silk spinning & weaving origins of the company and the Toyoda
family. Integral within this is a
focus on the absolute minimization of waste.
This major thread, the absolute minimization of waste comes via the
contemporaneous work of Frederick Taylor and Frank and Lillian Gilbreth in
North America in the late 1890’s and early 1900’s (2). Lillian Gilbreth visited Japan on a number
of occasions and Taylor’s work was translated and vigorously advocated by
Japanese nationals at the time. Not
only has the elimination of waste had a pedigree extending back to North
American industrialization in the 1900’s, it has also reappeared under the
auspices of; Kaizen, Total Quality Management, and World Class Manufacturing
– each of these being an attempt to describe key Japanese industrial
expertise. As I said, we have been
here many times before. A strand that
has been left out of the Lean mix is the impact that W. Edwards Deming’s
methods had on Toyota from 1960 onwards, and many other major Japanese
industries since 1950. Deming’s work
is based upon the foundations established by Walter Shewhart at Bell Labs in
the mid-1920’s (3). These days the
work of Deming is pretty much bastardized under the banner of Six Sigma and
we are all the poorer for it. And this
is why people have to talk about Lean and Six Sigma as a pair within
the same breath and within the same sentence. These three
approaches; the Toyoda’s, Taylor, and Deming/Shewhart were concomitant with the
development of modern industrialization and the needs that arose out of
that. By the mid-1920’s we had the
essentials of what we require except for one thing – an understanding that we
have only had since the mid-1980’s. We will come back to that soon enough. Another strand
that is left out of the Lean mix is the logistical backbone of Just-In-Time,
either the use of Kanban logistics or Tact time. The reason for this is two-fold. Firstly Kanban and Tact time really are
best suited for repetitive manufacturing.
There are nevertheless places in healthcare where they could be used –
drug and consumable resupply for instance – but generally they are not. This is because of the second reason, the
West’s predilection for data (detail complexity) and computer information
systems, especially those known as material resource planning (MRP II) or
enterprise resource planning (ERP). It
seems to be poorly understood is that Kanban logistics has the essential
function of stopping the waste of over-production. More
critically, Kanban is the focusing mechanism
or driver for process improvement within the Toyota Production System. A common enough analogy is a boat floating
over hidden rocks. The rocks (our
problems) are hidden in a sea of work-in-process. In healthcare we call these queues, and
they contain people called patients.
The Kanban system functions by reducing the sea of work-in-process
step-by-step until it uncovers a new problem.
The new problem is then addressed using various techniques and improvements
are made until there is no longer a problem.
The cycle then continues.
Without a focusing system for the whole process we are left with only local initiatives, and that unfortunately is how Lean
in healthcare functions at the present. What then of the
threads that have been added to Lean that ought not to have been? Well, the predominant one is value stream
mapping. The Toyota Production System
is recognized as a new sociotechnical system (4); it is characterized by
people who work within the system all of their working lives, it is
characterized by people who move around within the system, 6 months here, 2
years there, learning how the process works.
In the West where, to paraphrase Deming, we don’t have such constancy
of purpose, people don’t actual know the entire stream of their process, and
if we bring in consultants, which isn’t such an unusual occurrence, the
matter is made even worse. We can’t blame
our people, after all our whole management system is built around local
efficiency and departmental optimization, and if that wasn’t enough, our
career progression is determined by individual achievement, not group
achievement. That, however, isn’t a
good reason to adopt value stream mapping.
With focus, you can bring
about real improvement in the time that most people are still trying to work
out how to map their value stream. In the section
called “& More ...”
we discussed in some detail; Deming, Taylor, and Toyota – in
fact a page for each. The point of
this was to illustrate how they have each been systematically
mis-understood. They have been
systematically mis-understood because we operate under a paradox or a “cloud”
whereby our personal experience as individuals stops us from learning from
our everyday experience in industry.
We called this the fundamental cloud.
You can find two files in the PowerPoint section that address this in general terms. Lean and the
predecessors such as Kaizen, Total Quality Management, and World Class
Manufacturing will not help us because they are bereft of context. And the context must be systemic. The original work of Deming, Taylor, and
Toyota had the context embedded within it.
Descriptions of the derivatives lack this aspect. They are, as Taylor described it in 1911,
mechanisms without the essence. You
can see the problem isn’t a new one. Well, it is a
both a curious and fortunate thing that healthcare professionals are actually
exposed to this context, the essence, within their professional lives. Healthcare professionals do understand
systems – albeit a plethora of sub-systems – in the form of the human
body. And each of these systems has
some rate limiting factor, a weakest link.
So too with our healthcare processes.
Indeed the healthcare process is best viewed as a patient. Lets take a look. Healthcare
professionals know about rate limiting steps.
Rate limiting steps are of course a dynamic entity, however, we are
going to take a step back for a moment and use a simple static analogy – a
chain. Everyone knows
that;
What about this
chain then?
We must
replace this with a different paradigm;
But let’s now
change our analogy; change it away from a physical chain to one of a “group
of groups” of people. Let’s have a
look. Firstly, here
is a group of people.
And here we
have a group of groups of people.
Let’s have a
look at the basic components of the process.
Let’s look at
this another way. Jaques and Cason
define work as; “the exercise of judgment and discretion in making the
decisions necessary to solve and overcome the problems that arise in the course
of carrying out tasks (5).” This is a
non-trivial definition. If we no
longer need to exercise judgment and discretion we can mechanize or
computerize things and maybe automate them as well. This is where Ohno’s “autonomation” comes
in – and remember Ohno’s initial context was automated silk spinning and
weaving, way before any form of electronic control – machines replace the
judgment and discretion that was once the exclusive domain of people. And why would we want to maintain such
exclusivity if we can off-load it for more humanistically rewarding
endeavors? So ask
yourself; is the exercise of judgment and discretion a feature of
healthcare? That’s a rhetorical
question, isn’t it? Of course the
exercise of judgment and discretion is a feature of healthcare. That is why our health specialists train
for so long, and in fact never stop learning.
Therefore, we should expect some variability. And don’t forget the patients – they aren’t
exactly uniform either. The potential
mix of any one single patient’s “complicating factors” means variability is
rife within this process. If variability
is rife, then it is only natural that we should attempt to reduce it, and
hence the attraction of the various methodologies that we have
mentioned. If we can locally reduce
variability we ought to expect a better local outcome. Let’s show this.
Well, the
results across the world says no, the total output does not improve. We have buried money into this system in
the last decade and the productivity has been static, people have to be more
ill to be seen, and they wait longer and longer to be seen. Why, why, why, is this? Let’s have a
look.
It’s sad that
since at least 1911 we have known that; “In the past man has been first; in
the future the system must be first (6).”
But we still don’t understand what this means. We blame “the system,” even though we are
part of it, because we don’t understand it; and we don’t understand it in two
mutually exclusive directions; § Vertical hierarchy – the requisite number of layers and necessary
competence. § Horizontal process – the existence of serial dependency and
variability. And it is
within the horizontal process that is the second part of the issue with
systems lies. Let’s have a
look.
The two
earlier logistical systems, Ford’s process chain, and Toyota’s Kanban system
implicitly acknowledge the existence of a rate limiting step. Ford uses mechanical linkages and Toyota
uses cards to communicate, across the system, the speed of the rate limiting
step – these systems can’t operate faster than the rate limiting step and all
other parts can not over-produce relative to the
rate limiting step. Theory of Constraints
continues in this fashion using time as a logistical “rope.” It is also the first to explicitly
recognize the role of the constraint.
This is the one thing that has been missing since the 1920’s; explicit
recognition of the constraint – the rate limiting step. Deming was so
very close to this understanding when he described the obligation of a
component to the whole (7). And yes I
know I said there were no parts, but our language lacks the words to describe
this. Let’s draw the
understanding as described by Deming.
Rather we must
have this;
It may seem
counterintuitive, but the discipline for good subordination is far more
important than the discipline for exploitation. We know how to exploit, we try to do it
everywhere all of the time (just trying to doing our best), we need to focus
instead on just the one place where exploitation needs to be done in order to
improve the system as a whole, and subordinate everything else. We need a
systematic and systemic focusing process in healthcare to find and identify
the places to exploit and the places to subordinate if we are to replace
local improvements in outcomes with system-wide improvements in output. Let’s have look at such a process. Taylor,
Deming, and Toyota all have a systemic context embedded within their
methodologies, but none of these previous approaches explicitly recognizes the
role of rate limiting step in the process.
Theory of Constraints does.
Moreover, it recognizes time rather than materials as the fundamental
measure. By doing so, a series of
similar logistical solutions have been implemented that bring about rapid,
significant, and sustained improvement to industrialized processes;
manufacturing of all types, supply chain, and projects. The same principles can be applied directly
to healthcare with the same results, and have been for more than a decade
(8). Knowing what
you now know, would you choose to improve a step that is not rate
limiting? You might if there is a
significant deficiency in the current outcome at that step – a medical or
technical or quality issue. But would
that improve the output of the whole chain?
Unfortunately not. This is why,
cost of personnel excluded, so much money is expended upon healthcare for so
little improvement in output. What we have
lacked is focus, and the logistical solutions to go with it. However, both do exist. Let’s look at focus first. Goldratt
proposed a focusing process as follows (9); (1) Identify the system’s constraints. (2) Decide how to Exploit the system’s constraints. (3) Subordinate everything else
to the above decisions. (4) Elevate the system’s constraints. (5) If in the previous steps a
constraint has been broken, Go back to step 1, but do not allow
inertia to cause a system constraint. The background
to this is discussed in detail on the page called Process of Change, the central importance of time is discussed in detail on a page
called Evaluating Change, and nature of subordination is discussed on a page called Paradigms in the Strategy section. If
there is a “mantra” in Theory of Constraints, then the above focusing process
is it. Failure to use it, will mean
failure to succeed. However, there
is one caveat, you don’t have to go
through the sequence; identify, exploit, subordinate, elevate, every
time. Some constraints can be broken
at exploitation and you short-circuit the loop and start again. The various “loops” are discussed in a
subpage off the Evaluating Change page called 5 Step Method and also on the Strategy page where you can be so bold as to proactively select a constraint
rather than reactively identify one.
But these are all things that have to be learnt – and this takes time,
there is skill involved. The one thing
that we want to avoid, however, is that almost all non-systemic improvement
methodologies start at the start by identifying a constraint and then jump directly to the 4th step and try to elevate the
constraint by adding more of it; that is increasing production rather than
increasing productivity. This always
involves increased expenditure of some sort.
We will never ever learn if continue to do that. We are much
“tighter” than that. We expect to
ensure that we are getting the fullest potential out of our existing
constraint first, and that all of the other steps have fallen into line with
this and are protecting the constraint so that we don’t waste any of its
valuable capacity. That is a hugely
different mind-set at first for many people.
Believe me. The
exploitation and subordination tactics come from the work of Taylor,
Ohno/Shigeo, Deming, and a rather special understanding of the buffering of
safety from Goldratt. I urge people to
acquaint themselves with original work on Toyota, and the original work of
Deming. A health service is also a
rather special sociotechnical system but it doesn’t seem to know it. Having a
focusing mechanism with which to direct our toolsets is necessary, but this
of itself is not sufficient. We need
to articulate the broader context.
This is what I mean, we need to; (1) Define the system. (2) Define the goal
of the system. (3) Define the necessary
conditions. (4) Define the fundamental
measurements. (5) Define the role of the constraints. (6) Define the role of the non-constraints. We were
introduced to these concepts on the page on Measurements. A more healthcare specific approach was
presented on the page for Replenishment and Healthcare in the Supply Chain
section. There must be a strategic
intent if are to know how to apply our new found tactics. We summarized
this on the page for Paradigms as follows;
This shows the
relationship between the focusing process, our plan of attack, and the
broader context of the environment, our rules of engagement. These are well discussed throughout the
website. Essentially we
must replace the former reductionist/local optima approach of our pre-industrial
psychology with the systemic/global optimum
approach of our industrial reality. We must move past a fixation with detail complexity and recognize that dynamic
complexity is an equally valid component. Slowly we will learn that most dynamic
complexity is really quite simple – if only we would stop to listen and to
learn. We know enough
now to continue with some specifics of healthcare. Let’s summarize and get on with it. In order to
improve healthcare we must approach it in a systemic manner. We must understand the overall context and
then begin to look for the constraints that stop us from improving our
output. Currently we are approaching
the problem without the rigor of a focusing process, we are applying
improvement methodologies with the very best of intent, but without
focus. Indeed some of the improvement
methodologies are derivatives of more systemic approaches, but we need to
return to the fundamentals of the systemic approaches of Taylor, Toyota, and
Deming if we are to avoid another crash and burn. It is possible
to implement rapid, significant, and sustainable improvement in this
environment – healthcare. It is being
done so right now. The knowledge and
skills that have been developed in other environments are portable to this
one. Sure there are some singular
challenges in healthcare, but nothing that can’t be overcome. In the end it is about people, we create
the problems ourselves, and we can fix them too. Remember that
Deming said; “The system is such that almost nobody can do his best. You have to know what to do, then do your best.
Sure we need everybody’s best – everybody working together with a
common aim. And knowing something
about how to achieve it. Not just with
what seem to be brilliant ideas, but with a system of improvement (10).” It is just
amazing that more than 20 years after those words were last aired in the West
and more than 60 years after the Japanese listened, we are still feeling
around in the dark. We don’t usually
have a system of improvement. Who are
we kidding? Surely, only ourselves. In the next 3
pages there are three specific logistical approaches to healthcare. They cover the beginning, the middle and
the end points of public service hospitalization, that is; emergency
department, non-acute surgical intervention, and medical/surgical nursing and
discharge. They will require that most
people not do their best in most areas most of the time, and to do their best
in probably just one. Both the outcome
and the output will improve as a consequence.
If we use our experience developed with rate limiting processes then we
in fact understand this already. Taiichi Ohno said
it all in 1978 (11); “A business organization is like the human body.” Anyway, there
is lot to learn, let’s get on with it.
(1) Ohno, T., (1978) The Toyota production system:
beyond large-scale production. English
Translation 1988, Productivity Press, 143 pp. (2) Shingo, S., and Robinson, A., (editor) (1990)
Modern Approaches to Manufacturing Improvement: The Shingo System. Productivity Press pp 21-45. (3) Neave, H. R., (1990) The Deming Dimension. SPC Press, pp 22-23. (4) Hurst, D. K., (1995) Crisis and renewal: meeting
the challenge of organizational change.
Harvard Business School Press, pp 120-123. (5) Jaques, E., and Cason, K., (1994) Human
capability: a study of individual potential and its application. Cason Hall & Co., pg 10. (6) Taylor, F. W.,
(1911) The principles of scientific management. Dover Publications reprint (1998), pg iv. (7) Deming, W. E.,
(1994) The new economics: for industry, government, education. Second edition, MIT Press, pp 95-97. (8) Phipps, B.,
(1999) Hitting the bottleneck. Health
Management Magazine, February, pp 16-17. (9) Goldratt, E. M., (1990) What is this thing called Theory of
Constraints and how should it be implemented?
North River Press, pp 3-21. (10) Walton, M., (1986) The Deming Management
Method. Perigee, pg 32. (11) Ohno, T., (1978) The Toyota production system:
beyond large-scale production. English
Translation 1988, Productivity Press, pg 45. This Webpage Copyright © 2008-2009 by Dr K. J.
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