Theory of Constraints Handbook - James Cox Iii [603]
Example: A community hospital has 10 operating rooms, which are the constraint in the system. The hospital is losing money and it has to improve its net profit (NP); otherwise, it will face closure. When we do the data analysis, we find that General Surgery has a time block of two operating rooms for two days. The Throughput or dollars collected from General Surgery is far lower than Throughput of Neurosurgery for the equivalent time block. The priority will be given to Neurosurgery. If General Surgery only utilizes 60 percent of its time and the demand for Neurosurgical patients is high, the hospital might take away General Surgery’s unutilized time and give to Neurosurgery. If the hospital makes 75 to 80 percent utilization of a particular threshold, the hospital could then open the block times when another service is using less than its threshold levels. The hospital could also negotiate with staff, nursing, and administrative staff to open operating rooms for longer hours including Saturdays and Sundays. The goal should be to have flexible capacity to respond to patients’ needs and wants.
In examining the data in Fig. 31-7, one is cautioned to examine related factors like customer service and patient’s total comprehensive needs, which must be taken into account. We cannot always look at just one procedure in isolation of total patient care. That is why it is important to take the data for each procedure and view segments of population rather than dividing the total population of patients by each procedure. It is equally important not to be guided only by the details of this analysis by looking at just Throughput per unit of doctor time because it can result in partial care and dumping of patients on other practitioners, which can have serious negative effects. Example: A practitioner selects the higher reimbursement procedures over the low reimbursement procedures and sends those procedures to other specialists. A maxillofacial surgeon in private practice can refuse to treat facial trauma patients and send them to plastic surgeons or otolaryngologists or vice versa. This might not be consistent with customer service and reputation goals.10
FIGURE 31-8 Scheduling the doctor’s time based on buffers and BM.
Now having some idea of the type of exploitive steps that might be taken by physicians and hospitals, we move on to examine what it means to “subordinate.”
Step 3: Subordinate Everything Else to the Above Decision
TOC offers the following methods to subordinate to the constraint: DBR, CCPM, and BM. In scheduling the patient with the doctor, the schedule procedure should be setup such that the doctor’s time is fully utilized. See Fig. 31-8. Once a time in the doctor’s schedule has been identified, the patient is given an appointment (arrival) time such that he or she should arrive at the office with ample time to sign-in, show insurance card, fill out forms, be shown to the examining room, and be prepared for the doctor’s arrival. On average, the patient should have a short wait prepped in the examining room prior to the doctor’s arrival. This short wait is provided such that Murphy may occasionally strike, but the doctor performing his or her procedure is not delayed. Both the appointment time schedule and the checkout schedule are derived from the doctor’s schedule. All resources in the process should have ample capacity to respond to unexpected events (Murphy) and should do everything possible to keep the doctor on schedule. This extra or protective (or sprint) capacity of all supporting resources is available in case it is needed. This is subordination to the constraint. The buffer in Fig. 31-8 is the time it takes to get the patient to reach the doctor. There is much variability in patient’s arrival time, the skill sets of multiple staff members interacting