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with the patients, patient personalities, their medical conditions, the mental conditions of patients and staff on the particular day of interaction, etc. This interaction of variability among various factors results in delays or queuing in front of workstations. TOC provides techniques and tools of managing this interacting variability using buffers and BM reports. The buffers are placed strategically to protect the constraint resource—the doctor time. An experienced staff member takes the role of flow or buffer manager. He or she has two goals on a daily basis—to ensure that the doctor’s time is efficiently utilized and the patient is not in the system longer than he or she expected. If the doctor has scheduled short procedures every 30 minutes, then we have 30 minutes to get the patient from arrival time at the receptionist to the doctor. We have buffer time of 30 minutes with 10 minutes of green zone, 10 minutes of yellow zone, and 10 minutes of red zone. If the patient arrives 15 minutes late, we must expedite this patient by doubling up the resources or doing several tasks parallel to ensure that the patient reaches the doctor in 15 minutes when he or she is done with the first procedure. Protection of doctor time is the priority. Similarly, the checkout or discharge is also important so that the patient is not waiting in the system after the doctor care is completed. The buffer reports tell us the trends where we have delays. If we have check-in workstation delays, we provide staff training to identify and eliminate the delay; we then implement the Lean systems (5 S, mistake proofing, setup reduction, kitting, etc.) and re-evaluate. If we work on changing patient behavior to come on time by reminding them by phone, e-mails, text messaging, or penalizing late arrivals, then after a while, we could start reducing the buffer time when we have control over the internal variability.

In Fig. 31-9a, four patients are already scheduled by CCPM. The most heavily used resource in the system is black, the strategic resource: the doctor. These networks provide the basis for scheduling the doctor’s time throughout the day. If the doctor is the black resource, he or she cannot be with four patients at the same time so some shifting of the networks based on the black resource must be performed. In Fig. 31-9b, the doctor time from each network is shown. Notice that the doctor is fully utilized most of the time.

In Fig. 31-9a, the black resource is the doctor and he or she is supported by resources shown in other colors. The usual scenario in health systems is multitasking. The doctors and other resources are jumping back and forth to different patients without completing a single patient. This results in delays for everyone. We believe that the solution better than the DBR explained previously is CCPM. Each patient is unique and multiple providers or support staff have to work on them to get the Throughput. Multiple patients enter our system (practice) and several staff members work on these patients simultaneously. The system is prone to multi-tasking and unnecessary delays. CCPM for multiple projects with short durations can be utilized effectively to flow the patients rapidly. The Critical Constraint Resource is shown as black in Fig. 31-9a. As we can see, the black resource is overlapping in all four patients. This is overly optimistic scheduling that will result in delays, and the patients will be upset. Figure 31-9b is the first attempt to start scheduling the patient by staggering the schedule based upon black constraint resource or doctor time. Usually after three to four patients, a buffer is kept to absorb variability and Murphy which accumulated across patients. The buffers can be dynamically designed based upon customer input. If the patients start complaining within 30 minutes or 15 minutes of wait time, the psychological management of queues could be implemented. Usually for different procedures, the customers have different tolerance levels for waiting.11

FIGURE 31-9 Scheduling the doctor’s time based on patient