Theory of Constraints Handbook - James Cox Iii [605]
This mapping of the networks for all procedures can be performed manually and then the networks shifted around to fully utilize the doctor’s time, but software programs are being developed with patient care mapped out as a project. Multiple patients or patients with different needs and wants flow through our systems. We schedule a finite time that it will take to ensure that the patient exits the system within the promised time and quality of outcome. The project must start with an understanding of the patient’s expectations in addition to the medical diagnostic test results. The necessary conditions like finances (insurance, Medicare, etc.), time available and required, and patient’s existing medical condition are identified prior to starting diagnostic tests and treatment plans. After these initial steps, the best treatment designs or plans are chosen based upon the evidence-based medicine. Part of the treatment plan must take into account the patient’s inability to understand these complex concepts about their own care. Increasing the patient’s understanding or comprehension about the solutions to his or her problems will be an important step in the execution of the project for patient care so that we get full compliance from the patients.
Step 4: Elevate the System’s Constraint
Elevate the constraint when we need to increase system capacity or make significant investments to offload the constraint time. To understand our investment options for elevating the constraint, we need to understand something about the TA terms to be used. We defer these now, but examine TA in more detail later in the chapter. For discussion of the Exploit step, we only need to understand the following accounting terms. Definition of these terms is woven into our discussion of the Exploit decision.
First, we must look at the impact on NP and return on investment (ROI) in making the elevate decision.
T = Price–Totally Variable Cost
NP = T – OE (Net Profit = Throughput12 – Operating Expense13)
ROI = NP/I (Return on Investment = Net Profit/Investment)
Keeping this in mind, we can ensure that all of our investments in elevating the constraint will result in increases in Throughput greater than increases in OE and the ROI greater than cost of capital.
Step 5: If in the Previous Steps a Constraint Has Been Broken, Go Back to Step 1, But Do Not Let Inertia Cause a System Constraint
Sometimes the environment changes or in implementing Step 4 Elevate, the constraint moves. In these cases, one should go back to Step 1 Identify. Changes in reimbursement or regulations from insurance companies or Medicare can cause changes in product mix, for example.
This Five Focusing Step process (5FS) is one of the TOC POOGIs.
Thinking Processes14 for Identifying Root Cause of Physical Constraints to the Flow of Patients
The physical constraints once identified are still difficult to manage due to conflicts in the mental models of the stakeholders. The core conflicts come between cost containment (trimming personnel until everyone is always busy, for example) versus increasing Throughput (by having protective capacity at all support functions). The other related core conflict is between local optimization (measures that focus on individual performance) versus global results (measures that focus on organization performance). These core conflicts and other conflicts are studied using the Evaporating Cloud (EC) technique. In Fig. 31-10, the core conflict of increasing revenues versus controlling OE is portrayed as an EC with its assumptions and injections. Many of these injections15 (actions) were used in the doctor’s application.
FIGURE 31-10 EC with assumptions and injections of the core conflict of hiring more staff versus keeping few staff.
Throughput Accounting for Performance Measurement and Decision Making in Health Care16
TA for health care is different from the usual TA17 in that health care service is mostly intangible. In most instances, the doctor should be treated as the constraint and the patient