Theory of Constraints Handbook - James Cox Iii [623]
—Albert Einstein
Many healthcare facilities operate a variety of programs to try to gather and address the problems or undesirable effects5 (UDEs) the staff and patients experience, but few, if any, are able to effectively conclude this process to the satisfaction of all involved.
Often raising negatives in the form of problems to line managers can be done, but all too often the response from management takes the form of a survey or numeric analysis of data that attempts to quantify the extent of the raised problem and which often leaves the apparently lower ranking problems untouched in the subsequent improvement attempts.
What is often not recognized during these exercises is the degree of impact that some behavioral problems can have on a system. Even if such problems are raised, they are often accepted as being a “fact of life” that has to be tolerated rather than addressed.
Many facilities investigate “adverse events” and treatment effectiveness through the application of a form of cause-and-effect analysis, from which frequently operational changes are implemented based on the findings. This practice is inherent throughout healthcare, in both the medical and operations management fields. These analyses are often the basis of best practice models that are fast becoming the measurements for clinician performance and payment structures. However, the cause-and-effect analyses are all too often only used to analyze exceptional or isolated events and often fail to dig deeply enough to include otherwise unreported negative effects from such incidents—they fail to unearth the deepest root cause of the problem, as pictured in Fig. 32-1.
In addition to this, some facilities even lack an effective way to raise negatives. Some facilities possess cultures that place expectation on their staff to figure out solutions at a local level. Again, these solutions are far removed from the source of the problem.
These modes of problem solving result in the building of operational barriers between departments that serve to further isolate departments into operational silos and discourage systemic cooperation.
Adapting Industry’s Solutions for Healthcare
In an effort to try to rationalize the delivery of healthcare, many providers are turning to industry for improvement models. They often view the variation they experience as being a problem that needs to be eradicated, using tools such as Six Sigma and Lean. In some cases, the use of these tools are wholly appropriate if the core problem of a facility is a type of constraint that can be effectively addressed using these tools and will contribute to the goal of enabling facilities to treat more patients, better, sooner, both now and in the future. However, if the use of a particular management tool is one that violates any of the conditions of the goal or if it demands a compromise solution, then it is not the tool the facility needs to use to improve systemically.
Given that healthcare is overwhelmingly people-driven, the majority of the problems that demand the attention of the staff are those generated by the interactions between people. This “noise” has to be greatly reduced before the people working in the system can begin to recognize and be confident enough to address the operational issues that need to be fixed. Until this is achieved, “people will be people” and they will revert to old ways of working of protectionism, watching their backs, and apportioning blame. To reduce the “interpersonal noise” of a system, it is necessary to diagnose why this noise is being generated.
FIGURE 32-1 Using TOC Logic Tools (© E. M. Goldratt used by permission, all rights reserved. Source: E. M. Goldratt 1999. Viewer Notebook 137.)
Much as a physician uses the presenting symptoms of a patient to make a diagnosis, what is needed to find the core problem of a facility is a rigorous cause-and-effect analysis of the symptoms from which the system is suffering. The symptoms of a system are the UDEs being experienced by the people within the system.
Often the analysis