By Tim Connor, Rodeo! Performance Group, Inc.

Over the past 20 years there has been a hard focus on improvement in hospitals, including TQM, CQI, PI, Lean, Six Sigma, and various combinations of these. While all have provided tools for improving delivery of care and services, their biggest problem has centered around the local nature of their application. They have been applied to problems in Laboratory, in Nursing, in Emergency, and very frequently the improvements yielded have either been short-lived or haven’t come up to the initial expectations.

As a facilitator who’s used all of these from the beginning (1992) – and who has earned certifications in all – I can say that their application has addressed symptoms, and not root causes. Sure, root cause analysis, fishbone diagrams, and similar tools have been available and were used, but THEY fail because they don’t go deep enough. By deep enough, I mean they don’t look at the inpatient process as a whole, including the interdependencies of a department on many others at a given time.

Just What IS a Constraint?

Eliyahu Goldratt, the Israeli physicist who did much analysis of constraints, described a constraint as any part of a system which holds the system to a certain speed – in other words, won’t allow it to go faster.

We’ll use the gears on the right to explain this. In the diagram the gears are intimately connected together by the teeth in each gear, meshing with the teeth in at least one other gear. Which is the restraining gear? Obviously, it’s the one with a capacity of 15. It’s important to understand that even if those other gears have the capacity to run faster, that “15” capacity gear will allow no more speed in the system beyond 15, because that’s all it’s capable of handling. In fact, if one of the “higher capacity” gears tries to run faster, somebody’s gonna lose some teeth!

The same thing happens in a hospital within its processes. For example, consider the inpatient process. At the very least it consists of Admitting, Laboratory, Radiology, the Nursing Unit(s), Pharmacy, Central Supply, Medical Records, Case Management, and Volunteer Services, followed by Housekeeping. If a physician is considering timely discharge of the patient, and the Housekeeping staff can only clean 15 rooms in a four hour period, it doesn’t matter that Lab can do 43 patient tests, or Pharmacy can provide 37 meds, or Volunteer Services can complete discharges at the rate of 22 in that same time. The system will be limited to 15 patients at a time. It’s this fact which limits the effectiveness of tools and approaches from CQI, Lean, and Six Sigma IF they don’t address the constraint in the overall process.

Symptoms of Constraints in a Hospital

As with any medical issue, the existence of constraints always presents with symptoms. Among staff within the hospital, there are a number of symptoms arising to signal the presence of constraints, including:

Staff dissatisfaction
Increased turnover
Low morale
Grumbling and complaining
Conflict among departments
Conflict between staff and leadership

Even among leadership the continued existence of a constraint will present itself in ways that tend to surface among all leadership — but are especially notable at a department level. These symptoms include:

A sense of futility regarding reaching goals
Exasperation
Low morale
Increased turnover
Isolating the department from other departments
Hoarding information, staff, or supplies
“hiding” staff at budget time (really!)
Hiding illegal activities, with the aim of meeting goals impossible in any other way

Very often, and especially within middle management, these symptoms arise from the unreality of goal setting at the executive level. Below is a common example of a corporate goal, Provide High Quality Care, which, believe it or not, drives conflicting activities between the Emergency Room and the Nursing Units. See if you recognize the symptoms.

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As a leader, did you EVER think that setting a goal to provide High Quality Care would cause conflict!? Bet you didn’t, but it DOES!

The Emergency Room has one primary purpose: Get the patient stabilized and out of the ED. Why? Because there are more emergencies waiting in the Waiting Room, and we need to get their needs addressed quickly and effectively.

The Inpatient Units, on the other hand, have this primary purpose: Provide care that meets all the needs of that particular patient clinically, psychologically, educationally, and socially. Why? Because we’re mandated by standards of care, government regulations, etc., to meet the whole spectrum of care for the patient – and that takes time, specialized skill, and focus.

BOTH of those department goals perfectly address the corporate goal to Provide High Quality Care, but the two produce conflict. Here are common communications that arise from the conflict the corporate goal causes:

Emergency:
@#$%&! You’ve got open beds up there; I need to get this patient out of here so I can deal with the next one!
I don’t care whether you’re equipped to handle this type of patient, we’re not equipped to provide nursing care for them down here once they’re stabilized!
Inpatient Unit:
We aren’t equipped to… (choose one, depending on the nursing unit)

  • handle cardiac patients
  • handle pediatric patients
  • handle adult patients
  • handle a patient with that condition!
  • It will take us much more time to handle a patient like that. Plus, we’ve got meds to give, other patients to take care of, we haven’t entered our orders yet AND we’ve still got all our charting to do! Give us a break, send ‘em somewhere else!

    Over time, continuing conflict will completely end any type of cooperation between the departments, and it also makes staff unwilling to do a good job. Once this atmosphere is established it’s common for Emergency staff to hold patients until shift change (because that keeps them from having to take the next patient) dumping them on the Nursing Units just at report time. At the same time, Nursing Unit staff ‘forget’ to call Volunteer Services to discharge patients – for the same reason. It’s an escalating conflict that makes working at the facility a little slice of Hades.

    One Outcome of Managing the Constraint

    The above may sound like simplification, but it’s absolutely true. At the Ocala hospital, we found that the constraining ‘gear’ centered around the Lab phlebotomists! For years we had kept the phlebotomy staff numbers low to reduce costs, and the result was that we constantly had patients staying longer than optimum because the labs weren’t being completed fast enough. Believe it or not, focusing on that one constraining factor decreased length of stay by almost 24 hours in four months! The cost for more phlebotomy staff came to about $250,000, but the result was an increase in reimbursement – revenue – of over $12 million annually because the beds were turned over faster. Does that seem like a good trade?

    Major Processes Can Constrain Other Processes

    Currently, many hospitals are running at capacity (or near it) for at least part of the year. In Ocala, the Emergency process was chronically backed up, with waiting times frequently running into hours. We chartered a 15 month process improvement effort within Emergency, fully backed by executive management. At the end of that time recommendations totaled close to $2 million in improvements, and executive leadership approved all of them.

    The result? No change! The Emergency Department STILL remained backed up.
    It wasn’t until we piloted the house-wide constraints analysis that we discovered the constraint was the Inpatient Process. Focusing our efforts there immediately began opening beds on the nursing units, and that resulted in decompressing the Emergency Department. It worked.
    Lesson: In a hospital running at or near capacity, the number one constraint to Emergency Room flow is the Inpatient Process itself. On top of that, the major revenue opportunity for such a hospital lies in optimizing patient length of stay – removing any events that unnecessarily add to length of stay.

    In Summary
    It is this author’s experience that Performance Improvement efforts in hospitals almost never last if they are not first directed to a known constraint, and it’s the job of leadership to identify that constraint. Once identified, all efforts of involved departments should be focused on eliminating or reducing that constraint, and it’s then that CQI, Lean, and Six Sigma tools can be effectively applied. Done this way, the hospital will see an immediate increase in throughput and a notable increase in revenues – Kaizan at its best! Even more important, such improvements will last, and that’s the result which has long been missing in hospital performance improvement.