The TOC contribution to Healthcare

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The life of every physician is influenced by the oath to treat every patient and do no harm. A practical evil conflict appears when several patients require treatment at the same time.  If this peak of demand for the physician capability is sporadic then a certain priority mechanism, based on the net medical conditions of the “competing” patients, can handle the situation in a satisfactory way.

However, when the load on the medical resources is high, the conflict causes serious delays that endanger many patients and actually threaten the performance of the whole medical system.

Improving the flow of patients by exploiting the weak links in the medical chain and using buffer management for setting priorities is the essence of the current significant contribution of TOC to healthcare. This emphasis on FLOW is well expressed in Alex Knight’s excellent book Pride and Joy.  Alex Knight made a breakthrough in TOC in general by “translating” the insights of TOC, which were applied to manufacturing and multi-project environments, to a very different environment.  Healthcare is governed by different set of values and behavioral patterns.  Healthcare is also exposed to high level of fluctuations and it has to accept any demand that shows up.

Several other TOC people have contributed to the basic concept of improving the flow of patients, among them Prof. Boaz Ronen, Prof. James Cox, Bill Taylor and Gijs Andrea.

The core insight for improving a flow of patients, considering the uncertainty, the lack of enough capacity of critical capabilities and the value of healthcare to humanity in general, is based on creating one priority mechanism that mainly considers time. Only critical medical emergencies might disrupt the previous priorities, but they are less frequent than what outsiders assume.  The flow of patients in hospitals is significantly different than the flows in manufacturing and multi-project not just because the flow consists of live human beings.  The process of treating a patient includes substantial time between treatments where the patient simply rests and that time is part of the absolutely necessary “touch time”.  The sequence of medical treatments and checks can be approximately determined in the initial phase, but is subject to considerable uncertainty.  The flow of incoming emergency patients is definitely subject to very high uncertainty that impacts the whole system.

It is not surprising that TOC has started its penetration into healthcare in improving the flow at the emergency room – the center of the unplanned flow of patients. Few patients show up because of true emergency. Most patients show up for regular, still highly required, treatments.  We now know from wide experience that implementing buffer management priority shortens not just the longest stays in the emergency room, but also cut considerably the average time.  This effect can be explained only by impacting the behavior of the team, now actively looking for quick release of patients, and taking actions when the stay time starts to penetrate into the red.  Weekly buffer management meetings analyzing the Pareto List of the red and black cases adds much more to improving the flow.

TOC has also contributed to superior rules for planning and scheduling of appointments and operations. These planning rules apply to non-emergency requests within hospitals and also for external day-care clinics.  Using time buffers, checking closely the willingness and readiness of the scheduled patients to truly show up ready for the treatment, is part of process.  Being able to call patients to come in a hurry because a given slot of time is free is actually managing a buffer of patients who are ready to be called this way.

Improving the flow of patients in hospitals is aimed at shortening the time patients spend in the hospital. This is a key objective of uncovering capacity of beds that, many times, constrain the hospital from admitting more patients.  I like very much Alex Knight observation that “a hospital is a very unhealthy place to be.”

Can there be additional TOC contribution to healthcare?

The inherent conflict between the duty to give full and equal treatment to every person and managing the scarce capacity and money is still a major evil conflict that troubles not only every healthcare organization, but also governments. It touches upon another huge generic conflict of every government: exploiting the budget constraint. Healthcare causes a vicious cycle where the improved healthcare causes people to live longer and in better quality and both aspects require higher budget to sustain the improved healthcare.

The government conflict causes wide area of ramifications. The basic values between capitalism and socialism have considerable impact on how that conflict is handled.  While I still believe in Goldratt’s axiom that every conflict can be resolved, I admit I don’t know to resolve this key generic conflict of every government.   I believe I and other TOC experts are able relieve the intensity of the conflict, but not to resolve it in full.

What we can do is to accept the compromised budget and exploit the budget for the best healthcare for all citizens.  Of course, values regarding what is “best” and how to measure it, are part of both the obstacles and the solution.  Accepting the conflicting values as they are we still realize that the common current policies lead to behaviors that distort the exploitation of the healthcare budget.  The resulting behaviors do not really follow the original values.  Many of the common policies are based on flawed assumptions that cause distortions, quite similar to what we know in business organization.   Actually the core of TOC is revealing current flawed assumptions that distort the achievement of the goal.  TOC does not interfere with the values themselves.

Eventually every healthcare institution needs to develop a strategy to improve its current state of creating healthcare value.

When we go down to the level of a hospital, as a key example for a healthcare institution, we should assume the policies between the hospital and the government are given. But, within those policies the detailed offering of the hospital and the internal policies and processes there is a lot of room to improve the value generated by the hospital.

Shouldn’t we unite to map the cause and effects that impact the overall performance of healthcare organizations? Understanding how the government and other imposed policies impact behavior could lead us to generate a more universal solution to a truly wicked problem.


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Eli Schragenheim

My love for challenges makes my life interesting. I'm concerned when I see organizations ignore uncertainty and I cannot understand people blindly following their leader.

One thought on “The TOC contribution to Healthcare”

  1. Hi Eli,
    I hope you are well and sorry it has taken me so long to reply but I have been experiencing the patient flow of my mother through the health and social care system over the last few months. I think you capture the current state of TOC in this area very well with the focus on patient flow. However, although Alex and QFI naturally started with ED they quickly realised the system embraces health and social care and increasingly the complex needs of the elderly, like my mother. The NHS now realises this systems challenge and is desperately trying to operate health and social care as one and cross the traditional budget boundaries, but without the necessary breakthrough in thinking, so the elements revert to local optimisation especially where funds are increasingly stretched. QFI were working on developing an integrated care system but it has proved difficult to get the necessary buy-in from the different players in the system. I am interested in your challenge as I think the development of a TOCICO application in healthcare requires such a breakthrough.
    I am still researching patient flow systems through a PhD study, but this centres on a formal evaluation of patient flow systems with a particular focus on TOC and QFI implementations that have been sustained over time.
    I hope to get to the conference in July and it will be good to explore how this might be developed further.
    Kindest regards,


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