by Danilo Sirias

A Summary of Smash the Bottleneck: Fixing Patient Flow for Better Care Danilo Sirias Professor of Management

Danilo Sirias earned a master’s degree in industrial and systems engineering and a Ph.D. in business administration, both from the University of Memphis. He is also a Certified Critical Chain Project Manager and a certified Theory of Constraints (TOC) International Certification Organization thinking process implementer. Dr. Sirias is currently a professor in the Department of Management and Marketing at Saginaw Valley State University.

He has received multiple grants to further his research in the applications of TOC in healthcare. His research interests include managing patient flow in healthcare systems and developing strategies to improve quantitative reasoning. Dr. Sirias is a co-author of the book Bridging the Boomer–Xer Gap: Creating Authentic Teams for High Performance at Work (Nicholas Brealey Publishing, 2002), selected by Soundview Executive Summaries as one of the most influential business books of 2002 and by Foreword magazine as Book of the Year. He is also co-author of the book Success…an Adventure (Sirias Consulting, 2009), written to teach students thinking tools. Dr. Sirias is also the inventor of the methodology known as Problem Solving Maps, used to help students develop quantitative reasoning skills. Problem Solving Maps strategies are now being used in several countries around the world. He has published peer-reviewed research in several journals, including the Journal for Quality and Participation, International Journal of Applied Quality Management, International Journal of Production and Operation Management, International Journal of Production Research, and Journal of Education for Business.

In the following essay, Dr. Sirias provides a summary of key ideas from his Smash the Bottleneck: Fixing Patient Flow for Better Care (and a Better Bottom Line), which was published by Health Administration Press in 2020 and coauthored by Christopher Stears.

Effective health care facilities are an essential element of any society. In addition to providing care to the population in general, such facilities ensure access to care for vulnerable people, including the indigent, the uninsured, and the homeless. For this reason, the viability of a nation’s health care system is a significant public issue. Of the myriad problems affecting health care, patient flow has become one of the most important; however, the road to improvement is not easy. Hospital overcrowding, and therefore poor patient flow, has implications in quality of care delivered, hospital finances, patient satisfaction, and provider wellness. Overcrowding causes patient morbidity and mortality. It costs hospitals millions of dollars through ambulance diversions, prolonged inpatient lengths of stay, and malpractice. No less important, there is a shortage of primary care providers, patients typically wait for months for an appointment as outpatient clinics, and medical offices are overcrowded. As a result, it is often difficult for patients to address acute problems with their primary care providers or obtain

timely follow-up after an emergency department visit or hospitalization. This situation pushes patients even more away from primary care and toward more costly emergency services. Smash the Bottleneck: Fixing Patient Flow for Better Care introduces the Theory of Constraints (TOC), which posits that the productivity of any system is limited, at a point in time, by ONE constraining resource. Working as a team to identify, optimize, and break this constraining resource improves the performance of the entire system. TOC is a process of ongoing improvement similar in some ways to other operational methodologies, most notably Lean. However, at its most fundamental core, the emphasis of TOC is on “coordination,” whereas, for Lean, it is on “waste.” Lean looks to eliminate waste across a system to improve operations and TOC looks to focus improvement efforts through one specific resource (the constraint). In fact, one of TOC’s criticisms of Lean is that in Lean, there is often too much emphasis on eliminating waste, and if too much is eliminated, it could make the system anemic. Additionally, TOC shows that reducing waste around a resource other than the constraint does not really have a positive impact on system-wide flow. The book’s focus is to show how TOC can be used to improve patient flow in a hospital, clinic, or medical office. It presents three main tools and their application to healthcare: 1) the Five Focusing Steps (5FS), 2) Drum Buffer Rope (DBR), and 3) Buffer Management (BM). The 5FS of the TOC are a direct result of the assumption that the flow in a system is a function of its weakest link (see Figure 1). The 5FS are: 1) Identify the system’s constraint, 2) Decide how to exploit the system’s constraint, 3) Subordinate everything to the above decision, 4) Elevate the system constraint, and 5) If in a previous step, the constraint was broken, go back to step 1.

Fig. 1. The bottleneck determining the output of the system

DBR, the second tool, is a methodology whose objective is to create a schedule that is robust, is achievable, and can be executed with a significantly reduced amount of chaos. Scheduling resources to optimize the output of manufacturing and service systems is a complex problem. The challenge is how to create a plan that can withstand the realities of the expected variability that would inevitably occur during the execution of the plan. The Drum is the schedule of the constraint, and it should be as realistic and optimized as possible to get the most out of this resource. That schedule sets the pace of the entire system. Due to its importance, the Drum schedule is protected from disruptions using Buffers. Like a shock absorber in a car, Buffers protect the schedule from “bouncing around” to the point that the initial plan becomes obsolete and undoable.The final part of the system is the Rope,which is a mechanism

whose purpose is to ensure that the pace of everyone’s work is synchronized to the Drum. While Buffers ensure the Drum is protected from variation, the Rope is designed to ensure that buffers are not too long, too short, or excessive. It is designed to protect the system from being overloaded. See Figure 2 for a summary of DBR.

Fig. 2. The DBR at work

Finally, BM is a tool to manage the execution of the plan. The function of BM is to help resources prioritize tasks to improve synchronization, expedite urgent tasks to avoid delays, escalate situations requiring additional approval or resources, and improve critical processes preventing flow. BM becomes operational by using a color scheme based on how much each of the buffers determined in DBR are consumed. By continuously monitoring events during execution, we determine colors by “buffer consumption.” Buffers start as green, and, as they are consumed, they turn from green to yellow, red, and finally black. A system needs to be developed to determine buffer status dynamically without burdening employees. Visual tools (such as a computer display or colored stickers) are used to communicate the conditions of all buffers to all resources so they can prioritize their activities. These three tools can be adapted to improve flow in emergency departments, inpatient units, and clinics. 5FS is generic enough that can be used in any healthcare environment. DBR can be more quickly applied to clinics because the physician schedule is the Drum, and the system design requires it to determine the different Buffers and the Rope schedule. BM can also be applied to any healthcare environment, but it is more appropriate to be used in inpatient units where the Drum schedule is not possible. TOC offers an innovative and practical methodology to improve patient flow, an essential part of healthcare systems worldwide.