About TLS

Critical Chain Project Management/
Lean Project Management

Critical Chain/Lean Project Management is the combination of Eli Goldratt's Critical Chain schedule development and control with the Project Management Institute (PMI) Project Management Body of Knowledge(PMBOK). It was first described completely in Larry Leach's book:

Leach, Lawrence P. -- Critical Chain Project Management.
Boston: Artech House.

Healthcare Case Study

What's the biggest block to cutting NHS waiting lists?

- lack of resources?
- lack of staff?
- outdated working practices?

Or could it actually be a conflict of interest for those at the (literal) cutting edge?

Read this report – courtesy of Clarke Ching, who was quoting and commenting on an article from the Sunday Times:

UK SURGEON USES TOC (THEORY OF CONSTRAINTS) APPROACH TO DOUBLE CAPACITY AND ELIMINATE WAITING LISTS

A surgeon in the National Health Service has more than doubled his work rate by introducing a French-style “production line” under which he carries out overlapping operations in different theatres.

John Petri, a consultant orthopaedic surgeon, introduced the system after finding himself frustrated at spending time “drinking tea” while patients were being made ready for operations at his Norfolk hospital.

The results:

Trial figures show that over 50 operating sessions, Petri performed 270 major and minor operations using the dual theatre system. Two colleagues using the traditional single theatre approach together performed only 225 operations.
Petri can now operate on patients within two weeks of their first consultation. “I don’t drink tea between operations any more. My waiting list is zero,” he said.
At present the 1,530 NHS orthopaedic surgeons each have about 140 patients waiting three to nine months for surgery.

How did he do this? It looks like he either knowingly or intuitively used TOC's process of on going improvement (aka The Five Focusing Steps), namely:

Identify the constraint
Exploit the constraint
Subordinate to the constraint
Elevate the constraint
Go back to step one

First, he has identified himself – or surgeons in general - as the current system constraint:

“It took me some time to understand how the British system worked but I could not understand why it had waiting lists. When I asked, people would talk about resources. What I saw was that surgeons spent chunks of their time idle waiting to operate,” he said.
“If you were running a factory, you wouldn’t allow your most important and most expensive machine to stand idle. The same is true in a hospital.”

Second, he’s figured out how to exploit himself as the constraint – i.e. how to make him as efficient as possible:

He operates on one patient while the next is prepared in a second theatre. Petri moves on to the second patient while leaving a junior to finish the first. By the time the second operation is near ing completion, a third patient is waiting for him in the original theatre.
The system enables him to perform as many as five hip and knee replacements in a single shift, compared with one or two typically carried out by surgeons who use one theatre. They have to stop and wait after each operation for the next patient to be prepared.
He now operates for five hours at a time instead of the standard 3½-hour session.

Third, he’s subordinated the other resources in the process to make sure he is as busy as possible:

Petri convinced anaesthetists and theatre staff to change the way they worked but was unable to persuade fellow surgeons to join the initiative.
He uses two anaesthetists so there is always another patient waiting for him and the gap between operations is the five minutes that it takes to scrub himself down. He believes the system has reduced the time he is idle by between 40% and 60%.

Ahhh, but he wasn’t always the constraint, it looks like it was once theatre space. Petri persuaded his boss to spend some money to 4) ELEVATE the previous constraint. This was enough to give the theatres spare capacity so that Petri himself was the constraint.

He persuaded his chief executive to carry out a trial of his “dual operating” idea in 2001 and to build a new theatre.

And, other hospitals will perhaps have different constraints:

Anne Moore, of the Royal College of Surgeons, said lack of resources meant “dual operating” was not always viable: “There is nothing to stop surgeons operating Petri’s system. In America surgeons move between as many as 12 theatres but in the UK there are not enough anaesthetists, theatres or other staff to make it work.”

But, perhaps that’s not the biggest problem:

Petri’s initiative has been welcomed by his hospital managers who believe it could become a model to cut NHS waiting lists. It is being shunned, however, by his colleagues some of whom, he believes, may be deterred by “the sheer hard work” involved in the new system.

Doctors, afraid of hard work? Hmmm, I doubt many of them are afraid of hard work … it takes a lot of work to become a doctor …. perhaps there’s something else going on?

There could be drawbacks for surgeons employing Petri’s methods. As his NHS waiting list has been cut, so the incentive for patients to employ him privately has diminished.

He estimates that his private income has fallen 10% in the past year and he expects it to fall further next year.

Petri said: “I care about my private practice but I care more about people who have no money getting their operation tomorrow and not having to wait a year.”
A survey by the British Medical Association found that one in eight consultants earned at least £100,000 a year from private practice.