Breakthrough improvements in

Health Care
Using TOC, Lean, Six Sigma

Dr. Gary Wadhwa

Adirondack Oral & Maxillofacial Surgery
 Overview
Case History Adirondack Oral &
Maxillofacial Surgery
Breakthrough improvements in
Health Systems using TOC, Lean,
Six Sigma
Closing Thoughts
Case History Adirondack Oral &
Maxillofacial Surgery

Business plan development using Balance Score Card

Lean Implementation

Six Sigma Implementation

TOC implementation

Results
Breakthrough improvements in
Health Systems using TOC, Lean,
Six Sigma
Closing Thoughts
AOMS Journey started in Physician executive
MBA at UT in 1999 using Balance Score Cards
Simplified Business Plan

Select the right mix of Customers, Services and provide them with “WOW”
Services

Data Mining based upon ABC measurements

Customer surveys and Customer Complaint Management process

Identify Doctor as CCR and exploit the constraint

Moving to larger facility from 1200 sq ft in hospital to Professional Bldgs with 7800
sq ft

Subordinate to Doctor Time

Hiring staff, doctors and training programs to subordinate to CCR

Implement tools like Lean, Six Sigma

Staff Intellectual Capital Management

Hiring the right staff

Applied Knowledge training

Incentive Compensation & Bonus

Learning and Growth Environment
© 2007, Dr. G.S. Wadhwa. 4
 OMFS Delivery System
Lean System Training in 2000 at UT
Front Staff
Order Mgmt
Scheduling Lean
Communication Production
Supplier

Customer
The King

© 2007, Dr. G.S. Wadhwa. 5

 Customers by Service Families

Customer Segments by procedures

Dento alveolar

Wisdom teeth

Routine extraction of teeth, Apicoectomies

Gum Surgery

Dental Implants

Single

Multiple

Full Jaw reconstruction

Oral Pathology

Facial Trauma

Corrective Jaw Surgery/TMJ Surgery
© 2007, Dr. G.S. Wadhwa. 6
Customer and Service Families mapped
to Lean Manufacturing concepts

Customer Demand Cycle

At Once Emergency patients (Trauma patients,
Infections)

Build-To-Order (Elective Surgery like Wisdom teeth
removal and Orthodontic surgery patients)

Customization: Requires Extensive planning,
Consultations, Coordination, checks and balances (Dental
Implant patients, TMJ, Corrective Jaw Surgery and
Aesthetic Surgery)

© 2007, Dr. G.S. Wadhwa. 7

 AOMS
Customers
Source
Teeth ext. Wisdom
teeth
AOMS Services Dental implant Dentists

Most Jaw Sx
Profitable
Services
Oral Path

Most Time Hospital

Facial Trauma surgery
Consuming
TMJ Sx
Least Profitable
Physicians
service
Cosmetic Sx

8
 Perform macro-level Value Stream
Mapping of Current Processes

Patient flow

Information flow

Document flow

© 2007, Dr. G.S. Wadhwa. 9

 Value Stream Map
Check-
Greeter Check-In H&P Doc Discharge
Surg Out
P/T (8,2, 5)
P/T (8,2, 5) P/T (15, 5,8)
P/T (10,3, 5) P/T (20,5,10) P/T (15,5,8) _________
_________ _________
_________ _________ _________ C/O(3,1,2)
C?O((3,1,2) C/O(3,1,2) ___________
C/O(3,1,2) C/O(3,1,2) C/O(3,1,2)
___________ ___________ ___________
________ ___________

Value Added Time Process Time: 41 min

5 min 8 min 5 min 10 min 8 min 5 min

Wait Time 10 min 15 min 5 min 2 min 32 min

Total Value Quotient: 41/(41+32) = 56%

© 2007, Dr. G.S. Wadhwa. 10

 Identify & Eliminate Waste

Wait time

Walking distances

Handling Inventories

Defects/Rework

Equipment breakdowns

Lack of standardization

Supplies not at the proper place

Poor scheduling

Movement
© 2007, Dr. G.S. Wadhwa. 11
 Lean Process Flow

•Phone •Collecting
Information •Rapport •Checking
•Data Entry Building
•Probable Insurance
•Greeting •Diagnosis &/
Diagnosis •Making
Customers Or Treatment
•Prep for Surgery pymt plans

1 2 3 4

All necessary materials at point of use

© 2007, Dr. G.S. Wadhwa. 12

Receiving 12 Receiving 8
Greetings & Registering 10 Greetings & Registering 2
checking your data 1 collecting co-pay 5
communication to Nursing
and financial 1 communication to Nursing 1

Nursing 17 Nursing 74
Greeting & Introduction 2 Greeting 2
H&P 3 ck.H & P, consent, monitors 2

x-rays and other diagnostic

materials 10 assist in surgery 30
Briefing surgeon on Patient 2 Instruments 10
Surgeon 15 follow up care to patients 30

Greeting & Rapport building 5 Surgeon 42

Explanation of treatment and

risks 5 Greet parents and others 2
Signing of contracts 3 Perform surgery 30
Communicating to Receiving
and Financial 2 write charts 5
inform parents, referring drs
Financial 12 and others 5
Payment options, submit
Ins.Thank patient 10 Financial 6
Payment options, submit
Schedule the patients 2 Ins.Thank patient 6
total cycle time for
consultation 56Wadhwa.
© 2007, Dr. G.S. total cycle time for sx 130 13
 Standard Work: Method Sheets
Problem: Missed or incorrect information
Solutions: Method Sheets

Identified key processes and activities that were error
prone

Created posters with easy to follow pictures and

instructions and posted them at point of use

Written step-by-step instruction documents

Templates
© 2007, Dr. G.S. Wadhwa. 14
Flow Charts, Method Sheets

© 2007, Dr. G.S. Wadhwa. 15

 Lean Tool: 6S (workplace organization)
Eliminate waste and errors due to confusion, movement

© 2007, Dr. G.S. Wadhwa. 16

Lean Tool, Mistake Proofing
Shadow boxing

© 2007, Dr. G.S. Wadhwa. 17

 Lean Tool: Kanban System
ITEM NUMBER REORDER QUANTITY
001-1317 1 case
PRODUCT DESCRIPTION
Dextrose (5%) and NaCl (0.9%) 250mL
Bags
VENDOR ACCOUNT #
Ace Surgical 60190

MINIMUM STOCK LAG TIME

1/2 box 3 days

ITEM NUMBER REORDER QUANTITY

538249-54

PRODUCT DESCRIPTION
1" x 2 -5/8" Green 5971
VENDOR ACCOUNT #
Staples 4019340822

MINIMUM STOCK LAG TIME

2 days

© 2007, Dr. G.S. Wadhwa. 18

 Daily Check-Up
TPM
Daily Check Up

No. Task Frequency Responsible Time

1 Check Hand pieces and Electric Motors Daily in AM Nursing staff 0.5 min
2 Check Anesthesia Machines Daily in AM Nursing staff 0.5 min
3 Check Oxygen Tanks Daily in AM Nursing staff 0.5 min
4 Check Fail Safe mechanism Daily in AM Nursing staff 0.5 min
5 Check Gage on Sterilizer Daily in AM Nursing staff 0.5 min
6 Check Anesthetic gas tank Gages Daily in AM Nursing staff 0.5 min
7 Check behind the Compressors Daily in AM Nursing staff 0.5 min
8 Check Lasers Daily in AM Nursing staff 0.5 min
9 Check for Oil Leaks Daily in AM Nursing staff 0.5 min

10 Report problem and tag the machine Daily in AM Nursing staff 0.5 min

© 2007, Dr. G.S. Wadhwa. 19

 Culture Change at AOMS

Problem Focus on Processes not people

Culture of “Process of Continuous Improvement”

Complete Transparency

Minimum Hierarchical Structures: Developed Accountability

Doctor CEO, Strategic Leader

Partners and Associate Doctors leaders in technical and business process management

Site Leaders and Customer Service/Scheduling Leader accountable and responsible
for the staff work

Clear Roles, Responsibilities and Accountabilities

Matching Roles with Capabilities and work Complexity

Competitive Compensation and Bonus system (Increase in Profits)

Team Values/Individual Values and Team Security / Individual
Security…no layoffs

© 2007, Dr. G.S. Wadhwa. 20

 Six Sigma tools
Customer Satisfaction Data within control limits
Overall Customer Satisfaction
U C L=5.264
5.2
Individual V alue

4.8 _
X=4.713

4.4

LC L=4.162
4.0
1 6 11 16 21 26 31 36 41 46
O bser vation

U C L=0.6769
0.60
M oving Range

0.45

0.30
__
M R=0.2072
0.15

0.00 LC L=0
1 6 11 16 21 26 31 36 41 46
O bser vation

© 2007, Dr. G.S. Wadhwa. 21

 Six Sigma tools to Reduce Cycle
time of Collections
A/R Process Improvement Results

Percent
11/11/02 11/2/05 Improvement

A/C >30 days old

Regular 259 43 83%
AIN 41 7 83%
COB 27 5 81%
Total Ins. Related 336 55 84%

PVT Pay 130 64 51%

Medicaid 90
© 2007, Dr. G.S. Wadhwa. 15 83% 22
Six Sigma Tools in Accounts
Receivable Management
Six Sigma Tools to reduce
medication errors
Six Sigma Problem Solving tools
Overall Customer Satisfaction
U C L=5.264
5.2
Individual Value

4.8 _
X=4.713

4.4

LC L=4.162
4.0
1 6 11 16 21 26 31 36 41 46
O bse r v a tion

U C L=0.6769
0.60
Moving Range

0.45

0.30
__
M R=0.2072
0.15

0.00 LC L=0
1 6 11 16 21 26 31 36 41 46
O bse r v a tion

Temporary Fix
5 Whys? To get to root cause
Doctor to check H & P prior to
Why # 1: Doctors don’t check the Rx against
starting surgery
Medical History
Assistants to write Rx after
Why # 2: Assistants print the Rx and doctors
checking with doctor
just sign the Rx
Final Fix
Why # 3: Doctor time is very valuable, assistant
is subordinating to doctor time Educate about re-work that
decreases Throughput
Why# 4: Office wants to increase productivity
Why# 5: Everyone’s bonus is dependent upon Verification: No complaints
profitability in 6 months
 FMEA
Process Name: Prescription Preparation

Process Number: PPP 445

Date: 1/1/2006

B) OCCUR RISK
RENC C) DETECT PRIOR
E ION ITY
A) SEVE Proba Proba NUMB
RITY bility bility ER

Rate 1-10 Rate 1-10 Rate 1-10 RPN

ACTION
10=Most 10=Highest 10=Lowest TO
PROCESS FAILURE Seve Proba Proba IMPRO REVISED
STEP MODE re bility bility AxBxC VE RPN
1) Calculate 1) Incorrect 5 3 2 30
dosage dosage
prepared

2) Select 2) Medication 9 2 8 144

medication name
misread

3) Check 3) Interactivity 7 2 3 42
interactions analysis
not
performed
 Insurance Company
AOMS Complex Value
Family Dentist Chain TOC Methods
Hygienist

Patient
Wants & Patient
Specialists
Needs Centered
Surgeon Care

Complex
Supplier Dental Lab Systems
System Goals: Profitable Practice by focusing on High
Quality and Reliable Patient (Customer) Centric service

Metrics: T, OE, I, CU, OTC, DDP, TDD, IDD

Dentist Surgeon Dentist Lab Dentist

CCR (Capacity Constraint Resource): Dental Practices

Value Chain Concept
 5 Focusing Steps

Identify the Constraint in Value Stream…Dental practices,

valuable customers

Plan to exploit the Constraint…Mafia offer to Dental
Practices

Subordinate to the Constraint…Help Dental Practices
develop Profitable systems

Elevate the Constraint…Marketing/Sales and development
of dental practices into high value practices

Move to the other constraint that impacts the overall patient
value delivery
 INJ5: Hire staff to allow INJ6: Hire
time for Project staff to
Management & Quality Maximize
improvements that Doctor Time
result in ROI > OE Utilization
INJ4: Hire staff to
Market and sell that
result in increase in
Throughput greater
than Overhead
Expenses
Aspts1: Need staff for marketing and sales
Need to free up senior staff for training
Need to have protective capacity of staff
Need staff to off load from Doctor

Aspt4: Volume of
patients with higher BC-1: Increase
EC value results in
increase in throughput
Throughput
DC-1: Hire
more staff

Aspt3: You
INJ2: Hire the right can't hire
size of staff that and not hire
AC-1: at the same
Profitable increases T > OE
time
practice

CC-1: Control DC'-1: Don't

Aspt5: Overhead hire, keep
Overhead Expenses few staff
Expenses drain members
Profits

Aspts2: payroll is under control

INJ3: Hire additional
Management cost is controlled
staff to free up
Training cost is under control
experienced staff to
Less time wasted on interpersonal issues
train in services that
result in Throughput >
Overhead Expenses
 Super Injection
Implement TLS
(TOC/Lean/Six Sigma) in Practice

Implement Six
Implement TOC Implement Lean
Sigma

Implement
Distribution & Value Implement TP to Implement TOC Implement CCPM Implement Sales &
chain integration change Culture Finance & Metrics sDBR Marketing

Implement DFSS Implement Value

using Axiomatic Stream Mapping
Designs and TRIZ

Implement Lean
Implement DMAIC
Tools
Control Charts
6 S, SWF, Set Up
Red, TPM, Mistake
Proofing
Implement FMEA,
MEOST
 540: Staff
understand
(2): Next Page
priorities

INJ315: We focus
530: Work
on speeding up 535: There is
Load on staff
the Critical TOC lag time in
increases
Training builing
Programs CCPM, "Applied
sDBR Capabilities"
of staff

FRT 1 520: Volume

of patients 515: We increase
increase in Throughput
the practice

INJ320: Implemet
INJ305: Train Lean Tools:
Doctors and Staff 500: We Standard Work
505: We hire
in Throughput segment the Flow, 5 S, TPM,
adequate
Finance & market and Inventory Mgmt,
staff to
Metrics, provide price Patient Mistake Proofing
support the
Decision Tools value using to reduce
Throughput
T/CU variations and
protect Doctor
Time

SUPERINJ122: We implement TLS in the practice

 INJ405: We successfully INJ415: We implement Decision tools using T/OE,
implemented Global Metrics T, OE, I T/I, T/CU metrics to improve Productivity, ROI,
in practice Doctor Time Utilization

IO13: We expand our Obs13: We don't have

Physical Facilities to Physical facilities to
Obs5: Sometimes accomodate increase in accomodate increase
IO5: We have we won't know Throughput and to in Throughput
help in TOC how to make house increase in staff
Finance metrics complex
implementation decisions for
future planning

IO12: We develop
confidence in Decision
IO4: We start
decision making making process using TOC
process based Performance Metrics
upon T, OE and I

Obs11: We
IO11: Money is don't have staff
available to hire& train
IO3: Doctors and or skills to
staff to focus on
Key staff improve T/CU
PRT 1 understand the
TOC Metrics
marketing to higher
T/CU clients
through
marketing and
sales

IO10: Profits improve

IO2: Simulations,
Training games and Obs2:
case histories from Doubts
about IO9: Throughput
other industries are
available as proof of validity of improves
concept concepts

Obs8: We don't
IO8: We develop
training programs to have training
IO1: Time is programs to
scheduled for make new hires
Obs1: Lack of effective in improving rapidly train
training on line in time available new hires and
TOC Global Throughput
to learn new make them
Metrics T, OE and I Financial effective in
with Key staff Metrics improving
members & Throughput
Partners IO7: We hire staff
to improve
Throughput

Obs6: we don't
IO6: T/OE knowledge is available know when to
to help in decision making hire more staff
regarding hiring and once hired
staff,Throughput increase must how to
be greater than OE increase in effectively train
both short and long term them
 IO35: Staff/Partners
make decision based
upon P, T, OE, I & CU
time

707: Need to allow

708: It will cost time for all Team Act3: Develop Projects with
money & time Leaders/ Partners decision tools using TOC
away from to digest these Finance & Metrics
patient care concepts

706: It takes time 705: Simultation games

to learn new and case histories
concepts relevant to our Practice
are available

TT 1
704: Money is 703: Need to develop Act2: Develop P & Q ,
available to develop simulations and examples to Dime, Dollar and
TOC Finance/PM solve problems in TOC Performance Metrics
games and Finance and PM in the T/CU, T/I, TDD, IDD
simulations practice games

702: We don't have 701: Team Leaders and

many case histories Doctors are available for
& excercises to train training in TOC Finance and
in TOC Fin & PM PM

700: Partners and Team Act1: We hire

Leaders don't 698: We need to
additional staff and
understand the schedule training in
take Team leaders out
importance of TOC TOC Finance and
to train in TOC Finance
Finance and PM tools PM decision tools
& PM

696: Practice is extremely

busy to take time and 697: We don't understand
learn new Financial and the TOC finance & PM
PM tools decision tool
 AOMS Performance Metrics - Revenue
No. of $ Collection per $charge
patients patient per pt

2001 3417 636 1226.29 Increase in

patients
4144 680 1159.82
Increase in charge
4074 786 1360.98 per patient
4670 857 1385.29 Decreased billing
errors
4604 978 1412.43
Increase in
5058 1050
1406.72 collection per charge
2007 5448 1137 1568.71 Faster collection

© 2007, Dr. G.S. Wadhwa. 35

 AOMS Performance – Doctor Ratios

Patient/Dr. increased
Doctors Staff Staff/Dr Skill sets Patients/Dr
then decreased
2001

Policy change to
3 12 4 500 1139 concentrate doctors to
4 day week, ~ 10%
3 18 6 600 1381
productivity loss
2.5 27 11 650 1630
The 3 doctor becomes
2.7 doctor and
2.5 24 10 700 1868
Patients seen/Dr.
2.25 25 11 750 2046
~1823 in 2006

Staff Skill sets
2.77 30 10 800 1823 assumptions: Reliable
staff, cross trained
2007 2.77 35 12 900 1964
staff, Team Work,
Motivated
© 2007, Dr. G.S. Wadhwa. 36
 AOMS Financials
First “Viable Vision”
Year Charge out Collections Expenses Profits

2001 4,190,250 2,174,567 2,073,383 101,184

2002 4,806,307 2,819,595 2,213,722 606,228

2003 5,544,649 3,201,432 2,315,061 886,371

2004 6,469,285 4,002,588 2,828,885 1,173,703

2005 6,502,818 4,503,835 2,821,954 1,681,882

2006 7,115,183 5,311,128 3,196,018 2,115,110

2007 8,540,907 6,193,931 3,676,792 2,517,039

© 2007, Dr. G.S. Wadhwa. 37

Case History Adirondack Oral &
Maxillofacial Surgery
Breakthrough improvements in
Health Systems using TOC, Lean,
Six Sigma

Competing Value or Supply Chains

Each Value Chain develops it’s own
Viable vision to compete

Implementation of Viable Vision requires
TOC, Lean, Six Sigma tools
Closing Thoughts
 Health Care System is a process
Goal: Satisfy wants & needs of Patients

Larger Process
Sad & in Pain
Happy & Healthy

Input Process Output

Input Process Output Input Process Output Input Process Output

Pharmaceutical Insurance
Doctors Hospitals Companies Vendors
Companies
Health Care delivery System -a value chain
Labs Hospitals
Suppliers

Patient Specialists
Order Mgmt
Scheduling
Communication

Patient
Customer
Primary Care The King
Competing Supply Chains to provide best value for
customers-the patients
 Strategy & Tactic Tree
using integrated tools TOC, Lean, Six Sigma

Develop vision, goals with measurements using TOC
Financial Metrics (increase Throughput of patients)

Lean/Six Sigma/Reliability Engineering tools applied to
Critical Processes to improve Patient care

DBR/CCPM to improve Velocity of patient flow through
our systems

Increase Capacity then launch new Premier Services

Use TOC TP to overcome old Mental Models and change
the culture that allows smooth implementation of Strategy
& Tactic Tree
TOC Focused Management: 5 Step Method
0. Determine the system’s goal: Throughput Improvement
Strategy
0.5 Establish Global Performance Measures (Throughput Lost,
Quality/Reliability of service, Poor Due Date
Performance, Patient Queues in front of specific health
care providers)
Step 1: Identify the System Constraint
Step 2: Decide How to Exploit the Constraint; break physical,
dummy or policy constraints
Step 3: Subordinate the rest of the system to the constraint
Step 4: Elevate and break the constraint
Step 5: If the constraint is broken, return to step I Do not allow
Inertia to become system’s constraint
HEALTH AND SOCIAL CARE SYSTEM - The chain of
activities
Home Home
Home

Electives 4 hours Days Days

Days
Home Social & Social & Social &
Majors Health Health Health
Care Care Care

GP referrals Residential
ED Acute CH & Nursing
Care

Minors Social &

Health
Care

A&E
Home
Acute 12 hours Days Days
Social and Health Care
Community Hospital
Residential & Nursing Care
The End
 ED as a critical Department, an input into the system

M a ry W a s h in g to n H o s p ita l F a s t T ra c k
C u rre n t S ta te V a lu e S tre a m M a p L a b /Ra d io lo g y

Am e lio r EDIS

S tandard

P oint of U s e W ork
S upplies
S tandard
R apid P oint of U s e
W ork P oint of U s e
S etup P oint of U s e C hangeov er S upplies
O ne S upplies
R educ tion S upplies
P iec e

P atient B ed N urse Flow MD R N Initial A ncillary RN MD RN P atient

Triage Tech D uty
S ign-in P lacem ent E valuation E valuation Treatm ent Testing R eassess D ischarge D ischarge R egistration

2 5 3 2 2 3 2 2 1 3 1
FIFO
1 3 1 1 1 1 1 1 1 1 1 1

C/T = 4 m ni C/T = 7.1 m ni C/T = 7 m ni C/T = 8 m ni C/T = 6 m ni C/T = 5 m ni C/T = 10 m ni C/T = 4 m ni C/T = 7 m ni C/T = 4 m ni C/T = 5 m ni C/T = 3 m ni
M ni = 3 m ni M ni = 5 m ni M ni = .3 m ni M ni = 5 m ni M ni = 3 m ni M ni = 3 m ni M ni = 5 m ni M ni = 1 m ni M ni = 3 m ni M ni = 2 m ni M ni = 2 m ni M ni = 1 m ni
M ax = 9 m ni M ax = 20 m ni M ax = 2 m ni M ax = 15 m ni M ax = 15 m ni M ax = 10 m ni M ax = 30 m ni M ax = 10 m ni M ax = 15 m ni M ax = 15 m ni M ax = 10 m ni M ax = 5 m ni
FPY = 100% FPY = 90% FPY = 100% FPY = 75% FPY = 75% FPY = 90% FPY = 90% FPY = 80% FPY = 90% FPY = 90% FPY = 95% FPY = 100%

1 9.1 17.2 6.2 5 7 6 10 6.4 6 5 2

M in M in M in M in M in M in M in M in M in M in M in M in
4 7.1 7 8 6 5 10 4 7 4 5 3
M in M in M in M in M in M in M in M in M in M in M in M in

Total = 151 M inutes (2 hours and 31 minutes) Average LOS

IMPLEMENTING ‘DYNAMIC BUFFER MANAGEMENT’

Actively manage patients in the Amber zone to avoid them moving into
the red zone. Patients in the Red/Brown zone to be ‘expedited’ through
the remaining steps in the system. Review and eliminate underlying
causes once a week
 Aw
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30
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50
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Focus on Top three or four variables first

rg
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N
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Red

Total
Black
Amber
Break each one down by reasons and Pareto them further
Manage the Integrated Value Chain… not
local environment
Patient wants/needs analysis
using QFD
Using Axiomatic Designs,
Evidence Based Medicine, Fuzzy 13
418 0
442 56
1012 4
2000
13418 0442 56
1012 42000

Logic agree upon overall 44

44 7
7
1 % 3
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Treatment outcome goals 1
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1
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% 200 1

Communicate across network

200 S
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value chain similar to CCPM 13418 0442 1012

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projects with lean systems to 44

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improve door to discharge 200

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Record data for feedback

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 Patient Care Planning Tools
Action Plan
•Frequent component re-estimates required
•Enter completion date if component is ready (Components background turns Blue)

Patient start Estimated

Date Patient Tx Plan Starts Completion

Assessment & Plan in progress Buffer Zone

Planning Stage

Diagnosis
& Treatment Plan
QFD/Axiomatic
Designs
Fuzzy Logic, AI
Components
Pugh Matrix
(Challenging but achievable estimates)
CCPM/DBR

Estimate Reviews

Patient’s plan in progress- Components setup

 TOC Thinking Processes
Identify Core Conflicts, Implement Solutions
732: We are using CCPM and sDBR
INJ405: We successfully INJ415: We implement Decision tools using T/OE, in our patient care and projects
implemented Global Metrics T, OE, I T/I, T/CU metrics to improve Productivity, ROI,
in practice Doctor Time Utilization

731: Patient 730: There is a need to Act9: Train Program Manager in all
care is a train new Program facets of TOC ( TP, Finance and
IO13: We expand our Obs13: We don't have combination of Manager in TOC metrics, sDBR, CCPM, Distribution,
Physical Facilities to Physical facilities to CCPM and Principles and health Value stream Mgmt, Marketing/Sales
Obs5: Sometimes accomodate increase in sDBR care environment and People/change Management)
IO5: We have accomodate increase using 4 x 4 methodology
we won't know Throughput and to in Throughput
help in TOC how to make house increase in staff
Finance metrics complex
implementation decisions for
future planning

729: New 728: Program manager starts to

IO12: We develop schedule patients as projects and
Program
confidence in Decision manage the pipeline of other
IO4: We start Manager has
decision making making process using TOC no skills in projects pending in the practice
process based Performance Metrics TOC and CCPM
upon T, OE and I

Obs11: We
IO11: Money is don't have staff
available to hire& train
IO3: Doctors and or skills to 727: We don't have
staff to focus on 726: There is a need to have Act8: Hire or develop
Key staff improve T/CU talent pool in the
marketing to higher through a Program Manager to Program manager to

TT
understand the practice for
T/CU clients marketing and Program Manager
manage pipeline of projects manage Multi-Project
TOC Metrics environment in the practice
sales

IO10: Profits improve

IO2: Simulations, 724: Patients requiring coordination
Obs2:
INJ5: Hire staff to allow INJ6: Hire Training games and
case histories from Doubts 725: Staff is not among multiple providers, staff
training programs, marketing
about able to find time
time for Project staff to other industries are
available as proof of validity of
IO9: Throughput
improves
to update the projects, process improvement
projects and practice expansion
projects and still
Management & Quality Maximize concept concepts works intuitively projects are entered in Concerto

improvements that Doctor Time

Obs8: We don't AND
result in ROI > OE Utilization IO8: We develop
training programs to have training
IO1: Time is
INJ4: Hire staff to scheduled for Obs1: Lack of
make new hires programs to
rapidly train
training on line in effective in improving 722: There is a need for
Market and sell that TOC Global
time available
to learn new
Throughput
new hires and
make them
723: Project
Management is
quality of patient care
through coordination of Act7: Implement
result in increase in Metrics T, OE and I
with Key staff
Financial effective in not a commonly
used tool in
multiple providers and
implementation of process
Concerto from
Realization in the
Metrics improving
Throughput greater members &
IO7: We hire staff
Throughput
health care improvement projects practice
Partners
than Overhead to improve
Throughput
Expenses
Aspts1: Need staff for marketing and sales
721: Process Improvement 720: Patient wait time,
Need to free up senior staff for training Obs6: we don't
IO6: T/OE knowledge is available know when to
projects, marketing and practice
growth projects are constantly
long lead times, poor
coordination of patient

PRT
Need to have protective capacity of staff to help in decision making hire more staff delayed or never finish care is prevalent
regarding hiring and once hired
Need staff to off load from Doctor staff,Throughput increase must how to
be greater than OE increase in effectively train
both short and long term them
Aspt4: Volume of 670: Overall "
patients with higher BC-1: Increase
Applied
value results in DC-1: Hire Capabilities" of
Throughput more staff 672: Quality
staff are increased
increase in throughput
of work
increases

Aspt3: You 668: Staff

can't hire 674: 676:
retention is
INJ2: Hire the right
and not hire
Super Injection Customer Patient
increased
AC-1: size of staff that Service flow rate

Profitable increases T > OE at the same Implement TLS increases increases

time
practice (TOC/Lean/Six Sigma) in Practice
667: We are
able to
Provide
CC-1: Control DC'-1: Don't Implement Six opportunity
Aspt5: hire, keep Implement TOC Implement Lean
Overhead Sigma for staff to
Overhead Expenses few staff advance
Expenses drain members 680:
Profits Reputation of 662: We are able
Practice 664: We have training
Implement increases
to attract the best
Distribution & Value Implement TP to Implement TOC Implement CCPM Implement Sales & staff with programs to train
Aspts2: payroll is under control change Culture Finance & Metrics sDBR Marketing compensation staff with very short 665: We are
INJ3: Hire additional chain integration and incentive lead time able to grow
Management cost is controlled
staff to free up package the business
Training cost is under control
experienced staff to 685:
Less time wasted on interpersonal issues
train in services that Implement DFSS Implement Value Attractivenes
result in Throughput > s of practice
using Axiomatic Stream Mapping increases
Overhead Expenses Designs and TRIZ
660: Profits
improve
consistently
over time
Implement Lean 690: Patients
Implement DMAIC
Tools seeking treatment
Control Charts in the practice
6 S, SWF, Set Up increase

Conflicts &
Red, TPM, Mistake
Proofing A
Implement FMEA, 695: Practice has N
D 655: Overhead
MEOST capability of 650: Throughput
screening the Expenses significantly
dramatically
lag behind increase

Injections to blow
right patients improves

Assumptions
based upon T/CU increase in Throughput

assumptions Future Reality

Case History Adirondack Oral &
Maxillofacial Surgery
Breakthrough improvements in
Health Systems using TOC, Lean,
Six Sigma???
Closing Thoughts

Health care vs. Manufacturing

Variations and uncertainty

Inter dependencies

Integrated System of TOC, Lean, Six Sigma
 Healthcare vs. Manufacturing

Key Lean/Six Sigma Principles

Focus on Key Processes that deliver Customer
Value

Identify Constraints in the processes

Manufacturing Cut Sew Assemble Add

Grind
cloth Turn
segments Mill
segments Drill
buttons

Healthcare Order
Type Read
Obtain
Prep Perform
Type
Mail
scan
CT scan patient scan

Difficult to eliminate variations despite lean/six sigma efforts

 Key Lean/Six Sigma Principles

Key Principles

Focus on Processes that deliver Customer Value

Eliminate waste around the constraints

Movement

Inventory

Over-processing

Waiting

Correction
 Key Principles

Key Principles

Focus on Processes that deliver Customer
Value

Eliminate waste

Promote flow

Establish clear signals and handoffs

Reduce batching and variation

Synchronize and “tighten” processes
 Key Principles

Key Principles

Focus on Processes that deliver Customer Value

Eliminate waste

Promote flow

POOGI (Process of On Going Improvements)

Mindset of the entire organization, “community of scientists”

Problems and errors offer opportunities for fixing the system

Disciplined methodologies for improvement
 Integrated TOC, Lean,

TOC
Six Sigma Tools

Strategy & Tactic Trees

Financial and Performance Metrics

Focusing tools

Dynamic Buffer Management to manage variations and inter-dependence (CCPM, DBR)

Marketing and Sales Management

Management of supply chain

Thinking Process tools to overcome resistance and get buy in

Lean:

Improves Velocity of flow of patients through systems by implementing full kit concept around
CCR

reduces variations by 6 S, SWF, Set Up Reduction, TPM, Mistake Proofing, Kanban System and
Supplies management

Value Chain Management with one objective to improve Throughput of patients

Staff empowerment through involvement in implementation of lean initiatives

Six Sigma:

Provides Problem Solving tools like Run Charts, Pareto Analysis, Control Charts

DOE, Axiomatic Designs, New Process Designs with DFSS

Capability Analysis

QFD tools for patient expectations

Surveys and Feedback analysis

Change Accelerating Process tools (CAP), Work out tools