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We All Fall Down: Goldratt's Theory of Constraints for Healthcare Systems
http://www.100md.com 《新英格兰医药杂志》
     Some things are universal. Health care systems do not work optimally, especially in hospitals — regardless of whether they are academic or community hospitals. Managing throughput is a challenge, resources are constrained, the number of beds is often limited, and patients experience long delays in the emergency department while waiting for beds. Most institutions have tried many solutions without sustained improvement. Clinicians and managers blame each other and act to protect their own turf. Business consultants appear, and they suggest further changes, but their "tweaks" provide only temporary relief.

    These undesirable events are not unique to medicine; they occur in abundance in other professions and industries. During the past two decades, an approach dubbed the "theory of constraints" has grown in popularity and success in industry. This approach began with Eliyahu Goldratt's particularly readable "business novel" entitled The Goal, which is currently in its third edition (North River Press, 2004). Several related books have been published since then. The newest book in that array, We All Fall Down, extends the principles and analytic approaches of the theory of constraints to health care systems. The story is set in a mid-sized academic hospital in the United Kingdom, and the characters and their foibles are so familiar as to be both comforting and frightening.

    Coauthor Julie Wright, an adherent of Goldratt's approach, directed a hospital admissions department and then managed an after-hours service that provided primary care to half a million people in Britain's National Health Service. Coauthor Russ King is a freelance writer who tries to smuggle humor into science. Together they identify the core problem in the hospital; that is, the inability of the system and its managers to solicit and integrate the knowledge and experience of front-line workers (physicians, nurses, and support staff) and to shape and establish adequate "buy-in" for quality improvement plans. They also consider the inefficiencies created when patients are located on many different floors throughout the hospital; this arrangement makes it impossible for physicians to see all their patients in a timely fashion. Although the authors consider the inefficiencies (e.g., extra admissions) produced when less experienced physicians compose the staff of the emergency department, they do not consider the effect of tighter supervision on the education of young physicians. The authors describe the limitations of manual administration systems that track the flow of patients throughout the hospital, and they hypothesize that posting information about patient flow on an electronic "bed board," akin to a hotel reservation system, will improve throughput. The familiarity — or perhaps the universality — of these problems (or undesirable effects) to academic physicians in the United States leads me to believe that the authors' analysis (or at the very least, their approach) is probably widely applicable.

    Aside from important insights about the hospital setting, the book briefly introduces many of the tools associated with the theory of constraints. It provides a useful review for physicians and managers who may have seen these tools before, but the descriptions are quite telegraphic and not sufficiently detailed to allow a novice to apply them. However, the book might motivate practitioners and managers to approach Goldratt's previous business novels such as The Goal and It's Not Luck (North River Press, 1994), or even Lisa Scheinkopf's Thinking for a Change: Putting the TOC Thinking Processes to Use (Boca Raton, Fla.: CRC Press, 1999) and H. William Dettmer's Breaking the Constraints to World Class Performance (New York: McGraw-Hill, 1998). Wright and King's book provides useful approaches to managing change and overcoming resistance to change. It also offers a guide to the identification and management of bottlenecks or constraints to patient flow. In medicine, as in other environments, one core problem is variation. Advocates of "total quality improvement" and the "six sigma" approach try to stamp out variation, whereas advocates of the theory of constraints recognize that variation cannot always be eliminated. Rather, good physicians and administrators should be able to manage variation. Advocates of the theory of constraints argue for establishing and communicating a common goal within a system and developing measurements that support progress toward that goal in all parts of the system.

    We All Fall Down should be a respected addition to the libraries of clinicians who practice in a health care system and of managers of clinical enterprises.

    Stephen G. Pauker, M.D.

    Tufts–New England Medical Center

    Boston, MA 02111

    spauker@tufts-nemc.org(By Julie Wright and Russ )