We All Fall Down:
Goldratt's Theory of Constraints for Healthcare Systems

by Julie Wright & Russ King

Three little words! Just three words were capable of igniting the wrath of Fran the Fearsome. It was strange, I didn't regret saying them. I don't even remember allowing my mouth to let them out into the open. Sure, they were buzzing round my head like a flatulent bumblebee, but they should have been for my ears only.

Perhaps I had better explain. It was Monday, a day despised by nine-to-fivers around the world and dreaded by the Health Service. The family doctors get it first, the wave of patients dragging themselves in after a weekend of sickness. This delay in seeking medical attention results in many of them being so poorly that the overrun doctors have to admit them to hospital. The result? Their Monday morning rush becomes our afternoon rush, turning our daily crisis meeting into a catastrophe meeting.

We were all crammed into the Trust HQ Board room. It's a long narrow room with a ridiculously thick pile carpet that lurks silently, waiting to trip anyone accustomed to the smooth, polished floors of the corridor. The walls are decorated with expensive portraits of long dead Head Surgeons who view every meeting with justifiable distaste.

A long gleaming, solid wood table dominated the room. Chairs were packed around it and still more were crammed against the walls, but there were still some people standing. Me? I had grabbed my favourite spot, opposite the door with my back to the wall. The perfect spot for a manager who may be trusted to dole out bad news to dangerously ill people, but not to wear suitable clothes to work.

If you glanced in the room, it would have been easy to miss me, Mrs. Average with shoulder length mousy hair, just a mischievous glance away from being plain. I was trying to blend into the background despite the distraction of my horrific uniform of a navy blue synthetic skirt with a matching polka dot blouse. Yeuch! Here in my back-against-the-wall location I can watch the reactions of the others as they wait to hear just how bad it's going to get today.

Opposite me Fran the Fearsome, my boss, the Associate General Manager of Surgery was fulfilling her role as Duty Executive of the Day by starting the meeting. She looked effortlessly chic as she smoothed her elegantly tailored designer jacket and expertly flicked back her long, blonde hair as she started to speak. Not a synthetic polka dot in sight, but then she was senior management.

'Welcome everyone, despite the fact that we have just entered the month of July, we are still suffering from Winter Pressures,' Fran announced and paused. There were groans all round, just like every week I can remember. We spent all winter telling ourselves that the bed crisis would ease in the summer, only to find we have just as many patients now as in the cold months of winter. So what's new? I started to drift off as she waffled on about rocks and hard places, hitting the ground running and rising to meet the challenge. At last, she invited reports from the other members of the meeting and a tired and harassed looking male nurse from the Emergency Department kicked off proceedings.

'I'm afraid that unless five beds are found within the next hour we will have to report five, 24 hour trolley waits to the Department of Health, with another four, 12 hour waiters due before the end of the morning.'

There was a pause as everyone absorbed the depressing news before the ED man continued. 'As it's Monday we're not expecting the flow of admissions to slow down. In fact the usual Monday afternoon rush has been getting worse in recent weeks, not better as had been predicted.'

Next up was Joan, the Head of Nursing. Now here's someone who should be forced to wear a uniform. The poor woman has a severe problem with colour co-ordination and she was currently making a bold statement with an orange blouse and lilac suit. I think she's worked so many early shifts that she dresses in the dark. 'We have regular staff shortages on two thirds of the wards', she announced sternly, 'so please, please, be patient with the agency staff we have employed to fill the gaps.'

The Ambulance Liaison rep was just as critical as he reminded us that they 'cannot and will not' tolerate their ambulances being used as holding bays for patients that cannot be offloaded due to a lack of trolleys in ED. He stressed how this repeated behaviour is seriously impeding the services' ability to respond to 999 calls and threatened to take serious action if the management of the hospital cannot rectify the situation.

The reps from Trauma and Physio did a fine double act by listing all of their current patients along with their possible discharge dates. This was a totally unnecessary level of detail for this meeting; all we really needed to know was the number of patients they intended to discharge today. However, no one tried to stop them, as they seemed to be using this forum to justify their lack of discharges.

Eventually, it was my turn as Manager of the Admissions Department to spill my bad news and I started by gently correcting my ED colleagues. 'As you already know we have five, 24 hour trolley waits in ED with, I think you will find, another six, twelve hour waits to be reported before mid-day.' The ED Reps muttered to each other, but I ploughed on regardless. 'We have thirty routine surgical cases due in today, over two thirds of which are cancer or suspected cancer cases.'

I nodded to the Maxillio Facial Surgery Team, or Max Fax to those in the know. 'One of the cancer cases is a Max Fax patient, whom we cannot cancel.'

I was rewarded with a weak smile from the Max Fax team. 'We have nine routine medical patients due in. Three of these have been rolled from last week because of the lack of beds,' I continued. 'We have four outstanding requests for transfers from other hospitals, two to trauma,' I continued the nodding ritual with the trauma team, 'who have surgeons standing by to operate as soon as we can clear the necessary beds. The other two are waiting for medical beds, both terminal cases that need to be moved to this area to be near their families. 'Day surgery was opened over the weekend and we've already used all 10 beds in there. The teams on day surgery are furious as this goes back on last weeks promise not to use their beds. They are pushing my staff to move the patients off their unit before anyone else is allocated a bed.'

This comment provoked angry muttering from the ED, Ambulance Liaison and the Max Fax and Trauma teams so I was quick to continue. 'We have one critical care bed empty out of a total hospital bed-stock of 500 and the wards have only declared three definite, and eight potential discharges for the day. Leaving aside the possible discharges we need 61 beds to get the hospital back to normality, if it can be called that, and that doesn't account for any further requests for beds from ED.'

I sat down taking in the extra air of despondency my presentation had created. However, a bed temperature of minus 61 is certainly not the worst it's been and no one commented on my report. Fran nodded at me and turned her attention towards the other representatives in the room. As expected they couldn't produce any spare beds and the catastrophe meeting appeared to be drawing to a close without incident. However, I had an inkling that something bad was going to happen. Fran looked different, much too happy and my heart started bumping it's way down my spine the moment she asked the Heads of Departments to stay on for a few minutes.

The number of people in the room quickly reduced to a third of the original number and the remaining 10 of us waited for Fran to continue. 'I appreciate that the Monday meeting is not the customary place to announce such a major new project, but we concluded that the bed crisis was so acute that we could not afford to hang fire until the next scheduled monthly meeting,' Fran announced. 'I anticipate that my announcement today will encourage us to push the envelope and conclusively kick these problems firmly into touch. From next weekend, we will have a new team managing the hospital's beds. They will be called the Clinical Bed Management Team and they will be made up of Senior Nursing Staff.'

Bzzzzzzzz! Those three little words were already forming in my harassed little brain. Joan as Head of Nursing glowed in her lilac bloody suit and quickly scanned the room for a reaction. She didn't get what she expected as everyone was staring at me, waiting for my reaction. I looked down at the table, unable to meet their gaze, my head buzzing furiously.

'We all know the recent inspection by the Department of Health reported that we are working at a dangerously high capacity,' Fran continued. 'A major incident would leave us in dire straits. Their report demonstrated that we would struggle to get patients in and out of the hospital and it is for this reason that the board has decided to appoint a new team to tackle the problem.' Bzzzzzzzzz!

'Does anyone have any comments?'

Everyone in the room was looking at me, taking in my scowling face. The words were buzzing relentlessly inside my head and somehow I heard myself take a deep breath and quietly say. 'I don't understand.'

As uncomfortable silences go it wasn't the worst I've never heard. It was shorter than the time I called Mum from the States to tell her I'd just become engaged to Max. That lasted at least six seconds and was followed by a thud as Mum's backside landed on a chair. This one lasted about half the time, but there were no congratulations for me after it. The other reps looked embarrassed and Fran, well she looked as fearsome as I have ever seen her. Finally, she broke the silence. 'Details of the project will be emailed to you before the close of play today. Thank you for your time and Beth, please, will you stay for a while?'

I had to calm myself down, I pulled out a half written shopping list and started to jot down random items. Carrots, potatoes…I could hear the other people leaving, there were a few muttered words of congratulations to Joan. Onions, toothpaste, pizza…

I could hear Fran tidying her folder. Frozen peas, toilet cleaner, razor blades… It was just her and me. I looked up slowly to meet her steely gaze. We stared in silence for a few seconds, there was no way I was going to break it. I was boiling inside, the carrots and frozen peas hadn't helped. All I could think of were the razor blades. Eventually Fran decided to speak.

'Beth, Beth, Beth.' I tried to ignore the sickening maternal tone to her voice.

'You must have known something had to be done. You must see this is the best solution for everyone.'

She was obviously expecting a response from me, but I was on fire with a rage that I was determined to keep locked in. After another chasm of a pause, Fran continued, her voice sharper than a fresh hypodermic needle.

'This just will not be tolerated. Your position hasn't changed, you will be expected to step up to the mark and run with this project. The board are depending on you. I have told them you will, but with your current attitude I am beginning to doubt your ability to be a team player.'

I sensed that my silence was really getting under Fran's skin. I kept simmering quietly and restricted myself to looking at her with contempt.

'You have worked for me for five years and I can honestly say that your attitude has shown a marked deterioration during that time. You are developing a reputation for being uncooperative, at times downright obstructive.' Another pause, but I wasn't going to say a word.

'You must realise that this attitude will land you in trouble very soon. You know you will never get promoted if you keep this up! What do you have to say for yourself?'

I decided it was time to leave, I quietly picked up my file, checked my bleep that had silently gone off eight times during the meeting and walked towards the door.
Finally, I turned to Fran. 'I shouldn't have said, "I don't understand",' I said before pausing to wonder if I should really continue. A smirk crept across the Fearsome One's face so I drove the insult home. 'What I should have said was, You don't understand.' I turned sharply and strutted out of the room, leaving a stunned and very angry Fran.

Copyright © 2006 Julie Wright and Russ King