Leadership Lessons Learned From Improving Flow In Hospital Settings using Theory of Constraints
Dr. Chris Strear
Director, Patient Flow, Northwest Acute Care Specialists
I'm at Dr. Chris a medical doctor about three years ago at a Starbucks, not so far from here. When we talked about the theory of constraints, as it applies to a healthcare setting, I was so delighted that he was interested in writing a book and even more delighted that it was about his real world experiences, applying theory of constraints to massively increase flow, not just in an emergency department, but throughout the entire hospital. This was at a time when my dad had just suffered another stroke. And I was so grateful for the advice that he gave me at a time when I really needed help understanding how to navigate an extremely complicated healthcare system. He has since published his amazing book, smashed the ball neck, fixing patient flow for better care and a better bottom line. He will soon be serving as a chief medical officer at Columbia Memorial, and he has some amazing observations and lessons learned that I think is applicable to every technology leader. Here's Dr. .
Hi there. As Jean said, my name's Chris , I'm an emergency physician in Portland, Oregon. I've been an emergency physician here for about 19 years. It was my first job out of residency. I remember, I think I was probably practicing for a couple of years and I was starting to get an itch for what else is there that I can do besides seeing patients, um, I was working a pediatric shift with a resident and it was a slow shift and it turned out that while he was getting his MD degree, he also was getting an MBA. And I was asking him about business. I told him that I was thinking about wanting to learn more about the business aspects of healthcare, or maybe just business in general. And he suggested that I read a book called the goal. Well, I read it and it's no exaggeration to say that this book changed my life.
Even though the book is about a manufacturing plant. Every page I found aha moments about improving healthcare patient flow. And I probably read it three or four times one right after the other. And each time I found more and more interest in more and more information in the book serendipitously, a couple of years later, I had a chance to put what I learned to use. Now I work in a level one trauma center. It's an urban hospital. It's probably the closest thing that Portland has to a county hospital. We see a lot of trauma. We see a lot of very sick people. We see more methamphetamine than I ever thought existed. And around two seven, our hospital was struggling. We had unbelievable problems with flow. We were boarding patients in the emergency department for hours and hours, and sometimes days while they waited for an inpatient bed to become available, our hospital was so crowded and flow was so backed up that our emergency department was on ambulance diversion for 60 hours a month.
On average. Now that means that for 60 hours a month, our emergency department was closed to the sickest patients in our community. One month we hit over 200 hours of diversion. It was horrible. We couldn't keep nurses. It was such a hard place to work that nurses would quit. And we relied on temporary nurses on agencies for, for placing nurses or traveler nurses to fill in the gaps in staffing. And for the most part, these nurses weren't experienced enough to work in the kind of an emergency setting where we practiced and it felt dangerous to come to work every day. It felt dangerous to take care of patients. We were just waiting around for something bad to happen. The president of our hospital recognized how bad things were and she put together a committee for flow. And I was lucky enough to be on that committee.
And in fact, the sum total of my experience was reading the goal. I had read one book, but that was one more book than anybody else in the hospital he read. And so I became the defacto expert and I ended up being the director of patient flow. It was transformative within a year. We had basically eliminated ambulance diversion. We went from 60 hours a month to 45 minutes a month. We improved the length of stay of all of our admitted patients in the hospital. Um, we shortened the time patient spent in the emergency department. We, um, we virtually eliminated the patients who left the department without being seen because the weights were too long. And we did all of this in a time when we had record volumes, record ambulance traffic and record admissions, it was amazing. We took better care of patients. It was safer and it felt so much easier to take care of patients.
It was such an amazing turnaround. In fact, that we were able to stop hiring temporary nurses. And we were able to fill our staff completely with dedicated emergency nurses who are qualified to work there. In fact, our department became the number one place for emergency nurses to want to work in the Portland Vancouver area. Honestly, I had never been a part of anything that amazing before, and, and I haven't been since we made patient care better for tens of thousands of patients. And we made life better for hundreds of healthcare workers in our hospital. It was amazing. A few years later, the president of our hospital was replaced and the new president came in and didn't see that there was any flow issue. And shortly after she started her position, she eliminated the director's position for flow. Now it's not that I was particularly smart or particularly gifted.
What I was was the point person for flow. I was the one whose job it was to keep an eye on things. And when she eliminated that position, things devolved and all of the gains that we had made over the next few years slowly eroded. The last time I looked at our data was a couple of years ago and our ambulance diversion time had gone all the way back up to 60 hours. We had lost everything we had gained. So what's the difference. What was the difference between 2007 when the president of the hospital knew we were in trouble and did something about it in 2010, with a new president, my role changed over the next couple of years from being the director of patient flow at my hospital to being the director of patient flow for the system. And in that role, I was a kind of an internal consultant.
I would sit on Flo committees as an advisor at the various other hospitals within our system. And what was interesting is before I started with each hospital, I would meet with the hospital leader and the person who was in charge of the flow committee. And within probably five minutes, I could tell which hospitals were going to be successful and which hospitals weren't and without fail, the ones that I had a good feeling about did great. They made huge improvements in their flow and the ones that I was a little worried about really at the end of their flow work, they had nothing to show for it. What was the difference? How come some of them killed it. And some of them did nothing of substance for improving their flow. So honestly, flow has never been more important than it has recently with COVID. COVID was kind of interesting for an emergency physician on the one hand for a lot of us, it was business.
As usual. I came to work every day. I saw patients. I saw all the other people that I work with, who really are the people that I see most often day in and day out under normal circumstances. I would go home after shift, watch a lot of TV. I'd eat a lot of food that was bad for me socially. COVID didn't have a huge impact on my day to day routine. In fact, probably the biggest impact it had is I discovered food delivery services and gained a lot of weight because of it. At the same time, COVID was hard at work. I was lucky in Oregon. We didn't get hit too hard with COVID cases, but for the first time in my career, every day I went to work, I genuinely felt like my life was in danger. I genuinely felt like I could be exposed to someone I could get COVID and I could die.
And it was frightening. After years of procrastinating, I finally got the kick in the pants to get my willing in order. I didn't get to see my kids for a year because of COVID. And that was really hard from a flow standpoint. What really kept me up at night was when COVID first hit, our volumes were way down. There were days where instead of seeing 20 or 25 patients in a shift, I would only see a few patients in a shift and the hospital was empty. I remember my very first shift when COVID was a thing, there were maybe three people in our whole emergency department, three patients. I don't think it had ever been that slow in, in all the years, I had been working here. One of my three patients was on a ventilator. Now, keep in mind the, ER, it was dead.
There was nobody there. The hospital empty. If ever there was a time that we could have moved patients from one unit to the next quickly, if ever there was a time that flow was a non-issue. It should have been then. And yet it took six hours for them to move the patient from the emergency department up into our ICU. And I remember thinking, my God, this is one patient in an empty hospital and it took six hours. What's going to happen when COVID hits us. What's going to happen when we're genuinely overwhelmed with dying patients. If we can't move one patient what's going to happen when the entire department is filled with patients on ventilators. And that's what really scared me a short while ago, Jean invited me to participate on a COVID vaccination, uh, study. And what we're looking at is we're looking at different, uh, vaccination clinics, large, small public private.
And we're trying to understand why some of these clinics did an amazing job. And some of them really struggled now where we live. There's a mass vaccination clinic and it's a joint effort that was set up between four local healthcare systems. And my hospital, my healthcare system was one of them and Jean and I got to meet with the COO of my hospital system, who was one of the leads and developing this max vaccination site. And it was amazing in a month or two, they went from being able to deliver a couple of hundred vaccinations a day to almost 8,000. It was incredible. Imagine a clinic, the size of a couple of football fields with hundreds of people working in concert to deliver as many vaccines as they could.
At the end of the tour that we had, I asked the COO how it was that they were able to be so incredibly successful. They were able to start from scratch and build something so phenomenal in such a short period of time. Now keep in mind the same people in the same health field, working with the same other people, um, in the vaccine clinic, they were able to go from zero to 60 in nothing flat, but when you take these same people and you put them in my hospital or in the other hospitals, in my healthcare system, and you ask them to do the same thing, they couldn't absolutely couldn't, what's the difference? How come the same team in the same, in the same profession, with the same mission of improving health for patients and their community, how come they were able to do such a phenomenal job in the clinic and really not at all in the health, uh, in the health system, in the hospitals, what's the difference.
Um, constraint management theory of constraint, the operational methodology that I learned from reading the goal, as I said, had a profound influence on me. It has given me so much, it allowed me to be a part of improving the health for tens of thousands of people. As I said before, um, it had such a profound effect on me that I actually wrote a book, applying constraint management, applying the theory of constraints to, uh, patient flow through healthcare systems. And the book is called smash, the bottleneck. And this was a tremendous experience and hopefully it'll help teach what we learned to other healthcare systems that are struggling with flow. And there are a lot of them out there, but it was kind of a double-edged sword, right? Because now I see not just how the health care system should work, but I also see how it does work.
And it's hard. It's hard to look at a system that's broken and not be able to do something about it. What constraint management has allowed me to do is it's kind of taken me out of the matrix. I see things differently. Now I'll go into a shift in the emergency department and I'll look at our track board that tells us how many patients we have and where they are in the department and who hasn't been seen. And now within seconds, I'll be able to tell if it's a good day or a bad day, I will be able to change it. I'll just be able to recognize it. And after years of more and more bad days, I can't do it anymore. I can't go to work as just an ER doctor and not be able to do a better job, taking care of my patients and not be able to do a better job for reasons that are completely out of my control.
And so I'm leaving my job as an emergency physician, and I'm going to become the chief medical officer of a critical access hospital on the Oregon coast here, where I hope I can take some of the lessons that I've learned, not just about flow, but about leadership and apply them to my new hospital. And hopefully I'll do right by them. So I asked a bunch of times, what's the difference. And in the work I did in flow, I don't have all the answers, but I've seen some trends. I've seen some recurrent themes. And so what's the difference?
Well, flow needs to be important to leaders, not just in words, but in deeds, they need to walk the walk and not just talk the talk. And a lot of them didn't do that. Part of that is they need to create the bandwidth. Now, the hospital leaders, aren't going to be the ones that are actually going to be making the changes day to day. What they have to do is they have to allow the people who are going to be making those changes to have enough room on their plate, to put in the work. If a nurse manager, for instance, has 15 projects, 15 committee meetings that they have to go to day in and day out, and the leader comes along and says, flow's important, but now flows their 16th task and the 16th meeting that they have to go to really, it doesn't say that it's important.
All it says is it's, it's 16th most important. And then there's managers that aren't going to have time to put in for the 16th project. Leaders need to figure out what really is important and what can wait, what can take a back burner and then take an active role in clearing. Some of that work off of people's plates so that they can do a job and not just makes those people who have to do the work more effective, but it conveys to them in a very real, tangible, palpable sense that this new project flow is the most important task. You have to break down silos. You're looking at flow through a system. You're not looking at flow on an inpatient unit or flow just in the emergency department, because each of these departments, when, when taken individually, they have competing interests. When you move a patient out of the emergency department and onto an inpatient unit, you're creating work for the inpatient unit, you incentivize people differently throughout the hospital, um, when you're discussing how to make flow better.
And somebody says, no, it can't just stop at that. No, can't be the final word I heard time and time again, we can't do that because that's not how we've done things. And that's ridiculous. Noah's okay. As long as it's followed up with another idea to try, because if I have a lousy idea, but it's the only idea out there, then you know what my lousy idea is, the best idea we got going. And so that's the one we try leaders need to make sure that they're measuring things correctly and that they're, they're rewarding things thoughtfully. And, and what do I mean by that? Well, part of silos in a hospital setting is that a manager for a particular department is often measured on how things go just in that department. And they're rewarded accordingly people behave based on how they're measured and how they're rewarded.
And so if improving flow in the emergency department is what's right for patients and what's right for the hospital system, but it may shift burden onto another unit. And that other unit then falls off in their metrics. That should be okay because flow through the hospital is improved, who cares about flow through an individual unit. So make sure that what you're measuring is commensurate with what your overall goals are and make sure people are rewarded appropriately. And they're not unfairly penalized for improving flow through the system, but maybe not so much through their own domain, through their own a unit.
And again, you need to think about the system, not about the department, and then finally how we've set things up. That's all artificial. That's a constraint. It's not a natural law of physics. Keep that in mind because so much resistance comes from the uncertainty of doing something differently. And there's this mindset often that because we haven't done something a certain way before it can't be done, but again, we've made all of this stuff up. How, of how a body responds to a treatment that's not artificial, that that is kind of a natural law, but where you put a patient who's in charge of them, how you move a patient from one unit to another, we all just made that up and then perpetuated it. That's all negotiable.
So Jean said that I should finish my talk with an ask. And really my ask is I want collaborators. I want people to help me improve flow through healthcare systems. I want to help other people. If they're working in healthcare systems help improve their flow. And I also want to collaborate on domains outside of healthcare, outside of my comfort zone, pretty much everything that I've learned can be traced back to the goal. And the goal on the surface had absolutely nothing to do with healthcare. And I just, I got so much out of having to learn the application myself. I think all the major breakthroughs are as likely to come outside of healthcare. I'm sorry, all the major breakthroughs within the healthcare system or is likely to come outside of healthcare. And vice-a-versa, this is what's exciting for me. This is what gets me up in the morning. And I would love to work with anyone who thinks they have a project that would be interesting. And that my way of seeing things might be helpful. Thank you so much for the opportunity to speak with you.
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