Exploring orthopedic care process for identification of key factors that influence

care design: Theory of Constraints approach

2.1 Introduction

Care processes are often viewed as poorly designed and characterized by unnecessary
duplication of services, long waiting times and delays (Heuvel et al., 2006). By learning to see
our processes in a complete view with the problems clearly identified, we can then take the
next step of improving them (Fillingham, 2007). One way used to improve efficiency in
healthcare delivery is to search for the root causes of the failing systems and curing it at its
sources (Machado and Leitner, 2010).Identifying bottlenecks steps in the process is the
starting point for improvements initiatives in the patient care process. Literature documents
that location of healthcare bottlenecks is not apparent and a rigorous analysis would make an
imperative contribution (Young et al., 2004).

Radical thinking about the design of industrial processes over the last century has
significantly improved the efficiency of manufacturing and services. Similar approaches to
deliver highly efficiency healthcare could be tremendously valuable (Young et al 2004).
Surprisingly, the healthcare industry has been extremely slow to adopt these strategies such as
theory of constraints which is widely used by manufacturing industries and service (Breen et
al., 2002). This study seeks to fill that gap by showing how theory of constraints can be used
to identify bottlenecks in care processes. Theory of constraints helps to recognize the
significance and influence of single steps in the entire process and points out area of
improvements. Put it differently it helps to identify specific bottlenecks in the care process for
each step.

This study seeks to fill this research gap by addressing two interrelated research questions:
First, how a healthcare organization could identify its bottlenecks in the patient care process
that leads to process inefficiencies? Second, what are the potential gains that could be
obtained if these bottlenecks are eliminated? The identification of bottlenecks is made by
linear regression of Cobb Douglass production function and theory of constraints analysis and
followed by demonstration of possible gains if those constraints are eliminated. To the best
knowledge of authors this is the first study to use Cobb Douglas production function and
theory of constraint for demonstration of identification of bottlenecks in healthcare processes.
 2. Theory of Constraints.
2.1 The foundational keystones of TOC

“There is a famous story about a gentile who approached the two great Rabbis of the time
and asked each, ‘Can you teach me all of the Judaism in the time I can stand on one leg?’

The first Rabbi chased him out of the house, however the second Rabbi answered: ‘Don’t do
unto others, what you don’t want done to you. This is all of Judaism, the rest is just
derivatives. Go and learn.’ ‘Can we do the same; can we condense all of the TOC into one
sentence? I think that it is possible to condense it into a single word –focus” (Goldratt 2010,
p. 3).

2.2 Focus

Focusing on critical issues in the systems has a great positive impact on its performance.
According to Goldratt (2010, p.3), ‘focusing on everything is a synonymous of not focusing
on anything’. This section presents the foundation of theory of constraints and explains why
focus is so important and the rest of TOC is just derivatives.

Mismatch between demand and resources raises several issues or problems, which if
eliminated or improved can lead to positive impact on the system performance. For several
decades the Pareto principle (80/20 rule) helped to distinguish the issues that have a great
effect than others, by demonstrating that 80% of the effects come from 20%of the causes. E.g.
80% of healthcare clinical problems come from 20% of the causes, or 80% of all patients
complaints arises from 20% of system or organization problems. In practice if the small
number of root causes were eliminated then 80% problems in the system or process will be
eliminated. Hence to maximize the utilization of the limited resources we must focus on the
issues which have the great impact on our systems.

Interestingly Pareto rule cannot perform well in the system with interdependent events
associated with variability as noted by Pareto himself. In practice systems consists of
interdependent events associated with high variability, and the performance of these systems
is determined by small number of events. This is also supported by Goldratt as he highlighted
that approximately only 0.1 percent of the elements determine 99.99 percent of the system
performance. From theory of constraints perspective these few critical leverage are termed as
constraints (Goldratt, 2010).
TOC deduces that ‘every system must have at least one constraints’ (Rahman 1998). Meaning
behind this assumption is that, a system without any constraints would have unlimited
performance. Hence a constraint is defined as “anything that limits a system from achieving
higher performance versus its goal” (Goldratt, 1988, P.453). Given that constraints is a major
determinant of the system performance, devoting more effort on improving the constraint
could lead to better performance of the entire system (Rahman, 1998). Also, “since there are
few constraints in the system, management of these few key points allows for effective
control of the entire system” (Watson et al., 2007). In practice environment there are very few
constraints that limit the performance of systems (Goldratt and Cox 1984; Goldratt 1990b).

2.3 TOC and system view

TOC views all organizations as a series of interdependent events or processes where the
performance of one event depends on the preceding events. Therefore the structure of the
system interdependent events or processes is the major determinant of its performance (Breen
et al., 2002). In healthcare for example delay of lab tests results limits the examination
process at the clinic. A good example of interdependent events is elaborated by (Breen et al.,
2002) using a physician office or clinic.

The main steps could include, patient checking in at the front desk, delivering relevant
information, taken by a nurse for preliminary checkup, meeting physician, meeting the nurse
for any prescribed vaccination processes, and checking out. In this process physician is the
major determinant of the output, hence the system can only process eight patients within the
scheduled time. In case of any interruption which can result into physician to lower
throughput may be to five patients, the output of the entire system will be limited to five
patients regardless of how many patients are processed by preceding steps. This example
follows one of the focal point of TOC: “an hour lost on the bottleneck is an hour lost on the
entire system” (Goldratt 2010, P.4).

13 17 13
14
8
Check in Screening Vaccination Check out 8
Physician

Constraint

Figure 1: A simple system illustrated as a chain. Constraint is the major determinant of system throughput no matter the rate
of other resources at other events. (Adapted from Breen et al., 2002)
 2.31 Statistical Fluctuation and Dependent events

In practice statistical fluctuations occurs for number of reasons. For example some patients
may arrive early while some arrive late, or some patients spent more time at registration point
of physicians' offices. In systems of dependents events the occurrence of statistical fluctuation
or variation has a great impact on further down the chain. These may affect the performance
of the system if time lags accumulate and increase further down the chain. This will make the
constraint to wait for the work or be limited to pass it to the next event. Any time lost by the
constraint due to idleness or not being able to perform the work is the time lost for the entire
system. Put it differently any patient lost at the constraint, is the patient lost in the entire
system. This is just the start of the problem (Breen et al., 2002; Gupta and Kline 2008).

2.4 Types of Constraints

Literature documents three types of constraints: resource constraints, policy constraints and
market constraints (Watson et al., 2007). This study will focus on the resource constraints or
bottleneck, which is defined as “the most heavily utilized resource such that it cannot perform
all its assigned tasks” (Ronen et al., 2006 p.51). Resource constraints constitute other different
forms of constraints which are: Shortage of critical resource, Permanent bottlenecks, Peak
time resource constraints, Seasonal resource constraint and discrete event of resource
constrain (Ronen et al., 2006 P 54-56).

Critical resource becomes a bottleneck when the flowing demand exceeds its capacity.
Following the traditional rule of breaking the constraints by adding more capacity may be
difficult in short term basis due to associated cost such as capital investment. A permanent
bottlenecks refers to a situation where adding more capacity is not possible e.g. a unique skill
of a particular resource in the system. On the other hand peak time resource constraints is a
temporary constraints occurring mostly during peak hours, in which after that period it’s a
non-constraint. A seasonal resource constraint refers to the situation where demand varies
seasonally. And lastly the main cause of the occurrence of discrete events of resource
constraint is unforeseen events such as natural calamities which might cause crowding of
emergency department (Ronen et al., 2006).

2.5 COMPONENTS OF TOC

TOC has three major components: First a philosophy which is the foundation of the working
principles of TOC. This is often known as a TOC’s ‘logistics paradigm’ and comprises of five
steps for ongoing improvement, the drum-buffer-rope (DBR) scheduling methodology and the
buffer information management system (Rahman, 2002). Second is performance measurement
which arose after realizing that traditional cost accounting measurements are only suitable for
external purposes such as taxation at the executive level. They are not suitable for internal
purposes at the medium to lower management level.

TOC proposes a simplified set of operational measures which are throughput, inventory and
operating expenses. (Gupta and Kline 2008; Lockamy &Spencer 1998). Thinking processes
is the last component of TOC, sometimes referred s TOC problem solving methodology. TOC
suggest that many organization face policy constraints in their operation. These constraints
can be addressed by applying generic approach known as thinking process. It I believed by
experts that TOC thinking process has the great impact to the business (Rahman 2002;
Goldratt 1990, 1994).

2.51 Logistics paradigm component

Process of ongoing Improvement

The central principal of TOC provides a focus for a continuous improvement process. The
principal consist of Five Focusing Steps (5FS), the process used to implement TOC concepts.
Ronen &Spector (1992), and Coman &Ronen (1994; 1995), later enhanced and modified these
five steps into seven steps currently known as Process of OnGoing Improvement (POOGI)
where two more prerequisite steps are added. The first added step focuses on defining the
system under investigation and its purpose. After defining the system the second step is to
define measurements that suit the system to that purpose (Watson et al., 2007; Goldratt1988;
1990b). The steps of POOGI are illustrated in Figure 2

Step 1: Define the system’s goal

Systems goal represents the key reason for its existence. Clear definition of system goal is of
critical importance as it guides every decision and action in the organization. The goal is
something organization struggles to achieve without any success (Ronen et al 2006 p.48). For
example in healthcare industry, minimizing patient waiting time and maximizing throughput
is among the key goals in which healthcare actors strives to achieve.
Step 2: Global performance measures determination

Having defined the system’s goal, its critical importance to define measurements that align
the system to that goal (Watson et al., 2007). For easy determination of whether the actor’s
decision and actions supports goal achievement, global performance measures should be
applied. This is due to the fact that global performance measure helps to translate goals into
measurable units (Ronen et al., 2007).

Step 3: Identify the constraint

Constraint identification is the first step of the 5FS. It is important to identify system
constraints and also necessary to prioritize them according to their effect on the organization
goal (Rahman, 2002). Load analysis is one of the approach used to identify system constraint
through examination of capacity utilization of system resources (Ronen et al., 2006). It is easy
to identify constraints in manufacturing industries by piles of inventories waiting to be
processed by the next activity. In service sector waiting times are the key indicator of
constraints, in which the activity with highest waiting time is considered as system constraint
(Gupta and Kline, 2009). Literature stipulates that supportive staff are seen as the main
constraints in healthcare organization (In real sense they are not constraints). Most of cost
cutting steps focus on reducing clerical staff. This leads to key providers to spend more time
in clerical work and spend less time in their core activities. In fact physicians are the
constraints since they are expensive and difficult to create their capacity (Breen et al., 2002).

Step 4: Exploit the system’s constraint (s).

System constraint exploitation implies maximizing the performance of the system goal by
making most of the current resource. This can be in the form of maximizing the utilization of
system constraints by making sure that always it has a work to process. In healthcare context
for example delegating some activities previously performed by physicians can enable
physician to focus on patient and maximizing throughput. Given that, the moment lost on the
constraint is the moment of throughput lost for the entire system, constraints should therefore
focus on items whose contribution to the system are greatest when compared to the time
utilized by the constraint. The policy and dummy constraint should be eliminated not
exploited. (Ronen et al., 2006; Breen et al., 2002).
Step 5: Subordinate everything else to the above decision

After deciding on how the system constraint will be exploited it’s of critical importance to
develop strategies for subordination. Strategies should focus on how other resources and non-
constraint resource will operate in order to support the maximum use of the constraint for high
system throughput. For example in healthcare, every step in the clinical treatment process
should be designed to maximize the utilization of physician in order to achieve the required
throughput.

Step 6: Elevate the system Constraint

This step is contrary to step 2 which does not involve any significant investment in order to
maximize throughput, this step instead requires investment in the constraint. A good example
in this step could be hiring or employing another physicians’ in order to meet patient demand.

Step 7: If after the above steps the constraints shifts, go back to step 1. Do not allow inertia to
become system constraint. Additionally any optimal solution tends to change as the system
environment changes. TOC is a continuous improvement process and in reality no policy
remains appropriate in every environment.

Figure 2: TOC seven step methodology (POOGI) (Adapted from Coman and Ronen (1995, p.1406))

2.52 The TOC performance measurement systems components

Traditional financial statements such as Income statements and balance sheet are evaluated,
and financial measures such as Cash Flows (CF), Return On Investment (ROI) and Net Profit
(NP) are used to determine on how the organization is achieving its main goal. These are
useful for external use only e.g. taxation issues. They are not suitable for internal use for
operational managers in which the major decisions are focusing on achieving profitability
goal (Gupta and Kline 2008).

TOC offers three simplified set of performance measures: Throughput, Inventory and
Operating expense. These measures help the operating managers to determine if individual
decision and actions helps to fulfill the overall system performance objective (Goldratt, 1984,
1990). In for profit environments these measures are defined as (Goldratt &Fox 1986,p.29).

Throughput: ‘The rate at which the system generates money through sales’

Inventory: ‘All the money the system invests in purchasing things the system intends to sell’

Operating Expense: ‘All the money the system spends in turning inventory into throughput’

From these definition TOC develops the relationship among global performance measures. If
throughput increases and inventory and operating expense decreases then net profit and vice
versa. Lockamy & Spencer (1998) highlighted how the TOC definition of T, I, and OE differs
from their traditional definition. Based on industry throughput is considered as unit produced
or shipments while, TOC throughput is considered as the net sales, ‘revenue received minus
total variable cost’ (Sullivan et al., 2007 p.47). TOC values inventory (WIP, raw materials,
finished goods) at the cost of raw materials only rather than the cost of raw material plus any
other cost accumulated from every operation (i.e. value added).TOC considers all other cost
as the operating expenses. A good example is overhead which are traditionally allocated to
inventory as it moves through the production process are considered as operating expense.
Ronen et al elaborates that,

“The reason for measuring all inventories in terms of raw materials is that all the conversion
costs are considered fixed operating expenses. This creates convenience and transparency in
calculating and analyzing inventories. For example an increase in the WIP inventory is
obviously not from a change in the way various costs have been loaded, but rather, from a
real increase in quantities. This allows for quick corrective action”

Defining Goal and Performance measurements in health service context

There has been considerable number of debate concerning the definition of goal and
performance measurement as well as the prerequisite steps of POOGI. For the case of for
profit healthcare organization. There is a consensus that the goal of for profit healthcare
organization is consistent with any other business with profit making objectives (e.g. Breen et
al., 2002) - ‘to make money now as well as in the future’ (Goldratt 1990b, p.12). The same
applies to the definition of performance measures; the only different is that WIP is
represented by patients (Breen et al., 2002; Ronen et al., 2006).

In the case of not for profit healthcare organization two main streams of definition of goal and
performance measures has been provided. Outcome based definition (see for example Breen
et al, 2002; Hunink 2001; Sadat 2009). Breen et al., (2002 p.42) defined goal as ‘to provide
quality healthcare to a particular population now and in the future’ , they further defined
throughput performance measure as ‘units of health generated’ Another stream of definition is
based on output. These authors acknowledge that the goal should be something easily
measurable for easy and clear performance measure determination (Ronen et al., 2006).

Some of the output based definitions of the goal for public health service include ‘to treat
more patients, better sooner, both now and in the future’ (Wright 2010, p 958). ‘To maximize
quality medical services provided to its customers, subject to budgetary constraints’ (Ronen
et al., 2006, p.48). Applying the traditional definition of throughput, an output based
definition throughput is considered as patients discharged after receiving care. Inventory can
be patients in the queue waiting to receive care or patients in the waiting lists (PIP). In this
particular study author follows the goal definition as provided by (Wright 2010, p.958), ‘to
treat more patients, better sooner, both now and in the future’.

Author’s interpretation from this definition is that, “to treat more patients” means making
most of the current resources in terms of volume. ‘Better sooner’ means improving patient
flow in the process; put it differently increasing process efficiency. Both now and in the
future, implies focusing on the short term and long term basis.

3 Research setting
3.1 Healthcare delivery system in Tanzania

Public healthcare delivery in Tanzania follows a pyramidal structure. This structure operates
in a referral system divided into three levels with the lower level being dispensaries at which
patient are referred to the health centres and finally to the hospital level. The capacity of
dispensary is up to 10,000 patients, proving only basic treatment such as curative treatment,
maternal and childcare. The capacity of health centre is on attending up to 50,000 patients, it
provides more services than dispensary. A hospital is the highest level, providing more
advanced services depending on its level. The highest level is the referral hospitals which
provide more advanced and specialized services (URT, 2008). Tanzania faces a severe
shortage of healthcare workforce compared to available demand, with the shortage being
more critical at specialist level. This leads to high patients’ waiting lists, patient travelling
long distances to find care and crowded hospital facilities (URT 2014).

3.2 Bugando Hospital as empirical evidence

The hospital studied is Bugando referral hospital, one of the four teaching and consultant
hospitals in Tanzania. It serves primarily the Lake and Western zones of the United Republic
of Tanzania. Bugando hospital is situated along the shores of Lake Victoria in Mwanza City.
This 900-bed hospital has approximately 1000 employees. Bugando hospital is a referral for
tertiary specialist care serving six regions: Mwanza, Tabora, Kigoma, Kagera, Mara and
Shinyanga. Aforementioned hospital serves a population of about 13 million people.

The focus of this study was on orthopaedic clinic. With only four specialised surgeons, this
clinic deals with emergency and elective orthopaedic cases depending on the available
medical equipment. This study focuses mainly on the electives cases. Generally, Bugando
Orthopaedic Clinic was established for referral cases from regional hospitals in the Lake Zone
but due to lack of surgical capacity at lower level healthcare facilities some patients go
directly to this clinic through self-referral, contributing to high demand. The management of
the hospital is looking for efficient ways of accommodating patient demand using the existing
limited resources.

Bugando orthopaedic clinic is so crowded that patients are experiencing high waiting time.
With only four specialists surgeons it is not possible to meet all the patients’ demand who are
referred for specialist care from lower level healthcare facilities within northern part of
Tanzania. This in turn creates high patient waiting lists, which sometimes results into adverse
effect to patients such as, mortality or morbidity.
Another problem is those patients experience multiple visits at the clinic due to follow up of
ancillary services. The major protocol of this clinic is that patient has to meet with surgeon
first before taking any ancillary tests. The patient will take those test only after being ordered
by the surgeon during examination, hence patient has to come back again to surgeon after
obtaining ancillary test results. Meeting surgeons more than once on the same day visits
significantly increases magnitude of waiting time for clinical services since the same patient is
seen more than once on the same day visit.
As any other healthcare facility, the management of this hospital is struggling to improve its
care process so that it can accommodate more patient demand using the existing resources.
Identification of key bottlenecks in the orthopaedic care process could be a good basis for
process improvement initiatives. This study therefore aims at showing on how hospital
organization can identify bottlenecks in the patients care processes and potential gains which
could be obtained if those bottlenecks are handled.

3.3 Process mapping

Before identifying any bottleneck in patient flow, it is important to start with understanding
current patient flow. Orthopaedic care process consists of a sequence of interdependent
activities in which patients' moves through the clinic. First the patient arrives at registration
desk giving out demographic information and any relevant information. The patient is then
routed to orthopaedic clinic and waits until files consisting key information from medical
records arrives at clinical nurse desk. Upon arrival of the file the patient is escorted to the
exam room for examination with surgeons. During examination, a surgeon can order ancillary
tests for relevant patients. Patients with ordered ancillary tests will then go for those tests to
either X-ray or laboratory depending on the test ordered. After having ancillary tests results,
patients bring back their result to the surgeon for further diagnosis. This process is
summarized in figure 3.

Figure 3: Process map of Bugando current orthopaedic clinic flow: Five numbered steps show the multiple visits of
patients to surgeons
 4 Methodology
4.1 Data
We use data from orthopaedic department of Bugando hospital to explore our research
questions. Specifically our study is based on the interviews and observational data from
orthopaedic care process covering the period of three month from June 2012 to August 2012.
635 observations were obtained with 178 out of these observations undergoing the whole
process of care from arrival at the clinic to the discharge at the surgical room.
Our focus was to get important details on the number of care activities at orthopaedic clinic.
Therefore this study focuses on the orthopaedic clinic care process. The observed activities
include, Patient arrival process at the clinic. Patient registration process at medical record,
Patient diagnostic examination at the clinic by surgeons', Diagnostic testing (X-rays) and
Blood work at central laboratory. For each of the listed activities we differentiated between
service time and waiting time. Waiting time represent the idle time patient experienced while
waiting the service to be delivered and it adds no value to the patient. Service time represents
the time that orthopaedic care providers spent with patients.
We hired and trained students at Bugando Catholic University to conduct direct observation
of patient moving through the orthopaedic clinic. These students received a two day
orientation on the purpose and the nature of required study as well as the planned data
collection approach. Data collectors' recorded all the recommended details of patients at each
stage the patient passes. The data collectors documented start and end time of each process
using stop watch and a special form which was prepared for this project. This form included
information on patients’ arrival times, processes times per each patient service station and
number of resources per each service station.

4.2 Methods
The main objective of this paper was to show how healthcare organization could identify
potential bottleneck in the patient care process, and what are potential gains could be obtained
if these bottlenecks are eliminated. The result of interviews and observations was summarized
and contributed to the study with quantitative assessment. Descriptive statistics of variables
and assessment of parametric assumption for Cobb Douglas production function regression
was carried out and this covers multicollinearity, heteroscedasticity and normality.
 4.21 Descriptive data analysis and outliers assessment of variables
In this study, the descriptive statistics was used to describe the characteristics of each variable
in the patient care process. The variables mean, median, standard deviations were computed
after the removal of outliers. Since in healthcare outliers are the major concern for
improvement issues, further descriptive analysis was also performed to find out key
characteristics of these outliers which differentiate them from other patients.
Cases with extreme values in one or two variables are classified as univariate outliers while
on the other hand multivariate outliers are cases with a normal combination of score in two or
more variable (Tabachnick and Fidell, 2007). In this study the examination of extreme
univariate outliers was based on standardized scores. All cases with very large standardized
score (Z score) on one or more variables were considered as outliers based on the
recommended cut off of standardized score of +3. Literature recommends this cut off point
for small sample size while 4 or more is recommended for large sample size (Harrington,
2008). The SPSS standardized score resulted into the removal of 14 cases with a standardized
score of +3.
Furthermore each variable were subject to examination of multiple regression assumption. In
this study the graphical visualization using normality probability plot (Figure 5 appendix 3)
shows that the residuals are normally distributed (Mentler and Vannata, 2005). Plots of
standardized residue score against standardized predicted score using scatter plot which
indicated no signs of increasing or decreasing residuals hence supported the assumption of
heteroscedasticity (Tabachnick and Fidell 2007), (Figure 4 appendix 3). Based on the Pallant
(2011) recommended cut off point of bivariate correlation between independent variables
were all less than 0.7, thus they didn’t indicate any multicollinearity problems (Table 4:
appendix 2).
4.22 Regression of Cobb Douglas production function
There are different forms of functions that can be used to estimate the hospital production
function. These include for example, constant elasticity substitution, log form production and
Cobb Douglas production function. The first two-function face a limitation of considering
variables in general forms which leads to loss of key information in those variables. The
flexible log form creates multicollinearity between variables. To avoid this drawback, this
study opted to use Cobb Douglas production function. The key advantage of Cobb Douglas
production function is that its coefficients indicate production elasticity in relation to the
input. Elasticity explains to what extent a 1% change of variables changes the output. Cobb
Douglas production function is easy to perform and analyzing its results.
 4.231 Empirical specification and estimation procedure
We model the production function of orthopedic care process using the following production
function model:
Length of stay (LOS) = f (labor, capital)
Length of stay is defined as the total time patient spent from arrival at the hospital until
discharged from the clinic. The primary labor inputs are surgeons, nurses, and auxiliary staff
hours used to provide services to patients. The primary capital used in this study are patient
waiting time used waiting for particular service. This is due to the fact that patients used
hospital facilities such as waiting rooms for waiting. Those capital facilities are defined in
terms of patient waiting time. The estimated production function in this study was estimated
as follows:

LOS = β1LnRegW+ β2LnReg+ β3LnMedRec+ β4LnNur+ β5LnFirstW+ β6LnSecondW+

β7LnFirstExam+ β8LnSecondExam+ β9LnLabtestW+ β10Labtest+ β11LnLabresultW + β12
LnXRAY+ β13LnXrayW+β14Gender+ β15Age

Variable description : Length of stay (LOS), Registration waiting time (RegW),

Registration time (Reg), Nurse contact (Nur), First examination waiting time (FirstW),
Second examination waiting time (SecondW), First examination (FirstExam), Second
examination (SecondExam), Lab test waiting time (LabtestW), Labtest (Labtest),Waiting for
lab result (LabresultW), Xray (Xray), Wait for Xray (XrayW).

5 Results analysis

In this paper we used Cobb Douglas production function and theory of constraints to show
how critical bottlenecks can be identified on orthopedic care process. Variables were log
transformed and run on the multiple regressions. In Cobb Douglas production function the
estimates coefficients indicates the length of stay elasticity in relation to the process variables,
meaning that it shows to what extent 1% change of each variable increases the length of stay.
Elasticity measures enhanced the identification of the most influential variables.

5.1 Bottleneck identification process:

Following the seven steps of POOGI the main goal of this clinic is to maximize patient
throughput, while minimizing patient waiting time. The key performance measure is
 patient throughput. The third step which is the first step in the TOC 5S, focuses on the
identification of constraints. Several analyses were performed as shown below.

5.11 Effects of process variables on patient length of stay

It can be noted from the regression model that, coefficients of ten variables are highly
statistically significant with expected positive sign as presented in Table 1. Variables with
high elasticity are considered to have high effect in the process than other variables.

In this clinic the most influential variables are, waiting for lab result, first examination
waiting time, first examination, and second examination waiting, waiting for lab tests, lab
test, and waiting for X-ray. These variables have high elasticity compared to other
variables. This implies that 1% change of these variables could amplify the patient waiting
time, hence leading to overcrowding at the clinic. This gives good insights for where the
bottlenecks can be allocated in this care process.

Table 1: Orthopedic care process production function

Model Coefficients T Sig. Collinearity Statistics
B
Tolerance VIF
1
(Constant) 2,583 14,587 ,000
Registration waiting time ,042 6,744 ,000 ,524 1,907
Registration ,036 2,562 ,011 ,868 1,151
medical record waiting time ,042 8,257 ,000 ,672 1,488
nurse contact time ,006 ,705 ,482 ,944 1,059
First examination waiting time ,082 17,566 ,000 ,761 1,313
First examination ,042 5,836 ,000 ,924 1,082
second examination waiting time ,097 10,483 ,000 ,748 1,337
second examination ,041 3,885 ,000 ,827 1,209
Xraywaitingtime ,080 12,083 ,000 ,506 1,976
Xray ,037 ,905 ,367 ,845 1,184
Waiting for lab test ,078 6,520 ,000 ,803 1,245
Lab tests ,071 2,293 ,023 ,926 1,080
Waiting for lab result ,289 18,098 ,000 ,723 1,384
Patient age -,001 -, 237 ,813 ,868 1,152
Patient gender ,016 2,069 ,040 ,897 1,115
R2 = 0,933 , Adjusted R2 = 0.926 , Durbin –Watson 1.8
F value (136.820): P= 000
 5.12 Variable contribution analysis
Elasticity estimated in Table 1 can be used to assess the contribution of each variable in the
model to the length of stay. An approximate estimate of these contributions can be estimated
by multiplying average production of input factor by its elasticity (Crew and Kleindorfer 1999
P.240). Average production is defined as “the change in the output associated with a one unit
increase in the input, holding all others constant” (Folland et al., 2004 p. 328). Put it
differently it is define as the ratio of total output to the amount of particular input. In this
study the total patient length of stay at the clinic was considered as output, to obtain the
average production of each input factor the total length of stay at the clinic was divided by the
total time patient spent for each input factor. The results are presented in Table 2.
Average production = Y (output)
L (input factor)
Let Y represent the total length of stay at the clinic (output)
L represents the amount of particular amount of input factor (Eeach event waiting time
and service time) (input)
AP Registration waiting time = Y/LregistrationW = 85193/5762 = 14.79,
APRegistration =Y/Lregistration = 85193/2439 = 34.93
All other AP of each variable are calculated using the same procedure.

Contribution of each variable calculation

Variable contribution (CV) = Elasticity of input factor *AP of input factor.
CV Registration waiting time = 0.042 *14.79 =0, 62
CV Registration = 0.036 *34.93 = 1, 26
All other CV of each variable are calculated using the same procedure.

Multiplying the elasticity of each production factor with its average production, the result is
the final production or contribution of each variable, which indicates how much the output
changes, will with a unit increase in the input factor. From Table 2, the highest amount of
final production or contribution belongs to the service time at the clinic which is second
examination and first examination time followed by registration and x-ray time. This gives
good insights that second patient visit at the clinic due to follow up of ancillary service
contributes to the existence of surgeon bottleneck at the clinic.
 Table 2: Average production and final contribution of each input variable.
Total Average Production Variable
contribution (CV)
Elasticity * AP
Registration waiting time 5762 14.79 0,62
Registration 2439 34,93 1,26
Medical record waiting time 5268 16,17 0,68
Nurse contact 780 109,22 0,66
First examination waiting time 9591,5 8.88 0,73
First examination 2789 30,55 1,28
Second examination waiting time 8759 9,73 0,94
Second examination 2293 37,15 1,52
X-raywaitingtime 7053 12,08 0,97
X-ray 2769 30,77 1.14
Waiting for lab test 6738 12,64 0,99
Lab tests 4165 20,45 1,45
Waiting for lab result 26758 3.18 0,92
Patient age 4980 17,11 -0,02
Total clinic length of stay 85193

5.13 Descriptive analysis

Moreover we identified bottlenecks in this care process by using statistical analysis, which
included standard deviation of each variable with its equivalent mean. Resources with high
standard deviation and mean waiting time were considered as bottlenecks. From TOC
philosophy constraints are associated with high queues of customers or patients waiting for
service. In this care process surgeon at the clinic and auxiliary staff at central laboratory
experienced high standard deviation and mean patient waiting time. The result for descriptive
statistics is presented on table 3 in appendix 1.

1. Discussion

This study elaborates on how healthcare organization can identify critical bottlenecks in the
healthcare production process.

The results from estimated coefficients elasticity, demonstrated that waiting for lab test results
has high elasticity than other variables. Based on the simple meaning of coefficient elasticity
it can be argued that, waiting for lab test result has a significant influence in the orthopedic
care process. This indicates that patients spend more time waiting for lab results. From TOC
perspective this can be considered as constraint. However given that central laboratory service
is not an immediate service to orthopedic patients, further process exploration was performed
to find out critical resources, which have great and immediate impact to these patients.

Further analysis using variable contribution analysis in which variable average production is
multiplied by its elasticity demonstrated interesting results. In this analysis second
examination and first examination time at the clinic have high contribution to the clinic length
of stay than other variables. It is also noted that second examination time has a great impact to
patient total length of stay compared to first examination time. This is obvious due to the fact
that second visits leads to three effects in the process. First it increases patient waiting time,
second increases surgeons workload as the same patient is attended twice, and lastly increases
processes variation. The total effect of the second visit is the resulted process inefficiency
associated with inefficiency resource utilization. By increasing process variation it amplifies
patient waiting time in this process. This can be evidenced by the observation done in this
study. It was observed that patient spend more time waiting for examination service at the
clinic. This contributes largely to process inefficiency and inefficiency use of surgeons.

To get more insights as to where exactly can the critical process bottleneck be allocated
utilization analysis was performed. From TOC perspectives constraints is the resource which
is heavily utilized, but also expensive and difficult to expand its capacity (Ronen et al., 2006).
Based on utilization concept in this orthopedic care process we found that, surgeons are the
main bottleneck when compared to other resources on the entire process. These are highly
utilized resources with the current utilization of 92.43%. Utilization is calculated as the ratio
of actual hours used by surgeons to treat patients to the scheduled hours.

Literature stipulates that physicians are the key bottlenecks in the clinical process (Breen et
al., 2002). This argument is in line with our findings and is also supported by the regression
results from Cobb Douglass production function in which first examination and second
examination waiting times has high elasticity. Additionally is also supported by the variable
contribution analysis in which first and second examination time has high contribution to the
clinic length of stay. This indicates that surgeons has always high number of patients queuing
waiting for services and is the major determinant of system throughput. From this quantitative
analysis we can argue that surgeons are the main bottleneck in orthopedic care process.
In this clinic it was found that 0.1 issues determine 99.99 percent of process performance.
State it differently, surgeons’ constraint determines 99.99 percent of the entire process
performance. Furthermore, analysis of outliers’ patients revealed interesting information.
First of all outliers constitute 8% of the observed patients used for this study. It was found that
these are the patients who spent more than one hour at the clinic and laboratory services. Put
it differently these are the patients who wait longer to receive service in the orthopedic clinic
process. Using 80/20 rule it can be argued that 80 percent of clinic crowding problems are
faced by 20 percent of patients in the orthopedic care process. To improve this clinic
operation environment, hospital management should focus on improving surgeons' capacity
through process efficiency improvement.

2. Exploitation of critical resource: developing proposition

After identification of the constraints the next step is to exploit it. Exploitation can be done in
two dimensions: Efficiency and effectiveness. Efficiency refers to maximizing the utilization
of the constraints while effectiveness refers to working on the preferred items (Ronen et al
2006).

Proposition 1: Transfer activities related to ancillary tests from surgeons to downstream staff.

Given the severe shortage of surgeons in this clinic, the constraint can be exploited by
delegating some of the activities performed by surgeons to downstream staffs. This can be for
example transferring activities related to ordering of ancillary tests. This will enable surgeons
to focus on the key issues of patient treatments.

Proposition 2: Apply strategies such as lean and agile in different variables to eliminate non-
value adding steps and increase flexibility in the care process.

Applying lean and agile strategies on relevant variables can help on removing non-value
adding steps and increase flexibility in areas with high process variation.

3. Subordinate the constraint

To avoid statistical fluctuation in the orthopedic care process, clinic managers can apply
strategies such as lean and agile in relevant variables to make sure that surgeon’s utilization is
enhanced and maximized. Simulation methodology can be used in this redesign.
 4. Potential gains

From the average production analysis it showed that second examination has a great influence
to the total length of stay in the orthopedic care process. The effect of second examination can
be seen in three dimensions: First it increases surgeons’ workload by making the same patient
being attended twice on the same day visit. Second it increases patient waiting time as patient
has to join surgeon queue twice on the same day visit. Third it increases process variation by
increasing examination time and waiting time standard deviation. The main cause of second
visit in this clinic is due to follow up of auxiliary service.

Transferring auxiliary service to downstream staff can reduce the second visit surgeon’s
workload. From this description it can be argued that if patient is allowed to meet with
surgeons only once on the same day visit unless further tests are ordered by surgeons, the
second visit workload will be reduced. Reducing the second visit workload will enable
surgeons to attend more patients who could not be attended due to this effect. But also it will
reduce patients waiting time, unless surgeons’ orders further tests. Using powerful tools like
simulation can show those potentials gains after redesigning.

7. Conclusion and further research

From a healthcare organization perspective, identification of bottlenecks in patient care

process is a critical point for improvement initiatives. Application of Cobb Douglass
production function and TOC enhanced the identification of critical bottlenecks in patient care
process. The major lesson learned in this study is that design of healthcare process in
healthcare organization is a major contributor of clinical bottlenecks existence. In this study
second patient's visit to surgeons contributed largely to patient length of stay at the clinic.

From TOC perspective, focusing on the critical bottlenecks in the healthcare processes can
lead to performance improvement for the entire system. In this particular study if the
management will focus on reducing surgeons' activities, it will release capacity to surgeons
and surgeons will be able to focus on their core activities, hence accommodate more patients.

Further research can use powerful modeling tools such as simulation to tests these developed
proposition. Also some studies can focus on identifying which strategies such as lean and
agile are appropriated for each variable on the entire orthopedic care process.
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 APPENDIX: 1 Table 3: Descriptive statistics
Mean Median Standard Outlier mean Outlier Outliers standard
deviation median deviation
Regstratin waiting time 34,134 33 21,3526 16,429 10 15,17
Registration 14,872 15 3,88 14,071 13 4,6
Medical record waiting time 32,122 29 21,21 23,143 8,5 35,037
Nurse contact 4,7 4 2,2 4,5 4 2,4
First examination waiting time 58,48 48,5 41,7 106,53 85,5 79,9
First examination 17,177 16 8,2 18,143 18 5,8
Second examination waiting time 53,41 50 22,99 56,64 49,25 42
Second examination 13,98 13 5,3 15,85 15,5 5,08
X-raywaitingtime 43,006 45 28,51 35,92 10,5 44,2
X-ray 16,88 17 1,65 16,5 16 1,65
Waiting for lab test 41,085 42 12,7 40,57 38,5 15,9
Lab tests 25,3 25,5 2,9 25,8 25,5 3,1
Waiting for lab result 163,159 163,5 38,91 138,214 144 55,5
Patient age 30,363 28 16,24 27,85 29 14,4
Table 4: Bivariate correlation coefficient (n=164).

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1. RegW 1
2. Reg ,052 1
3. MedRe ,307** ,156* 1

4. nurse -,011 ,121 ,026 1

5. first
,133 -,055 ,142 ,043 1
examW
6. first
,088 ,099 ,066 ,138 -,110 1
exam
7. second
-,184* -,102 -,121 -,072 ,273** -,078 1
examW
8. second
-,265** -,103 -,237** -,052 -,066 ,172* ,180* 1
exam
9. XrayW -,333* -,272*
,382** ,125 ,263** -,016 -,113 ,075 1
* *

10. xray -,066 ,011 ,105 -,026 ,173* ,022 ,016 ,174* -,094 1
11. labtest
-,062 -,121 -,165* ,000 ,026 -,122 ,076 ,042 -,012 -,005 1
W
12. Labtest ,078 ,135 ,148 -,065 -,018 ,018 -,065 ,002 ,145 ,069 -,167* 1
13. Labresu -,388*
,256** ,015 ,141 ,094 -,001 ,116 -,101 -,016 ,166* ,137 ,192* 1
ltW *

14. Age -,140 ,054 ,018 -,045 -,030 ,025 ,078 ,083 -,131 -,169* -,057 -,032 -,152 1
15. Gender ,003 ,027 -,048 ,011 ,065 ,047 ,190 *
,015 ,041 -,104 ,099 -,033 ,044 -,047 1
16. 16 LOS ,572** ,085 ,496** ,082 ,583** ,140 ,176* ,125 ,423** ,164* -,075 ,183* ,547** -,141 ,124 1
APPENDIX 2:
**. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).

APPENDIX 3
Figure 4: Graphical assessment of heteroscedasticity

Figure 5: Normal probability plot.