The Goal

Now if I can answer your question a bit more precisely. When one is introduced to theory of constraints, the first thing you see is a system where the causality is hidden. In other words, it's chaotic. Things happen, you have no control. Suddenly, though, it becomes a system that can be analyzed in terms of certain key points-leverage points. And one learns that addressing these key points-rather than launch- ing a symptomatic firefight-is the way to exert control over these systems. Remember, this was in the early 1990s, before frameworks like systems theory had moved to the forefront and become part of the main buzz. Though the theory of constraints doesn't talk about systems theory, already it was offering an approach by which a com- plex system could be managed in terms of a few key leverage points.

DW: Did you wind up attending both weeks of the course?

AV: Correct. Then I came back to the hospital. There are two points I want to make. The first was that I underwent a mental change. In- stead of thinking that things were too complicated, too complex and not manageable, I now saw that if I could analyze the system cor- rectly, it was manageable. That was the first important breakthrough that I had, and many people I've taught this to subsequently have had the same breakthrough. There is a way-find it!

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Second, our outpatient clinic, like most hospital outpatient clinics at that time, and even now in many parts of the world, was plagued by inefficiencies and long waiting lists. The more we fought the ineffi- ciencies, the more money we poured into the system, the longer the waiting lists seemed to become. This is the problem with the national health system in Britain as we speak. Now in my department, it seemed to me as though the processing of patients by doctors could really be viewed as a production line, just as in The Goal. The times are differ- ent, and obviously people aren't machines. All of those issues I ac- knowledged. But I saw that parallel.

DW: How did you attack the problem?

AV: The manager in charge of that clinic and I sat down and I told her about the principles used in The Goal Between the two of us-with her doing most of the work-we identified our constraint. We realized that we lost a tremendous amount of capacity whenever patients or doctors wouldn't show up for scheduled appointments. That time lost was not recoverable. So we developed a call-in list, which we called the patient buffer. A day or two before a scheduled appointment we would phone patients and make sure that they would be coming into the clinic. If not, we would find substitute patients. The result was less loss of capacity. Our waiting list at that time was about eight or nine months long, which is common for this type of waiting list. As a mat- ter of fact in the UK now some of these waiting lists are over one year. In about a six month period we got our waiting list below four months, which was roughly half of what most other hospitals were doing in South Africa at that time.

DW: Yours is a public hospital?

AV: Yes, we're part of the state health system. In other words, not for profit. Patients pay only a small amount for services. Later on, after I started consulting with the Goldratt Institute in South Africa, we looked at a large private hospital, 600 beds, a flagship hospital with neuro- surgery and all the high-tech stuff. The issue there was loss of capac- ity in the operating rooms. The spin-off effect of that was that sur- geons were leaving the hospital and going to other private hospitals. It was a serious situation. We found that instead of focussing on local optima-making sure that my little department comes first-the real

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question people should be asking is, what can I do to achieve the larger goal of the hospital, which is to throughput new patients? It's a simple concept but implementing it took about two months of meet- ing with staff. Each person then developed an action plan aimed at making sure more patients moved through the system more efficiently. In a period of a year, this hospital moved from a 20% shortfall on its budget to where it began showing a profit.

DW: So you've become a Goldratt consultant yourself?

AV: Yes. I presented the results from our hospital's outpatient clinic at one of the Goldratt symposia in the early 1990s. This was the first report of a medical implementation of the theory of constraints. Eli Goldratt was there to hear my presentation, and afterwards he in- vited me to join the Goldratt Institute as an academic associate. I was based at the university but involved in the implementations of his consulting company. I did quite a bit of work in the mining industry- nothing to do with medicine! It was pure theory of constraints, straight out of the book. It allowed me to develop my own skills.

DW: What's a doctor doing advising mining companies?

AV: It's interesting that you say that. I'm a physician, not a surgeon, In other words I'm a thinker, not a doer. I say that facetiously but as a physician, it's all about diagnosis. And the whole process of diagno- sis, whether it's a patient or an organization, is the application of the scientific method. Eli Goldratt says that his theory of constraints is simply the application of the scientific method. So it's almost natural that an advisor to a mining company-in terms of diagnosing what's wrong and what to do about it-could be a physician. In fact some of the teaching materials that the Goldratt Institute uses refer to the medical model. It asks trainee consultants, How does a doctor ap- proach the problem? It gives them a parallel for how you diagnose problems in organizations.

DW: That's interesting. Eli has said that his overriding

ambition in life is to teach the world how to think.

AV: Right. And nothing he has done in the almost 14 years that I have known him suggests to me that that is a facetious statement. The

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theory of constraints is about thinking processes, it's a subset of logic. In other words, the scientific method.

DW: Has any of this made you a better teacher of physicians?

AV: Absolutely. Absolutely. I've told you that diagnosing a patient and diagnosing a business is the same thing. But a doctor learns to diagnose by watching other doctors. It's not taught as a science. The processes of diagnosis are taught but what might be called the phi- losophy of diagnosis is not taught as it is in the theory of constraints. The traditional approach is, watch what I do. The approach that I've since followed is, let's look at how the scientific method works, then let's see if we can apply this to a patient. Most students take to this very well.

Interview with Eli Goldratt continued... DW: That will do it

EG: Please, one more. The jewel in the crown, at least in my eyes, is the usage of TOC in education. Yes, in kindergartens and elementary schools. Don't you agree that there is no need to wait until we are adults to learn how to effectively insert some common sense into our surrounding?

Interview with Kathy Suerken, CEO TOC For Education,

An international nonprofit dedicated to teaching TOC think- ing processes to schoolchildren.

DW: You're a middle school teacher, not a plant manager. How does The Goal fit with the work you do with children?

KS: Well, it all started almost 15 years ago. I was kind of a new teacher at a middle school but I had been a parent volunteer for a while. I was running a voluntary math program for kids and my husband was giving me advice on how to manage it. The program was already a success, we had 100% participation. I asked him, 'Well, what do I do

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now? Go to a different school?' And he said, 'Kathy, you'll have to find another goal.' Six months later he said,