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When I first tried to read Eliyahu Goldratt's book, The Goal: A Process of Ongoing Improvement (North River Press, 1984), I couldn't get through it. It was about improving throughput in a manufacturing plant. Because I'd never worked in manufacturing, I just couldn't translate it into a service business. It made no sense to me.

In We All Fall Down (North River Press, 2006), Julie Wright and Russ King attempt to bridge that gap between manufacturing and healthcare. It's a novel about Beth, a bed manager, attempting to increase throughput in a 500-bed British hospital. Because of the National Health System, British hospitals run at nearly full capacity. The census at U.S. hospitals ebbs and flows. Both peak in the winter flu season.

Because the hospital runs at 98 percent of capacity, there's always a shortage of beds causing canceled surgeries and other issues. The constraint appears to be beds, but on further analysis, Beth finds that policies are forcing her to put patients in any available bed instead of a nursing unit suited to their needs. Surgical patients end up in medical units and vice versa. This causes doctors to commute all over the hospital to do their rounds. In a 500-bed hospital, commuting can devour a doctor's time. This causes delays in discharge, which further reduces the number of available beds.

From a Lean perspective, this is unnecessary motion. Lean and Theory of Constraints (TOC) offer two slightly different ways of looking at improvement. I think of them as different maps to the same territory.


Goldratt's premise about TOC is that systems are complex, but problems are simple. Problems congregate at bottlenecks. Fix the bottleneck, and you fix the system. Goldratt also believes that people want to do a good job, but the system prevents them from doing so.

While Beth is struggling to find the root cause of throughput problems, she has to wrestle other managers, doctors and knee-jerk improvement projects. See if you recognize any of Beth's findings:

  • Too many improvement projects fail to deliver.

  • Potential negatives and objections are overlooked.

  • Staff have seen it all before.

Meanwhile, Beth has to figure out how to present her findings in a way that can't be dismissed. See if you recognize any of the six layers of resistance Beth faces:

  • I don't accept your agenda.

  • I don't agree about the problem.

  • I don't agree about the solution.

  • I don't accept the benefits you claim.

  • I don't think you've identified all the negative side effects.

  • I don't think you can overcome the obstacles to implementation.

  • I'll agree, but I won't play.

One of the most interesting parts of this book is how Beth structures her presentations to various stakeholders to gain ...

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