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2015 TOCICO International Conference

Transforming Healthcare Track

Maria Aranguren
Goldratt Solutions LTD

Transformation of the Flow of Patient Centered Care in the Emergency Room
September 7, 2015

Healthcare systems appear complex. Each patient is different and requires the efforts of many different resources. The traditional response to this apparent complexity is to divide the system into parts and manage and measure each part separately in an attempt to improve the whole. This approach is only successful when the number of variables is relatively predictable and small, which is not the case in health systems.

The TOC solution is based on the belief that inherent simplicity exists in any goal-oriented flow system: only a few places have the power to affect the rate of output/performance – the system’s constraint(s). The methodology allows focus on these constraints by tackling the waiting times in the emergency department with the patient at the center of decision making. By establishing a buffered flow time target for the system, with traffic light color system, we create the visual awareness of delays and blockages to flow in order to prioritize management interventions.

Case Study:

The case study takes place in Venezuela. A country that has been going under severe political and economic transformations that have seriously impacted the level of care and attention in the public system. As a result, the need to be covered by insurance providers has created an increasing demand on private hospitals/clinics that are owned by Doctors – which are often not profitable organizations.  

This presentation is about the private sector where the hospitals (clinics) face the following challenges: 

  1. Growing demand for Emergency Services
  2. Constant challenges from insurance companies (costs/cash)
  3. Growing pressure from the government to control prices

The objective was to help the managers of emergency departments to achieve greater throughput of patients per $ invested in resources by focusing on the constraints that reduce the rate of flow. A software solution was developed in house for the emergency department patient information, which focuses management attention and support services based on the severity of their condition and length of stay in order to reduce delays caused by a prolonged waiting times. A patient color code gives alerts of delays in the process of care on a main screen, workstations and ancillary departments. The application generates statistics to identify bottlenecks and focus strategies to correct them and measure their impact on quality and speed of care.


In a very short time and with the adequate staff induction we obtained the following results:

  • Reduction of up to 80% on the overall service time, using the same resources and the same staff.
  • Specialist Doctors have responded quicker once they have the visual of the magnitude of the delays in a traffic color system (Green – Yellow – Red – Black). Being green in the first third of the target time, yellow the second third, red the last one and black over the target.
  • The shifts changeovers are done visually in front of the screen in a third of time they use to take before.
  • Reduction of 29% in the average length of stay in the ER.
  • As a result of the statistics on the major blockages to flow, a project to measure and manage availability of hospital beds was developed and has become a very important initiative contributing to the overall reduction in length of stay.
  • The overall flow inside the hospital has improved. Patients leaving the operating theaters are no longer waiting in the recovery area for a bed.
  • A spirit of team work has brought other areas connected to the flow (insurance, cleaning, lab and imaging/X-Ray services) to work in a more synchronized and friendly environment.
  • The hospital has increased bed turnover rate with important financial results.

This approach can be extrapolated to many other processes within the institution, such as: allocation of hospital beds, surgical management shifts and control of medical and administrative processes associated with the discharge of the patient, amongst others. 

The power of this solution is based on the simplicity of the system of the patient flow through a flexible and transparent graphic message. The first results were achieved within 3 months. 

MARIA CRISTINA SIERRAALTA ARANGUREN is a Mechanical Engineer. She graduated from Simon Bolivar University in Caracas, Venezuela. In 1995 she started working with Goldratt in successfully implementing TOC in a wide variety of organizations.  She has conducted extensive work on Operations and Supply Chain in Venezuela, UK and Central Europe. She had the opportunity to support implementations in the National Health Service in England and has recently implemented the TOC solution for Health Care Institutions in Venezuela. Maria Cristina was a Faculty member of Goldratt Schools supporting development in various countries.

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