Tag Archives: eli goldratt

Teal and Theory of Constraints

This is a series on Teal and Levels of Work. Here is the backstory for the series in case you are interested in the context. The purpose for the series is to explore the tenets of Teal through the lens of Levels of Work.
In his book, Reinventing Organizations, Laloux cites several examples as evidence of the success of Teal. I like examples, they provide detail excluded from a more statistical approach.

Laloux takes a large excursion through Buurtzorg, founded in 2006 by Jos de Blok. De Blok created a nursing organization unlike others, distinctive in its use of self-organizing teams. Each team of 12 serves approximately 50 patients with discretion over intake, planning, scheduling and administration. Buurtzorg now employs 10,000 nurses organized in this way with quality measures (patient outcomes) exceeding competing organizations. Here’s the punchline – these patient outcome measures required 40 percent fewer resources (hours of care) than the competition. This would seem a resounding endorsement for self-managed teams.

Here are my observations, based on Levels of Work, nested working relationships (hierarchy) related to problem solving and accountability.

Laloux described de Blok’s dilemma after spending years as a nurse. The evolution of nursing in the Netherlands had transformed into a Laloux’s Orange machine, with efficiency quotas of shots administered, medicine delivered and bandage changing. Nurses were routed and timed for patient visits with assignments tightly scheduled. De Blok observed that, while efficient, nurse morale suffered along with patient outcomes. Could a different organization make a difference? Self-organized into teams of 12?

First, little surprise that a team of a dozen nurses could solve most problems and make most decisions related to intake, planning, scheduling and administration. Most roles in nursing require S-II capability. This means that problem solving and decision making falls within S-II time frames (3-12 months). Highly likely these teams have requisite capability to make those decisions.

But that, for me, turns out NOT to be the insight. The state of nursing in the Netherlands was clearly focused on system efficiency, which is the hallmark of S-III. Unfortunately, the Dutch health care program was dealing with an S-IV problem. Eli Goldratt’s Theory of Constraints (TOC) lends insight.

The constraint in the system had nothing to do with bandage changing. The constraint in the system was the patient. Nurses could change bandages (efficiently) all day long, but the patient doesn’t get better until the patient gets better.

“Buurtzorg places real emphasis on patients’ autonomy. The goal is for patients to recover the ability to take care of themselves as much as possible.” The constraint in the system is the patient. Changing a bandage in seven minutes does not necessarily make the patient better.

Goldratt would tell us this. Identify the strategic constraint and subordinate everything else to the constraint, even if it means leaving a sub-system to idle. In nursing, leaving a sub-system to idle may mean having a cup of tea and conversation with the patient. It is certainly not efficient, but contributes to overall throughput. Sorry this sounds like a machine (Orange).

De Blok brilliantly identified the constraint in the system (the patient), abandoned (correctly) the KPIs related to bandage changing and focused on the patient. Efficiency had been killing the patients. Literally.

In the end, patient outcomes improved, costs reduced by 40 percent, team morale improved. Laloux would attribute all this to self-organized teams. Rather, I think de Blok intuitively understood the constraint in the problem better than the Dutch government.

Next, I think I want to explore what is happening inside these teams. What are the dynamics of self-organized?
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