The thinking process of the theory of constraints applied to public healthcare

Abstract

Purpose
The purpose of this paper is to present an approach based on the thinking process of the theory of constraints (TP–TOC) to support decision-makers, managers and professionals of health to diagnose and improve healthcare systems focusing on the service quality deployed to patients.

Design/methodology/approach
A case study was developed in a SUS-affiliated philanthropic hospital in southern Brazil, through the analysis of its ED processes and application of the TP–TOC. The Current Reality Tree and the Evaporating Cloud tools of the TOC were used to identify the root causes (RC) and their connections with undesirable effects.

Findings
The analysis of this case helped to understand and identify the causes of the current problems in the analyzed processes related to internal management and external causes. The proposed approach allowed the hospital team to progress in the understanding of such causes in a sequential manner, giving conditions to apport different perceptions and to identify relevant facets and causes related to the problem. The research provided a systemic and an integrated vision of the losses in the organizational processes and indicated the steps to be prioritized in order to eliminate such losses.

Originality/value
The paper proposed an approach that allowed the systematic and systemic analysis of organizational processes through the application of the TP–TOC. The recognition of the existence of RC responsible for processes losses represents an excellent opportunity for improvement because it allows managers to focus their efforts on the more productive areas.

Full text

Business Process Management Journal
The thinking process of the theory of constraints applied to public healthcare
Jéssica Mariela Bauer, Andrea Vargas, Miguel Afonso Sellitto, Mariane Cásseres Souza, Guilherme
Luís Vaccaro,
Article information:
To cite this document:
Jéssica Mariela Bauer, Andrea Vargas, Miguel Afonso Sellitto, Mariane Cásseres Souza, Guilherme
Luís Vaccaro, (2019) "The thinking process of the theory of constraints applied to public healthcare",
Business Process Management Journal, https://doi.org/10.1108/BPMJ-06-2016-0118
Permanent link to this document:
https://doi.org/10.1108/BPMJ-06-2016-0118
Downloaded on: 21 January 2019, At: 15:07 (PT)
References: this document contains references to 77 other documents.
To copy this document: permissions@emeraldinsight.com
The fulltext of this document has been downloaded 6 times since 2019*
Access to this document was granted through an Emerald subscription provided by emerald-
srm:478605 []
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald
for Authors service information about how to choose which publication to write for and submission
guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company
manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as
well as providing an extensive range of online products and additional customer resources and
services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the
Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for
digital archive preservation.
*Related content and download information correct at time of download.
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

The thinking process of the
theory of constraints applied
to public healthcare
Jéssica Mariela Bauer, Andrea Vargas, Miguel Afonso Sellitto,
Mariane Cásseres Souza and Guilherme Luís Vaccaro
Graduate Program in Production Engineering,
Universidade do Vale do Rio dos Sinos, São Leopoldo, Brazil
Abstract
Purpose –The purpose of this paper is to present an approach based on the thinking process of the theory of
constraints (TP–TOC) to support decision-makers, managers and professionals of health to diagnose and
improve healthcare systems focusing on the service quality deployed to patients.
Design/methodology/approach –A case study was developed in a SUS-affiliated philanthropic hospital in
southern Brazil, through the analysis of its ED processes and application of the TP–TOC. The Current Reality
Tree and the Evaporating Cloud tools of the TOC were used to identify the root causes (RC) and their
connections with undesirable effects.
Findings –The analysis of this case helped to understand and identify the causes of the current problems in
the analyzed processes related to internal management and external causes. The proposed approach allowed
the hospital team to progress in the understanding of such causes in a sequential manner, giving conditions to
apport different perceptions and to identify relevant facets and causes related to the problem. The research
provided a systemic and an integrated vision of the losses in the organizational processes and indicated the
steps to be prioritized in order to eliminate such losses.
Originality/value –The paper proposed an approach that allowed the systematic and systemic analysis of
organizational processes through the application of the TP–TOC. The recognition of the existence of RC
responsible for processes losses represents an excellent opportunity for improvement because it allows
managers to focus their efforts on the more productive areas.
Keywords Hospitals, Theory of constraints, Current reality tree, Public health
Paper type Case study
1. Introduction
Brazil recorded in 2016 a gross domestic product (GDP) of $1,913bn, accounting for 8.51m
square kilometers and about 200m inhabitants (IBGE, 2017). Brazil investment in healthcare
public services raised from 1995 to in 2014 from about 6.5 percent to about 8.3 percent of the
GDP (WHO, 2017). However, despite the increment of the investment, Brazil holds one of the
lowest worldwide investments in this kind of public service (Anahp, 2015). Even if
compared to other Latin American countries, such as Argentina and Chile, Brazil’s expenses
on public healthcare are significantly lower (WHO, 2017).
The Brazilian public system offers free and universal healthcare service to the entire
population. The Brazilian Unified Health System (SUS) covers consultations and treatments
recognized by the current legislation to the entire population, without any additional charge
(PWC, 2013). Ensured as a universal, equal and sustainable right by the Brazilian
constitution of 1988, about 76 percent of the Brazilian population depend solely on the SUS
health services (Anahp, 2015; Kuchenbecker and Polanczyk, 2012; Victora et al., 2011).
The system relies on service providers, as public and private philanthropic hospitals
(Anahp, 2015). While committed to their mission of reestablishing health to patients, these
organizations need to provide services in a sustainable fashion, leading to a trade-off
between service quality, availability and cost management. To find equilibrium and to
ensure sustainability in the long term to this service is a significant problem (Paim et al.,
2011). The SUS is a fundamental structure for healthcare in Brazil, as a significant part of
Business Process Management
Journal
© Emerald Publishing Limited
1463-7154
DOI 10.1108/BPMJ-06-2016-0118
Received 12 June 2016
Revised 18 November 2018
Accepted 6 December 2018
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/1463-7154.htm
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

the Brazilian population is not able to access the private system (PWC, 2013). Nevertheless,
SUS services are often associated to low quality, inefficient resources management and poor
infrastructure (Alástico and Toledo, 2013; Anahp, 2015; La Forgia and Couttolenc, 2008;
Paim et al., 2011). Service quality, as well as long waiting time, is recurrent complaining of
the population (Alástico and Toledo, 2013; Burmester et al., 2007; La Forgia and Couttolenc,
2008). For example, patients waiting for non-critical surgeries may take up to 36 months to
be served (Souza et al., 2016).
Under a global perspective, there has been an upward trend in the demand for quality in
healthcare services as well as increased expectations and requirements of cost reduction. To
be sustainable, health systems must focus on continuous improvement of their processes, to
avoid wasting resources or time. Healthcare providers should be able to use information
effectively to serve the community, preserve efficiency and assure the quality of the service
(Snyder et al., 2005).
The theory of constraints (TOC) may contribute to improving decision making in conflicting
situations (Goldratt, 1994) like those found in healthcare service systems. The TOC aims to
solve unstructured or ill-defined problems and also to identify cause-and-effect relationships
that may generate constraints (Mabin et al., 2010). Applications of TOC in healthcare services
are observed in association with computer simulation-based studies (Gunal, 2012) or lean
thinking (Mazzocato et al., 2010; Poksinska et al., 2016; Souza, 2009). The main issue is to
identify bottlenecks, reduce wastes, decrease lead times and balance the flow of patients.
The analysis of hospital organizations from a TOC perspective can contribute to
improving the quality of the provided services (Gupta and Kline, 2008; Nematipour et al.,
2014). Nevertheless, the application of the TOC in the hospital context is still incipient,
particularly in Brazil (Pergher et al., 2016; Ren et al., 2013; Souza et al., 2016; Wadhwa and
Schleier, 2010). Therefore, the purpose of this paper is to propose an approach based on the
thinking process of the theory of constraints (TP–TOC) to support decision-makers to
diagnose problems and improve healthcare service systems performance, focusing on the
quality of the service. The research method is the case study.
This research relies on the perspective of a SUS-affiliated hospital. As a mean to discuss
how the TP–TOC may support the improvement of healthcare service systems focusing on
the service to the patient, a case study was developed in a philanthropic hospital in southern
Brazil. Process analysis and the application of the TP–TOC were used to compile
information from internal documents, observation, publicized material and data gathered in
interviews. The Current Reality Tree (CRT) and the Evaporating Cloud (EC) tools of the
TOC were used to identify the root causes (RC) and their connections with undesirable
effects (UEs). The experience from this study, combined with the literature background
permitted to propose the main result of this research.
The justification of using TOC in public healthcare service systems relies mainly in the
capacity of TOC in handle conflicting systemic situations without using advanced analytical
or probabilistic solutions. Other approaches such as computer simulation or lean healthcare
require software packages, literature background and advanced support from experts, which
are rarely available in public healthcare service systems. TOC tools are intuitive and easy to
communicate. Therefore, managers and practitioners of public healthcare service systems can
easily employ and explore the set of TOC tools to manage conflict situations and quickly find
suitable solutions. Other managers and practitioners of public healthcare service systems can
use the TOC approach by applying the TOC tools in focusing the conflicting situations of their
organizations to uncover the main problems and to propose ultimate solutions.
The use of TOC is not novel in healthcare service systems. To ground the study, we
extracted some applications from the literature to explain how other studies had already
used the TP–TOC, which can also help to understand how managers and practitioners
would use the approach to improve the performance of their systems.
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Pergher et al. (2016) carried out a TP–TOC case study in the process of authorization of
radiotherapy service in a large Brazilian hospital. The main results allowed the definition of
a set of actions to eliminate or reduce the failure modes in their healthcare system. Souza
et al. (2016) analyzed the case of another large Brazilian hospital to improve bed
management using the TP–TOC. The research promoted an in-depth understanding
of the problems associated with the management of hospital beds and driven actions to
reduce wastes.
Stratton and Knight (2010) used TP–TOC to analyze the flow of patients in hospitals in
England and the Netherlands, reducing the waiting time of patients by 20 percent. Tsitsakis
(2010) applied the TOC in five public hospitals in Greece, aiming to solve capacity problems,
long waiting lists and low occupancy rate in hospitals. Groop et al. (2010) suggested a
constraint-based alternative to increase the transfer rate rather than reduce costs in a home
healthcare service in Finland. Nematipour et al. (2014) described the application of the
TP–TOC in the hospital supply chain of five hospitals in Iran and uncovered the core
problem, the environmental instability, which requires larger inventories to prevent
shortages. Finally, Ren et al. (2013) demonstrated how the TOC’s five focal steps can be
applied to the surgical process, to increase the number of surgeries, reduce overtime and
increase the patient’s satisfaction.
The following sections present a background on the TOC and TP–TOC in the
context of healthcare, the methodological approach and the results of the research. The
paper ends drawing some considerations regarding the produced results in the context
of healthcare.
2. Background
2.1 The TP–TOC
The TOC focus on elements that limit the ability of an organization to achieve its goal.
These elements are referred as constraints. TOC was initially created to improve production
and distribution systems, latter evolving to supply chain management, marketing and
strategy (Cox and Spencer, 1999; Polito and Capen, 2014; Rahman, 2002; Watson et al., 2007).
Its use also encompassed service organizations and non-profit institutions (Motwani et al.,
1996a; Watson et al., 2007).
According to Cox and Spencer (1999), TOC comprises three key approaches:
(1) The logistics approach: the management of buffers, the sequencing of production by
the drum-buffer-rope algorithm (DBR), and the analysis of the V-A-T production
structure (disassembly, assembly and transformation lines).
(2) The five focusing steps approach: the identification, subordination and exploitation
of the main constraint of a system, by increasing its capacity, the capacity of the
whole system is increased as a result.
(3) The TP–TOC approach: the use of cause-and-effect diagrams to resolve
organizational problems. The recommended tools are the Current Reality Tree
(CRT), the Future Reality Tree (FRT), the Prerequisite Tree (PRT), the Transition
Tree (TT) and the Evaporating Cloud (EC) diagram.
Organizational constraints can be either physical (a machine with lower capacity, suppliers,
people) or non-physical (the market, policies, procedures, standards and skills, daily
practices, thinking models) (Kendall, 2004). To explore non-physical restrictions, it is
recommended to use TP–TOC (Gupta and Boyd, 2008; Motwani et al., 1996a).
As the TOC seeks to identify the core problem associated with UEs, the TP–TOC may
support answering the three questions related to the organizational performance: “what to
change”;“what to change to”and “how to cause the change”(Dettmer, 1997). To do so, the
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

operational tools represented in Table I are utilized. Each tool requires a methodological
procedure to be constructed. Further discussion can be found in the studies of Cox and
Spencer (1999), Gupta et al. (2004), Kim et al. (2008) and Noreen et al. (1995).
The TP–TOC, made operational by the tools above, is considered a Socratic method, that
uses propositions in the form of “if […]so[…]”(Motwani et al., 1996a; Ritson and Waterfield,
2005). It contributes to self-disclosure, encouraging engagement and participation to focus
changes on the weakest link (RC) of a problem. The RC is responsible for most of the UEs that
hinder the organization on achieving better performance (Reid and Cormier, 2003; Taylor and
Churchwell, 2004).
The process allows the explanation of the managers’insights, who are usually unaware
of the real problems of the company in which they act, much less of the solution to them
(Goldratt, 1990). The CRT, for example, allows managers to work from the effects (above)
down to the causes (below) in a top-down logic. Then, the tree interpretation is given toward
bottom-up, using conditional relations established (Gupta et al., 2004). When an effect is
promoted by two or more causes, it becomes necessary to verify the conjunctions of causes
that cause the effect. This analysis may result in a logical operation “or”or a logical
operation “and.”The second case represents the obligation of a conjunction of causes, being
represented by an ovate symbol. It marks the situations where there may occur insufficiency
of causes to generate an effect (Wright and King, 2006). The trees drawn up by the actors
involved serve as a means to exchange and widespread information and knowledge.
2.2 TOC studies in healthcare organizations
Motwani et al. (1996a, b) conducted theoretical studies about the use of TOC in healthcare
organizations. Wadhwa and Schleier (2010) identified the five focusing steps, the TP–TOC
and the buffer management as the most used tools in public health. In addition to those, 25
articles published between 1999 and 2016 were identified: 9 related to the five focusing
steps; 14 related to the TP–TOC; and 2 related to buffer management. Table II presents a
What to change?
Current Reality
Tree (CRT)
The CRT presents hypotheses and possible causes of problems. It allows
representing secondary effects that, when confirmed, justify the existence of a
prior cause. The CRT allows the identification of a core problem that resonates into
several UEs, unresolved conflicts or erroneous assumptions
What to change to?
Evaporating Cloud (EC)
diagram
The EC diagram allows checking the assumptions related to the conflict or core
problem and understanding why the problem was not resolved. It forces to explicit
existing assumptions related to the core problem, to solve (evaporate) it by
generating a new conception of the situation
Future Reality
Tree (FRT)
The FRT organizes potential solutions to the problem in relation to the UEs arising
from the CRT. The FRT allows identifying the changes required from actions, as
well as to prevent problems that can arise from the solution implementation
How to cause the change?
Prerequisite Tree (PRT) The PRT identifies obstacles that prevent the implementation of the solution. The
PRT allows defining intermediate goals that span potential obstacles and enables
the development of an action plan to achieve the FRT
Transition Tree (TT) The TT identifies actions necessary to achieve the stated goals. It represents the stages
and phases of transition from the current situation to a desired ( future) situation
Negative Branch (NB)
diagram
The NB diagram allows constructing and experimenting possible solutions prior
to the effective selection of a course of action. It focuses on identifying the impacts
and any negative effects related to each action taken
Sources: Adapted from Cox and Spencer (1999), Mabin et al. (2010) and Polito and Capen (2014)
Table I.
The TP–TOC tools
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Authors Objective Method Results
Womack and
Flowers
(1999)
To increase the number of patients served, to
increase revenue and to control costs to make
the business viable
A case study with the application of the TOC’s
five focusing steps was carried out in the
366th Medical Group, a unit of the US Air
Force in Idaho
The patient waiting times have been reduced. The
satisfaction of customers and employees has improved
and the capacity has increased by 800 patients monthly,
generating revenues of $1.6m and a cost reduction of
$200,000
Kershaw
(2000)
Focus on the excessive (long) waiting times
for patients in the chemotherapy department
A case study with the application of the TOC’s
five focusing steps was carried out in the
chemotherapy sector of a for-profit cancer
clinic
The results reported an increase in the processing
capacity of patients of 20% to 25% per day.
Furthermore, the average treatment time was reduced
from 2.5 h to less than 2 h
Hunink (2001) To identify which heart procedure, a carotid
endarterectomy should be performed prior to
coronary artery bypass in the treatment of a
patient
ATP–TOC analysis was conducted and EC
diagrams were analyzed
The results recommend avoiding the carotid
endarterectomy procedure in order to avoid the risks and
costs in the treatment of a patient with asymptomatic
characteristics
Rotstein et al.
(2002)
To build a statistical model to predict the need
for allocation of additional doctors in the
emergency department (ED) of the hospital
Application of the TOC’s five focusing steps in
the hospital’s ED for immediate stabilization
and admission of patients
With the increased capacity, the patients’waiting time
was reduced by an average of 7.01 min. However, when
the number of patients is less than 80 or more than 120,
the increase of medical professionals has caused no
impact on waiting indexes. The impacts depended on the
availability of physicians being a constraint
Taylor and
Sheffield
(2002)
Analysis of the filing, processing and tracking
of medical insurance claims
A case study was carried out in a call center of
a for-profit hospital in Texas. TP–TOC and
tools as CRT, EC and FRT were applied
Training and qualification were provided to the
employees to ensure the reduction of overdue requests,
prepayment of the same and to increase profit margins
Mcnutt and
Odwazny
(2004)
To provide a conceptual framework for the
identification of causes of medical errors in the
Rush University Medical Center
TOC was used to review the adverse events
and the impact of clinical decisions and care
processes on errors. A timeline with a list of all
the decisions and the processes involved in the
care of patients. The chain of events leading to
adverse events was modeled through the CRT
It became evident to the managers the need for cost
reduction to increase the gain and not just investments
in diverse resources. This perspective has helped with
the planning of interventions, the reduction of adverse
events and it has contributed to improving the safety of
health and medical care involving the addition of people
and materials. Therefore, it was possible to increase the
safety and simultaneously reduce inventory and
operating expenses
(continued )
Table II.
Summary of TOC
application studies in
health systems
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Authors Objective Method Results
Silvester et al.
(2004)
To evaluate the causes of excessive waiting
lines in the National Health Service (NHS) and
delays in the patients’care
A theoretical study on the National Health
Service (NHS) in England and the possibility
of application of the TOC in the
healthcare sector
The main cause of long queues was not the lack of
capacity, but the variation and mismatch between
capacity and demand. The increase in availability of
non-bottleneck processes resources did not generate
improvements in the system. The reduction of waiting
times would only be achieved by improving the flow of
patients, management of bottlenecks and variation
reduction
Taylor and
Churchwell
(2004)
To analyze the budget constraints in
a hospital
A case study in a not-for-profit psychiatric
hospital in Texas, using the TP–TOC and
tools as CRT, EC and FRT
The constraint identified was the legislative funds. As a
result of the application of TOC, there was an
improvement in the quality of care, reduction of staff
overwork and improvement of staff morale
Lubitsh et al.
(2005)
To analyze the impacts of TOC in three NHS
Trust departments, neurosurgery, ENT, Eyes
and to reducing waiting lists in the system
and improving the throughput of patients
A case study based on the TOC’s five focusing
steps in three departments of a hospital in the
UK (Radcliffe Infirmary (RI), in the
departments of neurosurgery, eye and ENT.
Data were collected over a period of 40 months
With TOC application, on average, 184 people per month
were attended in less than 30 min, and 108 Department
of Otolaryngology (ENT). The total number of patients
on the waiting list has decreased in all of them. There
were no significant improvements in the neurosurgery
department which are associated with the complexity of
the system. And the bottleneck identified was the lack of
nurses in the hospital wing
Ritson and
Waterfield
(2005)
To identify how the National Health Service
(NHS) and the Social Services Department
(SSD) could manage changes in the local
mental health service
A case study in the mental health service for
adults living in the North East of the UK,
applying TP–TOC, and tools as CRT, EC,
FRT, PRT and TT
As a result of the study, the introduction of a Crisis
Resolution/Home Treatment Teams allowed the
reduction of time to admissions and the length of stay in
the hospital. The quality of treatments has improved for
users of services both at home and in the hospital as well
Sellitto (2005) To analyze the management of repeated use
materials in the public health of a Brazilian
capital in order to improve the assistance to
managers of community healthcare service
centers regarding the required materials in
quantity and time
A case study applying the TP–TOC in a
public health organization. The following
tools have been applied: CRT, EC, FRT, PRT
and TT
An increase of 60% of units delivered per month. The
average stock has been reduced by approximately 15%
and turning stock climbed about 2:30 times a year for
about five times a year. The complaints from managers
of healthcare service centers, which were frequent until
then, have been zeroed. Shortages of materials amounted
to negligible levels
(continued )
Table II.
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Authors Objective Method Results
Patwarddhan
et al. (2006)
To provide appropriate technical reports to
the clinic and public health policymakers in
the Center of Practical Evidence (evidence-
based practice centers (EPCs))
A case study applying the TP–TOC, and the
CRT and FRT tools
Improvement in the process of developing technical reports
on the basis of evidence that really informed decisions of
great importance to the EPCs and to policymakers
Umble and
Umble (2006)
To reduce the waiting time and admission to
the accident and emergency department
(A&E) at three hospitals
A TOC–DBR case study in three non-profit
hospitals in the UK (Milton Keynes Hospital
District, Horton Hospital, Oxfordshire and the
Oxfordshire Radcliffe Hospital)
Reduction of waiting times and admissions in the
departments. Additional capacity was generated
without investments. The percentage of patients waiting
less than 4 h in Keynes Hospital District Milton
increased from 85% to 90%, and the number of patients
attended per week increased to 1,200. At the Oxfordshire
hospitals, the numbers increased from 50–60 to 91%
Gupta and
Kline (2008)
To reduce waiting times for admission in the
psychiatry and therapy sectors, as well as to
reduce economic impacts related to
cancellation and missed appointments
A case study based on the TOC’s five focusing
steps was conducted in a chemical-
dependency unit of a community mental
health center
Through consultation reminders, the reimbursement has
increased to more than $50,000. The rate of cancellation
or non-attendance fell from 43 to 20%. There was an
increase in patients scheduled appointments, reduction
in missed appointments and also a reduction of
psychiatrist’s time wasted
Stratton and
Knight (2010)
To improve the patient flow in England and
the Netherlands hospitals
A TOC–DBR case study application was
conducted
A market constraint was identified. The patients waiting
time has been reduced by 20%
Tsitsakis
(2010)
To solve capacity problems, long waiting lists
and low occupancy rate in hospitals
A case study based on the TOC’s five focusing
steps conducted in five public hospitals in
Greece
The restriction was observed in the resources of the
diagnostic imaging laboratory, which was causing
delays and impact on the patient’s transfer rate
Groop et al.
(2010)
To support, through the TOC, the evaluation
of technologies to remove or relief
organizational constraints, in order to increase
the transfer rate, instead of cutting costs
A TOC-based case study in a home healthcare
service organization in Finland to implement a
mobile solution to improve mobility
Although the conventional financial approach
considered that the implementation would save time and
would be beneficial, the TOC has shown that technology
implementation aiming at an improvement of
productivity would bring adverse effects. The restriction
of the system was the distribution of workload. Leveling
the workload would result in serving more customers
and improvement of productivity
Mabin et al.
(2011)
To improve the satisfaction of patients in a
hospital pharmacy. The subject of the
research was a leading supplier of secondary
TP–TOC and tools have been applied, with
focus on EC diagrams
Reductioninthewaitingtimeofpatients,workloadand
overtime reduction, increased satisfaction of patients and
improvement of the team morale and people retention
(continued )
Table II.
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Authors Objective Method Results
health services in the North Island of
New Zealand
Groop (2012) To explore the mechanisms and practices that
inhibit the ability of home healthcare service
providers to make better use of available
resources, and to provide general models of
solving these problems
A TOC-based case study on the Espoo Home
Care (EHC), a publicly funded healthcare
organization located in Finland
TOC can provide a systematic structure for identifying
and addressing the factors that limit productivity. The
application of TOC in-home care reveals various policies
and practices that, intuitively might seem logical and
efficient, but in fact are counterproductive. As a result of
the investigation, the home care unit studied was able to
significantly reduce the use of outsourced labor and cost
reduction was estimated at €0.5m annually
Taylor and
Nayak (2012)
To determine the central problem that was
causing the loss of revenue in the ED of a
hospital
A case study of the application of TP–TOC
and CRT, EC and FRT tools in the ED of a
hospital located in Texas
The triage process was not conducted properly. As a
solution, a triage team was hired to improve the use of
the ED
Ren et al.
(2013)
To demonstrate how the five focusing steps of
TOC can be applied in the surgical process
A literature review on the application of the
TOC’s five focusing steps and its application
in the process of surgeries in the West China
Hospital
A higher number of surgeries, reduction of overtime and
increased patient satisfaction have been obtained by
eliminating the constraints in the process of surgeries
Sadat et al.
(2013)
To verify how the TOC complies with the
public health systems with respect to the
definition of goals, performance measures and
continuous improvement. The established
goal was to increase the quality and quantity
of life, both now and in the future
A system dynamics representation of the
TOC’s goal and performance measures for
publicly traded for-profit companies. A similar
model was created for publicly funded health
systems, including some of the factors that
affect system performance, providing a
framework to apply TOC’s process of ongoing
improvement in publicly funded health
systems
The authors created stock and patient flow diagrams to
define the relationships between the TOC goals and
performance indicators
Nematipour
et al. (2014)
To describe the application of TP–TOC tools
aimed at the recognition of critical issues and
factors of hospital supply chain in order to
understand the causal relationships between
these factors
A case study applying the TP–TOC in the
supply chain of five major hospitals in
Tehran. The pharmaceutical industry and the
distribution of medicines were analyzed
through the CRT tool
The root problem was the instability in the supply chain
environment of hospitals in Iran, which is located
beyond the range of control and sphere of influence of
chain members
(continued )
Table II.
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Authors Objective Method Results
Pergher et al.
(2016)
Proposes a diagnostics and improvement
approach based on total quality management
to apply in cancer healthcare service services
systems
A case study was applied in the radiotherapy
service authorization process in a large
Brazilian hospital
The main results permitted the definition of a set of
actions to eliminate or reduce the failure modes in
healthcare service systems. In addition to that, one of the
advantages of the approach proposed and applied is the
identification of the root causes (RC) of the problem in
flow management of patients, the undesirable effects of
these causes and the prioritization of the improvement
actions
Souza et al.
(2016)
Analysis of hospital bed management the
perspective of the theory of constraints (TOC)
under a large, private, non-profit hospital in
the Rio Grande do Sul state –Brazil
It focused on applying the Current Reality
Tree (CRT) proposed by the theory of
constraints to alleviate the undesirable effects
(UEs) related to the low availability of hospital
beds. This paper presents a study of a large
Brazilian hospital that aims to improve the
management of the number of hospital beds
using the TOC
The theory of constraints (TOC) seeks to map and act on
constraints, thereby contributing to the mitigation of
waste and the root causes of undesirable effects (UEs).
The number of hospital beds is a significant constraint
on the operation of healthcare service systems because it
receives demands from various areas and requires larger
volumes to implement and maintain
Table II.
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

summary of the research identified in the chronological order. The table shows objectives,
methods and results, as well as the TOC tools of each research. Not all the studies are totally
equivalent to what is made in our study, but the table reinforces the importance of using
TOC in an intrinsic, complex environment, such as healthcare service organizations.
In the healthcare service industry and in the analyzed articles, notable results of the TP–TOC
application are observed. In most cases, the implementation of the TOC seeks to reduce the
patient waiting times, accelerate the availability of beds and serve the largest number of patients
seeking both the patients’and the employees’satisfaction. The DBR was adopted by Umble and
Umble (2006) and Stratton and Knight (2010) in order to reduce waiting times and admission, i.e.,
the flow of patients in the hospital. Regarding the TP–TOC, the main tools adopted were the
CRT, the EC and the FRT. The studies of Taylor and Sheffield (2002), Taylor and Churchwell
(2004), Mabin et al. (2011) and Taylor and Nayak (2012) intended to increase revenue and reduce
costs, while Sellitto (2005) and Nematipour et al. (2014) focused on materials and supplies
management. Souza et al. (2016) presented a study of a large Brazilian hospital that aims to
improve the management of the number of hospital beds using the TOC. Finally, Pergher et al.
(2016) propose a diagnostics and improvement approach based on total quality management to
apply in cancer healthcare service systems.
3. Methodological approach
The research method was the case study (Yin, 2003). The focus of the study was exploratory
and sought field evidence on ways to improve the service quality of a philanthropic hospital
through the TP–TOC. The steps for the elaboration of the research are summarized in
Figure 1. The combination of internal documents and processes observation, publicized
Bibliographic Revision and Analysis
Definition of the Research Method
Analysis of intern documents and interviews with managers
Undesirable Effects (UDE’s) identification
Construction of the Current Reality Tree (CRT)
Development of the Evaporating Cloud (EC)
Indications of Improvement Actions
Discussion and Final Considerations
Theory of Constraints
Thinking Process (TP) of Theory of
Constraints (TOC)
Review of previous studies about TOC
application in Healthcare
Selection of the case object of study
Definition about instruments of
data collection
Proposal of a conceptual framework and an approach to
support decision making
Source: Adapted from Lacerda et al. (2010)
Figure 1.
Structure of research
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

material and data gathered in interviews offered data sources for triangulation.
Triangulation increases reliability and internal validity of the findings (Gibbert and
Ruigrok, 2010; Sellitto, 2018).
The literature review allowed identifying the variables related to hospital services used
in studies aiming the services quality improvement (Table III). Relevant studies retrieved
from the extant literature provided the variables. Two experts of the hospital and two
scholars reviewed and eventually completed the list.
The indicative variables of Table III helped to construct the conceptual framework of
Figure 2 that systematized the study and guided the application. The framework considered
both service quality and patient satisfaction as focal points for analysis. In addition, despite
the proposed framework based on peer-reviewed literature, to the best of our knowledge, no
previous model covering all the elements listed in Table III was found.
To discuss the appropriateness of the proposed framework, the case study conducted
focused on the emergency department of a medium-sized philanthropic Brazilian hospital.
The instruments for data collection and the research protocol were developed, and the study
proposal was presented to the hospital board for approval.
Data collection was carried out between April and July 2014 and included document
analysis, non-participant observation and semi-structured interviews. Interviews were
based on the research constructs presented in Table III and applied to the sources
presented in Table IV. The respondents were chosen based on their experience in the
healthcare sector, work experience in the hospital under study, internal processes
knowledge, strategic level of decision making and knowledge of the human resources
internal policies.
Construct Indicative variables Authors
Infrastructure Equipment for triage and diagnosis
Bed needs satisfaction
Suitable rooms and spaces
Necessary staff
Services and examinations for emergency
Ritson and Waterfield (2005),
Battaglia et al. (2012)
Internal
processes
Schedule for physicians’and nurses’activities
Workforce leveling
Time to admissions
Length of stay
Registration, triage and admission
Taylor and Nayak (2012), Groop
et al. (2010), Umble and Umble
(2006), Ritson and Waterfield
(2005), Lubitsh et al. (2005), Lowsby
et al. (2017)
Financial
context
Financial contributions or voluntary actions for hospital
activities (in countries where the public ownership
dominates in healthcare sector relatively little attention is
paid to the issues of financial management in hospitals)
Payments related to the medical services
Sources of revenue
Government awareness of the need to foster and support
the hospital sector
Bem et al. (2014), Gupta and Kline
(2008), Lee (2015)
Human
resources
Employees’training and qualification
Team career plan
Relationship and communication among employees
People retention
Mabin et al. (2011), Taylor and
Churchwell (2004), Taylor and
Sheffield (2002)
Patients
satisfaction
Waiting for appointments and emergency care
Need to seek treatment in another city
Taylor and Nayak (2012), Lubitsh
et al. (2005), Womack and Flowers
(1999)
Service
quality
Delays occurring in patient care
Challenges and opportunities in services
Mabin et al. (2011), Kershaw (2000),
Womack and Flowers (1999)
Table III.
Constructs and
indicative variables
associated with
studies on hospital
service quality
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Fromtheinterviews,thecoreproblemwasidentifiedasthepatients’dissatisfaction and
the low quality of services provided by the hospital. The non-participant observation
stage focused on the main processes of the SUS care system. Internal documents related to
the number of attendees per specialty were analyzed, and the processes have been selected
considering the relevance of the medical specialties to the hospital emergency care. The
non-participant observation stage was held for two weeks, accompanying the reception,
triage and nurses.
The items observed were: the physical infrastructure (general maintenance of the
building, furniture, equipment and utensils); the use of equipment and supplies; the
workload leveling between the teams was observed; the relationship between employees
during working hours in patient care and assistance in the emergency sector; the equipment
for triage; the occurrence of triage; the registration of patients; waiting times; and the
internal coordination of the team in regard to the patients’care.
The CRT and EC tools were applied to the core problem. From the data collection, the
research team, first, proceeded to the modeling of the CRT. The causal model generated
was validated with the organization representatives (head nurse, hospital president
and hospital CEO). Then, EC diagrams have been built to explicit premises and to
discuss the identified conflicts. These diagrams also have been discussed and validated
Health System
Patient
satisfaction
Service
quality
Internal
processes
Financial
context
Human
resources Infrastructure Action Plan
(Continuous improvement)
Root Cause Analysis
Causal Model
(Cause-and-effect relationships)
Current Reality Tree (CRT)
Figure 2.
Conceptual framework
related to TP–TOC in
a health system
Function Qualification Experiences
Head nurse Bachelor of nursing; specialization in
emergency care; emergency management; and
public health; masters’degree in education
25 years of experience in hospital services
and hospital management; 4 years of
experience in the studied hospital
President Bachelor in public administration;
specialization in business management
Hospital’s secretary from 2011 to 2013;
hospital’s president from November 2013 to
March 2015; secretary of the hospital board
from March 2015 to April 2016
CEO Bachelor in marketing science Experience of 10 years in the banking sector;
2 years in the studied hospital
Treasurer Bachelor of accounting science 2 years in the studied hospital
Nurses (tree) Technical training in nursing Average experience from of 3 years in the
studied hospital (minimum 2 years;
maximum of 5 years)
Administrative
assistant
Bachelor in business management 3 years’experience in the studied hospital
Table IV.
Interviewees’profile
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

with the same representatives, allowing an in-depth RC analysis. This analysis has served
as a basis for the discussions about the core problem, driving the analysis to the
proposition of improvement actions in the hospital. The actions were presented to
the hospital board and discussed with regard to their feasibility and the resources
required for their implementation.
The observations and experience arisen from the case study were then used to discuss
the framework proposal presented.
4. Results and discussion
The Hospital Foundation under study has been in operation since 1983. It offers SUS
services (medical assessments, glucose testing, nutritional assessment, blood pressure
control) and examinations (laboratory, EGG, x-rays, scans and endoscopies) to
the community. The hospital has 61 employees (25 nursing technicians, 5 people in the
sanitation sector and 31 in the administrative services, including billing, chairman, director).
The hospital had 52 beds and had been facing an increased demand for hospitalizations.
Monthly hospitalizations rose from 78 in 2013 to 168 in 2014, on average. Despite such
increase, beds were not a constraint yet. The average daily attendance in the ED had
doubled, from an average of 60.3 patients in 2013 to 126.6 patients in 2014. The projection
was a total amount of 45,000 medical appointments in 2014.
4.1 CRT and EC analysis
Figure 3 shows the CRT for the ED. Figure 3 embraces the logical relationships subjacent to
the CRT tool. The construction of the CRT is abundantly described in the extant literature.
High staff
turnover
The nurses become
unmotivated
The nurses carry the
most workload
There is no
workload leveling
between the team
Nurses do not
communicate
absence
There is no
continuous
training
There is no career
plan for nurses
Lack of
specialist
physicians in
the emergence
Patients are referred to
another town for treatment
Individualism and
competitiveness
among the nurses
Patients
pressure
the nurses
Nurses become
exhausted
The nurses do not do
not do their job with
so much willingness
Inefficient
quality of service
Patients become dissatisfied
with the hospital service
Patients look
for treatment
in another
hospital
Decision making is
flawed
Management lack of
processes visibility
Patients seek
private care to cover
their needs
Delays occur in patient
treatment
There is no performance
control by operational
efficiency indicators
Patients with simple problems
may take precedence in the
emergency rooms
The patients do not have
information which health
center they should go to
Lack of
structured
triage process
Patients prefer to
go to hospitals
due to ease of
access
Lack of some
patient triage
equipment Lack of
emergency
severity index
The resources for
equipment purchase
are limited
Legend UDE’S (Undesirable Effects) Internal Causes External Causes
Inequality of job
description/compen-
sation of nurses
Figure 3.
Current reality tree
for the ED patient’s
dissatisfaction
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Among many others, we point Kendall (2004) to further details on the construction.
The CRT corresponds to the causal model of Figure 2.
Figure 3 must be followed as in the following example: if “there is no emergency severity
index,”then “there is no structured triage process,”and then “patients with simple problems
may take precedence in the emergency rooms.”As a consequence, “delays occur in the
treatment,”leading to “patients seek to private care to cover their needs”and, as a
consequence, to patients’dissatisfaction with the hospital services and low quality.
The relationships between the causes and effects observed in the hospital lead to
dividing causes into internal and external. Mainly, the limited resources and the lack of
employee relationship between physicians and the hospital are external causes related to the
structure of SUS. Hospitals depend on government budget to operate, and other
inefficiencies in the bureaucratic system lead to delayed or poorly allocated resources. In the
same sense, physicians use the facilities of the hospital, but they are considered as partners
and not as employees in the system. This leads to agency problems ( Jensen and William,
1976), creating an environment in which negotiation tends to prevail over hierarchy, thus
leading to higher managerial complexity.
The internal causes relate to the lack of severity index for triage, the lack of demand
management for specialties based on schedules, the lack of career plan for nurses, the lack of
workload leveling among the teams and the lack of continuous training. These causes may be
correlated to the need of professionalization in hospital management (Bornhost, 2015; Butler
et al., 1996; Taylor and Sheffield, 2002) or the gap still existent between hospital services and
operations management (Butler et al., 1996; Li et al., 2002). Nevertheless, the internal RC allows
us inferring that action should be taken to improve the allocation and adequate use of the
workforce in the hospital, to reduce patient’s dissatisfaction with this service.
As a third category of RCs, patients lack information to choose the health center they
should go look for treatment and patients prefer to go to hospitals for ease of access. These
RCs have been classified separately since they represent a socio-cultural trend, effect of
another systemic problem: since there is an understanding of lengthy and cumbersome
public health service, patients tend to skip the level of the Basic Care Units (BCU –Unidade
Básica de Saúde) for assessment, and to go directly to hospitals. Hospitals are not allowed to
refuse patients, becoming hubs of excess demand. Meanwhile, the lack of information about
service and occupation levels in different BCUs and hospitals reinforces such population
behavior, since hospitals are seen as more prepared to attend severe cases.
From the analysis, it has become also evident that actions focused just on internal causes
would mitigate, but not completely eliminate the problem of patients’dissatisfaction. As the
UEs arise independently of other causes, any of these RC may lead patients to become
dissatisfied. This perception of independence of causes is coherent to the context of
healthcare (Groop et al., 2010).
As the hospital team was able to identify and to learn about the RC and their influence on
patient satisfaction and quality services, it was possible to move to the RC and conflict
analysis. The following step was to discuss how the hospital could draw up a plan to
provide better service to the population based on the improvement of the processes
associated with the internal roots identified.
A set of EC diagrams was built to explicit existing conflicts, in order to drive potential
solutions to the hospital. For instance, it was observed the lack an adequate triage system in
the ED. To implement such system the hospital must train the team and invest in equipment
and infrastructure. However, this requires investment in both personnel training and
equipment. The conflict arises since the hospital does not have resources to do so (Figure 4).
Figure 4 depicts the EC tool to find the RC (or core problem) of the ill-defined situation.
As for the CRT, the extant literature abundantly describes the construction of the tool. The
EC corresponds to the causal analysis of Figure 2.
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

As a plan of action, in the short term, it is suggested that the hospital develops a career
plan, as well as staff training, influencing their turnover rate. In addition, training should
only be provided to those employees with in-depth knowledge of the processes, with
minimum two-year company time. In the medium term, information should be provided to
the public so that they are aware of available services, and locations other than the hospital
to seek a diagnosis. Also in the triage process, the hospital can adopt a color system. In
addition, in terms of long-term investments in equipment can be made according to the
perspective of receiving and reimbursing funds at federal, state and municipal levels.
While external factors become more difficult to manage by the hospital, such as federal,
state and municipal government resources for the acquisition of equipment and expansion
of physical facilities. However, it is suggested to start-up funds from private entities and the
development of campaigns encouraging spontaneous contribution from the population, also
new ways of thinking public–private partnerships projects in healthcare service can
contribute to attendance improvement.
4.2 Discussion
SUS is a complex system (Paim et al., 2011; PWC, 2013). It consists of a series of
interdependent units that complement each other and seek to meet the population health
needs. The system evolved from previous national health policies, aiming at increased
efficiency. Nevertheless, it still falls short on its objectives due to factors such as the
identified as external in this study.
Information to the population is a key aspect: many citizens do not know if they should
either look for a BCU, an Emergency Care Unit (ECU) or a hospital ED. In 2003, the Brazilian
Ministry of Health created the ECU program to integrate emergency care and to reduce
waiting times in hospitals (Ministério do Planejamento, 2017). Nevertheless, no adequate
orientation was disseminating to the population. As a consequence, hospitals receive a
significant amount of cases that could be attended in BCUs distributed across the
neighborhoods. Intermediate-severity cases could be transferred from BCUs or directly
taken to ECUs, which act as hubs for BHUs (Ministério do Planejamento, 2017; Portal Brasil,
2011) allowing hospitals to care about their core focus: acute cases, and elective treatment. In
other words, part of patients’dissatisfaction is related to the misunderstood use of SUS:
many people end up in hospitals because there is full (excess) care, instead of being directed
to seek neighborhood health workers as soon as a health condition appears.
There are other contextual elements that contribute to patient dissatisfaction. The health
sector experiences problems originated from the public health management process. Despite
the tax exemptions received by the Hospital Foundation, as a philanthropic institution, the
amount the government reimburses the hospitals does not cover the costs of consultations
and procedures. This entails the Foundation’s deficit, which tends to generate long-term
concerns about investment and interferes with the service quality provided to the patient.
In the hospital under analysis, the triage process was not well structured and required
changes, as well as the training of personnel involved in this process. Such fact is similar to
There is an adequate
triage system
The team is trained in
the triage process
There is the necessary
equipment for patients triage
Constant investments in staff
training
Investments are made in
equipment and infrastructure
Conflict Figure 4.
Evaporating cloud
diagram for the lack
of adequate triage
system
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

that found by Taylor and Nayak (2012), in the emergency department of a Texas hospital. In
addition, it is at the ED that patients’expectations regarding staff communication with
patients wait times, the triage process, capacity and payment will determine a significant
part of a hospital’s revenue (Taylor and Nayak, 2012).
The triage is as an essential first step in efficient and effective emergency care (Lowsby
et al., 2017). The introduction of a risk classification in health centers, hospitals and
outpatient clinics can ease the burden of emergency and emergency services (Groop et al.,
2010; Taylor and Nayak, 2012). Patients can be redirected to other providers such as clinics,
urgent and/or private care centers. Lowsby et al. (2017) suggest the use of colored categories
triage systems since they ensure that patients with greater acuity are prioritized after
screening evaluation. Once patients are seen by a healthcare service provider, a decision is
usually made quickly with regard to greater management, i.e., discharge or admission.
The improvement of several processes, such as the screening system and the
communication, has a direct impact on patient care, as observed by Groop et al. (2010).
Training and qualification can improve the workload leveling, which would result in
serving more patients and improving productivity. These effects could also contribute to
reducing, in the specific case of the studied service, the nurse’s overload and the
staff turnover.
The development of a careers and salaries plan was also identified as relevant. For the
physicians, the SUS remuneration table is perceived as low-payment, leading newly
graduates do not want to work on the ED. For the nurses and technicians, the possibility of
foreseen career progression is also perceived as a motivational aspect.
Overall, implications drawn from this study are:
•The implementation of the TP–TOC was relevant for the hospital staff and
managers, agreeing with the stated by Goldratt (1990) and Reid and Cormier (2003).
In any organization, there are professionals with conflicting goals, as evidenced in
this study. The operational tools allowed to give attention and to combine the
opinions of those involved, revealing, in a constructive manner, the hospital current
reality and the root problems associated with the patients’dissatisfaction. The
collaborative and friendly approach enabled those involved to explain their
perceptions about the working atmosphere, forming a consistent and plural view of
the encountered problems (Goldratt, 1990).
•The incorporation of procedures in a systematic way as proposed in the framework
has allowed improving the decision making and action planning (Reid and Cormier,
2003; Taylor and Churchwell, 2004). In the specific context, it is possible to conduct
an in-depth analysis of the system and its relationships before any intervention
being performed.
•In a broader sense, it was evidenced by the participants the possibility of applying
the TP–TOC approach as an operational support in the preparation of certain
stages of the strategic planning, allowing the verification of the strengths and
weaknesses of the hospital processes through the CRT and the other tools. It was
possible to identify to which processes the actions should be directed to so that
there would be a greater gain to the hospital as a whole. This view agrees with the
presented by Cox and Spencer (1999).
In short, while the potential for applying the approach of this paper is observed, a lack of
operational mechanisms that allow tactical and strategic troubleshooting in health service
environments is inferred. This perception is coherent to that stated by Bornhost (2015) and
Butler et al. (1996). Although based on a single study carried out, the perception detected
from the participants’reports is that, at least regionally, there is room for improvement of
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

the planning and decision-making processes by means of this and other approaches of
operations management. This argument echoes also on the perception of mimetic
isomorphism found in hospital and care systems (Bornhost, 2015; Souza et al., 2016).
5. Final remarks
The aim of this study was to propose an approach based on the TP–TOC to support
decision-makers, managers and professionals of health to diagnose and improve healthcare
systems focusing on the service quality deployed to patients. A case study was developed in
a SUS-affiliated philanthropic hospital in southern Brazil, through the analysis of its ED
processes application of the TP–TOC. The TOC–TPC framework generated the application
of the CRT and EC tools that supported the construction of an action plan and the analysis
of its implications on the service, providing a connectivity along the steps of the study.
Data were triangulated from different sources to provide evidence on how UEs are
perceived and combined to generate patients’dissatisfaction. Delays in patients’treatment,
exhausted and unmotivated nurses and lack of adequate triage are examples of identified
problems. Root problems related to internal management were the lack of a workload
leveling between the team, lack of a program of employees’continuous training, lack of a
career plan for nurses and the lack of an emergency severity index. External RC also have
been identified and discussed, as limited resources for equipment purchase, lack of
information to patients choose the health center they should go to look for treatment.
The proposed approach allowed the hospital team to progress in the understanding of
such causes in a sequential manner, giving conditions to apport different perceptions and to
identify relevant facets and causes related to the problem besides the commonly referred
(such as lack of resources and excess bureaucracy). In the context of the study, developing a
structured method for screening patients as an emergency severity index is essential. In
addition, it was suggested to develop a system to prioritize some consultations with experts,
and demand management based on schedules that do not follow the logic “first to mark will
be the first to be scheduled.”As patients do not know which health center they should go to
according to symptoms, the city should create information plans to direct patients to BCUs
and ECUs, disclosing to the population when each provider should be sought for assistance.
From the perspective of the hospital management, the results of this research generate
evidence that can be confronted with research or similar contexts, and it can provide
support for the better use of resources. However, the TOC is an ongoing process and not an
appropriate and permanent solution to a particular situation (Lin, 2009). It is important to
consider changes in business environments. It cannot be generalized that a particular TOC
application will result in a gain for other similar philanthropic institutions.
As a suggestion for further research in the light of the TP–TOC, comparisons of the
costs incurred through the activity-based costing or throughput accounting and similar
applications in the healthcare sector could be made. Also, the framework proposed in this
work should be further analyzed and applied. Studies on bed management, surgical
centers and image diagnostic centers could provide evidence for testing and refine the
proposed approach.
References
Alástico, G.P. and Toledo, J.C. (2013), “Acreditação Hospitalar: proposição de roteiro para implantação”,
Gestão & Produção, Vol. 20 No. 4, pp. 815-831.
Anahp (2015), Livro Branco: Brasil Saúde 2015, Anahp, São Paulo.
Battaglia, D., Borchardt, M., Sellitto, M. and Pereira, G. (2012), “Service recovery: a method for
assessing performance”,Business Process Management Journal, Vol. 18 No. 6, pp. 949-963.
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Bem, A., Predkiewicz, K., Predkiewicz, P. and Ucieklak-Jez, P. (2014), “Determinants of hospital’s
financial liquidity”,Procedia Economics and Finance, Vol. 12, pp. 27-36.
Bornhost, S.G. (2015), “Método para o planejamento de serviços médicos em hospitais brasileiros”, PhD
thesis, Dissertação (Mestrado em Gestão e Negócios), Unisinos, São Leopoldo.
Burmester, H., Pereira, J.C. and Scarpi, M.J. (2007), “Modelo de Gestão para organizações de Saúde”,
Revista de Administração em Saúde, Vol. 9 No. 37, pp. 125-132.
Butler, T.W., Leong, G.K. and Everett, L.N. (1996), “The operations management role in hospital
strategic planning”,Journal of Operations Management, Vol. 14 No. 2, pp. 137-156.
Cox, J.F. and Spencer, M. (1999), The Constraints Management Handbook, St Lucie Press/APICS,
Boca Raton, CA.
Dettmer, H.W. (1997), Goldratt’s Theory of Constraints: A Systems Approach to Continuous
Improvement, ASQC Quality Press, Milwaukee, WI.
Gibbert, M. and Ruigrok, W. (2010), “The ‘what’and ‘how’of case study rigor: three strategies based on
published work”,Organizational Research Methods Journal, Vol. 13 No. 4, pp. 710-737.
Goldratt, E.M. (1990), What is This Thing Called Theory of Constraints and How should it be
Implemented? North River Press, New York, NY.
Goldratt, E.M. (1994), It’s Not Luck, North River Press, New York, NY.
Groop, J. (2012), “Theory of constraints in field service: factors limiting productivity in home care
operations”, PhD thesis, Aalto University School of Science, Espoo.
Groop, J., Reijonsaari, K. and Lillrank, P. (2010), “Applying the theory of constraints to health
technology assessment”,International Journal on Advances in Life Sciences, Vol. 2 Nos 3-4,
pp. 115-125.
Gunal, M.M. (2012), “A guide for building hospital simulation models”,Health Systems, Vol. 1 No. 1,
pp. 17-25.
Gupta, M. and Kline, J. (2008), “Managing a community mental health agency: a theory of constraints
based framework”,Total Quality Management, Vol. 19 No. 3, pp. 281-294.
Gupta, M., Boyd, L. and Sussman, L. (2004), “To better maps: a TOC primer for strategic planning”,
Business Horizons, Vol. 47 No. 2, pp. 15-26.
Gupta, M.C. and Boyd, L.H. (2008), “Theory of constraints: a theory of operations management”,
International Journal of Operations & Production Management, Vol. 28 No. 10, pp. 991-1012.
Hunink, M.G. (2001), “In search of tools to aid logical thinking and communicating about medical
decision making”,Medical Decision Making, Vol. 21 No. 4, pp. 267-277.
IBGE (2017), Anuário estatístico do Brasil, Vol. 77, Instituto Brasileiro de Geografia e Estatística,
Rio de Janeiro.
Jensen, M.C. and William, H.M. (1976), “Theory of the firm: managerial behavior, agency costs and
ownership structure”,Journal of Financial Economics, Vol. 3 No. 4, pp. 305-360.
Kendall, G. (2004), Viable Vision: Transforming Total Sales into Net Profits, J. Ross Publishing,
Ft. Lauderdale, FL.
Kershaw, R. (2000), “Using TOC to cure healthcare problems”,Management Accounting Quarterly,
Vol. 1 No. 3, pp. 1-7.
Kim, S., Mabin, V.J. and Davies, J. (2008), “The theory of constraints thinking processes: retrospect
and prospect”,International Journal of Operations & Production Management, Vol. 28 No. 2,
pp. 155-184.
Kuchenbecker, R. and Polanczyk, C.A. (2012), “Institutionalizing health technology assessment in
Brazil: challenges ahead”,Value in Health Regional Issues, Vol. 1 No. 2, pp. 257-261.
Lacerda, D.P., Cassel, R.A. and Rodrigues, L.H. (2010), “Service process analysis using process
engineering and the theory of constraints thinking process”,Business Process Management
Journal, Vol. 16 No. 2, pp. 264-281.
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

La Forgia, G.M. and Couttolenc, B.F. (2008), Hospital Performance in Brazil –The Search for Excellence,
The World Bank, Washington, DC.
Lee, M. (2015), “Financial analysis of national university hospitals in Korea”,Osong Public Health, and
Research Perspectives, Vol. 6 No. 5, pp. 310-317.
Li, L.X., Benton, W.C. and Leong, G.K. (2002), “The impact of strategic operations management
decisions on community hospital performance”,Journal of Operations Management, Vol. 20
No. 4, pp. 389-408.
Lin, Z. (2009), “Using TOC thinking process tools to improve safety performance”, World Congress on
Software Engineering, Xiamen, Vol. 3, pp. 13-17.
Lowsby, R., Kamar, C., Kamar, M., Nyhus, H., Williams, N., Bradfield, M. and Harrison, H. (2017), “An
assessment of nurse-led triage at Connaught hospital, Sierra Leone in the immediate post-Ebola
period”,African Journal of Emergency Medicine, Vol. 7 No. 2, pp. 51-55.
Lubitsh, G., Doyle, C. and Valentine, J. (2005), “The impact of theory of constraints (TOC) in an NHS
trust”,Journal of Management Development, Vol. 24 No. 2, pp. 116-131.
Mcnutt, R.A. and Odwazny, M.C. (2004), “The theory of constraints and medical error: a conversation
with Robert A. McNutt”,Quality Management in Healthcare, Vol. 13 No. 3, pp. 183-187.
Mabin, V.J. and Davies, J. (2010), “The TOC thinking process”, in Cox, J.F. III and Schleier, J.G. Jr (Eds),
Theory of Constraints Handbook, McGraw Hill, New York, NY, pp. 631-669.
Mabin, V.J., Babington, S., Caldwell, V., Yee, J. and Moore, R.M. (2011), “A change is as good as a rest:
using the theory of constraints to resolve resource constraints in a large public hospital”,in
Sengupta, K. (Ed.), Proceedings of the 42nd Annual Meeting of Decision Sciences Institute,
Atlanta: Decision Science Institute, Boston, MA, November, pp. 4271-4279.
Mazzocato, P., Savage, C., Brommels, M., Aronsson, H. and Thor, J. (2010), “Lean thinking in healthcare:
a realist review of the literature”,Quality and Safety in Health Care, Vol. 19 No. 5, pp. 376-382.
Ministério do Planejamento (2017), “UBS –Unidade Básica De Saúde”, available at: www.pac.gov.br/
comunidade-cidada/ubs-unidade-basica-de-saude/pr (accessed May 5, 2017).
Motwani, J., Klein, D. and Harowitz, R. (1996a), “The theory of constraints in services: part 1 –the
basics”,Managing Service Quality, Vol. 6 No. 1, pp. 53-56.
Motwani, J., Klein, D. and Harowitz, R. (1996b), “The theory of constraints in services: part 2 –examples
from health care”,Managing Service Quality, Vol. 6 No. 2, pp. 30-34.
Nematipour, M., Ramzi, J. and Parsanejad, M.R. (2014), “Introducing the theory of constraints-based
methodology to identify the hospital supply chain shortcomings”,Journal of Applied Sciences,
Vol. 14 No. 24, pp. 3633-3637.
Noreen, E., Smith, D. and Mackey, J. (1995), Theory of Constraints and Its Implications for Management
Accounting: A Report on the Actual Implementation of the Theory of Constraints, North River
Press, Boca Raton, FL.
Paim, J., Travassos, C., Almeida, C., Bahia, L. and Macinko, J. (2011), “The Brazilian health system:
history, advances, and challenges”,The Lancet, Vol. 377 No. 9779, pp. 1778-1797.
Patwarddhan, M.B., Sarría-Santamera, A. and Matchar, D.B. (2006), “Improving the process of
developing technical reports for health care decision-makers: using the theory of constraints in
the evidence-based practice centers”,International Journal of Technology Assessment in Health
Care, Vol. 22 No. 1, pp. 26-32.
Pergher, I., Brandolf, V., Pacheco, D. and Vaccaro, G. (2016), “A patient-centric approach to improve
health care services”,Cogent Business & Management, Vol. 3 No. 1, pp. 1-17.
Poksinska, B.B., Fialkowska-Filipek, M. and Engström, J. (2016), “Does Lean healthcare improve
patient satisfaction? A mixed-method investigation into primary care”,BMJ Quality & Safety,
Vol. 26, pp. 95-103.
Polito, T. and Capen, M.M. (2014), “Theory of constraints thinking processes: a copy shop case
application”,The Journal of American Academy of Business, Vol. 20 No. 1, pp. 33-39.
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Portal Brasil (2011), “Unidades ajudam a desafogar os prontos-socorros”, available at: www.brasil.gov.
br/saude/2011/08/unidades-ajudam-a-desafogar-os-prontos-socorros (accessed May 5, 2017).
PWC (2013), The Healthcare Market in Brazil, PricewaterhouseCoopers Brasil, São Paulo, available at:
www.pwc.com.br/pt/publicacoes/setores-atividade/assets/saude/healthcare-tsp-13.pdf (accessed
May 15, 2017).
Rahman, S. (2002), “The theory of constraints’thinking process approach to developing strategies in
supply chains”,International Journal of Physical Distribution & Logistics Management, Vol. 32
No. 10, pp. 809-828.
Reid, R.A. and Cormier, J.R. (2003), “Applying the TOC TP: a case study in the service sector”,
Managing Service Quality, Vol. 13 No. 5, pp. 349-369.
Ren, Q., Luo, L., Yang, C., Ji, J. and Gong, R. (2013), “Applying the TOC five-step focusing process in
surgical process”,10th International Conference on Service Systems and Service Management,
Hong Kong, pp. 228-231.
Ritson, N. and Waterfield, N. (2005), “Managing change: the theory of constraints in the mental health
service”,Strategic Change, Vol. 14 No. 8, pp. 449-458.
Rotstein, Z., Wilf-Miron, R., Lavi, B., Seidman, D.S., Shahaf, P., Shahar, A., Gabay, U. and Noy, S. (2002),
“Management by constraints: considering patient volume when adding medical staff to the
emergency department”,The Israel Medical Association Journal, Vol. 4 No. 3, pp. 170-173.
Sadat, S., Carter, M.W. and Golden, B. (2013), “Theory of constraints for publicly funded health
systems”,Health Care Management Science, Vol. 16 No. 1, pp. 62-74.
Sellitto, M. (2005), “TOC thinking process as a systemic alternative for organizational analysis: an
application in public health”,Gestão & Produção, Vol. 12 No. 1, pp. 81-96.
Sellitto, M. (2018), “Assessment of the effectiveness of green practices in the management of two supply
chains”,Business Process Management Journal, Vol. 24 No. 1, pp. 23-48.
Silvester, K., Lendon, R., Bevan, H., Steyn, R. and Walley, P. (2004), “Reducing waiting times in the
NHS: is lack of capacity the problem”,Clinician in Management, Vol. 12 No. 3, pp. 105-111.
Snyder, K.D., Paulson, P. and McGrath, P. (2005), “Improving processes in a small health-care network”,
Business Process Management Journal, Vol. 11 No. 1, pp. 87-99.
Souza, L.B. (2009), “Trends and approaches in lean healthcare”,Leadership in Health Services, Vol. 22
No. 2, pp. 121-139.
Souza, M., Souza, T. and Vaccaro, G. (2016), “Hospital bed management: an analysis from the
perspective of the theory of constraints”,Espacios, Vol. 37 No. 30, p. 3, available at: www.
revistaespacios.com/a16v37n30/16373003.html
Stratton, R. and Knight, A. (2010), “Managing patient flow using time buffers”,Journal of
Manufacturing Technology Management, Vol. 21 No. 4, pp. 484-498.
Taylor, L.J. III and Churchwell, L. (2004), “Goldratt’s thinking process applied to budget constraints of a
Texas MHMR facility”,Journal of Health and Human Services Administration, Vol. 26 No. 4,
pp. 416-438.
Taylor, L.J. III and Nayak, S. (2012), “Goldratt’s theory applied to the problems associated with an
emergency department at a hospital”,Administrative Sciences, Vol. 2 No. 4, pp. 235-249.
Taylor, L.J. III and Sheffield, D. (2002), “Goldratt’s thinking process applied to medical claims
processing”,Hospital Topics, Vol. 80 No. 4, pp. 13-21.
Tsitsakis, C.A. (2010), “The problem of capacity management in Greek public hospitals”,Management
of International Business & Economic Systems International Conference, pp. 541-545.
Umble, M. and Umble, E.J. (2006), “Utilizing buffer management to improve performance in a healthcare
environment”,European Journal of Operational Research, Vol. 174 No. 2, pp. 1060-1075.
Victora, C.G., Barreto, M.L., Leal, M.C., Monteiro, C.A., Schmidt, M.I., Paim, J., Bastos, F.I., Almeida, C.,
Bahia, L., Travassos, C., Reichenheim, M. and Barros, F.C. (2011), “Health conditions and health-
policy innovations in Brazil: the way forward”,The Lancet, Vol. 377 No. 9782, pp. 2042-2053.
BPMJ
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)

Wadhwa, G. and Schleier (2010), “Viable vision for health care systems”, in Cox, J.F. III and Schleier, J.G.
Jr (Eds), Theory of Constraints Handbook, McGraw Hill, New York, NY, pp. 899-954.
Watson, K.J., Blackstone, J.H. and Gardiner, S.C. (2007), “The evolution of a management philosophy:
the theory of constraints”,Journal of Operations Management, Vol. 25 No. 2, pp. 387-402.
WHO (2017), “Global health expenditure database”, World Health Organization, Geneva, available at:
www.who.int/countries/bra/en/ (accessed May 30, 2017).
Womack, D.E. and Flowers, S. (1999), “Improving system performance: a case study in the application
of the theory of constraints”,Journal of Healthcare Management, Vol. 44 No. 5, pp. 397-405.
Wright, J. and King, R. (2006), We All Fall Down: Goldratt’s Theory of Constraints for Healthcare
Systems, The North River Press Publishing Corporation, Great Barrington, MA.
Yin, R.K. (2003), Case Study Research: Design and Methods, Sage Publications, Thousand Oaks, CA.
Further reading
Goldratt, E.M. and Cox, J. (1984), The Goal, North River Press, New York, NY.
Ronen, B. and Pass, S. (2010), “Services management”, in Cox, J.F. III and Schleier, J.G. Jr (Eds), Theory
of Constraints Handbook, McGraw Hill, New York, NY, pp. 845-858.
Taylor, L.J. III and Thomas, E.E. (2008), “Applying Goldratt’s thinking process and the theory of
constraints to the invoicing system of an oil and gas engineering consulting firm”,Performance
Improvement, Vol. 47 No. 9, pp. 26-34.
WHO, “Global health observatory data repository”, World Health Organization, available at: http://
apps.who.int/gho/data/node.country.country-BRA/ (accessed March 1, 2016).
Corresponding author
Jéssica Mariela Bauer can be contacted at: jehbauer@hotmail.com
For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com
TP–TOC
applied to
public
healthcare
Downloaded by UNISINOS At 15:07 21 January 2019 (PT)