Clinical healthcare is the last place you’d find TOC. In fact, I’m the only person I know that has applied TOC to diagnosis and treatment. Maybe that’s why I have so few colleagues who think we can do a much better job treating addiction than we do today.
When someone is treating a patient for any illness, there is a series of steps necessary to execute that care. First the patient has to communicate the complaint, then the physician does an assessment, and then makes a diagnosis. The potential interventions for the diagnosis are discussed together and the two create a treatment plan they agree on. That plan is then executed, and, if successful, reaches an end point. If the executed treatment isn’t successful, alternatives are looked at and treatment is replanned to a successful endpoint. There’s a beginning, a middle, and an end. There are discrete steps that occur in a dependent order, and you could draw those steps in a Gantt chart. Treating a patient is a project.
Now imagine you have 15 patients in group treatment for addiction. They are all at different stages of completion, they require somewhat different resources for treatment, and they have different understandings of their roles in the process. You now have, in project management terms, a nightmare.
But all is not lost. Many organizations outside of medicine deal with multiple projects requiring overlapping resources and have for years. In manufacturing, computer programming, and construction, companies have been dealing with these issues. Many have found the TOC concept of Critical Chain to be helpful. Those who have an in depth interest may want to get the book. Others may just want the highlights below.
In the field of addiction treatment the goal is not well defined. You might think that it would be the cessation of use of a drug, but that doesn’t really work. Addiction as a brain illness doesn’t really care which drug you use, so even if you say cessation of all drugs, it will just chose something like overeating or gambling that doesn’t fall into your definition. So we need a real endpoint that matters to everyone involved in the system. But before I get there, let me take a short detour into the Levels of Care.
Addiction treatment has always centered around the Levels of Care: Inpatient, Residential, Partial Hospital, Intensive Outpatient Treatment, and finally, Outpatient. At every level, practitioners have focused on “treating addiction,” not getting patients to a lower level of care. In fact, in the rest of medicine, the goal of any inpatient treatment is to get the patient to outpatient status. The goal of outpatient status is to make the patient not an acute patient anymore. This gives us a clue about the goal of addiction treatment.
The point of treating a patient is to make them a non-patient, or someone who doesn’t need you. In addiction parlance, that would be a person in full voluntary recovery. It doesn’t mean AA sainthood. It doesn’t mean they don’t have problems any more. It only means that they are engaged in a process in which they don’t need you for further progress. That’s it.
If we’re going to do a better job managing patient care, we’re going to have to get clearer endpoints of treatment. We have to be clear about the goal of treatment. We can’t hang on to patients because we like them or we think they’re doing good work. No one runs a project that way, and we shouldn’t either.
Timing and LOS
In projects there is the concept of a time buffer. The project is projected to be completed on a date certain, but you never know in advance what could happen to delay you. So you put in buffers to allow for unexpected occurrences. Addiction treatment has had this kind of problem too, but didn’t have TOC to solve it. Enter Lengths of Stay (LOS).
Addiction treatment has used LOS as a measure of treatment completion rather than functional status from the very beginning. This stemmed from the focus on the first drug treated (alcohol), the time it took for the average patient to “clear” enough to be treated, and the time it took to get people to where they needed to be to leave. This is the famous 28 days.
The problem in projects is that getting it done faster generally isn’t rewarded, while problems that delay a step just get passed on to the next step and accumulate. This results in most projects being late. The same is true for addiction treatment. Give us 28 days and we’ll take 28 days. If we can get it done faster, we get paid less. Good luck with that. Finally, delays accumulate and each complication sets the whole treatment system back. No wonder everyone is calling the insurance company for more days at the end of the agreed upon period.
Taking treatment as a project and using TOC gives us a way to focus on the critical chain of steps of the treatment. It gives us a way to do treatment faster with less waste. Using TOC and a project based approach, I became convinced we could get IOP treatment down to two weeks from active addiction to full voluntary recovery. But it requires focusing on the critical chain.
One of the key aspects of TOC is the promotion of focus. It is often said that if you focus on everything, you are focused on nothing. This is true in medical treatment as well.
The need to focus gives us a way to find the critical chain of treatment in any given patient. We know the goal, we can map the progress towards the goal, and we can identify the barriers to that progress. What we need to focus on is what is the barrier today. Too often we as clinicians are distracted by interesting bits of history and fascinating exam findings that have nothing to do with removing the barriers to the goal. But they are interesting or easy to solve, so we concentrate on them.
The focusing steps of TOC give us a way to stay focused, but it’s also important to avoid multi-tasking. I used to work at a company that thought it “ran a lean ship.” Well, I guess it did, but it was so lean that everyone had 3 or 4 jobs. It’s no surprise that nothing got done, and no one ever met a deadline. If you have serial steps to complete, the fastest way to do them is one at a time. Jumping back and forth or taking focus off what you’re doing just delays things. We should not sacrifice the patient or the payor for the sake of “efficiency” by trying to do more than one thing well at a time.
Resource constraints and sharing
It often happens in projects that a step is ready to be completed but the person who is supposed to do it isn’t there. Maybe they were working on another project and haven’t finished, or the scheduling wasn’t done well. In projects this is called a resource constraint, and most companies with multiple projects have to share resources between them.
Just as in projects, treatment requires certain resources too. The patient has become cognitively ready to accept medication but the doctor doesn’t have an appointment until next Tuesday. This patient is ready to resolve a barrier regarding their anger, but anger isn’t covered in group until this Thursday. When we have patients waiting around ready with no resource to help them, we aren’t just wasting time. Unlike most projects, patients can move backwards if not moving forwards. Leaving someone who is ready to move forward just standing still, often leads to backsliding and a lot of rework.
Just as we can develop a critical chain for a patient, we can develop a critical chain for a treatment group. Various people in the group will require various interventions at various times. It is of course simpler to say Anger will be discussed on Thursday, but it doesn’t lead to better outcomes. With TOC we can move past the simple chatting with clients that our field has a reputation for and engineer actual individualized treatment plans that move patients towards the goal.
I’m sure you’ve noticed the biggest sticking point in this thesis. No one is rewarded for making treatment go faster in our current system. Anyone who shaves days off of LOS will make less money, because they are paid by the day. Well, TOC offers a solution for that as well, but that’s another story for another day.