Smash Bottlenecks

Smash the Bottleneck

Learn an innovative methodology to tackle the complexities of managing patient flow

Reached Top 3 in Amazon Hot New Releases for Hospital Administration

About the book

Poor patient flow has grave implications for quality of care, patient satisfaction, provider well-being, and an organization’s bottom line.
Smash the Bottleneck: Fixing Patient Flow for Better Care (and a Better Bottom Line) lays out a concrete methodology for getting to the root of patient-flow problems and addressing them—quickly. The book highlights a continuous improvement methodology known as the Theory of Constraints (TOC), which emphasizes identifying, optimizing, and breaking down bottlenecks to improve overall system performance. Introduced in Eliyahu M. Goldratt’s seminal business book The Goal, this method and its concepts have since been adopted by Fortune 500 companies worldwide.  

Uniquely, the authors tie TOC to healthcare delivery from a practitioner’s point of view. They provide numerous examples of common health system bottlenecks to illustrate how the methodology can be applied in readers’ own organizations.

In the book, you will learn strategies to

Coordinate resources and break down organizational silos

Reduce overcrowding and increase throughput in emergency departments

Decrease length of stay in inpatient units

Shorten wait times in primary and specialty care clinics, imaging centers, and surgery centers

Praises for Smash the Bottleneck

 "Using the Theory of Constraints, Smash the Bottleneck provides a clear, practical solution to break through the most intractable problem in modern healthcare: patient boarding.  This book is a game changer, a must read for clinical operations leaders in healthcare.  Every chapter contains multiple "Aha" moments.  Combining case examples with sound analysis, Strear and Sirias lay out why most patient flow improvement projects predictably fail ad how hospital leaders can enable real solutions to improve patient satisfaction, safety and throughput while improving bottom-line performance." 

Ron M. Walls, MD, FAAEM
Neskey Family Professor of Emergency Medicine
Harvard Medical School
Executive Vice President and COO
Brigham and Women's Hospital, Boston

 "Strear and Sirias address the key issue in healthcare operations today--how to breakdown capacity constraints and realize patient throughput.  Full of ready-to-implement examples, their practical application of constraint theory in healthcare will give every hospital director hope that bottlenecks can be smashed and flow restored." 

Renee Edwards, MD, MBA 
Senior Vice President and Chief Medical Officer
OHSU Health

 "Strear and Sirias' Smash the Bottleneck is one of the few books on patient flow that guides the reader thought this complex process, providing education at a high level without making the uninitiated feel they are overwhelmed by the weeds. The use of the Mattel factory analogy captivates the reader and brings these abstract components to life." 

Michael Granovsky, MD
President, LogixHealth

"Finally--a book that translates the business classic The Goal and its powerful Theory of Constraints into the healthcare setting.  Foundational to the science of flow, this is a must read for anyone engaged in healthcare operations, improvement, and flow.  It is impossible to read this book and not have a eureka moment." 

Robert Vissers, MD, FACEP, MBA
President and CEO, Boulder Community Health
Adjunct Professor of Emergency Medicine
Faculty Healthcare Executive, MBA
University of Colorado, Denver

Does the Theory of Constraints work?

A recent study* of 41 implementations in nine different countries found the following average results for healthcare systems using TOC:

Wait time reduction (50%)

Length of stay reduction (38%)

Overtime reduction (93%)

No-show and cancellations reduction (72%)

Number of surgical procedures increase (43%)

Throughput increase (31%)

* Bacelar, G, and Cox, J. 2020. "How to Achieve Breakthrough Improvement in Healthcare Services Applying TOC Services and Tools," Presentation at the 2020 TOCICO Virtual Conference

About our publisher

The American College of Healthcare Executives is the professional society for healthcare leaders committed to improving health.

For over 85 years, the American College of Healthcare Executives (ACHE) has focused on one mission—advancing leaders and the field of healthcare management excellence. We are the professional home to more than 48,000 healthcare executives who are committed to integrity, lifelong learning, leadership and diversity and inclusion. 

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Meet the authors

Christopher Strear, MD, FACEP

 Dr. Strear earned a medical degree from the University of Pennsylvania. He is currently the Chief Medical Officer at Columbia Medical Hospital.  Previously he was the Director of Patient Flow for Northwest Acute Care Specialists and an attending physician in emergency medicine at Legacy Emanuel Medical Center in Portland, Oregon. Additionally, he is a Clinical Assistant Professor of Emergency Medicine at Oregon Health and Sciences University in Portland, Oregon. He began his career in Operational Flow and Process Improvement as the Director of Patient Flow at Legacy Emanuel Health Center in 2008. His Emergency Department implementation resulted in a dramatic reduction of length of stay and in savings of $3 million dollars to the hospital in year one. His flow team was twice awarded the John G. King Quality Award for accomplishments in clinical quality and process improvement. He is currently patient flow advisor and internal consultant to multiple hospital flow steering committees in the Pacific Northwest.  He is co-author of the book: Smash the Bottleneck: Fixing Patient Flow for Better Care.

Danilo Sirias, Ph.D.

Dr. Sirias has a master’s degree in Industrial and Systems Engineering and a Ph.D. in Business Administration both from The University of Memphis. He is also a certified Critical Chain Project Manager and a certified TOCICO thinking process implementer.  Dr. Sirias’ research interests include how the Theory of Constraints can be used to improve patient flow in Emergency Departments, Inpatient Units, Operating Rooms and Outpatient Clinics.  He is co-author of the book: Smash the Bottleneck: Fixing Patient Flow for Better Care. Dr. Sirias is currently a Professor in the Department of Management and Marketing at Saginaw Valley State University.