Find and Remove Bottlenecks

Improving Primary Care Access

A constraint, or bottleneck, is anything that restricts the throughput of patients into and through the clinic system. Constraints occur when the demand for a particular resource (e.g., rooms, providers, tests) or part of the system is greater than the available supply. If changes are made to improve parts of a system without addressing the constraint, the changes may not result in reduction of delays and waiting times for the entire system. To manage the constraint, the practice must first identify the constraint and then drive unnecessary work away from the constraint.

Every system has a constraint called "the rate-limiting step" (i.e., the step that determines the rate at which work passes through the system). This constraint usually has the most valuable and scarcest resources. The focus should be on optimizing the supply of the rate-limiting step, not on optimizing every resource in the system. The rate-limiting step should never be idle, ensuring that work flows smoothly through it.
It is often difficult to identify a constraint by evaluating the demand and the supply for each resource because these elements can be masked by constraints in other parts of the system. To identify the constraint, observe where the work is piling up, or where the queues are forming. Look for certain signals within the system, such as places where material or information is in short supply, or where patients or staff are waiting, to help identify constraints. Clinics usually expect that the physician is the constraint, but there may be other factors.
In a clinic setting, the primary provider is often the rate-limiting step because he or she does a number of things that uniquely add value to the system. Any work that the provider is doing that is not related specifically to his or her unique skills and expertise as a provider should be assigned to other members of the care team (see Optimize the Care Team).

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