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What Public Managers Can Learn from the Ventilator Shortage

Every work system has its point of constraint, and that's the place to focus on to increase the organization's capacity. You're only as good as your weakest link.

The global pandemic is offering countless examples of public leadership and management in action. Many are truly heroic and inspiring, while some are just downright bizarre. But despite the best efforts of government leaders, epidemiologists, doctors and nurses, the success of the coronavirus response system for those seriously ill with COVID-19 has turned out to be critically dependent on one thing: the availability of ventilators.

Through the ventilator shortage, we are all learning a lot about a key management concept first made popular by Eliyahu M. Goldratt in his 1984 book, The Goal. The book was where Eli introduced the world to his Theory of Constraints. Essentially, any system will be limited in achieving its goals by a few key constraints. Said simply, you are only as good as your weakest link.

Take, for example, a simple four-step process in which each step has the following capacity to produce a service such as building permits: A (125) > B (150) > C (75) > D (150). The system will only produce 75 permits; step C is the system constraint. The outputs from A and B that exceed 75 will only pile up in front of C.

The power of Eli's theory is that to dramatically increase capacity, you don't have to do a lot of things. Rather, you have to focus on one thing — your point of constraint. You have to find it, study it and figure out a way around it. That is, when you increase the capacity of the constraint, you increase the capacity of the whole system. Conversely, if you don't fix the constraint, nothing else you do will have much impact on the system.

So, as we've learned, our system for treating people seriously ill with COVID-19 is governed by a constraint: the number and availability of ventilators. Like most systems, the demand on this treatment system is predictable. We are able to estimate how many people are likely to get sick in a given location, how many will be hospitalized and how many will need ventilation. Doing the math identifies the constraint. In New York state, for example, in late March the math showed that roughly 18,000 ventilators a week would be needed during the peak of illnesses. As of March 26, the state had less than 3,000.

Your agency or jurisdiction almost certainly has its own version of a ventilator shortage. That is, your organization has a few key work systems, and each of those has a constraint that prevents it from producing more. A DMV office is constrained by the number of windows it has working to serve the line of customers. A permitting process may be constrained by the availability and workload of a senior review engineer. Child-welfare investigations are often constrained by the limited availability of supervisors to review key decisions. You can do your own epidemiological math to figure out the predictable demand on your system and isolate the constraint. Or you can just walk around and observe. The constraint is usually where the work is piling up, the staff is tense, and the lack of progress chasing phone calls is the highest.

The ventilator shortage can teach us the key principles for eliminating constraints:

Get more constraint resources. In the case of the pandemic, this means procuring and producing more ventilators. I know this sounds obvious, but there is actually a key insight for us. So many of our agencies beg elected officials for more resources. And yes, we do often need more resources. But usually what we really need are more constraint resources. That is, rather than needing a few more of a lot of resources, we need a lot more of a few resources. Child welfare needs more case workers to monitor foster care. Environmental agencies need more senior permit engineers. DMV offices need more window workers during peak times.

Increase the capacity of the constraints you have. Because the capacity of the entire system is dependent on the capacity of the constraint, we also have to ensure the constraint is working at maximum efficiency. In the case of ventilators, this has meant first and foremost that ventilators not sit idle. Every possible ventilator needs to be deployed and needs to be properly working. The ventilator shortage has also forced another brilliant innovation: sharing ventilators. That is, medical teams have found a way to use one ventilator to pump air to two patients, effectively doubling the capacity of the constraint.

The key insight for agencies is to recognize the constraint resource and focus attention on helping staffers be as productive as possible. We do this in two ways:

  • Reducing the workload of the constraint resource by studying the work and eliminating unnecessary tasks. If the time it takes a worker to complete a DMV transaction can be reduced from 15 minutes to 10, we have 33 percent more capacity. Again, this is why this concept is so critical. Saving five minutes of labor elsewhere in the system is a mirage. But saving it at the point of the constraint is game-changing. The constraint focuses our attention.
  • Looking at the work that comes to the constraint point and ensuring that it is actually necessary and ready to be worked. For example, many DMV and public-assistance offices now deploy a "navigator" in their lobbies. Navigators determine why people have come in and whether they have the right paperwork, completed the right way, before they ever get in line to see a worker. While this appears to be a customer-service innovation, its true function is to prevent any waste at the constraint. You don't want a precious window resource spending 10 minutes with a customer only to find that the transaction can't be completed. Other "ventilator" strategies consist of moving customers to online transactions, double-manning counters during peak times, and moving complex or difficult transactions to specialists to minimize delays for the whole queue. The key principle is to keep work flowing, and to do that we must improve and manage our bottlenecks.
As you watch the nightly-news pandemic updates, listen for the ventilator-shortage strategies. Watch how data is being used to predict demand. Watch how ventilators are being deployed and redeployed. And then think about your own agency and its constraints. How well do you know them? Is there a crisis coming? Can we manage our constraints as vigorously as the ventilators are now being managed? Does our staff know this story? The steps you take now will better prepare you for when you don't have a choice.

Governing's opinion columns reflect the views of their authors and not necessarily those of Governing's editors or management.

Founder of the Change and Innovation Agency
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