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Pride and Joy: a healthcare novel
based on the application of
the Theory of Constraints
in health and social care

"A must read for all politicians and government involved in managing and improving healthcare" 

Kristen Cox, Executive Director of Utah Governor's Office of Management and Budget

"What should the health system prepare for after this pandemic? What is necessary to do so?

Whatever circumstances we are in, a management theory which that on patient flow to create more bed capacity, improve quality of care and the finances simultaneously, can greatly contribute to the system and bring pride and joy to all of us involved.  Dr. Toru Nishi

Director, Sakura-jyuji Yatsushiro Rehabilitation Hospital

Health and social care systems appear complex. Each patient/customer requires the efforts of many different resources - both people and equipment - before they are clinically fit to go home or move to the next stage of their health/social care journey. The most common response to this seeming complexity is to divide the system into parts and manage and measure each part in an attempt to improve the whole. Such an approach may have an impact when the number of system variables are relatively small and the variability within each dimension is relatively small. However, our health and social care systems are an example where almost the opposite extreme is true.

When health and social care spend is rising and rising as a percentage of GDP the affordability of care comes into question, as we so often see played out in headlines across the globe.  Unless things change, the only way to sustain the position is to ensure GDP grows faster than the growth in healthcare. The other, less palatable, option is for healthcare to be rationed. While, for example, the UK and the US health systems are different, the UK does have a cost of healthcare per head of less than half of that of the US - two countries separated by an ocean and suffering the same underlying dilemma: increase spend on healthcare versus reduce spend on healthcare. It is not a matter of choosing one approach over the other; both have their flaws. 


Our hypothesis is that it is not the nature of the systems that is the problem, it is the basis of our response.  

Pride and Joy is a business model about a struggling fictional hospital. The first third focuses on answering the questions,

'Why is there a need to change?' and 'What to change?' The analysis is based upon the typical situation found at a local level. 

The middle third of the book applies the Theory of Constraints (TOC) to the hospital's major streams of care and links in the healthcare chain. TOC is based on the belief of inherent simplicity - that in any goal-oriented system there are only ever a few places that have the power to affect the performance of the whole system: the weakest link(s)/constraint(s). In Pride and Joy the TOC principles have been adapted to fit the healthcare environment and through logical derivation the reader sees how the ideas are practical, common sense and can bet implemented in a short timescale to achieve unprecedented results. 

The final part of the book demonstrates how a nation can safely, and in an affordable envelope, achieve a breakthrough in performance at a national level and provides a working hypothesis for a global solution that involves a change in mindset of all stakeholders in the chain.

The book has been written as a novel to address a major point: such a paradigm shift in thinking needs to occur at all levels of the system - preferably simultaneously. As such, the audience for this book is anyone who is involved in, interested in and responsible for health care at a local, national and global level. 

Pride and Joy Reviews

This is a must read for politicians, policy makers, clinicians and managers. It tells the story of how healthcare systems can be managed in a sustainable way with the patient at the centre of decision making.

Dr Mike Williams

Pride and Joy wraps quality improvement techniques with a story and characters and thus presents the key messages in a highly engaging way.

Professor Viv Bennett, Director of Nursing for Department of Health and Public Health England

The weary staff in the struggling hospital described in this book reflects our future.
However, their challenge of chasing a silver lining gives us all a ray of hope.

Dr. Masayuki Chikamori, CEO, Chikamori Hospital, Kohchi Prefecture, Japan

Pride and Joy available from Amazon in paperback or Kindle

Pride and Joy Reviews

I read Pride and Joy with a mixture of feelings that is hard to describe. Firstly a sense of relief that from now on managers and clinicians will have a reference source when the challenge of delivering excellent patient care seems an impossible task. Secondly, it busts the myth that TOC is too complicated and not appropriate for the NHS and, thirdly, it picks up the human interest aspect and demonstrates how much passion and commitment NHS staff are prepared to invest for their patients. 

It is a must read for managers and clinicians but also for all those in the wider NHS family who may well have an influence or hold a trust or team to account. If they give providers a chance and the support to implement TOC then we could have a very different NHS.

My only regret is this book was not available when I was at the beginning of my career! Thank you, Alex, for writing it now.

Averil Dongworth, London

Pride and Joy has the potential to transform an entire health system. However, it is not just a good idea but shows how a dedicated and courageous team of clinicians and managers, can collaborate to achieve that goal.”

Dr Ruth Vander Stelt

President, Pontiac Family Medicine Group, Secretary, Executive Council of Physicians, Dentists and Pharmacists of the Centre de Santé et Services Sociaux de l'Outaouais Québec

In choosing to fictionalise his experience of working with many healthcare systems, Alex Knight challenges his readers to think about the realities of hospital management in new ways. 'Pride and Joy' is an essential read for those who wish to implement change and improve the quality of care within the hospital sector.

Ailsa Granne, Oxford, England

I love the book, it's full of golden nuggets of insight. I can see myself dipping into it and revisiting some of the sections. 

Head of Outpatients

Pride and Joy Reviews

This book is a must-read for all health professionals working in hospitals across the country. By challenging the mindset of workers and stakeholders, including patients, the author shows how major breakthroughs can be achieved with determination and vision.

The Nursing Standard

Our patient volumes have recently gone up significantly, but thanks to our initial efforts based on the principles from this book, we have maintained our flow and patient satisfaction continues to rise.

Clinic Manager, USA

I enjoyed reading Pride and Joy, largely because it resonated with a lot of my own experiences. In fact, I am just exploring the clinically derived planned discharge date in my current job to streamline our discharge process for complex patients. I thought the idea of explaining some of the theory through a story was great and made complex ideas much easier to follow - Alex always did this well at our training too. 

Paediatric Consultant

Pride and Joy Reviews

Over the last decades there has been a worldwide pursuit to adapt operations management principles from other industries to healthcare, in order to improve flow. Most initiatives produce meagre results, at best, because some fundamental assumptions are different in a healthcare context. The approach depicted in Pride and Joy is ingenious, in that it shows us how to bypass this issue, how to handle complexity, and how to identify where to focus our efforts. Everybody understands that you need to focus, but there is typically disagreement on what to focus on. Furthermore, most focusing efforts create sub-optimization. What Alex Knight explains, is that you simply can never know where you should focus before you have synchronized the complex web of patient flows that makes out a hospital environment. The good news is that synchronizing patient flows is surprisingly simple. Pride and Joy shows us how.

Dr Johan Groop, Senior Partner, Nordic Healthcare Group

Pride and Joy has the potential of doing to healthcare what Goldratt’s The Goal did to manufacturing and supply chain.  Alex describes the environment and crisis situations where they could take place in the US, UK, Australia, Canada, etc. The problems are universal. The situation is complex and impossible to many BUT as anyone in TOC knows, the more complex the situation the simpler the solution. Alex proves this to be correct.  Once you read each solution; your response should be: That’s brilliant!  You end up making this statement a number of times throughout the book. In my opinion, this book may provide the solution to implementing universal healthcare without bankrupting the country for the US.

James F. Cox III

Professor Emeritus, University of Georgia

The pressures on health systems are pretty much the same in all countries - "Pride and Joy" provides an invaluable guide to thinking through and resolving the challenges of providing effective health care.

Jeffery Worral

Director of Delivery and Improvement

NHS Improvement UK

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Pride and Joy in French Canadian