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Updated: Aug 8, 2026
Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
Published on: February 16, 2011
Improving the process of developing technical reports for health care decision makers: using the theory of
Meenal B Patwardhan1, Antonio Sarría-Santamera, David B Matchar
1Department of Medicine, Duke University Medical Center, Durham, NC 27705, USA. Meenal.P@Duke.edu
Objectives:
To apply the Theory of Constraints (TOC) to the Evidence-based Practice Center (EPC) process.
Methods:
Participants in the EPC process were interviewed, and the technical contracting literature was reviewed. Undesirable effects (UDEs) that might occur in the EPC process were identified and, in a TOC Current Reality Tree (CRT), a fundamental UDE was selected and tracked back to potential root causes, focusing on the core "constraint". The resulting draft CRT was presented at an EPC directors' meeting and finalized. From possible solutions obtained from interviews and literature, a Future Reality Tree (FRT) was constructed.
Results:
Three UDEs were identified and that a report is not used was deemed fundamentally undesirable. Nine root causes were identified, and using the CRT, a core constraint emerged: EPC partner does not know how to conceptualize and articulate needs, objectives, and specifications. Two change strategies ("injections") appeared to address the core constraint: establish an ongoing relationship between partners, EPC, and Agency for Healthcare Research and Quality early in the process, and use a changes clause; in a FRT the injections lead to the positive outcome-the production of a successful EPC report that meets partner needs and, therefore, will be used.
Conclusions:
As with any complex enterprise, the EPC needs to engage in self-reflection and active improvement to maximize its value. The development of technical reports intended to inform decision making represents a complicated area, involving a network of interrelated processes. Using the TOC permitted us to understand process failures; results serve as a guide to improvement.
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