Wednesday, 16 October 2013

Why are we waiting?

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  1. I went through a similar design experience at the UK Passport Service some 10 years ago. ! dramatically reduced waiting times for their public counter service by focusing on flow and an understanding of variation (queuing theory). Again, the thing people most commented on was the calm introduced. The images of Petty France prior to the redesign have stayed with me until this day!

  2. Hi Mark - excellent stuff. The context of this may be useful for your readers. A couple of weeks ago I was have a health debate with Mark C and others on Twitter in response to the familiar "we need more capacity" wail. I simply asked "what sort of capacity? Flow or storage?" This revealed a bit of a knowledge gap so I suggested an experiment to Mark C. I offered him a complimentary pass for the FISH course in return for him sharing his "ah ha" moments as he went along. He took up my offer. I suggested that outpatients was a fertile place to find low-hanging fruit. He kept his side of the deal and shared his charts as he went along and I just coached via a few tweets. Mark has completed FISH and I was delighted to send him his Certificate of Achievement yesterday. It seems to have created a bit of a ripple too which was the other purpose of the experiment. You are quite correct - there is a bigger picture to consider and the concept of process purpose and yield is very important in productive system design. Mark has demonstrated how easy it is to learn to use two powerful diagnostic tools. The Gantt chart (invented by HL Gantt in about 1909) and the Shewhart (or run chart) (invented by Walter Shewhart in 1924). Both pre-date Toyota and Deming by two decades, Lean by 50 years and the Vanguard Method by more than that. So when it comes to getting a grip on the healthcare improvement nettle starting with something easy that every doctor and manager could learn in a week seems like a worthwhile step to me. Mark C has shown it is possible. The purpose of FISH is to make it actual for many more who want to learn how to do this for themselves. The first win is a better patient experience and a calmer clinic and I'm guessing that is going to get a "Yes Please" from quite a lot of people. With that foundation in place we can square up on the much tougher design challenges - like "failure demand" as you cal it.

    1. Hi Simon. Thank you. Certainly aware that I am standing on the shoulders of giants. It is great Mark is doing what he is doing and sharing that learning too. Hopefully this will mean the NHS can move from doing things better to doing better things. Less of the wrong thing righter to more of just doing the right thing.

  3. I too am a surgeon and have used the systems design skills to redesign services and dramatically improve the patient flow. As a result the stress of a full waiting room disappears, a calmer environment develops and quality of experience, care and outcomes improves for both patient and staff. The added bonus is an empty car park which helps the patients and staff, but results in a loss of income for the organisation.

    I think it would be helpful to distinguish between the two different industrial models: the economies of scale model versus the economies of flow.

    In the economies of scale model, all the different manufacturing or clinical processes are broken down into the specialised tasks. Each specialist group is then grouped into a big specialist 'department' e.g. X-ray department. that focuses on that particular set of tasks: imaging. As a consequence all the patients on different routings (pathways or processes) have to queue and wait for a specialist to do their bit before each patient moves on to queue at the next specialist dpt.

    In the economies of flow model the processes are unravelled from the big specialist departments and the required skills and equipment for each process grouped around the patient so each patient flow is isolated from the variation in the other patient flows. This means many smaller 'point of care' machines and staff trained not in one skill but in two or three. Yes patients clinical and social needs do vary and the time they need with each specialist does vary and this is extraordinarily predictable. The secret then is to use some very basic statistics to 'balance the line' so that the patient flow smoothly from one resource to another without waiting or being harmed or neglected. Rather than one huge factory surrounded by a jam packed car park one ends up with several tiny focused factories or 'cells' that specialise in sorting out a particular group of patients problems. This allows for better feedback between the staff and the patients and a more collaborative approach to providing care that patients find cost effective.

    Unfortunately the manufacturing system engineering skills that are common place in industry are revolutionary in the healthcare and the NHS management training scheme teaches neither model. So managers blindly follow the dogma of achieving 100% utilisation of the resources (including the car park) in the blind belief that this is more 'efficient'.

    So Bravo to the doctors who are showing our very overpaid managers what they should be doing to design and manage the system while we doctors should be getting on with doing the work.

    The challenge now for Vanguard and other consultancies is to change the management accounting model. Currently the management accounts focus on achieving the lowest unit cost (cost of department/activity). This drives organisations down the economies of scale route and takes no account of the quality of the activity. The more challenging management accounting measure is the idea of cost effectiveness or productivity. Once we can show the finance director that the economies of flow are more productive and profitable than the economies of scale we can move on. At the moment our finance director is moaning about the loss of income from the empty car park.....

    1. Wherever you are they are lucky to have you. Great insights. I agree - bravo to the doctors, and anybody, who has the courage to follow through on what appear to be counter-intuitive approaches, especially when this is based on studying and experimenting. I would say that the problem is more one of managerialism than managers per se. It's probably why Ackoff (I think) said MBA stood for Mostly Best Avoided. Help people discover for themselves a better way to make the work work and they will respond. You are so right about unit costing. Cost is in flow, end-to-end and over time. Unit costs do nothing to help leaders understand that. Your comment about the car parking made me laugh out loud. But it is a serious point. Organisations take a very inside-out view of the world and this is the cause of much waste and unnecessary cost in the system. For us the challenge is to change management thinking. As Deming said, management is a prison. We invented it, we can re-invent it. It relies on constructively unreasonable people - like you perhaps!?

  4. In the economies of scale model, all the various producing or clinical processes ar countermined into the specialised tasks