Seven Flows – HCSE Blog

11/08/2018

Seeing The Voice of the System

It is always a huge compliment to see an idea improved and implemented by inspired innovators.

Health care systems engineering (HCSE) brings together concepts from the separate domains of systems engineering and health care. And one idea that emerged from this union is to regard the health care system as a living, evolving, adapting entity.

In medicine we have the concept of ‘vital signs’ … a small number of objective metrics that we can measure easily and quickly. With these we can quickly assess the physical health of a patient and decide if we need to act, and when.

With a series of such measurements over time we can see the state of a patient changing … for better or worse … and we can use this to monitor the effect of our actions and to maintain the improvements we achieve.

For a patient, the five vital signs are conscious level, respiratory rate, pulse, blood pressure and temperature. To sustain life we must maintain many flows within healthy ranges and the most critically important is the flow of oxygen to every cell in the body. Oxygen is carried by blood, so blood flow is critical.

So, what are the vital signs for a health care system where the flows are not oxygen and blood? They are patients, staff, consumables, equipment, estate, data and cash.

The photograph shows a demonstration of a Vitals Dashboard for a part of the cancer care system in the ABMU health board in South Wales. The inspirational innovators who created it are Imran Rao (left), Andy Jones (right) and Chris Jones (top left), and they are being supported by ABMU to do this as part of their HCSE training programme.

So well done guys … we cannot wait to hear how being better able to seeing the voice of your cancer system translates into improved care for patients, and improved working life for the dedicated NHS staff, and improved use of finite public resources. Win-win-win.

10/12/2016

Hungry, Hardworking, Humble

This week I read a new book by one of my favourite authors – Patrick Lencioni.

The book is The Ideal Team Player.

Patrick’s books are written as stories which makes them very accessible and easily memorable. And each one captures a priceless pearl of wisdom.

Improving a complex adaptive system such as health care can only be done by the people in the system working together and sharing expectations, experiences, knowledge, understanding and wisdom.

So each person needs to understand what it is to be able to contribute effectively to a team – because teams are how complex systems are designed and how they are improved.

Patrick identifies three “virtues” – and he uses that term appropriately.

Hungry … which means a having a burning ambition. Something needed and wanted. An unsatisfied longing. A vision. A mission. A goal. A pull. A purpose.

Hardworking … which means a willingness to do what is needed to satisfy the hunger. Going that extra mile. Reading that extra book. Solving that extra problem. Giving that extra bit of feedback. Doing that extra job that no one else wants to do. Investing in the future.

Humble … which means that Ego is not running the show. Confidence is linked to competence. Impact and intent are aligned. The mind is open to learning. The eyes are open to seeing. The ears are open to listening. And the mouth is only open for asking questions and telling stories.

The three virtues are necessary and sufficient, they are effective and efficient.

So if any one is missing the outcome is not achievable.

Time to pick up the mirror and look deeply into it … and ask:

“Am I hungry enough?”
“Am I prepared to commit my lifetime?”
“Am I open to learning from reality and from others?”

Our tangible record of past behaviour provides us with our answers.

It is the time to dig deep and ask the question: am hungry, hardworking and humble?

05/04/2014

Firewall

Fires are destructive, indifferent, and they can grow and spread very fast.

The picture is of the Buncefield explosion and conflagration that occurred on 11th December 2005 near Hemel Hempstead in the UK. The root cause was a faulty switch that failed to prevent tank number 912 from being overfilled. This resulted in an initial 300 gallon petrol spill which created the perfect conditions for an air-fuel explosion. The explosion was triggered by a spark and devastated the facility. Over 2000 local residents needed to be evacuated and the massive fuel fire took days to bring under control. The financial cost of the accident has been estimated to run into tens of millions of pounds.

The Great Fire of London in September 1666 led directly to the adoption of new building standards – notably brick and stone instead of wood because they are more effective barriers to fire.

A common design to limit the spread of a fire is called a firewall.

And we use the same principle in computer systems to limit the spread of damage when a computer system goes out of control.

Money is the fuel that keeps the wheels of healthcare systems turning. And healthcare is an expensive business so every drop of cash-fuel is precious. Healthcare is also a risky business – from both a professional and a financial perspective. Mistakes can quickly lead to loss of livelihood, expensive recovery plans and huge compensation claims. The social and financial equivalent of a conflagration.

Financial fires spread just like real ones – quickly. So it makes good sense not to have all the cash-fuel in one big pot. It makes sense to distribute it to smaller pots – in each department – and to distribute the cash-fuel intermittently. These cash-fuel silos are separated by robust financial firewalls and they are called Budgets.

The social sparks that ignite financial fires are called ‘Niggles‘. They are very numerous but we have effective mechanisms for containing them. The problem happens when a multiple sparks happen at the same time and place and together create a small chain reaction. Then we get a complaint. A ‘Not Again‘. And we are required to spend some of our precious cash-fuel investigating and apologizing. We do not deal with the root cause, we just scrape the burned toast.

And then one day the chain reaction goes a bit further and we get a ‘Near Miss‘. That has a different reporting mechanism so it stimulates a bigger investigation and it usually culminates in some recommendations that involve more expensive checking, documenting and auditing of the checking and documentation. The root cause, the Niggles, go untreated – because there are too many of them.

But this check-and-correct reaction is also expensive and we need even more cash-fuel to keep the organizational engine running – but we do not have any more. Our budgets are capped. So we start cutting corners. A bit here and a bit there. And that increases the risk of more Niggles, Not Agains, and Near Misses.

Then the ‘Never Event‘ happens … a Safety and Quality catastrophe that triggers the financial conflagration and toasts the whole organization.

So although our financial firewalls, the Budgets, are partially effective they also have downsides:

1. Paradoxically they can create the perfect condition for a financial conflagration when too small a budget leads to corner-cutting on safety.

2. They lead to ‘off-loading’ which means that too-expensive-to-solve problems are chucked over the financial firewalls into the next department. The cost is felt downstream of the source – in a different department – and is often much larger. The sparks are blown downwind.

For example: a waiting list management department is under financial pressure and is running short staffed as a recruitment freeze has been imposed. The overburdening of the remaining staff leads to errors in booking patients for operations. The knock on effect that is patients being cancelled on the day and the allocated operating theatre time is wasted. The additional cost of wasted theatre time is orders of magnitude greater than the cost-saving achieved in the upstream stage. The result is a lower quality service, a greater cost to the whole system, and the risk that safety corners will be cut leading to a Near Miss or a Never Event.

The nature of real systems is that small perturbations can be rapidly amplified by a ‘tight’ financial design to create a very large and expensive perturbation called a ‘catastrophe’. A silo-based financial budget design with a cost-improvement thumbscrew feature increases the likelihood of this universally unwanted outcome.

So if we cannot use one big fuel tank or multiple, smaller, independent fuel tanks then what is the solution?

We want to ensure smooth responsiveness of our healthcare engine, we want healthcare cash-fuel-efficiency and we want low levels of toxic emissions (i.e. complaints) at the same time. How can we do that?

Fuel-injection.

Electronic Fuel Injection (EFI) designs have now replaced the old-fashioned, inefficient, high-emission carburettor-based engines of the 1970’s and 1980’s.

The safer, more effective and more efficient cash-flow design is to inject the cash-fuel where and when it is needed and in just the right amount.

And to do that we need to have a robust, reliable and rapid feedback system that controls the cash-injectors.

But we do not have such a feedback system in healthcare so that is where we need to start our design work.

Designing an automated cash-injection system requires understanding how the Seven Flows of any system work together and the two critical flows are Data Flow and Cash Flow.

And that is possible.

02/03/201311/01/2022

The Seventh Flow

Bing Bong

Bob looked up from the report he was reading and saw the SMS was from Leslie, one of his Improvement Science Practitioners.

It said “Hi Bob, would you be able to offer me your perspective on another barrier to improvement that I have come up against.”

Bob thumbed a reply immediately “Hi Leslie. Happy to help. Free now if you would like to call. Bob“

Ring Ring

<Bob> Hello, Bob here.

<Leslie> Hi Bob. Thank you for responding so quickly. Can I describe the problem?

<Bob> Hi Leslie – Yes, please do.

<Leslie> OK. The essence of it is that I have discovered that our current method of cash-flow control is preventing improvements in safety, quality, delivery and paradoxically in productivity too. I have tried to talk to the Finance department and all I get back is “We have always done it this way. That is what we are taught. It works. The rules are not negotiable and the problem is not Finance“. I am at a loss what to do.

<Bob> OK. Do not worry. This is a common issue that every ISP discovers at some point. What led you to your conclusion that the current methods are creating a barrier to change?

<Leslie> Well, the penny dropped when I started using the modelling tools you have shown me. In particular when predicting the impact of process improvement-by-design changes on the financial performance of the system.

<Bob> OK. Can you be more specific?

<Leslie> Yes. The project was to design a new ambulatory diagnostic facility that will allow much more of the complex diagnostic work to be done on an outpatient basis. I followed the 6M Design approach and looked first at the physical space design. We needed that to brief the architect.

<Bob> OK. What did that show?

<Leslie> It showed that the physical layout had a very significant impact on the flow in the process and that by getting all the pieces arranged in the right order we could create a physical design that felt spacious without actually requiring a lot of space. We called it the “Tardis Effect“. The most marked impact was on the size of the waiting areas – they were really small compared with what we have now which are much bigger and yet still feel cramped and chaotic.

<Bob> OK. So how does that physical space design link to the finance question?

<Leslie> Well, the obvious links were that the new design would have a smaller physical foot-print and at the same time give a higher throughput. It will cost less to build and will generate more activity than if we just copied the old design into a shiny new building.

<Bob> OK. I am sure that the Capital Allocation Committee and the Revenue Generation Committee will have been pleased with that outcome. What was the barrier?

<Leslie> Yes, you are correct. They were delighted because it left more in the Capital Pot for other equally worthy projects. The problem was not capital it was revenue.

<Bob> You said that activity was predicted to increase. What was the problem?

<Leslie>Yes – sorry, I was not clear – it was not the increased activity that was the problem – it was how to price the activity and how to distribute the revenue generated. The Reference Cost Committee and Budget Allocation Committee were the problem.

<Bob> OK. What was the problem?

<Leslie> Well the estimates for the new operational budgets were basically the current budgets multiplied by the ratio of the future planned and historical actual activity. The rationale was that the major costs are people and consumables so the running costs should scale linearly with activity. They said the price should stay as it is now because the quality of the output is the same.

<Bob> OK. That does sound like a reasonable perspective. The variable costs will track with the activity if nothing else changes. Was it apportioning the overhead costs as part of the Reference Costing that was the problem?

<Leslie> No actually. We have not had that conversation yet. The problem was more fundamental. The problem is that the current budgets are wrong.

<Bob> Ah! That statement might come across as a bit of a challenge to the Finance Department. What was their reaction?

<Leslie> To para-phrase it was “We are just breaking even in the current financial year so the current budget must be correct. Please do not dabble in things that you clearly do not understand.”

<Bob> OK. You can see their point. How did you reply?

<Leslie> I tried to explain the concepts of the Cost-Of-The-Queue and how that cost was incurred by one part of the system with one budget but that the queue was created by a different part of the system with a different budget. I tried to explain that just because the budgets were 100% utilised does not mean that the budgets were optimal.

<Bob> How was that explanation received?

<Leslie> They did not seem to understand what I was getting at and kept saying “Inventory is an asset on the balance sheet. If profit is zero we must have planned our budgets perfectly. We cannot shift money between budgets within year if the budgets are already perfect. Any variation will average out. We have to stick to the financial plan and projections for the year. It works. The problem is not Finance – the problem is you.“

<Bob> OK. Have you described the Seventh Flow and put it in context?

<Leslie> Arrrgh! No! Of course! That is how I should have approached it. Budgets are Cash-Inventories and what we need is Cash-Flow to where and when it is needed and in just the right amount according to the Principle of Parsimonious Pull. Thank you. I knew you would ask the crunch question. That has given me a fresh perspective on it. I will have another go.

<Bob> Let know how you get on. I am curious to hear the next instalment of the story.

<Leslie> Will do. Bye for now.

Drrrrrrrr

Creating a productive and stable system design requires considering Seven Flows at the same time. The Seventh Flow is cash flow.

Cash is like energy – it is only doing useful work when it is flowing.

Energy is often described as two forms – potential energy and and kinetic energy. The ‘doing’ happens when one form is being converted from potential to kinetic. Cash in the budget is like potential energy – sitting there ready to do some business. Cash flow is like kinetic energy – it is the business.

The most versatile form of energy that we use is electrical energy. It is versatile because it can easily be converted into other forms – e.g. heat, light and movement. Since the late 1800’s our whole society has become highly dependent on electrical energy. But electrical energy is tricky to store and even now our battery technology is pretty feeble. So, if we want to store energy we use a different form – chemical energy. Gas, oil and coal – the fossil fuels – are all ancient stores of chemical energy that were originally derived from sunlight captured by vast carboniferous forests over millions of years. These carbon-rich fossil fuels are convenient to store near where they are needed, and when they are needed. But fossil fuels have a number of drawbacks: One is that they release their stored carbon when they are “burned”. Another is that they are not renewable. So, in the future we will need to develop better ways to capture, transport, use and store the energy from the Sun that will flow in glorious abundance for millions of years to come.

Plants discovered millions of years ago how to do this sunlight-to-chemical energy conversion and that biological legacy is built into every cell in every plant on the planet. Animals just do the reverse trick – they convert chemical-to-electrical. Every cell in every animal on the planet is a microscopic electrical generator that “burns” chemical fuel – carbohydrate. The other products are carbon dioxide and water. Plants use sunlight to recycle and store the carbon dioxide. It is a resilient and sustainable design.

Plants seemingly have it easy – the sunlight comes to them – they just sunbathe all day! The animals have to work a bit harder – they have to move about gathering their chemical fuel. Some animals just feed on plants, others feed on other animals, and we do a bit of both. This food-gathering is a more complicated affair – and it creates a problem. Animals need a constant supply of energy – so they have to carry a store of chemical fuel around with them. That store is heavy so it needs energy to move it about. Herbivors can be bigger and less intelligent because their food does not run away. Carnivors need to be more agile; both physically and mentally. A balance is required. A big enough fuel store but not too big. So, some animals have evolved additional strategies. Animals have become very good at not wasting energy – because the more that is wasted the more food that is needed and the greater the risk of getting eaten or getting too weak to catch the next meal.

To illustrate how amazing animals are at energy conservation we just need to look at an animal structure like the heart. The heart is there to pump blood around. Blood carries chemical nutrients and waste from one “department” of the body to another – just like ships, rail, roads and planes carry stuff around the world.

Blood is a sticky, viscous fluid that requires considerable energy to pump around the body and, because it is pumped continuously by the heart, even a small improvement in the energy efficiency of the circulation design has a big long-term cumulative effect. The flow of blood to any part of the body must match the requirements of that part. If the blood flow to your brain slows down for even few seconds the brain cannot work properly and you lose consciousness – it is called “fainting”.

If the flow of blood to the brain is stopped for just a few minutes then the brain cells actually die. That is called a “stroke”. Our brains use a lot of electrical energy to do their job and our brain cells do not have big stores of fuel – so they need constant re-supply. And our brains are electrically active all the time – even when we are sleeping.

Other parts of the body are similar. Muscles for instance. The difference is that the supply of blood that muscles need is very variable – it is low when resting and goes up with exercise. It has been estimated that the change in blood flow for a muscle can be 30 fold! That variation creates a design problem for the body because we need to maintain the blood flow to brain at all times but we only want blood to be flowing to the muscles in just the amount that they need, where they need it and when they need it. And we want to minimise the energy required to pump the blood at all times. How then is the total and differential allocation of blood flow decided and controlled? It is certainly not a conscious process.

The answer is that the brain and the muscles control their own flow. It is called autoregulation. They open the tap when needed and just as importantly they close the tap when not needed. It is called the Principle of Parsimonious Pull. The brain directs which muscles are active but it does not direct the blood supply that they need. They are left to do that themselves.

So, if we equate blood-flow and energy-flow to cash-flow then we arrive at a surprising conclusion. The optimal design, the most energy and cash efficient, is where the separate parts of the system continuously determine the energy/cash flow required for them to operate effectively. They control the supply. They autoregulate their cash-flow. They pull only what they need when they need it.

BUT

For this to work then every part of the system needs to have a collaborative and parsimonious pull-design philosophy – one that wastes as little energy and cash as possible. Minimum waste of energy requires careful design – it is called ergonomic design. Minimum waste of cash requires careful design – it is called economic design.

Many socioeconomic systems are fragmented and have parts that behave in a “greedy” manner and that compete with each other for resources. It is a dog-eat-dog design. They would use whatever resources they can get for fear of being starved. Greed is Good. Collaboration is Weak. In such a competitive situation a rigid-budget design is a requirement because it helps prevent one part selfishly and blindly destabilising the whole system for all. The problem is that this rigid financial design blocks change so it blocks improvement.

This means that greedy, competitive, selfish systems are unable to self-improve.

So, when the world changes too much and their survival depends on change then they risk becoming extinct just as the dinosaurs did.

Many will challenge this assertion by saying “But competition drives up performance“. Actually, it is not as simple as that. Competition will weed out the weakest who “die” and remove themselves from the equation – apparently increasing the average. What actually drives improvement is customer choice. Organisations that are able to self-improve will create higher-quality and lower-cost products and in a globally-connected-economy the customers will vote with their wallets. The greedy and selfish competition lags behind.

So, to ensure survival in a global economy the Seventh Flow cannot be rigidly restricted by annually allocated departmental budgets. It is a dinosaur design.

And there is no difference between public and private organisations. The laws of cash-flow physics are universal.

How then is the cash flow controlled?

The “trick” is to design a monitoring and feedback component into the system design. This is called the Sixth Flow – and it must be designed so that just the right amount of cash is pulled to the just the right places and at just the right time and for just as long as needed to maximise the revenue. The rest of the design – First Flow to Fifth Flow ensure the total amount of cash needed is a minimum. All Seven Flows are needed.

So the essential ingredient for financial stability and survival is Sixth and Seventh Flow Design capability. That skill has another name – it is called Value Stream Accounting which is a component of complex adaptive systems engineering (CASE).

What? Never heard of Value Stream Accounting?

Maybe that is just another Error of Omission?

13/08/2011

Design-for-Productivity

One tangible output of process or system design exercise is a blueprint.

This is the set of Policies that define how the design is built and how it is operated so that it delivers the specified performance.

These are just like the blueprints for an architectural design, the latter being the tangible structure, the former being the intangible function.

A computer system has the same two interdependent components that must be co-designed at the same time: the hardware and the software.

The functional design of a system is manifest as the Seven Flows and one of these is Cash Flow, because if the cash does not flow to the right place at the right time in the right amount then the whole system can fail to meet its design requirement. That is one reason why we need accountants – to manage the money flow – so a critical component of the system design is the Budget Policy.

We employ accountants to police the Cash Flow Policies because that is what they are trained to do and that is what they are good at doing – they are the Guardians of the Cash.

Providing flow-capacity requires providing resource-capacity, which requires providing resource-time; and because resource-time-costs-money then the flow-capacity design is intimately linked to the budget design.

This raises some important questions:
Q: Who designs the budget policy?
Q: Is the budget design done as part of the system design?
Q: Are our accountants trained in system design?

The challenge for all organisations is to find ways to improve productivity, to provide more for the same in a not-for-profit organisation, or to deliver a healthy return on investment in the for-profit arena (and remember our pensions are dependent on our future collective productivity).

To achieve the maximum cash flow (i.e. revenue) at the minimum cash cost (i.e. expense) then both the flow scheduling policy and the resource capacity policy must be co-designed to deliver the maximum productivity performance.

If we have a single-step process it is relatively easy to estimate both the costs and the budget to generate the required activity and revenue; but how do we scale this up to the more realistic situation when the flow of work crosses many departments – each of which does different work and has different skills, resources and budgets?

Q: Does it matter that these departments and budgets are managed independently?
Q: If we optimise the performance of each department separately will we get the optimum overall system performance?

Our intuition suggests that to maximise the productivity of the whole system we need to maximise the productivity of the parts. Yes – that is clearly necessary – but is it sufficient?

To answer this question we will consider a process where the stream flows though several separate steps – separate in the sense that that they have separate budgets – but not separate in that they are linked by the same flow.

The separate budgets are allocated from the total revenue generated by the outflow of the process. For the purposes of this exercise we will assume the goal is zero profit and we just need to calculate the price that needs to be charged the “customer” for us to break even.

The internal reports produced for each of our departments for each time period are:
1. Activity – the amount of work completed in the period.
2. Expenses – the cost of the resources made available in the period – the budget.
3. Utilisation – the ratio of the time spent using resources to the total time the resources were available.

We know that the theoretical maximum utilisation of resources is 100% and this can only be achieved when there is zero-variation. This is impossible in the real world but we will assume it is achievable for the purpose of this example.

There are three questions we need answers to:
Q1: What is the lowest price we can achieve and meet the required demand?
Q2: Will optimising each step independently step give us this lowest price?
Q3: How do we design our budgets to deliver maximum productivity?

To explore these questions let us play with a real example.

Let us assume we have a single stream of work that crosses six separate departments labelled A-F in that sequence. The department budgets have been allocated based on historical activity and utilisation and our required activity of 50 jobs per time period. We have already worked hard to remove all the errors, variation and “waste” within each department and we have achieved 100% observed utilisation of all our resources. We are very proud of our high effectiveness and our high efficiency.

Our current not-for-profit price is £202,000/50 = £4,040 and because our observed utilisation of resources at each step is 100% we conclude this is the most efficient design and that this is the lowest possible price.

Unfortunately our celebration is short-lived because the market for our product is growing bigger and more competitive and our market research department reports that to retain our market share we need to deliver 20% more activity at 80% of the current price!

A quick calculation shows that our productivity must increase by 50% (New Activity/New Price = 120%/80% = 150%) but as we already have a utilisation of 100% then this challenge looks hopelessly impossible. To increase activity by 20% will require increasing flow-capacity by 20% which will imply a 20% increase in costs so a 20% increase in budget – just to maintain the current price. If we no longer have customers who want to pay our current price then we are in trouble.

Fortunately our conclusion is incorrect – and it is incorrect because we are not using the data available to co-design the system such that cash flow and work flow are aligned. And we do not do that because we have not learned how to design-for-productivity. We are not even aware that this is possible. It is, and it is called Value Stream Accounting.

The blacked out boxes in the table above hid the data that we need to do this – an we do not know what they are. Yet.

But if we apply the theory, techniques and tools of system design, and we use the data that is already available then we get this result …

We can see that the total budget is less, the budget allocations are different, the activity is 20% up and the zero-profit price is 34% less – which is a 83% increase in productivity!

More than enough to stay in business.

Yet the observed resource utilisation is still 100% and that is counter-intuitive and is a very surprising discovery for many. It is however the reality.

And it is important to be reminded that the work itself has not changed – the ONLY change here is the budget policy design – in other words the resource capacity available at each stage. A zero-cost policy change.

The example answers our first two questions:
A1. We now have a price that meets our customers needs, offers worthwhile work, and we stay in business.
A2. We have disproved our assumption that 100% utilisation at each step implies maximum productivity.

Our third question “How to do it?” requires learning the tools, techniques and theory of System Engineering and Design. It is not difficult and it is not intuitively obvious – if it were we would all be doing it.

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07/05/2011

The Seven Flows

Improvement Science is the knowledge and experience required to improve … but to improve what?

Improve safety, delivery, quality, and productivity?

Yes – ultimately – but they are the outputs. What has to be improved to achieve these improved outputs? That is a much more interesting question.

The simple answer is “flow”. But flow of what? That is an even better question!

Let us consider a real example. Suppose we want to improve the safety, quality, delivery and productivity of our healthcare system – which we do – what “flows” do we need to consider?

The flow of patients is the obvious one – the observable, tangible flow of people with health issues who arrive and leave healthcare facilities such as GP practices, outpatient departments, wards, theatres, accident units, nursing homes, chemists, etc.

What other flows?

Healthcare is a service with an intangible product that is produced and consumed at the same time – and in for those reasons it is very different from manufacturing. The interaction between the patients and the carers is where the value is added and this implies that “flow of carers” is critical too. Carers are people – no one had yet invented a machine that cares.

As soon as we have two flows that interact we have a new consideration – how do we ensure that they are coordinated so that they are able to interact at the same place, same time, in the right way and is the right amount?

The flows are linked – they are interdependent – we have a system of flows and we cannot just focus on one flow or ignore the inter-dependencies. OK, so far so good. What other flows do we need to consider?

Healthcare is a problem-solving process and it is reliant on data – so the flow of data is essential – some of this is clinical data and related to the practice of care, and some of it is operational data and related to the process of care. Data flow supports the patient and carer flows.

What else?

Solving problems has two stages – making decisions and taking actions – in healthcare the decision is called diagnosis and the action is called treatment. Both may involve the use of materials (e.g. consumables, paper, sheets, drugs, dressings, food, etc) and equipment (e.g. beds, CT scanners, instruments, waste bins etc). The provision of materials and equipment are flows that require data and people to support and coordinate as well.

So far we have flows of patients, people, data, materials and equipment and all the flows are interconnected. This is getting complicated!

Anything else?

The work has to be done in a suitable environment so the buildings and estate need to be provided. This may not seem like a flow but it is – it just has a longer time scale and is more jerky than the other flows – planning-building-using a new hospital has a time span of decades.

Are we finished yet? Is anything needed to support the these flows?

Yes – the flow that links them all is money. Money flowing in is called revenue and investment and money flowing out is called costs and dividends and so long as revenue equals or exceeds costs over the long term the system can function. Money is like energy – work only happens when it is flowing – and if the money doesn’t flow to the right part at the right time and in the right amount then the performance of the whole system can suffer – because all the parts and flows are interdependent.

So, we have Seven Flows – Patients, People, Data, Materials, Equipment, Estate and Money – and when considering any process or system improvement we must remain mindful of all Seven because they are interdependent.

And that is a challenge for us because our caveman brains are not designed to solve seven-dimensional time-dependent problems! We are OK with one dimension, struggle with two, really struggle with three and that is about it. We have to face the reality that we cannot do this in our heads – we need assistance – we need tools to help us handle the Seven Flows simultaneously.

Fortunately these tools exist – so we just need to learn how to use them – and that is what Improvement Science is all about.