<Bob> Hi Leslie, right-on-time, how are you today?
<Leslie> Good thanks Bob. I have a specific topic to explore if that is OK. Can we talk about time traps.
<Bob> OK – do you have a specific reason for choosing that topic?
<Leslie> Yes. The blog last week about ‘Recipe for Chaos‘ set me thinking and I remembered that time-traps were mentioned in the FISH course but I confess, at the time, I did not understand them. I still do not.
<Bob> Can you describe how the ‘Recipe for Chaos‘ blog triggered this renewed interest in time-traps?
<Leslie> Yes – the question that occurred to me was: ‘Is a time-trap a recipe for chaos?’
<Bob> A very good question! What do you feel the answer is?
<Leslie>I feel that time-traps can and do trigger chaos but I cannot explain how. I feel confused.
<Bob>Your intuition is spot on – so can you localize the source of your confusion?
<Leslie>OK. I will try. I confess I got the answer to the MCQ correct by guessing – and I wrote down the answer when I eventually guessed correctly – but I did not understand it.
<Bob>What did you write down?
<Leslie>“The lead time is independent of the flow”.
<Bob>OK. That is accurate – though I agree it is perhaps a bit abstract. One source of confusion may be that there are different causes of of time-traps and there is a lot of overlap with other chaos-creating policies. Do you have a specific example we can use to connect theory with reality?
<Leslie> OK – that might explain my confusion. The example that jumped to mind is the RTT target.
<Leslie> Oops – sorry – I know I should not use undefined abbreviations. Referral to Treatment Time.
<Bob> OK – can you describe what you have mapped and measured already?
<Leslie> Yes. When I plot the lead-time for patients in date-of-treatment order the process looks stable but the histogram is multi-modal with a big spike just underneath the RTT target of 18 weeks. What you describe as the ‘Horned Gaussian’ – the sign that the performance target is distorting the behaviour of the system and the design of the system is not capable on its own.
<Bob> OK and have you investigated why there is not just one spike?
<Leslie> Yes – the factor that best explains that is the ‘priority’ of the referral. The ‘urgents’ jump in front of the ‘soons’ and both jump in front of the ‘routines’. The chart has three overlapping spikes.
<Bob> That sounds like a reasonable policy for mixed-priority demand. So what is the problem?
<Leslie> The ‘Routine’ group is the one that clusters just underneath the target. The lead time for routines is almost constant but most of the time those patients sit in one queue or another being leap-frogged by other higher-priority patients. Until they become high-priority – then they do the leap frogging.
<Bob> OK – and what is the condition for a time trap again?
<Leslie> That the lead time is independent of flow.
<Leslie> Um. let me think. That the flow can be varying but the lead time stays the same?
<Bob> Yup. So is the flow of routine referrals varying?
<Leslie> Not over the long term. The chart is stable.
<Bob> What about over the short term? Is demand constant?
<Leslie>No of course not – it varies – but that is expected for all systems. Constant means ‘over-smoothed data’ – the Flaw of Averages trap!
<Bob>OK. And how close is the average lead time for routines to the RTT maximum allowable target?
<Leslie> Ah! I see what you mean. The average is about 17 weeks and the target is 18 weeks.
<Bob>So what is the flow variation on a week-to-week time scale?
<Leslie>Demand or Activity?
<Leslie>H’mm – give me a minute to re-plot flow as a weekly-aggregated chart. Oh! I see what you mean – both the weekly activity and demand are both varying widely and they are not in sync with each other. Work in progress must be wobbling up and down a lot! So how can the lead time variation be so low?
<Bob>What do the flow histograms look like?
<Leslie> Um. Just a second. That is weird! They are both bi-modal with peaks at the extremes and not much in the middle – the exact opposite of what I expected to see! I expected a centered peak.
<Bob>What you are looking at is the characteristic flow fingerprint of a chaotic system – it is called ‘thrashing’.
<Leslie> So I was right!
<Bob> Yes. And now you know the characteristic pattern to look for. So what is the policy design flaw here?
<Leslie>The DRAT – the delusional ratio and arbitrary target?
<Bob> That is part of it – that is the external driver policy. The one you cannot change easily. What is the internally driven policy? The reaction to the DRAT?
<Leslie> The policy of leaving routine patients until they are about to breach then re-classifying them as ‘urgent’.
<Bob>Yes! It is called a ‘Prevarication Policy’ and it is surprisingly and uncomfortably common. Ask yourself – do you ever prevaricate? Do you ever put off ‘lower priority’ tasks until later and then not fill the time freed up with ‘higher priority tasks’?
<Leslie> OMG! I do that all the time! I put low priority and unexciting jobs on a ‘to do later’ heap but I do not sit idle – I do then focus on the high priority ones.
<Bob> High priority for whom?
<Leslie> Ah! I see what you mean. High priority for me. The ones that give me the biggest reward! The fun stuff or the stuff that I get a pat on the back for doing or that I feel good about.
<Bob> And what happens?
<Leslie> The heap of ‘no-fun-for-me-to-do’ jobs gets bigger and I await the ‘reminders’ and then have to rush round in a mad panic to avoid disappointment, criticism and blame. It feels chaotic. I get grumpy. I make more mistakes and I deliver lower-quality work. If I do not get a reminder I assume that the job was not that urgent after all and if I am challenged I claim I am too busy doing the other stuff.
<Bob> Have you avoided disappointment?
<Leslie> Ah! No – that I needed to be reminded meant that I had already disappointed. And when I do not get a reminded does not prove I have not disappointed either. Most people blame rather than complain. I have just managed to erode other people’s trust in my reliability. I have disappointed myself. I have achieved exactly the opposite of what I intended. Drat!
<Bob> So what is the reason that you work this way? There will be a reason. A good reason.
<Leslie> That is a very good question! I will reflect on that because I believe it will help me understand why others behave this way too.
<Bob> OK – I will be interested to hear your conclusion. Let us return to the question. What is the downside of a ‘Prevarication Policy’?
<Leslie> It creates stress, chaos, fire-fighting, last minute changes, increased risk of errors, more work and it erodes both quality, confidence and trust.
<Bob>Indeed so – and the impact on productivity?
<Leslie> The activity falls, the system productivity falls, revenue falls, queues increase, waiting times increase and the chaos increases!
<Leslie> We treat the symptoms by throwing resources at the problem – waiting list initiatives – and that pushes our costs up. Either way we are heading into a spiral of decline and disappointment. We do not address the root cause.
<Bob> So what is the way out of chaos?
<Leslie> Reduce the volume on the destabilizing feedback loop? Stop the managers meddling!
<Leslie> Eh? I do not understand what you mean. The blog last week said management meddling was the problem.
<Bob> It is a problem. How many feedback loops are there?
<Leslie> Two – that need to be balanced.
<Bob> So what is another option?
<Leslie> OMG! I see. Turn UP the volume of the stabilizing feedback loop!
<Bob> Yup. And that is a lot easier to do in reality. So that is your other challenge to reflect on this week. And I am delighted to hear you using the terms ‘stabilizing feedback loop’ and ‘destabilizing feedback loop’.
<Leslie> Thank you. That was a lesson for me after last week – when I used the terms ‘positive and negative feedback’ it was interpreted in the emotional context – positive feedback as encouragement and negative feedback as criticism. So ‘reducing positive feedback’ in that sense is the exact opposite of what I was intending. So I switched my language to using ‘stabilizing and destabilizing’ feedback loops that are much less ambiguous and the confusion and conflict disappeared.
<Bob> That is very useful learning Leslie … I think I need to emphasize that distinction more in the blog. That is one advantage of online media – it can be updated!
<Leslie> Thanks again Bob! And I have the perfect opportunity to test a new no-prevarication-policy design – in part of the system that I have complete control over – me!