October 2015 – HCSE Blog

24/10/2015

The Cost of Fragmentation

As systems become bigger and more complicated they may fragment into a larger number of smaller parts.

There are many reasons for this behaviour but the essence is that the integrity of a system requires the parts to be connected to each other in some way. Bonds that hold them together – bonds that are stronger than the forces of disruption that are always battering them.

In some systems these bonds are physical and chemical.

A diamond does not fragment, even under extreme pressure, because the chemical bonds between the carbon atoms in the crystal lattice are very strong . A diamond is not alive – the atoms cannot move around – and that is the secret of its extreme strength. So a diamond cannot adapt either … it is durable but it is dead.

In biological systems the bonds are informational.

A cell maintains its integrity because the nanoscale component parts are held together physically, chemically and with information.

Inside a cell the atoms and molecules move around – and that is the secret of its survival. It is alive. It senses. It responds. It evolves. It endures. And it is mortal.

So are the organisms made from cells. A lichen, a tree, an animal and a person.

And so are the organisations built by and from people. A couple, a family, a tribe, a nation, the world.

And it is informational bonds that hold people together – it is how they share data with each other.

These bonds manifest in many ways. Our senses – especially sight, sound and touch. Our language – body, verbal and visual. Our learning – individual and collective. And our emotions, beliefs and behaviours that emerge and evolve over time.

We all know we are mortal. We strive to protect our identity; and we yearn for longevity. We do not want to die. We want and need integrity – at all levels from chemical to cultural.

And to achieve that degree of synergy we need to share that which we have in common:

1) Shared purpose.
2) Shared language.
3) Shared pledge of acceptable behaviours.
4) Shared pool of data, information, knowledge, understanding and wisdom.

Everything else is dynamic. What we believe, what we decide, how we learn, what we do. It is that variability and adaptability that is part of our collective strength along with our shared commitment.

And the balance is critical.

Too rigid and we cannot flex quickly enough to a changing environment; too fluid and we fall apart at the first challenge. We need both stability and agility – so our system of information flows must be fit-for-purpose.

And the price we will all pay for not achieving that critical balance is death-by-fragmentation.

17/10/2015

A Case of Chronic A&E Pain: Part 6

Dr Bob runs a Clinic for Sick Systems and is sharing the Case of St Elsewhere’s® Hospital which is suffering from chronic pain in their A&E department.

The story so far: The history and examination of St.Elsewhere’s® Emergency Flow System have revealed that the underlying disease includes carveoutosis multiforme. StE has consented to a knowledge transplant but is suffering symptoms of disbelief – the emotional rejection of the new reality. Dr Bob prescribed some loosening up exercises using the Carveoutosis Game. This is the appointment to review the progress.

<Dr Bob> Hello again. I hope you have done the exercises as we agreed.

<StE> Indeed we have. Many times in fact because at first we could not believe what we were seeing. We even modified the game to explore the ramifications. And we have an apology to make. We discounted what you said last week but you were absolutely correct.

<Dr Bob> I am delighted to hear that you have explored further and I applaud you for the curiosity and courage in doing that. There is no need to apologize. If this flow science was intuitively obvious then we we would not be having this conversation. So, how have you used the new understanding?

<StE> Before we tell the story of what happened next we are curious to know where you learned about this?

<Dr Bob> The pathogenesis of carveoutosis spatialis has been known for about 100 years but in a different context. The story goes back to the 1870s when Alexander Graham Bell invented the telephone. He was not an engineer or mathematician by background; he was interested in phonetics and he was a pragmatist and experimented by making things. He invented the telephone and the Bell Telephone Co. was born. This innovation spread like wildfire, as you can imagine, and by the early 1900’s there were many telephone companies all over the world. At that time the connections were made manually by telephone operators using patch boards and the growing demand created a new problem. How many lines and operators were needed to provide a high quality service to bill paying customers? In other words … to achieve an acceptably low chance of hearing the reply “I’m sorry but all lines are busy, please try again later“. Adding new lines and more operators was a slow and expensive business so they needed a way to predict how many would be needed – and how to do that was not obvious! In 1917, a Danish mathematician, statistician and engineer called Agner Krarup Erlang published a paper with the solution. A complicated formula that described the relationship and his Erlang B equation allowed telephone exchanges to be designed, built and staffed and to provide a high quality service at an acceptably low cost. Mass real-time voice communication by telephone became affordable and has transformed the world.

<StE> Fascinating! We sort of sense there is a link here and certainly the “high quality and low cost” message resonates for us. But how does designing telephone exchanges relate to hospital beds?

<Dr Bob> If we equate an emergency admission needing a bed to a customer making a phone call, and we equate the number of telephone lines to the number of beds, then the two systems are very similar from the flow physics perspective. Erlang’s scary-looking equation can be used to estimate the minimum number of beds needed to achieve any specified level of admission service quality if you know the average rate of demand and average the length of stay. That is how I made the estimate last week. It is this predictable-within-limits behaviour that you demonstrated to yourself with the Carveoutosis Game.

<StE> And this has been known for nearly 100 years but we have only just learned about it!

<Dr Bob> Yes. That is a bit annoying isn’t it?

<StE> And that explains why when we ‘ring-fence’ our fixed stock of beds the 4-hour performance falls!

<Dr Bob> Yes, that is a valid assertion. By doing that you are reducing your space-capacity resilience and the resulting danger, chaos, disappointment and escalating cost is completely predictable.

<StE> So our pain is iatrogenic as you said! We have unwittingly caused this. That is uncomfortable news to hear.

<Dr Bob> The root cause is actually not what you have done wrong, it is what you have not done right. It is an error of omission. You have not learned to listen to what your system is telling you. You have not learned how that can help you to deepen your understanding of how your system works. It is that information, knowledge, understanding and wisdom that you need to design a safer, calmer, higher quality and more affordable healthcare system.

<StE> And now we can see our omission … before it was like a blind spot … and now we can see the fallacy of our previously deeply held belief: that it was impossible to solve this without more beds, more staff and more money. The gap is now obvious where before it was invisible. It is like a light has been turned on. Now we know what to do and we are on the road to recovery. We need to learn how to do this ourselves … but not by guessing and meddling … we need to learn to diagnose and then to design and then to deliver safety, flow, quality and productivity. All at the same time.

<Dr Bob> Welcome to the world of Improvement Science. And here I must sound a note of caution … there is a lot more to it than just blindly applying Erlang’s B equation. That will get us into the ball-park, which is a big leap forward, but real systems are not just simple, passive games of chance; they are complicated, active and adaptive. Applying the principles of flow design in that context requires more than just mathematics, statistics and computer models. But that know-how is available and accessible too … and waiting for when you are ready to take that leap of learning.

OK. I do not think you require any more help from me at this stage. You have what you need and I wish you well. And please let me know the outcome.

<StE> Thank you and rest assured we will. We have already started writing our story … and we wanted to share the that with you today … but with this new insight we will need to write a few more chapters first. This is really exciting … thank you so much.

St.Elsewhere’s® is a registered trademark of Kate Silvester Ltd, and to read more real cases of 4-hour A&E pain download Kate’s: The Christmas Crisis

Part 1 is here. Part 2 is here. Part 3 is here. Part 4 is here. Part 5 is here.

10/10/2015

A Case of Chronic A&E Pain: Part 5

Dr Bob runs a Clinic for Sick Systems and is sharing the Case of St Elsewhere’s® Hospital which is suffering from chronic pain in their A&E department.

The story so far: The history and examination of St.Elsewhere’s® Emergency Flow System have revealed the footprint of a Horned Gaussian in their raw A&E data. This characteristic sign suggests that the underlying disease includes carveoutosis. StE has signed up for treatment and has started by installing learning loops. This is the one week follow up appointment.

<Dr Bob> Hi there. How are things? What has changed this week?

<StE> Lots! We shared the eureka moment we had when you described the symptoms, signs and pathogenesis of carvoutosis temporalis using the Friday Afternoon Snail Mail story. That resonated strongly with lots of people. And as a result that symptom has almost gone – as if by magic! We are now keeping on top of our emails by doing a few each day and we are seeing decisions and actions happening much more quickly.

<Dr Bob> Excellent. Many find it surprising to see such a large beneficial impact from such an apparently small change. And how are you feeling overall? How is the other pain?

<StE> Still there unfortunately. Our A&E performance has not really improved but we do feel a new sense of purpose, determination and almost optimism. It is hard to put a finger on it.

<Dr Bob> Does it feel like a paradoxical combination of “feels subjectively better but looks objectively the same”?

<StE> Yes, that’s exactly it. And it is really confusing. Are we just fire-fighting more quickly but still not putting out the fire?

<Dr Bob> Possibly. It depends on your decisions and actions … you may be unwittingly both fighting and fanning the fire at the same time. It may be that you are suffering from carveoutosis multiforme.

<StE> Is that bad?

<Dr Bob> No. Just trickier to diagnose and treat. It implies that there is more than one type of carveoutosis active at the same time and they tend to amplify each other. The other common type is called carveoutosis spatialis. Shall we explore that hypothesis?

<StE> Um, OK. Does it require more painful poking?

<Dr Bob> A bit. Do you want to proceed? I cannot do so without your consent.

<StE> I suppose so.

<Dr Bob> OK. Can you describe for me what happens to emergency patients after they are admitted. Where do they go to?

<StE> That’s easy. The medical emergencies go to the medical wards and the others go to the surgical wards. Or rather they should. Very often there is spillover from one to the other because the specialty wards are full. That generates a lot of grumbling from everyone … doctors, nurses and patients. We call them outliers.

<Dr Bob> And when a patient gets to a ward where do they go? Into any available empty bed?

<StE> No. We have to keep males and females separate, to maintain privacy and dignity. We get really badly beaten up if we mix them. Our wards are split up into six-bedded bays and a few single side-rooms, and we are constantly juggling bays and swapping them from male to female and back. Often moving patients around in the process, and often late at night. The patients do not like it and it creates lots of extra work for the nurses.

<Dr Bob> And when did these specialty and gender segregation policies come into force?

<StE> The specialty split goes back decades, the gender split was introduced after StE was built. We were told that it wouldn’t make any difference because we are still admitting the same proportion of males and females so it would average out, but it causes us a lot of headaches! Maybe we are now having to admit more patients than the hospital was designed to hold!

<Dr Bob> That is possible, but even if you were admitting the same number for the same length of time the symptoms of carveoutosis spatialis are quite predictable. When there is any form of variation in demand, casemix, or gender then if you split your space-capacity into ‘ring-fenced’ areas you will always need more total space-capacity to achieve the same waiting time performance. Always. It is mandated by the Laws of Physics. It is not negotiable. And it does not average out.

<StE> What! So we were mis-informed? The chaos we are seeing was predictable?

<Dr Bob> The effect of carveoutosis spatialis is predictable. But knowing that does not prove it is the sole cause of the chaos you are experiencing. It may well be a contributory factor though.

<StE> So how big an effect are we talking about here? A few percent?

<Dr Bob> I can estimate it for you. What are your average number of emergency admissions per day, the split between medical and surgical, the split between gender, and the average length of stay in each group?

<StE> We have an average of sixty emergency admissions per day, the split between medicine and surgery is 50:50 on average; the gender split is 50:50 on average and the average LoS in each of those 4 groups is 8 days. We worked out using these number that we should need 480 beds but even now we have about 540 and even that doesn’t seem to be enough!

<Dr Bob> OK, let me work this out … with those parameters and assuming that the LoS does not change then the Laws of Flow Physics predict that you would need about 25% more beds than 480 – nearer six hundred – to be confident that there will always be a free bed for the next emergency admission in all four categories of patient.

<StE> What! Our Director of Finance has just fallen off his chair! That can’t be correct!

[pause]

But that is exactly what we are seeing.

[pause]

If we we were able to treated this carvoutosis spatialis … if, just for the sake of argument, we could put any patient into any available bed … what effect would that have? Would we then only need 480 beds?

<Dr Bob> You would if there was absolutely zero variation of any sort … but that is impossible. If nothing else changed the Laws of Physics predict that you would need about 520 beds.

<StE> What! But we have 540 beds now. Are you saying our whole A&E headache would evaporate just by doing that … and we would still have beds to spare?

<Dr Bob> That would be my prognosis, assuming there are no other factors at play that we have not explored yet.

<StE> Now the Head of Governance has just exploded! This is getting messy! We cannot just abandon the privacy and dignity policy. But there isn’t much privacy or dignity lying on a trolley in the A&E corridor for hours! We’re really sorry Dr Bob but we cannot believe you. We need proof.

<Dr Bob> And so would I were I in your position. Would you like to prove it to yourselves? I have a game you can play that will demonstrate this unavoidable consequence of the Laws of Physics. Would you like to play it?

<StE> We would indeed!

<Dr Bob> OK. Here are the instructions for the game. This is your homework for this week. See you next week.

St.Elsewhere’s® is a registered trademark of Kate Silvester Ltd, and to read more real cases of 4-hour A&E pain download Kate’s: The Christmas Crisis

Part 1 is here. Part 2 is here. Part 3 is here. Part 4 is here.

03/10/2015

A Case of Chronic A&E Pain: Part 4

Dr Bob runs a Clinic for Sick Systems and is sharing the Case of St Elsewhere’s ® Hospital which is suffering from chronic pain in the A&E department.

Dr Bob is presenting the case study in weekly bite-sized bits that are ample food for thought.

Part 1 is here. Part 2 is here. Part 3 is here.

The story so far:

The history and initial examination of St.Elsewhere’s® Emergency Flow System have revealed the footprint of a Horned Gaussian in their raw A&E data. That characteristic sign suggests that the underlying disease complex includes one or more forms of carveoutosis. So that is what Dr Bob and StE will need to explore together.

<Dr Bob> Hello again and how are you feeling since our last conversation?

<StE> Actually, although the A&E pain continues unabated, we feel better. More optimistic. We have followed your advice and have been plotting our daily A&E time-series charts and sharing those with the front-line staff. And what is interesting to observe is the effect of just doing that. There are fewer “What you should do!” statements and more “What we could do …” conversations starting to happen – right at the front line.

<Dr Bob> Excellent. That is what usually happens when we switch on the fast feedback loop. I detect that you are already feeling the emotional benefit. So now we need to explore carveoutosis. Are you up for that?

<StE> You betcha!

<Dr Bob> OK. The common pathology in carveoutosis is that we have some form of resource that we, literally, carve up into a larger number of smaller pieces. It does not matter what the resource is. It can be time, space, knowledge, skill, cash. Anything.

<StE> Um, that is a bit abstract. Can you explain with a real example?

<Dr Bob> OK. I will use the example of temporal carveoutosis. Do you use email? And if so what are your frustrations with it … your Niggles?

<StE> Ouch! You poked a tender spot with that question! Email is one of our biggest sources of frustration. A relentless influx of dross that needs careful scanning to filter out the important stuff. We waste hours every week on this hamster wheel. And if we do not clear our Inboxes by close of play on Friday then the following week is even worse!

<Dr Bob> And how many of you put time aside on Friday afternoon to ‘Clear-the-Inbox’?

<StE> We all do. It does at least give us some sense of control amidst the chaos.

<Dr Bob> OK. This is a perfect example of temporal carveoutosis. Suppose we consider the extreme case where we only process our emails on a Friday afternoon in a chunk of protected time carved out of our diary. Now consider the effect of our carved-out-time-policy on the flow of emails. What happens?

<StE> Well, if we all do this then we will only send emails on a Friday afternoon and the person we are sending them to will only read them the following Friday afternoon and if we need a reply we will read that the Friday after. So the time from sending an email to getting a reply will be two weeks. And it does not make any difference how many emails we send!

<Dr Bob> Yes. That is the effect on the lead-time … but I asked what the effect was on flow?

<StE> Oops! So our answer was correct but that was not the question you asked. Um, the effect on flow is that it will be very jerky. Emails will only flow on Friday afternoons … so all the emails for the week will try to flow around in a few hours or minutes. Ah! That may explain why the email system seems to slow down on Friday afternoons and that only delays the work and adds to our frustration! We naturally assumed it was because the IT department have not invested enough in hardware! Faster computers and bigger mailboxes!

<Dr Bob> What you are seeing is the inevitable and predictable effect of one form of temporal carveoutosis. The technical name for this is a QBQ time trap and it is an iatrogenic disease. Self-inflicted. (QBQ=queue-batch-queue).

<StE> So if the IT Department actually had the budget, and if they had actually treated the ear-ache we were giving them, and if they had actually invested in faster and bigger computers then the symptom of Friday Snail Mail would go away – but the time trap would remain. And it might actually reinforce our emails-only-on-a-Friday-afternoon behaviour! Wow! That was not obvious until you forced us to think it through logically.

<Dr Bob> Well. I think that insight is enough to chew over for now. One eureka reaction at a time is enough in my experience. Food for thought requires time to digest. This week your treatment plan is to share your new insight with the front-line teams. You can use this example because email Niggles are very common. And remember … Focus on the Flow. Repeat that mantra to yourselves until it becomes a little voice in your head that reminds you what to do when you are pricked by the feelings of disappointment, frustration and fear. Next week …

St.Elsewhere’s® is a registered trademark of Kate Silvester Ltd. And to read more real cases of 4-hour A&E pain download Kate’s: The Christmas Crisis