And when a big kick is made where there is no<\/strong> leverage point the effort is dissipated. Like flogging a dead horse.<\/p>\n Other names for leverage points are triggers, buttons, catalysts, fuses etc.<\/p>\n The fact that there is a big<\/strong> effect does not imply it is a good<\/strong> effect.<\/p>\n Poking a leverage point can trigger a catastrophe just as it can trigger a celebration. It depends on how it is poked.<\/p>\n Perhaps that is one reason people stay away from them.<\/p>\n But when our heath care system performance is in decline, if we do nothing or if we act but stay away from leverage points (i.e. flog the dead horse) then we will deny ourselves the opportunity of improvement.<\/p>\n So, we need a way to (a) identify the leverage points and (b) know how to poke them positively and know how to not<\/strong> poke them into delivering a catastrophe.<\/p>\n Here is a couple of real examples.<\/p>\n![\"\"](\"http:\/\/www.improvementscience.co.uk\/blog\/wp-content\/uploads\/Leverage_Point_Fuse.png\")
<\/a>When a nudge is made at a leverage point in a real system the impact is amplified – so a small cause can have a big effect.<\/p>\n
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\nThe time-series chart above shows the A&E performance of a real acute trust.\u00a0 Notice the pattern as we read left-to-right; baseline performance is OKish and dips in the winters, and the winter dips get deeper but the baseline performance recovers.\u00a0 In April 2015 (yellow flag) the system behaviour changes, and it goes into a steady decline with added winter dips.\u00a0 This is the characteristic pattern of poking a leverage point in the wrong way … and the fact it happened at the start of the financial year suggests that Finance was involved.\u00a0 Possibly triggered by a cost-improvement programme (CIP) action somewhere else in the system.\u00a0 Save a bit of money here and create a bigger problem over there. That is how systems work. Not my budget so not my problem.<\/p>\n