A Perspective on Flow
- 31 July 2017
- Posted in: Healthcare
Taking action using ‘vital signs’ within complex public services.
We are constantly confronted with headlines of public services failing to deliver. A&E 4-hour waiting times missed. Passport queues growing. ‘High risk’ individual watchlists that can’t be fully manned. There may be any number of reasons for this, but what people see and experience are delays and frustration, to which they may respond: “if only we could make things flow better”. We can get most things instantly these days, so why not a hip operation?
Resources within our public services are running ever “hotter” (more patients, more passports, less people to deliver) and so the resilience of the system as a whole is low, putting pressure on those individuals in whose hands delivery lies. Theories summarise the interplay between the vagaries of demand and supply; in complex systems, most agree that you need some available capacity most of the time to manage fluctuations. Many of our public services are ‘complex adaptive systems’ where “the interactions and relationships of different components simultaneously affect and are shaped by the system”. However, you don’t need to understand the cause behind every traffic jam to plan a better journey: these days, all you need to do is look on Google Maps for the red bits and plan a different route.
So how can public service leaders use this theory to improve flow? There are only four questions they need to ask:
What would the overall environment look like, if we were to view it from far above?
Yes, routes for different patients, passports or even procurement are different, but stand back and look at the main ‘junctions’ and the ‘roads’ which link them. It is actually more simple that it seems – you can represent it all on a page.
What are the ‘vital signs’ which tell you when and where is flow most constrained?
I met the inspiring Simon Dodds recently – engineer come surgeon come passionate improvement specialist – and he introduced me to the principle of ‘vital signs’ – what do you REALLY need to look at to know how you are doing? Here are two of them. First of all, look at the queues (think the red bits on Google Maps): where do they build up and how do they change with time? Knowing this is often enough to tell you where (and when) you are constrained. Secondly, and if you need to, look at time: how long is it taking people to get through? Some queuing and waiting is inevitable but how much is acceptable? Allied to this is the need to be clear in expectations – what do the vital signs need to show? How much waiting is OK? Be aggressively optimistic with expectations – “reach for the highest cloud”.
Where is flow constrained?
Most people who work at a ‘junction’ will know enough about the main causes of delays and inconsistencies to make informed judgements. Go to the front line and listen to those who experience it every day.
What can you do about it?
The first three questions are useful, but this is the most important. Make a decision to act, then act, then watch – and repeat. Your first decisions may not be perfect but they will be better than waiting and doing nothing in the meantime. As you watch your ‘vital signs’ change, you will know whether you are succeeding. Keep changing until you are.
Recently, we followed this process with a group of nurses on a hospital ward, and they managed to get patients safely back home from hospital on average a day earlier than was usual. What’s more, we left them to make their own improvements on the other wards.
So what are you waiting for? Make tomorrow’s journey different to today’s.
Mike Meredith is a Director at 2020 Delivery, a company focused solely on improving public services
