They are Ikea and the process is selling a kitchen to be delivered. It starts out promisingly. You can use an online, 3D design program to position your desired cabinets, drawers and appliances with the doors and handles that you want. You can whirl the 3D image around and print top and side views with dimensions on.

But when you go into the store to order the kitchen you designed it starts to unravel. The assistant in the kitchen department spent time with us so we could check that we hadn’t missed anything obvious and she did pick up that we had picked a waste sorting cabinet that wasn’t being used with a sink meaning she could change the drawers to be much deeper. But then she had to manually add text lines in the order that was generated from our design in order that we could see which group of five parts related to which cabinet. After this protracted process we collected the cabinet legs and other little bits from the warehouse and went to pay.

After paying we queued at the Home Delivery desk, where to our shock a very nimble fingered man took the printed order sheet that we got from the kitchen department and proceeded to re-key all the stock numbers and quantities for each one of the 45 individual parts needed to put together our kitchen into the picking and delivery system. Why the kitchen systems and the delivery system don’t talk to each other is amazing to me.

He was a bit put out when I asked to check his duplicate entry, but I knew that five minutes to spot a mistake was better than weeks to try and get Ikea to send the correct part. In fact it was all correct – this time – but I wonder how may orders get copied over incorrectly given the number of kitchens Ikea must deliver every year in all their stores.

To top it off we couldn’t choose a day for delivery. We ordered on Sunday so they pick the next day and deliver the day after that. So it was Tuesday or we wait three weeks. The reason given was that they don’t like to pick an order then have it lying around waiting for delivery. That I understand, but I see no reason that they can’t put our order on the Thursday pick schedule so they deliver to us on the Friday that is most convenient.

I wonder if any of their senior staff has walked through the process as a customer like I had to do this weekend? I’ll wager that they can’t have, since if they did they would want to change it quicker than I could say, “We’re missing half our kitchen.”

Best,

Rob

The financial implications from the latest court case could be serious. The council expects to save about £53 million by 2014 from limiting social services provision to adults with critical needs and may now have to find the money from elsewhere.

Waste Upon Waste

There are many examples of waste here. But the primary error is leading to an explosion of waste as a consequence.

That error is that the council seems to be trying to save money by cutting services and grants. Taking the social care aspect, this causes money to be spent re-assessing people currently in receipt of care. Some of those people will still require care after the assessment. Others will be reassessed at a lower level of service or none at all. In some of these cases the lower level of care will mean they place extra burden on family, friends and neighbours. In cases where other people can’t fill in, in the situation will deteriorate increasing the likelihood of hospital admissions and the need to receive a higher level of care than they currently receive much sooner.

In taking these measures Birmingham City Council have been taken to court. I dread to think how much that case cost to bring and for the council to defend. More waste. Add in the waste of the planning and implementation of the changes that are now halted and add onto that the cost of changing those plans.

There is more non-financial waste in the stress that is caused to the cared for. Stress and worry caused by firstly being told they would be reassessed and now being told those plans are on hold. This stress and worry may cause physical problems in the future which means that their care needs increase. The non-financial waste becomes financial.

Another Way

So what should the council have done instead?

If they had looked to improve their services first before cutting, they would have found that giving better service, more quickly, cuts the cost of providing the service and keeps people well for longer, reducing the need to increase the level of care. The court case could have been avoided and the stress and uncertainty would have been removed. Instead, people will have been happier with the improved service.

It is the art of not doing what is obvious, but instead doing what is right.

Best,

Rob

There is a lot of interesting topics covered in the report and I will be writing more about it in the future, but I wanted to start by focusing in on one of the recommendations (on page viii), which reads:

There is appreciable evidence that the NHS is over-administered as a result of extensive, overlapping and duplicating demands from both regulators and performance managers. There has not been a substantive review of the information demands placed on the service and its providers for many years. A review leading to a rationalisation of those demands is essential.

The words “substantive review” should always strike fear into the reader. A substantive review always seems to be a centralised exercise. They are run from the centre, by the centre and usually promote the needs of the centre. Government studies into what information need to be gathered by Whitehall, start from the premise that they need to determine what Whitehall and the government need. It would be a breath of fresh air to see a study that started with the needs of local work and worked the other way.

How might that work?

Instead of a study group gathering submissions about what data is collected, the starting point would be what data is needed to run the service locally? What data is needed to improve the delivery of value to patients? I would go so far as to say that there is a place for separating the production of data for government and the production of data for local delivery. Most larger trusts have statisticians, they should take over all responsibility for reporting to the centre and relive local managers to collect the data they need. Then locally you can decide how the two data sets differ. Only then should government be notified of the differences. This would have the added benefit of quickly relieving local managers and clinicians of much data collection and reporting responsibility, giving them more time to deliver and improve the care of patients.

If the cause of localism is true then the government will welcome local decisions on what data is collected, for what purpose and what is then reported centrally.

Best,

Rob

“The system will suffer”, they cry, “help our bit of it, but not theirs.”

Every service, region, council, lobby group and association will be calling on the government to treat them as a special case in the near future and from their point of view they are right. The important thing is to take a different point of view. When genuinely looked at as a system, public services need to do two things

1. See themselves as part of the whole system that is the economic and social complex of the country.
2. While bearing that in mind, look to their own systems of work to see how they can improve and save money.

I believe that focusing on purpose (what they are there to do) and improving the service they give is the best way to save money. It is not a direct route but doing what the service user needs, with no waste, errors or rework, as quickly as possible must be the cheapest way to deliver every service.

Most public services are nowhere near that state. So they need to look to themselves to solve their problems.

The only problem will be is if either the service managers don’t see this or the cuts come so fast that they can’t implement it. Though implementation can be surprisingly quick when people put their mind to it.

Best,

Rob

If you read the agenda for the 9th June 2010 cabinet that will be held this coming Wednesday, you will see it is full of things like “implement check list”, “targets for individual areas”, “make managers aware of absence costs” and “put up poster”.

Put up poster!

Nowhere is any mention of improving the work so that people feel they are doing a job with a purpose (serve the local community?) and doing it well. That is the thing that will lower the absence rate. All the other things are futile or will make the problem worse.

The most likely root of the problem is that staff are dissatisfied at what they do and at management constantly getting in the way of them doing a good job. Check lists and return to work interviews will simple antagonise the staff further and continue to reduce any motivation they may have to jump out of bed in the morning.

Give them a good job to do and they will love to come to work.

I wonder if anyone will raise this on Wednesday…

Best,

Rob

If you battle your way through the Stats Wales web site you can get the actual data series for this figure and it looks like this.

• Apr 09 – 65.5%
• May 09 – 66.5%
• Jun 09 – 66.7%
• Jul 09 – 63.9%
• Aug 09 – 54.6%
• Sep 09 – 67.1%
• Oct 09 – 66.4%
• Nov 09 – 65.8%
• Dec 09 – 59.4%
• Jan 10 – 58.5.%
• Feb 10 – 65.3%
• Mar 10 – 69.2%
• Apr 10 – 70.5%

Aug 09 doesn’t look so great. I bet they had some explaining to do that month, and the last month is really good. If you look at the last four months there has been a definite improvement. Or has there?

If we take these figures and plot them on a run chart we see this:

We can see that the percentages are up and down month by month. Again Aug 09 is bad and the latest is good. But quite jumpy nonetheless.

Now let’s show the mean on the chart to provide a bit of balance:

That just gives us a bit of perspective. We can see the points bouncing above and below the mean. There are some questions that we can ask:

• Why does it seem so variable?
• Is that variation excessive?
• Where is the variation coming from?

A technique which can help us answer this question is called Statistical Process Control. It gives a method to calculate limits from the data. If the data points lie within the limits then the variation is “common cause” i.e. normal variation due to the system and if points lie outside the limits then the variation is “special cause” i.e. due to some one off circumstance that can be pointed to as a particular cause of a very high or low figure.

Let’s apply these limits to our chart.

We can see that all the data points lie within the limits. It is worth emphasising that any data point that lies within the limits is entirely expected and is thus assumed to be due to normal variation within the system.

So we can conclude that the Mar 10 figure of 70.5% is within the limits. There is no special cause and there is no shift in the system and so that month’s figure is nothing special in the same way that the Aug 09 figure of 54.6% is also within the expectations of normal system caused variation.

Therefore the Welsh Ambulance emergency call response rates show no improvement.

In fact next month’s figure would be expected to fall anywhere between the limits of 54.3% and 74.9%. (Perhaps a keen reader could remind me to check up on that!)

So what do the Welsh Ambulance service need to do? They need to change the system to 1) move the average and 2) reduce the variation. It would be good to see a shift like this

Where we can clearly see a change in the system causing not only a shift in the mean but a reduction of variation.

This is the evidence of change that we need, not the clutching at straws that accompanies a month-by-month examination of figures.

But also something worse happens when you can’t judge whether the last month’s figure is due to common variation. If it is good, but within the limits, then the temptation is to congratulate people and to rest on our laurels, while all along nothing has really changed. The opposite case is as bad. If the figure is bad, we go looking to blame someone, to find fault, when again, if it is within the limits it is just due to normal variation. In both cases we are tampering, mistaking common variation for something special and acting on it (congratulating or blaming) when in fact we should just ignore it and look at the system as a whole and how we can change it for the better.

Understanding variation due to a system using the techniques described above is the first step toward taking action that is effective.

Best,

Rob

In summary, enforced targets do appear to have been successful in improving aspects of NHS performance, particularly in relation to waiting times, but there is some evidence of unintended consequences – for example, distortion of priorities or neglect of other non-targeted activities. However, it is important to recognise that such unintended consequences may not be the inevitable result of targets in themselves, but rather of the particular way in which those targets were designed and enforced.

Regular readers will know that I disagree with any use of targets. They are arbitrary and they skew behaviour to hit the target rather than delivering high quality care.

To say that unintended consequences may not be the result of targets but the way they are implemented is to miss the point that the setting targets necessarily constrains the methods used to improve. Worse, the methods excluded are precisely the ones that could far exceed the targets while completely avoiding the malodorous consequences and save money to boot. The use of Lean Service techniques along with Systems Thinking will get you further, faster and with a lot less hassle and effort.

The improvement seen from setting a target is like the progress seen when you bang your shoulder against a door that opens towards you. You might make several dents in the door and it may even bend slightly in the desired direction if you really give it some welly. But much more effective is to step back, turn the handle and step through the door. You achieve your aim of getting to the other side of the door faster, without bruising your shoulder and with no damage to the door.

There is no doubt many aspect of the NHS have improved, but that is in spite of the target regime and not because of it.

Best,

Rob

Now Plan, Do, Study, Act (PDSA) is the Shewhart Cycle (some know it as the Deming Cycle) which is a generalisation of the scientific method as applied to improvement in general.

Plan: make a plan or a hypothesis about what you are going to do.
Do: try it out, run the experiment.
Study (sometimes called Check): see how the plan came out.
Act: implement the findings. Either embed the new way or throw it out.

Then you cycle back to Plan with new information.

Anyway, back to this meeting. We tried our best to fill in the four quarters of the chart with our good and bad points about the meeting but try as the chair could he couldn’t explain what he meant in this context by the four quadrants in this context. As far as we could all see we were in Study. We had just Done the meeting and were Studying what we had done for the next Plan for the next meeting. A big row broke out because apparently the chair applied PDSA to everything without problems.

The only new information I gained was that you should never force a technique on a group of people if it is irrelevant and you can’t communicate it properly.

Best,

Rob

I bet the light works in your kitchen and you don’t even think about it. Well the strip light in this kitchen hasn’t worked properly for ages. For the want of 99 pence worth of a new starter, we have both been getting up on a chair to fiddle with the old starter to make the fluorescent bulb flicker and come on and stay on. We just hadn’t quite got round to going to an electrical shop to get the starter. So up on a chair every time we wanted to turn on the kitchen light. We even took to leaving the light on all evening when we left the kitchen so that if we popped back to make some tea, we didn’t have to get on the chair again to turn the light on again. Talk about a work-around.

The thing is we got used to it. After a while, getting up on a chair to make the light come on didn’t seem so much trouble. We forgot that it was a bother. It became the way things were done.

I recall way back when, working for an investment bank as an analyst messing with dozens of Access databases and Excel spreadsheets. One day I had to add an extra calculation to the daily work which would have meant a couple of days effort to update the Access database. Instead, because the trader wanted it that day, I exported the data to Excel, wrote a quick and dirty calculation in an hour, ran the calculation and then reimported the results to the database to continue the day’s work. This extra procedure added 90 minutes to my day, every day.

I continued that extra step for months. I forgot that it was slow and cumbersome. I got used to it.

It took six months before it started to bug me and I got so bored of the extra step that I spent the two days implementing the calculation in Access. After that the calculation whizzed along in the blink of an eye. Those two days spent right at the start would have saved me 24 working days over the six months I waited. In fact the two days of work would have paid for themselves in only eleven days.

In order to implement change, big or small, you need some negative emotions. You need to be dissatisfied, bored, shocked, appalled, angry and critical. If you are tolerant, accepting, placid and content with your lot, nothing will happen. This is why change agents are always searching for the “burning platform” so they can get people to jump instead of having to push them off a “quite comfortable thank you” platform.

For an evening, the newly fixed light was a revelation. “Wow! We don’t have to climb on the chair to turn the light on! Amazing!!” How sad that we take joy in things working as they always should have done. I recall my boss at the bank giving me a pat on the back for rewriting the calculation to save that 90 minutes a day.

A vision of a better way is nice and shiny, but how about a bit of tedium and rage to get us not just to where we should be, but beyond, to where we couldn’t dream of? If only we could stop being so accepting of the messy, awful, boring, infuriating status quo.

Get moving. Get some dissatisfaction.

Best,

Rob