Published: 05/02/2004, Volume II4, No. 5891 Page 30 31 32
'Forgiveness, not permission' is the approach to take to encourage success when an organisation fails - allowing people to make mistakes. As Jan Filochowski explains in the penultimate article of his series, the key to recovery is replacing faulty systems as soon as possible
In failing organisations, even if there are good systems and processes, many will become ineffective. To change this requires commitment from the leadership - usually from the chief executive. This involves understanding what is needed, a determination to carry it through and a commitment to ensure that barriers are removed. I describe this as a 'relentless algorithm' - in other words, a process that does not rest until the problem is solved.
Assistance must be given to those who can identify barriers but do not have the power to do anything about them, and this may mean extra resources. If this approach is adopted, the process becomes selfsustaining and can be spread across the organisation with decreasing resistance and increasing enthusiasm.
A failing trust will be missing key targets. The strategy I recommend is to set up a mechanism involving the key people who must deliver.
They must first identify the extent of the problem but, as there is likely to be insufficient data, those involved must produce it. This could be use of an already existing - but so far uninterpreted - data set, or by collecting new data.
Weekly collection and assessment will probably be needed.
You must scrutinise the data swiftly to see where the problem is. If the data collected does not yield answers, it is not sufficiently detailed or specific and it will be necessary to dig deeper. The data will be there somewhere. It needs to be set alongside a map of what is going on. For example, from booking a patient for surgery to getting the operation done or receiving an urgent referral for a patient with suspected cancer to the time of the consultation.
Most of the processes involve the passage of a significant amount of time, and the key indicator of something going wrong is too much time being spent on them.
At Medway trust we set up a system to go through all key indicators impacting upon our star-ratings each week.Where these showed we were going out of line, those responsible had to offer an explanation, or, if they could not, find one by the next meeting - or sooner - and they had to agree a series of actions.
We were careful to keep working to understand and improve the processes by which work is done and patients treated. To emphasise its importance, it was known as the 'do or die'meeting!
Those involved in this process will start to build an increasingly sophisticated picture of the flow of work. I have found methodologies which identify key events, decision points and information needed at particular times to be most useful. Key decision points pinpoint blockages or queues. From that, the reason for the queue can usually be found. It might be a shortage of beds or operating space, but mostly it is a shortage of someone's time - often, but not always, a doctor's.
Identified causes will throw up potential solutions, which need to be sifted for feasibility, acceptability, speed of application and cost. Some will make a difference, others not, but the net effect will be to increase performance. Each time a change is made the effect will be to focus more tightly on what the residual and sometimes large problem or problems are. In my experience, it is exceedingly rare for these problems to turn out to be absolute brick walls. There is usually some chink, which if worked on hard and long enough from different angles creates a gap.
It is equally important to work on the intervals in which little or nothing is happening - the avoidable danger zones. They happen in administrative processes taking hours, days or weeks, where nothing is done until the 11th hour, when all hell breaks loose.Usually it could have been done at the 10th, ninth, eighth - and even earlier.
A rigorous process needs to be built in to drive back decision-making to the earliest possible point and identify barriers to locating it there.
Doing it the Medway
At Medway trust, we had problems with seeing all urgent referrals for suspected breast cancer in 14 days.
We discovered that in many cases bookings were not being made for several days. Of the 14 days available, 10 had often gone before a problem was highlighted. This left very little time to solve it.
We changed the system so that a booking had to be made within 48 hours of receiving the referral. If this did not happen, the system raised an alarm. This triggered an exceptional effort to deal with the difficult case.We built in time to deal with a problem - time that had always been there which we had never taken advantage of.
This approach applies to the clinical staff seeing the patients as well as to the patients themselves.
One April we discovered that both our breast cancer surgeons had booked leave at the same time.
This made it virtually impossible to meet the target for patients referred in that two-week period.
This breach, for no more than two weeks, meant that only one month into the year we had already missed the whole-year target, all because there was no system in place to ensure co-ordinate leave.We immediately put safeguards in place so there would always be one surgeon available to see urgent patients, and built in a further back-up in case something unforeseen happened.
The next strategy is to keep improving performance.
Do this by reducing intervals, getting rid of blockages and do not stop when you approach - then reach - the targets. This is when you are very vulnerable. Just one unpredictable event - one thing going wrong - and the target is gone.
So in prudent systems management it is essential to create enough space to cope with the occasional unexpected failure without causing system failure.
If your target is 12 months and you are running at 11 you can afford the odd mistake or piece of bad luck. If you're running at 12 months you can't.
The solution is to push back that empty interval and to do what you are going to do anyway sooner. This strategy is applicable to virtually any booking or queuing system.
Next week, in the concluding part of the series, I write about how to involve the whole workforce in recovery. l How Bath got out of hot water Royal United Hospital Bath trust was in crisis, simply unable to cope with the emergency load. In the three months before I arrived the hospital had over 80 12-hour trolley waiters, plus ambulances regularly unable to unload patients into accident and emergency.By making it clear that long waits in A&E would no longer be acceptable and offering understanding, support and a methodology people could understand, we made an immediate impact.
Staff were asked to identify existing blockages, and to pinpoint any new ones. In each case those involved were asked to come up with proposals to sort the blockage. If they could not, we widened the circle of problem solvers.
If action was required beyond the area in which it arose, the potential solution providers were brought in to ensure that it could be implemented. If the proposal did not solve the problem, or provided only a partial resolution, we tried again.
Within a month, with enormous effort, we were no longer breaching 12 hours, but remained close.The fear of breach was constant, adding stress to the working lives of clinicians and managers.We looked at the cases going close to the 12-hour breach.The alarm bell to deal with these patients only rang one or two hours before the 12-hour point.Staff were busy with other, sicker patients.
When the alarm did sound, a disproportionate amount of effort was put into getting them moved.So we looked at what stopped us from bringing the decisions forward and removed the barriers.Sometimes this was easy - for example, if the delay was caused by a system running on autopilot. In other cases it proved difficult because the delay arose from another process running elsewhere that took priority over this one.
In the admissions ward, the ward rounds took place at the wrong time to clear beds for patients waiting in A&E.We went through them one by one seeking and eventually finding changes which helped the problem without jeopardising the process they were set up to serve.
At the beginning of 2002-03, well under 50 per cent of patients were treated or admitted in four hours, the fourth worst in the country.A year on, the figure was virtually double, well up in the 80s.
Hey, good booking: from laggards to leaders
At Medway, we moved from being laggards at partial booking to leaders in the Modernisation Agency's cohort.The confidence and enthusiasm that key staff developed allowed us to apply the methods to x-ray and other radiological booking in a pioneering way.
We started by identifying that it took over 30 steps to book an outpatient appointment, that if a patient could not make the appointment it was difficult for them to contact us to change it, and worse, we were the ones who cancelled and moved the majority of clinics.
We worked with a few consultants to show them what was happening and with clinic booking staff and secretaries to develop a rational, sensible six-step booking system.This included negotiating with patients on the date and time of appointment a maximum of six weeks ahead.The system prevented a build-up of long waits.
We then shared this with other secretaries and consultants, and in the wake of the success with the few won the commitment of the many.This enabled us to put together a coherent, single system in which we could identify problems quickly.We centralised outpatient booking through a call centre, which won the confidence not just of administrative or managerial staff but of consultants and their secretaries.
Common sense: all change for the central line At Bath, not only were there decentralised booking systems and an inability to manage unacceptable waiting times, but outpatient clinics delivered from several locations in different organisations, with different booking systems and multiple computer systems.
We tackled this by getting on top of our information in the hospital, setting up rigorous common booking mechanisms which were sensitive to the working patterns of clinicians in outpatients.
We, in common with our colleagues in the many community hospitals and four primary care trusts, realised that we had not co-ordinated this work across the whole area.So staff in each organisation made a huge effort to bring all this together.They worked in a co-ordinated and co-operative way so that within two months we had got a grip on the situation. It underlined that, as at Medway trust, a centralised booking system, even across separate organisations, can increase confidence and meet booking requirements.
In retrospect, these successes can look like the successes of common sense but they are immensely difficult to achieve.Apart from their immediate, direct benefit, they enhance the confidence of the organisation and the people within it.Problems are there to be solved and staff need to know they will be supported and helped to solve them.The problem-solving mentality becomes the norm, not the exception.
A leader's role is to be supportive, encouraging and rigorous but absolutely not to demand perfection or success every time.This will not happen, and if it is demanded it will put several nails in the coffin of failure.
You try to create - and it is not an original phrase - a culture based upon 'forgiveness, not permission'. If you are prepared to forgive reasonable and honest failures, you will get many, many more successes.