A Case of Chronic A&E Pain: Part 4

Saturday, October 3, 2015

Dr_Bob_ThumbnailDr 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