A Case of Chronic A&E Pain: Part 6

Saturday, October 17, 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 their A&E department.

The story so far: The history and examination of St.Elsewhere’s® Emergency Flow System have revealed that the underlying disease includes carveoutosis multiforme.  StE has consented to a knowledge transplant but is suffering symptoms of disbelief – the emotional rejection of the new reality. Dr Bob prescribed some loosening up exercises using the Carveoutosis Game.  This is the appointment to review the progress.


<Dr Bob> Hello again. I hope you have done the exercises as we agreed.

<StE> Indeed we have.  Many times in fact because at first we could not believe what we were seeing. We even modified the game to explore the ramifications.  And we have an apology to make. We discounted what you said last week but you were absolutely correct.

<Dr Bob> I am delighted to hear that you have explored further and I applaud you for the curiosity and courage in doing that.  There is no need to apologize. If this flow science was intuitively obvious then we we would not be having this conversation. So, how have you used the new understanding?

<StE> Before we tell the story of what happened next we are curious to know where you learned about this?

<Dr Bob> The pathogenesis of carveoutosis spatialis has been known for about 100 years but in a different context.  The story goes back to the 1870s when Alexander Graham Bell invented the telephone.  He was not an engineer or mathematician by background; he was interested in phonetics and he was a pragmatist and experimented by making things. He invented the telephone and the Bell Telephone Co. was born.  This innovation spread like wildfire, as you can imagine, and by the early 1900’s there were many telephone companies all over the world.  At that time the connections were made manually by telephone operators using patch boards and the growing demand created a new problem.  How many lines and operators were needed to provide a high quality service to bill paying customers? In other words … to achieve an acceptably low chance of hearing the reply “I’m sorry but all lines are busy, please try again later“.  Adding new lines and more operators was a slow and expensive business so they needed a way to predict how many would be needed – and how to do that was not obvious!  In 1917, a Danish mathematician, statistician and engineer called Agner Krarup Erlang published a paper with the solution.  A complicated formula that described the relationship and his Erlang B equation allowed telephone exchanges to be designed, built and staffed and to provide a high quality service at an acceptably low cost.  Mass real-time voice communication by telephone became affordable and has transformed the world.

<StE> Fascinating! We sort of sense there is a link here and certainly the “high quality and low cost” message resonates for us. But how does designing telephone exchanges relate to hospital beds?

<Dr Bob> If we equate an emergency admission needing a bed to a customer making a phone call, and we equate the number of telephone lines to the number of beds, then the two systems are very similar from the flow physics perspective. Erlang’s scary-looking equation can be used to estimate the minimum number of beds needed to achieve any specified level of admission service quality if you know the average rate of demand and average the length of stay.  That is how I made the estimate last week. It is this predictable-within-limits behaviour that you demonstrated to yourself with the Carveoutosis Game.

<StE> And this has been known for nearly 100 years but we have only just learned about it!

<Dr Bob> Yes. That is a bit annoying isn’t it?

<StE> And that explains why when we ‘ring-fence’ our fixed stock of beds the 4-hour performance falls!

<Dr Bob> Yes, that is a valid assertion. By doing that you are reducing your space-capacity resilience and the resulting danger, chaos, disappointment and escalating cost is completely predictable.

<StE> So our pain is iatrogenic as you said! We have unwittingly caused this. That is uncomfortable news to hear.

<Dr Bob> The root cause is actually not what you have done wrong, it is what you have not done right. It is an error of omission. You have not learned to listen to what your system is telling you. You have not learned how that can help you to deepen your understanding of how your system works. It is that information, knowledge, understanding and wisdom that you need to design a safer, calmer, higher quality and more affordable healthcare system.

<StE> And now we can see our omission … before it was like a blind spot … and now we can see the fallacy of our previously deeply held belief: that it was impossible to solve this without more beds, more staff and more money.  The gap is now obvious where before it was invisible. It is like a light has been turned on.  Now we know what to do and we are on the road to recovery. We need to learn how to do this ourselves … but not by guessing and meddling … we need to learn to diagnose and then to design and then to deliver safety, flow, quality and productivity.  All at the same time.

<Dr Bob> Welcome to the world of Improvement Science. And here I must sound a note of caution … there is a lot more to it than just blindly applying Erlang’s B equation. That will get us into the ball-park, which is a big leap forward, but real systems are not just simple, passive games of chance; they are complicated, active and adaptive.  Applying the principles of flow design in that context requires more than just mathematics, statistics and computer models.  But that know-how is available and accessible too … and waiting for when you are ready to take that leap of learning.

OK. I do not think you require any more help from me at this stage. You have what you need and I wish you well.  And please let me know the outcome.

<StE> Thank you and rest assured we will. We have already started writing our story … and we wanted to share the that with you today … but with this new insight we will need to write a few more chapters first.  This is really exciting … thank you so much.


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


Part 1 is here. Part 2 is here. Part 3 is here. Part 4 is here. Part 5 is here.