Posts Tagged ‘Dynamics’

One of the foundations of Improvement Science is visualisation – presenting data in a visual format that we find easy to assimilate quickly – as pictures.

We derive deeper understanding from observing how things are changing over time – that is the reality of our everyday experience.

And we gain even deeper understanding of how the world behaves by acting on it and observing the effect of our actions. This is how we all learned-by-doing from day-one. Most of what we know about people, processes and systems we learned long before we went to school.


When I was at school the educational diet was dominated by rote learning of historical facts and tried-and-tested recipes for solving tame problems. It was all OK – but it did not teach me anything about how to improve – that was left to me.

More significantly it taught me more about how not to improve – it taught me that the delivered dogma was not to be questioned. Questions that challenged my older-and-better teachers’ understanding of the world were definitely not welcome.

Young children ask “why?” a lot – but as we get older we stop asking that question – not because we have had our questions answered but because we get the unhelpful answer “just because.”

When we stop asking ourselves “why?” then we stop learning, we close the door to improvement of our understanding, and we close the door to new wisdom.


So to open the door again let us leverage our inborn ability to gain understanding from interacting with the world and observing the effect using moving pictures.

Unfortunately our biology limits us to our immediate space-and-time, so to broaden our scope we need to have a way of projecting a bigger space-scale and longer time-scale into the constraints imposed by the caveman wetware between our ears.

Something like a video game that is realistic enough to teach us something about the real world.

If we want to understand better how a health care system behaves so that we can make wiser decisions of what to do (and what not to do) to improve it then a real-time, interactive, healthcare system video game might be a useful tool.

So, with this design specification I have created one.

The goal of the game is to defeat the enemy – and the enemy is intangible – it is the dark cloak of ignorance – literally “not knowing”.

Not knowing how to improve; not knowing how to ask the “why?” question in a respectful way.  A way that consolidates what we understand and challenges what we do not.

And there is an example of the Health Care System Flow Game being played here.

Improvement Science is the knowledge and experience required to improve … but to improve what?

Improve safety, delivery, quality, and productivity?

Yes – ultimately – but they are the outputs. What has to be improved to achieve these improved outputs? That is a much more interesting question.

The simple answer is “flow”. But flow of what? That is an even better question!

Let us consider a real example. Suppose we want to improve the safety, quality, delivery and productivity of our healthcare system – which we do – what “flows” do we need to consider?

The flow of patients is the obvious one – the observable, tangible flow of people with health issues who arrive and leave healthcare facilities such as GP practices, outpatient departments, wards, theatres, accident units, nursing homes, chemists, etc.

What other flows?

Healthcare is a service with an intangible product that is produced and consumed at the same time – and in for those reasons it is very different from manufacturing. The interaction between the patients and the carers is where the value is added and this implies that “flow of carers” is critical too. Carers are people – no one had yet invented a machine that cares.

As soon as we have two flows that interact we have a new consideration – how do we ensure that they are coordinated so that they are able to interact at the same place, same time, in the right way and is the right amount?

The flows are linked – they are interdependent – we have a system of flows and we cannot just focus on one flow or ignore the inter-dependencies. OK, so far so good. What other flows do we need to consider?

Healthcare is a problem-solving process and it is reliant on data – so the flow of data is essential – some of this is clinical data and related to the practice of care, and some of it is operational data and related to the process of care. Data flow supports the patient and carer flows.

What else?

Solving problems has two stages – making decisions and taking actions – in healthcare the decision is called diagnosis and the action is called treatment. Both may involve the use of materials (e.g. consumables, paper, sheets, drugs, dressings, food, etc) and equipment (e.g. beds, CT scanners, instruments, waste bins etc). The provision of materials and equipment are flows that require data and people to support and coordinate as well.

So far we have flows of patients, people, data, materials and equipment and all the flows are interconnected. This is getting complicated!

Anything else?

The work has to be done in a suitable environment so the buildings and estate need to be provided. This may not seem like a flow but it is – it just has a longer time scale and is more jerky than the other flows – planning-building-using a new hospital has a time span of decades.

Are we finished yet? Is anything needed to support the these flows?

Yes – the flow that links them all is money. Money flowing in is called revenue and investment and money flowing out is called costs and dividends and so long as revenue equals or exceeds costs over the long term the system can function. Money is like energy – work only happens when it is flowing – and if the money doesn’t flow to the right part at the right time and in the right amount then the performance of the whole system can suffer – because all the parts and flows are interdependent.

So, we have Seven Flows – Patients, People, Data, Materials, Equipment, Estate and Money – and when considering any process or system improvement we must remain mindful of all Seven because they are interdependent.

And that is a challenge for us because our caveman brains are not designed to solve seven-dimensional time-dependent problems! We are OK with one dimension, struggle with two, really struggle with three and that is about it. We have to face the reality that we cannot do this in our heads – we need assistance – we need tools to help us handle the Seven Flows simultaneously.

Fortunately these tools exist – so we just need to learn how to use them – and that is what Improvement Science is all about.