If you think targets don't influence service design

A great programme from The Report on BBC Radio 4 from 17th Dec 2009 on how response times targets for ambulance services are distorting service design to concentrate resources too much in cities and towns and to have too many single responder vehicles that send a single paramedic that can't carry patients rather than a full ambulance to too many cases.

Plus, where does the 8 minutes come from in the first place?

Best,

Rob

PDSA applied to PDSA

I was once at a meeting of consultants and we had got to the end of an interesting day learning about new ideas regarding organisations and how to improve them. The volunteer chair of the meeting got to the part of the meeting where we would suggest things that were good and things that we should improve upon for next time. He decided to divide the flip chart into four quarters and label them each Plan, Do, Study, Act.

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

Targets are all SMART, let's make measures VVAPID

For many years I have been told that targets should be SMART. This means they should be Specific, Measurable, Achievable, Realistic and Timed. Well actually, all targets are already SMART:

Simplistic
Meaningless
Arbitrary
Road blocks
Torture

Simplistic

Targets are simplistic. Targets are a sledgehammer to crack a nut and they come with no context or method. Targets are imposed by managers and governments and they walk away thinking by setting a target that their job is done.

Meaningless

Targets don't have any relation to the system they are meant to apply to. They can't have. Targets are not related to purpose. Hitting or missing a target does not give you any new information. Having a target set does not give you any new method to improve it simply gives you something to focus on. And not anything useful. Aiming for a target does not give staff or managers any new understanding of the system. They will be so absorbed trying to hit the target they may well be even more oblivious of what is happening around them.

Arbitrary

An understanding of variation gives the insight that any level at which you set your target is wrong. A study of common cause variation for any measure will give you upper and lower limits within which the system will exhibit predictable variation. Setting a target above or below the limits means the target will always/never be hit (depending on whether higher or lower is better or worse). Setting the target at a level between the limits means that it is virtually random whether the target will be hit in any given period. Therefore there is no reliable way to set a target and hence all targets are arbitrary.

Road Blocks

Targets distract from genuine improvement by sapping energy toward the collecting, analysis and reporting of useless data. Worse, targets also actively get in the way and drag down performance. Think of the 4 hour A&E target that induced one hospital trust to keep patients in ambulances outside A&E, only letting them in once they were sure they could hit the target. Schools are measured and ranked on exam results and so they cheat to get the brightest children in their intake. This is not improving education for all, this is a road block to improving education.

Torture

Targets mean pressure to achieve meaningless, arbitrary, numbers. This is tortuous for staff, managers and inspectors alike.

Staff are judged, rated and rewarded by whether they hit arbitrary targets. They know that they have to apply their minds to hitting the targets when that means they have to degrade overall performance to do so. When staff have to cheat to hit targets that has an effect on morale, self-esteem and respect for their managers who are putting them in the position of having to do these things.

Managers are ravaged by the constant hitting and missing of targets in a seemingly random way. They can never seem to get a good explanation about why a target was missed even though when it is hit they tell everyone they can.

Inspectors often know that what they are doing is ruinous to the performance of the organisation that they are trying to judge. They know that most of the time they are simply assessing compliance to a standard and not looking at an intrinsic ability to give good service. This knowledge must eat away at a person.

Targets are tortuous to users. Using a target driven service will be boring, annoying, frustrating and perhaps dangerous and yet they will be constantly being told that the organisation is hitting or making good progress toward its targets.

So let's get rid of this culture of the target, SMART or otherwise, and move toward measures that are VVAPID.

Value
Variation
Aligned
Purpose
Informative
Deliver

Best,

Rob

Can't get no dissatisfaction

The light works in my girlfriend's kitchen.

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 back 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

Jim Womack Reflects

In Jim Womack's latest e-letter he describes a visit to the Arsenale in Venice where they pioneered flow systems in building war ships way back in the 15th century. All this looking backward made him wonder why Lean is not more widespread than it is. Reflecting on the spread of Lean he says,

...we haven't combined all of these tools and management methods in more than a few organizations.

Trouble is that the reasons why Lean hasn't been taken up as much as Jim and I would both like is hidden in that very sentence. Also from the e-letter,

It seems to me that we have already achieved several things of lasting value:

• We have transferred and adapted lean process tools for production, product development, supplier management, and customer support to a wide range of industries in a wide range of countries.
• We have experimented with all of the management tools - policy deployment, A3 analysis, and standardized management with kaizen - that are needed to introduce and sustain these process tools.

Again, the reasons for the low take up compared to the potential of Lean, are right there in those two very telling paragraphs.

The problem is the tools.

The best thing Womack and Jones ever wrote was the title of the book that came after The Machine That Changed the World. That book was called Lean Thinking. The title emphasised thinking (more than the book, I might add). This is the thing that people need to focus on. The tools are a red herring. It is the way that management and staff think that determines how they see they systems they work in and so how they try to change them.

Looking at work through a filter of a set of tools means that is what you see. If all you know is 5S, kanban, heijunka, poke yoke, work cells, supermarket pull systems, value stream mapping etc., then every problem is seen as an opportunity to apply one of these tools.

Every problem is instead an opportunity to learn. Every thing that is working badly is an opportunity to understand better how to improve.

Taiichi Ohno, the father of the Toyota production system, said, "don't codify method". He meant don't give things names, don't invent tools. When people ask me, "Which tool should we start with?", I ask them to guess which tool Toyota started with. The answer is they didn't start with a tool because they didn't have any. They started to understand their system and to develop solutions to the problems they encountered. These solutions have become codified as the Lean tools. Even the book Learning to See by Mike Rother, which has another promising title, is simply another description of how to apply a set of tools. It should be titled Learning to See Which Tool to Apply.

Jim Womack is in a considerable position of power in the Lean community and the trouble is that instead of reflecting and coming to the useful conclusion that he needs to drop the tools approach instead he is actually trying to extend it by inventing Lean Management Tools to patch up the poor effectiveness of the original Lean tools.

When the tools don't work, using more of them won't help matters.

Best,

Rob

Use and Misuse of Takt Time in Services

I had an interesting discussion about takt time not so long ago and I have been mulling over what was said regarding the use of takt time in service organisations.

Firstly, what is takt time? Well 'takt' is a German word meaning 'rhythm' or 'drum-beat'. Takt time describes the average time between every instance of a demand on an organisation. The easiest way to explain it is to describe an example. (The numbers are not realistic. They are dreamt up to make the arithmetic easy.)

Imagine a car manufacturer who gets on average 100 new orders for cars per day, they run the factory for five hours so that is 300 minutes per day. Thus to fill the received orders they need to build 100 cars in 300 minutes each day. If a car popped off the assembly line following a regular drum-beat, that would mean a car finished every 3 minutes. Thus the takt time would be three minutes. This takt time would be used to level the production so that all the processes followed the beat. Now you can't make an engine in 3 minutes so you would have lots of engine assembling stations so you might make 10 engines at the same time that took 30 minutes each to make. That would be an engine every 3 minutes, on average.

The takt time will be used to balance the processes so that they all take a multiple of just under 3 minutes to keep the factory humming along, pushing a finished car out every 3 minutes.

This is informative when you are making things since all the materials to make a car need to arrive at the right time to be attached to the right car and a drum-beat can help organise and regulate things. You also have the option to spread the work over a day or a week. However, in service, takt time should be taken with a pinch of salt. Some might apply takt time to arrivals in A&E, 999 calls to the police or other on-demand services. You need to have a good appreciation of demand in all these services because you need to know how much resource you need to meet the demand. However, managers need to realise that however tempting takt time may be, in a situation where you can't balance demand and delivery processes, takt time doesn't tell you anything useful.

Let's think about the police. Take the same (unrealistic) numbers from the example above. A police service receives 100 emergency calls in a 5 hour shift. Again that gives a takt time of 3 minutes. But this time the managers can't balance the other processes, because there is variety in the demand. One call may be about the discovery of a burglary and another about a mass brawl in a pub. These two calls will not be equivalent in the same way that making two different cars or even a car and a van might be on an assembly production line. The calls will require different response times, need different personnel, varying numbers of officers and all engaged for different amounts of time both in the field and doing different paperwork back at the station.

You may wonder if you have a service process that is more like a assembly line, perhaps processing mortgage applications, then maybe you can find a use for takt time. Perhaps you can, but the point here really is you need to ask yourself what it is telling you. It is only the average amount of time between points of demand and following down the takt time route gives you the feeling that you can treat your office like a factory which may blind you and in turn cause you to break up work even further.

You should always seek to understand demand. It is just that "I want a car." repeated many times a day is much simpler than most of the demands placed on service organisations even if the car itself is more complicated than many services. In most cases, it is the use of Systems Thinking to identify value to the customer and hence the removal of delay, errors, waste and hence failure demand in a process that really brings benefit. Chasing concepts like takt time more often than not take attention off the real problems.

Don't dismiss these tools, but rather apply them with care in your organisations and never use a tool until you understand the problem it is trying to solve and whether you actually suffer from the same problem.

Best,

Rob

Targets in A&E make people cheat

A couple of days ago I wrote about an analysis of Accident and Emergency department (A&E) waiting times that the NHS Information Centre released. It showed that a disproportionate number of patients were seen to in the 10 minutes before the 4 hours waiting time target. The Nursing Times ran a survey in response to that analysis which found that across the UK, trusts are cheating to be seen to hit the target. To quote from their article,

Forty per cent of nurses believe their colleagues are involved in helping to meet waiting time targets by underhand means, often referred to as “gaming”.

And one in 10 hospital nurses say they have personally been asked to engage in gaming to help meet waiting times this autumn.

The article goes on give a few examples of the type of gaming that happens:

• Discharge times for patients are changed
  
• Patients are temporarily moved from A&E to corridors, observation areas and theatre recovery wards
  
• Patients are unnecessarily admitted to mixed-sex bays or specialist wards
• In one trust, part of A&E was re-badged as a "clinical decision unit" and is now longer deemed part of A&E

This is no surprise. Targets make people cheat. It happens all the time and not just in the NHS. Remember the teachers in Bolton who were suspended over allegations of cheating to help students in GCSE language exams?

Targets do not, and never have driven improvement for patients they only drive inventiveness to try to hit the target by any means necessary. There is small cheating like adjusting discharge times and then institutional cheating by relabelling a part of A&E.

It is all wrong.

It is morally wrong but there is also the issue of the opportunity cost. All this effort and inventiveness is going into fiddling the system. Imagine if all that innovation went into improving the service. What about the boost to morale for the staff when they were released from the target and from the need to cheat? Think of the benefit to patients to feel that their care was the most important thing to the staff.

The other hidden problem is that when the figures get changed you no longer have reliable data upon which to base genuine improvement.

Anyone who thinks targets drive improvement has never been moved to a ward in order for the hospital to meet a target, only to be forgotten about because they should never have been transferred there in the first place.

Best,

Rob