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

Inspectors under fire

In The Guardian today, Ofsted (Office for Standards in Education, Children’s Services and Skills) has come under fire from its former Chief Inspector, Sir Mike Tomlinson,

"Inspection systems that rely too heavily on data and tick-box systems is not what we need. I worry we are heading that way."

It was Ofsted who was accused of giving Haringey a top rating before the Baby P incident in its initial report then downgrading it after the case came to light. One tragic case does not make a bad system but then a good review from Ofsted doesn't seem to reliably indicate good system either.

In another incident it was also Ofsted who said that two police officers may not look after each others' children while the other was on duty. This was an entirely reasonable arrangement of two women supporting each other to work and get child care from a trusted friend. Ofsted judged that it constituted "receiving a reward".

If inspection reports cannot be relied on to give a reasonable indication of the state of the organisation being inspected there is a serious failing in either the inspectors, or the whole methodology and assumptions behind the method of assessment and review.

Ofsted was originally only inspecting education and childcare but was given Child Services to inspect two years ago. But a position paper (Nov 2009) from the Association of Directors of Children's Services, which starts by praising some aspects of Ofsted's inspection regime goes on to say,

"But, all too often a reductionist approach is taken to the inspection, moderation and judgements of services, particularly local safeguarding services where risk-averse approaches on the part of inspectors are leading to perverse judgements and unintended consequences. The perceived punitive effects and the impact of judgements on services in terms of the local media and political response are in danger of creating a climate whereby the inspected manage for inspection rather than managing for quality and outcomes for children and young people."

This was Systems Thinkers have been saying for years. Dr. W. Edwards Deming had as point 3 of his famous 14 points: "Cease dependence on inspection." Deming knew that inspection has many unwanted consequences:

• People focus on passing inspections rather than doing what is right
• Time, money and effort that could be spent on the work is spent on preparing for inspection
• The fear of failing an inspection causes stress and worry which in turn reduces performance
• The banality of tick-box inspection regimes makes people demoralised and they question why they are doing the job if this is how they are judged

However, Ofsted is not to blame. The problem comes from the widely held belief that quality can be inspected into an organisation. Quality does not come from outside, it is grown from within. That is not to say that outside expertise is not needed to bring new thinking or that some form of audit or inspection is not required, but that audit should be restricted to checking for probity in regards to money and resources, i.e. that no-one is perpetrating any fraud, and inspectors should throw away all the forms with the tick-boxes on them and ask one question,

"What are you doing to understand and improve the work?"

Then if managers are struggling to get understanding or to find or implement a method of improvement, the inspector can pull in assistance. Importantly this would be help and support, not punishment.

Ofsted and its ilk (The Audit Commission etc.) all need to reoriented to focus on helping organisations to improve rather than inspecting them to ensure that they comply with centrally mandated criteria of success. The removal of the current inspection regime would firstly free organisations to do the work without distraction and then the implementation of supportive improvement mechanisms would enable them to far exceed the dreams of any narrow inspection system.

Best,

Rob

More on 4 hour target in A&E

The Times Online has an article about the 4 hour target data that I wrote about last time.

In the article, Mark Porter, chairman of the British Medical Association’s consultants’ committee, said that the admission rates were worrying.

“This suggests that when patients have been waiting close to four hours, there is a rush to discharge or admit them so that the hospital meets the four-hour target,” he said.

“Patients must always be treated on the basis of their clinical need, not simply because they have been waiting close to four hours.”

Katherine Murphy, director of the Patients Association said,

“This results in doctors making rushed decisions at three hours and 50 minutes, with patients having to be admitted inappropriately at huge cost to the NHS,” she said. “We have heard instances of ambulance drivers being forced to wait outside A&E with seriously ill patients, until staff have cleared a backlog of people who need to be seen within the four hour target.

“It is unfair to make NHS staff feel like they have to put meeting this target ahead of what’s in the best interests of patients.”

Mike O’Brien, the Health Minister defends the targets in the article. Why is it that ministers can not see the harm they are doing?

Best,

Rob

A&E targets distort behaviour

Yesterday the NHS Information Centre published a further analysis of the time that patients wait in Accident and Emergency departments before being seen to. The analysis showed that just before the 4 hour target, there is a huge peak of people being admitted to hospital. See the graph below from the report.


The rising peak just before the 4 hour deadline is very clear.

There is an accompanying Excel spreadsheet which lets you see this distribution for each of the trusts that submitted data. Most of them exhibit this kind of pattern.

The report deals mostly with data analysis but little time is given for the reasons why people are treated and admitted in this pattern. I would postulate that the reason is clear. They have a target to deal with people within a 4 hour window and so either people have something relatively minor and they are treated quickly with no follow up or referral to their GP or they are left to wait. Then as they come closer to the 4 hours someone is there to make sure that the target is hit and people are admitted. There is a further chart from the report that is quite revealing.



This is a chart of the destinations of patients who are dealt in each ten minute slot. The bands dealing with 'referred' (white on top), 'others' (bright green under referred) and 'discharged - referred to GP' (dark green, second from bottom) are all fairly flat. The two categories that seem to cause the peaks are 'discharged - no follow up' (yellowy green) which peaks around the hour mark, and 'admitted' (black, on the bottom) which has a little peak in the first 10 mins and then rises to a very steep peak just before the 4 hour mark.

All the catergories drop-off to almost nothing after the 4 hour point.

It is a pretty safe guess to say that the 'discharged - no follow up' peak at 1 hour because they have minor issues so they can wait a little while, but then they can be quickly dealt with and go home. (A bit like my cut finger!)

It is the admitted patients that are of the most interest. The 4 hour target is skewing behaviour. Why are so many patients being admitted just before the target? It can't be coincidence. How many of those patients are being admitted solely to meet the target and not for clinical reasons? The thing that really gives the game away is the massive cliff-like drop-off after the 4 hour point. If there were a smoother drop-off after 4 hours, it would indicate that the system was behaving more normally, but the fact that almost no-one is left to be dealt with after 4 hours, means that patients must be being treated differently as they come up to the 4 hour point.

Now, isn't it a good thing that people are seen within 4 hours? Well yes and no. It is good if people are seen quickly, of course. Patients with life threatening conditions will surely want to be seen straight away and the rest of us walking wounded don't want to be hanging around A&E for no reason. But the problem is that this data shows clearly that the 4 hour target is skewing behaviour. Patients are being admitted to meet the target and not to give them the best care. Also if this is happening then it must follow that resources are being used to meet the target. There must be some mechanism that is letting staff know that a patient is about to breach the 4 hour target and then staff are diverted away from other patients to get the near-breach patients admitted. This way of managing resources is taking away from treating people as they arrive which otherwise might move the curve as patients are treated sooner.

The irony is this, by diverting resources to ensure that people don't wait more than 4 hours you are ensuring that people are more likely to wait longer and thus more likely to breach the 4 hours. And what of the waste of resources in the rest of the trust when people are admitted to meet the target and then take up beds, nursing time etc. when they don't need it?

This target needs to be dropped and replaced with measures of value to the patient. This will give understanding of demand so the service can be designed to meet the needs of patients, giving maximum value as quickly as possible. If trusts were to be freed from the burden of this target and then given a proper method to improve, they would be able to wipe the floor with the 4 hour target instead of being held back by it.

This data shows that while the Department of Health and central government think that this and similar targets are driving performance, in fact these targets are holding performance back.

Best,

Rob

London Health 09 conference

On Monday and Tuesday this week I attended the London Health 09 conference. Day one was focused on local government and social care and day two on improving health outcomes for London.

All in all it was a very useful two days and it highlighted some really good things that are being done and also some fundamental problems.

It was attended by some very senior people including leaders of councils, advisers to the Mayor of London and senior executives in London NHS and local PCTs. They all had a very real need to do something good for the people in need in London and most of them felt a pull to do something different than had been done before. I was very encouraged by this, and if the rest of the health care staff in London are even half as committed then I am sure that some good things will happen.

I could write about many of the interesting talks but I will mention here a few that resonated or said something new.

The first was from Sir Michael Marmot from UCL. He presented research that showed that health inequalities were very strongly to do with social status. The bottom line is that if you are poor and uneducated then you will have a short life with multiple illnesses. His message was that even if social and health care were perfect they won't lift people out of poverty and so you will still have people who need lots of care just because of the start they get in life. It is other policy areas that need to deal with the cause and cure of that societal malady.

The second session I would like to highlight was a breakout session on telehealth. This is simply when you give patients the means (equipment) to monitor things like blood pressure at home with a direct link that sends the data to a nurse or other professional. This demonstrated that you can give people independence, save staff time and reduce the incidences of hospital admissions. This seems very innovative and everyone was very impressed but I don't think it is so clever. They said the units cost £2,000 to install, but you can get weighing scales that tweet your weight now. Having devices connected to the internet should not be so expensive. Or so surprising.

On the second day Dr Robert Chote from the Institute of Fiscal Studies showed us a lot of scary graphs that said that public finances are going down the toilet in the next few years. I think this is known in this community and a lot of the talk at the conference was about money and "doing more with less". Interestingly, I had a conversation over coffee with one panellist who said that he thought that because NHS pay had increased over the past few years and at the same time the mortgage costs had fallen, that meant that a lot of NHS staff were feeling personally a lot better off than they ever had. He thought that this personal feeling of extra wealth was preventing people from digesting the coming budget crash and that their comfort was stopping them doing the things they needed to prepare. One of the speakers, Jim Easton, NHS National Director for Improvement and Efficiency, addressed the audience directly and said, "This [budget] problem is coming and if you are not doing something now, you are burning time."

Lastly, there was a very interesting presentation from Conor Burke, Borough Managing Director, NHS Redbridge about an impressive scheme of polyclincs to join together social and health care services and run them together to remove duplication and budget wrangling between local authority and health services. I will comment further in another blog, but suffice to say there was a lot of talk about commissioning and joint working. Trying to make commissioning function better and putting together joint working between local authorities and PCTs is worthy, but it is really working around a big flaw in the system. The structure of the system shouldn't make it difficult to work together but all the mentions of joint working were mentioned in ways that made it seem like it was an amazing job, how wonderful was it that we can get together and do this. Working together for the purpose of giving the best care to the residents of London should be the number one priority. It shouldn't feel above and beyond to do that over simply delivering the services as mandated.

In the next few blogs I will talk more about commissioning, joint working, improvement methods (or lack thereof) and other topics.

Maybe I will see you at London Health 2010?

Best,

Rob

Total Place - integrated public services or more cost cutting?

Total Place is a scheme to join-up public services in an area or a city. Trials have been run in Kent and Birmingham.

It may be useful to read the report of the Total Place Roundtable in The Guardian since I will reference some comments from it there.

The sub-title of the article is:

Total Place is a new initiative to examine how cutting out duplication in public service delivery can improve quality and reduce costs. But is this really a 'magic bullet' solution?

Well nothing is ever a silver bullet. As W. Edwards Deming said, "There is no such thing as instant pudding." But the general idea to join up services to remove duplication and concentrate more on prevention than cure, is a a good one that most people would agree with. There are some encouraging comments, such as:

Hospitals have been trialling specific units for patients with alcohol related problems, where they can be given preventive treatment, with co-ordinated interventions from across a range of agencies.

Figures from the police reveal that a single murder costs around £1.1m in services, from investigation to the legal and social services work, so the scale of preventive cost savings – especially in reducing gang violence, for example – is parallel with the moral gains.

"The focus needs to be on changing the culture and behaviour within public services, rather than fixating on financial outcomes."

These are encouraging but one comment from one of the participants worries me.

The table first heard an account of the Birmingham pilot, where £7.5bn of public sector cash had been mapped out. "The idea was to follow the money, and see where it led us," a participant explained. "Families are facing a range of issues, some not interconnected, but the challenge was to dismiss short-term thinking to analyse the £7.5bn coming into Birmingham every year."

If you follow the money, then you will come to the wrong answer. Budgets and costs are an output. First you should seek to understand the demand on the system and if you do that with the whole system in mind, for example how mental health services, social services and hospitals can work together on chronic alcohol problems, then that is all the better. But we shouldn't be starting with the money. That is using the tail to wag the dog.

Efficiencies in the these type of systems can be made, but we must ask,

• What is our purpose?
  
• What is of value to the public?
• How can understand demand for that?
  
• How can we design service to meet the demand, designed for the value and removing the waste?

If you do this properly you design public services that the public like and as an output you save money. You also get improvements in results that far outstrip anything that anyone would have dared to set as a target.

One more little niggle from the article:

Kent, a two-tier authority with a £10bn budget, now has a single phone number and single web portal for all local government services.

It goes on to say that "getting even this far was an uphill struggle". Well instituting a call centre isn't providing value but it is certainly following the money. Trouble is the failure demand that will ensue will cause costs to rise, not to fall. Having one place to call does not mean that the services delivered will be joined-up, in fact quite the reverse. Whereas, previously you might have had the call answered by someone who did the work in the department you called, now you get a call centre agent who is, by construction, removed from the work and only connected to it by workflow systems.

I wish the Total Place idea well. I just hope the practice would match the intent.

Best,

Rob