12.9.14

What Gets Measured Gets Done...But....

....What gets pressured gets spun.



Targets. Targets. Targets.  A curious thing.  They include not only a prediction of the future, but also a prediction of influence on that future, and specific measurement of all that too.   Seeking that special sweet spot between being both challenging and achievable at the same time.

Of course in some cases it might well be visionary and aspirational, as in the old Eastern proverb ..."Aim for the top of the tree and you'll never leave the ground.  Aim for the moon and you might at least get to the top of the tree".  But more often than not it's about performance, and about success or failure.  Binary rather than multidimensional.

So big headlines around falsification of the measurement of cancer treatment waiting times to meet government targets.  The Care Quality Commission (CQC), the independent regulator of heath and social care in England found that measurements in one hospital, nearly a third of the patient records examined (22 of 66) had been altered to hide "extensive" delays for treatment.

What is measured and targeted sure does get attention and focus.  But once the that pressure tips the balance from being a priority, to being the pure judgement of success or failure, then unhelpful creativity and system redesign sets in.

That might just be managing the system.   There's the example from transport logistics moving electronically tagged parcels.  The sorting centre will bring the parcels inside only once they are ready to process them. Simply bringing them over the thresholds starts the electronic clock.   So best they wait outside until we can start the clock when it suits us.. That may well minimise the amount of time in the sorting centre, but overlooks the bigger picture of overall faster delivery.

It's also possible to entirely design out measurement of failure.  There were maximum waiting times from booking to appointment to see your local GP.  The solution.....take away the advanced booking system so you can only book on the day for the day.  No luck today, then it all starts again tomorrow.

What's disappointing is that the target it set at the minimum acceptable level.  So take the original four hour target for waiting times for Accident and Emergency departments.   So the margins can be managed, for example ambulances can be left queuing before patients are accepted which starts the hospital acceptance clock, and patients can also be transferred to "assessment units" which stops the clock.

That was strongly reinforced, hearing super presentation at the recent Royal Statistical Society Annual Conference (Sept 2014) from the joint academic and medic research team at the University of Sheffield. There's a fantastically clear spike where patients were admitted in the moments before they exceed the 4 hour waiting time.  The target has gone now but by all accounts the 4 hours is still a strong corporate driver.



What's even more staggering is some of the background measurement activities.  Different hospitals measure these things in different ways.  In fact it's possible to stay two nights and still not be classed as an admission.

So rather than the one dimensional focus on four hours, what about a four dimensional focus.....on the number of people waiting for 1hr, 2hrs, 3hs and then 4hr.   The elapsed time is being measured anyway so there's no additional measurement overhead.  That's a much more refined perspective.

Post four hours might well be failure, but how about some success focus too, at the 1hr and 2hr end of the spectrum.  Sure there might then be micro management at the hour margins, but at least it's a fuller and more multidimensional picture. Two A&E departments with identical performance at the 4hr threshold, might well look different when it's unpacked into the hour performance slots.  Even mean waiting times might give a more insightful view.