Service Improvement

Small is Beautiful

Unfortunately, as we come to the end of the year, it just feels like there are so many huge things that we still all have to deal with.  I have to confess that I now quickly scroll past any tweets or facebook posts about the rate at which the icecaps are melting.  I know that the planet is doomed and we have to act on it fast, I’m just so worried that no one is stepping up to do the major things that are required to make a difference, that I just speed on past, ‘deep in de middle of de nile’. 

Brexit, where are we further on that one? On the day of the referendum I posted something on facebook to declare that I have voted “Come on everyone! Let’s show the world that we’re not clinging onto some kind of isolationist fantasy!” My post was full of hope and trepidation, yet ultimately pointless.  My friend posted something that day (and every day, EVERY DAY, I marvel at his genius insight) “Vote Remain if you don’t want to hear about this every day for the next 4 years”.  They should have put that on a bus. 

Plus, as Malcolm Gladwell eloquently states,“I’m amused by how .. the British simultaneously will have all the elections they can stomach in as short a time as possible but the referendum is sacrosanct and we can only do that once”.  So yes, ANOTHER General Election, the result of which TERRIFIES me. A No Deal Brexit will be just the beginning of the years and years of trade negotiations. I am tired of stockpiling Calpol. 

So yes, many BIG things, but at least within improvement, there’s a clear trend towards the power of the small. Indeed, when looking at processes, often what’s required are major systemic changes which are really quite difficult to change. The weight and scale of the change needed can feel all too consuming, too much to contemplate. So, it’s refreshing to see a move to ‘one step at a time’ within the lean community.

The key focus for this activity seems to be the work of Mike Rother, whose book ‘Toyota Kata’ has catalyzed an improvement movement focused on training the brain to regularly apply a scientific approach to work via a series of small improvement experiments. If you were a fan of the Karate Kid film, Kata is the ‘wax on, wax off’, ‘paint the house up, paint the house, down’ repetitive practice that Mr Miyagi made his protégé undertake to learn the martial art (whilst helpfully completing a variety of household chores 🙂 ).  Kata helps your movements to become instinctive without the need to be enacted or processed.  Toyota Kata invites you to have a vision of where you want to get to, then understand where you are now, what your next goal is, and decide on an experiment about how to reach that next step.  It’s about regularly thinking about problems and change in order to ‘train your brain’ to look for improvement and iterate change to get closer to it.

I participated in a Toyota Kata workshop recently, which was great, and what was really interesting was that as we worked through a series of mini experiments, that our performance often ‘got worse’. To me this was such an important learning point, when it comes to change, we often just don’t know what’s going to happen as a result of the thing that we have done.  We can have a good idea of what might happen, but with so many variables at play within a system, as Newton’s third law of motion advises, “for every action, there is an equal and opposite reaction” so who really knows where that ‘equal and opposite’ change will manifest. 

I participated in the Toyota Kata workshop shortly after I had had a troubling experience with the Ambulance service and, as per usual, whilst encountering a service that wasn’t making the grade, I instantly started identifying all of the things that needed to change. It was interesting to reflect on the ‘improvement list’ that I had created in light of the kata ‘tiny steps might make things worse at first’ revelation. 

The Incident

My 13 year old stepson fell off a 1m high window ledge whilst snow stenciling Christmas decorations on his classroom window. This happened at 10.30 am, he was screaming in agony and his knee, quite obviously, was misshapen as if something had dislocated.  This happened on the third floor of his school, they had no lift, and he was in so much pain, he couldn’t be moved.  My husband went to be with him and I received regular updates where I could hear him crying out in pain.  I was very surprised when an ambulance hadn’t arrived by lunchtime, so I rang 999 (confident in my assertive and persuasive powers). They took me through a series of questions and said that they’d be there as soon as they could.  After not making a difference, I then rang the GP nearest the school to see if there was anything that they could do. They advised me that it wasn’t their responsibility and to try our GP, so I did, who then advised me that there was nothing that they could do, that this was indeed a 999 call, and that I should try ringing again.  So I rang 999 again.  I also rang a private healthcare provider to see if you could pay for a private ambulance – you can’t. I decided to go to the school myself, stunned that he was still in the same predicament, dislocated, some 4 hours later.  As I arrived at 3pm, I rang 999 again. That’s when I noticed the same questions that the responders went through, the same order, the same final response.  What was really strange was that they always asked for the person’s name at the very end of the questioning? I imagine because this piece of information is the least important in terms of determining urgency and identifying treatment? But as a concerned guardian, this really jarred. Each time I rang, we were advised to not have any food or drink in case of the need of surgery. I commented that if someone didn’t help him soon, he’d be at risk of dehydration. The cycle of desperately looking out of the window for help and ringing 999 continued, until it finally arrived at 6pm, long after the School had shut. The final time I rang I begged them NOT to go through all of the questions, that I had heard them all before, that they were making me furious, but alas, they had to and would not be moved. One responder advised that it was an exceptionally busy day and that all of the ambulances were stuck at the hospital as A&E couldn’t accept their patients. So because A&E couldn’t cope, the Ambulance service was rendered immobile. 

When they did arrive, the ambulance ladies were great, gave him ‘Gas and Air’ which chilled him out sufficiently so that they could put a brace on his leg and his kneecap ‘popped’ back into place. They also had a wheelchair on rollers that skated downstairs, which was very handy given the three flights we had to get down. Once they helped him, ‘all was forgiven’ but my head was buzzing about all the things that might have made a difference, baffled about the 7.5 hours of pain our child had just been through. How I thought that there was a system there to help him, but there wasn’t, and how I, as a parent, wasn’t able to help him either.

My ideas:

  • A roving NHS ‘gas and air’ motorbike team. Their role is to just chill people out and take away pain. How many medical/life situations could be solved with this approach? We’d have to study demand. 
  • A roving GP in every surgery to take on local ambulance type activity. Someone who could have just walked up the road to give him some pain relief and clicked the knee back into place.
  • An uber style app which showed me where all of the medically trained people were so I could hunt them down and appeal to their good nature. (Any Doctor reading this has just instantly recoiled in horror at the prospect of such a thing “LET ME LIVE” they cry!).
  • An A&E department that had enough space to deal with A&E admissions. This of course requires: GP services that are able to cope with demand so that people don’t go to A&E. Care opportunities at home and in the community so that hospitals aren’t full of people who simply can’t go home yet. Just a couple of small things to achieve 🙂 .

Is it dangerous to design service systems to deal with our particular situation? Particularly financially constrained service systems? Are they able to deal with every possible eventuality efficiently AND effectively?  Is that simply asking too much?  That’s the clever thing about kata I suppose. In the face of major challenges, all it asks of us is to just keep trying to do small things, little and often, to see whether they can make a difference.  Just not making me run through the massive script of questions every time I rang 999 would have helped me not feel so furious at least.  There are also some signs that it’s making a difference in the NHS already.

So I’m going to try to focus on the small things, things that I can control, statements that I can make, votes that I can cast, and hope that enough of these small things will add together to be able to make a difference. So often, that’s all that we can do.

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