Look at the Evidence – the Spike and Delay Pattern in Social Care
A number of years ago, I was transforming a city’s social care directorate and, as part of that transformation, we aimed to reduce the time it took to do anything when interacting with the service. The transformation was based on a more fundamental need to free up workers to be able to do the work they were meant to do rather than having to fight the fires caused by delays and resulting failure demand. I instigated a methodical approach for identifying which cycles to focus on first. As the team progressed through the cycles, I noticed a pattern; it’s the spike of activity followed by a lengthy delay as discussed in a previous article.
As we looked in particular at a few cycles of spike followed by a delay, I routinely advised the team to question the need for that common feature of bureaucracy: the signature.
Why require a signature?
In the case of social care, signatures are often required from service users or their representatives. This can be as proof that the content of a form is accurate or as a record of the service user providing consent (either for data to be shared from the form or for the authority to request data from other agencies).
These signatures create the spike-delay pattern in which a short spike of activity is followed by a lengthy delay while the authority sends the form to the customers and waits for the return of a signed copy. Part of that delay is caused by the postal service in both directions. Part will be the time it takes the service user to open the letter, read the form, make amendments, find an envelop and stamp and then go to the post box. Considering the high percentage of infirm service users compared to the general population, that sequence of activities can take a long time. Then we have the additional wait time caused by processing the response as it arrives into the authority.
So, my first instinct is to remove the need for a signature and thereby remove the need for the spike-delay round. This could be changed from requesting a signature to providing information on the form that the data will be used. If you don’t agree, don’t submit the form. The response from staff was that we needed the signature as a record of consent and/or accuracy, depending on the form in question.
On the fact of it, that seems a reasonable and fair response.
What does the evidence say?
However, the data showed a different reality. What actually happened is that, even if the form wasn’t returned, the process could still go ahead. True, it didn’t go ahead for every service user, but the fact that it could proceed implied that the signature wasn’t always required. Or rather, wasn’t required all of the time. We were able to look at the data to understand how many service users progressed without signature, we were able to look at common characteristics, etc.
By presenting this understanding back, we ended up moving forward in our joint understanding of the process; joint in that the consultant and the team had the same understanding. Before that point, they had had different interpretations.
So where does that leave us?
An undocumented process or exception is a risk. In the above case, we had uncovered that some of the cases were allowed to progress without signature, but there was no documentation defining which cases could proceed and which cases had to stop. Instead it was left to individual judgment, but again without defined criteria. So what happens if the usual staff members weren’t present? Were the decisions they made equal and equitable to all involved? How did we measure the outcomes?
Depending on the type of organisation and service involved, there will be a different focus regarding the risk involved.
In this case, we had a process with an unclear gateway, e.g. do we continue or do we halt and wait?
- Complete the analysis in terms of understanding when the process can continue.
- Engage with service users to understand what they need out of the process, what their engagement should be
- As a team, choose a default option, either they progress by default or they pause by default
- Help the team define the rules that govern the exceptions
- Implement a training and induction programme for ensuring that everyone knows how to apply the rules
I always prefer the default option to be the one that improves efficiency, e.g. the one that’s the most common option or the one that removes a spike-delay pattern.
The wider understanding that, in most cases, the signature wasn’t required let us to a better solution. Had we not challenged either with data or further questioning, we would have been left with the difficult situation of lack of signatures stopping the process and the resulting action of requiring signatures in order to proceed. Instead by challenging the assumption and developing solutions to the issues of the spike-delay caused by several signatures for a sequence of documents, we were able to reduce the expected time from 6 months down to just over one day (actually 2.5 completions per week). That’s a massive difference in expectations for customer and the organisation serving the customer.
Anything to say, get in touch at @alanward.