Look at the Evidence – the Spike and Delay Pattern in Social Care

signature
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.

First approach

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?
  1. Complete the analysis in terms of understanding when the process can continue.
  2. Engage with service users to understand what they need out of the process, what their engagement should be
  3. As a team, choose a default option, either they progress by default or they pause by default
  4. Help the team define the rules that govern the exceptions
  5. 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.

Impact

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.

Forthcoming Book on Improving Your Own Service

Lean Service Improvement Book

Some of you may already know, I’m in the process of writing a book on improving your own service.

Lean Service Improvement Book
write by followtheseinstructions under CC BY-SA 2.0

I’m aiming the book at the people who work the process themselves, e.g.:

  • nurses
  • social workers
  • claims adjusters
  • HR/OD staff
  • office managers
  • office administrators
  • hotel staff
  • and their managers
  • and change agents/analysts

As you can see, it’s not restricted to any industry, but will be most relevant to those working in service industries (whether from private, public and 3rd sector), so that should include:

  • public sector
  • health
  • finance
  • retail
  • leisure
  • legal

More accurately, the information in the book could be useful for any industry, however there already exist books for improving manufacturing production processes, so I have not covered them.

What’s the book about?

The focus is on improving a service without recourse to large consultancy fees and should work well on small changes locally within a team and managed changes with partner teams and organisations (e.g. suppliers and B2B clients). It’s heavily based on Lean concepts, using simple tools, but also includes a framework in which to manage the changes. I’ve borrowed from a number of methodologies and concepts to meld together a method that is suitable for the average worker and implementable in any service team.

Your Input

While I’m happy to write this book alone and for everyone to read, I really like the idea of the readers contributing their thoughts as I write it. This fits nicely with the Lean Startup model, so to accomplish this, I’ve listed the current table of contents below. Please have a read through the table of contents and let me know what you think. If you’re interested in this book, let me know what you want to learn from it.

Draft Table of Contents

Section I: Beginning
1    Introduction
2    Background
3    Where to Start?
Section II: Redesign
4    How to Redesign the Service
5    Detailed steps for How to Redesign a Service
Section III: Other Paths
6    Refocus service on customer
7    Only have today to make changes
8    Bottleneck Resolution
9    Reduce errors and improve service
10    Create a new service
11    Improve office layout
Section IV: Case Studies
12    A Real World Example: Capacity and Value Stream Owner
13    A Real World Example: Duty Role in Social Care
14    A Real World Example: Urgent Cases in Social Care
Section V: Extensions
15    Other sorting methods
16    Making it Happen
17    Managing the Change
Section VI: Continuing
18    Sustaining Change
Section VII: Reflections
19    Important Perspectives
20   Other Frameworks
21    A final piece of advice
Section VIII: Appendices
22    Appendix A: The Rules
23    Appendix B – Pocket Guide for Service Redesign
24    Appendix C – Indicators of Blocked Flow and Waste
25    Appendix D: Tools
26    Appendix E: References
27    Quotes

Trouble-shooting and Solving Problems

Wood pile
Wood pile
Wood pile, where is the underlying problem?

To be able to fix the problem, you first need to know what the problem is.

More specifically, you need to know which problem to fix first.

Your staff may already be telling you what the problem is, you may already know what it is, but what if that’s not the most important problem and the underlying problem is something else entirely?

That’s where using an external consultancy can prove valuable. We’re impartial, unencumbered by politics, with no axes to grind and passionate about uncovering the real underlying causes.

Uncovering your real problems and the causes of what’s troubling your department is the first step in improvement. It’s a ring-fenced engagement with a clear gateway meaning we’ll agree what work is to be performed before we commence to following stages, if at all.

This could be the start of a Lean improvement project or end up with a more strategic solution.

Want to know more, then contact us for more detail.