by Vanguard Skandinavien’s Andreas Ritter-Petersen (2015)  

“It is unacceptable that problems and examples of poor quality continuously persevere. Despite it being out of our party policy we must insist that all expenditures needed to solve this is to be used[1]

Martin Geertsen, Vice Chairman of Regional Council, Member of V party in Denmark, 31-03-2014.

On January 1st 2014, a new emergency phone based initiative was launched in the Capital Region of Denmark. The aim of this initiative was that the 1813 phone line would become the first point of contact for healthcare consultation for 1.7 million people in the region.

The 1813 phone service was expected to reduce costs and yield sought after savings for politicians. However, shortly after the implementation, problems started arising to which the Danish government reacted with a DKK 15 million aid package[2] to minimise the escalating telephone queues, complaints and the high turnover of 1813 personnel[3]. The system was receiving a great deal of attention in the media, with severe cases of sudden deaths being reported due to a lack of proper consultation of citizens who had initially contacted the 1813 service. The situation had to be rectified but the problems stubbornly remained.

In order to attain an understanding of why this brand new emergency phone system was/is not living up to expectations, we need to delve further into the reasoning behind the new system and the problem it was originally supposed to solve.

The 1813 service involved the centralisation of a range of functions to replace the GP emergency function. The old system was abandoned because the Capital Region health care service was unable to come to an agreement with the union of general practitioners (GPs).

Costs had to be made-to-fit ever more tightened budgets. The promise that 1813 would save DKK 5 on every single call (decreasing from DKK 90 to 85) as compared with the previous GP function meant that it was warmly welcomed by grateful politicians.

The inception of 1813 exemplifies the thinking in what Seddon (2008) calls the core management paradigm:

  • How much work is coming in?
  • How many employees do I have?
  • How much time is spent on each task of the work?

This paradigm is, based on Vanguard’s knowledge, a catalyst for a great many cost focused initiatives in the public sector providing increasingly greater pressure to deliver more service for less.

The core paradigm has manifested itself in 1813 operations as:

  • Separating and specialising front office phone consultation and back office functions (GPs, hospital emergency rooms)
  • Standardising protocols within IT systems
  • Implementing arbitrary targets such as budgets, Key Performance Indicators (KPI), service level agreements (SLAs), etc.

Breaking down processes to a standardised norm and adhering to stern targets set by management makes it easy for each department to receive-process-send information onwards, right? Let us explore each of the above bullet points to get an idea of what the systemic consequences are of this management thinking in 1813.

Separating and specialising front and back office functions

No two citizens are identical in terms of what their medical assistance needs are and how such needs are best understood and fulfilled which makes the amount of variation of demand in 1813 indefinite.

When a citizen enters the 1813 system with a demand he/she is met by a nurse who, based on a 6 week training course in the 1813 system, either provides counselling directly over the phone or decides to transfer the citizen through the system. The mere process of explaining the symptoms of an illness by phone is a difficult task for most people. The situation is further complicated when the nurse who is meant to treat the symptoms has inadequate knowledge of how to diagnose the appropriate treatment.

Such difficulties mixed with a focus on documenting all administrative procedures, out of fear of being accused by management or worse the media of risking people lives creates a system where responsibility is passed on with great risk of inaccurate treatment.

Separating and specialising functions in the 1813 service in this way is a result of assumptions being made, including that:

  • Using the telephone is a cheaper and more effective way of handling demand than face-to-face consultation
  • Frontline and back office staff must be separated to increase effectiveness by handling as much demand as possible

Bearing this in mind it is worth considering the following quote by Russell L. Ackoff:

“When a system is taken apart it loses its essential properties. Because of this, a system is a whole that cannot be understood by analysis”

The 1813 service is part of a large and complex healthcare system and must be approached with an understanding of the interaction (not the sum) of all parts in this system. Let us explore the consequences further.

Standardising protocols within IT systems

Treatment of citizens adheres to an IT system designed to limit errors and transfer comprehensible and box-ticked formulas to back-office staff throughout the system. The IT system set to facilitate this transfer should increase efficiency, if the right things are done right, right?

”When information from the 1813 emergency phone is transferred to hospitals and general practitioners it is not necessarily shown in an order beneficial to the recipients”

(KORA [The Danish National Department of Municipalities and Regions Analysis and Research] report 1813, 2015)

Within the first three months of 2014 the number of ambulance emergencies experienced a 15% increase as compared with 2013. The increase was deemed “dramatic” by Jakob Andersen, the chairman of the Union of Drivers (3F) in Copenhagen. In the wake of such incidents complaints from ambulance staff followed due to dissatisfaction with the high amount of unnecessary emergency ambulance journeys caused by the inadequate initial 1813 consultation. Standardising procedures in the IT system had thus created a range of unintended effects throughout the system where wasted ambulance journeys and the need to go to consultation twice were but a few examples. When highly variable needs of each citizen are handled by a standardised system it becomes like the Procrustean Bed of Greek mythology, made to fit the system by default, not vice versa.

Implementing arbitrary targets such as budgets, Key Performance Indicators (KPI), service level agreements (SLAs), etc.

A management obsession with cutting costs further exemplifies itself through the use of Key Performance Indicators (KPI’s). One such KPI is set to minimise queues by handling calls within a set target time.

A primary target states that 90% of all calls must be handled within 3 minutes. This is a noble intention on what knowledge of the system is it based?

KORA reports, news articles, forum debates, speeches given by politicians, etc. all focus on the 1813 system’s ability to achieve targets such as the one above as a sign of efficiency. They fail to ask themselves:

  • Is the 3 minute target related to the purpose of the system as defined by the needs of the citizen? How do we know?
  • Does this target help to improve the quality of service provided to citizens from when they enter the system until they leave the system with their needs fully solved? How do we know?

Such KPI’s are lagging measures warning a strained system capacity making the target obscure when trying to understand causes. It is a symptom because working on continuously lowering waiting time by having front line staff work harder, does not lead to an understanding of improvement of the systems ability to handle what matters to citizens. Current management thinking asks whether 1813 is successful in reaching the arbitrary targets. Problems that restrain achievement of such targets keep arising and they are “solved” as if the system was a game of “whack-a-mole”.

What is to be done?

Problems must not be solved they must be dissolved, meaning that they must be designed entirely out of the system. Before problems are dissolved we must understand what the problems are and why they exist by getting knowledge of the whole system. It all starts with defining the purpose of the system from the perspective of the citizen/user. Demand, being a central factor in 1813 must be related to such a purpose to distinguish it in terms of value and failure. Separating value demand (demand that fulfils the purpose of the system as defined by the citizens themselves) from failure demand (failure to do something or do something right [Seddon 2003]) avoids the mistake of equating increasing demand with a higher popularity of the 1813 service. Understanding demand indicates how well the system attains what is right for each citizen and his/her needs, which is in turn crucial for understanding:

  • How much waste is in the system (work not related to creating value for citizens)?
  • What conditions in the system hinder attainment of what is right (doing value work)?
  • Why do these conditions exist?

As within any system the healthcare service system must be continuously focused on improvement by dissolving causes of poor performance. Acting on symptoms such as making front line nurses work faster counterintuitively has a tremendous negative effect on demand and thus on overall performance. Instead of focusing on the people working in the system management should focus on the system itself, creating an efficient foundation for the people working in it.

Sources:

http://politiken.dk/forbrugogliv/sundhedogmotion/ECE2433017/rapport-svag-ledelse-foerte-til-kaos-paa-akuttelefonen-1813/

http://www.b.dk/nationalt/samlet-laegestand-retter-ny-kritik-mod-1813-ordning

http://www.b.dk/nationalt/1813-kan-vaere-skyld-i-18-doedsfald

https://www.regionh.dk/presse-og-nyt/pressemeddelelser-og-nyheder/Sider/rapport-saadan-kan-borgerne-faa-et-staerkere-akutsystem-i-region-hovedstaden.aspx?rhKeywords=kora

http://politiken.dk/forbrugogliv/sundhedogmotion/ECE2180089/regionsformand-er-parat-med-15-millioner-ekstra-til-1813/

http://bevarlaegevagten.dk/laegerne-om-1813/danmarkshistoriens-storste-medicinske-forsog/

http://bevarlaegevagten.dk/laegerne-om-1813/laege-hvorfor-har-sundhedsstyrelsen-ikke-grebet-ind-overfor-1813/

http://www.dagensmedicin.dk/almen-praksis/nyheder/politikere-vil-bruge-flere-millioner-pa-1813/

http://www.dr.dk/nyheder/indland/1813-markant-flere-akutte-udrykninger-siden-nytaar

Ackoff, Russell L. ‘Ackoffs Best: His classic writings on management’, Wiley, 1999.

KORA Report 1813, Januar 2015, Enstrenget og visiteret akutsystem i Region Hovedstaden

Seddon, J ‘Freedom from Command and Control’ Vanguard Press, 2003

Seddon, J ‘Systems Thinking and the Public Sector’ Triarchy, 2008

[1] Commenting on what it takes to solve the 1813 situation

[2] Approximately 1,5 million British Pounds

[3] By the end of 2014 data showed that more than 1/3 of the GP staff employed at 1813 in the beginning to 2014 had left the system.