Government has a capacity problem

CALGARY — Lacey-Jones McKnight was found dead in her car last month, allegedly murdered by a former boyfriend who had been stalking her for weeks. Lacey’s family placed numerous phone calls for help to the Calgary Police Service (CPS), but the case wasn’t a priority, so little was done.

Police activity went into overdrive after the family complained that the police had "failed" Lacey. A police PR effort spun the family’s concerns and fed the media stories of an overworked police force. That the police are overwhelmed is undeniable. But the PR tack left the impression that more was done to protect reputations than people. A review of files is promised.

In Edmonton, a judge recently dismissed a sexual abuse case against a man who, allegedly, repeatedly raped a young girl over the course of eight years, beginning when the girl was nine. Charges were laid in 2009, but three years of delays allowed the defence to have the charges stayed.

The victim’s family placed much of the blame for the delays with Crown prosecutors, claiming it took 18 months to interview the victim while highlighting other delays. A spokesperson from Alberta’s ministry of justice and the attorney general, stated "categorically" that availability of Crown prosecutors was not a factor, blaming, a storm and a sick witness for the delay. An investigation is underway anyway.

An investigation just concluded in the case of Samuel Takyi. Takyi went to emergency at the Grey Nuns because of extreme pain following a colectomy. He waited six hours to be seen by a nurse, and two more to be examined by an ER doctor, after which he was sent home. His condition worsened, but Takyi, understandably reluctant to return to emergency, waited too long. According to Provincial Court Judge Robert Philp; "The lack of emergency room resources at the Grey Nuns Hospital resulted in a lengthy wait for Mr. Takyi. Because of this wait, he was dissuaded from returning when his condition became critical."

Government has a capacity problem and it’s beginning to show, sometimes with tragic consequences. One reason that government struggles with the challenge of doing more with less is that it thinks about capacity as a cost/resource problem, producing solutions that do more harm than good.

Municipal, provincial and federal government typically improve efficiency by increasing the utilization of resources — facilities, equipment and staff. With hospitals, for example, this means getting the occupancy rate as close to 100 per cent as you can, leaving a little wiggle room, say one or two per cent, for unexpected variation in demand. Unfortunately, doing this actually reduces efficiency and effectiveness, guaranteeing long service times. This is why wait time targets are rarely met.

The Alberta health care system came to this realization in February. In an abrupt turnaround, the health minister ordered hospitals to lower occupancy levels to 95 per cent by Oct. 31. That date has come and gone but the targets haven’t been met. Why?

Because it was impossible. Capacity is governed by Little’s Law. It tells us that hospital occupancy rates can only be reduced in one of three ways. First, add more beds. However, no new acute care beds were coming before Oct. 31. Second, reduce the demand. Not too practical with government services although it can be done by reducing access so people, like Takyi, give up trying.

Which leaves reducing the time a patient spends in a bed (cycle time). This is done by improving patient flow, but flow is largely a function of structure, and changing the structure of AHS is not permitted. It should be though, because centralized, consolidated structures are the biggest barriers to flow, decreasing efficiency, effectiveness, flexibility and ultimately, capacity. With flow off the table, the only thing left is discharging patients faster, an option that comes with potential declines in quality of care and increasing patient risk.

Reducing demand, adding resources, or reducing cycle-time are the capacity increasing choices for health care, government services or any business. There are many sound, innovative ways of increasing capacity within these constraints, but setting arbitrary targets isn’t one of them. Neither is conducting individual case reviews or investigations.

Trying to improve capacity while ignoring Little’s Law, is like trying to improve aircraft performance by ignoring the law of gravity. Chances are, you’ll crash and burn. In case you haven’t noticed, it’s we citizens who are along for the ride.

Robert Gerst is a partner in charge of operational excellence and research & statistical methods at Converge Consulting Group Inc. He is author of The Performance Improvement Toolkit: The Guide to Knowledge-Based Improvement and Little’s Law: Master of Cycle Time.

—Troy Media