Please Take A Ticket

Far from the frustrated rantings of my last blog post, my latest musings are more about genuine puzzlement over why some managers seem intent on making extremely straightforward processes unnecessarily complicated.

I was at the Outpatient’s department of my local hospital today for a follow-up appointment to treat injuries sustained during one of my many recent acts of heroism (actually the real reason is too boring to share with you, so I just made that up). The booking-in process perplexed me – patients go to the reception desk and show the attendant their appointment letter, then are told to take a deli-style ticket from a nearby machine, before walking a few feet to a seated area in front of another reception desk and waiting there.

Above this second reception desk there is a large LED display that flashes up with big bright red ticket numbers every so often, in tandem with a cold, emotionless robotic voice that barks, “Ticket number (pause) Seventy (pause) four! (pause) Operator number (pause) two!” The patient with ticket number 74 then goes to the desk, speaks to the appropriate operator, shows their appointment letter again and the operator books them in. The process for booking-in therefore looks like this:

I couldn’t work out what additional benefit there was in having two reception desks in sequence, or why the ticket system was the chosen method of registration, so I politely asked why it was considered a better process than me just walking straight up to Desk 2, handing over my appointment letter and letting the nice helpful lady book me in, as she was doing now anyway. First of all she looked at me as though I had two heads, then gently explained (as one does to a very small child who doesn’t understand something extremely obvious) that it was ‘better with the tickets because it reduces queuing time’.

Actually it doesn’t – it increases queuing time. If Desk 2 can process two patients at a time (as there were two operators), yet Desk 1 only has one operator, then the speed that patients can be processed through Desk 2 is contingent on the speed that Desk 1 drip-feeds them through. Therefore, if there is a queue at Desk 1, this means that Desk 2 is under-utilised. Furthermore, the design of this process does not reduce queuing at any stage, nor remove the need to queue at Desk 2 – it merely puts patients into a seated queue instead. Smoke and mirrors. There is nothing at all to suggest the approach reduces end-to-end time one iota. Also, because the appointment letter has to be presented twice, the process introduces unnecessary activity, which is by definition, waste.

From a totally different perspective, the process is also quite dehumanizing. Patients effectively become numbers instead of people as they wait in the seated queue before Desk 2, and are ordered about by an inhuman, disembodied, automated master of ceremonies. How impersonal. Eventually after these hurdles, they get to speak to the helpful, personable human being behind Desk 2, who does the only thing of value in the entire booking-in process; i.e. booking in.

I maintain that the ticket system is rubbish. It takes longer, grates on people like me, is more costly (more desks, more staff, ticket machine, LED panel, robot announcer), does not reduce queues at all and has no discernible benefits whatsoever.

In contrast, what about this for an alternative model? – Patients go straight to the first available operator at a single reception desk and get booked in by the helpful human being sitting behind it.

Here’s the process map:

Radical, huh?

About InspGuilfoyle

I am a serving Police Inspector and systems thinker. I am passionate about doing the right thing in policing. I dislike numerical targets and unnecessary bureaucracy.
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12 Responses to Please Take A Ticket

  1. Well said. Hope the message gets out there.

  2. LovePublicHealth says:

    Lol. I enjoyed reading this. Seems very bizarre to still have such a system when the NHS are supposed to be cutting costs !

  3. patently says:

    No, the simple system would not advance the objects of the organisation.

    You have to remember that the NHS (like all organisations) is run for the benefit of its customers. However, contrary to popular opinion, the customers are not the patients. The customers of any organisation are the people who make the immediate decisions about payment for the organisation’s output, i.e. in this case, the local NHS Trusts and, ultimately, politicians.

    Those people want to trumpet ever-increasing levels of spending and “investment in health”. Therefore, the comparison between the two systems becomes quite simple:

    Your idea – Total investment:1x desk, 1x operator

    Their system – Total investment: 3x desks, 3x operators, 1x automated voice thing, 1x ticket machine

    Thus, their system is clearly far better for their customers as it enables them to announce over three times the level of investment in the nation’s health.

  4. How do you keep hitting upon my favourite bugbears in life???

    I’ve been in a fair few hospitals down the years (isn’t sport supposed to be good for your health?), and they all seem to run the same system. Fracture clinics are particularly frustrating, because after you’ve been through all those booking in and queuing hoops and finally get to see a doctor, they invariably then send you off for an x-ray. Guess what? Another desk to report to, another queue to wait in, finally a radiologist to x-ray you – then another wait, then back to the fracture clinic to join the queue again. Who’d have thought that would happen??

    The clinics always run late. Even if you have one of the first appointments, they’re always at least 40 minutes late. How do they manage to be so consistently late? You’d have thought by now that they’d have worked out how long it takes to handle a certain number of appointments, and would have planned accordingly.

    The people I feel really sorry for are the ones who come in via patient transport. They get dumped off first thing in the morning (after an even earlier pick-up from home), and then don’t get collected until the end of the day. Given that the hospital can control when these patients come in, you’d have thought by now that someone would have worked out the optimum time for them to arrive. It always seems to take the staff by surprise when the transport drops the patients off.

    Of course, one of the big questions is the date of appointment in the first place. There seem to be standard ‘you can see me in X weeks time’. Do you book that holiday or not? You then get a letter setting out a date which you rarely have any control over and bears no relation to the ‘X weeks’ promised. And heaven help you if you cancel the appointment. Don’t you know how much cancelled appointments cost the NHS!! I despair of all those warning notices about the waste caused by patients who fail to turn up for appointments. It’s not as if I’ve, like, had to take a day off work or anything! You’d have thought that by now someone would have designed a system where you could choose dates, and they could check you were coming…and that someone would have figured the common factors why there may be so many no-shows.

    A current trick to reduce waiting lists is to offer a cancellation, and then when that patient declines the offer (maybe they just booked a holiday?), you can then take them off the list. Yes, the NHS does that. Why? To hit the waiting list targets. Certainly not to heal people.

    Having spent a few weeks as an in-patient a few years ago, just try getting out. It’s very difficult. You can’t just get discharged, you know! There has to be a risk assessment. You need a familiarisation course with crutches. Crutches get delivered, but not the physiotherapist who does the familiarisation ‘course’. Wait another day. Finally you can go – but you need your medication. Pharmacy closes at lunchtime, the orders don’t get picked up from the wards until the afternoon. Wait another day. Finally you can go… but no, your consultant (who you’ve never actually met) has to sign everything off. And he doesn’t do his round until tomorrow morning.

    Have you been to your GP lately???!!!

    • HCSW says:

      What do you propose they do? X-ray everyone before they arrive?

      As for the clinics, they run over due to a number of reasons, the best I always point out to patients is that not all appointments are the same and require the same time. Some patients ask ALOT of questions or maybe they need extra attention. I always find people complain whilst they are waiting and moving through the system but once they are in the room with the Dr they quickly change their minds and take up as much time as they need… which is fine isn’t it? I mean if it was you who needed an extra ten minutes because you were upset etc you would expect the Dr to run over for you and not kick you out? As for planning accordingly I’m certain you don’t appreciate how hard it is to maintain patient experience whilst trying to see as many people as possible and making sure everyone goes home on time, we are people too you know, not robots.

      As for patient transport, it is sometimes very poor but you are forgetting most of these services are run by volunteer drivers and even privatised companies and they have to meet costs by ensuring they always have full capacity on their pick ups and drop off which is difficult as different out patients have variably different wait times! These people do a great service.

      I’m the first to admit the NHS is in a bad way but it does such an amazing job with the resources it has and we ARE struggling but it just frustrates me how people are so quick to point out all these flaws without acknowledging anything of the good things we do!

      I don’t mean to have a go as some times I hold my head in my hands and I feel like I can see all these things around me that are wrong also but feel powerless to change anything. But I fear that whilst we all stand and stare, wonder and shake our heads we will one day lose this service and then I think that’s when we will actually appreciate what we had and what we’ve lost.

      That waiting room system sounds like a nightmare, I’d knock that on the head straight away. Sadly paying nurses more doesn’t give them immediate managerial skills as the men in suits have decided. *Sigh*

      Kind regards!

  5. Many apologies for not pointing out the great work that the NHS does. We should never take it for granted that we have the great fortune to live in country where world class medical treatment is available to everyone. I see huge dedication and commitment to provide the best possible treatment. But with the pressure on budgets, I’m just trying to sell the argument that systems thinking will allow the service to be both improved and made more efficient. The alternative route is yet more queues and bottlenecks as individual departments cut their services back – and invest in ticket dispensers.

    And all these problems are equally apparent in policing, of course!

    I have the option of using two NHS hospitals via my GP. The one allows the GP to refer you on-line and select appointment dates, the other requires the GP to write to the consultant who then writes to inform you of the date they’ve allotted you. If you can’t make the date you’ve been allotted, you have to call the department and request a new date – which again you have no choice over. I don’t have any data, but I would make a confident bet on which hospital has fewer failed appointments, and which hospital has a more efficient system.

    As for going private – first there’s the huge cost, both in terms of insurance, and tax to pay for those who can’t afford insurance. I’ve only seen private medicine as a visitor, and whilst the menu choices are nicer, my observation would be that the same systemic problems exist – it’s just that cash allows you to queue jump, and purchase a few extra tests – just to be on the safe side, of course.

  6. namebox says:

    This is just conjecture on my part, but I suspect that the first desk starts a clock (arrival event) and the second desk stops it (entry into healthcare system event). I.e. the situation exists just to measure a target of some sort. And that target will appear on a spreadsheet somewhere several floors away.

    It might also shave a bit off the apparent waiting time if only the second desk can start the waiting time clock, the queuing before hand is not included. So it fiddles the figures.

    The screen is just a bit of distraction to imply progress. If you have ever been forced to use a well known catalogue store that sounds a bit greek, and watch the counter for your purchase, you’ll see that the display is bogus.

    The target mentality infested the private sector for many years, it began with things like ISO 9000. Giving gainful employment to bands of consultants, who knew nothing about what you did, but would tell you exactly how you should do it for a hefty fee. They have mostly all been kicked out of the public sector when people caught on to the con. No wonder they now infest the public sector.

    I’m tempted to blah on and on, but I can’t remember the name of the person that started the “Cult of Management” at the moment.

    If you want a sensible answer from someone who might know, you could ask the rather splendid Mr Kellet, he is on Twitter as @Reynolds.


  7. Blue Eyes says:

    OK late to this debate so apols if someone has already made this point.

    The system means you can queue sitting down, which might be an idea in an environment where people have things wrong with them.

    But presumably there have been problems with people either coming in and sitting straight down without a ticket and dying waiting, or people taking a ticket, waiting and then only once they reach the front of the queue they discover that they haven’t got an appointment or there is some other problem.

    As I understand it the first desk is purely for validation.

    Of course the question that poses itself is whether using a person to do the validation is better than having a big bold sign at the door saying something like: if you don’t have an appointment bugger off, if you do, take a ticket and sit down. That way the desk where the real work is being done could be better staffed and then the queue would be shorter!

  8. Paulh says:

    Where do I start with systems!! As clinical systems engineer in the NHS (and yes I have a clinical background before anyone points out I’ve never worked in a clinical environment) your example is far too common. Usually done by someone who has thought of a “good” solution but doesn’t understand the process. We completely redesigned one of our clinics by understanding the process from the patient’s perspective and redesigned teh whole system. One of the ways we did this was to put in an electronic check-in system; this reduced teh time taken to check-in, provided a trigger event for a tracking system and allowed the patient to validate their demographic details. result was reduced lead time through te department and reduced costs. It can be done.

  9. I’ve experienced precisely the same problem (booking in twice) many times now with my dear old Mum who’s been to hospital outpatients many, many times in the last 5 years (I’m her taxi). While waiting in reception area 2 recently (having gone through the desk 1, desk 2 process) I witnessed the following:
    Elderly couple enter reception area 2 with letter of appointment; helpful lady behind reception desk 2: “Have you booked in at ‘reception 1’?” elderly couple look confused, at each other, at helpful lady behind the desk, proffering their letter of appointment. Helpful lady behind the desk (henceforth ‘HL’): “you need to book in at reception 1” – more confused looks. HL: “go back up the corridor, turn right, reception there – show them your letter”. Elderly couple look at each other, turn and shuffle off in direction of Reception 1.
    I know from experience that they will join a queue there – one of three in front of one of 3 ladies (hopefully the right one, although there’s no way of knowing until they get their turn – they might have to start again at another station next door…) – this lady will look at their letter, consult her list, put a tick with a red pen against their name, and direct them back to Reception 2….
    Some time later, back at Reception 2: Elderly couple enter 2 with letter of appointment; helpful lady behind reception desk 2: “Have you booked in at ‘reception 1’?” elderly couple look confused, at each other, at helpful lady behind the desk “er, y-yes…?” proffering their letter of appointment. HL takes letter, consults her list, and puts a tick against their name (what is it with red pens in the NHS??) – “ah – you’re a little late for your appointment, but take a seat”. Meanwhile, the scrolling electronic screen on the wall in front of me still reads: “Appointments with Dr **** are running 90 minutes late; we apologise for any inconvenience”. Perhaps I should add – this is the cancer treatment dept where patients come for chemotherapy.
    I fear it’s too late for the elderly couple and my dear old Mum, but will it be any better when my turn comes…?

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