True Causes
JA

ATLAS · A CLAIM AND WHERE IT CAME FROM

An incident report goes into a system nobody reads back

Raised in 1 room

Why are waits in the emergency department so long?

→ What leads to it (1)

Managers are judged on the target too, so nobody questions it
certified in 1 room

→ What it leads to (2)

A patient waits for one test that takes ten minutes to run
certified in 1 room
The people who know the fix are never asked
certified in 1 room

Every room keeps its own record: its map, its rules, and every judged pair with its votes, downloadable from the room. ← The atlas