True Causes
JA
Nobody measures whether the patient got better
a walkthrough with stand-ins — a demonstration, not a finding · root cause · sealed
It significantly influences
Nobody may discharge at night, so a bed is lost for twelve hours
certified · 14 yes · 0 no
Judged not to be linked
Patients come here because they cannot get an appointment
judged not to · 0 yes · 14 no
We have had four reorganisations and no more beds
judged not to · 1 yes · 13 no
Social care and the hospital are funded from different budgets
judged not to · 1 yes · 13 no
Experienced staff leave and take the workarounds with them
judged not to · 1 yes · 13 no
Two systems hold the same patient under different numbers
judged not to · 1 yes · 11 no · 2 abstained
A decision to admit waits for a consultant round in the morning
judged not to · 1 yes · 12 no · 1 abstained
People wait hours in a corridor before anyone sees them
judged not to · 1 yes · 12 no · 1 abstained
Beds are full because nobody can be discharged
judged not to · 2 yes · 11 no · 1 abstained
Patients come here because they cannot get an appointment
judged not to · 2 yes · 11 no · 1 abstained
Nobody may discharge at night, so a bed is lost for twelve hours
judged not to · 2 yes · 12 no
We have had four reorganisations and no more beds
judged not to · 5 yes · 22 no · 2 abstained · cross-group
Social care and the hospital are funded from different budgets
judged not to · 8 yes · 20 no · 1 abstained · cross-group
Experienced staff leave and take the workarounds with them
judged not to · 2 yes · 12 no
Two systems hold the same patient under different numbers
judged not to · 0 yes · 14 no
A decision to admit waits for a consultant round in the morning
judged not to · 3 yes · 11 no
People wait hours in a corridor before anyone sees them
judged not to · 3 yes · 10 no · 1 abstained
Beds are full because nobody can be discharged
judged not to · 0 yes · 12 no · 2 abstained
A group’s judgement, not a measurement. Demo room. On the atlas.
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