True Causes
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Why are waits in the emergency department so long?
The people who know the fix are never asked
a walkthrough with stand-ins — a demonstration, not a finding · sealed
What significantly influences it
An incident report goes into a system nobody reads back
certified · 23 yes · 6 no · cross-group
Judged not to be linked
A pharmacy could have handled a third of today
judged not to · 3 yes · 12 no
Imaging closes at six and reopens at eight
judged not to · 0 yes · 14 no · 1 abstained
An incident report goes into a system nobody reads back
judged not to · 2 yes · 12 no · 1 abstained
A patient waits for one test that takes ten minutes to run
judged not to · 2 yes · 11 no · 2 abstained
Managers are judged on the target too, so nobody questions it
judged not to · 1 yes · 13 no · 1 abstained
The same patients come back within a week
judged not to · 3 yes · 12 no
A trolley in a different corridor stops the clock
judged not to · 2 yes · 12 no · 1 abstained
The target changes what we do more than the illness does
judged not to · 0 yes · 13 no · 2 abstained
Staff leave faster than we can hire them
judged not to · 0 yes · 15 no
A pharmacy could have handled a third of today
judged not to · 2 yes · 13 no
Imaging closes at six and reopens at eight
judged not to · 2 yes · 12 no · 1 abstained
A patient waits for one test that takes ten minutes to run
judged not to · 2 yes · 13 no
Managers are judged on the target too, so nobody questions it
judged not to · 2 yes · 13 no
The same patients come back within a week
judged not to · 0 yes · 14 no · 1 abstained
A trolley in a different corridor stops the clock
judged not to · 1 yes · 13 no · 1 abstained
The target changes what we do more than the illness does
judged not to · 2 yes · 13 no
Staff leave faster than we can hire them
judged not to · 3 yes · 12 no
A group’s judgement, not a measurement. Demo room. On the atlas.
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