Understanding bottlenecks in health and social care settings

Remember the game Kerplunk?

It’s a classic game of sticks, marbles, and strategy.

To play, you need to skilfully remove sticks from a large tube without any marbles falling into your square at the bottom.

To win, you need to have the least number of marbles in your square. Easy!

Can you feel a metaphor forming?

Turns out our health and social care sectors at the moment are like a giant game of Kerplunk. A lot of sticks (bottlenecks) are keeping our marbles (the clients) from landing in our squares (getting the care they need and arriving at their desired outcome).

In contrast to winning the actual game of Kerplunk, as health and social care providers we want to free up as many marbles (clients) as we can whilst ensuring everyone lands in the square they need, achieving the outcome they desire and need.

The challenge for both the actual and metaphorical game of Kerplunk is removing the right sticks at the right time to allow a smooth flow of clients and avoid pile ups.

In health and social care, and in this metaphor, our version of winning is a square full of marbles.

Through a Kerplunk (or Ker-pl-unplex!) lens – let’s peer closer at the problem of bottlenecks and discover how we can reduce them so more clients can benefit from our outstanding services.

Note: Even though ‘my version’ of winning Kerplunk is the reverse of the actual game, I like the visual so I’m sticking with it.

Setting the scene

Many health and social care organisations are battling reduced capacity to deliver responsive and great care to the individuals and communities they serve (aka getting the most marbles in the square theory).

There seem to be more clients than there are services, causing bottlenecks in service delivery to occur.

Bottlenecks present in many different forms but ultimately affect everyone equally – the individuals you are trying to serve; staff; the organisation itself.

A bottleneck might present as:

a long waiting list for services
delays to provision of care and support
reductions in the intensity and duration of care and support provided
reduction to the quality of care provided
restriction of services to assessment and triage only.

Let’s look at an example of a popular bottleneck.

In 2021, data were collected through a questionnaire about paediatric waiting lists and prioritisation, surveying 267 Speech Language Pathologists from ten different countries. It revealed that children are waiting an average of eight months for speech-language pathology services, with the longest wait up to 42 months (which is about three and a half years).

The basic Ker-pl-unplex strategy

In this metaphor, the sticks are the system – representing the hospitals, disability organisations, primary care clinics, staff, and equipment which are all interconnected.

The system’s stability gets tested as the tension increases.

The strategy is to identify all the sticks that are causing the bottleneck and then remove (or address) the ‘game changer’ stick/s that will have the greatest chance of unblocking the bottleneck and releasing the most marbles.

Let’s take the ‘not enough staff’ stick as an example.

If we remove that stick (recruit more staff), will that allow more marbles to drop (more patients to flow though)?
Will it alleviate significant pressure in your bottleneck and make a huge difference to your service capacity and client outcomes?
Or (I challenge you to consider), what are all the ways you could address the ‘not enough staff’ stick?

The challenge

Unfortunately removing some sticks will have a non-linear impact on the blockage.

Removing one stick might be disproportionately impactful, while another may have no impact at all.

Sometimes this is a game of trial and error. But, with some considered thought and a bit of a strategy, you could try to identify the stick (or sticks) that are most likely to have the greatest impact on relieving the blockage.

Try asking yourself,

“If every other area of your organisation/service delivery model remained, at its current level of performance, in which one area would you most want to achieve significant results?” (extract from The Four Disciplines of Execution: Achieving Your Wildly Important Goals)

This question helps you to clearly identify what you are trying to achieve at the end of your game. For example, is the aim of your game to increase the throughput of clients you see? Or is it to ensure every client that comes through your service achieves the outcome they are seeking?

Once you have determined your ‘wildly important goal’ the next step is to determine all the different sticks that are preventing you from achieving that goal or causing the blockage, and to evaluate the relative contribution each stick has on your goal bottleneck.

When you do this, you’ll better understand the potential impact of removing or addressing that one stick on your chance of winning your ‘wildly important goal’.

How will you know you have won, though?

Well, hello data (ah my happy place).

The best way to do this is by developing a baseline and then tracking ongoing key metrics that measure the extent of the problem. At the same time, develop and track metrics that allow you to understand the influence of your ‘stick removal strategy’ on your winning goal!

Here’s an example:

An organisation I’ve had the privilege of working with identified that one of their big blockages was that their support workforce felt unsupported when delivering care to their highly valued participants. They decided the winning outcome for their game in 2024 was to ‘create amazing support workers’.

To achieve this winning outcome they spoke to all support workers across the organisation and collectively identified 13 ‘sticks’ that were creating blockages to support workers being amazing (and as such being enabled to deliver great care to participants).

We’re currently working together to determine which of the 13 sticks will be the most important to address to work towards their winning 2024 goal. We’ll also determine the kinds of activities they will need to undertake to remove those sticks! So, watch this space.

The winning strategy

Identifying potential bottlenecks before they escalate is key.

So, a winning strategy involves proactive problem solving.

Particularly, it involves the following steps:

Identify what winning the game looks like (what is your wildly important goal?).
Identify all your sticks that are standing in the way of this happening.
Then do your homework.
Spend time gathering the information that will help you understand how you might know if you have won the game, how many sticks you have and the extent to which each stick might impact on your chance of winning/releasing your bottleneck.
Identify all the possible ways you could un-budge each stick.
Estimate the ‘effect size’ of each ‘un-budge’ solution on its capacity to unblock the bottleneck.
Choose your stick and execute your move.
Observe/measure the impact of your move.
Choose the next stick.

Getting ready to play

I hope this metaphor has helped you to view the complexities of bottlenecks in health and social care service delivery a little differently.

I’ll leave you with some questions to ponder before you tackle the big ones.

Do you know what winning looks like in your organisation?
Do you know your sticks?
Are you confident about which ones will give you the greatest chance of winning?
Are you ready to play?!

Need some help doing this work?

If you need help identifying potential bottlenecks in your service delivery, we can help.

At Unplex we work alongside you and your team to turn your complex problems into solutions you can implement. We do this so health and social care organisations can deliver more and better care to the individuals they serve.

We’d love to get to know you – jump onto our Connect page to join our newsletter and gain more insight, or send us an email at hello@unplex.com.au and we’ll be in touch!