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When slacker is safer


Themes: Health management

Professor Stefan Scholtes warns that exceeding the ‘tipping point’ can have serious consequences

2014_features_tippingpointThey turn up late. They seem immune to deadlines. They don’t mind being carried by the team. Slackers are not usually the most popular people in the office – but could it be that a little slack might actually be useful?

While the classic sneaker-wearing, authority-shirking slacker is probably taking the idea of slack too far, it is certainly true that we all have a tipping point: a pressure point beyond which we are no longer efficient and effective, but just stressed and confused.

For most of us reaching the tipping point just means that productivity starts to suffer but, for some, particularly in the healthcare industry, that tipping point could be a matter of life or death.

Indeed, new research in clinical settings has major implications for the way we think about capacity and stress in the workplace.

The research, conducted by Professor Stefan Scholtes, Dennis Gillings Professor of Health Management and Academic Director of the Centre for Health Leadership & Enterprise, together with two German collaborators, has demonstrated conclusively that far from maximising efficiency, exceeding a capacity “tipping point” on a hospital ward can have dire consequences.

“We all suspected that outcomes would deteriorate,” says Scholtes. “But previously there were assumptions of gradual deterioration. We identified a tipping point strongly at around 92 per cent [patient occupancy relative to ward capacity].” What happened if the tipping point was exceeded? Patients began dying – in significant numbers.

The research draws on the discharge records of more than 80,000 German patients across six clinical conditions with a high mortality risk. The data enabled the researchers to track patients at the level of specific hospital departments, and measure daily occupancy levels of those departments. In a department functioning at above 92.5 per cent capacity, the researchers concluded that one in seven of all deaths among patients could be attributed to this exposure to elevated occupancy levels during their first week in hospital.

Below that point,” says Scholtes, “there may be other effects, but there was no discernible effect on mortality. What shocked us was the size of the effect above the tipping point. One in seven deaths are attributable to an organisational factor such as occupancy. That suggests there’s a Mid Staffs in every hospital, every once in a while.

Professor Stefan Scholtes

Professor Stefan Scholtes

What actually causes these deaths, so numerous as to merit comparison with the scandal-hit English hospital investigated in the late 2000s for its unusually high levels of patient mortality? The research is clear: each organisation has policies and managerial responses in place to cope with demand variation. However, when these responses are depleted and demand continues to rise, the pressure is passed on from management to frontline clinical staff, who are forced to ration resources and, at the same time, become more error-prone as a result of elevated stress hormone levels. These findings may mean we need to rethink our approach to employee stress and workload, not just in the healthcare sector but across the board.

Of course the concept of “stress” is unexpectedly recent, not coined until 1956 by a Hungarian endocrinologist named Hans Selye. In his definitive The Stress of Life, Selye formulated the notion that stress is the response of the human system to alterations in its normal, balanced state, caused by ‘stressors’.

Today, those stressors seem to be all around us – and nowhere more prevalent than in the workplace. The World Health Organization (WHO) defines “occupational stress” as “the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope.” The UK’s Health and Safety Executive states that in 2011-2012, out of more than a million cases of work-related illnesss, by far the highest proportion – 40 per cent – was due to stress. A worker under pressure is stressed, may be ill, and certainly unproductive.

Yet opposing this conclusion is the principle of “efficiency”, famously pioneered by Frederick Winslow Taylor who in the 1880s and ’90s argued that steel-workers were not working either themselves or their machines at maximum capacity. Taylor’s thinking was melded, in the 1950s (at the same time Selye was refining his notions of stress), with Frank and Lillian Gilbreth’s analysis of workplace habits across multiple industries, birthing the celebrated concept of “time and motion” study. For believers in this school of management theory, the efficient workplace was one that operated at maximum capacity.

“This is a very old argument,” says Scholtes, who, though careful not to draw generalisations, nonetheless believes that his research sheds light on the complex relationships between efficiency, stress and productive outcomes.

But we are in a situation after the financial crisis in which all hands are on deck to make up productivity. Yet that approach actually drives down performance and it drives out innovation – people are kept busy just firefighting.

It’s a recognisable scenario. Even uber-innovator Google has reportedly abandoned its celebrated “20 per cent rule”, which allowed staff to spend just 80 per cent of their time on the day job and the remaining 20 per cent pursing side projects.

Scholtes believes the lessons of the tipping point should be heeded across business sectors – he himself has worked with banks and engineering firms as well as healthcare organisations, and teaches on the Cambridge MBA and Executive MBA programmes – and that companies of all kinds need to examine how they respond to pressure and underperformance.

“The immediate response is to move to reduce costs,” he says. “But that usually means reducing capacity – and we know that simply isn’t the answer in the long run.”

Find out more

Visit Professor Stefan Scholtes’ faculty webpage
Learn more about the Cambridge Centre for Health Leadership & Enterprise (CCHLE)