CASE STUDY:This month's case study looks at a medical clinic that is struggling to deal with queues of angry patients on waiting lists, which is causing serious staff frustration due to the lack of services available

RYAN FLYNN normally gets his secretary Siobhan to log complaints from irate patients, but one morning, she called him in to read a letter and warned him: "You'd better have a look at this."

Flynn is the manager responsible for patient service improvement at a large regional hospital with the task of creating a system of "signals" that would alert senior management to the need for change.

It had taken Flynn a year to instigate the current system, where patient letters were recorded and processed in a way that he could perform some analysis of their content. Still, he suspected that letters could find their way to anyone in the hospital: canteen services, individual consultants, ward managers. He knew it wasn't good enough. But time and resources were against him and his agenda was full.

"It's from a member of staff?" he queried Siobhan.

"No signature," she answered, but it was obvious that it was.

Flynn read the letter. As well as his local roles and responsibilities, he served on several national committees. Coming from the private sector originally, he accepted the need for decisions in health to be made nationally, whilst at the same time feeling the frustration any business manager would at not being able to implement change locally when it became clear change was needed. However, he hoped with perseverance he could make his point.

"I have had to make the clinic's, doctors' and nurses' names anonymous," the letter began, "because I don't want to get anybody into trouble and nor do I want to stir up trouble for myself. But having worked here now for five years, I could not continue saying nothing about the way the hospital, well my part of it anyway, seems to create problems for itself and for us nurses.

"Our clinic operates from 8.00am until 6.00pm every day of the working week. We offer specialist services on a non-appointment basis, first come first served, and I want to tell you what it is like," the letter continued.

"Our patients are queuing outside from 7.00am onwards, some even earlier, in the hope of being seen within the first hour of clinic hours. They do that come rain or shine. By the time we open the doors at 8.00am, however, the morning's consultation slots are pretty well filled.

"Patients arriving after 8.00am often have to wait until after lunch to be seen and patients arriving by 10.00am may be waiting until 6.00pm. Imagine what it's like for anybody who suddenly needs our services at three in the afternoon?

"Let me explain what happens. They wander into a corridor that is full of complaining, frustrated people and squeeze their way into an overflowing waiting room which is hot, airless and seething.

"This happens every day. When we meet the patients in the morning, our first line response to them is, leave your name and come back in four hours. Some of these people are in pain.

"Of course they don't come back in four hours, because they are afraid of queue jumpers, so the majority either go away for an hour or block the corridors all day. More patients means more frustration. What it means for our doctors is they are virtually tied to their seats for the first four hours of the day. If they go for a coffee break or a toilet break, the questions start. 'Will that mean more delays?' 'Where's she going?' 'When's she coming back?'

"Dealing with angry people becomes our routine task and working in an environment that you know is going to be unpleasant before you get in there each day."

It was the kind of complaint Flynn heard when he stopped off for drinks with colleagues in the evening. Yes, nationally resources had gone into reducing waiting lists and there were many new initiatives that got into the press. But on the ground, the system was not responding to the pressure of complaints.

The letter went on. "We don't suffer violence and drunkenness from patients like they do in A&E, but maybe that's why we are easy to ignore. Nobody talks in public about the time our patients wait. And believe me, I've seen it in other clinics. I've seen it in oncology and ENT where patients with appointments can wait hours."

With a background in the commercial sector, Flynn knew that market signals play an important role in refining and even revolutionising service businesses.

Service design is the new buzz phrase. Get service design right and much follows in a service-orientated economy like Ireland. The nature of service design, what it is and how to go about it, though, is little understood. There wasn't a book he could pick up, a guru he could quote in committee. Service designers in public sector organisations face different pressures from those in the commercial sector. If you work for a company, then you know poor service or poor processes eventually lead to a fall in sales and profits, and have an immediate knock-on effect throughout a company. Improve quality and sales and profits go up. Everybody is happy. Theoretically.

Service quality in public sector services functions differently. Poor service leads to growing dissatisfaction, which staff have to deal with, perhaps for years before the signals reach senior management. In contrast, improvements in quality might yield very little in the way of feedback for an organisation.

For staff, that means dealing with dissatisfied customers for longer periods of time than might be the case in the private sector. Flynn had been reading in the morning paper the various ways the service sector was responding to change.

"The services economy, which ranges from road haulage to finance, contracted for a fifth straight month in June. Financial service providers registered the sharpest rate of decline with activity falling at a record pace," Flynn read.

But the fact is, after three months of rising prices, service companies had done an about turn and began reducing price. That's the kind of agility he would like to have seen in his own department. Three months to affect change. Whereas companies have markets to respond to, public sector services had neither market mechanisms nor tried and trusted techniques for creating change at the grass roots.

The result wasn't only that staff time and energy gets disproportionately spent calming patient nerves and explaining delays instead of processing patients, tests and directing patients to clinics. Staff themselves start to feel like a victim of the system.

How do you go about redesigning a service where dissatisfaction is the order of the day, Flynn wondered. He was aware that various parts of the hospital had started change programmes only to have the carpet pulled from under them when resources were tight, so it wasn't just about change but also commitment.

He knew if he could come up with a plan based on experience somewhere else, there was a chance to use the nurse's letter to signal the need not just for a change in services, but also the need to find a method that could be used again and again.

Thinking the problem through, Flynn thought, the main areas he needed to address were: How to initiate change yet again - where does one start?

How to recapture staff confidence, involve patients and deal with resource issues, and how to be sure change will work this time around?