Sunday, July 17, 2011

How we keep score determines how the game is played

“Don’t let him in, Dad!”

I was driving my son to his soccer game when we ran into road construction.  Signs indicated that the right lane was closed ahead, so we merged into the left lane.  The very congested left lane. 

As we crawled along, a few cars zipped ahead in the right lane, which wasn’t blocked off for another 10 car lengths.  When these drivers reached the barricade, they signaled their intent to merge into the left lane.  My son’s sense of justice was offended by this “butting in line”, and he exhorted me to keep driving and prevent the right-lane bandit from merging.

To be fair to my son, his attitude has been informed by my own kvetching about drivers who don’t play by the rules.  Well, by my rules, anyway.  Why should this guy get to cut in when I’ve been stuck in this lane for all of 3 minutes?!  He can just sit there for another few minutes. 

I talked tough, but when it came down to it, I let the other driver merge.  My son was disgusted with me.

This led to a discussion about which method would get more cars through the construction zone more quickly: Option 1 - everyone merging into the left lane as soon as they saw the “Right Lane Closed Ahead” sign, or Option 2 - some drivers continuing in the right lane until it was barricaded, and then merging.  We couldn’t figure out the answer, but my son told me it didn’t really matter.  What mattered to him was how fast we got through, so he could get to soccer on time. 


I can see how he would come to that conclusion.  Getting to his game on time was the only benchmark he had.  In fact, maneuvering through the construction-zone traffic had become a game unto itself, and our goal was to get through in the shortest time possible.  Setting that goal lead to our (fantasized) tactic of blocking other drivers who wished to merge into our lane.  That tactic would get us through the line a little quicker, but at the expense of the other driver.

What if the game were played differently?  If there were evidence that Option 2 is actually more efficient, traffic engineers may want to promote it.  They could post signs asking drivers to continue in the right lane until the last moment, and then encourage courteous merging.  But, even if this option is more efficient for the driving collective, individual drivers will still “win” if they are selfish and refuse to allow anyone to merge in front of them.

Maybe we need a different way of keeping score, and a scoreboard to let drivers know how the game is going.  The engineers could set up an electronic sign that indicated how many cars per minute (CPM) are passing through the construction zone.  Perhaps every time a driver exhibited the desired merging behaviour, a happy face would flash and the CPM number would increase.  If someone blocked a merge, the opposite would happen.  I’m not sure what the most effective sign/scoreboard would be, but whatever it was, it should give this message: We’re all in this together!

Last week, I spoke with a friend who works in a chronic disease management program.  Her program had been trying to secure funding for an initiative that would engage patients in their own care, with the intent of reducing disease progression and hospital admission.  She was frustrated because the acute-care department that managed patients in hospital had received funding for a high-tech intervention that would benefit a few patients with severe disease, yet her program had been unable to obtain a fraction of that amount to promote an intervention that would keep many more people from being hospitalized in the first place.

This will be a familiar story to clinicians who see behaviour in another department affecting their own department (e.g. surgeons griping about medical specialists’ discharge patterns – see this recent post), yet feel powerless to influence that behaviour because it’s happening “outside their silo”.  Everyone is playing the game for themselves, sometimes to the detriment of the system/patient.

Healthcare organizations often use “dashboards” to show key performance indicators at various levels, e.g. mortality rates over the entire organization, consultation wait times at the department level, or complication rates for individual surgeons.  The trick is to make all these dashboard/scoreboards relevant for what really matters: the patient’s experience. 

It’s the patient’s experience that cuts across all of healthcare’s self-imposed boundaries, yet our current scorekeeping emphasizes those boundaries.  Budgets are assigned according to categories created for provider convenience – medicine vs. surgery, inpatient vs. outpatient, acute care vs. prevention.  I think that most providers, if in a conflict over behaviour or budget, would let a colleague “merge” ahead of them, if they could see that it would be better for the collective effort. 

The challenge, then, is to set up dashboards/scorecards that emphasize (and reward!) that collective effort, rather than individual success.   We're all in this together!

P.S.  If you want the answer to the “Late Merge” question that my son and I couldn’t figure out, take a look at this interesting explanation by a Minnesota traffic engineer.


  1. Interesting article on 'late merging' one of those 'late mergers' who often gets dirty looks from other drivers, it provides a small measure of affirmation.

  2. Excellent and articulate piece Kishore! Keep up the great writing, your use of metaphor really illustrates our problems well.

    David Maier, Flight Nurse
    Saskatchewan Air Ambulance

  3. Sorry for the late reply, David, but thanks for the encouragement. Keep up the conversations in your workplace!

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