Responses to Service Work Pressure

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We previously introduced the difference between workflow and patient flow in the ED by considering the inflow of hours of work into a workload (backlog or todo list) stock) and the outflow of completed work depending on the work rate. In any service industry, work pressure builds up when there is not enough service capacity to meet the completion deadline, or the desired completion time, and at the required service standard of quality. Here is a causal loop diagram representation showing the causal links among these concepts. In a fully flexible world, we could just adjust service capacity to match the work load, negotiate the deadline to allow more time for completion or reduce the additional demand for services. However these things take time, or are out of our control, and so other adjustments are often made instead


Basic Picture

Fig. 1 - Responses to Service Work Pressure [Source]

Unfolding 1

Rogelio Oliva has described these adjustments to work pressure in service industries with the following causal loops

Fig. 2 - Responses to Service Work Pressure -1 [Source]

Unfolding 2

Fig. 3 - Responses to Service Work Pressure -2 [Source]

Unfolding 3

Fig. 4 - Responses to Service Work Pressure -3 [Source]

Unfolding 4

We can work longer and harder to get on top of the workload, usually by paid or unpaid overtime. We can shave time off each service, perhaps by skipping paperwork or other non-essential corner cutting. Meanwhile we try to adjust service capacity with more staff or more time-saving technologies, but these often take time to implement due to training and procurement delays, or a lack of flexible resources. We can also adjust our threshold for deciding to admit patients, as discussed by Morrison and Wears.

Over time these adjustments lead to other unintended consequences. Prolonged periods of increased work intensity produce fatigue and worker burnout, and loss of the capacity to complete the work. Continually cutting corners eventually leads to erosion of high service standards, and shortcuts become the norm. Quality suffers, but because it is difficult to measure accurately, this erosion of service quality goals is difficult to monitor and demonstrate. This leads to a coping but not coping effect, when the quantity of work appears under control but the quality slips. People appear to have learnt how to do things faster and with the same service capacity, but it is false learning associated with a hidden drop in service standards. And finally, because of this appearance of coping, capacity adjustment doesn’t take place, and a death spiral ensues. The long term effect of this death spiral is the acceptance by patients and staff of low quality service that takes as long as it takes. Once this attitude is entrenched, Oliva showed it is extremely difficult build back up to a high quality service standard.

Fig. 2 - Responses to Service Work Pressure -4 [Source]


  • R. Oliva and J. D. Sterman (2001) Cutting corners and working overtime: Quality erosion in the service industry. Management Science, 47, 894-914. [Download]
  • Oliva, R. & Sterman, J. (Forthcoming). Death Spirals and Virtuous Cycles: Human Resource Dynamics in Knowledge-Based Services. The Handbook of Service Science. P. Maglio, J. Spohrer & C. Kieliszewski. London, Springer. [Download]
  • J. Bradley Morrison and Robert L. Wears Emergency Department Crowding:Vicious Cycles in the ED ISDC July 2011
Questions & Comments to Geoff McDonnell
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