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Nude descending a staircase
Snapshots, movement and blur
Nude Descending a Staircase (or, to give it its proper name, Nu descendant un escalier No. 2) is a 1912 painting by Marcel Duchamp that caused a bit of stir when it was exhibited in New York 1913.
Let’s have a look at it.
It’s an attempt to portray motion within the confines of a still image. It’s as if Duchamp has “overdrawn” several static images (I count at least four) of the moving figure onto the same canvas.
For me, this modernist painting has become a symbol of all attempts to capture movement in a still image. And I think of it every time someone uses the phrase “patient flow”.
Patient flow. There’s a big clue in the second word of the phrase: “Flow”.
“Flow” implies that something is moving all the time. If you look up “Flow” in a dictionary, you get: 1 (of liquids) to move or be conveyed as in a stream.
When we try to make sense of patient flow in the NHS— particularly when we try to use data to make sense of patient flow — we tend to use static images. With no sense of movement, no sense of blur. We take individual snapshots; we don’t shoot movies.
But if we want to understand how something moves, we need to find a way of representing and visualizing movement. And there are two aspects to movement.
The first aspect is that movement takes place over time. So if you keep taking snapshots of the same place, you’ll find that the snapshots change each time you press the shutter. For example, the number of people in the Emergency Department will be different at 1am from what it was at midnight. It’ll be different again at 2am. And different again at 3am. But if we keep taking repeated snapshots, and view them in sequence, we will get a better sense of those changes.
Secondly, there is a space aspect to movement. When things move, they don’t stay in the same place. They don’t stand still. So we have to see the movement taking place in different locations. We have to be able to see many locations simultaneously.
Which means it’s not just about tracking movement through time (a camera on a fixed tripod looking at the same scene changing — a bit like Marcel Duchamp’s painting); it’s also about tracking movement through space. So we need cameras to be placed in different positions.
Or we need a very wide-angle lens so that we can see everything simultaneously.
Flowopoly shows movement in both time and space. It makes patient flow visible in both time and space.
The first thing we have to see is movement. We have to see patients moving into the system, through the system, out of the system.
How many patients arrived? How many of them moved from one place to another? How many of them departed?
What was the clustering like? Did the patients arrive with monotonous, uniform regularity? Or did the bus arrive and a whole load of patients arrived at once?
It’s difficult to see movements such as this when it’s just a collection of random still images. And what I mean by “still images” is usually a numeric summary description of the things that moved in one day. Yesterday: 126 Emergency Department attendances. 21 Acute Medical Unit admissions. 14 specialty ward discharges.
Describing a day like that using static numbers. That is like painting a picture of a horse. Which is fine. Sometimes pictures of horses can be useful and nice.
Here, for example, is a painting of a horse by George Stubbs.
But horses move. And for centuries we marvelled at how they moved. Particularly when they moved fast, when they switched from walking to trotting to cantering to galloping and the human eye wasn't quick enough to work out how it was doing it. And how many legs were off the ground at the same time.
Until that is, Eadweard Muybridge came along in the 1870s and worked out how to take sharp photographic images of horses in full gallop. And then put them together in sequence. The result was a series of iconic images showing how horses move.
Looking at Muybridge’s motion studies is like watching something in slow motion. Slow motion is a way of making sense of something that happens very fast. A series of still images that the human mind can somehow visualize as motion.
But with patient flow, we have a sort of opposite problem to the horse problem.
With horses, the movement is happening so fast that we need to slow it down to make sense of it. Whereas with patient flow, the movement is happening so slowly in real time for us to make sense of it, that we have to speed it up.
So we need a tool that’s more akin to time lapse photography than slow motion replay.
We need to speed up time.
That’s what Flowopoly does. It speeds up time so that we can look at what 24 hours look like but it only takes 40 minutes or so to witness those 24 hours. And the speeding up of time enables us to see the patient flow (or the lack of it) more clearly.
That’s the time thing. The second thing is the space thing. We have to see this movement, this activity, but we have to see it wherever it occurs. Patient flow isn't just happening in one place; it’s happening all over the place.
We have to be able to follow patients whenever they move from place to place. We have to be able to get a visual sense of how many patients arrived in the Acute Medical Unit via the Emergency Department versus how many of them arrived directly. We have to be able to get a sense of which specialty wards the patients from Assessment got transferred to. Not just when, but where.
So Flowopoly makes the whole system visible. We go to some lengths to make the boards on the table as “architecturally correct” as possible so that the wards and departments resemble as closely as possible the wards and departments they represent.
So we have to show the whole system on one table, so that everyone can see the whole system in one eye-sweep. No walls impeding the view. No staircases in the way.
The visual metaphor that springs to mind here is the stitched-together polaroid images that David Hockney did back in the 1980s.
Or take a look at the panography images of the German photographer Mareen Fischinger.
So we have to make patient flow movement through space visible as well.
Flowopoly does this.
It acts as a springboard for helping NHS management teams work out what data they need in order to monitor and redesign their emergency care systems.
Duchamp said of his Nude Descending a Staircase painting that he was aiming for “a static representation of movement, a static composition of indications of various positions taken by a form in movement.”
But with Flowopoly we aim for a dynamic representation of movement, a dynamic composition of indications of various positions taken by patients as they move from one part of a hospital to another.
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