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June 6, 2017

Breaking the Rules for Better Care

Author Affiliations
  • 1Institute for Healthcare Improvement, Cambridge, Massachusetts
JAMA. 2017;317(21):2161-2162. doi:10.1001/jama.2017.4703

A few years ago, the Dean of the School of Business at the University of Leicester, Dr Zoe Radnor, tried to understand the reasons for the “bicycle book” that she discovered at an English hospital she was studying. All staff who arrived at work by bicycle routinely signed a register book at the front door. Hundreds of these registers, once full, had been collected and stored for decades in clearly marked boxes. “Why?” Professor Radnor asked. No one knew.

The answer took some sleuthing. The first books dated from World War II—when rationing of fuel was the rule of the day, and when any staff who commuted by bicycle thereby earned extra food ration credits for saving on gas. Now, three-quarters of a century later, the bicycle book process remained alive and well, embedded in the organization’s brainstem, not its cortex. It was pure waste.1