Each stakeholder just cares about its own interests and tries to maximize the use of the common resource. Consequently, the common resource dwindles, in turn affecting the part of each stakeholder
This is the story of a FQHC in Northwest Texas. The surveyor found that many referrals were not closed. This finding was cited at previous surveys. There were no setup of the urgency or criticality of the requests for referrals. Each department provider just sent requests for referral to the referral team, which was overwhelmed. As a consequence, there was a backlog of referrals and there was not enough time to follow up each referral.