I'm reading a book at the moment. Actually its more of a manual than a book and it's called "Making Hospitals Work: How to improve patient care while saving everyone’s time and hospital’s resources". It tells the story of a fictional hospital and its new CEO. The CEO doesn't have any NHS experience but comes from an industry where they worship at the alter of "lean." The hospital in trouble. The CEO has been appointed by the board to turn the ship around. The troubles are not new or surprising. Patients waiting too long in A+E, delays to ward discharges, longer length of stay, medical patients on surgical wards, cancelled operations and so the list goes on. These are very familiar to anyone who has worked in the NHS. The manual tells the story of a the lean approach to assessing and making changes. Now I haven't finished the book but what strikes me so far in its analysis is the large amount of wasted time which occurs in the NHS. We are constantly waiting for things to happen, duplicating work (patients re-clerked and reviewed multiple times during admission) and dealing with huge amounts of apparent inefficiency.
The book make you start to think about you own experiences and practice and here is an example.
Its a Saturday afternoon and I happen to be in my office catching up on paperwork, The phone rings and the caller display flashes up a colleagues name. "I wonder if you can help us" he starts, "we have a patient where we suspect a pericardial effusion. The patient needs an echo, we tried to refer them elsewhere but there are some administrative difficulties." I stop him at that point because although they don't know I am in the hospital the decent thing is for me to just go to the ward and do the echo myself. This is good because it saves the patient being transferred and it gets the test done soon. Better patient care, consultant delivered, on the weekend - no argument with that.
So I get the machine, go to the ward and do the echo. There is a large effusion - it needs to be drained. The patient is transferred to the coronary care unit and while this is happening I scurry round CCU to find all the bits of equipment I need.
First a metal clinical trolley - I can't find the large one we usually use - no one has seen it. Then we find it acting as a stand for a "clinical wipe warmer". No I hadn't heard of that either but I guessing clinical wipes are a bit chilly on the skin so the patient experience is better if they are warmed before use. The pericardial drain set comes in a nice sterile pack with a bag and other bits and pieces so that is good but I also need other things. A sterile gown, sterile drapes, green needle, 50ml syringe, 10ml syringes, a silk straight needle suture, sample bottles, lignocaine and a dressing. I have to locate all of these items. There are spread throughout the ward in multiple locations - the clinical room, the sluice, the store room, trolleys on the ward, a hidden cupboard. It takes time, the Sister, feels sorry for me, helps but even she's not sure where some of the things are. We start talking.
"Who is responsibility for stocking up?" I ask, "Well it's all of our responsibility" she says. "When the stock arrives who deals with it?" I ask, "Well whoever is on duty is supposed to put it away" she says. It's clear I know very little about how the ward actually operates but In my experience anything that is everyone's responsibility rapidly becomes no ones responsibility. It makes me see how the nurses must think of the doctors as a bit like guests in a hotel who visit for short periods, use the facilities but don't know anything about how the rooms get cleaned or the toiletries get replaced or how any of the supplies are ordered.
I start to think about the lean manual I am reading and the what if questions begin? What if all the things I needed for my drain were in one clinical room? What if every clinical room on every medical ward in the hospital had the same layout with the same stock in the same places? What if the labelling systems were the same? What if there was a person who visited the ward twice a week to stock take, restock and organise these rooms? What if the stationary on the ward was in standardised cabinets so I didn't have to look though 3 filing cabinets to find the consent form. The amount of time wasted looking for things would be reduced. More time could be spent on direct patient care. I suspect that stock control on the wards is not as efficient as it should be and my what if might even save money by reducing the amount of waste and over-ordering. This isn't rocket science it's just common sense so why aren't we doing it?
Dr Richard Bogle
The opinions expressed in this blog are strictly those of the author and should not be construed as the opinion or policy of my employers nor recommendations for your care or anyone else's. Always seek professional guidance instead.