Yesterday I spent the entire day observing three outpatient departments in ‘my’ case study hospital. I talked to the Orthopaedics, Surgery and Gynaecology outpatient departments and watched how surgeries are planned and organized. The night before I prepared the visit by looking at the facts and figures – the production data of 5 years, from 2013-2017 – of these three departments:
- Orthopaedics has 6 operating people (operating orthopedists)
- Surgery has 30 operating people (surgeons)
- Gynaecology has 9 operating people (gynaecologist who do surgeries)
This all turned out to be fake information. There were 4 orthopedists, 11 surgeons and I don’t know how many operating gynaecologists, but it’s less than 7, because there are 7 gynaecologist who do not all do surgeries. How come the data were so misleading? I will explain with an example.
The 30 individual surgeons are coded in the data as follows: 00908, 00909, 00910, 00911, 00912, 00917, 00922, 00927, 00928, 00930, 00931, 00934, 00935, 01305, 05009, 42371, 509139, 509179, 509217, 509231, 509238, 509239, 509250, 509261, 509269, 509274, 509276, 509283, 509284.
I remembered that someone had said earlier that ’50’ codes were doctors-assistants (a doctor-assistant is a doctor who has completed his medical studies and is fully qualified, but not (yet) a medical specialist). So that leaves 13 people out in this case. I noted that some codes had a different structure than others: there are 12 009XX codes and some others such as 01305. And I found out that 42371 is actually a plastic surgeon.
For the other two medical specialities I did the same decoding of the data. For Gynaecology I could still not entirely work out the math. If there are 7 gynaecologist who not all do surgeries, then who are the 7 operators who have done a certain number of surgeries? That I will have to ask someone later in the process of this case study research.
OK. So the IT system does not really provide me with the right data. Well, the data are correct, probably, but they do not seem to provide the right information on the reality. I find it worrying, because many large strategic decisions are based on (high level) data.
This is nothing new for outpatient secretaries. They have realized for quite some time that the IT system is not perfect. They don’t really use the system for planning, just for registration. Although the IT system they use is provided by the market leader for hospital information systems in the Netherlands – Chipsoft, they do not use it for planning. All 7 secretaries I talked to independently stated that the system does not provide the overview they need to plan surgeries and that they have to bear in mind so many decision and control rules, that use prefer their own planning system. This system basically consists of their own brains and common sense. The tools they use look complety old-fashioned and obsolete. In fact, when they showed their folders, piles of A4 papers, paper diaries and whiteboards, they immediately started to apologize for their apparently middle aged methods. Some of these ‘tools’ had been used for over 20 years and were starting to fall apart. But, as they explained what the planning rules are that they use, their brains form a very advanced system. For example here are some of the rules they compile in their heads every day:
- For a TEA carotis call the Intensive Care for a bed and arrange an EEG and plan vascular examination one day before the surgery takes place
- For the combined PTA make an order for an X-ray
- If there are multiple shoulder prosthesis surgeries, plan 3 days in between these
- Doctors X, Y and Z are on a conference on dates A, B and C
- Staff meetings for the upcoming months are on times X and Y so don’t plan surgeries then
- There are only 2 instrument sets Y in the hospital so don’t plan 3 surgeries at the same time for which these are required
- The Radiology starts at 8:30 each day so if an X-ray is required for surgery do not plan this before 9:00
In total it was said that there are about 70 rules and planning principles, but I believe this is just the tip of the iceberg. I have seen around 50 to 60 on paper documents, in emails, on walls and so on, but with each new person I talk to, new rules are added to my list. I haven’t heard them all, I am sure.
It seems a bit odd: the hospital has a state-of-the-art IT system but it does not suffice for more intelligent stuff. Secretaries do the thinking using tools that look unsophisticated, but what they actually do comes accross as very sophisticated, not in the least because they are an important coordination node in a very large network of agents. Often they have worked in the hospital for years (10 to 20 years) and their experience is priceless. The software, on the other hand, is actually unintelligent, I would even say stupid, but looks advanced. Maybe we are fooling ourselves when it comes to what or who is believed to be smart.