Characteristics of OR logistics

In many other industries outside health care, it is argued that well-functioning logistics positively affects the operations of an organization. Logistical optimization has led to cost efficiency, quality improvement and customer satisfaction. It is argued that this can also be applied to hospitals. But, to what industry should we compare hospitals?

Logistics in fruit supply chains is different from logistics in offshore companies. Newspaper logistics has similarities to fruit logistics because the product has limited shelf life. Logistics of mail is very standardized because it is a simple product, but the volume is large which makes it complex in other aspects. In short, there is no such thing as one logistics concept for the commercial industry.

My first data analysis in the case study research was aimed at determining what was the nature of the ‘product’ of the OR. It is the surgery on a patient. Some key figures for the hospital I am currently looking at are:

  • Over 12.000 surgeries per year, with top specialties being Surgery, Orthopedics, Ear Nose and Throat surgery
  • Around 350 different surgeries

So on average each surgery is performed 34 times a year. But the distribution in frequency of surgeries is not even. There are over 260 surgeries that are only performed less than once a month. Only 2 surgeries are performed daily,  an average, and 23 surgeries are performed once a week. In short, many surgeries are not performed on a very regular basis, while a limited number of surgeries are more common. At least, that is what the data tell me.

Another indication that we are not dealing with a mass product here, is the fact that over 100 surgery types are only performed by one specific surgeon. It could be that these surgeries are rarely performed – and therefore only one surgeon has done these – but there are 59 surgery types which are performed on a regular basis, that are also only done by one specific surgeon. Probably he or she is the only person who can to the job. For the other 250 surgeries several surgeons have operated patients, but still this could be done by little as two different surgeons. Apparently we are dealing with a very specialised job.

What does this mean for logistics? First of all, the knowledge required to prepare and organize the surgery is concentrated with a few people. Secondly, the resources to do the surgery are scarce. If the surgeon is not available at the right moment, this will have impact. And let’s not forget the patient; if he or she is not there, or is not in the right condition to be operated, the whole plans fails as well. Having the right patient, doctor, nurse, materials on the right time and moment in the same place, that’s the challenge. And it appears that no one day is similar to the one before.

I counted a minimum of 20 different people who make preparations for that one person who needs surgery, some of which are unique resources required for that specific type of surgery. So we are dealing with highly specialised, sometimes ‘one off’ services that can be provided by a large number of scarce resources. I am wondering in what business that logistics challenge is similar.

I am thinking of offshore platforms that require very specific parts to be shipped to a far away place at sea, with unpredictable conditions. I worked for a large offshore company once; they too organized their logistics in very specialised units, all focussing on a specific part of the platform. They did not communicate or coordinate activities between departments, resulting in one missing essential part that had to be flown in by a helicopter. We advised them to set up a logistics department that would coordinate all logistics activities. In hospitals this is also introduced, for example by using concepts such as Integrated Capacity Management, which aims to coordinate patient planning accross departments. However, materials are often no part of this, but this too should be coordinated in coherence with patient flows. I am wondering if there is an industry where both people flows as well as materials are organized in coherence with one another. The aviation industry? Train transport? Sure, these are people logistics processes – and much to learn from these. But the ‘product’ of service these industries offer is much more standardised than doing surgeries. Perhaps we need to develop a logistics concept for medical specialties, inspired by other products or services but not copy these.

Observing the nursing department

Last week I observed two nursing departments while preparing several patients for their surgery. In the morning I was linked to a nurse on the day care department. Together with another nurse they were responsible for guiding and preparing 10 patients for surgery for that day.

I have modelled many hospital processes over the years and they, when its done to gain overview, we tend to simplify these. The patient process of an OR patient can be very synoptic going from admission to the nursing department, to the holding, OR, recovery and back to the nursing department. Sounds easy right?

Taking the perspective of a nurse the process is something like this:

  • Intake patient 1
  • Intake patient 2
  • Premedication patient 1
  • Intake patient 3
  • Talk to partner of patient 2
  • Take patient 1 to holding
  • Premedication patient 3
  • Premedication patient 2
  • Answer questions of partner of patient 2
  • Take patient 2 to holding
  • Collect patient 1 from recovery
  • Take patient 3 to holding
  • And so on…

These steps can have a different order on every day. All process steps are related to several patients and are related to different stages in the process. These steps are not planned, but depend on telephone calls from the OR. Every 5 minutes the phone rings with a message that patient X or Y can be taken to the next stage of the process. Nurses have an idea of when to expect what step, based on experience. The logistics that these nurses do, is very agile. In quiet moments they prepare for what they know will come – only the moment is unknown. They prepare medication, print information sheets for when patients go home etc.

Again, just like on the outpatient departments, the logistics is organized locally: that means it is planned for the space one can oversee: a hallway with a number of nursing rooms, mostly being one department. There is constant communication between nurses on where they are in the day scheme and how to reallocate tasks. It is dynamic realtime planning without any tools. Disturbances from outside their own space are every day’s business.

It also became very clear that an important data source for the logistics process is the patient. The condition and preparation of the patient determines how smooth the process will go: nervousness, whether the patient has followed all instruction on intake of food (no intake), medication, has he or she been recently ill, how thick is their blood are but a few factors that influence the process of that day and nobody really knows beforehand what to expect. Again, this requires agility and the nurses I observed are constantly busy sensing and observing what is going on in their environment and act on it. Sometimes so much unexpected things happen, that they feel they aren’t able to take time for the patient or listen well to their thoughts or worries, they said. It reminded me of being unable to listen to my kids on busy days; when you are constantly arranging things or making plannings in your head, there is no ‘mindful’ way of dealing with the people around you. And what I found out as well: nurses all walk very fast. It does not look that way, but each time I walked along I could not keep up with them….at all.