My first journal paper now available open access

My first journal paper of my PhD research was published last November. It was my first scientific paper ever. Although I have written many reports and papers over the past 20 years, writing a scientific paper was something else. It was a team effort of all authors. It was peer reviewed twice. It took a time: 1,5 year from first submission to publication.  This week I received an offer from the publisher to make it open access (for free). Good news, now people can now actually read it!

You can read or download it on the website of SAGE: https://journals.sagepub.com/doi/10.1177/0951484818813488. If this link does not work, then search on ‘Identifying logistical parameters in hospitals’ or copy DOI code 10.1177/0951484818813488 into the internet search engine.

This paper is about the logistical parameters that are used in research on hospital logistics. The aim of this research was to see what logistical parameters are mentioned in international literature. I was particularly interested to see which parameters were mentioned in relation to hospital strategy, because in my experience logistics and hospital strategy did not seem to go together (see an earlier blog).

To put it bluntly I hardly found anything on logistical parameters in relation to hospital strategy and on the operational level I found, well, maybe I should say, too many logistical parameters. There were 106 in total.

What are some practical lessons to be drawn from this paper?

Local and global logistical parameters 

One of the reviewers of the paper commented that it would be very useful to be able to draw some kind of framework from this, in order to present decision makers with a useful tool for controlling hospital logistics. That would be extremely useful indeed, I agree, but how on earth would that be possible? Not only did we find 106 logistical parameters, they were mentioned in the context of 92 very different subsystems of the hospital. I think we have to distinguish between local parameters – relevant in a particular context or department – and global parameters that have a hospital wide relevance and impact. It is related to the issue of the right ratio between integration and differentiation in a hospital (see this blog).

Define logistical parameters that are relevant for the context 

Another thing that struck me is that logistical parameters were not defined clearly (or not at all) in several papers. Throughput time and lead time for example seem to be used as interchangeable words, but are they really the same? So a first step towards any framework would be to define what is meant with these logistical parameters. A next step would be what norms are useful: when does waiting time become a bad thing? This can be valued in different ways in different contexts, subsystems or even situations. Frameworks therefore need some kind of standards, but also need to be flexible, that is: using different standards for different situations. Standards will have to be developed in the hospital practice and there needs to be a debate about them between the different agents in the hospital.

Find the relation between logistical parameters

It is important to relate logistical parameters to one another. We all understand that if there is no waiting patient in the holding, the utilization of the surgeon in the Operating Room will be low. So utilization and waiting time are related. That is easy. With 106 parameters this leads to a very complex model. But I believe it is essential for hospital management.

Optimization or balancing 

Most people want to optimize, to achieve the best possible result. In the over 1000 research papers that I read, in the individual studies researchers tried to optimize one or maybe two parameters. However, this optimization of one logistical parameter can lead to undesired effects for other parameters. It’s not just that we have to know how parameters influence each other, perhaps we need to balance parameters. I am not really sure yet how this should work, but it would mean something like getting all parameters at their most feasible optimum, in relation to each other.

 

 

Anesthesiology: a hidden logistics power?

When I started my case study research in the hospital, somewhere in the back of my mind there was this thought: I have been working in hospitals for over 10 years, so what more will I learn from this? Of course I did not really believe the answer to be ‘little’ – otherwise I would not have even started the research – but in hindsight I must admit it was a bit confronting when I realized that some things, I discovered in my research I had not known or seen before.

One of those things was the role of both the Anesthesiologist and the Nurse Anesthesist. First of all, about the name. When my paper – currently under review – was proofread, I had a discussion about the word Anesthetist and Anesthesiologist. In Dutch we say ‘Anesthesist’ or ‘Anesthesiologist’ for the medical specialist who is responsible for the administering of anesthesia to patients. In English the ‘Anesthetist’ can be either a doctor or nurse who has been trained to administer anesthetics. In Dutch we call a nurse who assists the ‘anesthesist’ an ‘anesthesie medewerker’ (which translates into something like ‘anesthesiology co-worker’). I decided to call this assistant to the Anesthesiologist the Nurse Anesthetist.

Although it is interesting that apparently the name and role of people involved in Anesthesiology is different in different countries or languages, the real eye opener was that both the Anesthesiologist and Nurse Anesthetist play an important role in the logistics of surgery in a hospital. The Nurse Anesthetist has the highest centrality in the entire network (see previous blog on nurses). He or she  – there are also a lot of men who are Nurse Anesthetist, as opposed to other types of nurses who mostly seem to be women – decides at what moment the patient is called to the holding and later accompanies the patient from holding to recovery. The Nurse Anesthetist overlooks the process from ward to OR and presents himself to the patient as his or her ‘guardian angel’ (OK, this is what I call it, because it sounded very comforting when in the holding they say something like: ‘hi, my name is Peter and from now on I will be with you the whole time’). Further, the Nurse Anesthetist represents the Anesthesiologist in the Operating Room (OR), when the Anesthesiologist is not there. In short, the Nurse Anesthetist overlooks the process of the patient, accross the walls of the Operation Room (Theatre).

With regard to the Anesthesiologist, he or she plays an important role in making sure that the day program of the Operating Theatre (OT) runs smoothly. Even though this is the prime responsibility of the day program coordinator, the program coordinator consults the Anesthesiologist to discuss last minute changes to the program and asks them on occasion to first consult these changes with the surgeons, before he does. The Anesthesiologist has an interest in a smoothly running OT program, because he works in two operating rooms at the same time. Any unexpected delays or lateness in one OR have an impact on the other OR that he is working in. This is inconvenient and not in his best interest. In addition to his own interest, the Anesthesiologist is more qualified to discuss medical matters with surgeons than coordinators, who are not medically trained.

So, Anesthesiologists and Nurse Anesthetists tend to look at the whole OT system on a day, rather than just focusing on administering anesthesia for one patient in the OR. This perhaps makes the Anesthesiologist a hidden logistics power in the hospital system for surgery or patients.

Postscript!

In response to this blog I was happy to receive feedback from Anesthesiologist Marcel de Korte of Maastricht UMC+ in the Netherlands, stating that the system of Anesthesiologists working in two parallel OR’s is a typically Dutch way of working. However, often, in other countries it is the Nurse Anesthetist who switches between OR’s and the Anesthesiologist who stays in one OR. He adds that nevertheless, according to his view, Anesthesiology plays an important role in OR logistics.