Einde noch begin

Transformation is like an invisible wind (the effects of which are perceptible everywhere) (Francois Jullien in Treatise on Efficacy)

Welkom op de website van Squrious. Sinds 2017 schrijf ik regelmatig blogs over mijn promotie onderzoek op deze website. Squrious is ook het bedrijf van waaruit ik sinds 2014 ziekenhuizen adviseer, onder de vlag van SQwin. Het label SQwin verdwijnt nu en  ik werk vanaf nu vanuit Squrious.  Kleine en grote veranderingen in de 10 jaren SQwin zijn er altijd geweest en de effecten ervan worden nu zichtbaar.

Er zullen vast nog meer veranderingen volgen. Ik wil mijn advies- en onderzoeksactiviteiten meer te integreren en ook nieuwe structurele en duurzame samenwerking realiseren met anderen. Veel blijft ook hetzelfde. Ik zal me blijven inzetten voor vraagstukken op het gebied van logistiek, capaciteitsmanagement, operations management en ICT in de zorg. Hoe ik dat als onderzoeker doe, is al te zien in de diverse blogs. Wat ik als adviseur doe, zal komende tijd op deze website verschijnen. Hoe en met wie, dat zal de toekomst leren.

 

 

5 tips for 2020

Since the start of this blog in 2017 I have written 36 blogs, which were read by over a thousand readers. So far it has been a very rewarding way of sharing findings and ideas related to my PhD research because I got in touch with a lot of new people and had nice and interesting conversations about it with people I already knew. Most of the blogs have had an analytic and observative character, but with the start of a new year, it’s time to share some tips on what to do with this in 2020.

1: Embrace complexity 

Complexity is about seeing an (or multiple) organization as a system of interrelated and interacting elements. Often in hospitals a system perspective is perceived as similar to viewing a hospital as a factory, with patients as products and doctors as robots, something completely standardized, but inhuman. During the observations in my research nurses or doctors I was observing more than once said to me: ‘oh, are you going to assess how efficient we work?’ This is not what a system perspective is about, or should be about. It is about knowing how the hospitals works, what for example happens when the capacity planner is on sick leave, what happens when the Central Sterilization Department is outsourced or how we can organize work for doctors and nurses in such a way that they perform at their best. The social network analysis for example clearly shows that if the three hospital coordinators are absent, then the coordination of surgeries, beds and materials will probably be much worse, leading to cancelled surgeries and long waiting times for everyone. It also shows that hospitals are not coordinated by managers so when they are not there, little goes wrong in the short run. It shows that simply moving out a part of the network and outsourcing it to somewhere else, without wondering what the interactions are about, is a stupid idea. The hospital system works when specialised people with skills and knowledge interact well, when IT systems and spaces are connected and so on. Knowing the complexity, accepting, or even embracing this, is important.

2: Accept the reality in order to change it

You now may think that I believe outsourcing is bad. Well, I don’t. Sometimes it has become a reality, as a result of one thing or another. It can be the best idea given the circumstances. Mergers are another real phenomenon that are often debated in terms of good or bad. Although we know from research that mergers do not lead to better performing hospitals, as it appears, mergers are also a reality. Simply debating if it is a good or a bad idea, is a bit pointless when it already happened, but arguing it is best for everyone, is nonsense as well. So, when a merger happens, make sure that the new system stays coherent and people stay or are connected. Sometimes there is a tendency to focus entirely on the new reality, trying to break from how things are now, thereby losing the coherence within the system. Preserve what is working well. Again, you need to understand and like to know the complexity. You may not like complexity, and I agree it can be overwhelming. Therefore tip 3 is important.

3: Make simple what can be made simple

It may sound as a contrast to complexity, but making some things more simple is an important prerequisite for better performing hospitals. For example data should be managed. It may not be the most appealing task – most people want to manage people, not data – but it has to be done. If there are five different names for every surgery, material, room or function in the hospital, complexity becomes a monster. It is like American, German and Chinese people working together, without a common language but still pretending to understand one another. It sounds a bit surreal, but I have seen it happen often.

Further, doctors and nurses are often not the best at data management – and why should they be. Instead of leaving it up to them and then blaming them for having no discipline or being sloppy about it, we have to help them getting this sorted. There are plenty of other people who excel in structuring large data sets and who appreciate doing this important task. Hire these people and let them service those who coordinate hospital logistics and capacity management (i.e. nurses, doctors, hospital coordinators).

4: Debate and reinvent hospital leadership

If those who manage the hospital do not have strong links with the operational system nor are they central in the network , as shown by the social network analysis, there is a serious risk of disjointed strategy and operations. Central agents in the network (see last year’s blog on this) have no formal hierarchical position but are actually leading the network, at least to a certain extent. This too comes with risks, in case these people are not informed or aware of the strategic impact of what they are doing. I think it is one of the major important challenges for hospitals to connect or even better, align strategy and operations. We have to move away from the traditional hierarchical structure thinking, as this does not reflect how leadership in hospitals works. This is not a new thought- and a lot has been written about it – but in practice, in my experience, for some reason people still act as though this is the way things work. We need management to overview the network, to see from the top of the mountain how things are (not) connected, to make sure that connections that are needed are there and that cooperation is effective. In that case they participate in the network as a sort of lookout high up the mountain. And if they ever feel like nobody is paying attention to what they are saying (as I guess hospital’s managers must be feeling like sometimes), perhaps they are too far away. A motto like ‘if you can’t beat them join them’, may be helpful. So go down into the valley to make the right connections!

5: Tips always come in fives but I have already reached my limit-for-the-maximum number-of-words-in-blogs. So I will finish off with wishing you all the best for 2020. Hope to be in touch in the new year!

Why Material Management is (unfairly) overlooked

For two days a week in the past 6 years I have been working on material management as a consultant, in various Operating Room Theatre complexes. During this time I have been thinking and talking a lot about bills-of-material, storage capacity and layout, inventory levels, transport carts and all sorts of materials that I had never even heard of before. I don’t think I am exaggerating when I say Material Management is a largely ignored subject in hospital management. You may think: but hey, as a consultant you are being paid to work on the matter by at least someone! Point taken. The main reason I have been working on it, is because new hospital buildings are built smaller and storage space for materials is decreased – or even left out – and Just-in-Time has to do the magical disappearance trick. But as I am not a magician nor is anybody else who is involved with this subject, this material stuff easily shifts from a spatial puzzle into a wicked operational problem. The thing is that materials seem to be everywhere as soon as you start paying attention to them, not just in numbers, also in cost. And they come in all sorts: beds, gasses, medical equipment, linnen, food, medication, implants, blood samples, medical instruments, medical consumables, OR tables, uniforms, waste of all sorts, to name but a few. Someone once told me that the logistical network of a hospital has more links than the worldwide logistical network of a multinational like Cisco.

I think that might be true – I modelled several hospital networks and found thousands of distribution lines – but the funny thing is that, from my research, I now better understand why material management is somewhat overlooked. In my research I almost forgot about it myself. In this series of blogs I wrote about nurses, surgeons, secretaries, anesthesiologists and coordinators, but not about materials. Communication on materials is somewhat invisible in the big spaghetti social network diagram shown in the blog on nurses. Of the 31,499 communication links between the 635 people in the network only 134 are about materials. So if you have 99,6% communication links about people – patients and staff – , it makes sense that materials are not really in everybody’s top of mind. It’s not really anyone’s business. People in hospitals often say: materials just have to be there. And yes, materials are usually there, in great piles of inventory, disguised in hundreds of storage rooms, carts and cupboards and, ironically, still not always on time at the right place. But this comes at a cost. Approximately 40% of the total hospital cost relates to material management, according to literature.

Besides its cost, there is another reason why paying attention to material management is so important. Instead of anybody’s business, it’s everyone’s business. Besides a handful of material logistics workers, outpatient secretaries, surgeons, OR nurses, ward, holding and recovery nurses all deal with materials. Materials are ordered, stored, searched, picked, collected and prepared, in particular by nurses. In these times of high shortages of trained nursing staff, the major issue is to get Material Management tasks off their plate and have logistical professionals do the job. In order to succeed in this, Material Management must be made visible, even when that initially feels like tidying up an enormous attic (or rather, hundreds of them) or receiving shock therapy when reality, i.e., the cost of material management, really kicks in.

 

Getting to the top with peer review

Last week Japke-d. Bouma, a Dutch column writer, stated that in order to be happy you don’t always need to go to the top. She got the advice from a wise man saying that the view halfway also brings you happiness  (for Dutch readers here is the column). A feel good phrase putting things in the right perspective I thought. In that same week received the reviewer’s comments of my second paper and I thought, well, maybe I am halfway the mountain….

I like mountain climbing – not the insane or heroic Mount Everest type of climbing – but just walking up the mountain in the area I happen to be in (which is always abroad because in the Netherlands we don’t have mountains). When climbing I always want to go to the top, not to test my condition (this is the mostly disappointing part of the experience) or to act heroic, but because of the view. I really love to have an overview of the area, I want to see it all, not just one side of the mountain, but also the other side. I simply love to stand on a top of a mountain and look around. That is why I need to go to the top. I also like making the effort to get to the top: I once took the elevator on the CN Tower in Toronto and enjoyed the view, but this experience does not stuck in my mind like the mountain climbs I have done.

Back to the review comments. When a paper is finished you think you have reached a top, you’ve read the literature, done the research, (re)written the paper, had it proofread and then you think you’ve seen it all and it’s finished. It took me about a year to finish the paper on social networks. After submitting it to a journal you leave it for a while and by that time you have forgotten you even submitted the paper – 6 months later – the reviewers point out to you that there are other mountains in the area you perhaps may have somewhat overlooked. In the case of this paper on social network analysis one reviewer asked what other social network analysis had been done in hospitals. Good question!! I searched the university library database for in ‘Hospital’ and ‘Social network analysis’ and yes, there have been studies!! There are few – a low mountain perhaps – but they are worth looking at. There are two literature reviews that provide a nice overview of social network analysis done in healthcare:

  1. Benton DC, Pérez-Raya F, Fernández- Fernández, MP, González-Jurado MA. A systematic review of nurse-related social network analysis studies. International Nursing Review, 2015; 62: 321-339.
  2. Chambers D, Wilson P, Thompson C, Harden M, Coiera E. Social Network Analysis in Healthcare Settings: A Systematic Scoping Review. PLoS ONE 2012; 7, e41911. Online this is available here (open access).

In these papers several examples of social network analysis in hospitals are mentioned. Not one is related to the complete logistical system of hospitals, but there are other interesting studies that present findings on how network structure impacts the hospital’s performance. For now, I will continue working on the revision of my paper, because if you want to see it all from the top, you need to get to the bottom and then, up again.

 

 

 

 

 

 

Hospital operations: finding the rules of the game

Some days doing research gives you the feeling it is going nowhere. Then there are simply not enough hours in a day, not enough energy, concentration, memory or brain capacity to take it all in. Today is such a day.

I am trying to structure the rules of planning surgeries. Or rather, I am trying to figure out how the people in the hospital allocate time and space to hospital resources – surgeons, anesthesiologists, nurses, equipments, materials, operating rooms, beds and so on. They do have standard procedures. A lot of standard procedures. Medication protocols, time out procedures, planning procedures, MRSA procedures. These are procedures everyone seems to know without writing them down. It’s something like my household protocol. I don’t have it, but still me and my family know how things are done. I have breakfast every day, at a certain time, each family member has their own standard food etcetera. The  difference with hospital protocols is that while most people will know that I eat breakfast, as it is quite a common thing to do, hospital procedures are only known to a small group of people. In order to get a grip on the way things work in the hospital I could not ask one or two people, but studied 55 documents, did 16 days of observation sessions, 25 interviews and afterwards sent various hospital staff members emails or whatsapps on details that I, after all this, still did not understand (wondering on occasion if I was clever enough to ever be able to know how it all worked…)

The data have been collected now, I am quite sure of that, but structuring these data is a new challenge. It takes more days than I had ‘planned’. Which is probably the whole point: for hospitals planning is probably like that as well. Life is what happens to you while you’re busy making other plans, as John Lennon said.

The thing that makes this research feel like Sisyphus labour, is the fact that the standard way of working has so many ‘standard variations’. For example:

  • Medical disciplines get standard slot times for surgery, but there are multiple ‘standard’ slot times defined (i.e. from 8.00 to 10.15 or from 8.00 to 12.00 or from 9.15 to 11.35 etc etc) , different per medical discipline or day or time or operating room. So there are around 20 different ‘standard’ slot times.
  • Trauma surgeries are done by trauma surgeons, but not on Tuesday’s once a month. Then Orthopaedic surgeons do this (but only on parts of the body that orthopaedic surgeons can fix of course!)
  • If the waiting list increases, more surgery time is given to medical disciplines, but only if they have used their OR time slots well in the past and they show good cooperation towards the collective
  • Resource use should be 85%, but not for Eye Surgery, for them 75% is good enough
  • Emergency surgeries are planned in the elective time slots (there are emergency time slots as well) when it concerns patients who do not show up in the Emergency room in the past night or today (or other reasons I have not found yet)
  • Some people mention that it is standard to adjust standard surgery time. A sort of meta standard!

This too is like having breakfast: on Mondays I eat breakfast at 7 am because I have to travel to work at 7.30 am. On Tuesdays I eat breakfast at 7.30 am because I always stay in a hotel for work and breakfast is served from that time. On Wednesdays I have breakfast later, whenever I feel like it, because I work from home, on Thursdays I take my son to school so I have breakfast at 7.15. In holidays all days are different, whenever I have meetings or special occasions the standard procedure changes as well. It is a variable rhythm, though stable over time and dependent on rules that are logical. It makes sense.

For the hospital I have hundreds of these type of rules, 24 pages full at the moment. So, yeah well, I don’t know where this will end. What I have seen in the hospital is that the people who work there mention the rules as though they are perfectly sensible and normal. They have often worked in the hospital for 15 to 25 years. They have variable rhythms but know the rules and principles behind them. Not everyone in the hospital knows all the rules , but they have learned to recognize patterns and mostly deal with this complexity. I find it fascinating, but I am struggling to find a way to write it all down in such a way that it becomes something as simple as having breakfast.

 

 

 

The hospital coordinator: broker, negiotiator, educator, pedagogue, administrator…

In the series of blogs on who is running the hospital, so far I have talked about nurses , surgeons and anesthesiologists. They all have coordinative tasks. Besides these agents, there are three people in the hospital with perhaps the most important position of all.  Let’s call them John, Anne and Nikky. It does not feel very ‘scientific’ to write about three specific people, but since they are the most important people when it comes to integrating the hospital’s operational system, I think it’s good to write about them. Who are they?

John is the Operating Theatre (OT) day coordinator. He makes sure that every day all planned and unplanned surgeries are executed, without delay. In preparation to this day, he makes sure that materials are ordered with suppliers, schedules all OR nurses and nurse anesthetists for the day program of the OT. When people call in sick, he reschedules, when emergency patients arrive, he puts them into the OT schedule, when equipment needs maintenance, he decides when this is best done, when he foresees surgeries running late, he discusses the options with anesthesiologists and surgeons, when a Radiology image needs to be made during surgery he arranges this with the Radiology department. He is the control centre of the OT with a time horizon of 2 weeks before surgery until (and including) the day of surgery. He is in touch with all OR nurses, nurse anesthetists, holding nurses, surgeons, anesthesiologists, outpatient secretaries, OT manager, OT team leaders, central sterilization and radiology staff. He is the most central agent in the network.

Ann is the OT capacity planner. She has a similar job as the OT day coordinator but her time horizon is larger.  She is involved in making the OT master schedule, the clinical bed plan, in planning patients from 6 months until 2 weeks before surgery takes place. She checks whether all conditions for surgeries are met, from preoperative screening to the number of MRSA patients on a surgery day (plus hundreds of other conditions). She decides on the order of surgeries for one day, but is also the one who can shift OT sessions from one medical discipline to another, like a sort of trader. She interacts with outpatient secretaries, surgeons, anesthesiologists and is the link between outpatient, clinical departments and the Operating Theatre. She also has a central position in the network and works closely together with John.

Nikky is the clinical bed plan boss. That is not really a formal function, people just call her that way. She is a secretary of a nursing department who wanted to help out making things work better. She took up the task of controlling the clinical bed plan of all nursing departments. This means that she has to make sure that no one takes a bed that is not meant for them and when someone is short of a bed, she arranges it. She is in touch with the outpatient secretaries and the nursing department team leaders. But, most importantly, she works closely together with the OT capacity planner, who does have a larger reach in the network. Since this month her job has become formalized, after having practically invented it in the past year.

One of the things these three people have in common is that they do not have any formal authority towards others. Their effectiveness depends on persuasion, negotiation, being liked or feared – whatever works best -, on how well they debate with or educate people, continuously following different strategies for different surgeons, nurses or anesthesiologists.  They have no mandate, sometimes to their own frustration, but on the other hand they can act somewhat under the radar and influence the network as a lot of information flows via them. They are not invisible, but do not draw all the attention (and resistance) because they are approachable. They are not ‘the big boss’. In social network analysis terms, they are the brokers (if you like you can read social network for dummies here to explain a bit more about social networks). It requires special skills, that (I guess) can hardly be trained.

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.