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.

 

 

 

 

 

 

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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.

 

 

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. 

Regarding the hospital as factory

One of the fun things about doing observations in a hospital is that you see lots of unexpected things. When observing surgeries or patient consultations in the outpatient department I was introduced to doctors and nurses. After been told what my background was (systems engineer/consultant) some asked whether I was going to investigate how efficient they really worked (‘uh no, not really’). At the same time many classified their hospital as a ‘production hospital’. Based on this I got the impression that this indeed was a factory in which patients are treated in a smooth and standardized process. In the observations I was surprised that nurses and doctors were very much focussed on being on time and organizing tasks as efficient as possible, even when the circumstances obstructed this. This could be because I was there (you never know) but I don’t really think so, given the many times I was in the hospital. The more surprised I was when I analyzed the ‘production data’.

This figure shows the yearly volume of all surgery codes and how much variation there is in surgery time (standard deviation as a percentage of the average surgery time). First of all there are many surgeries that are performed less than 100 times a year (less than twice a week). There is one type of surgery that is performed over 700 times a year. Secondly most surgeries have a variation in surgery time between 20% and 60%.

Volume variability

Further I discovered that there are 187 unique routings for 10,000 surgery patients, from outpatient deparment to discharge from the ward after the surgery took place. There are 2881 unique combinations of medical instruments being used for surgeries and 7640 unique combinations of people participating in one surgery. 

This apparent variability is interesting because it does not seem to reflect the factory metaphor at all. In a factory such variability would be challenging (if not impossible) for mass production or even mass customization. According to Johnston et. al. [1] high variation and low volume processes require a high decision making autonomy and flexible interaction between people. This may be reflected in the social networks I made.  Lean and Six Sigma focus on standardization and variability reduction, an approach that fits a process with low variability and high volume, according to Johnston et. al. [1]. Following this reasoning perhaps lean/six sigma are not the panacea we are all hoping for.

However, this conclusion is premature. First of all we don’t know what causes this variation: is it caused by patient demand and/or caused by the hospital itself? Is the autonomy of doctors the cause or the effect of variation? Is variation avoidable or would we be able to reduce it? Another issue are the data; do the 394 surgery codes really represent completely different types of surgeries? Without central master data management for surgery codes, there could be multiple codes for the same type of surgery. If that is the case, then production volumes shown here are too low.  In conclusion, further research is recommended…..

[1] See this paper of Henri Boersma, Tiffany Leung, Rob Vanwersch, Elske Heeren and Frits van Merode

Surgeons: the hospital’s nomads

Surgeons lead nomadic lives in hospitals. Nomads have no fixed habitation and regularly move to and from the same areas (special thanks to Wikipedia for this non scientific definition, but for this purpose it will do). Surgeons travel between places that are run by nurses, in order to service their patients. Interestingly this type of nomadic life – travelling to where clients are – is seen among gypsies or Roma people, but these are not the first kind of people you think about when doctors are concerned. However, unlike nurses who mostly work from a fixed home base, surgeons move around the hospital. The only thing that comes close to home is perhaps the outpatient department.

In the social network of surgeons this nomadic way of life is not visible, as these networks do not take place and time into account. But you can see something else here. In contrast to nomads, we see in these networks that surgeons do not act as a group. Below you see the social network of one eye surgeon (left) and one general surgeon (right). The eye surgeon clearly has a different social network from the general surgeon. Surgeons do not travel in groups, but alone.

Netwerk oogartsNetwerk chirurg

Another contrast to nomads* is that wherever the surgeon lands he is the ‘primus inter pares’ or ‘the boss’ if you like, when it comes to treatment policy, whether to discharge a patient or how to care for the patient. This can cause an interesting tension between the people who run things at home (nurses) and those who walk by giving the orders (surgeons). From what I have seen in the hospital this appears to be an accepted and natural division of roles (this also includes making jokes or mocking about each other).

What intrigued me when observing these surgeons and analyzing their working schemes was the complete lack of a repetitive rhythm in it. Below you can see three graphs of three weeks. On the X-axis are the days and times of one week. The Y- axis represents doing surgery (1) or doing something else (0). The different colours represent the 5 different surgeons. Each week is different for each surgeon, both in number of surgeries as well as at what time and frequency they do surgery.

Rhythm surgeons

So, not only do surgeons travel all the time, they do so in a variable rhythm. Once on their destination they have to focus on complex tasks, having full responsibility for most of what happens in places they stay in temporarily.

As a consultant I have been involved in many building projects where the personal room of doctors was to be replaced by something like a shared backoffice. Even though it is true that outpatient rooms generally have low occupancy rates, I must admit I now much better understand the doctor’s resistance against losing that space. Without that – or some kind of informal group space – he or she could feel like a real nomad, belonging nowhere.

* I don’t know much about nomads but it is my impression that they do not particularly rule the place they stay in, in contrast to surgeons who (have to) take the primary responsibility and medical knowledge to treat patients.