Open Kitchen Science

Today I was at a meeting with a bunch of scientists who (want to) do research in an open way, in some cases as a guest of a university, in some cases outside the university or as part of the university. It turns out that the university is not heaven on earth for everyone and competition for funds is fierce. It was estimated by this group that the time spent on applying for funds and teaching takes up to about 70 to 80% of their working time. And then there is the fierce competition between scientists that some have experienced and that stands in the way of collaboration.

I was unaware of this. I fund myself through my consultancy work and the University of Maastricht is hosting me for my PhD research. I work with a great team there and am very grateful for it. I have not experienced fierce competition or university politics, but that could be because I am almost never there. In the Open Kitchen Science group, as we call ourselves, most people are very motivated to change the research world from a closed, competitive environment into a more open, accessible and fun place to be. It is inspiring to hear their stories and I have come to realize sharing my way of doing research might be a good thing.

I have been doing PhD research since 2015. Half of my week I work for hospitals, advising them on hospitals, building (re)design, IT systems and such (see http://www.sqwin.nl on what we do). In the other half of my week I work on the PhD research.

I have not been very outspoken about my motivations for this PhD research. In my private life not many people even know about it (or perhaps they have forgotten about it when I told them three years ago…’still doing that?’ yep). I have started it as a hobby (‘other people ride a horse, I do a PhD’) or voluntary work (because it’s useful and work, but unpaid). The main reason to do it, was that I wanted to have an intellectual challenge and work with inspiring people who share an interest in hospital logistics and management. I wanted the topic of logistics to become part of the strategic hospital agenda, because it was my impression that a lot of money is wasted in hospitals, while health care costs are increasing like crazy. I worked on numerous (re)building hospital projects with disappointing results or high cost because no attention was paid to logistics processes in the design phase. I was involved in one of the largest failures in Dutch history of implementing a hospital wide information system in the Netherlands, because the system did not meet the basic requirements of hospital processes (well, OK, history of hospital IT systems doesn’t go back ages but still..). That was frustrating. I got convinced that this was not the failure of a few silly or incompetent people, but there seemed to be a systematic and structural problem. I have worked on numerous great and successful projects as well, but nevertheless I thought that a new approach toward hospital operations, redesign and transition issues was needed and important. It should be based on principles from the field of logistics, operations research, organization theory and system theory. And the approach should include a lot of data analysis, not only because would we be able to know more about the hospital system and experiment with it in computer models, but it is the only way to make health care professionals (doctors and nurses) participate in the change. They can be convinced using data. Another thing is that these data should be easy to communicate about, so health care professionals and management would be able to quickly understand it or even better, they would be able to design their own effective hospital.

I thought, if there is little awareness for this topic in hospital boards – which was my impression -, through research I might be able to create it. And, to be honest, my ideas on how to do things differently, needed to be worked out. Once I started writing down my ideas and work out concepts, I discovered that what was on my mind, was not clear and good enough. By doing a PhD I committed myself to find out, in a more rigorous way, what hospital logistics is or should be about in relation to large scale hospital transformations.

For me it was relevant not being paid for it. Nobody offered payment, so it has not been an option either, but I see it as an advantage, because it means freedom and independence. As a consultant you are always of service to the person or institution who pays you. It is a fair deal and it surely has other rewards besides being paid for it; for example when a client is really satisfied that you have solved his or her problem. But it also limits pursuing your own ideas or answering questions that have not been asked. And like in every commercial business, time is money. I am often hired to solve a problem with the deadline being yesterday. I understand it – it’s part of consultancy life – but sometimes you want to think things through better. To me research feels like heaven in that sense.

 

 

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Social network analysis on hospital logistics

In the past weeks I have been wondering what the next blog could be about. I have been working on social networks over summer and there is (too) much to say about that and at the same time I have questions on how to use these networks. I could probably blog 60 pages easily but that is not the idea of a paper, let alone a blog. So here I will just start with something.

In the figure below you can see what I found in the case study research with regard to the interaction required for tactical planning of resources required for surgery patients. Every node is a person and every tie represents some kind of communication taking place – either verbally, by email, telephone, whatsapp – between the two nodes. It’s a qualitative model, in the sense that ties do not represent communication frequency. I colored every person according to the organizational unit they belong to. Red is Operating Theatre (OT), blue is medical staff, green and purple are a care departments. There are 134 nodes and 875 unique ties in this network.SNA tact planThere are five tasks in this planning phase; making the OT schedule is the most important one since all other tasks depend on this schedule. In the OT schedule the time slots and operating rooms are allocated to nine medical disciplines. The OT schedule is the result of a collaboration between the OT capacity planner, OT manager, two cluster managers and surgeons from medical discipline and an anesthetist. In the social network this is visible right in de middle. Around the middle various groups of people are visible; these are the surgeons of each medical discipline and the group of anesthaesists. They make their own working schedule, in collaboration with with the secretary of the outpatient department they belong to. Other derivatives of the OT schedule are the OT nurse schedule (visible on the top left) and the clinical bed plan.

Different people probably see different things in the image. What I see is that the OT capacity planner (OTPLAN) is central to the entire tactical planning. Without this one person, not all subsystems who perform a subtask, would be connected. The surgeons who represent their medical discipline group and the anesthetist also clearly have an integrative role in this planning phase.

A measure used in social network analysis for this is ‘Betweenness centrality’. It is a measure for how important a node is in providing a “bridge” between different parts of the network. It highlights the nodes that, if removed, would cause a network to fall apart.  Interestingly enough management plays a less central role in this network than the surgeons and the capacity planner. The top 10 of people with highest betweenness centrality are (1) OT capacity planner, (2) the OT team leader, (3) the OT day coordinator followed by the anesthaesist and surgeons who participate in the process of making the OT schedule.

Integration and differentiation in hospitals

In December last year I wrote a blog about the review of my first article. In this first article I described 106 logistical parameters, which I found in international literature. In the majority of the papers I had read, the focus was on one particular parameter – resource utilization or length of stay for example – and the minority of the papers considered looking at the hospital as a whole.  In my selection of almost 300 papers I identified 95 different parts of the hospital that had been researched. Among these were the OR department, the IC patient process, the process of blood samples and so on.

This showed fragmentation of logistics in research, while at the same time many researchers claim that there should be more integration in healthcare. In our first revision we described integration as coordination and cooperation between entities that function together as a unified whole. Last week I received the response of the reviewers on this first revision. The main theme they wanted discuss was ‘integration’: what it is and in what way does it relate to logistical parameters.

Integration is a very interesting and relevant issue I think. People working in hospitals – in the projects I am involved in – often talk (and complain) about the lack of collaboration and communication between the various people and departments in hospitals. But the adverse is true as well: a lot of effort already goes into meetings to talk things through and create common ground for changes in hospitals. For example, in the design and building of a new hospital  I was involved in some years ago, we had around 150 meetings with groups of future users of the building, in a period of about 1,5 year. The contractor, who built the hospital, found this number of intense meetings (they lasted for about 2 hours each) pretty insane and would probably say too much integration effort was going on. Others would still claim they had not been involved enough in the process of designing the hospital. So the question is when integration is ‘good’ and needed and in what cases differentiation is required to be able to work effectively?

This is the central theme in the work of a paper called ‘Differentiation and Integration in Complex Organizations’ by Lawrence and Lorsch, a classical work according to my professor, published already in 1967, but new to me. I found it very interesting because this research, done in the chemical processing industry, shows that both integration and differentiation are required for organisations to perform well. In this research it is stated that an organisation consists of subsystems, that each execute a part of the overall task, in relation to the (sub)environment of the (sub)system. Integration is defined as ‘the process of achieving unity of effort among the various subsystems in the accomplishment of the organization’s task.’ So subsystems have their own tasks and relate to their own environment – say  for example the Purchasing department relates to hospital’s suppliers and the Board of Directors relates to the local or national authorities – and they would need to be unified to to achieve overall effective performance of the system.

The next step is to describe, based on the case study research I have done, what are the subsystems in a hospital, how they collaborate, integrate or not and whether this is (seen as) effective.

Surgery patients: standard or unique cases?

Over the past months I spent 14 days in the hospital for my case study research. I met and talked to more than 50 people, directly or indirectly involved in patient surgery and watched over 20 patients who were at some stage in the process towards having or having had a surgery.

There are a lot of things that struck me. I was surprised by the variety of surgeries they do, given the fact that this what they call themselves: a production hospital. The hospital did 350 different surgeries in 2017 of which only 34% was actually done more than once a month on average. So that means that 66% of the surgeries is once a month or less. In interviews I asked hospital staff how I should interpret this. Is the variety of surgeries really that large and what does this mean for the predictability of these surgeries?

People confirm that the variety of surgeries is large, although if you look at the variety per medical specialism, this is not perceived that way by everyone. The fact that there are 9 medical specialisms in itself illustrates that. When I look at the list of surgeries, the average surgery times and variations, it seems hard to identify similar surgeries or groups with similar logistics characteristics. Outside hospitals logistical families for product types with the same characteristics are defined, but I do not know these for surgeries. When looking at the list of 350 surgeries together with people working in the hospital  this complexity was somewhat put into perspective, because they know what  surgeries are ‘standard’ or what are the less predictable ones. From a medical perspective ‘easy’ is seen as part of a routine, from a logistical perspective this ‘routine’ might be judged differently. And the type of surgery is not the only determinant for how the logistics should be organised. For anesthesiologists the condition of the patient determines the way he or she is treated. So even for standard surgeries, the specific case of a patient is a factor that can make the surgery less standard.

What does this mean for the logistics of surgery patients? The logistical task is to get the right patient, the right surgeon, anethesist, materials, equipment and OR nurses together, at the right place and moment. Looking at the data of all surgeries in 2017 hardly  a ‘standard’ combination of  resources was used for one surgery. About one third of the surgery types is performed by one specific surgeon. Looking at medical instruments, there are over 2,500 unique combinations of instrumental sets used for the 10,000 surgeries that took place in 2017. In total over 70% of all surgeries involved a unique combination of surgery type, surgeon, anesthesist and instrument sets.

This impression of surgeries being unique cases, could have multiple reasons. The variation of instrument sets could be for reasons of customization, either with regard to the patient or the surgeon. It could also be for reasons of scarcity: if instrument set A is not available instrument set B is used instead. The fact that surgeries are only performed by a small number of specific surgeons could be because this is the way it is planned – the surgeons doing the most of a specific surgery are picked first – or that surgeons are really that unique in skills or experience that this a specific surgeon is required for quality reasons. These data implicate a high degree of customizing – that every case is almost unique and requires specific scarcily available resources – requiring the logistical network to be very flexible, in order to fulfill the needs of patients. But are they really? What logistical families would there be in surgeries?

Good logistics prevents crisis

A few weeks ago I observed 5 surgeries in the operating room. I had never been present at surgeries from start to end so this was an exciting experience for me. In the weeks before I had observed outpatient and nursing departments and I had been in the Operating Room Complex a lot, but being inside the OR made me realize that this is where everything comes together and, most importantly, it has to come together. There is little time for improvisation and a lot is at stake.

The atmosphere in the OR appeared both calm and tense to me. People seem to know when to keep silent, when concentration is required, but at times they were discussing their last holiday, at times when the surgery went smoothly or not everyone was constantly involved in the surgery. Intense concentration and waiting alternate.

There were some logistical issues, but nothing major for as far as I could see: for the large part the materials were there, the patient was there, the surgeon, the anesthesist, the OR assistants, anesthesist assistant, the equipment was working – except for one monitor who apparently failed but did not seem to be too critical. Still it was clear to me that everyone in the room was very aware of what might be required or happen, there seemed to be a collective concentration. In some surgeries there were some disturbances of concentration – the failing monitor, an anesthesist that had to come but who was busy in another OR room or a phone call to the surgeon about another patient. It was clear that these disturbances, although they appeared common, were enough to make people agitated for a moment. I found the atmosphere tense at times. I could be because of the ‘my first surgery’ experience, but I think surgery could be seen as the climax to which the entire supply chain is working towards, and that a certain tension will always be involved.  From this observation it became very obvious to me that in order to be able to do surgeries in a safe and effective way, the logistics has to be arranged very, very well. Otherwise the tension will easily go through the roof.

Some weeks after this, I had a logistics crisis of my own. Last week, when going to Greece for a family holiday we missed our plane. It turned out we were on the wrong Dusseldorf airport, where we discovered our mistake at the very moment we stepped into the airport building. From the moment we discovered this, we had one goal: to get to the right airport as soon as possible. That failed. Then, trying not to think about what a gigantic and stupid error we made, we had to find a way to save our trip. About 2 hours of enormous stress followed in which we tried to find another flight (googling on our phone), talk to the airport people (who apparently did not have the same flight options as our iphone) and try to comfort the children who were sad and shocked that this could even happen.

Later, when we reached our destination Athens – two days later and via Milan – I realized what working towards an event that has to go right the first time really means. Catching a flight and doing a surgery have to be prepared perfectly, there is only one time to do it right and there is extreme stress when something fails. It is easy to miss certain information, if you combine data in the wrong way (as we did), especially when you are distracted (as we were in the days before our flight due to work and other things on our mind). For surgeries this is even more crucial because someones health is at stake.

 

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.