Science blogging: just do it

This is going to be my first Dutch blog (indeed, bad start!). I was at a conference on science blogging and as most sites I will refer to are in Dutch, this seems like the most obvious thing to do.

Via Rosanne Hertzberger had ik van dit symposium vernomen . Met haar en iets van inmiddels 30 andere mensen zijn we een tijdje bezig om een soort platform op te richten, geheten Open Kitchen Science. Zie ook mijn eerdere blog hierover. Dit symposium sluit daar erg goed bij aan.

Er zijn al diverse mensen die samengevat hebben wat er besproken werd, dus dat ga ik niet herhalen (zie deze blogs van Marten van der Meulen en Jona Lendering, twee van de organisatoren). Hier een paar highlights (ja sorry, ook dat is geen Nederlands) die er voor mij uitsprongen.

Roy Meijer, communicatie adviseur van de TU Delft (‘mijn’ universiteit waar ik nog steeds de alumniblaadjes van krijg maar die ik bijna nooit lees omdat ik het te ingewikkeld/technisch vind…waarbij ik me dan meteen afvraag wat voor rare ingenieur mij dat dan maakt, maarja) benadrukte het nut van bloggen: ‘ze helpen het maatschappelijk debat’, daarbij Carel Stolker (universiteit Leiden) citerend. Daar draag ik dus aan bij, dacht ik, wat leuk. Stories of Science, het verhaal achter het onderzoek van de TU Delft, lijkt me interessant. Dat lees ik dan graag weer wel in het TU blaadje; het verhaal achter de onderzoeker of het onderzoek.

Grappig was dat Jona Lendering duidelijk een bekende blogger was in dit gezelschap maar ik hem niet kende. Als deze man zo leuk schrijft als hij spreekt, dan ben ik straks ook voor de oudheid gewonnen. Belangrijkste punt voor mij was dat hij stelde dat het publiek niet geïnteresseerd is in vakdisciplines of zeer gespecialiseerd onderzoek, maar meer in een onderwerp.

Suze Zijlstra vertelde over overdemuur, waarin geschiedenis in de context van de actualiteit wordt geduid. Super interessant. Geschiedenis was mijn favoriete vak op de middelbare school, precies om die reden. Ik ga deze blog zeker volgen. Haar hoofd boodschap was dat activisme en wetenschap goed samen gaan. Dat is wel een spannende vind ik, want als ik blogs schrijf vraag ik me soms af of persoonlijke gedachten en objectieve bevindingen niet te veel door elkaar lopen.

Sander Ruys van uitgever Maver gaf tips hoe wetenschap in een boek te gieten is. De blog ziet hij als een speeltuin, waaruit ooit een serieus (en lekker lezend) boek uit kan voorkomen, zonder dat het een ‘te lang artikel’ of een dik vormig visitekaartje wordt. Leuk, ga ik misschien wel doen als ik toe ben aan het presenteren van mijn ‘big idea’. Eerst maar eens promoveren (en boven de stof komen te staan, want anders wordt het ook niks volgens Sander).

Podcasten is ook nog een optie, persoonlijk heb ik er nog nooit naar eentje geluisterd, wat niet wil zeggen dat het niks is, maar ik geloof dat ik daar niet aan toe ben (if ever). Leuke andere invalshoek, dat wel. Ook dit verhaal ging heel erg over hoe wetenschap aan een breder publiek aan de man te brengen. Ik vind dat persoonlijk heel relevant en goed. Open Kitchen Science beoogt echter (ook?) wat anders, namelijk om het onderzoek zelf, de data, de methoden en mislukkingen te delen met ‘peers’. Zie verder http://www.openkitchenscience.nl/ (een website in wording).

Toen stond de ietwat transgender ogende minister van Engelshoven achter het spreekgestoelte. Iedereen herkende hem als journalist Maarten Keulemans, behalve ik, want ik lees NRC. Een mooi opzwepend betoog aan bloggers volgde – speel, doe gek! – en hij stelde het CBV fonds in. Centen Voor Bloggers. Daar ging de discussie die erop volgde ook over: moet er niet geld komen voor bloggers? En zouden wetenschappers er niet tijd van de baas voor moeten krijgen?

Wat mij daarbij opvalt is dat mensen die wel willen bloggen of iets dergelijks, het soms niet doen omdat het niet als onderdeel van hun taak gezien wordt of hun carrière niet vooruit helpt. Dat verbaast mij nogal. Ik zie onderzoekers toch wel als zeer slimme, autonome, eigenzinnige mensen (en ook dat bleek die middag te kloppen). Als je een promotie onderzoek hebt weten af te ronden (mij moet dat nog zien te lukken hoor), dan laat je je toch niet (meer) door zoiets als een taakomschrijving leiden? Gewoon doen, het werd herhaaldelijk geroepen op deze middag. Zeer motiverende middag was het, om precies dat te doen.

 

 

 

 

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Keeping up with the nurses

I received quite some response on the blog on nurses who run the hospital. It appears that to several people who are a nurse or represent nurses it felt like some kind of recognition or appreciation for what they do. Nevertheless, the fact that nurses ‘run’ the hospital is not necessarily good news. It means that nurses have a lot of activities that are not ‘nurse related’, such as stock management, administration, walking around to pick up materials from elsewhere, transporting patients, calling doctors or other nurses multiple times a day, transferring patients to others. Given the fact that there is a large shortage of nurses, as has been in the news in the Netherlands for quite some time, it seems quite obvious to do something about this.

For my research I observed two nursing wards and I joined nurse Alice in doing her work. Besides the logistical activities I saw her doing, I was struck by another thing. Process researchers or consultants tend to model healthcare processes as a linear series of activities. Below you see what process a surgery patient goes through on the nursing ward: 10 consecutive steps in time (from left to right). This takes place within one day or during multiple days, depending on the type of surgery.

patient proces

This process is not like this at all for nurse Alice. She is doing every step of the way in an order as presented below, or in another order as this is just an example. First the intake for patient 1 takes place, then the intake for patient 2, 3 and 4 and then she receives a call from the nurse anesthetist saying that patient 2 should have premedication now, then the call for patient 1 comes in, then for patient 2 and 3. And so on. The 10 steps are executed for, in this case, 4 patients, in a sort of random order. The order is not fixed as all steps are triggered by other agents than the nurse: the patient (arrives at some point), the nurse anesthetist (calls at some point), the recovery nurse (calls at some point).

nurse process2

Nurses therefore constantly shift between tasks. In factory terms: they have changeovers. I assume this costs valuable time as well. Even if we were to consider a nurse as a machine (which of course is a bit insulting and untrue, because I don’t think machines are as empathic as nurses to name only one thing), we could state that even machines need changeover time. So why not nurses?

What nurses do to manage their work, is to look for information or any sign to make the sequence of events predictable and keep changover times short. They look at the surgery program every 5 or 10 minutes, they call people all day, they ask their colleague who has just been at the Recovery about how other patients are proceeding in the process. Alice who is a experienced nurse had all sorts of signs she would constantly be looking for to make work more manageable. What a job. A bit confronting as well I must say. As I was walking along with nurse Alice and other nurses, I could not keep up with any of them, whether they had long or short legs. Apparently this is part of their training, as someone confided to me: walk fast all the time, but don’t make it look like running.

Centralization without hierarchy: a ground for organizational firework?

Vuurwerk

Happy new year! These fireworks are in fact nine social networks for nine tasks that are performed in order to do surgeries for patients. The entire network in my previous blog is built up from 23 social networks, one for each task. Tasks are for example: making the master schedule for the operating theatre (OT), admitting the patient to the ward or performing the surgery. The networks shown here all show centralization. Centralization is the extent to which a set of people are organized around a central person. This is seen in the networks here as one or a few persons in the middle, surrounded by people who interact with the central person(s).

You might expect that these central persons have a hierarchical position towards the others; that they are the boss who ask or instruct people to do things. This is not the case. In most cases in these networks the persons in the middle have no hierarchical position towards others whatsoever. The central people in the networks shown here are the OT day coordinator and the OT capacity planner, logistical staff, secretaries and nurses. In fact the people who do have formal power, in the organizational structure of the hospital, do not have central positions in the operational system of the hospital I studied.

So, not only is the hospital run by people in the operational system itself – mainly by nurses -, it appears that the operational system functions largely on its own, independent or loosely connected to management. This reminds me of one of my first blogs in which I was amazed at the unexpected and undesirable outcomes of strategic transformations of hospitals. I am wondering if it is true that management knows so little about how the operational system works that strategic decisions can lead to unpredictable outcomes. They are not able to observe the operational system and data on the operational system do not always seem to represent reality (see previous blog). This has little to do with competence, but rather with the impossibility to oversee the operational system. And perhaps this applies to all of us, people not working in this operational system. And does it also work the other way around? Do people working in the operational system know what other interests (financial, legal, ethical, technological etc etc.) are at stake besides treating the patient? I think connecting the strategic and operational reality is one of the most important challenges of our time. In 2019 I will make a further attempt to make some kind of contribution to that.

 

 

Do nurses run the hospital?

Professor Frits van Merode had already said it to me in the early days of my PhD research: hospitals are actually run by nurses. I think his statement did not fully hit me or maybe in my subconscience I thought it was one of those things that is also said about ‘the wife behind the man’. Something true, a nice statement, well said, but uh, what about it.

But now the social networks of how tasks for OR patients are performed have been finalized, I see much more clearly what he meant: nurses are the glue in the hospital network. As an example below you see the network position and connections of one anesthetic nurse. The network shown here includes all interaction links between persons (nodes in this network) who are involved in patient surgery, from the outpatient or emergency department where patients are admitted to hospital discharge. The red lines are all connections that one Nurse Anesthetist has.ANNU

This Nurse Anesthetist has interactions with 390 other agents  for performing tasks for surgery patients. All Nurse Anesthetists have a central position in the network, as shown by the central position in the network figure. Besides assisting the Anesthesiologist in surgeries, they call the nurses in the wards to tell them to administer premedication to the patient, then they ask the nurses to take the patient to the holding. From the holding until the recovery the Nurse Anesthetist accompanies the patient along the way and with each transfer (from holding to OR, from OR to recovery) the Nurse Anesthetist makes sure all relevant information is transferred. In the OR they stay with the patient and the Nurse Anesthetist is the eyes and ears of the Anesthesiologist, who serves multiple operating rooms at the same time. And just in case anyone wonders: the 19 Nurse Anesthetists in this hospital are both male and female.

There are other nurses as well: operating room, recovery, holding and ward nurses. A total of almost 400 nurses in this hospital take care of surgery patients, and they all perform logistical, communication and coordination tasks along side with patient care.

 

Hospital management by learning

Time flies; my last blog was in September when I thought I was almost ready with my hospital social network. The social network is not yet complete – soon will be!! – so I will wait sharing that. In the meantime my first (scientific) paper (ever) has been accepted and will be published any time soon in the journal Health Services Management Research. I was very happy with the news, since a lot of time and work (not to mention patience!) had gotten into it. The paper was born two years ago and has grown up in the past one and a half year of reviews.

As I read it again, for proof reading, I was thinking about the two Dutch hospitals that went bankrupt recently (see news item). I wrote in my paper that managing and controlling 106 logistical parameters, is a ‘challenge’ for strategic management (see blog about this). In the context of a scientific paper this is the right way to express it, but it is an understatement. I think it is impossible for one man, women or board of directors or whatever other small group of people.

If you want to control the hospital you need to know how these 106 parameters, such as Waiting Time, Lead Time, Inventory Cost, Length of Stay, Bed Utilization and so on, influence one another. Then you need to know how these parameters translate into financial parameters. The way that hospital care is financed seems to be uncoupled from the operational system so this is hard. Costs are made for staff, materials, equipment and infrastructure, but are not yet known in terms of one (type of) treatment of a patient. Negotiations with healthcare insurers on payment per treatment are therefore not really based on actual cost. One hospital manager once said to me: ‘our budget is largely based on past year’s budget and some idea of what next year will bring, but usually from June, when we know how far we are with the budget, we are fighting in the rest of the year to get the budget for the treatment of all of our patients.’

This is changing; hospitals are trying to get more overview on parameters, costs and manage these. That is a good thing for sure. This will however only work in an environment that is willing to learn, because knowing how you perform is not always fun. Revealing bed utilization (that low?), material cost (my goodness, how high!) or space utilization (what?! not higher than about 30% on outpatient departments?!) usually raises a few eyebrows and causes headaches. When I presented some pretty disturbing figures on logistics in a meeting some years ago,  someone asked who would like to work on the required improvements. The hospital facility manager then looked out of the window and sighed: ‘Well, not me!’

This response is perfectly understandable if individual people are held accountable for a performance they can barely influence themselves, if we assume that the 106 parameters all matter. Nobody volunteers to fail very visibly. An effective hospital is perhaps more of a learning system, in which continuous adaptions are made, based on what is happening around and in the hospital, which is detected and led by a network of people who have overview on all aspects and performance indicators of the hospital. When discussing the social network of the hospital I will get back to that.

 

 

 

 

Peer review from my dad

The fun thing about this blog is that I receive comments from different kind of people. Some people comment that they think my blog too long to be a blog (it turned out all individual blogs all in one long thread came accross as one (yes indeed) very long blog: if you click on the three lines on the top left, you can see blogs per month). I also received some comments from people in the case study hospital on specific results that they were surprised about. And several people working in hospitals say they find the blogs so very recognizable.

Last week my dad responded on the social network blog. First of all he indicated it was hard to understand and he wondered whether he was the actual target group. My primary reason for writing the blog was that people working in the field of hospital (logistics) would be able to read along with me, not having to wait until journal papers would be published (still waiting for the first one to come!). Secondly I don’t think many people in the field (or rather, all people outside the academic world) read journal papers. I find them hard to read myself, although after having read a couple of hundred, it becomes much easier. I wanted to offer something else and bridge the gap between academic stories and practical use of knowledge. At the moment my main focus is to get the academic story right and do a little bit of knowledge transfer through this blog.

My dad is not easily beaten though and he came up with some very good points on the blog itself. He asked what is to see in the middle of the network presented (see blog). In the middle you see a lot of blue names (GENS1, UROS1, AN1 etc.). These are surgeons and one anesthaetist who decide together what the Operating Theatre master schedule will be like. There is also one red person (CM1) and this is the OT manager. He and the OT capacity planner (OTPLAN) have a central role in this, connecting the medical staff, outpatient secretaries (the green agents called ‘SEC…’). Each surgeon acts as a bridge between this group in the middle and their own colleagues in their medical discipline. So for example one Urology surgeon (URO1) discusses the OT master schedule on behalf of the other Urology surgeons. You can see a circle around all Urology surgeons (UROS1 to UROS8) as they interact when preparing their own working schedule based on the OT master schedule. This collective scheduling is typical for hospitals I believe and not controlled in a hierarchic manner. My professor calls the OT master schedule a ‘peace agreement’. That is what it is.

My dad also mentions that it is hard to distinguish the anesthaetists from the surgeons in the network. Indeed, a legend would be useful. In short: AN stands for anesthaetist, all other blue names are surgeons, all SECGEN are secretaries, ORAS are OR assistants. But I must say that the network presented here has changed so much since this blog came out, that it would be better to explain it well once the network is final. Since then I showed all networks to the hospital people for validation, and a lot of other interactions have been added or changed. The discussion of these social networks with my research team has led to major changes in the networks also. There are now 9141 unique interactions in my database, that took place in 2017 between agents. But I am still counting.

In relation to my statement that surgeons and anesthaetists have an integrative role in this planning phase, my dad asks what I mean by this. He asks: “aren’t all stakeholders mutually dependent and responsible for the integration of the planning?” Yes, I think the mutual dependency is very clear. For as far as responsibility goes, there are issues to be explored and discussed. First of all even though there is a lot of collaborative decision making in hospitals, I doubt that all stakeholders always feel responsible for it. Decision making in a hospital (or in any large organization?) can be experienced as ‘vague’ (did we take that decision? when?). Decisions can be invisible or unconsciously taken. Sometimes there is a tendency towards something and looking back it is unclear how this or that happened. This way of doing can be part of a strategy, or it just happens, in my personal experience. Secondly, there could be alternative models for decision making with regard to allocating time and space. A central person, department or even a computer model can make a master schedule, based on forecasts on how many patients are to be expected hospital wide. Or one could not make a master schedule at all, but rather let the schedule emerge as the patient demand becomes clearer. There are several new ways of planning that are currently explored in many Dutch hospitals, under the heading of ‘Integrative Capacity Management’.

This last issue is what the paper I am working on right now is about. It addresses questions like: to what extent is the hospital network integrated, is that good or not, and most importantly what is the necessary integration? I wrote a bit about it earlier, but now I am using the theories mentioned here  to work out the case study. I will come back to that another time.

 

 

 

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.