Centralization without hierarchy: a ground for organizational firework?


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.



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.