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.

Hospital IT systems are replaced by intelligent agents called secretaries

Yesterday I spent the entire day observing three outpatient departments in ‘my’ case study hospital. I talked to the Orthopaedics, Surgery and Gynaecology outpatient departments and watched how surgeries are planned and organized. The night before I prepared the visit by looking at the facts and figures – the production data of 5 years, from 2013-2017 – of these three departments:

  • Orthopaedics has 6 operating people (operating orthopedists)
  • Surgery has 30 operating people (surgeons)
  • Gynaecology has 9 operating people (gynaecologist who do surgeries)

This all turned out to be fake information. There were 4 orthopedists, 11 surgeons and I don’t know how many operating gynaecologists, but it’s less than 7, because there are 7 gynaecologist who do not all do surgeries. How come the data were so misleading? I will explain with an example.

The 30 individual surgeons are coded in the data as follows: 00908, 00909, 00910, 00911, 00912, 00917, 00922, 00927, 00928, 00930, 00931, 00934, 00935, 01305, 05009, 42371, 509139, 509179, 509217, 509231, 509238, 509239, 509250, 509261, 509269, 509274, 509276, 509283, 509284.

I remembered that someone had said earlier that ’50’ codes were doctors-assistants (a doctor-assistant is a doctor who has completed his medical studies and is fully qualified, but not (yet) a medical specialist). So that leaves 13 people out in this case. I noted that some codes had a different structure than others: there are 12 009XX codes and some others such as 01305. And I found out that 42371 is actually a plastic surgeon.

For the other two medical specialities I did the same decoding of the data. For Gynaecology I could still not entirely work out the math. If there are 7 gynaecologist who not all do surgeries, then who are the 7 operators who have done a certain number of surgeries? That I will have to ask someone later in the process of this case study research.

OK. So the IT system does not really provide me with the right data. Well, the data are correct, probably, but they do not seem to provide the right information on the reality. I find it worrying, because many large strategic decisions are based on (high level) data.

This is nothing new for outpatient secretaries. They have realized for quite some time that the IT system is not perfect. They don’t really use the system for planning, just for registration. Although the IT system they use is provided by the market leader for hospital information systems in the Netherlands – Chipsoft, they do not use it for planning. All 7 secretaries I talked to independently stated that the system does not provide the overview they need to plan surgeries and that they have to bear in mind so many decision and control rules, that use prefer their own planning system. This system basically consists of their own brains and common sense. The tools they use look complety old-fashioned and obsolete. In fact, when they showed their folders, piles of A4 papers, paper diaries and whiteboards, they immediately started to apologize for their apparently middle aged methods. Some of these ‘tools’ had been used for over 20 years and were starting to fall apart. But, as they explained what the planning rules are that they use, their brains form a very advanced system. For example here are some of the rules they compile in their heads every day:

  • For a TEA carotis call the Intensive Care for a bed and arrange an EEG and plan vascular examination one day before the surgery takes place
  • For the combined PTA make an order for an X-ray
  • If there are multiple shoulder prosthesis surgeries, plan 3 days in between these
  • Doctors X, Y and Z are on a conference on dates A, B and C
  • Staff meetings for the upcoming months are on times X and Y so don’t plan surgeries then
  • There are only 2 instrument sets Y in the hospital so don’t plan 3 surgeries at the same time for which these are required
  • The Radiology starts at 8:30 each day so if an X-ray is required for surgery do not plan this before 9:00

In total it was said that there are about 70 rules and planning principles, but I believe this is just the tip of the iceberg. I have seen around 50 to 60 on paper documents, in emails, on walls and so on, but with each new person I talk to, new rules are added to my list. I haven’t heard them all, I am sure.

It seems a bit odd: the hospital has a state-of-the-art IT system but it does not suffice for more intelligent stuff. Secretaries do the thinking using tools that look unsophisticated, but what they actually do comes accross as very sophisticated, not in the least because they are an important coordination node in a very large network of agents. Often they have worked in the hospital for years (10 to 20 years) and their experience is priceless. The software, on the other hand, is actually unintelligent, I would even say stupid, but looks advanced. Maybe we are fooling ourselves when it comes to what or who is believed to be smart.

 

 

 

Variation in Operating Room production; predictable or not?

If the demand for products or services are stable, then logistics is easy. In any household for example there are repetitive rythms, determined by meal times and working days. Meal times determine the moment that food supplies need to be in the house and working days could determine when there is time to buy these. Weekends differ from week days, and for someone working irregular hours the week pattern of activities could be different. Not every system has to be the same in order for it to be predictable. A variable rythm could be ‘nice’ in the sense that it repeats itself and has a certain flow, fitting for example with a natural life rythm.

I  believe a ‘nice’ rythm or flow is important for any person or system to be effective. So this would be important for an OR department as well. But what is the rythm of an OR department? And if we could define it, is it known to anyone working in the OR department? And do nursing departments or a sterilization unit know the rythm of the OR and do they adjust to this? Or does the OR adjust to the rythm of these ‘suppliers’ of patients and materials? Or do they each work in their own rythm, not matching the others?

First of all I therefore analysed whether the OR production data shows any patterns at all.

Looking at the weekly pattern of production, as shown below, there is variation. Each line represents production levels per week in a year. Each year has the same ups and downs in the production. These coincide with the school holidays in the Netherlands. The large dip, roughly between weeks 28 and 35, are the summer holidays. In the Netherlands regions do not all have the same school holidays and they shift every year. That is visible in weeks 7 to 10 for example: in this periode there is a recurring holiday, which takes place every year, but not always in the same week.

Blog productie patroon

Although the fact that there are ‘reduction weeks’ seems common use in the hospital world – at least I never heard anyone mentioning it as odd -, I find it remarkable that production varies based on school holidays. In contrary to for instance the education sector, demand for health care does not necessarily have a link with schools or children. The average age of patients in this OR is 54 years old. Do they want to be in surgery outside holiday periods? Or just before it? Or is (un)availability of staff the factor in this pattern?

Then there is a weekly pattern. In the figure below for each week day the total number of surgeries on a week day is presented, for 5 consecutive years: 2013 to 2017. Sunday is 1, Monday 2 etcetera. So in 2013 (blue column) the Tuesday was the day with the most surgeries and for 2017 (green column) this was Monday.

Blog productie weekpatroon

There are only emergency cases in the weekends (day 1 and 7). Friday appears to be a day with the least surgeries planned. Is that because one aims to have low occupancy rates in the nursing departments in the weekends? Is the expected length of stay a factor for planning surgeries on specific week days? Why is every year (or week) different?

This leads to several questions:

  • Is this year production pattern universal – in the sense that it is linked to national holidays for other hospitals as well? 
  • How could this production pattern be explained? Is patient demand or resource availability leading? 
  • Does this rythm serve a purpose (and if so, what purpose) or is it ‘just the way it is’?
  • How come that the variation in production changes for week days?

Please let me know by sending me a message what are your thoughts on this.

Blogging on scientific research

I am writing this blog for several reasons. First of all because I just like writing. Secondly I would like to share knowledge with people working in hospitals, with logistical or healthcare operations experts and basically anyone else who is interested in my research, including my friends and family who occassionally inform how my research is progressing. Thirdly I would like to experiment with sharing knowledge resulting from scientific research to a wide audience. Writing journal papers is one way to share knowledge. It is certainly valuable and very informative, also for myself, because of the peer review that comes with submitting journal papers. However, to share knowledge with the field, I believe journal papers are not sufficient. Journal papers are tough to read sometimes, especially when you are not familiar with academic writing.

This blog experiment is also meant to see whether this could be a way to share thoughts and ideas on the research itself. A common issue with case study research is that n = 1 (or, in my case 4 or 5). This raises a question like: are the things I see universal for hospitals or do the results only say something about the one hospital I have seen? In my experience, this last argument is used a lot in hospitals. I see a lot of similarities, but they are not always that obvious or they need to be made explicit.

Furthermore, my own experience, interpretation and maybe even personality could influence the outcomes. It is valuable to look at reality through more than one pair of eyes and by sharing my observations, I could perhaps put conclusions based on this, to the test. This is all the more necessary because I am an ‘external PhD candidate’, meaning I do the research in my own time, besides working as a consultant. I would like to see it as volunteery work rather than a hobby. A hobby would be merely for having fun – which is the basic motivation for doing this besides a full time job -, but I would like to think that it serves (some parts of) society.

The thing is: how do I reach the right audience? And how do I get these to respond, in these times of information overload and having questionnaires about every daily service you use?

In my next blog I will present some data from the case study research, asking explicit questions about these data. I will send an email to all Operating Room staff I know to respond to these questions and post the blog in Linkedin interest groups. Let’s see if this generates some feedback.

Starting case research

In the past weeks I have started my first case study research in a hospital. My main research question is of what elements the logistical system consists and how it functions. My focus is on the Operating Room department (OR) and all its supply  chain partners, varying from nursing departments to the central sterilization unit. I selected a relatively small hospital of which from earlier experience in my work my impression was that they were doing a good job in their daily business of running an OR. The idea behind this is that in a relatively small hospital, that is in a stable situation, we would then get to know the logistical system of any hospital.

First of all: how did I get the impression that this hospital was stable and functioning quite well? I got this impression from two consultancy jobs I did in the past years. When I ask people in this hospital for data, they deliver these. When you make appointments on meetings or actions, they show up or follow these up. This is not always the case in all hospitals. Many times hospitals cannot quickly find data on processes or performance. In this hospital, they seem to work together as a team and everyone I have ever spoken to in this hospital, knows how things are working or they tell you that they do not know and get the right person to answer the right question. For me, it had always been a pleasure to work with these people. So I asked them to work on this case study research together.

In the past month I have collected all production data from the past five years and over 40 documents on patient, material and staff planning. I am still in the middle of getting a grip on all these data, but, as first impressions are the best, I share some here.

Data are hard. They are hard to get; it makes you feel part of a scavenger hunt and being a girl scout. I started with the application controller, who gave me the production data, but after that I have walked around the OR talking to people who then showed me their paper lists, system overviews and information sheets that they use daily for preparing surgeries.

Data are also hard to interpret, as everything is coded. That is not to be secretive about it, but to limit the number of letters or words in systems or on lists. Names of medical specialties are are pretty easy to understand as three letters, but the other dozens of codes reveal (or rather hide) a world unknown. And the thing is, every group of employees uses its own codes. The OR planner uses different codes as the internal material staff. The people using the information systems talk in system codes, those who don’t use other jargon. You need an interpreter.

Further, there is a lot of data. The number of surgeries are large, the different kinds of surgeries are numerous and they have names that I cannot reproduce. Interestingly enough a seemingly easy question – how many surgeries does each medical specialty do per year- requires a lot of effort. I have worked on this for half a day and I still do not know. I need the interpreters and system experts to go along on my hunt for this, for not all surgeries have a medical specialty registered.

Almost every data set is filled with gaps. Some for good sensible reasons, some gaps are inexplicable. The inner circle – a few people on the OR – know why this is the case and how to interpret it. Where would be without these people, I wonder. We would be lost. Maybe we are already, because I have not met anyone yet who uses these data for strategic purposes. In fact, it appears there is no relation between the hospital budget and the number of surgeries planned or realized.

Recently one of the board members of the merging academic hospitals in Amsterdam stated that larger hospitals are necessary for transparency. Hmm, if for one OR it is quite a lot of work to find out how many surgeries per medical specialty there are on one OR department, then how transparent will two merging academic hospitals become?  I don’t think I would use the word transparency for current logistics. It is a mystery to most people.

Hospital strategy and logistics: separate worlds?

Besides looking at logistical parameters I also did a scoping review on hospital strategy and logistics. I was wondering to what extent logistical parameters play a role in making hospital strategies. From personal work experience I did not expect a strong link between hospital strategy and logistics, given the observations I mentioned earlier. But, I was hopeful that my lack of experience with boards was one of the reasons I had not seen it. There must be some sensible idea behind hospital strategy, at least that was my hope.

I searched the international literature on the same keywords as before (see my blog on the logistical parameters) and added the words ‘Strategy’ and ‘Strategic’. This resulted in 129 articles with strategic hospital topics mentioning logistics in some way. Half of these articles actually mentioned logistical parameters. There were articles on quality improvement, access to healthcare and how to use scarce resources, but hardly any article was on how logistics could strengthen the quality of care or competitiveness of hospitals. There were no articles on mergers or how good building or organization design supports strategic goals. There were some articles on the theoretic link between logistics and strategy, for example on lean or business process reengineering.

Surprisingly enough more than half of the articles (39) did not consider the entire hospital, but a subsystem of it, such as Emergency care or patients requiring surgery. I wasn’t sure these articles were even strategic at all. Using the word ‘strategic’ does not make the approach of an issue necessarily strategic.

If logistics and hospital strategy are not interrelated in literature, what does this mean? Is it considered irrelevant? Is it impossible? Are strategies made regardless of how hospitals work in practice?  Are strategy makers purely interacting with the outside world, legitimizing their existence rather than making it indispensible by outstanding performance? What is hospital strategy about and does it have any impact? How are we going to control health care costs when no one includes logistics into their strategy? This raises more questions than I can possibly answer.

I was struck by these results although it fitted in my own impression of hospital strategy in practice. But I hoped it was not true. I started to think about explanations.

Given the fact that hospitals have perhaps become too complex to handle, lack of a central logistics strategy could be a way to survive as board. If everyone in the organization organizes himself this could be very effective. Perhaps expensive, but it could work.

Another factor could be that the hospital’s environment is so dynamic that it takes all the time of boards to adapt to all developments. Maybe it is their job to keep the dynamics of the outside world away from the doctors so they can do their job. Maybe the ability to adapt is more important than operational efficiency. In my talks to boards of directors this last thing was certainly one of their remarks. One did not always believe in the theoretical advantages of mergers, but they stated that mergers were more or less enforced by external developments, such as legislation, less budget or mergers in the insurance company sector. One board member explicity stated that hospital strategy was not about efficiency but about surviving and adapting and making sure that the quality of care remained guaranteed. Hospital strategy would then be like renovating the operating rooms and keeping these fully productive at the same time, as is common for hospitals.

Survival of the fittest (the most adapted) is of course a very strategic goal. If this, at any cost is the task of a hospital board, then the main issue would be how we can  adapt the hospital in such a way that the logistical system remains intact or even improves? How do we keep this continous adaptation affordable? And if we adapt without taking into account the logistical system, how do we transform without accidently breaking it down? This is where understanding of the logistical hospital system comes into play. That is my next step: to find out how the logistical system of a hospital functions in practice.