Hospital operations: finding the rules of the game

Some days doing research gives you the feeling it is going nowhere. Then there are simply not enough hours in a day, not enough energy, concentration, memory or brain capacity to take it all in. Today is such a day.

I am trying to structure the rules of planning surgeries. Or rather, I am trying to figure out how the people in the hospital allocate time and space to hospital resources – surgeons, anesthesiologists, nurses, equipments, materials, operating rooms, beds and so on. They do have standard procedures. A lot of standard procedures. Medication protocols, time out procedures, planning procedures, MRSA procedures. These are procedures everyone seems to know without writing them down. It’s something like my household protocol. I don’t have it, but still me and my family know how things are done. I have breakfast every day, at a certain time, each family member has their own standard food etcetera. The  difference with hospital protocols is that while most people will know that I eat breakfast, as it is quite a common thing to do, hospital procedures are only known to a small group of people. In order to get a grip on the way things work in the hospital I could not ask one or two people, but studied 55 documents, did 16 days of observation sessions, 25 interviews and afterwards sent various hospital staff members emails or whatsapps on details that I, after all this, still did not understand (wondering on occasion if I was clever enough to ever be able to know how it all worked…)

The data have been collected now, I am quite sure of that, but structuring these data is a new challenge. It takes more days than I had ‘planned’. Which is probably the whole point: for hospitals planning is probably like that as well. Life is what happens to you while you’re busy making other plans, as John Lennon said.

The thing that makes this research feel like Sisyphus labour, is the fact that the standard way of working has so many ‘standard variations’. For example:

  • Medical disciplines get standard slot times for surgery, but there are multiple ‘standard’ slot times defined (i.e. from 8.00 to 10.15 or from 8.00 to 12.00 or from 9.15 to 11.35 etc etc) , different per medical discipline or day or time or operating room. So there are around 20 different ‘standard’ slot times.
  • Trauma surgeries are done by trauma surgeons, but not on Tuesday’s once a month. Then Orthopaedic surgeons do this (but only on parts of the body that orthopaedic surgeons can fix of course!)
  • If the waiting list increases, more surgery time is given to medical disciplines, but only if they have used their OR time slots well in the past and they show good cooperation towards the collective
  • Resource use should be 85%, but not for Eye Surgery, for them 75% is good enough
  • Emergency surgeries are planned in the elective time slots (there are emergency time slots as well) when it concerns patients who do not show up in the Emergency room in the past night or today (or other reasons I have not found yet)
  • Some people mention that it is standard to adjust standard surgery time. A sort of meta standard!

This too is like having breakfast: on Mondays I eat breakfast at 7 am because I have to travel to work at 7.30 am. On Tuesdays I eat breakfast at 7.30 am because I always stay in a hotel for work and breakfast is served from that time. On Wednesdays I have breakfast later, whenever I feel like it, because I work from home, on Thursdays I take my son to school so I have breakfast at 7.15. In holidays all days are different, whenever I have meetings or special occasions the standard procedure changes as well. It is a variable rhythm, though stable over time and dependent on rules that are logical. It makes sense.

For the hospital I have hundreds of these type of rules, 24 pages full at the moment. So, yeah well, I don’t know where this will end. What I have seen in the hospital is that the people who work there mention the rules as though they are perfectly sensible and normal. They have often worked in the hospital for 15 to 25 years. They have variable rhythms but know the rules and principles behind them. Not everyone in the hospital knows all the rules , but they have learned to recognize patterns and mostly deal with this complexity. I find it fascinating, but I am struggling to find a way to write it all down in such a way that it becomes something as simple as having breakfast.




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