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.