By observing working practices first-hand, it can be easier to challenge the status quo and increase productivity.

A key part of my role is to help teams of staff from a range of service areas in the NHS to 'see' their systems and processes with fresh eyes and develop solutions to the problems that they see..

Here I refer to my recent experience of working with health records and sterile services. The same.principles apply to a number of service areas in the NHS.

The health records department has 30 members of staff and processes 8,000 to 10,000 patient records per week. By wearing a pedometer for a week, we found that each member of staff walked 30 to 35 miles, which equates to 40,000 to 50,000.miles per year for the whole department, spent.searching for missing patient notes that are not in the library. This represents between seven and eight whole-time equivalent staff searching for missing notes or around 12,500 person hours per year, based on a walking speed of 15 minutes per mile.

The sterile services department draws on the services of hospital transport staff to move clean and dirty operating instruments between sterile services and theatres. The sterile services department also seconds one full-time staff member to expedite priority sets to and from sterile services and theatres.

Overcoming work arounds

These are two examples of where, due to system problems, 'work arounds' become custom and practice. Health records staff often find it impossible to locate patient notes when and where they need them. An expediter is employed because the operating instruments that are needed in theatres are not available when and where they are required.

The running of health records and sterile services has an enormous impact on a hospital's ability to function effectively and yet these problems seem to be fairly commonplace in organisations that I visit.

The examples resonate with staff in much the same way that ward staff empathise with the experience of expediting orders for materials they don't have, pathology and pharmacy get swamped from 11am onwards and patients are not always in theatres when they are needed.

Accepting that these problems cannot be solved overnight, in time we can improve the situation demonstrably if we can 'see' the problems and are not satisfied with maintaining the status quo.

Generally, when you start to investigate some of the issues I have highlighted and ask staff how long they have worked in this way, they say 'as long as I have worked here', and this can be anything from a week to 30 years plus.

Let's stop tolerating.the status quo and start to address the root cause of the problems. A good way to start is to go to the workplace and observe what is going on.

Sterile services tend to hear from theatres more often than not when they do not have something they need. Arrange some dedicated time out of the day for frontline staff members from theatres and sterile services to observe how the process works from closing up a patient to delivering a sterile set back to theatres. Observe how often sets are picked up from theatres, how long theatres wait for a pick-up, where, when and how many sets accumulate and are expedited.

By observe, I mean leave the office, go to the place of work and see what is happening. Our recollection of what happens if we sit in an office is more likely to be what should happen than what does happen.

Document the process that you have seen at the place of work, separating out steps in the process from problems identified within the process. This can be a simple process map with one post-it per process step, one colour for process steps and one for problems.

Keep the group focused on what really happens before leaping to solutions.

As a group, everyone will have seen the same things, the good and the bad, so as a group start to identify data that might be needed to make more informed decisions such as:

  • How many sets do theatres use per hour? Measure total sets hour by hour over a couple of weeks to understand demand. This can be replicated with patient notes for outpatients, inpatients and accident and emergency.
  • How many notes/sets/other are missing when you need them?
  • How many times per day does one group call another to chase items?
  • What changes could be made immediately that would improve the situation? Could all sets be returned to theatres every hour? Is there any way to reduce the number of times we handle a patient's notes/set? Can we reduce the distance travelled to get the same result? Can we reduce the expediting?

One way of tackling these issues is to get everyone in the room to understand each other's perspectives and the whole picture. If no one knows that health records staff are walking 50,000 miles, it is not a problem so long as those that need them receive their notes when they want them.

Similarly, if sets are expedited all day every day, the immediate solution is simply to purchase more kit, but if dirty sets are sitting in theatres for hours before being sent to sterile services, perhaps fewer new kits are required than first thought?

Understand demand and then our true capacity to meet demand. Our capacity to meet demand will be influenced by custom and practice and how much waste there is. Remove waste to get a true picture of capacity. Then work on a principle of small batch sizes, or little and often, rather than feast and famine to improve the flow of patient notes, operating sets or patients through the hospital. Then and only then consider if it is appropriate to increase capacity.

Andrew Castle works for Applied Angle.