Friday, 17 June 2011

View from an inpatient bed (2): The one about waste

Warning to reader: minutiae alert – apologies, but it’s often the little things that count….

My time was one thing that didn’t go to waste during the three days I spent as an inpatient recently. Not only was I set on the path to recovery, I was able to watch the comings and goings of a hospital trust, still wearing my service improvement hat, but viewing daily routines through the eyes of a patient.

The emergency department appeared very efficient, but I would love to know how many patients were there because they either didn’t have a GP or the out of hours service from their local practice was inadequate. There was a large number of walking wounded, or as we used to call in the trade – ‘bites, bumps and bee stings’. Alas my daughter stopped me from undertaking an instant poll on every new entry as I waited for the doctor.

Regular readers of this blog will know that I’m pathway obsessed and believe that tailored, locally agreed pathways using national evidence-based criteria for best practice will lead to efficient patient services. Which brings me to my first question. I knew I was to be admitted so the routine tests such as a targeted blood screen, blood pressure and temperature were to be expected. But I also had a chest X-ray, which is ‘routine’ according to the radiographer. There may be a very good reason to screen every patient pre-admission (I wasn’t due for surgery) but I would like to understand why this was done. Check for signs of T.B. maybe? Or is it simply because they always have done? Multiply this by the 48,000 inpatients admitted annually to the hospital and the sums start to get interesting.

Although I needed regular intravenous medication, I wasn’t actually unwell (infected ear) and was as in control of my faculties as I’ll ever be, so I was a little frustrated when I was told I must wait for a porter to take me to the ward. 20 minutes later, a cheery chap with a wheelchair turns up, and despite my protestations, insisted that I must be wheeled to my destination. Already institutionalised, I meekly sat on the chair and he wheeled me to the centre of the emergency department when he was called away. So I was left, stranded like a broken-down car in the middle lane of the motorway, smack in everyone’s way. (A highly amused doctor kindly moved me over to the hard shoulder). And when my chauffeur did finally appear I had a very rocky ride to the ward and can safely say that was the only time I actually felt sick during my whole stay! A time wasting exercise which meant that the department nearly missed the admission time target for this particular patient.

And this was the theme throughout my stay. Yes, I had excellent care and wanted for nothing – but how many processes and practices are undertaken simply because they always have been?

A considerable amount of nursing and healthcare assistant time seemed to be spent in ‘handovers’. And not very efficient handovers at that. Every nurse was told about every patient. Surely if they reverted to the old system of allocating a nurse or nurses to a bay of patients there would be far better continuity of care, and less time wasted on handover. And ‘bring back Matrons’ I hear you all cry in unison. Lack of time seemed to be the commodity that nurses complained of most yet if they studied their policies and practices I’m sure that significant savings could be made. The water jugs were changed three times a day – possibly by a volunteer. But I doubt if a volunteer was washing them. Is it really necessary to give a patient 21 different water jugs in a week? They say look after the pennies and the pounds will look after themselves.

Another fine example of wasted resource was the drug round. The nurse undertaking the drug round (which most times took forever because each nurse didn’t seem very confident in handing out the drugs) wore a bright orange plastic apron with ‘Drug round in progress – do not disturb’ emblazoned on the front. Not only did this make the wearer look ridiculous (I’ve only ever seen do not disturb sign on a door not a person), this has to be a waste of money.  The fact that the person doing the drug round is pushing a big trolley full of medicines is a bit of a giveaway without the apron which  was discarded after each round. I calculated that at least 50,000 – yes 50,000 of these aprons would be used in this one hospital annually. (I told you I used my time well…)

This may all seem trivial but multiply these few small examples by 1 million NHS in-patient admissions a month and you can see how small changes can have a big impact,

Talking of time well spent – the volunteers that came to change the beds daily were brilliant. I reckon they took an average of half the time to change one bed compared to two nurses. Possibly because they were happy to come to the hospital for a couple of hours and ‘do their bit’.
This is where Cameron’s Big Society can play a role. Well trained volunteers undertaking menial tasks could save a great deal of trained staff time.

NHS reform shouldn’t be just about cutting staff or - as I’ve quoted before – rearranging deckchairs on the Titanic with complex, and sometimes pointless restructure. Good managers creating robust, sustainable and lean systems of care, both clinical and pastoral could create the efficiency savings needed.

Best clinical practice, supported by well organised daily care and good man management is the most cost effective and efficient way to run an improved NHS.


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