The Doctor

August 15, 2014 4:20 pm

The organised chaos of hospitals

There is no universal system, as each ward is a village with its own customs and traditions, let alone across the NHS

My key card had stopped working again, trapping me in a corridor. After swiping the card up and down the reader a few hundred times, I gave up. I longed for a key-coded door: you can nearly always find the code written somewhere, if you search the wall and the frame for long enough. (Sometimes you find it right above the keypad, which is handy, in the same way as sticking a Post-it note of your computer password to your monitor is handy.)

I peered through the locked door, occasionally tapping the window. You are rarely alone for long in hospital. Soon there was a jingle behind me: it was the night security guard, hung about with keys, phones and ID badges. “You rattle, don’t you?” I said as he opened the door. “It’s a deliberate strategy, flower,” he said. “Let them hear you coming – gives them time to run.”

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I once attended a talk about improving efficiency in hospital. It was illustrated with flip-chart drawings about a Japanese carmaker – Honda, I think. In the pictures, Honda cars slid through Honda’s flawless systems to emerge shining and on schedule. This in no way resembled my experience of life on the wards. I remembered my abandoned early research project, formed in my thoughts during the relentless corridors of my first job. It was to be called something like “How Many Days Does it Take to Find a Tendon Hammer In Here?”

In a fun combination of treasure hunt and educational endeavour, I was going to issue the junior doctors with timers and get them to record how long it took to locate basic medical items. The list went from the commonplace – a cannula, an oxygen mask – through the rarer – a pair of sterile gloves, a blood gas test kit – to the rarest treasures of the hospital ward – an ophthalmoscope, a working printer.

There are many reasons why hospitals do not function like well-run factories, most of them to do with people being individuals and illness being more complicated than building a car. A few habits of hospital life do add to this. Each ward is a village, with its own customs and traditions. There is no universal system throughout one hospital, let alone across the NHS.

Elements of systems thinking have permeated tradition, but in an uncoordinated fashion that would break a Honda boss’s heart. For example, the vogue for pathways and algorithms (which can be helpful in themselves) has led to the development of many questionnaires about patients’ social circumstances, their blood clot risk, their likelihood of falling over. Each speciality adds its own customised documents. This all has to be printed out and integrated into patients’ medical notes by the ward clerks (without whom all systems would collapse).

The average set of notes therefore consists of a cardboard folder that has tried to swallow a thousand pieces of A4, from stapled pro formas to defunct drug charts. These tattered bundles are then squeezed into hanging files from which the identifying tag is invariably missing. Further research: “How Many Minutes Do Staff Waste, Per Day, Looking for Somebody’s Notes?”

And there’s not much budget, as everyone knows. But this doesn’t just affect access to lifesaving drugs, and the provision of doctors and nurses, porters, pharmacists and physios, but also the unglamorous stuff: stationery, storage, batteries and computers. Do not lose your pen: there are no spare pens in hospital. Three floors and 20 swipes away, there is a special lady who will sign you out a new Bic. You’ll need to show your ID.

Sophie Harrison is a hospital doctor in South Yorkshire. This column appears fortnightly

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