Lean nursing: a foreign concept in EC and ICU?

“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. And then he feels that perhaps there isn’t.”                                                                                                                            – A.A. Milne, Winnie-the-Pooh

Recently I started doing some in-hospital shifts again. Since my first shift, I’ve been pondering whether I should say something or if I should just suffer in silence. This blog is about my experience in one private hospital group. I’m well aware that, by posting this blog, I’m exposing myself to not working in said hospital group again. So, why risk future shifts and cash flow by posting this blog? Because I feel that I have to be true to me and what I stand for. And I don’t think that these experiences are specific to the hospital group or applicable to only nurses.
It’s my experience that most nurses working in hospitals feel like Edward Bear: they have a feeling that maybe their working conditions could be different, that there should be another way than the daily struggle that has been normalized. Maybe because I have worked outside of the industry, and as manager within the industry, I know that the daily conditions of clinical nurses can and should be different.
In his book Lean Hospitals, Mark Graban says that healthcare providers often think that our job or the value that we bring to the hospital is our ability to deal with problems and just work around the issues and get on with things, to improvise and cope. We think that it makes us heroes to go home broken after a tough shift. We do things that should not be done; we work hard at the workarounds that adds no value to the facility, to us or most importantly to the patient. I think that it’s especially true about nursing. Here is why:
1) Inefficient systems and waste within nursing
After being involved in LEAN projects, I look at most nursing processes and see them as beyond absurd. The amount of waste, workarounds and the inefficiencies are downright ridiculous. There is much more to LEAN than it being a process improvement philosophy, but I’m going to describe it as that for now. I do think that the LEAN approach at times tends to oversimplify complex issues, but it’s generally a good approach for linear problems. LEAN thinking categorizes wastes (inefficiencies) in the system that any organization should attempt to reduce such as:
The waste of unnecessary motion: Walking up and down to fetch medication, equipment, linen, water, bedpans, etc. are not always necessary. I’ve been tracking my kilometers walked per shift. My average over 2 months is 5.2km per 12 hour shift. To walk 5.2 km on a flat surface takes about an hour, implying that I spend one hour a day walking, not nursing. Most of my shifts have been in ICU, where the patients are within close proximity to each other and the ‘specialized nurse’ is supposed to be mostly at the patient bedside. Thus, one would expect that ICU nurses walk less than nurses in other units. So how much time do nurses in, say, surgical units spend walking versus nursing?
The waste of waiting: I also work in the emergency center (EC). A well-described concern in ECs across the world is access block. Yet, from a nursing perspective, there seem to be more constraints keeping the patient in EC, than processes that enables the flow of patients through the EC. The EC is at its busiest after hours and on weekends. Yet, this is typically when other services in private healthcare slow down and operates on skeleton staff– including radiology and pharmacy. Inevitably, the EC nurse becomes a gatekeeper for these systems, e.g. the EC nurse needs to call the radiographer prior to a patient going to X-rays. This increases the workload on the nurse and waiting time in the EC, and not to mention that after hours the patients are only allowed to X-rays one at a time.
The waste of overproduction: Again in EC, we overdo the administration. Why, for a follow up patient that only needs to see the doctor for a quick checkup requiring no nursing input, does the nurse need to complete a 4 page document? And, for admission, does the nurse need to copy 8 pages of nursing notes and the doctor’s notes? I know it’s for auditing purposes, but what is the value? With only one printer shared amongst EC and reception staff another delay is created for no obvious reason.
To transfer a patient from ICU to the ward requires similar overproduction of nursing notes. There is the implementation record, the transfer record and the ICU chart. Then, there is the ward documentation that some wards insist that the ICU nurse should complete. Again, overkill. Ordering simple blood tests is another complicated process. The doctor writes up the request (this can be on one of two places, so the nurse better check both!). Then, the nurse ticks it off on the blood request form, writes the bloods, patient name and bed number into a diary for pathology and has to write it into her notes. Re-writing the blood request that might be written in two places into three places increases the chances of error or omission of a test (and it happens regularly, especially when the unit is busy).
The waste of overprocessing: Overprocessing means doing things not wanted by the client. In the EC, the patient is required to sign out at two places before they can be discharged (creating a delay): once to say that they did not handover any valuables or received them back and then to agree to discharge. Asking why we need to do this, the answers varied between ‘it’s the hospital’s rule’ ‘its proof of our input, should the patient complain’ and ‘it’s for auditing purposes’. Considering the risk/benefit profile, is it really true that the risk of a patient complaint is worth the time lost and the compromise on patient flow?
And why do the nurses need to rewrite everything that the doctor wrote down? Would a simple nursing checklist on the doctor’s notes, especially in EC, not improve patient flow?
2) Conflict between job description and client expectation
Patients in private healthcare often state that they are paying a premium for the care that they receive and, as such, they have a right to demand a certain level of care. More often than not, the nurse is responsible for meeting these patient demands. Often, these requests are in conflict with the described nursing functions. In a way, this has created a reverse incentive, where, if the nurse meets the patient’s demands, then on paper it will appear as if the nurse didn’t do their job. But, meeting the job description and doing the job on paper means not meeting the patient’s expectations. Is the exhausting paper trail that nurses must leave (which, it seems, is mostly for auditing purposes) really patient centric and valuable?
It’s a core nursing function to coordinate all other service providers (e.g. physiotherapy, dietician, food requests, and radiology) and all of these services have preconceived ideas of what the nurse’s function and responsibility is. So, it is not surprising that nurses’ end up feeling pulled in every direction and is consistently told that they are not meeting someone’s expectation of what they were supposed to do that day.
3) Doctors behaving like toddlers
Doctors still throw their toys out of the cot…and nurses are still required to pick it the toys. I count quite a few doctors as close friends, so I felt apprehensive making such a blanket statement. But, hear me out – there is no formal process that prevents doctors (and other service providers) from behaving poorly towards nurses. When I worked on the cruise ships, there was a guest vacation policy. Guests could be asked to disembark or leave a public space if they behaved rudely towards the ship’s staff. Perhaps hospitals need to implement a similar kind of policy for inappropriate behavior towards nurses. Nurses are at the core of service delivery in private healthcare and, as such, the hospital and nursing management should ensure the psychological safety of their nurses.
On a recent shift, a doctor behaved poorly in front of patients, visitors, and other staff by shouting at a nurse. He had the nurse in tears for something that was completely out of her control. When he eventually left, even the patient was in tears. How is this patient-centered? And, why should the nurses still be expected to cover for this type of behavior, smooth things over and apologize on behalf of the doctors to the patients and their families?
Another LEAN principle is respect for people…nurses are also people and should be treated as such.
4) My time is valuable
This has probably been the toughest part of returning to clinical nursing. Covering the unit is the most important aspect of a nurse’s life. Family events or plans after work simply need to be adjusted according to the unit’s needs. Fulltime staff members’ shifts change regularly, sometimes at incredibly short notice. If a shift change happens late, the other shift just needs to stay on, no explanation needed. Even though a part of me gets that, a part of me also rebels against the frequency with which it happens.
As an agency nurse, there is the opportunity cost of being booked for a shift. The agencies have the right to cancel your shift up to 2 hours before your shift was due with no financial compensation. Yet, you probably said no to other work or gave up on other opportunities in order to be available for the agency. Taking into consideration that you are required to be on shift 15 minutes early and sometimes have a 30-60 minute travel time, they basically cancel you as you are already on your way to work. Not really fair….and, beware- should you cancel a shift, you are ‘punished’ by not being booked for a few days.
5) The absence of nursing leadership
There are good nursing managers out there. But, are they showing leadership and advocating for nursing care? As I’ve been told: you can see that the unit is busy because the unit manager is hiding in her office behind a closed door.
Why do they do hide? Are they ignorant of the issues on the floor? I think not. I think it’s more a case of the managers feeling as helpless and disempowered as their staff… and they are caught between the staff and the higher levels of management.
Again referring back to LEAN, ‘Go and See’ is crucial. What the nurses on the floor need is for the nursing managers (hospital managers, head office representation) to be there, to be involved, to produce policies that enable them to do their job, to remove constraints and workarounds, basically to operationally manage the unit. By going and seeing those positioned to improve circumstances can experience the current conditions and frustrations. Currently  they remain removed from the daily grind and they hide behind their audits, checklists and paperwork. Nursing and nursing management has become paper and audit driven rather than patient driven. Why this irrational fear of protection with administration?
6) Level of dissatisfaction
In the short time that I’ve been doing shifts again, I’ve really felt disheartened with the level of frustration expressed by nurses. Not to mention the lateral violence, where nurses take out their frustrations on peers or those lower qualified. I daresay that the lateral violence is a direct result of the daily frustrations with waste and inefficient processes, the behavior of doctors and lack of nursing leadership. There is very little psychological safety within the current nursing environment and, again, as someone told me: the managers don’t have our backs.
The LEAN philosophy describes another waste: the waste of human potential. It’s my belief that the current hospital environment wastes nursing potential and therefor is losing great nurses.

A quick unscientific Facebook stalking of my university nursing friends revealed that maybe 3-5 of them are still clinically nursing in hospital. Something must be wrong. Especially seeing that people love telling us that nursing is a calling. If that is true, then we all seem to have lost our calling…
Or, is it that the environment has become so detrimental that nursing is no longer appealing or sustainable as a long-term career option? I wrote this blog because I believe that we can and should change the environment. But, it will take strong nursing leadership. Step one of being the patient’s advocate is by being a nursing advocate, advocating for better nursing conditions so that we can be better patient advocates.

Stock-outs in SA hospitals…could it be that our daily inventory systems are outdated?

Innovation is for many what medical progress is about.  It is about better technologies to diagnose, intervene or new treatment regimes.   What about the way in which hospitals are managed? Some of the standard practises appears to be rather outdated.  A good example of such an outdated hospital management system is the inventory system used in South African Hospitals.

Despite doing nursing management as subject at both under and post-graduate level, inventory or stock management was hardly mentioned.  The course work for a dispensing license only addressed one stock management system.

I chose to speak about a few inventory systems with Emergency Medicine Registrars recently.  The doctors did their undergraduate degree at various medical schools in South Africa.  None of them had hospital inventory and stock as part of a course at med school.  I understand that undergraduate medicine (and nursing) is not about management, however if persons are expected to manage a department based on their undergraduate qualification then maybe it should be addressed?  We cover management as an undergraduate module for applied sciences students, why not for nurses and doctors?

The highest financial expenditure in a hospital is human resources.  The second highest expenditure is inventory or stock.  Supply chain expenditure forms about 30% of a hospital budget.

The questions to answer when choosing an inventory control system is: how often do we need to check inventory, when can we reorder inventory (supplier relationships influence the decision) and how much to order at a time (cost and storage implications, lead time).

Various inventory systems exist.  I’m only going to speak about three.

Every hospital that I’ve ever worked at used a fixed system.  This can take one of two forms.  In a fixed quantity order system orders are placed when the stock in the unit reach a pre-determined level or a fixed time order system where orders are placed from pharmacy on specific days or times.  During a course for a license to dispense medication this was the only system discussed.  This method works best when:

  • Usage is stable with minimum variation
  • The order amount is the difference between current stock and maximum level.
  • Stock can be monitored often – this is why trained nurses count all the stock in the department on a daily basis.  This is also why after a resuscitation the nurses are counting and replenishing stock as opposed to caring for patients and assisting in resolving the backup of patients that had to wait for care whilst the doctors and nurses was busy with the resuscitation

In the 1980’s the retail industry developed the quick response and automated system.  A main characteristic of this system is that ordering is computer assisted, with the dawn of the internet these systems are nowadays linked with the suppliers making it very responsive.  This method works best when:

  • The ability to be responsive to fluctuation is important
  • There is not enough staff to continuously monitor stock usage
  • Stock reordering are required to be based  on actual product usage
  • Labour cost needs to be reduced
  • There is strong relationships with suppliers

The grocery industry developed the efficient response system.  It is similar to the above system with a key difference being that this system relies almost exclusively on electronic data exchange. This system works well when

  • The inventory is fast-moving such as groceries
  • Time to replenishment is crucial
  • Inventory needs to be continuously available, yet there is variation in use
  • There is strong relationships with suppliers

Examples in practise

The fast food industry: McDonald’s has been using electronic systems for stock management since the early 1990’s.  Their system electronically captures all purchases; information is captured in an in-store processor that calculates supplies and predicts demand.  The information can be customised to automatically reorder inventory when certain levels are reached and it transmits demand predictions to suppliers for planning.

The retail industry has been using bar codes since 1973 to reduce the cost of inventory.  Software systems are used exclusively and the bar codes are regulated internationally.  This inventory method reduces overstocking and product spoilage whilst providing real-time data and trends. These are important factors in an industry with great variation and strong competition.  A South African example is Shoprite/Checkers that use an online supplier system to manage their supply chain over fifteen countries.  Their distribution centre in Johannesburg is the largest on the continent.  Their supply chain is highly complex and inventory moves fast.

The healthcare industry:  a Johannesburg hospital.  The pharmacy storeroom holding stock to the value of R57 million and there is regular stock outs.  The average monthly trade deficit is R3 million, mostly unaccounted inventory.  Stock to the value of R700 000 are disposed of annually due to it expiring prior to use.  The authors estimates that the cost of poor management and lack of inventory control are R40 million per annum.   The stock system is a paper based system relying on staff to physically count the R57 million worth of stocks and manage the paper entries.  There is no electronic system to aid.  Due to late payment, some suppliers do not deliver on time or do not deliver until paid.  This aggravates stock outs.


We desperately need to innovate on our health management systems.  Changing an inventory system would be a radical change.   Maybe it would be too much. Perhaps we can start with incremental innovations from other industries including the ones mentioned above.  The examples mentioned appear to have similar needs as healthcare: inventory systems that is robust enough to deal with fluctuating needs and limited staff involvement.  However healthcare is lagging behind and it’s time for a change.

It’s more complex than it seems….19 babies received the wrong vaccinations

A week ago there was an incident at one of the private hospitals.  Nineteen new-born babies received the incorrect BCG vaccination and are now at risk for contracting Tuberculosis and suffering other side effects.   According to the media reports, the vaccine was confused with another drug used for a different patient population (adult and new-born) with different indications. But vials are similar in appearance.

No doubt the parents are furious and the media has a duty to report and allow for public comment.  I keep telling myself not to read the comments alas I still read it.  The readers has crucified the nursing staff involved and are blaming the lazy, stupid, can’t read, how-hard-can-it-be-to-do-your-job nurses.   Stupid nurse, fire the nurse.  End of story.  Problem solved.

Errors and failures in complex systems such as hospitals are not that simple.  It is not linear with a direct and clear relationship between cause and effect.  And neither are the interactions between the various functions within the system linear either.   In complex systems there is no single most “fundamental” reason for an error.  There is an interaction of several causal factors originating from various places within the system.  The inquisitive investigator will find patterns between apparently unrelated incidents prior to this incident.

The impact of a blame culture or over simplified cause and effect investigation results in system failures being “blamed” on the last “link” prior to the incident.  This last link is typically the doctor or nurse involved in patient care.

Possible contributing factors to the vaccination error:

  • The drug manufacturers.  There has been an increasing push on manufacturers to distinguish medication and provide visual cues on ampoules as warning prompts.  For instance the difference between medication manufactured for adult, paediatric and neonatal should be visible by either colour or tag.
  • The pharmacist that dispensed the drug had a duty to check and label it.  The question should be asked that if an adult drug ended up in a new-born unit, was there a dispensing error?
  • Responsible person receiving and unpacking the medication in the unit.  This person has to check medication received against requested medication.  The role is performed by an administrator with no nursing background.  If the packaging was familiar and the name similar, they would miss the error or assumed it is a generic.
  • The first nurse to administer vaccination using the vial.  There is policies dictating that nurses perform the 5R’of medication administration to ensure that it’s the right drug, right dosage, right route for the right patient, at the right time.  Was this done, and could the nurse complete the check without interruption?
  • Normalizing deviance.  If the same constraints are experienced on a regular basis it is accepted as normal.  When it’s accepted as a “new” norm it creates an environment where failure or error is inevitable.  Nursing shortages has become normal; this has an impact on safe medication administration practises as well as the frequency of interruptions during this risky time.  This normalizing deviance results in medication error becoming inevitable; the question is simply when it is going to occur, not if.
  • Latent factors includes management decisions, staffing levels, general policy and procedure, design of the unit, the pharmacy and the hospital, staff related factors such as perceived time pressure to perform tasks, fatigue, amount of recent shifts worked, was this an overtime shift, how many hours since the last uninterrupted break.  Level of experience of the nurse, pharmacist, ward administrator.  These latent factors can be dormant in a complex system prior to it causing failure.

Errors involving drugs must be the most common hospital safety event and it has been researched widely.  The high error rate may be because there is an over reliance on human factors with a disregard of heuristics during medication preparation and administration.  We need to avoid relying on the flawed human aspects of decision making.  When making rapid decisions we apply cognitive shortcuts. An example would be reading the first few letters on a familiar looking vial, kept in the normal storage space in a container marked with the vaccine name.  So we make an assumption that this must be the right drug and we continue to the next decision. The innovative safety-vests stating do-not-disturb can reduce the pressure to make rapid decisions before the next interruption.

I certainly felt that I could relate to this incident.  It could’ve been me making the error.  I wish that I could say that I always do rigorous medication checks; or that I trust my own decision-making towards the end of a twelve hour shift with limited breaks.  I wish that I could say that at the end of back to back shifts I’m still as conscientious as during the first shift.  I wish that I could say that frequent interruptions do not affect the task that I’m busy with.

 In summary

According to statistics by the Institute for Healthcare Improvement approximately 5% of medical error and harm is caused by incompetence or negligence.  The other 95% involves conscientious, competent and possibly caring individuals.  Mistakes such as this error were probably caused by a bad system and not a bad healthcare professional.

There is a saying that: “a bad system will beat a good person every time.”

The unsafe workspace…patient rage caused by waiting

Waiting feels like a waste of time and is intensely disliked by most people. I used to avoid the waiting area of the emergency centre like the plague, especially on busy days.  At times it would feel like the patients in the waiting room has become an angry mob and I was uncomfortable just walking past. It’s like there is a “peer pressure” in waiting rooms and if one patient complains shouts or is rude it gives permission to others to join in.

As manager I had to deal with patient complaints and staff emotions after a busy day, staff was left feeling emotionally depleted after some shifts.  Last week I attended staff meetings in different parts of an outpatient clinic.  Their previously day was exceptionally busy and the staff expressed similar emotions. There was an increased burden to process more patients, files, scripts and exposure to what I would like to call “patient rage caused by waiting”.

Why the rage?

Hospitals are emotionally taxing environments. Visiting a hospital is stressful for patients and their family. Whilst waiting in line the patients may be in pain, they might’ve just received bad news about their condition; they might lack clarity about their condition or need to come back for more tests or results.  They are required to join a variety of queues for different functions:  registration, doctor consultation, tests, scripts, to make a follow-up appointment and so on.

Add in the length of some queues, poor communication on why they are waiting and duplicated work. Now add in the environment that is crowded, with poor ventilation, unsettling amounts of noise and limited signage of where to go next.

Truth is that patients spend a disproportionate amount of time waiting for that little value adding step and reason why they came to the facility, and then…it’s over in minutes. They might wait three hours for a repeat script. They might wait four hours to be attended to for ten minutes by an absent-minded doctor.

There is so much uncertainty of not knowing what is happening and when it’s happening that it is no wonder that the patients become agitated.

How patients demonstrate their agitation

Both verbal and non-verbal ways of demonstrating unhappiness are traumatic to the staff involved. Verbal rage includes speaking in a raised voice or making verbal threats and insults.  Non-verbal rage may include glaring, rolled eyes or shaking the head.  Emotions can evolve and escalate so basically if the patient’s agitation is not addressed constructively the more queues the patient joins in this emotional state, the more likely emotionally fallout are.

In a study done with Emergency Centre nurses in the USA 97% of nurses reported to have been victims of verbal abuse in the year preceding the study.

A study done in Japan took it one step further. Staff that reported verbal abuse was asked to complete a questionnaire designed to diagnose Post –traumatic stress disorder. The result: 21.3% scored positive for PTSD.

The patient is always right…Not

The buzz words the past few years have been patient centred care, quality care and the patient journey. Regrettably quality patient care and service delivery is associated with the idea that the patient is always right. This idea has resulted in excessive tolerance to be displayed towards patients that are misbehaving fuelling unrealistic expectations by the patients and perhaps creating a certain sense of entitlement.

There’s been this message that the patient’s emotional outbursts and verbal abuse of staff is the result of bad service practise. In one of the hospitals that I worked at we were consistently told that patient outbursts were due to us being lazy, that’s it root cause: lazy staff.

It creates pressure that you will end up in trouble for the patient’s behaviour. Frontline staff feels responsible for patient aggression and if only we did this or that; the patients would not have shouted at us. It is overwhelming and when you compare the emotions and if only’s with the three stage cycle of domestic violence, the similarities are scary.

Patient expectation is often unrealistic and a large part of frontline staff’s jobs revolves around managing expectations and fire fighting. It’s time to acknowledge that it may be unrealistic or hard to deal with.  It also needs to be acknowledged that patients do step out of line.

Where is management?

Bishop et al (2005) did a study on violence in employment services. They demonstrated that although service providers experienced customer behaviour as violent, it was systematically denied by management who failed to acknowledge the behaviour as violent.

Hospital management owe it to the staff to provide a healthy and safe work environment. And perhaps on a busy day hospital management should support frontline staff by visiting patient waiting areas to speak with patients and check in on staff.

Yes to make it better for the patient. Yes the patient is important.  Yes we should be patient centred.

However we need staff to care for patients, to feel compassionate and to pitch at work.   The impact of a verbally abusive patient may linger long after the patient has left.  Exposure to aggressive behaviour by patients has long-term psychological effects on staff including staff burnout, diminished job satisfaction, reduced self-esteem and morale.

This can increase absenteeism which creates a vicious cycle of more pressure on the remaining staff, high turnover of staff and a negative work space.


I’m not sure if there is any fixes to ultimately resolve waiting times and queues.

What I do know is that we need to think about the impact that our dysfunctional system has on staff retention and satisfaction.

I wish that I could find the right words to express that emotion felt by health workers, the sense of futility, regardless of how hard I work and try, they shout at me and then it’s my fault.

For too long in health care we have said that it’s ok if patients direct their rage at us. That it’s part of the job and that it’s something that staff on the floor just need to accept.  You are seen as street savvy if you can cope with it. We need to change this thought process, now!

Bishop, V., Korczynski, M., Cohen L. The invisibility of violence: Constructing violence out of the job centre workplace in the UK. Work, Employment and Society, 19 (2005), pp. 583–602

Florence Nightingale’s other legacy: innovator in descriptive statistics

“To understand God’s thoughts we must study statistics for these are the measure of his purpose” Florence Nightingale

The lady with the lamp….Florence Nightingale is best remembered as the pioneer of modern nursing. What is less known about Florence is that she was deeply committed to the field of statistical analysis in health care.   So much so that Florence was in 1859 elected the first female member of the Royal Statistical Society.  Florence was an innovator in the field of descriptive statistics and she was part of a transformation that showed how social phenomena could be objectively measured and subjected to mathematical interpretation.

Nightingale realized that she had to make data come alive to effectively convey a message; one of her persistent messages was that health care facilities needed to improve. Nightingale held the belief that visual aids and graphs should be easy to understand.  She believed that Queen Victoria and parliament who were not accustomed to statistical data would not understand traditional statistical reports.  So Nightingale innovated and developed the polar area diagram; occasionally called the Nightingale rose diagram.  This was an innovation on the pie chart, invented by William Playfair in 1801.

She was the first person to use visual presentations to report the conditions of health facilities. Data that she presented visually to implement health care reform includes the illustration of seasonal sources of patient mortality in military field hospitals, graphs to report on the nature and magnitude of conditions of medical care in Crimean war, bar charts to show how soldiers living in barracks in England were dying at a faster rate than civilians in the cities around them because of sanitary conditions. She used the visual graphs to demonstrate how mortality could be decreased and after implementation of her recommendations how it was decreased.

“…for me this experience emphasized the great importance of correct hospital statistics as an essential element.” Florence Nightingale

Nightingale was the first to use systematic documentation of deaths in hospital, using the records to calculate death rates due to different causes.   She convinced the politicians of the role of statistics in government pointing out inconsistencies in data such as mortality rate measurements that needed standardisation.  She then took it one step further designing a hospital statistical form for hospitals to collect and generate consistent data.

“…of what use are statistics if we don’t know what to make of them?” Florence Nightingale

Data visualization is the modern branch of descriptive statistics. It involves the creation and study of the visual representation of data with the goal of communicating clearly and efficiently.   It can be used in health care improvement to indicate what should happen and what are happening.

It is not recorded whether nursing documentation existed before Florence used it to drive improvement of care in hospitals and I think that she was the first nurse to use nursing documentation. Her aim with keeping nursing documentation was to illustrate the implementation of doctors’ orders and to use nursing documentation data for statistics on hospital environment, patient safety and quality of nursing care.

It is as imperative now as it was then that nurses should use documentation to push for change and improvement. Nursing documentation should not only be limited to patient care it should extend to drive health care change in the hospital environment.

Health care practitioners are already experts at using visuals to present patient information by taking real time clinical measures of patients, presenting it on charts and then using it to make decisions, implement actions and measure effectiveness. For example vital signs charts, input and output charts, temperature charts, pressure area charts, medication charts.

“Not that the habit of correct observation will by itself make us useful nurses, but without it we will be useless.” Florence Nightingale

We also intuitively understand the importance of taking the right measure and an exact measure. We don’t report that the patient has an ok blood pressure or mild blood pressure.  We don’t expect “some” temperature or “slight” outputs.  We know that if we are to care for the patient to the best of our ability exact measures and trends are important when interpreting charts and vital signs.

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” Florence Nightingale

We need to follow Nightingales guidance and use visual data to improve health care as a greater whole.  Innovating on her concepts and using functional visuals to plan our actions better and at a glance know where the bottlenecks could direct our daily work.  Imagine how we would or could perform if we had this data available to us throughout the day.  I can just imagine the state of nirvana for most emergency nurses glancing at the information and knowing that the EC does not need to overflow with patients because the wards are discharging and there is space for our patients….mmmm…what a happy thought!


A little note: this blog was supposed to be on the visual management of data for improvement, I completely ventured off the topic when I started reading about Florence Nightingale. I’ve read her work on nursing before and visited her museum in the UK, and I’ve always been aware of her nursing accomplishments. Somehow I missed the significance of her other work! They reckon that she was the driving force behind most health related legislation in England for a period spanning more than 50 years, she was instrumental in developing nursing in other countries, health care reform in India, and I could go on and on.  It is mind blowing that one person could impact change on so many levels.  Such an inspiration!  And they reckon that there are more than 300 Nightingale biographies alone!

Vertical and horizontal development in hospitals

Whilst facilitating training in Tanzania last week, we spent time in an emergency centre where immense development and improvements has taken place.  The development has been possible due to financial aid of an external donor.  In addition the external donor has enabled international health care professionals to share their expertise whilst working within the unit on a rotation. Despite the fact that the donor program does not extend to the rest of the hospital, some of the practises has no doubt diffused beyond the emergency centre boundaries.

The ability to render better immediate emergency care and resuscitation has led to improved Emergency Centre (EC) resuscitation survival rates; resulting in more admissions into general hospital. Can the ICU and wards cope with the increased demand, as there has not been foreign aid and focus on their departmental development?  How much stress is the improvement in the EC placing on the rest of the hospital? 

In this blog I attempt to answer a few of my own questions including: can we afford to focus on only isolated parts of a hospital system? How much can we improve before the improvement cause bottleneck somewhere else, or before our improvement boomerangs back and cause problems in the “improved” department?  Is it feasible to start with one part and once it is greatly improved move on, or do we start with a full system?

Within the global health arena the phenomenon of vertical versus horizontal development is extensively debated.  The horizontal approach is focused on integrated health care for the greater community and all aspects of disease and disease prevention.  In-Hospital this means a development program where all aspects of the facility is strengthened simultaneously.  

Vertical development is focused on a specific target population and/or target disease.  In Africa the trend has been for external donors to invest heavily in vertical improvement projects.  Possible reasons includes the relative ease of investing in vertical health programs, measurable results, shorter timeframes to demonstrate improvement resulting in higher and faster return on investment, increasing the attractiveness. 

On the flipside vertical development is criticised for weakening the local health infrastructure and creating dependency on foreign donors.  There is a risk that if external funding is withdrawn the efforts and improvements may fall flat, raising questions on sustainability.  Further criticism of vertical development programs includes that the focus on diseases like HIV/TB has been at the expense of other diseases, resulting in skewed development and luring resources away from further vital health care aspects.  It is stated that vertical development is top-down approaches and the external funder may have preconceived ideas of the problem and how to best solve it disregarding local factors.  I think that these comments are best judged on a case to case basis, what is clear though is that vertical development within an in-hospital setting can result in fragmented care and loss of communication or synergy between departments.

The WHO 2010 World Health Report estimates that 20-40% of all global health spending are wasted through inefficiency and poor governance. It’s believed that this percentage is much higher in Africa and the rest of the developing world.  This poor governance counteracts the fact that horizontal development programs may be more cost effective over the longer term.  In addition one should question the strength of African health systems and whether these systems can cope with the implementation of a full system approach.  In some African countries the risk to invest in horizontal programs are unattractive due to high levels of corruption, political motivation and unrest.

Horizontal health system improvement is dependent on interrelated factors external to the health care which can analytically be allocated to different levels of the system (macro, meso, micro).  All of the above makes vertical developments with quick wins sound so very appealing!

Taking a few lessons from global health; I think that the negative impact of a vertical development program would be more pronounced within the in-hospital setting due to the strong dependency of departments on each other and the patient flow; patients are served by more than one department at any given time during their patient journey.   Any major change in service delivery from one department to another will have a dramatic impact on the patient and on the other departments.

In-hospital systems required synchronization from all the parts/departments and the contribution of one department is always strongly dependent on another department.   The Emergency Centre is dependent on theater, ICU and ward capacity.  The entire hospital is dependent on pharmacy and supply chain factors that are managed from pharmacy.  The entire hospital is dependent on cleaners, porters and administrative services in order to render care.  The advanced technical aspects of EC, ICU and theatre need up to date clinical engineering insights and availability of resources for calibration and servicing of advanced equipment. 

We create boundaries in systems so that we can manage, understand and even manipulate it.  These boundaries are arbitrary and every tiny part of the system is interrelated with other parts that might not be within the boundaries created.  You cannot improve a full system by only focusing on a tiny aspect of it. 

The crucial success factor in making the system work is not the individual parts or how brilliantly they perform independently.  The make or break of a health system or an in-hospital system is the seamless transitions between the various subsystems.  The patient should not even be aware that they are being served by various subsystems; they should experience it as one fully functional system.   The old cliché applies that the strength of a chain is not determined by its strongest link, it is determined by the weakest link.  As such the strength of an in-hospital service is not determined by the best equipped and advanced service provider, but the weakest.

Vertical development such as the approach that I have witnessed is a fantastic and worthwhile first step. The important part of the development is however the next step: evolving into a horizontal approach.  Maybe an appropriate question would be how to decide when to transition successful vertical development into a more horizontal approach?  Examples of such case studies exploring the transition in health care seem to be scarce and it would be interesting to know whether there are any success stories.


So to answer my questions: We need the parallel development of capacity integrating vertical projects into full horizontal system development.  One of my concerns with horizontal development is the time frame before results are seen.  Momentum is an important push to maintain development.  As such a few select vertical projects with quick win strategies may be a great start, but it’s should never be the end of the process.