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.

The logframe…time to move on?

‘Those development programs that are most precisely and easily measured are the least transformational, and those programs that are most transformational are the least measurable.’ (Natsios, ex USAID 2010)

Are resource rich funders obsessed with linear planning methods that have measurable interventions? Logical frameworks, showing the trajectory of the proposed project seems to be a prerequisite by most funders. 

The logical framework (logframe) forms the methodological basis for the project.  The framework is designed in such a way that activities lead ‘logically’ to outputs, outcomes and impact.  Six elements are used to evaluate the activities namely relevance, efficiency, effectiveness, impact, sustainability and contribution.  The logical, linear approach forces the project planning team to think about the required steps in order to achieve the outcomes.  

A concern with such a well-planned trajectory is that once set, it becomes rigid leaving little space to learn by doing or make adjustments as the projects progresses. And because it is logical and linear, it runs a risk of being overly narrow and focused.  In some projects focus and rigidity is good.  However in projects that involve multiple stakeholders, focused rigid outcomes runs the risk of reducing the project to simple measurable interventions as opposed to harder to measure sustainable long-term change.

For example community projects with multiple stakeholders are complex with unknown realities and variables. Considerations during the planning phase include multiple stakeholder priorities, diverse cultures, genders, educational backgrounds and experiences. Establishing appropriate indicators prior to commencing the project is difficult.  Some factors will change as the project matures and the rigid ‘logical’ framework may be unable to respond to the emerging knowledge. As such logframes could prevent learning from doing and it prevents tapping into innovative local solutions.

Thus Logframes are not feasible for every project. Participatory approaches including sense-making and PDCA cycles are alternatives that funders need to consider as opposed to linear progression.  In most participatory approaches monitoring is perceived as a learning process whereas in logical frameworks there is a strict separation between planning and implementation. Participatory approaches engage all stakeholders and allow flexibility. On the downside it costs more, is labour intensive and the outcomes may be less measurable.

In the end the method chosen consider the type of project and the priorities.  Participatory approaches work well in complex multi-factor projects requiring change and innovative concepts.  Logframes work well for straightforward projects e.g. vaccination campaign. 



A brief summary: health systems of Uganda, Zambia, Tanzania and South Africa

To improve the delivery of emergency care; awareness of the health system and in-country factors that influence the delivery of healthcare services are needed. Recently I visited Uganda, Tanzania and Zambia. This blog aims to compare relevant existing health data between these countries and South Africa as my point of reference. Data is according to WHO country profiles and World Bank.

Country Data Uganda Zambia Tanzania South Africa
1 World Bank income class Low Lower-middle Low Upper- middle
2 Population (thousands) 37579 14539 49253 52776
3 % of population under age of 15years 48% 47% 45% 30%
4 % of population living in urban areas 15% 40% 30% 64%
5 Total expenditure on health as % of GDP 9.8% 5% 7.3% 8.9%
6 Government expenditure as % of total expenditure on health 44% 58.3% 36.3% 14%
7 Out of Pocket expenditure as % of health (OOP) 69.1% 66.7% 52.1% 13.8%
8 Private prepaid plans as % of private expenditure on health 0.3% 3.5% 1.5% 61.1%


Number 2 -4

Population is relative to the size of the country and when expressed as population per sq.km of land; Uganda is the most populated country of the four; 188 ppsqkm, followed by Tanzania (59ppsqkm), South Africa (45ppsqkm) and then Zambia (21ppsqkm).

Zambia has the lowest population density and 60% of the population live in rural areas. Due to the distances between referral facilities and external factors including infrastructure, transport facilities etc.  Zambia probably face the most challenges to improve access to emergency care

In Uganda, only 15% of the population lives in urban areas. Due to the high population in rural areas, access and availability of care are also challenging.

Number 5- 8

An important question to consider when talking about health systems is: who is spending how much and for what.  The answer to this determines whether people can access care. In Africa (and other developing countries) the expenditure measurements is typically divided into three categories:

  • The government’s direct expenditure to health care services
  • Private expenditure on health care, divided into out-of-pocket expenditure and medical insurance
  • External sources including foreign aid and non-profit organisations contributions

Government’s Expenditure on health

Total expenditure on health as % of GDP demonstrates the level of resources channelled to health in relation to the wealth of the country.  GDP (Gross Domestic Product) are defined as the total market value of all goods and services produced within a country per year.

The government expenditure on health shows the relative weight of government resources in the total expenditure of health.  It provides an indication of the need and priority of healthcare in government policy and budget.  The amount of resources that are assigned to the health sector as %GDP also provides clues about the relative size of the health sector.

In Zambia there is a large difference between healthcare as %GDP and government expenditure. This is interesting and it appears slightly disproportionate in comparison to the other countries.  I’m not sure of the reason, one possible explanation is that Zambia might be training more healthcare professionals (government expenditure includes training of healthcare professionals).  However, this is unconfirmed.

In 2001, all heads of state of the African Union pledged to commit 15% of their national (domestic) budgets to healthcare.  This was to not only to improve healthcare but also to show the African government’s commitment to improving healthcare.  It is observed that none of the four countries adheres to the pledge.

Low government health spending is associated with high out of pocket (OOP) expenditure resulting in catastrophic health expenditure and increased mortality and morbidity.  Furthermore, when government restricts the expenditure on healthcare, they may reduce training budgets thus creating additional barriers to access care.

Private expenditure on health

OOP expenditure is described by WHO as a measure providing insight into the relative weight of direct payments in total health expenditure. If the OOP expenditure is high, a single visit to a health facility may result in catastrophic health expenditure. In Uganda and Zambia the OOP expenditure is very high. It is concerning and OOP expenditure as a government policy is doomed to fail in lower income countries.

Number 7 demonstrates the importance of not only considering single measures.  At first glance it appears as if OOP in South Africa is low.  However health insurance (private prepaid plans) are not included in this measurement; it is shown in number 8.

Private prepaid plans includes expenditures of pooled resources with no government control. It shows the relative weight of voluntary health insurance payments in total health expenditure. This includes voluntary health insurance, medical aids and direct payments for health by non-profit organisations. South Africa has a very high rate of private prepaid plans (81%) in comparison to Uganda’s 0.3%.  OOP expenditure and private prepaid plans are characterised by limited regulations; exposing the population to exploitation and catastrophic expenditure.

External sources to fund healthcare is not discussed here.


In this blog I’ve only touched on the health systems, and some of the potential vicious cycles. It would be interesting to explore each of these cycles. Watch this space!

Please feel free to comment!

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.”

Inspiring ICU….

I was honoured to be invited to speak at the Inspiring ICU Critical Care Congress last week.  My plan was to attend one or two talks and that’s it…I ended up being there for the duration of the Congress.  It was absolutely inspiring. For a few reasons:

– I always thought that Emergency Medicine is leading the way….but I changed my mind….Critical Care is leading the concept of multidisciplinary inputs.  There was physiotherapists and nurses speaking in the main stream.  Most streams consisted of a combination of disciplines hosting and speaking.  It integrated disciplines and described the patient management as shared amongst specialities.  (Not to mention that it described the patient as one)

– Nursing (and other allied health workers) publications and work in end of life care, vital signs, pain scales and numerous other topics was referred during physician’s talks. Apologies if I offend anybody, but in most other conferences I’ve attended the tendency has been that disciplines only refer to research done in their disciplines creating an “us versus them” mentality

– I’ve not attended any other congress where people referred to other people’s talks so many times.  It felt as if everyone was making notes and paying attention

– Improvement was mentioned….all of the time…in most streams….

This was just a short impromptu blog.  I’m inspired….

The key to sustainability…Habit

Workplace improvement and weight loss programs are similar.  Quick and magical fixes are popular and preferred over hard work with incremental results.  Quick wins are frequently followed by worse outputs, greater weight gain and despondency.  The market is insatiable and every few months there is a new fad.

Whatever the improvement is; whether it’s an organization, job process or a diet, the X-factor appears to be that it needs to become a way of life.  There is no magic formula…its creating new ways and consistently being aware of what needs to be done.

I would like to highlight three things that I’ve seen work in organizations and uhm weight loss…


I used to go to a personal trainer that insisted on taking measurements at every session.  The measurements kept me on track….the dread of it going up was deterrent enough not to eat that chocolate or have another glass of wine.  Once I reached my target weight, I decided that I don’t need the measurements (or the trainer) anymore….and I’m sure that you can guess what happened!

In both personal and organizational life, there are so many priorities that unless we have constant reminders of what and how we are doing at them, we lose focus.  Measuring performance can direct focus.  There is no need to have numerous measurements telling the same story.  Less is more, keep it simple, and decide on the focus areas and then focus!  It demonstrates the priorities best if it’s made as visible as possible.

Some organizations view measures as static or passive.  A purpose of measures is actions.  As soon as things change, analysis and actions are required to bring it back on track.  If the measures are going in the right direction it also needs some analysis so that the progress can continue.


Meetings are a great way of ensuring collaboration and sustainability.  Timeless weight loss programmes such as Weighless have regular meetings to provide support, increase morale and motivate people.

Unfortunately meetings have a bad reputation in organizations.  It’s typically perceived as useless because of pointless conversations, limited decision making, and the complaints sessions or dominated by a few opinions.

I’m referring to regular, short meetings.  Assess the measures, identify when it’s going well and anticipate any potential obstacles today and decide how it will be dealt with.  People can become very busy with their own things and lose sight of the bigger picture so introducing a quick daily huddle where everyone can look at the measured priorities will promote focus.

Consistent Continuous improvement

I learnt that there are two battles to keeping weight off.  The first and easiest is to reach is the target condition.  The second and tougher battle is to sustain the target condition, never mind improve on that! The only way to sustain is to pay attention every day. Some days are better and easier than others and bad days are ok, as long as a bad day is not turning into a bad week or month.  If poor performance is allowed it to slip beyond a certain point, it’s very hard to get back on track.

Organizational improvements are the same.  The real battle is not improvement or even implementation; the real battle is sustaining.  Big interventions less frequently are not sustainable.  It should become habit to experiment and improve every day, every process, and every habit.  The word continuous says it all; there is no end or selectivity to it.


Sustainability requires engagement, planning, preparations and constant attention.  There is no easy way. There is saying that nothing in life is good or bad, it’s what you think about it that makes it good or bad. Thus sustainability is dependent on thought processes which are demonstrated through attitude.

As Aristotle said: “We are what we repeatedly do. Excellence, then, is not an act, but a habit”