Stock-outs in SA hospitals…could it be that our daily inventory systems are outdated?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 Some of the standard practises appears to be rather outdated.  A good example of such an outdated hospital management system is the inventory system used in South African Hospitals.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.

Summary

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.

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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.

Summary

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!

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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!

Gratitude for our Health Care system

I’m not a fan of the latest fad on facebook to nominate people to publically do gratitude.  That being said it has inspired me to do a little gratitude for the South African Health Care system.  A system that I think we do not always appreciate enough!

I have been very blessed to have had exposure to other African country’s health systems and I made this list after collating field notes after visiting health facilities in Zambia, Tanzania and Angola.

Yes there are South Africans especially in the Eastern Cape and the Free State that would find the below little list all too familiar however most of us can appreciate that:

  • We do not need to walk for hours to reach the closest very basic health care facility
  • We do not need to arrange for our own transport when our condition is too serious at a health care facility and we need referral
  • We do not need to arrange our own transport when involved in a motor vehicle accident
  • Our own transport does not involve ox wagons, wheel barrows or being carried by our neighbour
  • When admitted to hospital, as part of the service we are fed and we do not have to rely on our family to sleep outside of the facility in order to bring us meals during meal times
  • Hospitals have safe running tap water, we do not need to walk 700 meters to the closest pitted well for water to take our tablets
  • We generally work at a better ratio than 7 doctors giving orders whilst  1 nurse executes the orders
  • If we are assaulted we can go to the hospital first and the police later as opposed to vice versa in these countries
  • We do not follow a “gross triage protocol” where you are extubated in the emergency centre should there not be enough beds in ICU.  If you survive extubation you go to the ward.  If you don’t survive it, well then you don’t really need a bed do you?
  • We have Ambulance services that are run by qualified prehospital practitioners with equipment and supplies inside of them as opposed to a stretcher and single driver system
  • We have created a capacity to deal with major incidents
  • Most of our waiting rooms and areas at health care facilities are inside a building, offering some protection against environmental elements like wind, rain, cold.

So today I’m simply saying thank you for our health care system in South Africa.  We are blessed in so many ways.

IMG_6039 Hand washing facility in health care facility

IMG_5887 Waiting area.