Saturday, November 16, 2013

Game-changer III: Ward priority and transparency

So we all want to run a hospital smoothly as regards patient flow, don't we?Then as part of the Game-changer series, may I suggest to leaders to step out of the power points, step out of the meetings where they keep reading and listening about regular senior review of patients and actually make it happen?

We talk about regular senior presence, so why isn't that a core part of teams job description? Lets be bold, make it very simple...each team must have regular senior presence...lets start with 5 days, shall we? We want 7 day service in the NHS while we still haven't worked out how to produce regular 5 day senior doctor presence on wards, have we? Again, if the core business of the Trust is to ensure safe smooth flow of acutely ill patients, then it must be the core business of teams to have senior presence on wards each day. Consultant job plans are not that difficult, its just that most medical or otherwise managers struggle to actually get some to perform to agreed job plans, thus the need to revise the Consultant contract again. Not needed in my view, if you have the tools to be open and transparent about job plans and the requirement to be on the wards. What would the senior do? Make sure each new patient is seen after transfer from MAU, make sure all other patients under the teams care is either viewed or plan discussed with juniors..make time to meet patients relatives, and oh yes, be there for your juniors. For lots of physicians, it sounds like an alien concept, but ask our ITU colleagues, they have been doing so for ages.

In job plan terms, depending on acuity and number of patients, you need 3-6 hour per day on the Consultant contract language, that's 15-30 hours / week or 4-8 sessions/ week i.e. less than 1 Consultant dedicated to the wards to do what should be the primary reason you are affiliated with an acute hospital. Yes, I am oversimplifying it but there are teams who would rather prioritise their clinics and their procedures and leave the wards light..stick to 2 ward rounds / week.."It worked when I was a junior, surely it will now?"...cue over stretched juniors, cue no time for training, cue sick patients not having regular senior review, cue blockage in system and frustration from front door colleagues..who get frustrated at the lack of focus on flow of patients but rather on specialist work.

So, want to change the game...yes, of course primary care can do better, yes of course, community teams can pull patients quicker, yes of course, some patients who come to A&E could have another place to go to...but all those excuses a valid one AFTER all hospital teams make sure they prioritise their ward teams. Lets go one step further, make all job plans transparent..make it mandatory that all teams show commitment to the wards, show commitment to patient flow...of course it's much more attractive to go and do the specialty work such as a pump clinic or an endoscopy list...but then again, in a climate where we know regular senior presence is of such high importance on so many levels, that should not even be a debate. You do what needs to be done for patients and in a hospital, there is no bigger need than ensuring that sick patients are reviewed each day by a senior.

I am no preacher but only saying things what I have put in place for our team. A regular senior presence on the wards for our team is a non negotiable issue for all Consultants...whatever be the case, an 8 am presence is essential. Do I have other commitments...yes...a host of commissioned services within the Trust along with 2 community spare me when other specialists insist their elective activity is too much. What has that resulted in?  one of the quickest turn over of patients, a firm which consistently comes top on ratings by juniors as regards education, a team which stays within EWTD hours. Why the inconstancy all around the NHS then? Is it because we like to pamper to certain individuals or is it because we have traditionally designed systems based on what is our convenience rather than what suits the patients? Of course a physician likes to start at's because its convenient. We do so at 8 am..and has made our lives much more simpler..yes, on a social level, does involve juggling kids drop offs etc..but if you want to start the flow of patients in the hospital, you start early, not late..and certainly not when suits us.

For starters, lets do that.Make job plans open to all, make them transparent, make it mandatory that each team provides senior review each day on wards and if they are not, then do some genuine performance management...not one of those which sounds amazing, shows lots of revenue generated but doesn't take into account what the patients feel or what your juniors think of your inconsistent presence. And if individuals are not delivering whats in their job plans, then step up to the plate and find out/ challenge where  they are when they are getting paid by the taxpayers money. As regards departments who are facing increasing pressure regards elective work, my advise? Plan the wards first...and then if there is a shortfall for the wards, then try and build business cases..engage in workforce planning...but don't make the war your second choice.

In healthcare, what the patients say, what the patients need has to be paramount and for that, you make the changes that need to be done..not pander to egos, not make job plans as per individual likes.
So you want to sort patient flow within hospitals? Make some ground rules, be real leaders, step up to the plate.and deliver. That is what being a Game-changer is all about. we attend yet another meeting to hear about the more time or should we step up to the plate?

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