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Archive for October, 2013

It’s not about the form… it’s the human touch

20 Oct, 13 | by Toby Hillman

A ‘typical’ request form?

There are several problems which rear their ugly head every few months / years in healthcare and yet seem impossible to crack.

In the main they pass by, unnoticed by the great and the good, and not usually causing discernible problems for patients.  But, time taken to gather phlebotomy equipment, delays in prescribing ‘TTAs’ and ordering too many tests are all a waste of resource.

Waste is the enemy of efficiency in any system, and the 7 wastes:

  • transportation
  • inventory
  • motion
  • waiting
  • over-processing
  • over-production
  • defects in work performed

are the target of many improvement projects (especially those relying on lean thinking)

One such improvement project has shown a successful, and sustained reduction in the waste of excessive laboratory tests.


The paper reports the process undertaken to introduce a change in the practices of an emergency department, through a forcing function of only allowing junior staff to order tests once a senior had approved the request.  The largest excesses in requests were targeted and significant changes over time were achieved.
The report puts some of the change into context, but I wonder if a follow up, qualitative study might be required to really evaluate what changed.

I may be wrong, but this intervention doesn’t seem like one which was imposed rigidly from above, but instead was developed in collaboration with the key clinical decision makers in the department, and with an eye on what would actually work on the ground – in *their* department.

And this is the messy bit.

For senior clinicians, and managers who see the headline: ‘Change in form reduces tests, saves $$$‘ there could be a shock coming.

Firstly, the change took time to bed down – see the histograms for the weeks after the intervention – so no quick fix.

Secondly – don’t kid yourself that it was the change in the form which made the difference – it was a shared vision for change from senior, middle and (probably) junior grade doctors.  After signing up to a shared goal, there was a change in working practices, backed up by a staffing and service delivery model (note the absence of a 4 hour target, and retention of responsibility by the ED for short stay patients) which encouraged a dialogue between seniors and trainees. Moreover – and crucially, in my view – the change opened up the possibility of real-time, on the job, training.

Each interaction for an additional request seems like it will have been a discussion point – and trainees benefitted from a culture of learning within the department.

So, could this be reproduced in the UK? In some departments, I’m sure, in others – no way.

In trying to replicate such successes we should not concentrate on the mechanics of the intervention, but the human factors and cultural context. Work on that, alongside such innovations and you stand a much better chance if success.

For more information on human factors (if you’ve not heard the phrase – look it up – it could change how you view your world and where you work) then see the Clinical Human Factors Group  and an inspirational video on human factors in patient safety from the incredible Martin Bromiley:

Burnout – its not just the hours.

1 Oct, 13 | by Toby Hillman

A burnt-out doctor. via


Burnout is a condition which is all too common amongst junior doctors.

The accepted research definition is:

’emotional exhaustion and a reduced sense of personal accomplishment associated with prolonged occupations stress.’

This is probably a familiar state of mind to many junior doctors out there, and many senior doctors – either from their current experiences, or their training years. The fact that this is such a familiar feeling is worrying in its own right – surely we don’t want people ‘caring’ for us who are emotionally exhausted.  If one has exhausted one’s own emotions, there is little spare capacity to appreciate the human tragedies being played out on our wards on a daily basis

So – what to do about it?  The traditional position from educators / monitoring authorities and professional bodies has been that the duration of duty is the killer – and that shortening hours will sort things out. But, with the advent of the European Working Time Directive (EWTD) juniors hours in the UK were limited significantly – and the lounges of clubs and colleges started to echo with the refrain of a multitude of ‘when I was…’ arguments. Indeed –  without wishing to sink to the depths of the Monty Python sketch there is some truth in the old stories of how long juniors used to work, and how the current generations of juniors can’t imagine some of what was expected of their now seniors.

The EWTD is a limit on hours – and it has undoubtedly changed the way junior doctors work forever.  A recent study has looked at the effect of similar (but crucially different) legislation in the US.

Reading this – the most impressive thing which struck me was not the finding of the huge rate of burnout (76% – sadly this wouldn’t have surprised me as a JHO [old money FY1])

The feature of the study which struck me most was that, of the 76% who reported being in a state of burnout, those reporting burnout reported a whole tranche of characteristics which go slightly further than the definition of burnout highlights. The top third of burnt out doctors reported that the quality of patient care they were delivering was ‘good’ or better only 29% of the time.   They made errors due to workload at least ‘sometimes’ for 94% of the time, and 29% of them did not feel motivated to improve their practice, and 35% of them didn’t think that management were interested  These last figures are worrying.

To think that doctors, struggling due to workload, and in a system where they don’t think that they would feel safe as a patient would feel un-motivated to improve, and that those with the power to change these circumstances would not be interested in their ideas is evidence of a once proud profession beaten into submission, and highlights major risks to patient safety.

The study also shows that burnout is not a simple factor of hours worked – other important factors are at play. The working patterns, and cultural aspects are important too.

I believe that it is possible to limit the risks to doctors and patients through fatigue and burnout through more imaginative means than simple hours limits.  Firstly doctors must feel empowered to highlight concerns to ‘management’ (and note – this includes consultant colleagues) and must be supported in efforts to improve their working lives – they are the ones working them.  Solutions must come from the front-line – as this example shows. Indeed – this thinking is starting to make an impact at high levels – the recent Keogh Report into 14 failing hospitals contained the ambition that junior doctors would not be seen only as the clinical leaders of tomorrow, but of today.

I am convinced (and the research to prove this is probably under way  – or needs to be) that junior doctors work in conditions which stifle creativity, and create passive operatives – rather than vibrant, active and positive members of what could be the highest performing health system in the world.

Limiting hours was an important step to start to address the conditions clinicians used to train (and treat patients) under, but the changes required to create excellent working conditions for healthcare professionals, with the resultant benefits in patient care will be more subtle, but involve tectonic shifts in the cultures of medicine, medical management, and healthcare provider organisations.

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