Who’s (or Where’s) the Boss

Back in the very early days of our time working in healthcare (our apprenticeship if you like) we asked to meet the Ward Manager of the first ward that we were working with. Asking her deputy if the ward manager was around she replied “I’ll have to check the Off Duty”.

We immediately though that this was strange, why ‘off duty’ what about who’s ‘on duty’ (the off duty - a whole other article in itself) and why doesn’t the deputy know where her manager is. That’s how naive we were in this industry.

It transpired that the Ward Manager was on a ‘Management Day’ but was contactable. So we met with her in the hospital library. This is where we learnt that although she was the Ward Manager, responsible for a 36 bed ward, around 50 staff and around 45 patients (per day due to admissions and discharges) she was actually ‘part of the numbers’ she was, when on duty, being a nurse looking after a bay of 9 patients.

This meant that she was working a shift pattern along with the rest of her staff and that when she was not working there was no manager available. Coming fresh from manufacturing and putting this into perspective, we were used to there being a Shift Manager or at the very least a Shift Team Leader so this came as a bit of a surprise.

We imagined the equivalent in manufacturing – a manager who with was responsible for 50 staff working a 27/7 shift system , manufacturing around 45 different batches per day but was actually working ‘full time’ on the line and on shifts.

So at this vital ‘unit level’ the Hospital Ward, if the Manager was working night shifts this week this meant that during the busiest period where everything happens, during the day, there was no one managing at all.

We could not imagine any other industry that would tolerate this. How can she possibly manage? So what was this management day all about? She explained that twice a month she was allowed to spend a shift working out the ‘off duty’, balancing budgets, staff issues and training, complaints and so on. In other words all the stuff that a manager, in other industries, normally does every day. It was admin work not management.

Being naive we had seen the old movies where ‘back in the day’ there was a Matron who was the boss but here it turns out there wasn’t one.

Over the ensuing moths we formed an excellent relationship with this ward manager, who freely admitted that due to her constraints had no chance to know her staff let alone all the patients on her ward. With her assistance we sat down with this ward manager and calculated that for no additional cost she could actually become as we tend to call it in the UK healthcare industry ‘supernumerary’. In other words, by applying a scientific approach to the ‘off duty’ we could free her up to Manage the Ward working normal office hours (when everything was happening) and no longer required to work in one single bay.

Like all experiments we needed to get a base line, a current state. It turned out that whilst on shift, and due to her position as the manager she was interrupted 194 times. As a result, through no fault of her own, if you happened to be a patient in the bay in which the ward manager was responsible for, you actually received less care than a patient occupying a bed in the other bays on the ward.

The ward manger’s boss, looking at both our calculations and base line data, agreed that she could and should, indeed, be supernumerary. Great for ward manager and us.

So we could now introduce simple, yet extremely effective visual operational management – a Plan for Every Patient (PFEP) whereby immediately upon a patient being admitted to the ward a complete plan was drawn up, visually, for the patient, from admission until they were medically fit for a safe discharge.

The process was drawn up and followed whereby the ward manager would at a given time of day invite the nurses responsible for each bay to attend and report whether the patient actually received what they were planned to receive yesterday and if not (variance to plan) how to catch back to achieve the plan, and to re-iterate today’s plan.

During this period planning accuracy, in other word the Patient receiving exactly what was planned for them (On Time and In Full) rose from 41% to 86%. It also provided an excellent means for the ward manager to ascertain which members of staff were ‘on the ball’ knew their patients status or did not.

Through Industrial Tourism this approach proved to be extremely popular with other hospitals within the organisation (and beyond) wishing to adopt it. Great, but a word of caution (from lessons learnt) – don’t tell the Finance Department. Once they know that you can actually install a supernumerary ward manager they may well cut the budget. On this occasion they actually attempted this, yet another battle and yet another blog.