How To Do Today's Work Today

Dear Colleague 

When you book a room in a hotel, what does the hotel tell you about when you should arrive? They will tell you that you can check in after midday – right? 

What about the day you leave? You have to be out of your room by late morning – agreed?

This is something we’re all completely used to and we would be astonished if a hotel didn’t make these conditions clear to us when making our booking. 

The reason why hotels do this is obvious. They have a fixed number of rooms available. Their business requires them to do two things successfully. 

  1. First they must maximise the number of rooms occupied overnight.
  2. Second, they must create a good customer experience. 

They achieve this by insisting that customers who are leaving the hotel, leave their room early in the day. This allows the hotel staff to clean the room, make the bed and stock up any items that need to be re-filled.

By asking customers to arrive later in the day, they can be confident the room will be ready for them – even if the room had been occupied the previous night.

By now, you’ll probably have guessed where I’m going. 

Managing Flow

At Al Wakra Hospital we are under pressure to admit early in the day. This is partly because we have to accommodate patients who have been assessed as needing admission overnight and also because a lot of our planned and elective patients will arrive first thing in the morning.

When we look at when most of our discharges happen, the bulk of them happen later in the day.

Imagine what a hotel would be like if that’s what happened. There would be dozens of angry customers waiting in reception, frustrated they can’t get into their room.

This is what happens to us. In fact we are roughly four or five hours out of sync. If we could bring forward the majority of discharges by four of five hours, congestion in the Emergency Department would be greatly reduced.

This seems so obvious, the wonder is that we are allowing this to happen every day. The reason has a lot to do with 2 things.

Complexity Means We Lose Sight Of Simple Truths

The first is complexity. It is actually quite complex to organise a discharge for a patient. It’s certainly much more complicated than leaving a hotel room. 

Letters have to be composed, prescriptions organised, after care arranged and transport sorted. All of this work is often required when doctors and other clinical staff are at their busiest, first thing in the morning.

In all the busyness of our daily work, we can lose sight of such a simple truth. Enabling the hospital to be ready to meet today's demands earlier, will create a much better impression of the hospital. It will also be safer, provide better quality and reduce the stress that staff feel when we can't move patients into a bed.

The second thing that gets in the way are our own assumptions.

We Can Be Prisoners Of Our Own Assumptions

When I worked in Cardiff we asked doctors who were responsible for filling the take home prescription why they didn’t do this the day before the planned date of discharge. After all, they knew they would be busy in the morning and a late prescription is one of the main reasons why patient discharges are delayed.

They answered that they didn’t do this because the prescription was often changed on the day of discharge, once the final review had been done.

We thought this was interesting and so we did some research. What we found surprised everyone, including the doctors. We found that in a very high proportion of cases, the prescription that was set on day of the admission, was unchanged at the time of the discharge. This was true in over 90% of all cases.

Once this was understood, the doctors were able to adjust their practice – preparing the prescription the night before, accepting that once in a while they would have to adjust it.

Paediatric Division Leading The Way – Medicine Division Following

I have been asking our teams at Al Wakra to start thinking about this issue. I am delighted to say that the Paediatric Division have done a lot more than just think about it. They have completely re-designed they way they do discharges and now more than 60% of patients of their patients are consistently leaving the hospital before 10.00. A massive well done to them.

The Medicine Division have now started to work on this. We all need to get behind Medicine and help them, because if they can crack this we will make an enormous difference to our patients’ experience of urgent care. 

I believe it is possible to design a way of working which much more closely fits the experience we have in hotels. I know we have a more complex job on our hands, but I also know we are more than capable of skilfully dealing with this complexity.

I don't think we are going to be prisoners of our assumptions either. There really is no reason why hospitals like ours can’t do this.

Over the next few months I’m looking forward to being able to share with you more and more good news on this issue.

For now however, let me wish wish good health and happiness for you and your family for the week ahead.

Keep well.

Adam