In the healthcare sector, we know how important the voices of patients are. Most healthcare organizations promote the idea that patients come first. On the other hand, patients expect time – their time – to be used efficiently. Lean institutions focus on the essentials and on eliminating areas of waste that do not add value for patients and staff. They try to eliminate forms of waste in the system. A young doctor has experienced both. She knows what it means to work in a lean institution and what it means when waste is not actively eliminated within the organization. In this article, she describes how a day in both institutions usually went and where she experienced the differences.
The following article is an experience report by a young female doctor in 5 parts: Part 1 is dedicated to the topic of “Starting the day”. Part 2 focuses on the ward round. Part 3 is all about surgery planning. Part 4 takes place on the emergency ward. And the final part 5 focuses on the “end of the day”. The author has already worked in various positions in her career. From this wealth of experience, she compares “Clinic A”, which operates according to classic hospital processes, and “Clinic B”, a clinic that operates according to lean principles. Sven Schüpbach has prepared the findings and is happy to answer any questions.
The first part focused on starting work, while the second part dealt with the ward round. Now we present the third part, in which the young doctor shares her experiences in the operating theater. As a surgeon, this area is of crucial importance to her, and she provides an insight into the challenges and special features associated with working in the OR. Everyday life in the OR is both fascinating and demanding. You can’t afford to make mistakes here.
The differences between the two clinics where the doctor worked could not be more pronounced. While one clinic is structured according to the principles of lean management and has optimized its processes as a result, she experiences a completely different reality in a smaller rural hospital.
“Surgery & surgical planning”
Clinic A (non-lean)
The elective surgery plan is usually fixed weeks in advance, but the surgeons are not assigned until the day before at the earliest. There are often changes in the evening and surgeons are often only allocated on the same day. To keep up to date, it is essential to check the schedule every few hours. Today I am at the clinic early and consult the operation schedule first so that I can work out my plan for the day accordingly. I am scheduled for the first operation of the day, an open revision of an incisional hernia. In the afternoon, I will be attending a cholecystectomy, leaving 1-2 hours in between for ward rounds. As I arrive early enough, I usually have time to read up on the cases and patient histories. If I postpone the paperwork until the afternoon, it’s sometimes enough to skim through the surgical steps. This wouldn’t be possible if I didn’t arrive until 7 a.m., as the official start of work stipulates. However, there’s also a lot going on on the ward today, so I have to read up here too. As I am primarily responsible for the inpatients, I prioritize this. In the end, I have 10 minutes before the report. As a junior doctor, I will probably only be assisting with the incisional hernia revision, but may be allowed to perform the cholecystectomy myself, so I primarily read up on this case and prepare myself for it.
On report, I find out that there are still two patients on the emergency ward who are to be operated on today in addition to the elective program. The senior physicians nod, but an operating team is not yet decided on; this happens spontaneously. After the report, I make my way straight to the operating theater, as the first operation always starts at 08:00 sharp. The patient’s medical history is complex. As she has had several previous operations, her anatomy is completely different and difficult to understand. I have to ask the senior consultant in order to understand to some extent what he is doing and what his plan is. I explain to him that unfortunately I hadn’t been able to prepare myself. He kindly tells me the patient’s story.
After 3.5 hours, we have finished the operation and I rush upstairs to make the ward round before the cholecystectomy. I’m just getting to the nursing office when my phone rings – it’s the surgery dispatcher. “You can come to room 2 now,” it says. I am confused. Surely the cholecystectomy isn’t scheduled until the afternoon? The nice surgical nurse tells me that the emergency appendectomy is now in progress and that I am registered as the surgeon – I haven’t been informed of this yet. So I rush back into the operating room and turn my attention to the appendectomy, knowing neither the patient nor his history. The senior doctor operating with me doesn’t know much more either. We were both spontaneously assigned to the emergency operating room. The operation goes well. It’s now 2 p.m. and I hurry upstairs to the ward round. When I reach the 4th patient, the phone rings again. I am now to go to room 4 for the cholecystectomy. I ask the nurse to finish the dressing I’ve opened on the patient, excuse myself and rush to the operating room. The ward round has to wait.
Clinic B (lean)
The elective surgery schedule is set weeks in advance and the surgeons are entered on a weekly basis, so that on Friday evening it is known who will be operating on whom and what the following week. I can therefore read up on the relevant surgical steps at the weekend if I am scheduled for an operation that I have never seen before. I usually read up on the patient’s history the day before. When I come into the office in the morning, I already know from the day before what to expect in the operating theater today. I can therefore concentrate on the inpatients before the morning report and take care of some of the administration. I know that I will be involved in the first operation today, a sigmoid resection. Later in the afternoon, I’m scheduled for a minor proctological procedure, where I’m the first surgeon. Through my preparation, I know that the first patient has status post multiple diverticulitis and is severely obese, so the surgery may be a little more difficult and take longer. I therefore see the critical patients early in the morning before the report so that I can delegate any problems for the time I am away. At the report, we learn that an emergency gall bladder operation still needs to be performed, and the group is asked who else has the capacity for this. I put my hand up and the boss nods. After the report, I go straight to the operating room for the first operation, which always starts at 08:00. As I pass by, I tell the coordinator there that she should sign me up for the cholecystectomy, which is still scheduled. The sigmoid resection goes more smoothly than expected. Thanks to my preparation, I was able to ask a lot of questions about the indications for the operation and why the surgeon was using this or that technique. Shortly before 11 a.m., I walk out of the operating wing and make my way to the ward round. When I reach the 2nd patient room, my phone rings and the surgical coordinator tells me that I can come to room 4 for the gallbladder in 20-25 minutes. This is enough time for me to complete the ward round in the current and next patient’s room in peace and quiet and to briefly read through the patient’s emergency documentation. In addition to symptomatic gallstones, she probably also has a small umbilical hernia that needs to be treated. I am therefore planning to make my approach below the navel instead of to the left. The cholecystectomy goes well, I’m back on the ward by 2 p.m. and can continue the ward round and finish it in peace. As I start documenting the progress in the office, my phone rings again. The first proctologic procedure will be ready in 15 minutes. I quickly finish writing up my progress notes and have a snack. After the last operation of the day, I finish the necessary office work and read through the patient files for tomorrow’s planned operations.