4 ms·

>The fix is one that Hospital admins don't want. Pay your nurses more and hire more As someone who worked in hospitals to help redesign their processes, this o

by bumby 5y ago

>The fix is one that Hospital admins don't want. Pay your nurses more and hire more As someone who worked in hospitals to help redesign their processes, this one piqued my interest. For every project I worked on (and I mean literally every one), the team lead wanted to jump to the solution that they just need the ability to hire more people. In the rare instances where they were able to convince hospital admins to do so, it never fixed the problem. Not once. Why? Because it never addressed the root causes. They needed to take a process-oriented approach. There's a saying that adding more people to a broken process makes things worse. You can hide a lot of quality issues with inventory; if you have a requirements for 100 widgets a day and you have a crap process that only makes 10 quality widgets, you can meet your goal by increasing throughput 10x, but nobody thinks that would be a good approach. It's the same with injecting more staff onto a broken system. If the system causes nurses to spend disproportionate amounts of time on admin work and not on direct patient care, it may be better to look at your admin processes rather than just hire more nurses. It's natural when people to feel overwhelmed to think the solution is to just hire more people, but it's almost always better to hold off on hiring until the system/process is fixed. Edit: I'm curious about the downvoting. I think it would help illuminate the conversation if you could explain where your disagreement lies. I'm basing my statements on actually tracking when hiring was increased to the levels desired and metrics did not improve.

ben0x539 5y ago
i think that argument works a lot better in a field where they arent bullying people into working overtime near constantly
- bumby 5y ago
  Perhaps. But again, why is the overtime needed? If it's because it provides more patient care beyond what a nurse can provide in a good system, it might be a valid point. But if it's because the system is fundamentally broken, I'm skeptical that hiring more people will actually fix anything. From personal experience, it will only create a lag that will require the same need for more hires down the road.
  - ben0x539 5y ago
    if the overtime isnt needed let people go home after 6 hours each day
    - bumby 5y ago
      I think maybe I'm miscommunicating the point. Yes, if overtime isn't needed people should be sent home. Hospitals agree on this; they don't want to pay overtime if it's not needed. The issue I'm pointing to is that sometimes it's "needed" because of a bad process, like when there is redundant work. Sometimes it's needed because the system needs slack to compensate for disruptions in system dynamics. Sometimes it's "needed" because "that's how we've always done things." Point being, if it's needed, it should be because it contributes directly to better patient outcomes rather than bad processes.
      - ben0x539 5y ago
        My contention is that if you reduce redundant work, staffing levels will be reduced to match to go back to the current equilibrium of overwork.
        xeromal 5y ago
        And that seems to speak to his point exactly. The problem isn't that there isn't enough staff. It's the management is performing badly at scheduling or some other process. The internal problem needs to be fixed before hiring is increased.
        watwut 5y ago
        The issue is that you hold this as axiom valid across industries. Since your personal experience with IT projects was that process was always issue, therefore when nurses say the hospitals need to hire more nurses, you assume they must be wrong. And you also completely ignore industry specific realities - like there being surge of patients due to covid.
kedean 5y ago
You're describing Brook's Law from The Mythical Man-Month. It was an observation of collaboration in software engineering specifically, and it cannot be applied universally to every industry. Really, anything that is highly parallel (medicine, teaching, stocking shelves, waitstaff, deliveries) can benefit from hiring more people until you reach saturation, and medicine isn't there or we wouldn't be having the conversation. The problems are caused by a "just in time" approach to staffing, where you have exactly enough people to cover the shifts at bare minimum. What solution would you suggest other than more people? They are not saying to throw more nurses at patients simultaneously, they are saying to hire more nurses so existing ones aren't bound to spent the entire week stretching themselves across the hospital. Also, I think you are being downvoted because you are applying software engineering rules to medicine.
- bumby 5y ago
  It's interesting because they aren't software engineering rules. If anything, they are industrial engineering rules that pre-date software and certainly older than the mentioned book from 1975. The approach I was using was developed specifically for healthcare and with great effect in some organizations. I know this is HN, but I think it's an error to assume everyone is coming at a problem from a software perspective. >What solution would you suggest other than more people? It obviously depends on the situation but most of the time it comes down to reducing process waste. That may be automation through software where a nurse was hired specifically to only generate reports 40 hours a week, to re-designing a layout that minimizes travel time for nurses when they are delivering to patients. My experience with the staffing situation is that managers did not know how to staff to meet the needs of their patient loads and just revert to simple heuristics that left them understaffed at some times while being overstaffed at others.
  - phil21 5y ago
    > re-designing a layout that minimizes travel time for nurses when they are delivering to patients. I think talking about micro-optimizations like this misses the forest through the trees. It's neat and cool. Fun to wring out those last bits of efficiency. But the fact you even need to discuss it shows how hiring adequate amount of bedside staff is the absolute last thing any medical system will do. > revert to simple heuristics that left them understaffed at some times while being overstaffed at others Showing that they were better than modern day automated shift planning. I will submit that if your hospital floor staff is not 50% idle on your average given fully-staffed boring day, you are understaffed. Only extremely exceptional events should cause your staff to be booked 100%. When it happens it should be root cause analyzed and be immediate cause for executive concern. The trope of card playing nurses should be true, because of all industries there are - you want surge capacity in healthcare. Both physically speaking in terms of warm bodies available, as well as mentally speaking in brains not being stressed to their max the entire shift. I understand these ideas don't end up with maximal efficiency. I am likely naive as well - but it's pretty clear that hospital systems are being operated in an intentional manner to keep staffing cut to the bone right up until the point the system or people break. This doesn't just hold true for healthcare, it's endemic in a lot of service industries where the bottom tier employees are expected to live in service of the profession and take up all the slack from above.
mcv 5y ago
> If the system causes nurses to spend disproportionate amounts of time on admin work and not on direct patient care, it may be better to look at your admin processes rather than just hire more nurses. I get the impression that the same is often true for teachers, academics and cops: too much focus on administration, which takes the focus away from the reasons they chose these jobs in the first place. Streamline the administrative process, or have dedicated administrators help them with the boring stuff, so the nurses, teachers and cops can focus on the actual content of their jobs.
- bumby 5y ago
  I would say streamlining is definitely preferential to do first and sometimes hiring staff afterwards. If the latter is done first it can quickly result in administrative bloat. I often wonder if that's part of the issue with higher education and contributes to some of the increased costs in recent decades.
sanotehu 5y ago
If you're interested in chatting about this sort of stuff, let me know. I'm a UK doctor working in the field, always looking to optimise processes while keeping quality. Email is in my profile.

by bumby 5y ago

ben0x539 5y ago

i think that argument works a lot better in a field where they arent bullying people into working overtime near constantly

bumby 5y ago
Perhaps. But again, why is the overtime needed? If it's because it provides more patient care beyond what a nurse can provide in a good system, it might be a valid point. But if it's because the system is fundamentally broken, I'm skeptical that hiring more people will actually fix anything. From personal experience, it will only create a lag that will require the same need for more hires down the road.
- ben0x539 5y ago
  if the overtime isnt needed let people go home after 6 hours each day
  - bumby 5y ago
    I think maybe I'm miscommunicating the point. Yes, if overtime isn't needed people should be sent home. Hospitals agree on this; they don't want to pay overtime if it's not needed. The issue I'm pointing to is that sometimes it's "needed" because of a bad process, like when there is redundant work. Sometimes it's needed because the system needs slack to compensate for disruptions in system dynamics. Sometimes it's "needed" because "that's how we've always done things." Point being, if it's needed, it should be because it contributes directly to better patient outcomes rather than bad processes.
    - ben0x539 5y ago
      My contention is that if you reduce redundant work, staffing levels will be reduced to match to go back to the current equilibrium of overwork.
      - xeromal 5y ago
        And that seems to speak to his point exactly. The problem isn't that there isn't enough staff. It's the management is performing badly at scheduling or some other process. The internal problem needs to be fixed before hiring is increased.
        watwut 5y ago
        The issue is that you hold this as axiom valid across industries. Since your personal experience with IT projects was that process was always issue, therefore when nurses say the hospitals need to hire more nurses, you assume they must be wrong. And you also completely ignore industry specific realities - like there being surge of patients due to covid.

kedean 5y ago

You're describing Brook's Law from The Mythical Man-Month. It was an observation of collaboration in software engineering specifically, and it cannot be applied universally to every industry. Really, anything that is highly parallel (medicine, teaching, stocking shelves, waitstaff, deliveries) can benefit from hiring more people until you reach saturation, and medicine isn't there or we wouldn't be having the conversation. The problems are caused by a "just in time" approach to staffing, where you have exactly enough people to cover the shifts at bare minimum. What solution would you suggest other than more people? They are not saying to throw more nurses at patients simultaneously, they are saying to hire more nurses so existing ones aren't bound to spent the entire week stretching themselves across the hospital. Also, I think you are being downvoted because you are applying software engineering rules to medicine.

bumby 5y ago
It's interesting because they aren't software engineering rules. If anything, they are industrial engineering rules that pre-date software and certainly older than the mentioned book from 1975. The approach I was using was developed specifically for healthcare and with great effect in some organizations. I know this is HN, but I think it's an error to assume everyone is coming at a problem from a software perspective. >What solution would you suggest other than more people? It obviously depends on the situation but most of the time it comes down to reducing process waste. That may be automation through software where a nurse was hired specifically to only generate reports 40 hours a week, to re-designing a layout that minimizes travel time for nurses when they are delivering to patients. My experience with the staffing situation is that managers did not know how to staff to meet the needs of their patient loads and just revert to simple heuristics that left them understaffed at some times while being overstaffed at others.
- phil21 5y ago
  > re-designing a layout that minimizes travel time for nurses when they are delivering to patients. I think talking about micro-optimizations like this misses the forest through the trees. It's neat and cool. Fun to wring out those last bits of efficiency. But the fact you even need to discuss it shows how hiring adequate amount of bedside staff is the absolute last thing any medical system will do. > revert to simple heuristics that left them understaffed at some times while being overstaffed at others Showing that they were better than modern day automated shift planning. I will submit that if your hospital floor staff is not 50% idle on your average given fully-staffed boring day, you are understaffed. Only extremely exceptional events should cause your staff to be booked 100%. When it happens it should be root cause analyzed and be immediate cause for executive concern. The trope of card playing nurses should be true, because of all industries there are - you want surge capacity in healthcare. Both physically speaking in terms of warm bodies available, as well as mentally speaking in brains not being stressed to their max the entire shift. I understand these ideas don't end up with maximal efficiency. I am likely naive as well - but it's pretty clear that hospital systems are being operated in an intentional manner to keep staffing cut to the bone right up until the point the system or people break. This doesn't just hold true for healthcare, it's endemic in a lot of service industries where the bottom tier employees are expected to live in service of the profession and take up all the slack from above.

mcv 5y ago

> If the system causes nurses to spend disproportionate amounts of time on admin work and not on direct patient care, it may be better to look at your admin processes rather than just hire more nurses. I get the impression that the same is often true for teachers, academics and cops: too much focus on administration, which takes the focus away from the reasons they chose these jobs in the first place. Streamline the administrative process, or have dedicated administrators help them with the boring stuff, so the nurses, teachers and cops can focus on the actual content of their jobs.

bumby 5y ago
I would say streamlining is definitely preferential to do first and sometimes hiring staff afterwards. If the latter is done first it can quickly result in administrative bloat. I often wonder if that's part of the issue with higher education and contributes to some of the increased costs in recent decades.

sanotehu 5y ago

If you're interested in chatting about this sort of stuff, let me know. I'm a UK doctor working in the field, always looking to optimise processes while keeping quality. Email is in my profile.