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Decent work & regulation: Insights from research on hospitals

A vital sector, interesting, unionised & an essential service!

 Greg J Bamber

 Monash university, Melbourne, Australia  & Newcastle University Business School

 www.gregbamber.com  This summarizes work in progress. Before quo=ng this, please seek

permission from [email protected]  Thanks to the excellent NUBS ESRC Team. This draws on 2 research projects that were supported by the Australian Research Council &

other funding agencies. Thanks to them too!

Influences of Regula/on on work can be posi/ve, neutral or nega/ve; it may depend on your perspec/ve!  FIFA & the banks!  They make the case for more regulation & refute the argument for self-regulation.

 Airlines  De-regulation opened the gates e.g. to Ryanair –

 Notoriously bad as an employer: bogus self-employment of pilots; huge churn of staff! If you even dream of Voice via a union it sacks you!

 As Carol put it; its in a ‘race to the bottom’!

 Hospitals  Self-regulation failed e.g. Working hours junior hospital Drs

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What is decent work?

 Reflects the aspira=ons of people in their working lives  Involves opportuni=es for work that is produc=ve & delivers a fair income  Security in the workplace  Prospects for personal development & social integra=on,

 Freedom for people to express concerns, organize & par=cipate in the decisions that affect their lives  Equality of opportunity & treatment.  Source: summarised from: www.ilo.org Also Steve Hughes!

Hospitals: Complex Organisa/ons! Highly educated, skilled, altruis=c clinical staff – oZen in short supply! Powerful professionals associa=ons & unions. Work roles bounded by professional jurisdic=ons, regula=ons & industrial rela=ons (HR/IR) agreements. Clinical staff organised in func=onally differen=ated ways – in different groups. Nature of pa=ent care (unpredictable) oZen confounds a^empts at ‘standardisa=on’ 24/7 Context of increasing demand, expecta=ons of improved quality of care, improved efficiencies & effec=veness & resource constraints.

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Hospitals: A ‘perfect storm’! Ø  Increasing patient presentations in accident &

emergency (A & E); inpatient demand for beds & services.

Ø High on political & media agendas Ø  Increased demand by elderly with complex co-‐

morbidi=es (i.e. more complex management and care required)

Ø  Reducing resources in healthcare through e.g. efficiency dividends; management by KPIs and targets; etc.

Ø  Aging popula=on with limited community care services Ø  Shortages of aged care community beds.

Key problems in hospitals Ø Annually increasing numbers of A&E presenta=ons and admissions

Ø 100% or higher rates of bed occupancy Ø Lack of available hospital beds to cope with increasing pa=ent demand (‘bed block’)

Ø Problems with capacity management Ø A&E ‘access block’ i.e. A&E beds full and unable to transfer pa=ents requiring admission onto ward beds.

Ø Long pa=ent waits for assessment and treatment in triage wai=ng room.

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Much Regulation: 8 hr targets in A & E  Adapted from NHS!  Induced health services in Oz & Canada to apply notions of ‘Lean’ to increase flow of patients through A & E.  Also in the UK & US!

What is Lean Management (LM)?  A produc=on method that shortens the =me between order placement and product delivery by elimina=ng waste from a product’s value stream.  It is a holis=c approach to management as well as a set of tools developed in car manufacturing: the ‘Toyota Produc=on System’ (Womack and Jones 1993).  Advocates & cri=cs!

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‘Leaning’ hospitals with limited resources: Accident & Emergency (A&E) Departments in Canada & Australia Many similarities to the UK, but some differences! What about the workers?

THANKS TO: RICHARD GOUGH (VICTORIA UNIVERSITY);

RUTH BALLARDIE (CHARLES STURT UNIVERSITY);

PAULINE STANTON (RMIT UNIVERSITY),

AMRIK SOHAL (MONASH UNIVERSITY),

TIM BARTRAM AND SANDRA LEGGETT (LATROBE UNIVERSITY)

Intended to increase efficiency of nursing work processes & ‘release =me for direct pa=ent care’ Inves=gated the implementa=on: the impact on managers and workers, including nurses. Interpreta=ons of ‘pa=ent care’ from different perspec=ves: top & bo^om!

Lean A&E Ini+a+ve

GREG BAMBER, MONTAGUE BURTON VISITOR, CARDIFF UNIVERSITY/MONASH UNIVERSITY, 2014 10

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 Nursing work is ‘chao=c, fragmented, and subject to frequent interrup=ons’.

 Average 72 tasks per hour; only 37% =me on direct pa=ent care.*

 Increasingly ‘busy wards’ with more paperwork (audi=ng).

 Nurses face increasing pressure to accelerate pa=ent discharges (complex & =me consuming), so more can enter!

-‐-‐-‐-‐-‐-‐

*Duffield, C., Diers, D., O'Brien-‐Pallas, L., Aisbe^, C., Roche, M., King, M. & Aisbe^, K. (2011) ‘Nursing Staffing, Nursing Workload, the Work Environment and Pa=ent Outcomes’ Applied Nursing Research, 24(4) pp. 244–255.

What about nursing?


REGULATION

Ø 80% pa=ents requiring hospital beds to be admi^ed within 8hrs Ø 90% of all pa=ents out of A&E within 4 hours.

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Ø Enhanced pa=ent safety! Ø Lean promises ‘releasing =me to care’ through efficiency gains.

Ø Able to do more with fewer resources!

Key findings: from the top Success stories!


 Different perspec=ves….

Key Findings: From the boRom!


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 Pressure for ‘more efficient’ use of beds by decreasing pa=ents’ length of stay.  In contexts of c.100% bed occupancy, means faster pa=ents turnover.  Aim to increase efficiency using Lean, undermined by prevailing high workloads, managers seeing it as a quick fix & scarce resources!  More & sicker pa=ents in same number of beds: work intensifica=on for nurses!

 No evidence of increased ‘=me’ released. But if so, it would be used dealing with more pa=ents: work intensity!

Work intensity: Not Decent Work!


 Yes perhaps, but it depends on the context; yes in the OZ & Canadian cases, but not at Virginia Mason, US!

 No, insofar as there are also other more powerful Work Intensifica=on drivers e.g. New Public Management, budget cuts, staff shortages & ‘poli=cal’ targets!


Does Lean induce work Intensifica/on for nurses?

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Work intensifica/on  Australian nurses complained of increase work intensifica=on due to the redesigned care process -‐-‐ resulted in A&E becoming a produc=on line.

 Canadian nurses had reduced staff on night shiZ and work intensifica=on.  In both places:

 Nurses on Lean projects not backfilled, so work done in own =me. High levels of work intensifica=on a barrier to par=cipa=on on under-‐resourced lean projects.

 Nurses complain of work intensifica=on associated with increasing numbers of pa=ents & faster rates of flow. In Australia, 90% A&E nurses report coping by working part-‐=me (mostly 0.8) with similar reports in the Canadian hospital!

 “Its too demanding to work full =me!”

Does Lean induce work intensifica=on in Healthcare?

 Perhaps, but not necessarily if it is adapted & implemented consistently, systemically and sustained, not seen as a quick fix!

 Encouraging 5 year =mescale being adopted by NHS!

 It is the involvement, sustained commitment & engagement of the Drs, nurses, managers & other staff that really makes the difference for pa=ent care & the workers!


Conclusions

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Conclusions  Hospitals as complex systems significantly affect the implementa=on of lean.  Wider poli=cal contexts affect the experience of work.  Lack of resources and external and internal regula>on can impact more significantly than Lean on the work intensity of staff in nega=ve ways!

Thank you! Let’s discuss…. Comments or questions welcome now or e.g. via email:

[email protected]

Professor, Monash University, Melbourne.

Visiting Professor, Newcastle University Business School

More reading? See: www.gregbamber.com

Esr csem5vers4 sj0615

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