Week 2 – 21st June 2015
So, week 2. Overall this week turned out to be more about me getting to know more detail about how the maternity unit’s processes work, especially the stock and ordering systems, shift handovers and daily checks. It was a week when I realised that there are many parallels between how the team in the maternity unit work and how we work in steel industry and when the reality of working in a health setting really hit home.
On Monday I returned to the ‘on-call’ rooms that I had worked in the previous week and counted and estimated the value of the materials that had been collected for use in Friday’s workshop. It’s difficult to be accurate but a rough estimate is that the materials were worth around 100,000 Gambian Dalasi (GMD), which is around £1600 or €1150. To put this in context, a new roof for the two inpatient wards at the maternity unit currently being planned is likely to cost around 200,000 GMD. So the value is quite significant. This was motivating for the team to hear and we pledged to start work on the second room this week.
Also on Monday I spent some time with the department manager, understanding his daily checks. One thing we realised whilst working together was that he was checking a number of things that other people were also checking, so there was an opportunity for some streamlining of those daily audits.
Finally, we introduced a mini-suggestion scheme to the team. It hadn’t been tried before and with no PCs we couldn’t use an online tool. So we went for post-it notes and set up the ‘Post-it Notes Ideas Box!’ We explained to the staff that we wanted to hear their ideas of how we could improve things for them and for the patients. They could leave their name or just write anonymously. We gave everyone a small pack of notes and I finished the day wondering if the idea of having an ‘ideas’ box would work.
Well Tuesday came and the doctors and I were more than a little excited to see that there were in fact more than ten post-it notes in the box! The ideas ranged from things related to terms and conditions to things such as ensuring support for staff in one department that is currently short staffed and ensuring that key pieces of equipment had specified locations to make running the daily and shift checks easier. Some things we could act on straight away, such as ensuring an allocation to the ward round (where the patients get medication or decisions to be discharged), others were part of larger processes but overall we were able to show how we would work with the team to support them in finding solutions to the issues that they raised.
I was also able to shadow the shift leaders doing their daily checks and with one leader we created a spaghetti map to see what the checking process looked like in ‘journeys and time.’ It turned out to be over 40 steps and a similar number of minutes to complete. We learnt that the sheet for doing the daily checks was organised in alphabetical order but if followed in order this meant crossing between locations more than once. The shift leader suggested changing the order of the list to match the stock locations in order to make it easier to take fewer journeys to complete the checks.
Tuesday was a very positive day for the team because one patient, who had been in the ward since Saturday night, was well enough to go home. One of the things that I have learned about here is how the shift patterns work and that the senior doctors, although not always in the hospital or even ‘on call’, are always ready to step in and support each other in the case of complications. In the case of this patient that was exactly what happened. On the previous Saturday night at 10:30pm we had been sat round discussing the week after dinner when one of the doctor’s phones rang. As I walked to the kitchen get a glass of water I heard, “Is she having a seizure?” “Put her on her side and make sure that the airway is clear.” And in the time it took for me to walk back the two doctors had made the decision and left the house to help their colleague deal with the patient. It was quite a dramatic moment for me personally and I found myself worried for the patient and her family but impressed with how quickly and decisively the doctors had acted. It was literally seconds between them receiving the call, asking a few questions, and leaving for the hospital. The patient also turned out to be a relative of one of the nurses, so it was particularly significant for the team that she had such a good recovery after her operation.
Later that week I spent some time working in the key area that I have been asked to look at in the ward – the sterilisation area. Sterilisation of equipment is important in any hospital but with a reduced range of equipment and limited space to carry out sterilisation in, I learned that the team were experiencing a number of issues including:
Adherence to different procedures for metal and plastic equipment – items were sometimes going through incorrect steps;
Mixing up of sets of equipment that were being dried together in the same location but needed to be packed separately leading to sterilised sets of equipment with the wrong tools in – only discovered when they needed to be used.
A lack of suitable facilities for drying and storing sterilised sets of equipment.
This will be an area that I will show lots of pictures of in future posts.
Thursday provided an opportunity to learn about the pharmacy ordering system. The pharmacist was very helpful, explaining how he translates the maternity unit order into orders to his supplier (the regional pharmacy). There were several things that he wasn’t able to supply though and as many of these things are important for the normal running of the department, such as antibiotics and other critical medicines and kit, the team have to find alternative sources to be able to provide a service that we would actually consider to be the basic service in Europe. Often, these costs are picked up by the charity, MCAI, that I am volunteering with, and this is why I am committed to helping them to raise the funds to keep the unit running so that women can receive maternity services here, rather than travelling a further 45minutes on to the next nearest hospital.
The importance of giving the team every chance to provide an excellent service to their patients was made clear to me on Thursday, when both a baby and a mother died. The mother was a former patient who been in the department a few weeks earlier but had since suffered from an infection that, despite a huge and well-coordinated effort by the team, they were not able to treat successfully. I saw how hard they all worked to try and save her but they only have a certain number of options in the health centre here and things such as intensive care are only available at the main hospital in the capital. It was humbling to see how the team worked and very upsetting to see her family coming to the ward to be told what had happened.
I saw the little baby brought over to the resuscitation area, which is just next to the sterilisation area, whilst I was working there. He had died during childbirth and after carefully being cleaned, he was wrapped gently in a piece of fabric that the mother had brought with her and set on the bed until the mother was well enough to collect him. I could see that despite it being something that is not uncommon to see in the department, the midwife was very sensitive, treated the baby with absolute care and felt very sad for the mother of this little boy.
These two experiences have given my work here a different context. Although I am not working directly in the medical field, I feel passionate about helping to support the team here with the best infrastructure possible. On this note, there were lots of other activities during the week – speaking with contractors to organise quotes for a new roof for the department; starting work on the second ‘on-call’ room to get them cleared so that they can be finished and used by the staff and getting new wiring fitted to the sterilisation area to enable the layout to be changed.
The weekend offered an opportunity to meet with a colleague of one of the doctors, to discuss a national programme for specialist training of maternity doctors. We were fortunate enough to be invited to his house and treated to some lovely Gambian food and the hospitality of his family.
Next week the work on the sterilisation area will continue, as will the stock system work and several meetings with wider staff in the hospital to look at how the maternity unit interacts with other areas.