Hospital-at-Night
What’s its true place in a competitive service?
Written by: Andrew Vincent, Medicology Ltd. Published: 3rd June 2010
Hospital-at-night predates much of themove towards a competitive healthcaremarket economy but is an essentialcomponent of the overall care a personreceives. Whereas clinical excellence willalways be the true mark of a successfulservice, there is growing recognition thatthere is more to a successful service that theoutcome alone. Is it time to re-visit hospitalat-night to re-evaluate its true purpose andhow it contributes to overall service successin our increasingly unforgiving environment.
Understanding service success &how H@N applies to it
If we are to re-visit the role or structure ofhospital-at-night, we need to consider whatservice success needs to be built on and howthis relates to the night time environment.Besides clinical excellence, services needto consider their financial stability, theirstrategic evolution as the market evolves,how patients are attracted to the service,patient experience and how well the teamworks together, which arguably enables allof the others.
The original purpose of H@N was two-fold;coping with service delivery requirementson reduced junior-doctor hours whilstproviding a better training environment tocompensate for the degradation of trainingby hours & rest time restrictions. However, ifwe are all honest, we know that the formerhas taken much greater priority over thelatter and most H@N teams find little timeto specifically focus on learning, other thanthe experiential component that comesfrom working across specialties and eventhen, most doctors working during thenight as part of the H@N team find the workstretching from a load perspective but notfrom a learning one.
What we want to consider is the potentialimpact of incorrectly focused H@N on thefactors influencing service success as awhole. Let’s look at just some of the potentialissues
| Clinical excellence | Financial performance | Patient experience | Strategic Evolution |
| Does the H@N team support orlead clinical effectiveness in thenight time environment? | Are the H@N team activeparticipants in CIP? | How does the patient experiencediffer at night? | Does the H@N team understandthe longer term vision for aservice? |
| Do they understand what clinicalexcellence looks like for patientsin specialty X,Y or Z? | Do they disproportionatelyconsume some resources e.g. aspecific drug? | Is it adding or subtracting fromthe overall service perception? | Are they complimentary to it orinadvertently detracting fromthat vision? |
| Are they truly assisted in gettingit right e.g. through effectivehandover? | Do they make it easy for thecoders to identify what’shappened to someone? | What is the overall level ofexperience necessary? | Do they have partial ownershipof that vision or are theydisengaged from it? |
This brief set of questions only touches onthe range of issues that come to bear butalready we can see that the H@N team hasthe potential to seriously impact success,either positively or negatively and yet weare constantly surprised by just how muchH@N teams are ‘forced’ to work in isolation ofthe day-time services, with the predominantinteraction being one of clinical handover,not strategic collaboration. In all too manyinstances, we also find that it is not for wantof trying to engage but more the subject ofhow people perceive the role of the hospital-at-night service.
Evolving the vision for H@N
Firstly, H@N has the unenviable premiseof being both a service in its own right,with a distinct team, its own structure andprocesses etc, as well as effectively beinga part of every service they support. Thisdifferential view is important in two respects,one internal to the team and one a real wakeup call for the services they support.
Taking the internal perspective first, the truepurpose of the H@N service is to enablesuccess for each and every other servicein the hospital. Contrast this to somethingmore akin to ‘get through the night safely’and we can already see a likely change fromreactivity towards proactivity. Longer term,this allows H@N teams themselves to ask aseries of enabling questions such as:
- How can we better support the surgeonsto compete in the market?
- How can we contribute to a positivepatient experience for night-timeadmissions?
The key here comes from understanding thegame you are a component of and in manyrespects developing that understanding isthe role and responsibility of senior leaders,as well as service leads. Failure to do sois a bit like employing an expert withouta job description or never telling Grannythat you’ve outgrown cardigans and thenmoaning when you get another one forChristmas!
Services expecting proactive and supportiveassistance from H@N teams need totake on board just how important it is topositively engage with them to define whatthat support really looks like and how itcontributes to your own service success. Inmany respects that is an ongoing, two-wayprocess or even the start of a partnership inwhich both teams needs should carry similarweight in order to work towards ever greatersuccess for both. It involves those enablingquestions running both ways:
To the service: How can we, the H@Nteam, best support your vision for serviceexcellence?
From the service: How can we, the service,assist you, the H@N team to get it right forus?
Failure to actively address these twoquestions misses a massive opportunityto develop excellence across a hospitaland possibly even leaves one third of thepatient experience entirely up to an oftenover-worked, under-supported group ofindividuals whose most frequent marker ofsuccess is “we got through the night withouta serious incident”.
Fully integrated H@N
Fully integrated H@N involves bringingthe H@N team fully into the workingenvironment of each service, not as ‘servants’but as equal owners of the vision that servicehas established for itself. Service leaders,whose whole stability and existence relieson attainment of that strategic vision, needto firmly recognise the role and contributionof H@N to that vision, as well as how they asa service impact on how easy it is for H@Nteams to successfully conduct their role, forinstance with handover practices. That goeswell beyond simply ‘tiding us over until theday team takes control again’.
Over time, service and H@N teams needto consider what they both really wantout of the night time environment. Howdoes training fit into this? How can clinicaleffectiveness be developed further acrossthe night? How is the H@N team keptabreast of service developments, stressesand priorities? What shared goals do theycollectively own? What resources does thenight team need to successfully operate?And so many more questions too...
Hospitals that fail to address this preexistingissue place themselves at acompetitive disadvantage to those that doand potentially give themselves an uphillstruggle to compete on even the basics suchas clinical results. Our fear, or the challengeto be resolved, is that the further dropin junior doctor hours that we have justadopted is likely to place H@N teams undereven more pressure to achieve on even lessresource, leaving precious little opportunityto resolve the bigger picture as it getsswallowed by the immediate stress of thenight time load. Or we could just do it!
