ESRC Regulation Seminar

1. 11/06/15
1
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
GregBamber@Gmail.Com
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

2. 11/06/15
2
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.
4

3. 11/06/15
3
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.

4. 11/06/15
4
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!
8

5. 11/06/15
5
‘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

6. 11/06/15
6
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?
GREG
BAMBER,
MONTAGUE
BURTON
VISITOR,
CARDIFF
UNIVERSITY/
MONASH
UNIVERSITY,
2014
11
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.

7. 11/06/15
7
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!
GREG
BAMBER,
MONTAGUE
BURTON
VISITOR,
CARDIFF
UNIVERSITY/
MONASH
UNIVERSITY,
2014
13
Different
perspec=ves….
Key Findings: From the
boRom!
GREG
BAMBER,
MONTAGUE
BURTON
VISITOR,
CARDIFF
UNIVERSITY/
MONASH
UNIVERSITY,
2014
14

8. 11/06/15
8
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!
GREG
BAMBER,
MONTAGUE
BURTON
VISITOR,
CARDIFF
UNIVERSITY/
MONASH
UNIVERSITY,
2014
15
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!
GREG
BAMBER,
MONTAGUE
BURTON
VISITOR,
CARDIFF
UNIVERSITY/
MONASH
UNIVERSITY,
2014
16
Does Lean induce work
Intensifica/on for nurses?

9. 11/06/15
9
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!
GREG
BAMBER,
MONTAGUE
BURTON
VISITOR,
CARDIFF
UNIVERSITY/
MONASH
UNIVERSITY,
2014
18
Conclusions

10. 11/06/15
10
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:
GregBamber@Gmail.com
Professor, Monash University, Melbourne.
Visiting Professor, Newcastle University Business School
More reading? See: www.gregbamber.com