Time management is fundamental. It is fundamental to effective systems, and it is fundamental to healthcare. And yet it is something that is neglected throughout the NHS.
As a trainee, I was lucky enough to have some (three whole hours!) time management training as part of my vocational training scheme. And yet, that was the exception rather than the rule. Time management as a whole is something that NHS staff have little to no training in. As a result, many of us are feeling the effects acutely.
Time management has been shown to help resilience on an individual basis. It has also been shown to improve efficiency on an organisational basis. So what is it?
At its most basic, time management has two fundamental principles.
Number one is that one person can only be doing one thing effectively at any one time.
Number two is that one person has only so much time in the day that they can work effectively.
What this means is that your staff are a finite resource and need to be deployed judiciously. On a personal level, this means that your own time is a finite resource and needs to also be used judiciously.
This has some pretty profound implications.
It means that as we approach one hundred percent resource efficiency, our flow efficiency is likely to drop. Resource efficiency is about how much we use a resource such as a person or a piece of equipment. One hundred percent resource efficiency is when someone or something is in action for the whole time that they are available, with no down time. Flow efficiency is about how effectively stages in a process get done so that the aim of the process is fulfilled.
This tension between resource efficiency and flow efficiency is known as the efficiency paradox.
This can manifest itself as the nurse who works non-stop for a whole shift (resource efficient), and yet ends up making errors (flow inefficient). It can mean the junior doctor running from ward to ward on-call (resource efficient), but never actually solving any problems (flow inefficient). It can mean the stressed out GP causing harm to their patients by making mistakes (flow inefficient) because they’ve seen too many that day (resource efficient).
The problem with all these flow inefficiencies is that they end up creating extra work. Huge amounts of it. And this extra work is profoundly unfulfilling. Amongst other things, it’s work such as responding to complaints, holding disciplinary investigations, and repeatedly seeing heartsink patients that aren’t getting better.
It means that whenever we choose to do something as a team, we also have to choose what we’re not going to do in order to do the new thing. This is also known as “opportunity cost”.
This is not what currently happens. Outpatient departments are routinely overbooked because targets demand it. GPs are pressurised into seeing unsafe numbers of patients because targets demand it. Nursing staff work with sub-optimal numbers on the wards, and still have to fill in all the paperwork. Again, because targets demand it.
A common misconception is that people can get around these limits by working faster. Amongst management, this translates into the belief that workers would be more productive if they just worked harder. Unfortunately many staff also hold the same beliefs about themselves, and this leads to the culture of hard work that pervades the NHS. How many times have we seen the opening line of a job advert “hard working practice seeks hard working GP to join their team”?
If you think about it, is that what we really want? Do you really want your airline pilot to be hard working? Your surgeon? Your Nurse? Your GP? Do we want people to be making safety critical decisions when they're tired?
So what's the answer?
Well, a big part of time management is learning to say “no”. Often to people who aren’t used to being told “no” such as senior managers and the like.
This has to happen on a personal, professional, and systematic level. In line with the Berwick Report, we need to concentrate on safety, followed by effectiveness, with patient experience being supplementary to those two qualities.
We have to give ourselves and our staff time to do our jobs properly. By doing this, we’ll reduce the amount of errors that we make. This will reduce the amount of wasteful work that we’re doing. In the long run, it will reduce our workload.
No order to do this, we have to be clear about what our job is. And more importantly about what it isn't. We have to support ourselves and others to feel safe to say no to work that is not possible to do.
And it all starts with time management.
To this author, this is the only option that the NHS has if it is to survive the challenges ahead.
Let me know what you think about the challenges of time management in the comments...