Hitting the target but completely missing the point?

Comments: 6

Karen Sanders, Senior Staff Nurse at North Bristol NHS Trust, describes how, too often, frontline staff are at the sharp end of competing priorities. This is one in a series of stories that the Point of Care programme is presenting on the issues that staff face in trying to ensure a positive patient experience. The views given in this series are of the authors and do not necessarily represent the views of The King's Fund.

A colleague approached me on the ward asking: 'This protected meal times thing for patients – does it cover requests for radiology? Waiting for the end of meals is making it difficult to achieve our scanning targets'.

Protected meal times were brought in to ensure patients' meals were uninterrupted. A protected time to eat your food, whilst it is still hot and looks edible seems a basic right. And protected meal times focus ward staff on the importance of meals and the people who need extra nutritional support. Patients should be able to eat in a timely and dignified way. Protected time reminds staff that other tasks on the to-do list can actually wait. The sanctuary of the meal time prevents everyone else (the occupational therapist, physiotherapist, pharmacist, doctor) from doing what they need to get done, just because it fits with their schedule.

Protected meal times were launched against a back drop of headlines such as: 'patients starve in our hospitals', 'nurses don't care', and patients now require 'water to be prescribed'. Isolated incidences they maybe, and perhaps gross generalisations, but protecting meals helps to slow the speeding juggernaut of hospital business blundering its way through patients’ meal times. We know that people who eat well get better sooner and leave hospital faster, and that those who get better quicker are at less risk of developing an infection, pressure sore or of falling over.

'So' I said, 'I'm afraid radiology will have to wait until after protected meal times to call for their patient. I’m sorry your tight schedule is even tighter as a result, but after all, the Care Quality Commission inspects on many levels for the adherence to protected meal times and grades us accordingly'.

My colleague understood the rationale for protected meal times, but radiology departments face a logistical nightmare every day – slotting outpatients and inpatients into their busy schedules. To her, waiting for meals to end seems insignificant compared to the patient’s need for a scan, X-ray or investigation to inform the diagnosis and plan of care. So, to her, the obvious solution is to allow the porters to call for the patient at any time: clinical need trumps nutritional need every time, and the dreaded breach of the radiological target comes with a hefty fine.

No one would question the fact that patients who need emergency radiology should receive it, irrespective of the meal time or time of day. But for patients who do not need urgent investigations, shouldn’t we respect their right to eat in peace and resist fear of breaching the target to dictate service delivery over respect and wellbeing?

For me, the story perfectly illustrates the fact that, as frontline staff, we are often at the sharp end of competing priorities. Too often, senior executives and board members do not seem to be aware of conflicts and trade-offs, and they leave middle managers to slug it out with us. Almost invariably, it is the most vulnerable patients who can't speak up for themselves, or the patients who don't have visitors, who lose out. They are the ones whose meal times are interrupted, and who get moved for non-clinical reasons, often in the middle of the night. This is why it is so important that the people who run hospitals carefully think through, and articulate to themselves and their staff, what the hospital is for and whose needs and priorities matter most.

Just as the radiologist and I agreed a reasonable solution, a new patient arrived on the ward from the Emergency Department. The meals service was totally disrupted, the domestic packed away her meal trolley, nurses scattered to deal with the new admission, tables, beds and chairs were moved to accommodate the porters and much noise and fuss was made. When I asked the nurse why she had brought the patient into the ward during protected meal time, she said 'Sorry but the patient was about to breach the four-hour Emergency Department waiting target. We would have been fined. I had no choice'.

Karen Sanders, Senior Staff Nurse, RGN BSc (Hons) Nursing BSocSc (Hons) – Frenchay Emergency Department, North Bristol NHS Trust


#989 Paul

Why can't the times when meals are served be flexible?

That would probably suit both patients and clinical staff better.

#990 Karen Sanders
Registered Nurse
North Bristol NHS Trust

Hi Paul

When I read your comment, I thought a flexible meals service would be difficult to achieve in a hospital and then I thought again.

Currently the meals service in hospital is an enormous operation, which takes many skilled staff to ensure it reaches the patient in a cost efficient, nutritious and presentable way. Hospitals exploit a large economy of scale to ensure the food service is delivered daily and currently this can only be managed by producing meals at set times.

However I am sure there is much more we can do to ensure that hot, nutritious food is always available for those patients who have missed meals or arrive out of hours such as those patients in the Emergency Department or those in the Maternity Units. All that is required are alternative meals or snacks which can be heated up locally on wards, which is current practise but not a consistent alternative. I am aware of some hospitals who have taken the menus away all together and now offer a whole different type of meals service which is based on snacks and finger food which is sometimes all that is required when you feel ill or when you are recovering from surgery. Snack bars and more frequent tea trolleys are also provided by some of the PFI hospitals.

As an organisation we are still generally providing a meals service which suits the hospital and not the patient, perhaps now is the time to open up the debate on food provision in hospitals just as it has been in schools and prisons?

#991 Ita

If protected mealtimes are established and communicated - can the diagniostic Dept use this time to get on with their outpatient/emergency lists. Another approach could be to look at shift patterns for these services instead of trying to fit everything into 9 to 5

#992 Mary Hawking

As far as radiology goes, couldn't in and out patient appointments be co-ordinated?
Many outpatients would prefer appointments during their lunch hour...
I agree about conflicts between diferent priorities: could there be a brainstorming session on this?
Kings Fund?

#993 Dr Gordon Caldwell
Consultant Physician

I think the top priority in acute care is getting the patient better as fast as possible so he can safely start living outside hospital again. During that time of course he needs food, drink, to be clean, warm and continent and suffer no avoidable harm. Crucial to "getting better" is for us Doctors to work out "What is wrong" (Diagnosis) and then to apply the correct treatment and constantly review progress. This is highly complex, risk laden work, that takes place on the daily clinical review (Ward Round). I have published on "How Long Should a Ward Round Take" as well as on how so many hospital processes slow the pace of work. It is frequently impossible to maintain the pace of work and the quality of work, without going into protected meals times. The NHS needs urgently to optimise daily clinical reviews so that they can be done more swiftly and yet as or more safely. This only needs some simple time, motion and costs work, using video ethnography. Those with the money should always calculate the cost of getting it wrong on rounds e.g. failure to prescribe VTE prophylaxis causes a DVT, pulmonary embolism and a chronic varicose ulcer - highly expensive and greatly increased length of stay.

#994 Karen Sanders
Registered Nurse
North Bristol NHS Trust

Thank you Dr Caldwell for your comments and many thanks for the link to your work.

I am currently rolling out the "Productive Ward" programme and I really value your experience on delivering the ward round more effectively. I agree that using simple time and motion studies do help to identify some of the more pressing operational issues in our hospitals today. I agree that optimising care should be the target and that the NHS should correctly process map the hospital day and identify points in the patient journey where priorities clash, this I believe would help to make a more efficient service instead of using targets and fines as a blunt weapon with which to beat staff with.

Many thanks again for your link and sharing your experience.

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