No 19 - An Ode to C.O.W.s: a cheap force-multiplier to improve NHS IT and efficiency
Tldr
Recently, moving trusts has made me appreciate COWs, or Computers On Wheels as they are more formally known. In the article, I lay out why these are an under-appreciated game changer for NHS efficiency.
I have recently been reading Turn The Ship Around by L. David Marquet and I can not recommend it highly enough. I have also recently changed training jobs to a different trust, which has a noticeably different IT infrastructure to my last job. This combination of thought provoking book and new environment has made me appreciate the little things in life.
The military uses a term called “force multipliers”for any ‘thing’ that, quite literally, increases your bang for your buck. So, a good example is that military doctors are force multipliers because they return injured soldiers back to the front line and if your doctors are better than your opponents then you can keep more soldiers fighting and overwhelm them. Doctors are cheaper than missiles and therefore a cheaper way to win a war. Force multipliers!
I believe there are many under appreciated force multipliers in healthcare and some of them deserve more credit, because it they got more credit and were more widely adopted then we could improve the care of our patients without having to spend a fortune.
The first ‘thing’ that I would like more people to appreciate is the humble COW, or Computer on Wheels. I will explain below just why these COWs deserve more credit, but first, I think its important to step back and explain the bigger picture.
What are doctors paid for?
A simple question, and before you think that I am “having a dig” at doctors salaries, let me explain.
Ideally, doctors would be paid to do things that only doctors can do. This would be the most efficient way to maximise the cost of doctors - which is a significant payroll bill! Traditionally, “doctor-only” skills have been: diagnosising; examining; ordering tests; reviewing results; prescribing and performing some procedures. In the modern world many of these skills can be done by other HCPs but for simplicities sake, lets keep calling these Dr-skills.
So, in the real world what do doctors actually spend most of their time doing: typing; writing; data entry; calling people; emailing; writing discharge letters; copying scan results onto notes; updating handover lists; copying blood test results into notes; finding notes; finding bits of equipment; basic skills like bloods and cannulas. For the sake of argument lets call these “other-skills”.
The simplest way for the NHS to improve its overall efficiency is to increase the time doctors spend doing Dr-skills and reduce the time they spend doing other-skills. Just a change in this ratio could have a dramatic impact on patient outcomes, flow and satisfaction.
Suggestions for improving doctors efficiency
Most of the other-skills involve administration, so why don’t we hire someone on minimum wage to do all the admin for the doctors? Call them something like a Healthcare Assistant or Physicians Assistant or Hospital Administrator? That way the doctor could be doing the Dr-skills while their team mate does the admin side of things.
While, I am sure that doctors would love this, it would be a very costly solution to double the work force just so doctors don’t have to write things down.
So, here’s an alternative approach, why don’t we reduce the time doctors spend doing the other-skills? I know, I know. This is not a novel suggestion. But rather than coming up with a fancy, long and impractical list of things that doctors could stop doing, I am simply proposing a solution to make it faster for doctors to continue to do all of the same stuff.
The COW
The conventional COW has a number of cheap components that are force multipliers.
It is a laptop. These tend to be cheaper than desktops. Laptops do not require desk space.
They are height adjustable stands. This allows the user to sit or stand. Freeing up desk space.
They have wheels. This allows the user to move away from … the desk space.
Some of them have a solid shelf. This provides additional DESK SPACE. That can be used for holding patient notes, Obs charts, blood forms etc and means you can write the blood forms without having to sit at a desk.
They normally have the diameter of a laptop, which is smaller than a desk, freeing up floor space.
The Trust that I am currently working in has quite a good software system for some tasks but it is severely lacking in desk top computers and even more lacking in desk space!
Honestly, you may not believe this, but my recent experience is that desk space is a huge constraint on doctors efficiency.
The desktop computers take up desk space. The offices are already tiny and whole wards of 30 patients might only have 3 computers. That means that only 3 clinicians can do anything at once, so only 3 patients can have a task actioned at once. This causes delays while clinicians queue up to order tests or write notes.
The lack of desk space also makes it more difficult to write in the paper notes or to write on the blood forms. This sounds trivial but it does have an impact. It slows the tasks down, means that staff are always looking for something to write on or just squiggle a few words any old how as they use their arm as a rest for the flimsy bit of paper.
Lastly, if the computer is on a desk at the centre of the department and its the only one then every congregates around it. This means everyone is talking, or putting stuff on the desk, or answering the phone by the computer and this makes the environment loud, cramped and busy. This is not the environment you want when you are trying to put your thoughts into writing, or when you are trying to work out a complicated dose per weight calculation or when trying to persuade a senior colleague about a rare condition based on a flimsy examination. This is a mundane example of a patient-safety risk. When the environment is chaotic and loud, it is easy to make a mistake.
This set up of desk, phone and computer creates a physical bottleneck where everyone is constantly getting into everyone else’s way.
Coming from a department that had lots of COWs to a hospital that has none has been quite a culture shift for me. It feels like going back in time a decade or two. It adds friction and effort to almost every task, making every little thing just that little bit harder. Over the course of the day, this little friction adds up and can be frustrating, especially when you finally get to the front of that queue, get that desktop and then have to spend 10 minutes waiting for it to log off and on again!
Conclusion
Computers On Wheels are a cheap, quick, and efficient purchase that reduces the need for desk space and improves the efficiency of staff. If you are a senior doctor or NHS manager, please put away your big plans for a million pound re-design of the building to increase “work space” and just buy your team a few COWs and watch their frustration melt away.
In an ideal world, every doctor, nurse, physio, OT and social worker would have their own COW. Or maybe 50% would have COWs to provide the shelf for notes and 50% would just use a tablet. Either way, the first step is just buying a few COWs. Please. We are begging you!
The COW reduces the time that doctors need to spend on other-skills and increase the time available for them to spend on Dr-skills. Improving the patient experience and the service performance. COWs are force multipliers to get more expensive skills from healthcare professionals by making it easier for them to quickly do the other tedious tasks they have to do. The same principle applies to nursing tasks, physio tasks and all other HCP tasks. They all get easier and quicker with COWs compared to desktops.
Thanks for reading. If you agree that the humble COW deserves more credit then please feel free to like and share this article. If you are a senior executive at an expensive management consultancy firm then please feel free to offer me a lot of money to shut me up and stop me reducing your fees.
As always, if you have any ideas on how to improve this article then please let me know in the comments section below. If you want a regular dose of medically related articles then sign up to the newsletter below.