Wednesday, ten to five. The angiography list is running late again. Third day in a row.
The lab is staffed. The consultants are here. Apparently there are two empty beds on the ward, though someone is checking whether we can actually use them.
A man who was supposed to have his procedure at two is still in the day unit in a gown. He wants to know whether to ring his daughter.
I don’t have a useful answer for him.
We have a huddle. The rota comes up. Then the electronic referral system, which has taken the blame for quite a lot since March. Someone asks whether we need agency cover.
A staff nurse waits for a gap.
“Maureen’s away.”
Maureen is our pathway coordinator. Band four. Nineteen years here. She’s in the second week of a holiday she booked in January.
We all know she’s away. We just haven’t quite understood what that means.
Over the next hour, we start finding out.
There’s the transport from the other hospital. If it hasn’t arrived by ten past two, Maureen knows who to ring. Usually someone she’s dealt with for years. If he doesn’t answer, she has another number.
She knows which patients still need a conversation with the registrar. Which bed is technically available but probably won’t be. Who to ask about moving someone, and who will say no unless you explain it a particular way.
There are things she checks before the rest of us know they need checking.
I’m making this sound more orderly than it is. There isn’t a secret checklist in her drawer that we’ve somehow overlooked. Some of it is memory. Some is knowing people. Some is noticing that something hasn’t happened yet and doing something about it before it becomes everyone else’s problem.
Ask her what she does and I suspect she’d say, “Just sort things out.”
We’ve let that description stand for years.
Meanwhile, we’ve talked about how well our pathway works. We presented it at a regional meeting once. There was a slide with arrows.
I’m wondering now how many of those arrows were Maureen.
When a service starts struggling, I tend to look for something recognisable. Staffing. Beds. A process that needs changing. Those things matter, obviously. But they’re also the things I know how to put on an agenda.
“It works because Maureen keeps an eye on it” is harder to admit. Particularly if you’ve been calling it a robust pathway.
There’s an ecological idea I keep coming back to here: the keystone species. Robert Paine’s work with starfish showed how removing one species could change a whole community far more than its numbers might suggest.
The comparison only goes so far. But most of us know someone whose absence has an effect that their job description doesn’t begin to explain.
A secretary. A coordinator. The pharmacist who knows how to get a difficult discharge moving. Someone who has been there long enough to remember why the sensible-looking solution didn’t work last time.
They go on leave and suddenly everything takes six phone calls.
Through Cognitive Oxygen® (COx), the question I find myself asking is: how much of the department’s thinking have we quietly left to this person?
Maureen is remembering, anticipating, checking, adjusting. Holding unfinished things in her head while the rest of us move on to the next patient or meeting.
I don’t know whether she finds that exhausting. We haven’t asked. Perhaps she enjoys much of it. Being good at something and being worn down by it can coexist, though, and I’m not sure we’d notice the difference while the list was running on time.
There’s a practical use for Red Team Thinking® here. A Pre-Mortem Analysis™ could start with something very ordinary:
Maureen has retired. It’s three weeks later and the lists are a mess. What did we fail to prepare for?
I suspect the staff nurse would have plenty to say. So would Maureen, if we gave her time and actually listened.
An Assumptions Challenge™ could be simpler still. Take one of those arrows on the pathway slide and ask what has to happen for a patient to get from one end of it to the other. Who checks? Who chases? What happens when the first phone call doesn’t work?
We should probably have asked before Wednesday.
Of course we need cover. We need to write things down. “Only Maureen knows” cannot be our permanent operating arrangement.
But I’m wary of turning this into another job for her. Please document nineteen years of experience, fit it around your usual work, and train someone while you’re at it.
Some of this will need time alongside her. Someone else making the calls, learning the awkward bits, getting to know the people. And some of the chasing shouldn’t be necessary in the first place. We need to hear about that too.
In the end, someone rings her on holiday.
She asks three questions and gives us a number. The man has his procedure that evening.
We’re relieved. We’ve also interrupted her holiday to get through an ordinary working day.
When she comes back on Monday, there are flowers and a card. An apology.
“I did wonder how long you’d manage,” she says.
I’m not entirely sure how to take that. I laugh, then wonder whether she’s been trying to tell us for a while.
At the next huddle, we ask whose leave we find ourselves worrying about. A few names come up very quickly.
We haven’t fixed it by naming them. But at least we’re talking about the work they do, including the bits none of us had bothered to understand.
You probably have a name in mind already.
What do they keep sorting out? And when they next take two weeks off, who will have had the time to learn?
Maureen and the angiography list are a composite, drawn from several services. The reference to Paine’s starfish research is a simplified account.