Conducting Observations in Clinical Areas

puzzle-magnify-800pxI’m going to start a series of posts on the type of observations that can be useful in Lean work, and on the forms that are often used to collect and display the information. In advance of that, I want to write about observation etiquette.

In an ideal state, everyone in a work area knows that improvement work is happening, has been asked their opinion, and has an opportunity to discuss and contribute in advance. This is the ideal, but it doesn’t always happen. It is common for there to be sixty or more staff associated with a single ward area in one way or another, for example, with multiple shifts and staff who work across several areas.

With holidays, illness and general communication delays, it is common to find that not everyone has heard about the work. In other cases, people have heard, but haven’t entirely understood what is happening. Lean has a fundamental value of respect for staff, and going the extra mile to demonstrate this is always worthwhile. People are very quick to identify a dissonance between what you say and what you do.

The effect is that, if you turn up in a service area to help with observations, all may not be as you expect. Consequently, I have developed some standard work around observations.

Advance Planning

Work out when you are likely to be in the area. Tell the relevant manager and shift lead that you intend to be there, and discuss any issues they want to raise. If at all possible, meet with them and show them the forms you expect to use, explain their purpose, and show examples of previous use so they can see how the information comes together to support their change work.

Offer the opportunity to help with the observations – more on this later. The more people understand about the process, the more transferable skills they acquire. Lean is not something you ‘do to’ people – the intent is to support people to understand the principles and methods so that they can apply them to their own service.

If work is underway on an event, such as a Rapid Process Improvement Workshop, it can be easy for people to feel they are being ‘done to’ rather than being supported to develop new skills. When you have learnt about Lean, there is a temptation to run the whole thing yourself – resist this temptation at all costs. If you are helping with an RPIW, perhaps as Team Leader or Workshop Leader, the skills the team acquire are at least as important as the outcome of the event itself.

Identification and Introductions

Wear a name badge, showing your name, job title and organisational affiliation: you can’t expect everyone to know you. Strive for humility.

As soon as you arrive in an area, ask for the person in charge, introduce yourself, and explain the purpose of your attendance. If the person already knew you were coming, that is an added bonus. Don’t assume that the discussion with the manager or team lead will have been passed on. Things happen:people are ill, are hurried, forget things – make no assumptions about what staff have already heard.

Use the opportunity. Every person you speak to is another person you can talk to about the process, about the principles, and about their role in the work. Explain the structure of the work, timescales, the aim, and ask their thoughts. If they have time, show them the forms and explain how they are used. I often ask if they would be interested in collecting any information themselves, if time permits.

It can seem tedious, but this has to be repeated every single time you go in to an area, at least as much as making yourself known to the person in charge, and the relevant people on the shift. It is common to discover that people have forgotten some of what you told them, in any case, or have misunderstood it. Engagement does not happen by accident: demonstrate interest, listen and value the information and advice you are given.

Observations in Clinical Areas

If you want to follow a patient or other service user, always ask permission. There are a very few occasions on which this may not be possible – with an unconscious or anaesthetised patient, for example – but even there, it is often possible to explain what you are doing to a relative of the person, and to seek their agreement.

A standard script can be useful – your name, your role, the purpose of the current work, a guarantee of anonymity, and a clear explanation that the focus is on the process. It is uncommon for people to decline, but if they do so, respond courteously, thank them for their time, and move on. Respect their decision.

When people do agree, it is often unecessary to enter a consulting room. The focus is frequently on delays between processes. Even when a process is being timed, it is often unecessary to enter the clinic room itself. If it would be useful to observe a clinical process involving a patient, then explain this – and explain why – , and check that the permission you have been given also covers this interaction. Some people will be willing to have you take timings of waits, walks and so on, but unwilling to have someone else present at an examination, interview or test. Again, respect this decision.

People using services have often used the service before, and may want tell you of their experiences. This is useful: take careful notes of any information the person volunteers to share. Generally, it is possible to separate observations from patient feedback, but sometimes people are so keen to tell you about their experience that it would be discourteous to decline. Make sure notes are anonymised, unless the person specifically wants you to bring something to the attention of the service. It is useful to know the specifics of the complaints procedure for the organisation, so that you can explain it if asked.

In other cases, you may want to look at the flow in an entire area, rather than following individual patients. In this case, where you are recording timings for several cycles at once, it may be possible to put a notice in the room explaining that observations are being conducted, and how to ask for more information. Members of the public are used to the idea of quality control, and often find it reassuring to know that someone is observing processes, even if the detail of the reason is not completely clear to them.

In this situation, you may find service users looking across at what you are doing, and even squinting to see the observations you are making. This can again be a useful opportunity for interaction. If it is not disruptive to care, I make eye contact, introduce myself, and ask if the person would like to see what I am recording. This gives instant assurance that no individually identifiable information is being collected, and often evolves in to a discussion of the person’s experience of the service.

Sharing Observations with Staff

As with service users, if a staff member looks curious, it is useful to show them what you are doing, and to talk it over with them. Even if you have explained the idea before, seeing observations in practice can be a different thing and may benefit from more explanation. It also gives reassurance that no information on individual staff members is being collected, or at least that the focus is on the process, rather than on staff.

Showing people what is being collected has the added benefit that it reduces later debate. People know that the information has been collected directly, because they have seen it being done, and have often seen the timings. It also begins to throw up ideas that the staff member may want to feed in to the improvement work.


There may well be no such thing as too much involvement. The more people know about what is happening, the more they can contribute to it, and the more they know that it is based on direct observation of processes, the easier it is for people to invest in the work. The mantra of ‘big eyes, big ears, small mouth’ is good advice, particularly combined with ‘be humble’: the people using the service, and the people running the service are the experts on it, and observations are a way of capturing current practice, not of catching people out.

Image courtesy of pnx at


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