It takes an onion – not an eon – to bring about changes with impact for patients | Samantha Jones

Samantha Jones

Samantha Jones takes a look at the origins and impact of Operation Onion.

When I was a staff nurse thinking of going into management, there were many things I thought I would be doing.  Talking about 'onions' was never one them – however, it is what I am doing, with my team, on a daily basis. 'Onionising something' is becoming part of the language at West Hertfordshire Hospitals Trust.

What is it?  Although we joke about it, it has a serious beginning and a reason that keeps it live and a part of how we do things around here. It came about following a very difficult weekend, when the trust was extremely busy.

It was coming to the end of winter and the trust was full; all surge areas were occupied, and A&E was unable to admit patients into hospital. And, as it was a Sunday, the routine services available during the week were unavailable, preventing discharge of patients. This particular evening, A&E was full and the trust had to take the very difficult decision to divert, as six ambulances were waiting to bring patients to hospital, with another seven on the way. Unfortunately, the level of pressure was routine.

And this was the point. I spoke with the A&E staff, the people that had been on duty, the managers who had all worked tirelessly, and heard a very sad patient story where we were unable to provide the proper level of care to a young person and his family in extremely sad circumstances. What struck me, however, was the acceptance from those involved that they were doing their best, but this is how it was.

I have since come to term this 'institutional blindness'. As the trust's new chief executive – having been in post for a month – it bothered me significantly that staff had slipped into accepting that the level of care we were giving was good enough in the circumstances.

Hearing other patient stories that made me very unhappy, I decided enough was enough and called a summit to ask the question: "What can we do today and tomorrow to make a difference to our patients now?”

Operation Onion was born...peeling back the layers. It's about listening to our clinical and non-clinical staff and looking at immediate changes we can make to ensure our patients are treated quickly, efficiently and correctly, first time. We are challenging everything we currently do and seeing if there are ways we can do things differently, and better. The essence is: what can we do to make it happen, not why it can’t be done. It also focuses on how we do things, not just what we do.

Since Op Onion started 10 weeks ago, and through the daily Onion meetings that I chair, with representatives from across the trust – of all professions and grades – with different departments and with all executive directors, we have done a range of things, all put forward by staff:
  • additional therapists across hospitals and wards
  • senior nurses becoming supervisory with immediate effect across the hospital where possible
  • additional transport made available, and for longer hours
  • hourly turnaround for diagnostics in the acute ambulatory unit (AAU)
  • additional portering dedicated to AAU and diagnostics
  • enabling the Computer on Wheels to work immediately to facilitate the immediate ordering of tests by juniors on ward rounds
  • getting hot meals in the evening for patients in the AAU & A&E, where needed
  • medical staff working differently, for example reviewing patients faster
  • fixing the blood gas machines that haven’t been working for months
  • changing forms that weren’t completed correctly
  • addressing how agency staff are booked and coordinated.
This hasn’t been about money, although we have invested – it has been about doing the right things first time for our patients, and working together as a team to make it happen. Comments from staff include:

 "Feels much calmer generally, people doing the roles they should be doing, staff feel in control and beginning to believe that things are changing for the better for both patient and staff."

"Operation Onion has sorted something out in three days that I haven’t been able to sort in a year."

We haven’t got it all right, and some things we have done we have stopped, as they weren’t working.  The exciting thing is that clinical staff are owning it, and are leading the way on peeling back those layers. We have evidence that it is working – our emergency care performance is one indicator, there are many other softer ones that are being felt by all.  We also know when we don’t keep the focus, things can slip – and we are learning!

We have more to do.  It's intense, it's hard work, and it requires the executive team to give it their time and commitment to show we are serious about it. And we are – all of us. And it’s working, and I am personally proud of the achievements so far 10that would have been thought impossible.

One final comment. Working together, listening to what is being said by the people who really know does make a difference. Op Onion is change in action – making a difference for our staff and patients, and we keep peeling!

Samantha Jones is chief executive of West Hertfordshire Hospitals NHS Trust. Follow Samantha on Twitter @SamanthaJNHS

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