Have you ever seen an expert chef’s kitchen? Everything is in its place… and they definitely do not want you fooling with anything. How about an expert surgeon? Same thing. They both have the same goals in mind: ergonomics (they can lay their hands on the tools the way they are going to deploy the tools), efficiency of movement (no wasted/unnecessary steps/ no reaching across yourself), and economy of movement (one step flows into the next).
Mise en place is French for “putting in place” or to gather the ingredients, tools, and bowls in the part of the kitchen you will be working so as to ensure it is ergonomically sound and provides for economy of movement. Dr. Roger Kneebone M.D. unpacks this really well in his book Expert.
Mise En Place goes beyond just having items within easy reach, labeled, or color coded.
Procedures and step by step instructions that accompany them are prone to failure, generally not from a lack of competence or acumen, but from a lack of attention to the logistics required for the procedure to be successful. This is one element of the “logistics” that folks are talking about when they say: “Amateurs talk about tactics while experts discuss logistics.” It doesn’t matter if you have the neatest gadget if it is not where you need it to be and properly set up when you reach for it. This can include something as simple as the way you set up for IVs to bigger things like how you set up the back of your ambulance or your clinical workspace. Everything in its place, set up and ready for when YOU will use it, and set up to facilitate good FLOW or economy of movement.
This gets to the heart of something that I have noticed at different points within different organizations in my career. Bags and bag layouts, procedural set-ups, etc. seem to bring about a certain level of angst when they come up, and changing these set-ups is often a months or years long campaign of tug-o-war that attempts to satisfy everyone. Avoid this. Know where the gear is, and set it up how you need it for when it is time to execute.
Why Does This Matter?
Setting up a procedure with what you need the way you want it is a massive cognitive offload tool and confidence builder. You know that you have everything you need (confidence builder) and you know it is exactly where you want it to be (cognitive offload). It feels effortless (more confidence) because you aren’t having to burn up brain power to think about every little step and hunt down every little item.
You do not have to constantly break focus during a critical procedure in order to look for something because it is not in an accessible space. This allows you to maintain situational awareness. It is human to lose your place or forget what you were doing when distracted. Put that exact scenario within the context of a stressful resuscitation or procedure and the negative impact of not being set up compounds itself.
“A cluttered workspace is a cluttered mind.” (Jiro Oro)
Messy and unkempt workspaces can be visually overwhelming and add to the stress and cognitive load of the moment. Your brain has to make sense of the mess it is seeing and orient you to where you need to be. Which is much harder when the workspace is a disaster. It is not about being OCD, but keep it neat and tidy so that you can get right to what you need to get to in the heat of the moment. This pertains not only to setting up for procedures, but to patient packaging as well. If you have never experienced the joy of untangling IV lines in flight so that you can trouble shoot a pump alarm, be patient, it is coming. This can happen with a critical medication (like a vasopressor) and the patient is not receiving it until the clutter is mitigated, the line is found, and the pump is restarted. When the patient arrives at their destination, there should be no guessing at where things are and there should be no tangles or mix-ups during the transfer.
Tidiness keeps you on pace. You won’t waste time looking for things that should be there. In a time critical situation you can lose the initiative (your window of opportunity) scrambling for things that are not there when they should be. The time gets lost when you have to open three or four compartments to gather all of the things you need, or open the bag inside the bag inside the bag to get the item out and then take it out of the wrapper… You can see where there is a ton of room for improving the economy of movement so that you can stay on pace.
Practicing Mise en Place can also set things up so as to serve as a prompt for what is coming next and keep you on track. You actually SEE the next step coming and can transition effortlessly to it without having to pause and try to remember it. Everything should be out and OPEN, not still in the packaging. That can be problematic in certain contexts as well. For example, once your gloves become contaminated with blood/fluids, you will notice that you have a hard time opening some of the packages on some of the supplies, costing you time while you attempt to get it open. I say open it before you need to, however, there are some things you cannot leave open or out of the package indefinitely. In an attempt to defeat this problem you could “bunny ear” the packaging. This is where you take strips of tape and leave long ears (an inch or so), hanging loose near the “dummy notch” of the packaging of the device. This improves grip and leverage so that you can more easily tear open packaging.
Some tips:
1.) If it does not need to be sterile or “clean” take it out of the package. You waste time and add an insane amount of clutter to the site with unneeded or recently discarded packaging.
2.) Your organization can mandate that something be in the bag or in the box… but you need to take ownership for how YOU deploy it. So move it to where it works for you. (Don’t be a doober, put it back where it was at the end of your shift). You never know when you may set a new standard for the organization.
3.) SIMPLIFY. Yes, two is one and one is none, but take care not to over engineer solutions and/or pull more kit out than you need. You don’t need three sizes of tube or blade up and down from the primary size you choose sitting out in the immediate area. Anticipate issues and ensure contingencies are readily accessible, so you could have your extra sizes still in the case, but the case is open and near you for easy retrieval of supplies. But avoid unnecessary cluttering of the workspace.
4.) Set up IN SEQUENCE, don’t just dump the kit in the work area and try to sift through it all to get what you need. You also should not rely on a “gopher” or an assistant to give you a piece of equipment. A simple and effective set-up saves more time than a kit dump and hunting/pecking through a pile of gear.
NOTE:
Inspired by Roger Kneebone’s expert and a post by frontline_medics.
