Action Learning Pilot Programme

1
Action Learning Pilot Programme

• Project Khaedu
• Rob Ferreira Hospital - preliminary findings

10 February 2005
2
Agenda

• Executive summary
• Current situation
• Complications
• Some suggested resolutions

3
Executive summary (1)
Situation

• Weak organisation structure and management
  structures at both hospital and provincial level
  delay decision-making, but most critically
  resolving the major human resources and
  industrial relations issues
• Some important processes such as Outpatients need
  to be overhauled at both a macro (I.e. Province
  must engage) and a hospital level to solve
  excessive wait times (3-10 hrs)
• While the unions appear obstructive, this is
  often due to lack of engagement and management
  attention to key issues

Including conditional grants
4
Executive summary (2) some suggestions

• Urgently review the decision-making processes
  between the 3 spheres of authority
• Consider delegating authority in critical areas
  like budget and HR down to the Hospital level
• Reinforce the hospital management team
• Restructure roles and responsibilities
• Hire (even on a short-term contract) key IR, HR
  and technical skills
• Engage with organised labour
• Remove key contentious issues such as career
  progression and training
• Consider a one-off testing of staff seeking
  promotion
• Fill roles through promotion where possible
• Aggressive recruitment campaign headed by a
  dedicated hospital HR project manager
• In outpatients, develop an overall strategy to
  move patients back to primary healthcare and/or
  spread the load of patients across the day by
• Communication campaign at Province and District
  level
• Schedule repeat appointments in the afternoon
• Create a dedicate 0800 toll-free number for
  appointment scheduling
• Reengineer the registration process with
  particular regard to filing, where the process is
  collapsing (critical consequences)
• Review budget priorities in the province (e.g.
  more wards being built while we are chronically
  short of staff to run existing)

5
Agenda

• Executive Summary
• Current situation
• Complications
• Some suggested resolutions

6
Current situation what weve seen and heard
Process and physical
Organisation design
People management
Financial and procurement

• High volumes of patients, many of whom are
  primary healthcare patients and come from other
  areas
• Very long wait times in OPD - patients unhappy
• High occupancy rates (average of 86 last year)
• Long waiting lists for non-emergency functions
  (e.g 18 months for prostheses)

• High level of centralisation at the provincial
  head office level
• Limited branch delegation
• Cumbersome with many delays
• Unclear mandate of the hospital as a tertiary
  health institution
• Severe shortage of professional and support staff
  for a long time (years)
• Executive management and professional staff
  levels and remuneration do not appear to match
  levels of responsibility
• CEO job overstretched with 3 hospitals over large
  geographical area

• Staff at all levels frustrated and very
  demoralised
• Management lack credibility with staff
• Unions play very dominant (and sometimes
  obstructive) role
• Ongoing resistance to PMDS
• Basic supervisory and management skills not
  sufficient to meet challenges
• People management skills
• Problem-solving skills
• Communication
• Discipline a challenge
• No clear HR plan / strategy

• Hospital has limited autonomy and delegation
• Centralised provincial procurement function
  appears to add little value and is cumbersome and
  slow
• Long delays in
• Procurement of equipment
• Maintenance of facilities and equipment
• No Finance Director to drive alignment of budget
  with strategic objectives

7
Despite a number of challenges, there are some
positive elements

• Rob Ferreira continues to be perceived as the
  hospital of choice in the District
• Many patients travel long distances to access
  facilities
• Patients are happy with the treatment received
  and service from staff members
• Many of the staff appear loyal and are trying
  their best despite the many frustrations
• Good coordination with Home Affairs for births
  and deaths registration
• Management making a concerted effort to turn
  things around

8
Bed occupancy is consistently higher than other
hospitals in the region
Estimate from RF management needs to be
checked Source DHIS, CIO Rob Ferreira Hospital
9
and outpatient activities have been steadily
rising
10
with a large proportion of patients being
primary healthcare candidates from out of the
area
Target patient for Rob Ferreira
Could be seen at local clinic
Source Note that this data is based on estimates
of interviewed doctors
11
leading to bottlenecks and long wait times at OPD
12
Although patients are frustrated with the overall
process and cleanliness of the facilities, they
are happy with the treatment
13
There appears to be a persistently severe
shortage of staff
14
The CEO is stretched and management levels appear
to not match the associated responsibility,
resulting in difficulty attracting the right
candidates
CEO
750 people organisation
Director
Medical Manager (Superintendent)
Nursing Service Manager (Senior Matron)
Hospital Manager
Themba
Bongani

Dep. Director
Finance Provisioning
Patient Admin
Auxiliary Services (166)
HRM
Ass. Director
5 senior clerks attending to all HR matters incl.
pensions and payroll
DG
245 people organisation (National DPSA)
CFO Chief Director
Director People Management
Director Finance
Internal Auditor
Director
Dep. Director
Skills Development
Labour relations
People Management
Employee Helath Wellness
15
Staff are unhappy with the facilities, career
progression, overall quality of management and
level of training
16
but are relatively happy with communication,
their job content and competency of co-workers,
and feel that they provide a good service to
customers
17
The application of the PMDS is a bone of
contention

• Resistance to the PMDS.
• Lack of understanding of the system
• When asked about their responsibilities the
  subordinates response is This is not your
  farm.
• Subordinates do not sign PAs as they have not
  received instruction from their provincial
  office.(A total misunderstanding).
• They want to be trained and receive performance
  incentives yet they do not want to sign PAs,
  which are the basis of training and development
  salary progression and other performance
  incentives.
• Other staff members who have signed and have been
  evaluated are discouraged because they have not
  received any feedback, they got the same
  evaluation mark(3) and the same percentage (1)
  and are therefore not encouraged.

18
Agenda

• Executive summary
• Current situation
• Complications
• Some suggested resolutions

19
The outpatients process is cumbersome and slow
Join queue 2 Records Clerk take details of
patient on dummy
Send dummy to filing room
Retrieve file and replace with dummy
Send file to clerk who calls patient hands over
file
Send file to clerk who calls patient hands over
file
Yes
A
Patient arrives at hospital and goes to OPD
Previous patient?
Join queue 1 Records Clerk registers new patient
and creates file
No
Go to pay clerk and pay
Yes
Need to pay?
A
Consult with doctor
Take file to dispensary and queue to wait for
medicine
Collect medicine
Walk to Outpatients and queue for doctor
No
Total process 3-10 hrs
20
Our patients arrive en masse in the morning
21
Other complications

• Clarification of the mandate regarding the
  tertiary status of RF Hospital (and enforcement
  thereof) is likely to be a long-term resolution
• Inherently political in nature
• Requires a mind-set change from a large portion
  of the population (mostly poor and many rural)
• Requires upgrading and improvement of primary
  healthcare clinics and secondary hospitals
• Many are still suffering from the legacy of
  apartheid neglect
• Role of provincial vs district vs hospital likely
  to be politically driven and also long-term in
  nature
• Any permanent change in the delegation and
  authority levels will have knock-on effects with
  other hospitals in the region
• Change of levels (and remuneration) of management
  and professionals is likely to take a long time
  since this is likely to be a national decision
• Changing attitudes of staff and improving the
  relationship with organised labour will be a
  challenge due to cynicism having set in, and
  distrust between management and unions
• A major bottleneck is the current recruiting
  capacity of HRM departments at both hospital and
  provincial level
• With the best will in the world, the current
  capacity is simply not able to efficiently handle
  the massive increase in recruiting requirements
  in the time frame required

22
Agenda

• Executive Summay
• Current situation
• Complications
• Some suggested resolutions

23
Prioritised recommendations

• OPD
• Organisation structure macro and micro
• Recruiting
• Organised labour
• People Management

24
1. The OPD challenge

• There are 2 main problems to solve in OPD
• Reduce the volume of primary healthcare patients
  flooding the facility
• Spread the volume of patients more evenly
  throughout the day to avoid bottlenecks

These 2 problems should be attacked from all
angles and the resolution will combine short-term
with longer-term initiatives
25
1. The OPD challenge
Reduce Volume
Spread volume
Short-term

• Introduce Help-desk at reception point to inform
  patients of procedures

• Improve management of file archives
• Improve queue management
• E.g. give patients numbers when they arrive to
  enable fair tracking

Medium long-term

• Continue with provincial communication campaign
• Introduce gate clinic
• Improve facilities at clinics and district
  hospitals

• Appointment system
• 0800 number to book times with Doctor
  (Switchboard will have to be upgraded)
• Appointment desk at reception for repeat patients
• Those who do not book have to wait
• Investigate use of a WIP (work in progress)
  system to track location of files

26
2. The organisation structure challenge
Hospital Organisation Structure
Role of province vs district vs hospital

• Recommend that certain functions and delegations
  be decentralised down to hospital level to
  improve efficiency e.g.
• Recruiting and appointments
• Provisioning
• Labour relations
• Establish disciplinary committee at hospital
• Training and development
• Batho Pele revitalisation strategy roll-out

• Hospital management levels and remuneration
  commensurate with degree of responsibility
• One CEO per hospital, with CEO level tied to the
  size of the hospital
• Finance and HR reporting directly to the CEO
• Different post levels and grades should allow
  high level responsibility and accountability
• Align budget with strategic objectives
• Need for balanced proportion between line (956)
  and staff (294) functionary
• Workstudy in progress
• Regular review of org structure based on new
  service delivery priorities/mandate
• Link to HOs vision and mission

27
3. The Recruiting Challenge

• Check list
• A costed strategic plan, the practical MTEF cycle
  and the annual action plan.
• Revised and re-aligned organogram
• Clearly outline recruitment plan with time-frames
  , processes and priorities.
• Job description of each employee .
• Identify and Evaluate critical areas of
  employment that need immediate attention.
• HR plan

• Possible interventions.
• Appointment (outsourcing) of project manager to
  coordinate, monitor and implement recruitment
  plan and processes.
• Contract medical specialists with attractive
  packages
• For a long run benefit train more medical
  personnel (offering contractual bursaries)
• Recruitment strategy aligned to HR plan.
• Retention strategy

28
..continue

• CONSIDERATIONS PRIOR TO RECRUITMENT
• Nature of skill required
• Head hunting for scarce skills
• Employee Induction plan
• How,when,what, who
• Availability of physical resources
• Budget to accommodate needs and benefits of new
  employees.
• Office space, computers, vehicles,
  furniture,clothing etc.
• Housing allowance, medical aid, training, st
  etc.
• Legislative mandate
• Equity plan (gender, race,disability etc)
• Is filing of some post a temporary need or
  permanent.
• A sound and realistic retention plan

29
Plan to address the 513 posts Backlog

• Appointment (outsourcing) of contract project
  manager to coordinate, monitor and implement
  recruitment plan and processes.
• Appoint temporary staff in areas where theres
  bottleneck parallel to the recruitment processes
  since funds are available for those posts.
• Put clear time frames for wiping out the entire
  backlog (e.g to be completed in the MTEF cycle)
• Consider over-time for packages for staff.
• Consider moonlighting of medical and support
  staff from neighbouring primary health care
  institutions.

30
4. The organised labour challenge
Use the give-and-take strategy to improve
relationship with labour i.e what are the key
objectives of management and what can we give in
return?
Management key objectives
What can management offer in return?

• Implement PMDS at all levels in the organisation
• Improve discipline
• More cooperation with open lines of communication

• Alleviation of staff shortages by May 05
• Training and development of staff to improve
  upward mobility
• Correct application of PMDS

31
5. The people management challenge
Recruitment and selection
Performance Management
Retention and Maintenance

• Recruitment and selection of levels from
  Assistant Director downwards must be done at the
  hospital/CEO level to speed up process and reduce
  red-tape
• All adverts must be specific about the signing of
  PA within three months
• Orientation and induction (done immediately by a
  training officer who is conversant with all the
  legislative framework, BP and disciplinary
  procedures-Code of conduct to be signed by all
  employees

• Develop an annual consultative strategic plan -
  establish a good rapport with labour
• All staff to be re-trained on the use of PMDS.
• PAs and Workplans to be signed by all staff by 30
  April of each year-This will form the basis of
  evaluation, training and development, performance
  incentives.
• A labour relations committee must be set up to
  deal immediately with disciplinary hearings.
• Khaedu and Change Engagement programme to be
  undertaken by Executive management

• A good communication strategy with all staff must
  be developed. (Monthly management and staff
  meetings)
• Reward good and punish poor performance