Improvement Studies in Emergency Department of Sporting Student Insurance Hospital

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Improvement Studies in Emergency Department of
Sporting Student Insurance Hospital

• Prepared by
• Dr. Gamal Essawy
• Dr. Sayed El-Taweel
• Dr. Amal El-Sharawy
• Dr. Nehal Yakout
• . Dr.Manal Saleh
• Dr. Ahmed Mustafa
• Dr. Aser Khamis
• Dr. Islam Galal

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content

• Introduction
• Aim of this report
• Data collection findings.
• SWOT analysis
• Evaluation of the current situation
• Conducting an improvement plan.
• Limitations
• Conclusions
• Future work

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Introduction

• History
• Sporting student school hospital was opened in
  1938, belonging to Jewish community, the hospital
  was nationalized in 1964 and it was conducted to
  HIO since 1994.

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Introduction

• Background
• Sporting student school hospital is located
  In Alexandria. It follow the Health Insurance
  organization, provides health care services for
  school students of Alexandria, and consider as a
  referral hospital for Kafr El-sheikh, and Behaira
  governorate in collaboration with Gamal Abdel
  Nasser hospital.

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Introduction

• The hospital consists of three buildings
• -outpatients clinic
• -emergency.
• -and inpatients area.
• The inpatients building consist of
• male-female surgical dept.
• medical dept.
• pediatric dept.
• neonatal ICU.( new )
• Pediatric ICU.
• Haemdialysis unit.
• orthopedic department.
• 4 operation theaters

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Introduction

• The total hospital capacity beds are two hundred
  beds, with occupancy rate 70-75.
• Total hospital personnel is 500 .150 physicians,
  and 170 nurses.

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Introduction

• ER
• Consists of 8 beds, observation room, x-ray room,
  laboratory room, small waiting room.
• ER service is available 24hours a day.
• The waiting area accommodate for nearly about 20
  persons. Usually 25 persons are waiting at a
  time.
• the mean average waiting time 20 - 40 minutes.
  Till receiving the whole service.

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Aim of this report

• The aim of this project is to identify the state
  of current services in the ER and the evidence
  relating to patient satisfaction in emergency
  medicine, thereby providing useful information
  for clinicians, and helping to guide future
  strategies for assessment and improvement in this
  area.

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Data collection The Findings
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Statistical data collected from ER (2009)
Number of patients seen in ER (2009))
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Surgery
Orthopedic
TYPES OF CASES SEEN MONTHLY IN ER (2009)
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Inpatients refereed from ER (2009)
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COMPARISON BETWEEN PERCENTAGE OF MEDICAL AND
SURGICAL CASES TREATED IN ER (2009)
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SWOT ANALYSIS
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Strengths

• It a specialized hospital dedicated to a certain
  niche (school aged children) mostly all of
  specialties are offered by highly qualified
  trained doctors (specialists and consultants).

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Strengths

• New GM cooperative, with Quality education
  background and 20 years experience in the same
  hospital. GROWING LEADERS IN YOUR OWN BACKYARD.

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Strengths

• The Hospital has a Vision and mission announced,
  written and distributed all over departments
  walls.

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Strengths

• Analyzing the mission we found it was highly
  credible, clear to understand, covering all
  important aspects of the hospital and it is
  service oriented.

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Strengths

• Organized social services activities dealing with
  all the needy cases.
• High Hospital average occupation rate 75.
• Adequate hospital infrastructures.
• Strong informal communication channels among
  hospital departments.

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(ER)Strengths

• Separate building, easily accessible.
• Emergency lab, X ray room available 24hours a
  day.
• Nurses are well trained with long experience in
  ER.
• Teamwork spirit among staff.
• New ER building well designed, well equipped with
  good landscape is about to be opened in 3 months
  (still under construction).

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Weaknesses

• Centralized decision making rendering the
  organization into a rigid form delaying important
  decisions .
• No clear plan for staffing, recruitment, training
  and education of the Hospital staff.
• More than 40 of hospital staff are clerks and
  administrative personnel.
• Poor marketing system with minimal data and
  information about other competitors and their
  market share.

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Weaknesses

• Customer service is only based upon social
  workers and social activities with No feed back
  about customer service and almost all of working
  staff got no training on communication skills.
• No proper implementation of an Information
  Technology System ending into insufficient
  conducted statistical studies about the hospital
  health indicators.

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Weaknesses

• No implementation of a good quality system.
  (Current status has to be measured) though some
  steps has been taken in that long path.
• Insufficient accountability regarding medical
  errors.
• Unavailable of ideal standards that required
  protecting patient's confidentiality and privacy.

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(ER)
Weaknesses

• ER building is not suitable, small area not
  adequate to actual demands, only one way for both
  entrance and exit, small waiting area with poor
  ventilation, no enough available rooms for every
  service needed (no isolation room- one
  examination room- no office for head of
  department), Bathrooms are located outside the ER
  building and also no alternative electric source
  to ER department.

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(ER)
Weaknesses

• Department has no clear mission, goals or
  objectives clear to the staff working in it.
• Head of department is a part timer not dedicated
  to ER (ER manager overloaded with other technical
  job).
• No specialized ER doctors

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(ER)
Weaknesses

• Generally understaffing of hospitals nurses
  including ER department.
• No Job description available for any staff member
  in ER.
• High turn over scale among ER doctors.

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(ER)
Weaknesses

• Performance appraisal system is not based on real
  indicators (activity, productivity, efficiency or
  effectiveness).
• Lack of work innovations and creativity working
  atmospheres with weak incentives to ER doctors.

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(ER)
Weaknesses

• No guidelines, organizational chart, Protocols,
  policies or procedures available to the working
  staff in their own working area.
• Medical Records still needs to be much
  systematized, still multiple patients records
  for a single patient could be found.
• no ER sheet for patients with clear plan ttt and
  discharge strategy .

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Opportunities

• National politically supported trend for
  development, improvement and expansion of health
  insurance.
• Planning and implementing of a new Health
  insurance law.
• Collaboration with Alexandria University in
  different fields such as research and
  training...etc.

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Opportunities

• highly qualified university professors
  contracted to perform operations in the hospital.
• Opportunity to get involved in different
  educational programs provided by different health
  institutes

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Threats
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Threats

• Centralized politically affected decision making,
  this renders decisions difficult to be made in
  time.
• New legislations may lead to uncertainty of the
  expected effect.
• New legislations will raise competition with
  private sector.

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Threats

• other well equipped university private hospitals
  sharing the same specialties market.
• High staff income in private hospital sector.
• Insufficient central funding resources. Lack of
  external fund resources for development of nurses
  and other hospital employees.
• Unpredicted unexpected diseases or disasters that
  need contingency plans to deal with e.g. swine
  flu..

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Evaluation of the current situation in ER
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• The methodology used was through
• Evaluation of the current process flow chart and
  its effect on service provision.
• An analysis of the customer satisfaction state
  whether internal or external.
• An analysis of the workload of nursing personnel.
• An analysis of all the results of the previous
  sections.
• Application of various prioritizing and decision
  making techniques to draw conclusions on main
  areas of improvement that can benefit from
  quality improvement efforts

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Generate a process flow chart for the current
state of service provision in ER.
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ER Flow chart
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Patient/customer satisfaction survey

• Methodology Questionnaire.
• Delivery self completed.
• Timing During ED visits.
• Respondent Patient or accompanying person.
• Sample 100 patients' random samples.
• Results

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Main Findings

• important Factors are (Waiting time,
  information, personnel attitude care, courtesy,
  concern and pleasant environment).
• Doctor's manners and waiting times are the main
  cause of patient's satisfaction.

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Main Findings

• patient's dissatisfaction could be attributed to
  work overload in ER regarding nurses.
• Significant process of care measures triage
  status, significant problems (poor explanation of
  problem cause and test results, not informed when
  to resume normal activities or when to re-attend)
  are strong causes of patient's dissatisfaction,
  this could be attributed to work overload in ER
  regarding nurses.
• Least satisfaction was noticed for the layout and
  infrastructures conditions of the waiting area
  (entrances, cleanliness, toilets availability
  e.g.)

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• Only 37 of patients were satisfied with the
  triage area.
• Least satisfaction was noticed for the layout and
  infrastructures conditions of the waiting area
  (entrances, cleanliness, toilets availability
  e.g.)

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This work reveals three interventions worthy of
further study are

• Improving interpersonal. Attitudinal and
  communicational skills in ED staff. Short
  training courses maybe highly effective in this
  regard.
• Provision of more information and explanation.
• More reduction of the perceived waiting time.

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Employee satisfaction survey

• Methodology Questionnaire.
• Delivery self completed.
• Timing During working hours.
• Respondent all types of ED staff (doctors,
  nurses, clerks, security personnel).
• Sample 30 patients' random samples.

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EMPLOYEE SATISFACTION SURVEY RESULTS
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Main Findings

• Most of employees are satisfied with their jobs
  despite of the work overload and the low
  financial benefits.
• Lack of suitable environment and convenient
  layout of the department caused great deal of the
  staff dissatisfaction.

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• Communication channels seem to be working well.
• The amazing issue was the unavailability of ED
  flow chart, error reporting system, any
  guidelines or Sop's regarding ED, however job
  duties were fully known and workers complaints
  were strictly handled. As a whole, though a
  documented quality system in not well
  implemented, yet an informal system is in place
  that monitors the performance of the unit which
  can be built upon for improvement efforts.

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Service target method ( Regarding ER Nurses)
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• The daily nurse tasks
• Registration2minutes/patient.
• Triage2minutes/patient.
• Vital signs5minutes/patient.
• Doctors assistance in examination7minutes/patient
  .
• Treatment execution5minutes/patient.
• Monitoring observation3minutes/patient.
• After care 1minute/patient.
• Other duties5minutes/patient.

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• Nurse working time
• 60minutes6hours6days48weeks
  103680minutes/year.
• Expected ER patients
• 180p/d365day65700patient/year.

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• The standard working load for each task
• Registration103680/251840.
• Triage103680/251840.
• Vital signs103680/520736.
• Doctors assistance in examination103680/714811.
• Treatment execution103680/520736.
• Monitoring observation103680/334560.
• After care103680/1103680.
• Other duties103680/520736.

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• Number of nurses needed for each task / year
• Expected patients/year Standard working load
• Registration65700/518401.26
• Triage65700/518401.26
• Vital signs65700/207363.16
• Doctors assistance in examination65700/148114.4
• Treatment execution65700/207363.16
• Monitoring observation65700/345601.9
• After care65700/1036800.6
• Other duties)65700/207363.16

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• Number of nurses needed /day
• 1.261.263.164.43.161.90.63.1619
  nurses/day
• N.B. The actual nurses number in ER is 11nurses

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Conducting an improvement plan
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Brainstorming (to identify our targeted problems
to improve)

• 1) Unsuitable layout and infrastructures
  conditions of the waiting area (entrances,
  cleanliness, toilets availability e.g.)
• 2) Lack of a well activated organ gram with a
  clear job description to all staff members.
• 3) No clear plan for staffing, recruitment,
  training and education of the Hospital staff.
• 4) Poor marketing system with minimal data and
  information about other competitors and their
  market share.
• 5) Poor customer service system
• 6) Communication skills should be increased to
  all staff members
• 7) No proper information system technology
• 8) No specialized ER doctor
• 9) No job description available
• 10) No innovation environment
• 11) High turn over among staff

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• 12) Medical Recording system needs to be much
  supported.
• 13) Nurse shortage (numbers)
• 14) Shortage in quality improvement programs
• 15) Lack of information and explanations provided
  to patients.
• 16) Non suitable perceived waiting time.
• 17) Incentives and performance appraisal is not
  based on real indicators (activity, productivity,
  efficiency or effectiveness).
• 18) No Clinical guidelines, protocols, policies
  procedures available at ER.
• 19) Flexible Organ gram should be formulated.
• 20) Head of ER not fully dedicated to his work
  and needs to have a clear job description and to
  be trained on his managerial duties.
• 21) ER should have Mission, Vision and strategies
  (this should be done through complete
  collaboration between ER staff members).
• 22) Suitable environment should be considered
  (e.g. air-conditioning, cleanliness, toilets
  availability, good furniture)

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Ishikawa (Cause Effect) diagram
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which problems should we direct first?
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Poly voting
RANKING VOTING PROBLEMS
0 1) Unsuitable layout and infrastructures conditions of the waiting area (entrances, cleanliness, toilets availability e.g.)
1 2) Lack of a well activated organ gram with a clear job description to all staff members.
4 3 3) No clear plan for staffing, recruitment, training and education of the Hospital staff
0 4) Poor marketing system with minimal data and information about other competitors and their market share.
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1 5) Poor customer service system
1 6) Communication skills should be increased to all staff members
2 5 7) No proper information system technology
0 8) No specialized ER doctor
1 9) No job description available
0 10) No innovation environment
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0 11) High turn over among staff
0 12) Medical Recording system needs to be much supported
1 6 13) Nurse shortage (numbers)
3 4 14) Shortage in quality improvement programs
0 15) No Clinical guidelines, protocols, policies procedures available at ER
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0 16) Flexible Organogram should be formulated.
0 17) ER should have Mission, Vision and strategies (this should be done through complete collaboration between ER staff members).
0 18) Suitable environment should be considered (e.g. air-conditioning, cleanliness, toilets availability, good furniture)
0 19) Head of ER not fully dedicated to his work and needs to have a clear job description and to be trained on his managerial duties.
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0 20) Incentives and performance appraisal is not based on real indicators (activity, productivity, efficiency or effectiveness).
0 21) Lack of information and explanations provided to patients.
5 2 22) Non suitable perceived waiting time
N.B. The unsuitable layout was least voted upon
in this project since this problem will be
resolved by the new ER building which is under
construction.
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Priority Matrix (to prioritize our problems)
RANKING TOTAL FREQUENCY FEASABILITY IMPORTANCE PROBLEMS
1 224 76 70 78 1
5 175 65 45 65 2
3 192 67 51 74 3
4 177 61 54 62 4
2 207 70 62 75 5
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Result

• Top 2 ranked problems to start with are
• Nurse shortage.
• Long perceived waiting time.

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Action Plan for solving the nurse shortage problem
Due date Responsible person Task
1 MONTH ER head nurse 1- Separate the work elements that can exclusively be carried out only by nurses, assuring that they have more time to carry out their essential (value adding) duties. (new job descriptions to be formulated)
6 MONTHS ER head nurse 2- Standardize (to the degree possible) the tasks of the charge nurse (SOP'S)
1 YEAR GM 3- Use flexible staffing to respond to patient surge (physician/triage/clerking) (new staffing and recruitment should be applied).
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1 MONTH ER head nurse 4- Carry out registration and triage simultaneously, where possible (new procedure should be added at registration level).
6 MONTHS ER MANAGER 5- Paramedical may take a role at different stations in ER process of work (e.g. triage, resuscitation room)
1 MONTHS ER HEAD NURSE 6-Reduce clerical work at triage.
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1 MONTH HOSPITAL HEAD NURSE 7- Applying skill mix could eliminate some current tasks to be done by nurse's assistant.
1 MONTH GM 8- Extra incentives for ER staff based on a performance appraisal system are not guided by real indicators (activity, productivity, efficiency or effectiveness).
1 YEAR GM 9- Annual staffing recruitment plans (nurses) based on actual studied for hospital needs.
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Action Plan for solving the unsuitable perceived
waiting time problem
Due date Responsible person Task
2 MONTHS ER manager 1- Provide more signs/maps guiding patients (explaining wait time situation) to save triage nurse time.
3 MONTHS ER manager 2- Install a visual board (electronic display) to make waiting room announcements
3 MONTHS ER manager 3- Redesign perimeter of triage and registration desks (glass window around them dampens the sound and hampers communication).
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1 MONTHS ER manager 4- Ensure that the profile of triage nurse is most experienced in her role, where assessment is made.
1 MONTH ER manager 5- Re-consider the amount of info at triage
1 MONTH ER manager 6- Re-design the flow to avoid traveling and over processing.
2 MONTH ER manager 7- Categorize ER patients according to the severity level of their medical condition. Patients are assigned a triage number of 1 to 5 (1 being most emergent, and 5 being the least) when they report to the triage nurse.
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1 MONTH ER head nurse 8- Introduce demand-dependent mini-triage.
6 MONTHS GM 9-No tools in the world can provide sustainability without a change in the culture, mindset and behaviors of the personnel. Provide training and informative lectures aiming to obtain that result)
3 MONTHS ER manager 10-Provide pleasant environment in the waiting area.
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Limitations

• Although a lot of effort was invested in this
  study of Hospital Emergency Department,
  limitations attributable to multiple factors
  exist due to
• Limited time span of the study.
• Limited availability of resources.
• Limited scope of the study issues related to
  cultural, mindset and behavioral change were not
  covered.
• The project did not consider any financial
  implications or commitments from the hospital
  management.

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CONCLUSIONS
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Chart explaining ER overload problems
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• one of the key challenges to health care
  access in hospitals is the growing overcrowding
  of the Emergency Departments (ERs), leading to
  the medical personnel overload, and the excessive
  waiting times to receive proper care.
• These adverse effects directly impact the
  patient satisfaction levels, the ability of the
  medical professionals to attend promptly to
  patients health issues, and generate unnecessary
  costs.
• Addressing the sources of waste and improving
  the process provides better care and higher
  patient satisfaction, as well as increases
  operational efficiency and the ability of the
  medical professionals to intervene on time.

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FUTURE WORK

• No tools in the world can provide
  sustainability without a change in the culture,
  mindset and behaviors of the personnel. Unlike
  machines and processes that can be changed and
  improved relatively quickly, changing outlooks
  and mindsets takes plenty of time and skill

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• We would like to express our appreciation to
  hospital staff, and in particular Dr. Ayman Morsy
  the General Manager, for his great support, helps
  in collecting the data, numerous discussions, and
  guidance throughout the work.
• We also extend our thanks to Dr. Khaled Abul
  Ela for his cooperation.
• Special thanks to our supervisor Prof. Dr.
  Moshira Rateb for her assistance, stimulation,
  guidance and empowering throughout the whole
  process of the work.

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• Special thanks to our
• Prof., Dr. Said Rateb MD, FRCS,
• The spirit father of healthcare
  management program for his great effort and ideas
  for this program to see light and his kindly
  teaching course and arrangement of the whole
  program.

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Thank you