1. 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

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

3. 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.

5. 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.

6. Introduction The hospital consists of three buildings:
-outpatient’s 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

7. Introduction
The total hospital capacity beds are two hundred beds, with occupancy rate 70-75%.
Total hospital personnel is physicians, and 170 nurses.

8. 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 minutes. Till receiving the whole service.

9. 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.

10. Data collection & The Findings

11. Statistical data collected from ER (2009)
Number of patients seen in ER (2009))

12. TYPES OF CASES SEEN MONTHLY IN ER (2009)
Surgery
Orthopedic
TYPES OF CASES SEEN MONTHLY IN ER (2009)

13. Inpatients refereed from ER (2009)

14. 16%
84%
COMPARISON BETWEEN PERCENTAGE OF MEDICAL AND SURGICAL CASES TREATED IN ER (2009)

15. SWOT ANALYSIS

16. 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).

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

18. Strengths
The Hospital has a Vision and mission announced, written and distributed all over department’s walls.

19. 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.

20. 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.

21. (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).

26. 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.

27. 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.

28. 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.

29. (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.

30. (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

31. (ER)
Weaknesses
Generally understaffing of hospital’s nurses including ER department.
No Job description available for any staff member in ER.
High turn over scale among ER doctors.

32. (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.

33. (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 patient’s records for a single patient could be found.
no ER sheet for patients with clear plan ttt and discharge strategy .

34. 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.

35. 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

36. Threats

37. 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.

38. 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…..

39. Evaluation of the current situation in ER

40. 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

41. Generate a process flow chart for the current state of service provision in ER.

42. ER Flow chart Triage by Inspection NO Registration Waiting Area Yes
Patient Arrival
Ambulance Arrival
Triage by Inspection
Is patient at Risk?
Registration NO
Waiting Area
Examination Room
Patient Triage
Yes
Is patient Diagnosed?
Investigations
Interpretation of results
Is patient severely ill?
Initial treatment
Out clinic follow-up
Is service available?
Admission
Referral
ER Flow chart

43. Patient/customer satisfaction survey:
Methodology: Questionnaire.
Delivery: self completed.
Timing: During ED visits.
Respondent: Patient or accompanying person.
Sample: 100 patients' random samples.
Results:

44. Patint's satisfaction survey results0%
20%
40%
60%
80%
100%
Patint's satisfaction survey results
Satisfied
74%
66%
81.50%
37%
81%
73%
26.75%
37.75%
9.50%
Unsatisfied
26%
34%
18.50%
63%
19%
27%
73.25%
62.25%
91.50%
Overall
satisfaction
willingness
to return
Examinatio n
Triage
Registration
Staff
attitude
Safety,scur
ity&sanitati on
Waiting
area
time

45. 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.

46. 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.)

47. 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.)

48. 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.

49. 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.

50. EMPLOYEE SATISFACTION SURVEY RESULTS

51. 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.

52. 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.

53. Service target method ( Regarding ER Nurses)

54. The daily nurse tasks;
Registration=2minutes/patient.
Triage=2minutes/patient.
Vital signs=5minutes/patient.
Doctors assistance in examination=7minutes/patient.
Treatment execution=5minutes/patient.
Monitoring & observation=3minutes/patient.
After care =1minute/patient.
Other duties=5minutes/patient.

55. Nurse working time
60minutes×6hours×6days×48weeks= minutes/year.
Expected ER patients
180p/d×365day=65700patient/year.

56. The standard working load for each task
Registration=103680/2=51840.
Triage=103680/2=51840.
Vital signs=103680/5=20736.
Doctors assistance in examination=103680/7=14811.
Treatment execution=103680/5=20736.
Monitoring & observation=103680/3=34560.
After care=103680/1=
Other duties=103680/5=20736.

57. Number of nurses needed for each task / year
=Expected patients/year ÷Standard working load
Registration=65700/51840=1.26
Triage=65700/51840=1.26
Vital signs=65700/20736=3.16
Doctors assistance in examination=65700/14811=4.4
Treatment execution=65700/20736=3.16
Monitoring & observation=65700/34560=1.9
After care=65700/103680=0.6
Other duties)=65700/20736=3.16

58. Number of nurses needed /day
= =19 nurses/day
N.B.: The actual nurses’ number in ER is 11nurses

59. Conducting an improvement plan

60. 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

61. 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……)

62. Ishikawa (Cause &Effect) diagram:
ER Improvement
Staffing
Layout
Communication& Training
Marketing
Quality Implantation
IT management
Lean training
Install a sign leading patients to triage.
Ensure that the profile of triage nurse is “most experienced”
Change layout to support continuous flow
Larger area for triage
Improved physical space design
Entrance management into ED
Plan for staffing recruitment,
Having two triage nurses at all times, instead of two clerks
Reduce charge nurse non-essential duties.
Electronic display for updates e.g.
Wait announcements etc.
Re-consider the amount of info at triage.
Implement Standard Work
Quality system is needed
Error system
Marketing plan.
Bench marketing.
Search about market share.

63. which problems should we direct first?

64. Poly voting RANKING VOTING PROBLEMS
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
4) Poor marketing system with minimal data and information about other competitors and their market share.

65. 1
5) Poor customer service system
6) Communication skills should be increased to all staff members 2 5
7) No proper information system technology
8) No specialized ER doctor
9) No job description available
10) No innovation environment

66. 11) High turn over among staff
12) Medical Recording system needs to be much supported 1 6
13) Nurse shortage (numbers) 3 4
14) Shortage in quality improvement programs
15) No Clinical guidelines, protocols, policies &procedures available at ER

67. 16) Flexible Organogram should be formulated.
17) ER should have Mission, Vision and strategies (this should be done through complete collaboration between ER staff members).
18) Suitable environment should be considered (e.g. air-conditioning, cleanliness, toilets availability, good furniture……)
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.

68. 21) Lack of information and explanations provided to patients. 5 2
20) Incentives and performance appraisal is not based on real indicators (activity, productivity, efficiency or effectiveness).
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.

69. Priority Matrix (to prioritize our problems)
RANKING
TOTAL
FREQUENCY
FEASABILITY
IMPORTANCE
PROBLEMS 1
224 76 70 78 5
175 65 45 2 3
192 67 51 74 4
177 61 54 62
207 75

70. Result: Top 2 ranked problems to start with are: Nurse shortage.
Long perceived waiting time.

71. 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
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).

72. 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.

73. 1 MONTH
HOSPITAL HEAD NURSE
7- Applying skill mix could eliminate some current tasks to be done by nurse's assistant. 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
9- Annual staffing & recruitment plans (nurses) based on actual studied for hospital needs.

74. 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
2- Install a visual board (electronic display) to make waiting room announcements
3- Redesign perimeter of triage and registration desks (glass window around them dampens the sound and hampers communication).

75. 1 MONTHS
ER manager
4- Ensure that the profile of triage nurse is “most experienced” in her role, where assessment is made.
1 MONTH
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
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.

76. 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.

77. 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.

78. CONCLUSIONS

79. ER Overload Chart explaining ER overload problems Complex Technology
LAB, CT, MRI
Increased
Processing
Time
Complex Work-ups
Unfamiliar Patients
Unknown Problems
Need for Specialists
Fewer
Physicians
Hospitals
Decreased
Capacity
Fewer nurses
ED’s
Variability
ER Overload
Demand
Population
Number
Age
Distribution
Changing Preferences
For ED care
Chart explaining ER overload problems

80. 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.

81. 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

82. 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.

83. 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.

84. Thank you