Presentation on theme: "Prepared by Dr. Gamal Essawy Dr. Sayed El-Taweel Dr. Amal El-Sharawy"— Presentation transcript:
1Improvement Studies in Emergency Department of Sporting Student Insurance Hospital Prepared byDr. Gamal EssawyDr. Sayed El-TaweelDr. Amal El-SharawyDr. Nehal Yakout. Dr.Manal SalehDr. Ahmed MustafaDr. Aser KhamisDr. Islam Galal
2content Introduction Aim of this report Data collection &findings. SWOT analysisEvaluation of the current situationConducting an improvement plan.LimitationsConclusionsFuture work
3Introduction 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.
5Introduction 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.
6Introduction 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
7IntroductionThe total hospital capacity beds are two hundred beds, with occupancy rate 70-75%.Total hospital personnel is physicians, and 170 nurses.
8IntroductionER: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.
9Aim of this reportThe 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.
16StrengthsIt 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).
17StrengthsNew GM cooperative, with Quality education background and 20 years experience in the same hospital. [GROWING LEADERS IN YOUR OWN BACKYARD].
18StrengthsThe Hospital has a Vision and mission announced, written and distributed all over department’s walls.
19StrengthsAnalyzing the mission we found it was: highly credible, clear to understand, covering all important aspects of the hospital and it is service oriented.
20StrengthsOrganized 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).
26WeaknessesCentralized 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.
27WeaknessesCustomer 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.
28WeaknessesNo 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)WeaknessesER 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)WeaknessesDepartment 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)WeaknessesGenerally 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)WeaknessesPerformance 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)WeaknessesNo 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 .
34OpportunitiesNational 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.
35Opportunitieshighly qualified university professors contracted to perform operations in the hospital.Opportunity to get involved in different educational programs provided by different health institutes
37ThreatsCentralized 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.
38Threatsother 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…..
40The 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
41Generate a process flow chart for the current state of service provision in ER.
42ER Flow chart Triage by Inspection NO Registration Waiting Area Yes Patient ArrivalAmbulance ArrivalTriage by InspectionIs patient at Risk?RegistrationNOWaiting AreaExamination RoomPatient TriageYesIs patient Diagnosed?InvestigationsInterpretation of resultsIs patient severely ill?Initial treatmentOut clinic follow-upIs service available?AdmissionReferralER Flow chart
43Patient/customer satisfaction survey: Methodology: Questionnaire.Delivery: self completed.Timing: During ED visits.Respondent: Patient or accompanying person.Sample: 100 patients' random samples.Results:
45Main 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.
46Main 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.)
47Only 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.)
48This 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.
49Employee 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.
51Main 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.
52Communication 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.
54The 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.
55Nurse working time60minutes×6hours×6days×48weeks= minutes/year.Expected ER patients180p/d×365day=65700patient/year.
56The 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.
57Number of nurses needed for each task / year =Expected patients/year ÷Standard working loadRegistration=65700/51840=1.26Triage=65700/51840=1.26Vital signs=65700/20736=3.16Doctors assistance in examination=65700/14811=4.4Treatment execution=65700/20736=3.16Monitoring & observation=65700/34560=1.9After care=65700/103680=0.6Other duties)=65700/20736=3.16
58Number of nurses needed /day = =19 nurses/dayN.B.: The actual nurses’ number in ER is 11nurses
60Brainstorming (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 system6) Communication skills should be increased to all staff members7) No proper information system technology8) No specialized ER doctor9) No job description available10) No innovation environment11) High turn over among staff
6112) Medical Recording system needs to be much supported. 13) Nurse shortage (numbers)14) Shortage in quality improvement programs15) 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……)
62Ishikawa (Cause &Effect) diagram: ER ImprovementStaffingLayoutCommunication& TrainingMarketingQuality ImplantationIT managementLean trainingInstall a sign leading patients to triage.Ensure that the profile of triage nurse is “most experienced”Change layout to support continuous flowLarger area for triageImproved physical space designEntrance management into EDPlan for staffing recruitment,Having two triage nurses at all times, instead of two clerksReduce charge nurse non-essential duties.Electronic display for updates e.g.Wait announcements etc.Re-consider the amount of info at triage.Implement Standard WorkQuality system is neededError systemMarketing plan.Bench marketing.Search about market share.
64Poly voting RANKING VOTING PROBLEMS 1) Unsuitable layout and infrastructures conditions of the waiting area (entrances, cleanliness, toilets availability e.g.)12) Lack of a well activated organ gram with a clear job description to all staff members.433) No clear plan for staffing, recruitment, training and education of the Hospital staff4) Poor marketing system with minimal data and information about other competitors and their market share.
6515) Poor customer service system6) Communication skills should be increased to all staff members257) No proper information system technology8) No specialized ER doctor9) No job description available10) No innovation environment
6611) High turn over among staff12) Medical Recording system needs to be much supported1613) Nurse shortage (numbers)3414) Shortage in quality improvement programs15) No Clinical guidelines, protocols, policies &procedures available at ER
6716) 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.
6821) 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.5222) Non suitable perceived waiting timeN.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.
70Result: Top 2 ranked problems to start with are: Nurse shortage. Long perceived waiting time.
71Action Plan for solving the nurse shortage problem Due dateResponsible personTask1 MONTHER head nurse1- 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 MONTHS2- Standardize (to the degree possible) the tasks of the charge nurse (SOP'S)1 YEARGM3- Use flexible staffing to respond to patient surge (physician/triage/clerking) (new staffing and recruitment should be applied).
721 MONTHER head nurse4- Carry out registration and triage simultaneously, where possible (new procedure should be added at registration level).6 MONTHSER MANAGER5- Paramedical may take a role at different stations in ER process of work (e.g. triage, resuscitation room……)1 MONTHSER HEAD NURSE6-Reduce clerical work at triage.
731 MONTHHOSPITAL HEAD NURSE7- Applying skill mix could eliminate some current tasks to be done by nurse's assistant.GM8- Extra incentives for ER staff based on a performance appraisal system are not guided by real indicators (activity, productivity, efficiency or effectiveness).1 YEAR9- Annual staffing & recruitment plans (nurses) based on actual studied for hospital needs.
74Action Plan for solving the unsuitable perceived waiting time problem: Due dateResponsible personTask2 MONTHSER manager1- Provide more signs/maps guiding patients (explaining wait time situation) to save triage nurse time.3 MONTHS2- Install a visual board (electronic display) to make waiting room announcements3- Redesign perimeter of triage and registration desks (glass window around them dampens the sound and hampers communication).
751 MONTHSER manager4- Ensure that the profile of triage nurse is “most experienced” in her role, where assessment is made.1 MONTH5- Re-consider the amount of info at triage1 MONTHER manager6- Re-design the flow to avoid traveling and over processing.2 MONTH7- 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.
761 MONTHER head nurse8- Introduce demand-dependent mini-triage.6 MONTHSGM9-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 MONTHSER manager10-Provide pleasant environment in the waiting area.
77LimitationsAlthough 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.
79ER Overload Chart explaining ER overload problems Complex Technology LAB, CT, MRIIncreasedProcessingTimeComplex Work-upsUnfamiliar PatientsUnknown ProblemsNeed for SpecialistsFewerPhysiciansHospitalsDecreasedCapacityFewer nursesED’sVariabilityER OverloadDemandPopulationNumberAgeDistributionChanging PreferencesFor ED careChart explaining ER overload problems
80one 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.
81FUTURE WORKNo 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
82We 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.
83Special thanks to ourProf., 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.