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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 Slide 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 Slide 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. Slide 4 Slide 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. Slide 6 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 Slide 7 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. Slide 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 20 - 40 minutes. Till receiving the whole service. Slide 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. Slide 10 Data collection & The Findings Slide 11 Statistical data collected from ER (2009) Number of patients seen in ER (2009)) Slide 12 TYPES OF CASES SEEN MONTHLY IN ER (2009) Surgery Orthopedic Slide 13 Inpatients refereed from ER (2009) Slide 14 16% 84% COMPARISON BETWEEN PERCENTAGE OF MEDICAL AND SURGICAL CASES TREATED IN ER (2009) Slide 15 SWOT ANALYSIS Slide 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). Slide 17 Strengths New GM cooperative, with Quality education background and 20 years experience in the same hospital. [GROWING LEADERS IN YOUR OWN BACKYARD]. Slide 18 Strengths The Hospital has a Vision and mission announced, written and distributed all over departments walls. Slide 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. Slide 20 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. Strengths Slide 21 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). (ER) Strengths Slide 22 Slide 23 Slide 24 Slide 25 Slide 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. Slide 27 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. Weaknesses Slide 28 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. Weaknesses Slide 29 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. (ER) Weaknesses Slide 30 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 (ER) Weaknesses Slide 31 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. (ER) Weaknesses Slide 32 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. (ER) Weaknesses Slide 33 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. (ER) Weaknesses Slide 34 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. Opportunities Slide 35 highly qualified university professors contracted to perform operations in the hospital. Opportunity to get involved in different educational programs provided by different health institutes Opportunities Slide 36 Threats Slide 37 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. Slide 38 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.. Threats Slide 39 Evaluation of the current situation in ER Slide 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 Slide 41 Generate a process flow chart for the current state of service provision in ER. Slide 42 Patient ArrivalAmbulance Arrival Triage by Inspection Is patient at Risk? Registration NO Waiting Area Examination Room Patient Triage Yes Is patient Diagnosed? Investigations Interpretation of results Yes NO Is patient severely ill? Initial treatment NO Out clinic follow-up Is service available? Admission Yes Referral NO ER Flow chart Slide 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: Slide 44 0% 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 TriageRegistration Staff attitude Safety,scur ity&sanitati on Waiting area Waiting time Slide 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. Slide 46 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.) Main Findings: Slide 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.) Slide 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. Slide 49 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. Employee satisfaction survey: Slide 50 EMPLOYEE SATISFACTION SURVEY RESULTS Slide 51 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. Main Findings: Slide 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. Slide 53 Service target method ( Regarding ER Nurses) Slide 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. Slide 55 Nurse working time 60minutes6hours6days48weeks= 103680minutes/year. Expected ER patients 180p/d365day=65700patient/year. Slide 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=103680. Other duties=103680/5=20736. Slide 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 Slide 58 Number of nurses needed /day =1.26+1.26+3.16+4.4+3.16+1.9+0.6+3.16 =19 nurses/day N.B.: The actual nurses number in ER is 11nurses Slide 59 Conducting an improvement plan Slide 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 Slide 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) Slide 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. Slide 63 which problems should we direct first? Slide 64 Poly voting RANKINGVOTING PROBLEMS 01) 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 staff 04) Poor marketing system with minimal data and information about other competitors and their market share. Slide 65 15) Poor customer service system 16) Communication skills should be increased to all staff members 257) No proper information system technology 08) No specialized ER doctor 19) No job description available 010) No innovation environment Slide 66 011) High turn over among staff 012) Medical Recording system needs to be much supported 1613) Nurse shortage (numbers) 3414) Shortage in quality improvement programs 015) No Clinical guidelines, protocols, policies &procedures available at ER Slide 67 016) Flexible Organogram should be formulated. 017) ER should have Mission, Vision and strategies (this should be done through complete collaboration between ER staff members). 018) Suitable environment should be considered (e.g. air- conditioning, cleanliness, toilets availability, good furniture) 019) 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. Slide 68 020) Incentives and performance appraisal is not based on real indicators (activity, productivity, efficiency or effectiveness). 021) Lack of information and explanations provided to patients. 5222) 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. Slide 69 Priority Matrix (to prioritize our problems) RANKING TOTALFREQUENCYFEASABILITYIMPORTANCEPROBLEMS 12247670781 51756545652 31926751743 41776154624 22077062755 Slide 70 Result: Top 2 ranked problems to start with are: Nurse shortage. Long perceived waiting time. Slide 71 Action Plan for solving the nurse shortage problem Due date Responsi ble 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 YEARGM3- Use flexible staffing to respond to patient surge (physician/triage/clerking) (new staffing and recruitment should be applied). Slide 72 1 MONTH ER head nurse4- Carry out registration and triage simultaneously, where possible (new procedure should be added at registration level). 6 MONTHS ER MANAGER5- 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. Slide 73 1 MONTH HOSPITAL HEAD NURSE 7- Applying skill mix could eliminate some current tasks to be done by nurse's assistant. 1 MONTH GM8- Extra incentives for ER staff based on a performance appraisal system are not guided by real indicators (activity, productivity, efficiency or effectiveness). 1 YEARGM9- Annual staffing & recruitment plans (nurses) based on actual studied for hospital needs. Slide 74 Action Plan for solving the unsuitable perceived waiting time problem: Due date Responsib le person Task 2 MONTHS ER manager1- Provide more signs/maps guiding patients (explaining wait time situation) to save triage nurse time. 3 MONTHS ER manager2- Install a visual board (electronic display) to make waiting room announcements 3 MONTHS ER manager3- Redesign perimeter of triage and registration desks (glass window around them dampens the sound and hampers communication). Slide 75 1 MONTHSER manager4- Ensure that the profile of triage nurse is most experienced in her role, where assessment is made. 1 MONTHER manager5- Re-consider the amount of info at triage 1 MONTHER manager6- Re-design the flow to avoid traveling and over processing. 2 MONTHER manager7- 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. Slide 76 1 MONTHER head nurse 8- 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. Slide 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. Slide 78 CONCLUSIONS Slide 79 Complex Technology LAB, CT, MRI Increased Processing Time Complex Work-ups Unfamiliar Patients Unknown Problems Need for Specialists Fewer Physicians Fewer Hospitals Decreased Capacity Fewer nurses Fewer EDs Variability ER Overload Increased Demand Population Number Population Age Population Distribution Changing Preferences For ED care Chart explaining ER overload problems Slide 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. Slide 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 Slide 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. Prof. Dr. Moshira Rateb Special thanks to our supervisor Prof. Dr. Moshira Rateb for her assistance, stimulation, guidance and empowering throughout the whole process of the work. 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. Prof. Dr. Moshira Rateb Special thanks to our supervisor Prof. Dr. Moshira Rateb for her assistance, stimulation, guidance and empowering throughout the whole process of the work. Slide 83 Special thanks to our Prof., Dr. Said Rateb 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. Slide 84