Transcript Addington Hospital

Action Learning Pilot Programme
Project Khaedu - Addington Hospital report-back
20 May 2005
Agenda
Executive Summary
Current situation
Some best practices identified
Some remaining challenges
Khaedu Addington
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Key messages
Addington is a well-run hospital within the constraints in which it exists,
with a capable, tightly-knit management team
Best practices
OPD process
 Patient
information
 Patient
screening
HR Management
 Recruitment
and retention
strategy
 Motivation and
awards
 Medical records
 Training and
development
 Multi-skilling
*Out of the direct control of hospital management team
Challenges
Macro*
 Provincial
Health
Department
overhead
structure
Micro
 Pharmacy wait
times
 Staff
communication
 Uncertainty
around future
location and
role of
Addington
Khaedu Addington
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Agenda
Executive Summary
Current situation
Some best practices identified
Some remaining challenges
Khaedu Addington
4
Current situation – what we’ve seen and heard
Process and physical
Organisation design
 Large hospital with
high volumes of
patients
 Relatively high level of
delegation down to the
hospital
- Over 1200 per day
outpatients
 Mixture of regional and
district services
 Very good OPD process
 High inpatient
occupancy rates
(average of 91% last
year)
People management
 Majority of staff
appear positive
- 83.6% in employee
satisfaction survey
 Relatively good
relationship with
- Causes some confusion
unions which has
with patients, and
complicates management
improved over time
and communication
 Provincial Health
Department overhead
 Relatively good level of
structure
infrastructure and
- Potential duplication and
maintenance
unclear roles between
 Relatively good basic
supervisory and
management skills
on the ground
 Very good human
resource
management
district and region
 Geographically very
spread-out, with
 Vacancies are lower than
resulting fragmentation
 Regular, clear
provincial average
of some processes
communication may
- No vacancies at senior
and middle management
improve relationship
 Patients happy with the
level
with staff further
service and treatment,
 Capable experienced
but…
 Good training and
management with clear
development
 …very unhappy with
strategy and good
programmes
long wait times at the
execution
pharmacy
Financial and
procurement
 Apparent high cost
per patient, but
difficult to
benchmark
accurately with
current information
 Some delays in
procurement of
supplies due to
Provincial Stores
 Difficulty in
controlling budget
allocation due to
top-down process
and limited overall
resources
Khaedu Addington
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Addington has a very high volume of outpatients on
a daily basis, and this appears to be growing
Number of outpatients per day
1,526
1,500
2005 average
1,400
1,300
1,491
1,352
14%
increase
1,326
1,249
1,200
1,100
1,000
2004 avg
Jan 05
Feb 05
Mar 05
Apr 05
Khaedu Addington
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Patients are happy with the service and treatment,
but very unhappy with wait times…
Patient score of happiness with Addington
Very happy
5
4
Happy
3.4
3.3
3.3
3
3.3
3.1
2.9
2
Very unhappy
1.7
1
0
Tx
received
Service
of staff
Access to
toilets
Availability Cleanliness
of
medicines
Overall
process
Wait time
Khaedu Addington
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There is a capable, experienced management with a clear
strategy and good execution
5 Strategic Objectives
Optimal, costeffective clinical
outcomes for
patients within the
available resources
and current
provincial health
policy
Attraction &
retention of talented
staff by providing an
exceptional work
environment
conducive to staff
well being,
participation,
development,
learning & research
Enhanced customer
satisfaction ensuring
the dignity & rights
of patients, staff and
other customers
Sound financial
management
Improved
coordination and
communication with
stakeholders
including the
promotion of
partnerships with the
Community and the
eThekweni District
Health Office
Khaedu Addington
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Addington appears to have a relatively high cost per patient day
2000/2001
2001/2002
2002/2003
Ngwelezane
Addington
Empangeni
Edendale
Ladysmith
King George
V
R K Khan
Prince
Mshiyeni
Port
Shepstone
Stanger
1400
1200
1000
800
600
400
200
0
But difficult to do like-for-like
comparison due to significant
factors e.g. training college and
increased maintenance being on
the beach front
Mahatma
Ghandi
Cost (R)
Regional Hospitals
Cost (R) per equivalent patient day
Khaedu Addington
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Agenda
Executive Summary
Current situation
Some best practices identified
-OPD
-Human resource management
Some remaining challenges
Khaedu Addington
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Despite the very high volumes of outpatients, Addington has
instituted a number of measures to manage this…
Good information regarding:
-Status of the hospital and services available
-Where to go
Rigorous and efficient screening process
-Separates PHC patients from appointment and
emergency patients
Very efficient medical records process
Khaedu Addington
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The outpatients process
Patient
arrives
Appointment?
No
Gate clinic for
screening
Yes
10-15
mins
10-15 mins
Emergency?
No
Yes
Register and
pay at OPD
counter
PHC
problem?
See
prof.
nurse
No
See
Doctor
Consult with
Dr
No
Yes
A&E
Directed to
relevant clinic
(file already
there)
Medication
required?
Given slip &
referred to
on-site polyclinic
Yes
Yes
Go to Pharm &
hand in script
Receive
medication
Patient
leaves
Medication
required?
No
Khaedu Addington
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…e.g. patients receive information in their own
language
Knowledgeable security guards at all entrances to
direct patients
“The voice of the voiceless” – a ‘walk-about’ sister
ensures that all patients know where to go and why
they are waiting
Khaedu Addington
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…e.g. patients receive information in their own
language
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Medical records has developed a number of best
practices
All O/patients have to have an appointment before
they are seen at Outpatients
All files logged out on the computer as soon as they
are drawn
All appointment patient files drawn 2 days prior to
appointment
Moved to respective clinics 1 day prior to appointment
Colour coding system to prevent mis-filing
Repeat prescriptions separated out and filed in
separate area for rapid retrieval
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All files are logged out out on the computer as soon
as they are drawn
Khaedu Addington
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All appointment patient files drawn 2 days prior to
appointment
Photo taken on 18/5/05: Files ready
to go to Medical Outpatients clinic
Khaedu Addington
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All files are colour coded…
…to enable quick identification of
misplaced files
Mis-placed files
Khaedu Addington
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Repeat prescriptions are separated out and filed in
separate area for rapid retrieval
Khaedu Addington
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Agenda
Executive Summary
Current situation
Some best practices identified
-OPD
-Human resource management
Some remaining challenges
Khaedu Addington
20
In the absence of PMDS, management have instituted
individual and team service excellence awards
“Service excellence
awards are handmade teak plaques
made from a part of
Addington”
“Employee
satisfaction at
83.6% in last
employee
satisfaction survey
(2004).”
Khaedu Addington
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… Good training and development programmes,…
80% of training and development money allocated to unskilled
categories e.g. general assistants and handymen
 ABET for 53 students last year
 Developing tradesman aid to handyman to artisan (plan submitted by
line manager to HRD; training coordinated by HRD)
Remaining 20% pooled and coordinated at Head Office level
… structured attraction and retention strategies,…
Recognised the fact that the sale of Addington has an impact on
attracting and retaining staff
Set up committee to address these issues and find other ways to attract
and retain the best staff
Appears to be having an effect – lower
vacancy rates than other hospitals
Khaedu Addington
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Addington has a 13% vacancy rate, which is lower
than many of its peers
Addington vacancy % by category
50%
Provincial average
43%
40
Addington
38%
34%
37%
30
23%
20
24%
23%
19%
18%18%
21%
14%
19%
14%
10
Add avg
8%
4%
0
Pharma- PhysioRadiocist
therapist grapher
Nurses
Student
Nurse
Medical Grounds- Principal Cleaner/
Officer
man
& Snr MO FSA/
General
Admin
clerk
Khaedu Addington
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…multi-skilling in the team
A, B, C consultant
D, E, F consultant
G, H, I consultant
J,K,L consultant
 Leave
 Leave
 Leave
 Leave
 Appointments
 Appointments
 Appointments
 Appointments
 Orientation
 Orientation
 Orientation
 Orientation
 Persal issues
 Persal issues
 Persal issues
 Persal issues
 Other human
relation
issues
 Other human
relation
issues
 Other human
relation
issues
 Other human
relation
issues
Multi-skilling, with each consultant with a “set of clients”
Khaedu Addington
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Addington is struggling with absenteesim
Leave (Addington) Oct 04 - Mar 05
4%
3.8%
3.3%
2.9%
3
2.4%
Other
2
0
1.7%
Sick/AWOL
1
2.7%
Oct
Nov
Dec
Jan
Feb
Mar
 Numerous employee awareness programmes attempt to address the absenteeism challenge
- Employee assistance programme
- Life-style diseases management programme and health awareness days
- IOD and needle-stick injury management programme
- TB/AIDS surveillance programme
Khaedu Addington
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Agenda
Executive Summary
Current situation
Some best practices identified
-OPD
-Human resource management
Some remaining challenges
Khaedu Addington
26
The pharmacy has instituted a number of measures
to improve the process of dispensing medication…
Allocating numbers to patients as they arrive
Separate counter for critical/emergency patients
Opening satellite pharmacy at Addington Children’s hospitals
(value to whole system open for debate)
Planning further satellite clinics for MOPD and Polyclinic (value to
whole system open for debate)
Separate process for old-age homes in bulk
-1 representative collects for whole home
Khaedu Addington
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…However, nearly all patients interviewed complained
about wait times at the pharmacy
“We wait very long to receive medicines – often more
than 4 hours”
“It is not an acceptable waiting time – I am going to miss
the taxi back home because I have waited so long”
“I waited nearly the whole day at the Polyclinic and then
had to come back the next day”
“The dispensary is too slow”
Khaedu Addington
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There appears to be a bottleneck at the pharmacist
part of the process
Time taken to
process (mins)
Amount of work
(mins)
Staff required
(8hr day) @
70% efficiency
Staff assigned
Excess/deficit
Script/file
Scripts Batch
Batch
Medication
handed in at batched logged in moved to selected
window and
daily stat dispensa and placed
patient & file
sheet
ry table on tray
given number
0.3
0.0
0.1
0.1
2.0
When 3
Pharmacist checks When 3
When
Hand over
scripts
script and prepares scripts ready, counter
medication
ready, tray label and combines tray moved to full, call
moved to
medications in
dispensing
patients to
pharmacist plastic bag
window
window
0.3
3.0
0.3
0.1
0.5
300
0
100
100
2,000
333
3,000
333
100
500
0.9
0.0
0.3
0.3
6.0
1.0
8.9
1.0
0.3
1.5
7.0
-1.9
2.0
Khaedu Addington
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Addington has a high vacancy rate amongst
pharmacists
Addington vacancy % by category
50%
Provincial average
43%
40
Addington
38%
34%
37%
30
23%
20
24%
23%
19%
18%18%
21%
14%
19%
14%
10
Add avg
8%
4%
0
Pharma- PhysioRadiocist
therapist grapher
Nurses
Student
Nurse
Medical Grounds- Principal Cleaner/
Officer
man
& Snr MO FSA/
General
Admin
clerk
Khaedu Addington
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…and it is unlikely that we will be able to recruit significantly
more pharmacists (and we have budget constraints)
Pharmacists per
100,000 persons
% Total retail pharmacies
vs % total population
60
2.0
40
WHO norm for
industrialised
countries
1.5
1.0
SA average
SA average
20
0.5
0
Gaut.
KZN FS NW NC EC
NP
WC
Mpum
0.0
Gaut
NC KZN FS
WC
NW EC NP
Mpum
Source: “Equity and the Provision of Pharmaceutical Services”, Andy Gray, Pharmaceutical Policy Practice Group, University of Durban-Westville
Khaedu Addington
Initiative for Sub-District Support, HST
31
…and we are losing them quicker than we can replace them
Facing the recruitment and retention crisis in pharmacy: looking
abroad
Pharmacy in Britain is facing one of its biggest ever recruitment
crises. The lack of newly qualified pharmacists, the result of the
fallow year, has left employers looking for other sources of
pharmacists to fill the gap. One of the answers has been to
look abroad.
The Boots experience
Boots The Chemists started recruiting pharmacists from abroad
about 18 months ago. The company has been on several
recruitment visits to both Spain and South Africa. It is planning
to return to both countries later this year.
The Pharmaceutical Journal Vol 267 No 7156 p45-46
Khaedu Addington
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The use of flat trays means medication slides around
and also causes disruption of numbering process
Top tray scripts came in
later than bottom tray,
but will be dispensed
first
Bottom tray scripts
came in first, but will be
dispensed later
Khaedu Addington
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Batching of more than 30 scripts at a time means
that patients wait much longer than is necessary
Khaedu Addington
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Some preliminary ideas to ease the bottleneck at
Addington
Physical
 Improve layout to
match the process
 Categorize and
separate out
“complex”
prescriptions
- E.g. Schedule 5’s
 Change ‘flat trays’
to shallow,
rounded box
containers to
prevent sliding of
drugs from one
patient to another
- Also assists in
stacking
 Eliminate batching
Systems
Times
People
 Motivate for the
implementation of
the pharmacy
module of
MediTech
 Synchronise
opening times of
pharmacy and
pink card section,
e.g.:
 Careful
implementation of
the PMDS for
pharmacists as
well as assistants
- Automatic
printing of labels
- Limited checking
of patient name
etc
 In the interim,
ensure
certification of
post-basic PA’s to
do writing of labels
for Pharmacists
- Open pharmacy
at 6am, but do
not start handing
out medication
until 7.15 (to
prevent “timecreep” earlier and
earlier
 Potentially spread
the opening time
of the pink card
section over a
longer period
- Hold pharmacists
and PA’s to
accepted norms
 Potential for
teaming between
e.g. 3 pharmacists
and 3 PA’s
- Institute league
tables for best
team
Khaedu Addington
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Improve the layout to match the process
Table
Table
slide
slide
slide
slide
Table
Table
windows
Table
Window
Khaedu Addington
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Remaining Macro challenges
Inability to recruit and retain staff due to
impending sale of Addington
Moratorium in filling of posts even if there
are funded vacancies
Very hierarchical provincial overhead
structure
Khaedu Addington
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The overhead structure in Health appears very
hierarchical leading to delays in decision-making
MEC
HOD
15
DDG
(Health
DDG
DDG (Health
(Health
Services
Cluster)
Services
Services Cluster)
Cluster)
14
District Health
Development
13
eThekwini District
Officer
13
CEO (Hospital
Manager)
What is the difference in the roles
and job description of these two
posts?
Khaedu Addington
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