Nedcor OPD outpatient department

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					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   2
 Key messages
 Addington is a well-run hospital within the constraints in which it exists,
 with a capable, tightly-knit management team



             Best practices                                         Challenges


   OPD process           HR Management                        Macro*             Micro

 Patient               Recruitment                      Provincial       Pharmacy wait
  information            and retention                     Health            times
 Patient                strategy                          Department       Staff
  screening        Motivation and                         overhead          communication
                    awards                                 structure
 Medical records
                   Training and                          Uncertainty
                    development                            around future
                                                           location and
                        Multi-skilling                    role of
                                                           Addington


*Out of the direct control of hospital management team                        Khaedu Addington   3
Agenda




     Executive Summary
     Current situation
     Some best practices identified
     Some remaining challenges




                                       Khaedu Addington   4
 Current situation – what we‟ve seen and heard
                                                                                              Financial and
 Process and physical           Organisation design          People management
                                                                                              procurement

 Large hospital with        Relatively high level of        Majority of staff           Apparent high cost
  high volumes of             delegation down to the           appear positive              per patient, but
  patients                    hospital                            - 83.6% in employee       difficult to
     - Over 1200 per day     Mixture of regional and
                                                                    satisfaction survey     benchmark
       outpatients
                              district services             Relatively good                accurately with
 Very good OPD process                                      relationship with              current information
                                  - Causes some confusion
 High inpatient                    with patients, and       unions which has              Some delays in
  occupancy rates
                                    complicates management   improved over time             procurement of
                                   and communication
  (average of 91% last                                        Relatively good basic        supplies due to
  year)                     Provincial Health                 supervisory and              Provincial Stores
                             Department overhead               management skills           Difficulty in
 Relatively good level of   structure
  infrastructure and                                           on the ground                controlling budget
                               - Potential duplication and                                  allocation due to
  maintenance                    unclear roles between        Very good human
                                district and region            resource                     top-down process
 Geographically very                                                                       and limited overall
  spread-out, with                                             management
                           Vacancies are lower than                                        resources
  resulting fragmentation   provincial average          Regular, clear
  of some processes           - No vacancies at senior   communication may
 Patients happy with the
                                and middle management    improve relationship
                                level                    with staff further
  service and treatment,
  but…                     Capable experienced         Good training and
                            management with clear        development
 …very unhappy with        strategy and good
  long wait times at the                                 programmes
                            execution
  pharmacy
                                                                                             Khaedu Addington   5
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    1,491
   1,500
                                                                2005 average
   1,400
                        1,352                                    14%
                                 1,326
                                                               increase
   1,300
             1,249

   1,200

   1,100

   1,000
           2004 avg     Jan 05   Feb 05   Mar 05   Apr 05



                                                      Khaedu Addington   6
  Patients are happy with the service and treatment,
  but very unhappy with wait times…
        Patient score of happiness with Addington

  Very happy   5

               4
                    3.4        3.3         3.3          3.3
                                                                    3.1
      Happy    3                                                                 2.9


               2                                                                             1.7

Very unhappy   1

               0      Tx      Service    Access to   Availability Cleanliness   Overall   Wait time
                   received   of staff    toilets        of                     process
                                                     medicines



                                                                                          Khaedu Addington   7
There is a capable, experienced management with a clear
strategy and good execution
5 Strategic Objectives
                            Attraction &                                                          Improved
  Optimal, cost-      retention of talented                                                   coordination and
 effective clinical   staff by providing an                                                communication with
                                               Enhanced customer
   outcomes for          exceptional work                                                       stakeholders
                                              satisfaction ensuring
patients within the        environment                                 Sound financial          including the
                                               the dignity & rights
available resources     conducive to staff                              management              promotion of
                                              of patients, staff and
    and current             well being,                                                    partnerships with the
                                                 other customers
 provincial health         participation,                                                   Community and the
       policy             development,                                                       eThekweni District
                       learning & research                                                      Health Office




                                                                                         Khaedu Addington   8
Addington appears to have a relatively high cost per patient day



                                                                                                                              2000/2001
                                                Regional Hospitals
                                                                                                                              2001/2002
                                         Cost (R) per equivalent patient day                                                  2002/2003
                                                But difficult to do like-for-like
              1400                             comparison due to significant
              1200                            factors e.g. training college and
                                             increased maintenance being on
              1000                                     the beach front
   Cost (R)




               800
               600
               400
               200
                 0




                                                                                                                  Empangeni
                     Mahatma




                                                       Mshiyeni




                                                                                                       Edendale
                                                                  R K Khan




                                                                                           Ladysmith
                                                                             King George
                                           Shepstone
                               Stanger




                                                                                                                               Addington


                                                                                                                                           Ngwelezane
                      Ghandi




                                                        Prince
                                              Port




                                                                                  V




                                                                                                                               Khaedu Addington         9
Agenda




     Executive Summary
     Current situation
     Some best practices identified
         -OPD
         -Human resource management
     Some remaining challenges




                                       Khaedu Addington   10
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   11
The outpatients process                             10-15 mins


                                                                        Given slip &
Patient     Appoint-              Gate clinic for     Emer-              referred to
                            No                                    No
arrives      ment?                 screening          gency?            on-site poly-
                                                                            clinic

               Yes
                                                        Yes                                           See
                                                                           PHC
          Register and                                                                    Yes        prof.
                                                                         problem?
          pay at OPD                                                                                 nurse
10-15                                                  A&E
            counter
mins
                                                                             No
            Directed to
          relevant clinic
                                                                            See
           (file already
                                                                           Doctor
               there)

          Consult with
              Dr                                                  Yes    Medication
                                                                         required?



            Medication            Go to Pharm &       Receive                No
                            Yes
            required?             hand in script     medication


                                                       Patient
                No
                                                       leaves                     Khaedu Addington     12
…e.g. patients receive information in their own
language

                                                    “The voice of the voiceless” – a „walk-about‟ sister
Knowledgeable security guards at all entrances to   ensures that all patients know where to go and why
direct patients                                     they are waiting




                                                                                      Khaedu Addington   13
…e.g. patients receive information in their own
language




                                           Khaedu Addington   14
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


                                                 Khaedu Addington   15
All files are logged out out on the computer as soon
as they are drawn




                                           Khaedu Addington   16
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   17
All files are colour coded…




                               …to enable quick identification of
                               misplaced files




            Mis-placed files




                                                    Khaedu Addington   18
Repeat prescriptions are separated out and filed in
separate area for rapid retrieval




                                           Khaedu Addington   19
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 hand-
                                      made teak plaques
                                     made from a part of
                                         Addington”

                                          “Employee
                                        satisfaction at
                                         83.6% in last
                                           employee
                                      satisfaction survey
                                            (2004).”




                                        Khaedu Addington   21
… 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   22
Addington has a 13% vacancy rate, which is lower
than many of its peers
 Addington vacancy % by category
 50%                                                                     Provincial average
          43%                                                            Addington
  40   38%                 37%
                  34%


  30
                23%                  23%                        24%
                                                        21%
  20                    19%                 18%18%                       19%

                                   14%                                            14%
                                                                                                Add avg
  10                                                                                         8%
                                                      4%


   0   Pharma- Physio-    Radio-   Nurses   Student   Medical Grounds- Principal Cleaner/   Admin
         cist  therapist grapher             Nurse    Officer   man   & Snr MO FSA/          clerk
                                                                                 General


                                                                                      Khaedu Addington   23
…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          Other human             Other human            Other human
  relation              relation                 relation                relation
  issues                issues                   issues                  issues




                Multi-skilling, with each consultant with a “set of clients”




                                                                               Khaedu Addington   24
Addington is struggling with absenteesim
Leave (Addington) Oct 04 - Mar 05

       4%                     3.8%
               3.3%
          3                                                        2.9%
                                                                          2.7%
                Other                                 2.4%

          2                              1.7%
                  Sick/AWOL




          1


          0
                 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   25
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   27
…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   28
    There appears to be a bottleneck at the pharmacist
    part of the process



                 Script/file      Scripts Batch         Batch      Medication    When 3         Pharmacist checks When 3             When         Hand over
                 handed in at batched logged in moved to selected                scripts        script and prepares scripts ready, counter        medication
                 window and                 daily stat dispensa and placed       ready, tray label and combines tray moved to full, call
                 patient & file             sheet       ry table on tray         moved to       medications in        dispensing     patients to
                 given number                                                    pharmacist plastic bag               window         window
Time taken to                 0.3       0.0         0.1        0.1         2.0              0.3                   3.0            0.3          0.1        0.5
process (mins)

Amount of work              300          0       100        100        2,000              333                 3,000             333         100         500
(mins)
Staff required               0.9       0.0        0.3        0.3          6.0              1.0                   8.9            1.0         0.3         1.5
(8hr day) @
70% efficiency
Staff assigned                                                                                                   7.0                                    2.0
Excess/deficit                                                                                                  -1.9




                                                                                                                            Khaedu Addington      29
Addington has a high vacancy rate amongst
pharmacists
 Addington vacancy % by category
 50%                                                                     Provincial average
          43%                                                            Addington
  40   38%                 37%
                  34%


  30
                23%                  23%                        24%
                                                        21%
  20                    19%                 18%18%                       19%

                                   14%                                            14%
                                                                                                Add avg
  10                                                                                         8%
                                                      4%


   0   Pharma- Physio-    Radio-   Nurses   Student   Medical Grounds- Principal Cleaner/   Admin
         cist  therapist grapher             Nurse    Officer   man   & Snr MO FSA/          clerk
                                                                                 General


                                                                                      Khaedu Addington   30
…and it is unlikely that we will be able to recruit significantly
more pharmacists (and we have budget constraints)

                Pharmacists per                                                           % Total retail pharmacies
                100,000 persons                                                           vs % total population
                60                                                                         2.0




                                                             WHO norm for
                                                                                           1.5
                                                             industrialised
                40                                           countries


                                                                                           1.0
                                                                                                                                       SA average
                                                             SA average

                20
                                                                                           0.5




                 0                                                                         0.0
                     Gaut.   KZN FS NW NC EC    NP                                               Gaut        NC KZN FS       NW EC NP
                          WC                Mpum                                                        WC               Mpum

Source: “Equity and the Provision of Pharmaceutical Services”, Andy Gray, Pharmaceutical Policy Practice Group, University of Durban-Westville
Initiative for Sub-District Support, HST                                                                                    Khaedu Addington     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   32
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   33
Batching of more than 30 scripts at a time means
that patients wait much longer than is necessary




                                          Khaedu Addington   34
Some preliminary ideas to ease the bottleneck at
Addington
       Physical                 Systems                     Times                       People

 Improve layout to        Motivate for the          Synchronise               Careful
  match the process         implementation of          opening times of           implementation of
 Categorize and            the pharmacy               pharmacy and               the PMDS for
  separate out              module of                  pink card section,         pharmacists as
  “complex”                 MediTech                   e.g.:                      well as assistants
  prescriptions               - Automatic                - Open pharmacy            - Hold pharmacists
                                printing of labels         at 6am, but do             and PA‟s to
    - E.g. Schedule 5‟s                                    not start handing          accepted norms
                              - Limited checking
 Change „flat trays‟           of patient name            out medication
                                                           until 7.15 (to
                                                                                 Potential for
  to shallow,                   etc
                                                                                  teaming between
                                                           prevent “time-
  rounded box              In the interim,                                       e.g. 3 pharmacists
                                                           creep” earlier and
  containers to             ensure                         earlier                and 3 PA‟s
  prevent sliding of        certification of
                                                      Potentially spread           - Institute league
  drugs from one            post-basic PA‟s to                                        tables for best
  patient to another                                   the opening time
                            do writing of labels                                      team
    - Also assists in                                  of the pink card
                            for Pharmacists
      stacking                                         section over a
                                                       longer period
 Eliminate batching


                                                                                 Khaedu Addington   35
Improve the layout to match the process



                                           Table




         Table           slide
                         slide
                         slide
                         slide




                 Table



                                  Table
                                                   Table




                                 windows
                                                                   Window
                                                           Khaedu Addington   36
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   37
The overhead structure in Health appears very
hierarchical leading to delays in decision-making
                          MEC


                          HOD


              15      DDG (Health
                       DDG (Health
                       DDG (Health
                    Services Cluster)
                     Services Cluster)
                     Services Cluster)


              14     District Health
                                         What is the difference in the roles
                     Development
                                         and job description of these two
                                         posts?
              13   eThekwini District
                        Officer


              13     CEO (Hospital
                       Manager)



                                                          Khaedu Addington   38

				
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