Action Learning Pilot Programme

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

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 Macro* Micro OPD process HR Management • Patient information • Patient screening • Medical records • Recruitment and retention strategy • Motivation and awards • Training and development • Multi-skilling • Provincial Health Department overhead structure • Uncertainty around future location and role of Addington • Pharmacy wait times • Staff communication *Out of the direct control of hospital management team

Agenda • Executive Summary • Current situation • Some best practices identified • Some remaining challenges

Current situation – what we’ve seen and heard Process and physical Organisation design People management Financial and procurement • Large hospital with high volumes of patients • Over 1200 per day outpatients • Very good OPD process • High inpatient occupancy rates (average of 91% last year) • Relatively good level of infrastructure and maintenance • Geographically very spread-out, with resulting fragmentation of some processes • Patients happy with the service and treatment, but… • …very unhappy with long wait times at the pharmacy • Relatively high level of delegation down to the hospital • Mixture of regional and district services • Causes some confusion with patients, and complicates management and communication • Provincial Health Department overhead structure • Potential duplication and unclear roles between district and region • Vacancies are lower than provincial average • No vacancies at senior and middle management level • Capable experienced management with clear strategy and good execution • Majority of staff appear positive • 83.6% in employee satisfaction survey • Relatively good relationship with unions which has improved over time • Relatively good basic supervisory and management skills on the ground • Very good human resource management • Regular, clear communication may improve relationship with staff further • Good training and development programmes • 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

Addington has a very high volume of outpatients on a daily basis, and this appears to be growing 2005 average 14% increase

Patients are happy with the service and treatment, but very unhappy with wait times… Very happy Happy Very unhappy

Optimal, cost-effective 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 There is a capable, experienced management with a clear strategy and good execution 5 Strategic Objectives

Addington appears to have a relatively high cost per patient day But difficult to do like-for-like comparison due to significant factors e.g. training college and increased maintenance being on the beach front

Agenda • Executive Summary • Current situation • Some best practices identified • OPD • Human resource management • Some remaining challenges

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

The outpatients process 10-15 mins Patient arrives Given slip & referred to on-site poly-clinic Gate clinic for screening Appoint-ment? Emer-gency? No No Yes Yes See prof. nurse PHC problem? Yes Register and pay at OPD counter A&E 10-15 mins No Directed to relevant clinic (file already there) See Doctor Consult with Dr Medication required? Yes Go to Pharm & hand in script Receive medication Medication required? No Yes Patient leaves No

…e.g. patients receive information in their own language “The voice of the voiceless” – a ‘walk-about’ sister ensures that all patients know where to go and why they are waiting Knowledgeable security guards at all entrances to direct patients

…e.g. patients receive information in their own language

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

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

All appointment patient files drawn 2 days prior to appointment Photo taken on 18/5/05: Files ready to go to Medical Outpatients clinic

All files are colour coded… …to enable quick identification of misplaced files Mis-placed files

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

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).”

… 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

Addington has a 13% vacancy rate, which is lower than many of its peers Provincial average Addington Add avg

…multi-skilling in the team A, B, C consultant D, E, F consultant G, H, I consultant J,K,L consultant • Leave • Appointments • Orientation • Persal issues • Other human relation issues • Leave • Appointments • Orientation • Persal issues • Other human relation issues • Leave • Appointments • Orientation • Persal issues • Other human relation issues • Leave • Appointments • Orientation • Persal issues • Other human relation issues Multi-skilling, with each consultant with a “set of clients”

Addington is struggling with absenteesim • 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

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

…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”

There appears to be a bottleneck at the pharmacist part of the process

Addington has a high vacancy rate amongst pharmacists Provincial average Addington Add avg

…and it is unlikely that we will be able to recruit significantly more pharmacists (and we have budget constraints) WHO norm for industrialised countries SA average SA average Source: “Equity and the Provision of Pharmaceutical Services”, Andy Gray, Pharmaceutical Policy Practice Group, University of Durban-Westville Initiative for Sub-District Support, HST

…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

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

Batching of more than 30 scripts at a time means that patients wait much longer than is necessary

Some preliminary ideas to ease the bottleneck at Addington Physical Systems Times People • 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 • Motivate for the implementation of the pharmacy module of MediTech • 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 • Synchronise opening times of pharmacy and pink card section, e.g.: • Open pharmacy at 6am, but do not start handing out medication until 7.15 (to prevent “time-creep” earlier and earlier • Potentially spread the opening time of the pink card section over a longer period • Careful implementation of the PMDS for pharmacists as well as assistants • 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

Improve the layout to match the process

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

The overhead structure in Health appears very hierarchical leading to delays in decision-making MEC HOD DDG (Health Services Cluster) DDG (Health Services Cluster) 15 DDG (Health Services Cluster) 14 District Health Development What is the difference in the roles and job description of these two posts? 13 eThekwini District Officer 13 CEO (Hospital Manager)

Action Learning Pilot Programme