Improvement Studies in Emergency Department of Sporting Student Insurance Hospital

1. Improvement Studies in Emergency Department of SportingStudentInsuranceHospital 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

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

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.

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.

6. Introduction • 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

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.

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.

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.

10. Data collection & The Findings

11. Statistical data collected from ER (2009) Number of patients seen in ER (2009))

12. Surgery Orthopedic TYPES OF CASES SEEN MONTHLY IN ER (2009)

13. Inpatients refereed from ER (2009)

14. 16% 84% COMPARISON BETWEEN PERCENTAGE OF MEDICAL AND SURGICAL CASES TREATED IN ER (2009)

15. SWOT ANALYSIS

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).

17. Strengths • New GM cooperative, with Quality education background and 20 years experience in the same hospital. [GROWING LEADERS IN YOUR OWN BACKYARD].

18. Strengths • The Hospital has a Vision and mission announced, written and distributed all over department’s walls.

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.

20. Strengths • 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.

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).

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.

27. Weaknesses • 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.

28. Weaknesses • 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.

29. (ER) Weaknesses • 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.

30. (ER) Weaknesses • 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

31. (ER) Weaknesses • Generally 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) Weaknesses • 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.

33. (ER) Weaknesses • 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 patient’s records for a single patient could be found. • no ER sheet for patients with clear plan ttt and discharge strategy .

34. Opportunities • 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.

35. Opportunities • highly qualified university professors contracted to perform operations in the hospital. • Opportunity to get involved in different educational programs provided by different health institutes

36. Threats

37. Threats • 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.

38. Threats • 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…..

39. Evaluation of the current situation in ER

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

41. Generate a process flow chart for the current state of service provision in ER.

42. Patient Arrival Ambulance Arrival Triage by Inspection Is patient at Risk? NO Registration Waiting Area Yes Patient Triage Examination Room Is patient Diagnosed? Out clinic follow-up NO Yes Investigations Is service available? NO Yes Admission Interpretation of results Referral Yes Is patient severely ill? Initial treatment NO ER Flow chart

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:

44. Patint's satisfaction survey results 100% 80% 60% 40% 20% 0% Safety,scur Overall willingness Examinatio Staff Waiting Waiting Triage Registration ity&sanitati satisfaction to return n attitude area time on 74% 66% 81.50% 37% 81% 73% 26.75% 37.75% 9.50% Satisfied 26% 34% 18.50% 63% 19% 27% 73.25% 62.25% 91.50% Unsatisfied

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.

46. Main 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.)

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.)

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.

49. Employee 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.

50. EMPLOYEE SATISFACTION SURVEY RESULTS