Action Learning Pilot Programme

Action Learning Pilot Programme Project Khaedu Witbank Hospital - preliminary findings 04 March 2005

Agenda • Current situation • Complications • Suggested resolutions

Process and physical Organisation design People management Financial/Maintenance • High volumes of patients, some of whom are primary healthcare and referral patients • Very long queues in OPD in the mornings • A significant number of lost files (estimated at 5%) and files not returned from wards (these need to be collected when the patient arrives) • The network infrastructure is not reliable thereby affecting uptime of the patient admin system (PAAB) • An ongoing shortage of professional and support staff • CEO job may be overstretched with 1 tertiary hospital and 2 district hospitals. • Top management of the hospital have limited HR delegations with many decisions having to be referred to Head Office • Low morale often leads to poor service delivery to patients and limited cooperation with management • Performance management partially implemented but not followed up with regular reviews • No real incentives flowing from the PMDS • Current budget does not provide for approved vacancies • Equipment often does not have maintenance contracts Current situation – what we’ve seen and heard

Despite the challenges, there are many positive elements • Witbank hospital is considered one of the well managed hospitals within the province • The management team is both capable and committed to service delivery • Facilities at Witbank hospital are well maintained • The OPD process is user-friendly and highly efficient. Elements of this could be used as best practice by other government hospitals

Patients are happy with overall process and cleanliness of the facilities and the treatment received Source: PSW week surveys

Outpatient activities have been steadily rising 11.5%

…with some patients being primary healthcare candidates from out of the area… Target patient for Witbank Hospital Could be seen at local clinic Source: Note that this data is based on estimates of interviewed staff

…leading to long queues in the morning at OPD

There appears to be a persistently severe shortage of staff

Staff are relatively unhappy with the facilities, career progression and overall quality of management… Source: PSW week surveys

…but are generally happy with communication, their job content and competency of co-workers, and feel that they provide a good service to customers Source: PSW week surveys

Patients arrive en masse in the morning 12:45 AM – 20 patients 7:45 AM – 110 patients

Other complications • Long lead times to approve appointments at Head Office is severely hampering hiring of staff (due to limited HR capacity). This often leads to applicants accepting positions at other institutions. • There is no indication that salary levels of medical professionals are likely to be reviewed in the short term • A national shortage of medical professionals exists especially nursing staff • Severe staff shortages is a contributing factor to low morale as staff are overstretched • The relationship between management and the unions is often problematic and this impacts on the decision making processes • Although the 548 posts have been approved, limited budget is available to finance these positions

Prioritised recommendations • Shortage of staff (esp. nurses) • Addressing staff morale issues • OPD • Improving PMDS application

1. Addressing the shortage of staff (esp. nurses). The shortage of staff has to be addressed at both the Micro (Hospital level) as well on a Macro (provincial/national level). Micro recommendations Macro recommendations • Engage with nursing agencies • Continue to focus on effective planning to match nurse deployments to demand • Employment offers to community service workers should be processed early to allow for delays • A national retention strategy is needed to address remuneration levels of medical professionals • Providing Hospital CEO’s with HR delegations will improve recruitment efficiency

2. Addressing staff morale issues • Staff morale in the organisation appears low in some areas with • many staff having a poor attitude towards patients and • management • To address this it is suggested that: • Regular meetings be held between management and staff • Feedback is provided to staff on crucial issues/decisions within the hospital – especially to balance union report backs • Management regularly perform ‘walk and talks’ to staff on the ground • The role of the union be more clearly defined in terms of decision making

3. Improving OPD process The OPD process is highly efficient. Despite this, long queues exist as patients arrive en masse in the morning To address this the following is suggested Micro recommendations Macro recommendations • Bookings are currently made by day, not by hour – therefore a daily 2-shift booking schedule could be piloted (e.g. 7am and 11am) • When piloting this, the transport logistics should be considered with patients residing close by scheduled in the afternoon • Investigate the feasibility of the integrated electronic patient admin system that has been used in Kimberley for the last 5 years • Discipline around returning of files from wards to OPD should be enforced • A national/provincial communication strategy is required to convince people to visit the primary health care center first BUT • This has to be done in conjunction with an upgrading of service delivery at primary health care centers, including ensuring that medicines are available there • A review of the network infrastructure for PAAB is needed to improve system reliability

4. Realising the benefits of PMDS The PMDS system has been partially implemented but not fully applied • To address this: • The provincial HR forum should be approached to form a project team to assist Witbank in the implementation of PMDS • All new staff placements should be subject to the signing of a performance management contract • Performing quarterly reviews for staff should be a performance measure for management • Regular feedback on performance should be given and this performance must be linked to incentives

The OPD process – An example of best demonstrated practice for other hospitals

The outpatients process is efficient… Case presented to doctor Doctor decides to see patient or refer Checks vital signs Assisted by a queue helper No Patient arrives at hospital and goes to OPD Has an appointment? Joins the queue for screening Yes A electronic Number system used Issued with admin # and colour Receives file at clerks desk and pays Checks vital signs Consult with doctor Take file to dispensary and queue to wait for medicine Collect medicine and return file Total process = 2-6 hrs

…and well supported Queue helper Numbered queuing system

Action Learning Pilot Programme