Project Khaedu SMS Action Learning Programme

1. Project KhaeduSMS Action Learning Programme Ladysmith Hospital - preliminary findings 21 October 2005

2. Agenda • Executive summary • Situation • Complications • Some suggestions

3. Executive summary and key message Ladysmith Hospital is assisting approximately 12,500 patients monthly under difficult conditions, with dedicated staff and improvements evidenced in many areas… Absolute shortage of key resources and limited physical space in the hospital complicate opportunities for improvement, but whilst poor morale is evident at some levels, many opportunities exist for improvement in process and people management

4. Situation Absolute shortage of key resources and limited physical space in the hospital complicate opportunities for improvement, but whilst poor morale is evident at many levels, many opportunities exist for improvement in process and people management Situation • Key resources are critically short relative to increasing demand • Severe congestion and long waiting times at OPD • High numbers of “unnecessary” referrals from District and Clinics increases the load • Cordial relationship with organised labour • Staff morale appears low, especially Drs & Nurses • Poor working relations in the Maintenance Dept • Deteriorating infrastructure, poor layout and space constraints

5. Ladysmith hospital is swamped with high numbers of outpatients per day… *

6. …which impacts on service delivery

7. “I have been waiting for my file for 3 hours and I am only here to collect medication” “The nurses don’t care” “The helpfulness of the staff is not up to standard” “We used to wait a long time at the pharmacy, but now things have improved” “Medication is often not available at the clinics – only panado and disprin” “There are not enough doctors at the clinics” “The clinic staff are not very willing to help” “The clinics close before lunch time and send us away – then we come here” “Limit Hill Clinic staff go out of their way to help and advise us – they are exceptional” “Ezakheni Clinic staff need to be more empathetic when dealing with patients” Patients are unhappy with waiting times and helpfulness of staff, but are happy with availability of medicines and cleanliness V good Good OK Poor Very poor

8. Key resources are critically short

9. Staff are unhappy with career progression, skills development and lack of appreciation for their efforts V good Good OK Poor Very poor

10. What are staff saying? “No meaningful interaction with senior management” “Breakdown of communication with senior management” “We work long hours of overtime with no recognition or gratitude” “Medical staff are going beyond the call of duty and are very dedicated” “Community Doctors are abused – they are given the bulk of the heavy work, and work unreasonably long hours (up to 36 hrs at a time)” “Inflexible allocation of package” (e.g. pension) “Management is improving” “If you are in this place, you are here to serve a life sentence” “There is no facility for Doctors to interact with each other in order to support each other” “Little skills development and poor career progression for doctors and nurses” “Unnecessary referrals from clinics and other district hospitals” “Allocation of doctors between sections and wards is not optimal” “Facilities and layout of the hospital need attention” (esp labour ward to theatre) “Off-duty roster for nurses needs to be revised” “We are not given recognition for extra work, but are shouted at as soon as there is a little mistake” “Little training opportunities and unfair allocation of opportunities”

11. Staff feel that upward communication is stifled and downward communication is autocratic Nursing Services Manager Deputy Nursing Services Manager Zonal Matrons Zonal Matrons Zonal Matrons Zonal Matrons Upward communication is perceived to be ‘buffered’ and does not reach senior management Unit Manager Unit Manager Unit Manager Ward nurses Ward nurses Ward nurses Ward nurses Ward nurses Ward nurses “We don’t have access to the senior management – we don’t even know if our message goes up and when the answer comes back, it is a directive”

12. Complications Absolute shortage of key resources and limited physical space in the hospital complicate opportunities for improvement, but whilst poor morale is evident at many levels, many opportunities exist for improvement in process and people management Situation Complications • Key resources are critically short relative to increasing demand • Severe congestion and long waiting times at OPD • High numbers of “unnecessary” referrals from District and Clinics increases the load • Cordial relationship with organised labour • Staff morale appears low, especially Drs & Nurses • Poor working relations in the Maintenance Dept • Deteriorating infrastructure, poor layout and space constraints • Unlikely to recruit and retain quality professional staff at current levels of salary • Patients arrive en masse early in the morning complicating congestion • Physical layout of OPD registry compounded by staff shortage in file retrieval • Dept of Works very slow • PHC Clinic management a concern • Lack of coordination and cooperation between district and clinics and the hospital • Management stretched

13. Patients arrive en masse early in the morning, causing severe congestion

14. The registry file retrieval system causes a major bottleneck to the OPD process How soon would you be able to identify and retrieve 600 files per day from here?

15. New structure Nursing Services Manager 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 7 7 7 8 8 8 1 Primary Healthcare Coordinator – one person to supervise 18 Clinics 9 10 11 12 13 14 15 16 17 18 Clinics Poor supervision of clinics leads to many unnecessary referrals putting further strain on hospital staff Clinic management is a concern Old structure District Community matrons 9 10 11 12 13 14 15 16 17 18 Clinics

16. Senior management is very stretched, mainly due to a vacuum at the middle management level HR Manager HR Practices (1) HRD & Planning Employee relations Middle management vacuum Staff establishment = 29 Filled = 8 Situation duplicated and perhaps more severe in Finance and Systems

17. Management time is consumed in uncoordinated Head Office meetings, often at very short notice • Little time to prepare for meetings, implement and/or follow-up on the outcome • Elaborate teleconferencing facilities exist, but are not used to reduce time spent at and traveling to and from meetings

18. Some suggestions Absolute shortage of key resources and limited physical space in the hospital complicate opportunities for improvement, but whilst poor morale is evident at many levels, many opportunities exist for improvement in process and people management Situation Complications Suggestion Provincial • Key resources are critically short relative to increasing demand • Severe congestion and long waiting times at OPD • High numbers of “unnecessary” referrals from District and Clinics increases the load • Cordial relationship with organised labour • Staff morale appears low, especially Drs & Nurses • Poor working relations in the Maintenance Dept • Deteriorating infrastructure, poor layout and space constraints • Hospital is unlikely to recruit and retain quality professional staff at current levels of salary • Patients arrive en masse early in the morning complicating congestion • Physical layout of OPD registry compounded by staff shortage in file retrieval • Dept of Works very slow • PHC Clinic management a concern • Lack of coordination and cooperation between district and clinics and the hospital • Management is stretched • Reappraise salary bands for prof. / managerial staff • Urgently consider coordinating Head Office meetings (between programmes) Hospital • Consider a radical decongestion strategy for OPD • Review the registry / medical records process • Address staff morale • Improve referral processes from District and Clinic to Hospital

19. Options for decongesting the hospital 1. Reduce overall volume as much as possible and spread throughout the day 2. Streamline process flow & improve physical environment 3. Increase resources at key bottlenecks • Rigorously divert all PHC patients to the Gate Clinic and encourage use of home clinic (effort already underway) • Divert all repeat prescriptions to patient’s nearest Clinic • EDL items dispensed at Clinic • Non-EDL scripts pre-dispensed at Hospital and sent to Clinic • De-congest repeat/chronic patients by drawing files out 1-2 days prior to appointment and sending them directly to clinic • Allow and encourage patients to come later in the day – remove notice of opening time 7-13h00 Short-term • Install movable ‘book-ends’ at end of each file rack to avoid files falling over • One-off “file-clean-up day” to find and re-order missing files • Log-out files electronically (remove manual recording of all drawn files) • Urgently pursue and resolve the issue of non-functional computers • Review use of numbering system (it currently serves no purpose) Long-term • Move medical records closer to OPD and consolidate records if possible (up to 3 yr old files?) • Ensure 2 resources dedicated to file retrieval between 6.30am and 10am • Continue drive to recruit more doctors

20. Diverted Pre-dispensed and sent to clinic Diverted Dispensed at clinic Appointment - straight through to Clinic* (files requested & drawn 2 days before) Decongested No appointment (referred by another Dr/Institution) or wrong appointment day New file Retrieve existing file 50% of our daily patient load can be diverted immediately, while another 30-50% can be decongested Repeat scripts OPD *Options for payment at OPD cashier or Clinic cashier from blue carrier card to be discussed

21. It is possible to reduce the current OPD registration queue to 30% of current Diverted Repeat scripts Decongested OPD Remaining queue

22. 250 current patients can be diverted away from the hospital by pre-dispensing medication to the outlying clinics Patient receives repeat prescription from Dr Receives 1st issue of treatment from Hospital Pharmacy Hospital Pharmacy files pink card in date order of next treatment Patient receives repeat treatment card Patient collects medication at clinic Treatment delivered to Clinic using same delivery system used for lab samples 2 days prior to next treatment date, Hosp. Pharm pre-packages treatment Patient takes repeat treatment card to Clinic Yes No Process repeated Medication returned to Hosp Pharm after 30 days Hosp Pharm cancels repeat order Dr needs to reassess

23. Improve staff morale • Team-building and relationship-building exercise in critical areas (Maintenance & Medical?) and diversity management programmes • Consider implementing a formal mentoring system for medical professionals • Mentoring system linked to succession planning and career progression • Management to seriously consider spending more time (formally and informally) giving positive feedback to staff • Thank you goes a long way!! • Consider making space / room for doctors to informally communicate and support each other • A tea-room would make a big difference to morale • Make a concerted effort to bridge the management / staff divide • Many staff (including Doctors) have never even met senior management (including the hospital manager) • Creatively address the staff shortage • Consider using SDL funds to bridge the gap between the abundant supply of staff nurses and the shortage of professional nurses • Shuffling of staff should not compromise skills acquired (eg. midwife to orthopedic or electrician to plumbing) • Review and strengthen the functions of the EAP • Fast-track recruitment of Labour relations officer in order to play a visible role in improving employer/employee relations • Consider grouping medical professionals into a separate category for the purposes of salary bands and career progression (National issue)

24. Backup – it’s working at Addington!

25. Patients are met at the door and directed to the right place “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

26. 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

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

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

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

30. Repeat prescriptions are separated out and filed in separate area for rapid retrieval. Repeat prescription patients do not queue in the OPD queue