1. Action Learning Pilot Programme Project Khaedu Themba Hospital - preliminary findings 4 March 2005

2. Agenda • Executive summary • Current situation • Complications • Some suggested resolutions

3. Executive summary • Themba hospital is not managing service delivery to the required standard e.g. • The hospital facilities are falling apart • Patients wait for up to 10 hours to receive treatment • Patient files get lost • Patients are sometimes sent back home without being seen • The reasons for this are mostly out of the control of hospital management • Organisation structure is severely out of kilter with recognised norms in the public service and there is no approved budget to rectify this • There is very little delegation of authority at the local level, thereby paralysing decision-making at the hospital • The issues that are within reach of management are unlikely to be resolved due to the critical shortage of management capacity (quality and quantity) • It is recommended that a major turnaround strategy, based on centres of excellence, is embarked on in the province with external assistance

4. Agenda • Executive Summary • Current situation • Complications • Some suggested resolutions

5. Organisation design People management Financial and procurement • Severe shortage of staff at all levels and in all departments, but particularly at a management level • Minimal HR function at the hospital – all functions except payroll referred to Head Office • Levels and pay do not appear to match levels of responsibility • Limited delegation of authority at the local level • Disconnect between the strategic direction of Province and implementation at the local level • Inadequate management and supervision in both professional and administration areas • No HR plan or strategy • No performance management and development system (unions refuse to sign performance agreements) • Limited career progression at all levels • Limited recruiting capability and no authority to do this • Morale low • Absolute budget allocation a severe problem with little indication of improvement in the next year • Overspending on employee compensation driven by • Very high overtime • Scarce skills and rural allowances with no budget allocation • Limited strategic financial skills and limited financial delegation • Many procurement decisions taken at provincial level with questionable value for money Reactive management “We are just fire-fighting all the time, we keep Panado’s with us in the car” Current situation – what we’ve seen and heard Process and physical • High volumes of OPD patients, many of whom are primary healthcare patients, swamping the hospital • Very long wait times at OPD – patients very frustrated • Increasing number of very sick HIV&AIDS patients • Filing management a concern • Poor/dangerous environment • Misfiling a common occurrence (lost files) • Major cause of OPD bottleneck • Hospital old and in a very poor state of repair, with no hope of significant improvement with current resources

6. High volumes of patients swamp the hospital on a daily basis

7. The hospital is in a very poor state of repair Plumbing,…

8. The hospital is in a very poor state of repair …building,…

9. The hospital is in a very poor state of repair …and electrical

10. There is a persistently severe shortage of staff *Required number is that stated in the latest organisation structure, which has not yet been approved

11. The CEO is stretched and management levels appear to not match the associated responsibility… 818 people organisation, budget of R115M CEO Director Nursing Service Manager (Senior Matron) Senior Medical Superintendent Hospital Secretary Rob Ferreira Bongani + Dep. Director Ass. Director (R133K pa) Management vacuum Level 8/ Snr Admin Officer (R89K pa) Finance & Provisioning Patient Admin HRM (acting for 6 years) Auxiliary Services (acting) Level 6 (R67K pa) 3 HR clerks Level 4 & below

12. …compared to a typical national department 245 people organisation (National DPSA) DG DDG DDG DDG CFO (DDG) Chief Director Chief Director (3) Director: People Management Directors (5-7) Director Dep. Director Skills Development Labour relations People Management Employee Helath & Wellness

13. If year-to-date spend is annualised, Themba will overspend by about R14M this year, driven by employee compensation 14% over-spend

14. If the current spending pattern continues, together with inflation, the proposed 05/06 budget will fall short by ~R7M…

15. …however, Themba appears out of line with other local benchmarks with respect to staff

16. Although patients are frustrated with the overall process and cleanliness of the facilities, they are happy with the treatment Source: PSW questionnaires, Nov 2004

17. Staff are unhappy with the facilities, career progression, overall quality of management and level of training… Source: PSW questionnaires, Nov 2004

18. …but are relatively happy with communication, their job content and competency of co-workers, and feel that they provide a good service to customers Source: PSW questionnaires, Nov 2004

19. Despite a number of challenges, there are positive elements • Many of the staff members (including management) are very committed and are trying to improvise to the best of their ability • Scarce skills and rural allowances have helped alleviate pressures to some extent (although these were not accommodated in the budget) • Policy of community service has increased number of intern allocations (although this has brought its own challenges e.g. mentoring and supervision) • Open lines of communication between organised labour and management • Golf carts working very well

20. Agenda • Executive summary • Current situation • Complications • Some suggested resolutions

21. Complications preventing solution of the current situation The biggest problems at Themba are structural in nature and out of the control of hospital management (Organisation structure and budget). Those that are in control of management (e.g. improving OPD) are unlikely to be resolved due to the critical shortage of management skills (quantity and quality). • Reducing the volume of patients by diverting to primary healthcare clinics is likely to be a long-term resolution • Requires a mind-set change from a large portion of the population (mostly poor and many rural) • Requires upgrading and improvement of primary healthcare clinics, including medicine distribution) • Role of the province vs district vs hospital (i.e. delegating more authority to the local level) is likely to be politically driven, and therefore also long-term in nature • Any permanent change in the delegation and authority levels will have to include other hospitals in the region • You cannot increase delegation without improving capacity • Change of levels (and remuneration) of management and professionals is likely to take a long time since this is likely to be a national decision • There is currently no budget approved for appointment of any extra staff or promotion of current staff • Even if there was budget approved: • There are major capacity constraints in the current recruiting capacity at both hospital and provincial level • There is a national shortage of medical professional staff

22. Agenda • Executive Summay • Current situation • Complications • Some suggested resolutions

23. High-level recommendations Incremental improvements in the current situation will not turn Themba around. This has been attempted many times in the past 10 years. Hospital management on their own are not able, and cannot be expected, to achieve this. A comprehensive turnaround strategy, together with a coordinated financial plan driven by a dedicated project team (on contract) is recommended. A similar approach to the Limpopo “Centres of Excellence” approach could be very successful

24. High-level recommendations Process and physical Organisation design Finance and procurement • “RAMP* project” methodology recommended for turnaround of facilities • In the short-term, finalise and manage the service level agreement with PW for sustainability of RAMP • In the longer-term, decide on ideal model for maintenance • Should PW be used in an arms-level relationship? • Finalise the organogram based on logical rationale and match the budget to approved organogram • Re-evaluate management levels across Provincial Health • Dedicated CEO per hospital • Urgently re-evaluate responsibilities and delegations between Province and local level • HR and finance should be key functions at the local level with much more delegation of authority • Increase the level of delegations in accordance with hospital requirements • Re-evaluate budget allocations between hospitals in the Province • Consider and actively pursue the use of other funds in a coordinated manner for the turnaround strategy *Renovation And Maintenance Project

25. Backup

26. 70% of Themba’s costs are ‘fixed’ costs Variable Fixed

27. The outpatients process is cumbersome and slow Join queue 2: Records Clerk take details of patient on dummy Send dummy to filing room Retrieve file and replace with dummy Send file to clerk who calls patient & hands over file Send file to clerk who calls patient & hands over file Yes A Patient arrives at hospital and goes to OPD Previous patient? Join queue 1: Records Clerk registers new patient and creates file No Go to pay clerk and pay Yes A Consult with doctor Take file to dispensary and queue to wait for medicine Collect medicine Walk to Outpatients and queue for doctor No Total process = 3-10 hrs

28. Our patients arrive en masse in the morning