Operations Management & Quality Improvement in Hospitals - Term Paper Example

Operations Management & Quality Improvement in Hospitals Outline Outline Introduction 2. Importance of Hospital Operations Management 3. Process Mapping a. Uses of Process Maps 4. Problems identified from the Process Map a. Waiting Time – The Bottle Neck b. Human Resources c. Other Problems and Confronting Issues 5. Improving Work Flow & Service Quality a. Addressing the Delay b. Demand and Capacity Management c. Using SPC as a Quality Improvement Measure d.Human Resource Issues e. Other Service Delivery Issues 6. Conclusion References Appendix – Figures & Tables Table 1: Data collected from Urgent Care Clinics Table 2: Data collected from the ER Fig.1: Cross-functional Flow Chart for Patients Arriving by Ambulance Fig.2: Cross-functional Flow Chart for Other Patients Fig.3: Cross-functional Flow Chart after Quality Improvement Measures have been Implemented Figure 4: Typical Control Chart Fig. 5 : Control Chart for LoS of ER Patients Fig 6: Control Chart for the LoS of UCC Patients 1. Introduction Health related investments form a large chunk of the budget of almost all the nations around the world. Major percentage of the expenditure is attributable to the increased percentage of elders, disease prevalence, technological advances, treatment etc. Health being described as a person’s primary wealth, emphasizes its vitality and justifies the investment. Considering this, the seriousness of a critical health contingency, importance of emergency medical facility and the use of emergency rooms is apprehensible. American College of Emergency Practitioners defines Emergency medicine as “patient-demanded, widely available and continuously accessible care by physicians trained to engage in the recognition, evaluation, stabilisation, treatment and disposition of patients in response to acute illness and injury.” Such a situation demands evolving instantaneous solutions and putting them into action, in order to evade death or further weakening of health. Emergency care primarily requires immediate evaluation of the level of triage, addressing the urgent medical concerns of patients and providing necessary treatment. This has to take place in a necessarily caring environment, which gives the patient a hope of recovery. The hospital under question, specialises in emergency room and has a capacity of 40-beds. It also has an Urgent Care Clinic. Owing to its location and the population growth rate, the hospital faces heavy inflow of patients. This is being translated into long waiting times, due to the absence of proper operations management procedures in place. The ensuing sections explain the problems faced by the hospital, which are reflected from its process map. An attempt is made to list out the available strategies to tackle these deficiencies, using the concepts of hospital operations management. 2. Importance of Hospital Operations Management Emergency care, while being essential, is also an expensive affair and insists quality treatment and service. There is definitely a shortage of trained personnel, whether doctors or nurses. Technology is also a factor pushing their survival. Other concerns such as service co-ordination, location and inventory, equipment and resource management carry equal weightage. Internal processes such as caregiving, scheduling and resource routing are to be accomplished. Patient flow has grown into a strainful affair, mainly due to population growth. Crowding and staff limitations are found to be the causative factors for time lags in emergency department. Limited capital resources such as beds, equipment etc add up to the patient inflow, resulting stress in the employees. Operations management in hospitals concerns applying normal managerial functions of planning, organising, directing and control to the various services it offers. The routine activities related to all the resources including human resources, finance, service are included in hospital operations management. Along with this, such management also embraces forecasting such as future in-flow of patients, improving quality perception, level to which the present operations need to be developed etc. The whole process deals with the alignment of resources available, services and patient data, along the lines of handling emergency services in a free-flowing manner, so that the waiting time, delays and long queues are avoided. Use of operations management concepts in hospital management aids competent use of resources, while making the processes cost-effective and quality-driven (Bertrand & Vries, 2005). Evidence-based quality improvement is an evolving insight in this area (Kitson, 2000). It aims to enhance the quality of service by implementing the best practices available in not only in carrying down the process, but also patient care. These practices should have been established by evidence, rather than being anecdotal (Shojania & Grimshaw, 2005). 3. Process Mapping Process mapping is visual depiction of the flow of a process, in order to ease better understanding and communicate it effectively to the stakeholders (Conger, 2011). It is defined as creating a map of the course a patient takes, through the relevant administrative processes and pertinent procedures, in a pictorial format (NHS, 2006). a. Uses of Process Maps Process maps have a number of uses. They help in explaining the work flow to new employees while clarifying the job responsibilities of existing ones. The process maps also assist in identifying weak and strong points of the organisation, problems associated with the process and strategising process improvement efforts etc (Trebble, 2010). These provide new insights into developing advanced interfaces among different processes in order to achieve efficiencies. Process maps also bring forth the cost structure and the main cost centers in the organisations (The Royal Society, 2007). Many types of process maps can be generated, based on the objective with which they are developed (The Scottish Government, 2010). Process Maps are of particular importance in patient care because they interpret the flow of the processes involved, the hurdles in the progress and the aspects in which quality improvement is essential. In the present case study, the focus is on diagnosing the problems associated with the work flow of a hospital and improving the quality of service delivery, while minimising waiting times, keeping the resource constraints in terms of limited number of beds, in view. Cross-functional flow chart is the best process map to serve the purpose. Here, there are lines demarcating the persons responsible for each of the activities that form a part of the flow chart (Savory & Olson, 2001). The cross-functional flow chart for the patients arriving by ambulance at the hospital addressed in the case study can be found in figure 1. The same for the other patients is shown in figure 2. 4. Problems identified from the Process Map The flow chart enables in establishing the problems associated with the work flow at the hospital. Waiting time is the first hurdle in the process. Limited number of triage nurses and doctors in the hospital seem to be the reason for these time-lags. Further, limited equipment available with the hospital, such as 2 x-ray machines, etc, constrain its effective functioning. Duplication of work, such as quick registration, followed by that, done by the ER clerk, delays the process, leaving a low image of the hospital and its quality in the patients. a. Waiting Time – The Bottle Neck Starting with arrival at the hospital, until the patient is discharged, after conducting necessary diagnostic tests and dispensing necessary medicines, all the steps in the process map precede some waiting time. From the data collected from the UCC, as shown in table 1, it can be noted that a patient who arrives at the hospital, spends around 1.5-3 hours before meeting the doctor during most part of the day. However, the waiting time seems to be less during afternoon, when it is less than half-an-hour. This signifies the time when patients entering the hospital are less compared to the other timings. It can also be deduced from the UCC data that after visiting the doctor, there is not much delay before the patient is discharged (maximum 25 minutes). The data collected from emergency room(ER), as shown in table 2, illustrates that the emergency registration and waiting time is less when compared to that at UCC. During morning hours, the time taken for disposing the patient once the consultation with the physician is done, is not much time-taking process. However, the diagnostic tests or dispensing medicines or administering injections and then scheduling appointments or admission is taking more time after 8am. These significantly depict the process delays. Even after registration, the patient needs to wait for the doctor to examine him. Following this, based on the availability of nurse for administering injections or giving away the medication, the patients may have to wait again. If the doctor suggests some diagnosis tests, the incumbent has to further wait for his turn for the test or blood sample collection. During the next step, there is a delay in fixing an appointment with the doctor, before getting discharged. This shows that all the activities in the hospital come with a tag of time delays. The hospital boasts itself of dealing only with emergency and urgent care patients. Such delays could become expensive and life-threatening mistakes for the hospital, if they are not addressed at the earliest. It is a welcome step that the registration and triage for T1 and T2 patients is conducted at the bedside. This saves the time of such patients. Though the hospital resorted to establishing Urgent Care Clinic, to redirect less fatal cases, the efforts were defeated due to process delays. This only left extra pressure on the doctors and nurses. b. Human Resources The hospital has 14 nurses in total. Two of them are charge nurses, who are responsible for the operation of the hospital and thus, administration rather than actual activity is their duty. Two nurses are again dedicated to UCC, which serves less than one-third of the patient flow daily. The remaining 10 nurses need to take care of all the activities involving patients in the hospital, for the actual functioning. They have to look after the registration, assess the level of emergency, support the doctors, conduct necessary tests or assist the doctor in treatment, fix appointment with the doctor and then prepare for discharge. Some nurses are absolutely necessary to constantly look after the patients in resuscitation area. Paediatric patients need special attention from the nurses too. On top of all these work flow functions, the nurses also shoulder the responsibility of serving the patients, attending to their needs, monitoring their recovery and according them all the required support. So, 12 nurses for a 40-bed emergency hospital is not a reasonable proportion. Availability of doctors is also a constraint at the hospital. When the hospital serves emergency patients, every patient who enters it expects immediate scrutiny by the doctors. Though triage nurses primarily evaluate the seriousness of emergency, patients will not be satisfied that their concerns are properly address, unless doctor gives the final re-assurance. 3-4 doctors in each shift means hectic schedule and pressure in terms of number of patients as well as time. Knowing the patients personally stretches the consultation time further, increasing the length of queue of waiting patients further. The age of doctors seem to deteriorate the process flow. Though 50-year olds are well-experienced, they should have developed a standard system of diagnosis and treatment, which they do not agree to by-pass or shorten. Their briskness in terms of adapting to advanced technology, acquiring latest knowledge, movement etc might be hampered because of their age. Considering these factors, there is every need to induce young blood into the hospital, while also increasing the number of doctors. c. Other Problems and Confronting Issues The capital equipment available for reception, diagnosis and treatment is also limited in the hospital. The bed capacity of the hospital cannot be stretched, but for the fact that the patient in-flow is ever-increasing. The number of x-ray machines and the capacity of blood test lab, dispensaries etc add to the waiting time. This 2-step-process of registration for ER patients only delays the procedure. ER in the present hospital is the primary care provider, because of the absence of other hospitals nearby. Thus, the responsibility of the hospital is extended further. Given the fact that the patients frequenting the hospitals are mainly labourers from the nearby factory discloses information. These labourers may not be financially sound enough to pay for the services, which reflect on the revenues of the hospital. Thus, the services need to be cost-effective, in order to serve this money-constrained population. The hospital also has the propensity to attract more patients because of the proximity to highway and ever increasing population. Being located among the government residential neighbourhoods, it is guaranteed good patient inflow. These considerations should be borne in mind, as these emphasise the need to streamline the operations management in the hospital, while cutting on the costs. 5. Improving Work Flow & Service Quality While the inputs in hospital operations management are tangible elements, the output is intangible. Thus, the productivity cannot be measured directly, but in terms of patient satisfaction and quality of service provided. This is again a product of the efforts put in by the caregivers. So, the best way to improve the operations is to make the staff sensitive and service-minded. It is of utmost importance when the product dealt with is emergency medicine. a. Addressing the Delay The delays and waiting times can be tackled in a number of ways. Integrating the various stages, such as consultation, diagnostic tests, treatment etc by the service providers quickens the process. The human resources should be scheduled such that the doctors and nurses work in co-ordination, so that the patients queuing up in the waiting area are not many. The importance of emergency services must be reinforced in a timely manner in the staff through brief training programs, hand-outs, displays addressing them (Hall, 2006). Finally, the caregivers have to keep themselves abreast the developments, i.e., they should constantly monitor the number of patients outside and then plan their schedule accordingly. This also addresses the issue of doctors getting into long conversations with the acquainted patients (Ronen, Pliskin, & Pass, 2006). Service delays may also be resulting from inefficient use of resources or lack of complete knowledge of their proper usage. In the emergency situations, failure to co-ordinate among the resources such as non-availability of lab personnel, when the test needs to be conducted in the doctor’s room, may cause delays too. Delays are also observed when the admitted patients are made to wait before the surgeries. For avoiding this, the bed allocation system and the theatre allocation system must be co-ordinated by the scheduling personnel. All the departments in the hospital should have an idea regarding the rate of patient flow not only due to the newly arriving ones, but also within the hospital, such as registration discharge department to billing, appointments to billing system etc (Vaswani et al., 2010). The top and middle management must gather best practices of customer flow and queue management from not only other hospitals, but non-medical sectors with similar crowding. They should learn and strategise such operations management practices in their hospital too. The variability in patient flow can be taken into consideration to harness operational efficiency. For example, the documentation and discharge formalities can be scheduled during the time when the patient inflow is not much. When the patient inflow is high, the staff from these departments can be diverted to registration and reception so that the waiting time is minimised. All the doctors and nurses must have a clear idea of the patient flow and peak and non-peak hours, so that they can plan their responsibilities accordingly. This shows the doctors the time available for them to be spent on each patient roughly, so that they can stick on to the schedule, rather than end up in personal interactions with the familiar patients. Such an initiative addresses both delay and effective service delivery issues. b. Demand and Capacity Management Managing the patient inflow constitutes the demand management and planning and organising the staff accordingly makes up the capacity management (Trott, 2010). Changes do occur in the demand. Changes in hospital operations management occur in 4 respects, which are the 4V’s; namely Volume – this shows the demand for different types of offerings of the hospital Variety – the range of services offered by the hospital Variation – the differences or the fluctuations in demand Visibility – the amount of processes and procedures that is exposed and is visible to the patients (Slack et al., 2004) In the hospital where the demand exceeds the capacity by large extent, especially for the emergency room, it is advisable to investigate and figure out the service delivery procedures, finite perception of demand, the activity, capability of resources and the queues (Heizer et al, 2009). This helps in strategic re-design of the entire service process, re-aligning it to the new demands or changes. c. Using SPC as a Quality Improvement Measure Statistical Process Control(SPC) is a strategy towards quality improvement. SPC is defined as “the use of statistical methods and analysis to assess the present process capability and quality specifications and exercise quality control in order to meet the specifications with minimum variations” (Park & Kim, 1998). In case of emergency services, SPC can be useful in tracking the treatment as well as functional aspects. Control on the communication of hospital-induced and other infections and the duration of patient’s stay in the hospital constitute the former. The latter includes cutting losses from uncompensated treatment costs (Arthur, 2008). Variations in the process and procedure are common, as human element is an essential part of them and service is a nurse-intensive process. For example, when the caregivers compromise on personal hygiene during the reign of epidemics, due to time constraint; the negligence is reflected in the rise in the spread of infection within the hospital. SPC aids in analysing the causes of quality and process variations (Rodriguez, 2010). Control charts are the tools that illustrate the process variations and pre-cursor the need for quality control, by introducing simple procedures and setting standards in patient care (Young et al., 2004). Control chart is a line graph of data with a mean at the middle. Upper control limit(UCL) is signified by +3 sigma(standard deviation) and -3 sigma characterizes the lower control limit(LCL). At least 99.7% of the data must lie within these limits. A deviation from the ideal percentage signals the need for finding the causes, special causes and analysing them (Kelley, 1999). Figure 4 shows a typical control chart. Control chart for Length of Stay(LoS) for ER patients is shown in Fig. 6. Y-axis shows the number of minutes of stay of patients in the hospital. It shows that 4 out of the 11 data points lie outside the control limits. Even the average time of stay of 193 minutes is high. Immediate steps must be taken up to bring down the mean. The special causes for these deviations can be evaluated and corrected, in order to achieve quality control. Once these reasons are addressed, the justification for long waiting lists is automatically deduced. Even the control chart for the length of stay for UCC patients, as shown in figure 6 is not encouraging. The numbers show an average of 133 minutes, which is more than 2 hours, of which an average of 120 minutes is spent in waiting before consultation with the doctor. 3 of the 11 values lie outside the tolerable limits. Reasons must be assessed and similar analysis as that for tackling ER deviations must be undertaken. d.Human Resource Issues The care givers themselves must take the initiative to improve the processes involved, so that its overall quality, i.e., service can be enhanced. Nurses must be trained in advanced and modern technology in emergency care (Prahlad & Krishnan, 1999). Leadership and emergency management capabilities must be considered in the doctors, rather than their years of experience. Rather than bringing personal differences and grudges to foreground, it is essential that the staff keep the superordinate goal of serving the patient in top priority, while working as a team. This is of vital importance for emergency care, as such battles brought into profession may become life-threatening situations for the patients. Being human, even the emergency caregivers are no exception to committing errors. However, wisdom lies in openly accepting the mistakes, learning from them and taking all the necessary care not to repeat them in future. This not only helps in avoiding mistakes in emergency situations, but also improves the overall quality of service (National Research Council, 2007). The nurses and doctors must be encouraged to participate in decision making and problem solving regimen related to the management of hospitals, as they are the actual caregivers. They are in constant touch with the patients and understand the operational problems better. They can give an innovative edge to solution-finding exercise (Haraden & Resar, 2004). Ethical management should become an essential element of the hospital, as the management with such a perception can only inspire service motto in the staff. This helps in developing a confidence and optimism in the staff, which in turn helps in employee retention. Such service-oriented team is definitely a competitive advantage for the organisation. These teams also enable flexibility, as emergency medical care is more a customised service, rather than standard procedure (Towill, 2009). Nurses should develop good rapport with the relatives of patients and take their help in registration, understanding the patient’s medical history. This allows the patients to get rid of the hurdles of registration and directly wait for the next step in the process. Along with all these efforts, the doctors, nurses and all the staff involved in emergency and trauma care hospitals must be adequately trained in disaster management so that they are prepared to handle any type of emergency situation with ease and composure, rather than yielding to the pressure of crowding and patient intensity during disasters. Taking the present hospital from the case study, the staff must understand the occupational hazards and disasters possible in the factory nearby and they must be sufficiently aware of tackling them. e. Other Service Delivery Issues Emergency care hospital must be so designed such that registration is at the entrance, followed by the a large waiting lounge and triage area. The latter must be well-equipped. UCC must be located near triage area, as most of the patients who perceive emergency care may have less complicated and non-life threatening problems, which can be easily filtered at the triage and sent to UCC immediately, avoiding the ER. This decreases the waiting time for real ER patients. A different entrance area for the patients coming by ambulance can be planned, so that they can directly access the resuscitation room (Dave et al., 2001). Information technology is yet another powerful tool that can be used in process management. Using it for monitoring patient flow, co-ordinating the patient data within the hospital, taking cues from the information during decision-making, retrieving operations management data, forecasting the future demand, documentation purposes, gain general awareness about public health etc. All these efforts support the emergency departments in providing safe, quick as well as quality service (Haux et al., 2004). Proper documentation regarding patients, such as admission and discharge documents, treatment and diagnosis records, etc,. administration and other data pertinent to the hospital is important. It must be fed into the information system and updated and maintained in a timely manner. These efforts avoid duplication and aid to keep quality of service in focus. This can be used as an input to the marketing system, which returns the feedback related to service improvement and productivity (Langabeer, 2008). Some of the emergency and trauma treatments are not compensated by the insurance companies, for which the hospitals serve at subsidised rates. These costs are a burden on the hospital (Gorey, 2012). These endeavours of the hospital need to be funded by government, as they may run into losses if not properly compensated for their service (Litvak & Bisognano, 2011). The hospital must put efforts to constantly get in touch with the patients and learn about the problems they are facing with the hospital and understand their satisfaction levels. These efforts help to keep the staff informed and aid them improve the performance, by making reforms in the work flow activities. Self and peer assessment is another tool to performance quality improve of the staff. Establishing and upgrading standard protocols and feeding them with constructive comments and evaluation give the triager necessary boost up to provide quality service and improve it (Mittal & Khanna, 2011). The communication channels within the hospital, be it horizontal or vertical must remain open, as these connect the various processes. Their efficiency thus reflect on the quality of the processes. Unless the laboratory communicates the test results effectively to the doctor, the latter will not be able to make proper diagnosis and accord necessary treatment. Standardizing such procedures helps in clarifying the channels. At the same time, it is important to note that silence is equally appreciated in emergency care, as the patients are sensitive to the disturbances caused by noise. Hygiene and cleanliness within and in the area surrounding the hospital is important. Wastes must be properly incinerated before disposal. Unless these steps are undertaken properly, hospital-induced infections spread easily, as the patients are in emergency condition and are vulnerable to infections. Cleanliness also leaves a positive image of hospital in the patients and improves the quality perception of their service. 6. Conclusion Operations management is an essential endeavour for any hospital today. Process mapping, particularly cross-functional flow chart helps in identifying the problems in the system and brings forth the scope for improvement. Waiting time, limited resources and service delivery issues were found to hinder the productivity and efficiency of the hospital concerned in the case study. Tackling these contentions with effective management of human resources, cutting short the delays through coordinated efforts of all the departments, proper monitoring and use of information technology and statistically process control, can work wonders for rendering quality service in emergency care centres. Having implemented all the above mentioned quality improvement measures, the new process map of the hospital changes drastically, which is depicted in figure 3. References Arthur, J.. (2008). Statistical Process Control for Healthcare. Available: http://www.qualitydigest.com/june08/articles/03_article.shtml. Last accessed 8th Feb 2012. Bertrand, W. & Vries, G.. (2005). Lessons To Be Learned From Operations Management. In: Vissers, J. and Beech, R; Health Operations Management: Patient Flow Logistics in Health Care. 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Appendix – Figures & Tables Table 1: Data collected from Urgent Care Clinics Length of Stay (minutes) D/C Time Waiting Time (minutes) Time in Arrival Time Patient # 138 12:09 117 11:48 09:51 1 124 12:23 116 12:15 10:19 2 147 13:02 122 12:37 10:35 3 152 13:15 130 12:53 10:43 4 46 14:03 24 13:41 13:17 5 188 14:15 181 14:08 11:07 6 193 14:31 185 14:23 11:18 7 122 17:30 118 17:26 15:28 8 120 17:36 114 17:30 15:36 9 129 17:49 117 17:37 15:40 10 107 17:47 89 17:29 16:00 11 Table 2: Data collected from the ER Length of Stay (minutes) D/C Time Waiting Time (minutes) Time Seen Arrival Time Patient # 55 8:30 23 7:58 7:35 1 132 10:42 54 9:24 8:30 2 141 10:47 115 10:21 8:36 3 171 11:06 25 8:40 8:15 4 330 14:00 30 9:00 8:30 5 202 12:02 50 9:30 8:40 6 210 12:12 53 9:35 8:42 7 249 14:40 40 11:11 10:31 8 242 13:47 51 10:36 9:47 9 333 17:37 71 13:15 12:04 10 67 14:27 36 13:56 13:20 11 Fig.1: Cross-functional Flow Chart for Patients Arriving by Ambulance Patient Support Process Triage Nurse Doctor Comments Separate entrance, which is near the resuscitation room, can be planned for the patients arriving by ambulance Good that the registration and triage are done bedside, saving the patient’s time Waiting time is avoided as much as possible Fig.2: Cross-functional Flow Chart for Other Patients Patient Triage Nurse Support Process Doctor Comments Long waiting times at every step Duplication of registration process for ER patients Resource limitations in terms of both human resources and equipment Fig.3: Cross-functional Flow Chart after Quality Improvement Measures have been Implemented Patient Triage Nurse Support Process Doctor Figure 4: Typical Control Chart Fig. 5 : Control Chart for LoS of ER Patients Fig 6: Control Chart for the LoS of UCC Patients Read More