Discussion Questions for MGMT 351

(paragraph format)

1. What optimal policy should the National University Hospital implement to reduce overcrowding in the Emergency Department? How should the hospital execute this policy?

2. What alternative solutions could reduce Emergency Department overcrowding? Justify your proposed solutions

3. What are the possible causes of Emergency Department overcrowding? What are the expected bottlenecks?

Preview File Edit View Go Tools Window Help NE ) 97% [ Mon 1:17 PM E The National University Hospital (2018).pdf (page 2 of 16) ~ Q Search Page 4 yDIOUUIL Page 3 yDIOUUIL roots outside the ED, such as inefficient operations in specialty wards, bed management units (BMUs), 1985, Kent Ridge Hospital was renamed the National University Hospital Singapore. The NUH started laboratories, and other non-ED areas. In-patient capacity was considered a significant factor in ED serving the public on June 24, 1985, with 180 employees treating 56 outpatients and four in-patients. The overcrowding, while prolonged ED boarding time (i.e., the time from the ED doctor's decision to admit the MOH Singapore decided to strengthen the NUH in 1987 and handed over control to the Health Corporation patient until the in-patient bed was occupied) was considered the major cause of ED overcrowding, which of Singapore under the MOH. In 1990, the Singapore government acknowledged the vigorous role played could be controlled by improving the timing of in-patient discharges." by the NUH and decided to elevate its status to one of the major teaching institutes in the field of medical sciences, thereby handing over administration of the NUH to the National University of Singapore (NUS). An early discharge policy could help to ensure a stable patient flow, resulting in bed availability in a timely manner." A study conducted in an Ontario hospital supported the argument that prolonged ED boarding In 1986, the NUH started its ED on a 24/7 basis. That same year, the NUH proved its competency level after time could be eliminated altogether by moving the peak discharge time to four hours earlier. However, an performing its first successful open-heart surgery. After becoming a major teaching institute, the NUH early discharge policy could also have negative outcomes, such as the probability of readmission, either to recognized the importance of computerizing the allocation time in the operation theatre to deal with scheduling the same hospital or to a busier or more crowded hospital, and receiving treatment without optimal attention issues. In 1996, the operation theatre was equipped with an efficient and effective scheduling process, and in being paid. ' Globally, the effective approaches to reducing ED overcrowding included an optimal lie Leitch from Aug 26, 2019 to Dec 14, 2019. 2000, the NUH deployed its Computerized Patient Support System to manage its patients' histories. After admission protocol, aggressive bed management, effective scheduling, optimal resource utilization, and 2000, the NUH initiated a focus outside of biomedical sciences, to include additional fields, such as early discharge policies. 10 engineering, behavioural and social sciences, material sciences, computing, and mathematics in an effort to improve system performance with some permanent solutions on an early basis. As a result, automation was used to influence process improvement. It also improved the NUH's utilization of in-patient resources and Health Care in the United States and Si reduced the patients' LoS at the hospital. However, to achieve better patient outcomes, the NUH still needed to optimize its resource allocation to accommodate more in-patients in a timely manner. In 2014, Bloomberg ranked Singapore as the country with the most efficient health care." The ranking criteria were based on a country's life expectancy and its relative and absolute per capita costs of health is a copyright violation. care. In 2011, Singapore had a population of only 5.18 million" but, surprisingly, had a gross domestic Quality of Health Care product (GDP) per capita equal to US$53, 121.40," which was slightly higher than the U.S. GDP per capita of US$49,781.40. "* However, Singapore spent only 3.9 per cent of its GDP on health care, whereas the In 2001, the NUH's administration decided to focus on quality of service (QoS) and established a Quality United States spent 17.1 per cent of its GDP on health care." Also, Singapore's mortality rate (per 1,000 Improvement Unit that was responsible for visiting in-patients on a regular basis to ensure they were receiving people) was just five deaths, in contrast to eight deaths for the United States (see Exhibit 1).10 quality health care. In that same year, the NUH initiated a further step toward achieving Qos by establishing Authorized for use only in the course MGMT 351 at University of Mississippi taught by Kellie Leitch from Aug 26, 2019 to Dec 14, 2019. one-stop outpatient treatment facility for women. The following year, in 2002, the NUH obtained three ISO" ersity of certifications: ISO 9001 (Quality Management System), ISO 14001 (Environmental Management System), The Ministry of Health Singapore and ISO 18001 (Occupational Health & Safety Management System) The Ministry of Health (MOH) Singapore was fully devoted to providing quality health care to The QOS in the health sector could be defined as the right treatment for the right patient at the right time. Singaporeans, which was why it remained committed to ensuring healthier living, preventive health-care As such, the administration of the NUH focused on reducing response times by increasing system efficiency programs, and basic medical services for all. The MOH realized that in 2017, compared with 2007, the not only in in-patient wards but also in allied departments, such as laboratories and pharmacies. Therefore, growing health-care demands of its population, and therefore the public sector, were enriched with the NUH's lean management team remained engaged in streamlining the processes to improve patient care." approximately 50 per cent more doctors and approximately 70 per cent more nursing staff. As a result, the In 2003, with the aim to improve overall system performance, the NUH pharmacy introduced the Medicine doctor-to-population ratio reached 1:520 (i.e., 1 doctor for 520 people) in 2012, whereas it had been 1:620 Top-Up Service and Medicine Delivery Service to address the issues of long queues. To access the services n 2007. The nurse-to-population ratio reached 1:154 in 2012, down from 1:205 in 2007. In addition, the regular patients phoned in their medication requests to the pharmacist, and their prescribed medicines were MOH worked closely with public sector hospitals to develop key performance indicators (KPIs) to evaluate delivered to their given address. In 2004, the NUH became the first Singaporean hospital to achieve Joint hospital performance, such as ED boarding time, bed occupancy rate, and length of stay (LoS). The NUH Authorized for use only in the course MGM Commission International accreditation, "which was considered an international standard reflecting excellent and all public sector hospitals in Singapore were required to submit weekly reports regarding these KPIs to clinical practices for patient safety and quality of care.2 the MOH Singapore, and the MOH made these statistics public on its website. As such, all public sector hospitals in Singapore, including the NUH, were constantly seeking effective and efficient solutions to provide a high quality of care and to meet the targets for all KPIs. Resources The NUH remained focused on aligning its resources with society's increasing demands. As a result, the THE NATIONAL UNIVERSITY HOSPITAL SINGAPORE hospital, which had started functioning with a capacity of 280 beds in 1985, increased to 997 beds in 2010, History and then to 1,068 beds in 2011. In addition, the number of employees (180 in 1985) increased to 5,576 in March 2010. In the 1980s, the NUH's nurse-to-patient ratio was approximately 1:8~10 (i.e., 1 nurse for 8 Kent Ridge Hospital Singapore was initiated in 1972 and completed in 1984 with a capacity of 280 beds to 10 patients). Although it later reached 1:6 in September 2010, resulting in better care for patients, the under the supervision of Temasek Holdings, a government investment holding company. On January 15, patient demand was much higher in 2010 than in the 1980s."2 The NUH encouraged its doctors, nursing staff, and allied health professionals to take on effective roles in the NUH health system and, consequently,I' Preview 0 O v QQ File Edit View Go Tools Window Help L? X \"3 E d 97%[8- Mon1=17PM a The National University Hospital (2018),pdf (page 6 of 16) v a rage I) at: touuu recommendation, were transfened to an in-patient ward and referred to as \"ED-GW patients." Outpatients had a higher probability of revisiting the ED than in-patients. Intensive Care Unit The ICU was considered one of the NUH's most expensive units in terms of operational expenses and was, therefore, reserved for those patients who had the most critical conditions. These patients might be admitted from the ED, specialty wards, or referrals from other hospitals or outpatient clinics, due to the severity of the illness. Because of limited bed capacity and to accommodate more patients who had critical medical conditions, ICU patients were transferred to specialty wards when they were considered out ofdanger and in a stable condition. High Dependence Wards The NUH operated HDWs for patients who required less intensive observation and nursing care than ICU patients, but more care than those in specialty wards. Patients could be admitted to HDWs from the ICU, the ED, specialty wards, or referrals from other hospitals. Depending on their medical condition, HDW patients could be discharged directly from the HDW or transferred to specialty wards. Elective Patients Patients referred by clinical physicians for surgeries involving less urgent medical conditions were known as elective (EL) patients. The admission of these patients was preschedulcd based on available resources such as the surgeon, an operation theatre, and allied resources For these reasons, EL patients were advised to arrive at the hospital for admission in the aemoon, one day prior to surgery. The beds for these scheduled patients were reserved to avoid delays in bed allocation, while admission in the aemoon helped them to bypass the crowd of discharged patients. After their surgical procedures, these patients were transferred to inpatierit wards, where they remained until they were discharged. Same-Day-Admission Patients SDA patients had the most urgent medical conditions and visited the operation theatre for surgical procedures before admission to the ward. The NUH SDA unit was equipped with approximately 50 beds that were allocated on a temporary basis until recovery. SDA patients were transferred to a specialty ward alter their recovery and remained there until they were discharged. HOSPITAL OPERATIONS Emergency Department Operations Patients who visited the ED typically presented an array of adverse medical conditions. The ED at the NUH dealt with a variety of patients on a 24/7 basis, ranging om those who had urgent medical conditions to those who had minor issues. ED stair at the NUH were required to follow a standard operating procedure, such as initially taking the patient's temperature, having the nursing staff screen the patient, and referring patients who had a high temperature to a temperature facility. Otherwise, the patient was moved forward to the Authorlznd tor tiso only iii the course MGMTSSl at University 0, Mississippi taught by Kclllc LCllCll troin ting 26 20l910 Doc M we use outsioathese parameters is a copyright violation VEDQ rage r at: tuuuu registration counter to register and pay the initial deposit fee. Aer the registration process was complete, a triage nurse evaluated the patient's medical condition. Triage nurses at the NUH were responsible for categorizing patients based on their most and least severe medical conditions, determining the most appropriate treatment area, providing guidance to patients and their relatives, assisting the ED doctors, and controlling the congestion within the ED. Aer an initial assessment, the patient was referred to an appropriate doctor who performed a complete medical assessment ofthe patient, and based on the results, decided whether to refer the patient for admission to a ward, request tests from the lab to further diagnose the problem, or advise the patient to take prescribed medication along with bed rest at home (see Exhibit 5). The calculation for the ED boarding time until admission to the in-patient ward started immediately aer the doctor decided to admit the patient. At the NUH, approximately 20 per cent of those patients who visited the ED became ED-GW patients.\" ln-patient operations were complex phenomena based on the various medical conditions. Consequently, poor patient flow due to inefcient operations led to bottlenecks and, ultimately, ED overcrowding. 2' The probability of bottlenecks greatly increased during peak hours, due to a higher number of patients requiring limited resources such as the ED doctors, the ED nurses, and other support staff. Bottlenecks could be expected at any stage of ED operations, from the patient's entry until the patient's exit (see Exhibit 5). BMU Operations The NUH bed utilization rate was approximately 85 per cent because 15 per cent ofthe bed capacity was reserved for emergency patients only. The BMU's centralized computerized system enabled staff to check the status of all beds in the in-patient wards, including bed occupancy, bed vacancy, expected time of vacancy, and cleaning process after vacancy. Aer patients were referred for admission to an in-patient ward, they had the right to choose the in-patierit ward of their choice with some limitations, such as the specialty area. Most patients preferred to choose highly subsidized wards that were funded by the government. However, only Singapore nationals, permanent residents, valid employment pass holders, and valid work permit holders were entitled to be admitted to such wards (see Exhibit 3). Aer the bed requests were registered in the EMU, the staff preferred to accommodate those patients in the specialty wards rst, depending on the availability of in- patient beds. Otherwise, patients were required to wait in the queue for up to six hours before being assigned to an available bed in an in-patient ward, regardless of the specialty required. This situation resulted in complicated bed allocations, unnecessary travel time for the doctor, delays in specialized treatment, and ultimately. the worst patient outcomes. Aer the bed was allocated on a provisional basis and occupied by the patient. the EMU staff started negotiations with the in-charge bed allocation staff (i.e., the ward nurse) of the in-patient wards. This negotiation was done on an individual basis according to the specialty, gender, and type of ward until the patient was accepted for admission into a specialty ward. The BMU would immediately inform the ED about the availability of a bed to initiate the ED discharge process and transfer the patient to the in-patient ward. The transfer of patients was still based on their medical condition. If the medical condition did not support the transfer of the patient to a specialty ward, the bed could be allocated to another patient and a new request would be initiated for the original patient, based on their less severe medical condition. The ED nurse initiated the ED discharge process based on the patient's stable medical condition and submitted the ED discharge application to the ED doctor along with complete lab reports to obtain approval for the patient's discharge from the ED. The ED nurse was responsible for transferring the patient to a specialty ward with the help ofa porter. and the ward nurse nalized the admission process by admitting the patient (see Exhibit 6). q Authorized tor use only iii :hc course MGMT Sal at uiiivcrsity o' Mississippi taught by Kclllc LCllClt lroin Aug 26 20l910 Doc l4 zole 6 Use outsioethese parameters is a copyright violation Page 14 9B18D012 Page 15 9B18D012 HIBIT 6: PROCESS FLOW AT THE NATIONAL UNIVERSITY HOSPITAL'S BED MANAGEMENT EXHIBIT 8: NATIONAL UNIVERSITY HOSPITAL'S IN-PATIENT WARD OPERATIONS UNIT Recommended ED patient requested for Day started/Routine Morning rounds Parallel Operations for admission by bed checkup by nursing staff of senior doctor ED doctor Not Available Available Patient Discharge BMU ED informed by BMU bed discharged documentation informed BMU Allocation of provisional Negotiation for allocation Time taken for bed allocation prepared bed of bed in concerned ward allocation In-patient Ward Operations Bed cleaned Admission Patient ED discharged actualized arrived the patient Bed allocated by Kellie Leitch from Aug 26, 2019 to Dec 14, 2019. Initial checkup by Initial screening No Decision duty doctor & history file to Reported to ED to start discharge ED discharge process Time taken for bed Routine evening Evening rounds Necessary treatment as occupied Yes checkup by nursing of senior doctor recommended during the day staff ED nurse & porter Patient admitted / transferred the patient Bed occupied Note: BMU = bed management unit; ED = emergency department. Source: Created by case writers based on operation analysis. Note: ED = emergency department; BMU = bed management unit. Use outside these parameters is a copyright violation. Authorized for use only in the course MGMT 351 at University of Mississippi taught by Kellie Leitch from Aug 26, 2019 to Dec 14, 2019. Use outside these parameters is a copyright violation . Source: Created by case writers based on operation analysis. EXHIBIT 9: NATIONAL UNIVERSITY HOSPITAL'S IN-PATIENT DISCHARGE PROCESS EXHIBIT 7: NATIONAL UNIVERSITY HOSPITAL'S TRANSFER PROCESS FROM THE EMERGENCY DEPARTMENT TO AN IN-PATIENT WARD Patients' check- Discharge process up/Discharge Lab tests started / Doctors' round forecasted recommended Doctor's decision ED (Transfer Process) Initiated bed request Tests reports Authorized for use only in the course MGMT 351 at University of Mississippi ta Patients' willingness medical condition Poor submitted to doctor to get discharged ED informed informed ED BMU notified by ED Discharge decision by doctor Day of discharge Bed BMU searched for bed Bed cleaning ED confirmed the Discharge process Stable Bed executed/Necessary Yes medical allocated assigned patient discharge documentation (Clearance condition Patient admitted/ Patient handed over to ED nurse & porter Patient discharged Bed occupied nursing staff of ward transferred the patient from ED Pharmacy informed Medicine received Guidance about the for medicine from pharmacy use of medicine Bed vacated Transfer process completed Exited/Discharge process completed Note: ED = emergency department; BMU = bed management unit. Source: Created by case writers based on operation analysis. Source: Created by case writers based on operation analysis.IIVEy t Publishing 9318D012 THE NATIONAL UNIVERSITY HOSPITAL: OVERCROWDING IN THE EMERGENCY DEPARTMENT Muhammad Adnan Zahid Chudhery, Jingui Xie, Mabel C. Chou, Joe Sim, Sarah Safdar, and Zhiying Liu wrote this case soieiy to provide material for class discussion. The authors do not intend to iiiustrate either effective or ineffective handling of a managerial situation. The authors may have disguised certain names and other identiMng information to protect confidentiality. This publication may not be transmitted, photocopied, digitized, or otherwise reproduced in any form or by any means without the permission of the copyright holder. Reproduction of this material is not covered under authorization by any reproduction rights organization. To order copies or request permission to reproduce materiais, contact ivey Publishing, ivey Business School. Western University, London, Ontario, Canada, N66 0N1; (t) 519.661.3208; (e) cases@ivey.ca; www.iveycases.com. Coggright 2018 iveg Business School Foundation Version: 201806.08 It was June 2009, and Benjamin Ong, who had taken over the chief executive officer position at the National University Hospital (N UH) three months earlier, was ipping through the reports that his staff had prepared on various performance measures. Suddenly, he stopped ipping through the papers and fell into deep thought. It was the overcrowding in the emergency department (ED) that caught his attention. From January 2008 to June 2009, patient arrivals had peaked in the morning, whereas patient discharges had peaked in the late afternoon. A patient who visited the ED between 7 am. and 11 a.m. was expected to wait, on average, for more than four hours to be admitted to a ward at the NUH. More than 30 per cent of the patients who visited the ED between 7 am. and 10 am. had waited six hours or longer to be admitted to a general ward.1 The prolonged waiting time resulted in a growing inventory (i.e., an increased number of patients) in the ED, which led to serious overcrowding. When the ED was overwhelmed, its ability to respond to large-scale emergencies and disasters could also be compromised. The NUH was a leading public sector hospital in Singapore, and Singapore's health sector was acknowledged to be one of the most efficient health-care service providers around the globe.2 Ong wondered which strategy the NUH should adopt in an attempt to reduce the ED's overcrowding issues, and how the NUIl should execute such a strategy. BACKGROUND ED Overcrowding: A Global Problem Over the past few years, ED overcrowding had attracted much attention around the globe, due to recognition of its emerging threat to both patient safety and quality health care.3 The negative consequences as a result of ED overcrowding included a higher rate of patient walkouts and a higher number of claims for medical negligence.\" According to the Joint Commission on Accreditation of Healthcare Organizations, the use of emergency services by patients with non-urgent medical conditions had a signith inuence on emergency overcrowding.5 ED overcrowding could also be based on various other factors, many of which had their Authorized tor use oniy in the course MGMT 351 at University ot Mississippi taught by KeEIEe Leitch from Aug 26. 2019 to Dec 14. 2019. Use outside these parameters is a copyright violation