When an acutely ill patient needs to be treated urgently, the whole healthcare system has to respond in a co-ordinated manner. For example, if a patient attends local doctor’s (general practitioner’s) clinic with abdominal pain and the doctor assesses this as a probable acute appendicitis, the patient needs to be admitted to hospital for surgery immediately. First the local doctor might phone a house officer (doctor) at the local general hospital to agree the probable diagnosis, so that the patient can be ‘surgically accepted’ by the hospital. An ambulance will be immediately requested, to take the patient to hospital. However, the target response times may be breached if the ambulances in the area are allocated to other emergencies.

When an ambulance arrives to take the patient to hospital, the local doctor usually gives the paramedical letter of admission to take with the patient. This contains any immediate patient information that the hospital staff may find useful, including drugs that have recently been prescribed for pain relief. Ideally, ambulance paramedics should be given the same information so that they know what treatment has already been given, to avoid duplication. This does not always happen, especially if the doctor is unable to meet the ambulance crew.

When the ambulance arrives at the hospital, it is normal for the patient to be taken to either the accident and emergency (A&E) department or to a specialist ‘surgical assessment unit’. First, the patient will have to be booked into the system by a receptionist and the ambulance staff will not be allowed to leave before this is done. This is to ensure that accurate information about the patient’s condition is given to the hospital staff receiving the patient. The booking procedure needs to establish the patient’s identity accurately, so that the correct patient’s notes can be retrieved from the hospital’s archives. Other details, such as the patient’s next of kin, are also required, so that relatives can be informed, particularly if the patient is extremely ill. The patient’s arrival will be cross-referenced with the call to surgically accept the patient. Once the patient has been booked in, they will be assessed for the urgency of their condition. This ‘triage’ will usually be performed by a senior nurse. 

A house officer (doctor), supervised by a senior house officer, will then hopefully provide an accurate diagnosis. The first steps in the diagnosis will usually involve basic blood tests and Xrays. Most hospitals have their own emergency X-ray units attached to A&E, staffed by radiographers. These often become very busy with patients, especially where specialist fracture clinics share the resource. Each X-ray needs to be assessed by a radiologist and a report typed up by a medical secretary. When blood is taken, the most common tests might be analysed using small testing machines located near the A&E department. Most samples are sent to central pathology labs, where they are processed alongside the hundreds of routine samples that each lab has to deal with each day. Skilled pathology technicians operate the equipment and ensure that the results are accurately obtained. Pathologists assess the results, which are usually reported on a computer printout. Urgent results are sometimes telephoned through. Only a few departments have electronic reporting of this type of information.

Often one of the biggest hurdles for the patient is to be found a bed within the hospital. This is the responsibility of a specialist team of bed managers. Wards are divided into medical and surgical units with male- and female-only wards. Given that most hospitals in the UK work with 90 per cent or more occupancy of beds, finding a space for up to 50 acute admissions per day can be a real challenge. Acute admissions typically comprise 30 per cent of all admissions and so emergencies compete with elective cases for bedspace. The space available partially depends upon the surgical lists that drive the elective admissions. Commonly, Mondays and Wednesdays see most elective surgery and so these are frequently the most difficult days for unplanned admissions. In many hospitals, medical wards overflow at times. This can result in patients’ medical outliers’ being placed on surgical wards, further restricting space. One bed manager highlighted other problems:

Requests for beds should come through us. This does not always happen, as patients can be admitted via the ‘back door’ by consultants etc., without telling us. It can be confusing when we think we have free beds but we haven’t. We continually monitor where beds are available on the computer and by doing a ward round. We conduct a census on wards to find free beds not recorded on the computer.

When a patient needs urgent surgery, a theatre slot needs to be found. This can be complicated as the theatres usually have particular elective clinical specialisms booked for each half-day session, with just a few slots reserved for emergencies. Theatres are not all equipped in the same way: theatres specialising in orthopaedics, for example, need specialist pieces of equipment. There are also issues to address when assembling the most appropriate surgical team of surgeons, anaesthetists, nurses and support staff, since not all staff are multi-skilled or available. Staff time taken by emergency surgery inhibits other activities such as ward rounds. The theatres also have to ensure that there is a readily available stock of sterilised equipment, and it usually takes 24 hours for used equipment to be cleaned and resterilised.

Patient welfare is also enhanced by the array of support services. The catering services need to provide patients with three meals a day. Cleaning services need to ensure that all areas are kept as clean as possible. This is a difficult task because they must not interfere too much with the daily workload. The traffic of thousands of staff, patients and visitors bring in dirt and waste incessantly. Cross-infection caused by poor hygiene requires a massive coordinated preventive programme.

Hospitals also need efficient discharge procedures. If patients are discharged later in the day, they may occupy the bed unnecessarily. Delays can be caused by poor coordination with pharmacies, as patients wait for take-home drug prescriptions to be prepared for them. If these are not ready by 5.00 p.m., pharmacies often close for the day, forcing patients to stay an extra night on the ward. Other delays can be caused by waits for porters or transport. Relatives often only pick patients up in the evening, once they have come home from work, causing a bed blockage.

Adapted Source: Johnston, R., Clark, G., & Shulver, M. (2012). Service Operations Management: Improving Service Delivery (4th ed.). Pearson Education Limited. Medina, A. F. (2020). Malaysia’s Healthcare Sector: A Rising Giant in ASEAN. ASEAN Briefing. https://www.aseanbriefing.com/news/malaysiashealthcare-sector-a-rising-giant-in-asean/

Question 1 Differentiate operations in a hospital from operations in an iPhone production factory. 

Question 2 Explain reasons that cause delay in the admission, treatment and discharge process. 

Question 3 Suggest FIVE (5) quality tools to measure the performance of the hospital. Explain how the tools are applied and their objectives. 

Question 4 Explain the reasons why private hospitals’ charges are expensive for a simple appendicitis surgery from operational perspective.