XYZ Hospital is a local private health care organization located in Sulaymaniyah founded in 2013. It is a family business established to provide health services like doing multiple kind of operations such as orthopedic, obstetric and gynecology, plastic surgery, general surgery and cardiothoracic, emergency services, and medical consultancy. The mission of the organization is bringing professional health staff, nurses and doctors plus advanced medical equipment, to provide a standardized health service to the people in the city and its rounding.

Few years ago, from 2015-2019, the hospital was undergoing some serious issues in the management and organization facilities that negatively impacted the total performance of the hospital and a terrible customer service. The organization was in the merge of shutdown as they were receiving few number of patients and patients feedback were totally disappointing. Finally, in March 2019, the shareholders of the hospital decided to have change in the complete structure of the organization, changing the strategy and management structure and innovating all the facilities including the equipment and building.

They started by inviting two specialists, cardio thoracic surgeon and general surgeon, from Iran whom they have their own in hospital in Iran. Beside their specialty, these two practitioners have a good experience and an intensive knowledge in establishing hospitals and the types of services to be provided. Moreover, they have worked with some other hospitals in both public and private sector in Iran. After two meetings hold with the owners of the hospital, first meeting in Iran and second one in Sulaimanyah, they agreed to sign a contract to diagnose the main issues in the hospital and recommend the best solutions possible.

The two specialists started their duties, entering and contracting, by opening their own clinic inside the hospital and receiving patients on daily basis. Throughout this, they were able to interact with all other sections inside the hospital. They were hypothesizing the issues and, every day, they were sitting with the teams, or sometimes in person discussing different matters inside the organization. The purpose of having these practitioner was clear to all the hospital staff, so they were talking openly without having any fear. The specialists were motivating the employees to frankly talk about their issues and point out the obstacles they were facing during the work. They sat down with the finance manager and discussed the system of payments and patient deposits. They also had meeting many times with the nurses to point out what issues they are facing in the wards, inside the operation theater (OT), equipment and treatments. The two practitioners, beside receiving patients in their clinics and doing operations, they were preparing their notes daily and after three weeks they end up with mentioning a list of eleven points which they believed they are the root causes of the issues. The root causes included:

Not having enough space in the building and enough space for parking cars.

Lack of having a proper oxygen system

Not having a sub way beside the stairs for the handicap people

Not having the unit for neonatal caring (NICU) for post C/S surgeries and normal deliveries.

Not having segregated wards for different types of operations

Not having intensive care unit (ICU)

Less variety of medication in the pharmacy and required medication for operation process.

Not having enough staff (nurses and assistance doctors) for post operative follow up.

Increased number of ambulances for transferring some emergency cases.

Not having a proper payment system.

Digitalizing patient information.

After the issues were pointed out, the owners of the hospital and the practitioners agreed to implement the planned changes and fix the issue the best way they can. In the first step, they started to renovate and expand the building of the hospital. Furthermore, they increased the parking lots in the parking area which was specialized for the cars of the staff, patients and chaperones. Before, the building was quite old, wards were too small, and patients had difficulty to find a space for parking their cars.

Soon after the reconstructing the building and expanding the parking area, they started fixing the facilities and services. They fixed the oxygen system by replacing the oxygen bottles with an advanced medical gas supply system. Before, when patients were in need of oxygen, they were receiving through bottles which was quite risky on the life of the patients because it was time consuming to replace the bottles especially for the cases under GA (general anesthesia) during operations, patients admitted inwards and in need for oxygen, neonates who are admitted in NICU (Neonatal Intensive Care Unit). Such kind of cases need a continuous oxygenation till the end without any interruption. The hospital established a central medical vacuum system located in the basement of the hospital and delivered to the units systematically.

Previously, when babies born with caesarean sections and normal deliveries, some neonates were having medical emergencies which required NICU and it was not available inside the hospital. They were transferring to other hospitals where this unit was available. In the transformation process, they opened NICU with the most advanced devices and technologies.

The wards expanded and segregated as per the types of the surgeries. In the beginning, different cases were admitted in the same ward. This was making difficulties for the nurses and medical assistances to deliver a proper service to the patients, and this was making the life of the patients at risk in case of receiving a wrong dose of treatment. Nurses and assistance doctors are somehow specialized as per the cases. They can give treatments only to those cases which they are familiar with as per the training and courses they have taken. For example, a nurse who she is only taking care of the newly born babies doesn’t know how to give treatment for a patient who had heart surgery. So, the hospital segregated the wards with dedicating specialized assistance for each ward accordingly.

Because major and super major operations like heart, kidney and brain were taking place in the hospital, the OD practitioner thought there should be also an ICU (Intensive Care Unit) ready for the patients who need this unit after surgery. In such kind of operations, usually patients cannot be released and send back home. They need a good follow up and care for one day or more, if they thought his/her health is going to be well, then they will allow him to leave. Before opening this unit, patients were not coming for such operations in this hospital, because they thought if they need to stay after the operation, they have to move to another hospital which has ICU.

Another issue the hospital and the staff struggling with was the lack of having some kind of medication in the pharmacy were was required for emergency cases. For example, when a patient was becoming cardiac arrest under GA during operation, the nurses were asking the family of the patient to go outside the hospital and buy a kind of injections called troponin and adrenaline. Another example, some cases were becoming hypotensive during surgeries, the medication, again, was not available in the pharmacy, families and friends of the patient were asked to get in other pharmacies outside the hospital. This practice was, in one hand, time consuming and putting the life of the patient at risk because sometime families of the patient had to go far to find the medicine. On the other hand, it was a hit to the hospital financially and reputationally. The profit in selling such medicines was going to somewhere else while they could easily make for themselves. So, finally, they came with an intensive check for the availability of the kinds of the medicine in the hospital and signed contracts with some vendors to provide them the needed medicine.

Not having enough staff, nurses and assistant doctors, was another issue in the hospital. During the load, having a big number of cases, the available staff were not able to follow up and care of the cases properly. Among the cases, some cases were neglected and patients were suffering. In some child birth cases, the mother was become shocked because at the beginning she was having a mild bleeding and her chaperon was going to the nurses informing them regarding the complain, but due to the busyness of the nurses, they were unable to pay a visit and finally when they were checking the patient, they were realizing the mother has lost hug amount of bleeding and became shocked. When the OD practitioners saw this situation for more than one time in the hospital, they got shocked. They informed the hospital owners that it is a disaster and need to increase the number of trained nurses in a way for each four patients there should be a specialized nurse to take care of them.

In the entire hospital, there were only two ambulances and the OD practitioners thought this is not enough for a big hospital because usually, any hospital, must expect receiving sudden top emergency cases like RTA (Road Traffic Accident), Bullet Injuries, fall from height (FFH), stab injury and explosion. These are cases when happening it needs more than an ambulance to transfer the patients. They recommended to the management team of the hospital to acquire three more ambulances. They thought it is right that all these ambulances not always will be in use together in one time but, as they are dealing with the life people, one case is enough to hit the reputation of the hospital.

Before the hospital had a poor payment system. On daily basis they were facing issues with the patients while they were paying the charges. The system was old and customers didn’t have a clear guide regarding the amounts of the money they were paying. For example, while releasing the patient, then they were giving the invoice to the patient, and many patients were denying to pay the requested amount. The requested amount was a total charges for the doctor, hospital, nurses and drugs. The patient was familiar with only one amount which was informed by the doctor as the fee for the surgery. They were not aware of other charges. So, they came up with the solution that any patient before admitting to the hospital, he or she should pay total fees plus an amount as a deposit which they were returning back to the patient at the end.

Properly recoding the patient’s information, the medical history and the kind of the treatment was an issue for the hospital. Any recording was done physically on paper. This was having the risk to lose information and difficult to track the patient’s information in case of revisit. What they did was totally digitizing these records. They bought a system, data base, for recording each and every information about the patients. Any patient, when admitting to the hospital, the admission team was making a code for him and opening an account for him in the system. They were entering the information related to the patient in the system including date of the visit, full name, and medical history. And these information were updating daily according to the type of the treatment and doses the patient was receiving. This system is very beneficial for both of the nurses and patients. Every morning, when the doctor or nurse visit the patient no need to ask him what treatment he/she has taken or what they have to take, just by check the system they can know everything and do what is required for them. In another way, in case of re-visiting the patient to the same hospital, just by giving his code to the admission department, the hospital will re-load all the related data about the patient. It will be no need to open another account for him. And the doctors and nurses will not take medical history again as they have the old history in the system.

Answer these questions depending on the case study:

(1) changes the organization is going through (scope and context for change),

(2) what challenges they faced as they are/were undergoing change (describe those challenges),
(3) present two or more relevant, integrated OD interventions that the organization used to successfully adapt to these challenges,

(4) provide measures of success for the OD interventions suggested,

(5) recommend the best intervention that the company.