Situational Analysis

Situation Analysis: Gordonia Hospital
Hospital Management in Gordonia District Hospital, Lower Orange District
A Situation Analysis of Gordonia District Hospital, Northern Cape Province.

December 1999
Conducted by:
The Initiative for Sub-District Support (ISDS) Health Systems Trust in conjunction with Gordonia Hospital staff and the District Office of the Northern Cape.
Beth Engelbrecht, Lesley Bamford, Natalie Grazin and George Isaacs
Funded by the European Union via the National Department of Health
Executive Summary
Managers generally follow an approach whereby a situation analysis is conducted to inform planning. Such a situation analysis forms a crucial part of the service management cycle and also forms the first step in a quality improvement cycle. The objectives of conducting a situation analysis of the Gordonia Hospital in Upington, in the Northern Cape Province were to: Have a snapshot picture of what is happening in the hospital as a whole Highlight issues that require further attention Have a baseline how the hospital is performing. Allow the staff to be involved and share their experiences The cover page reference to The First Lady of the Northern Cape reflects the vision that the management teams of the Lower Orange District and of Gordonia Hospital has for this hospital. This document attempts to describe and analyse the present situation answering to the objectives above. The approach followed during the situation analysis was to prepare a list of questions that would focus on the key issues to be recorded and analysed. During this preparation phase a lot of literature and experts were consulted. This was followed by individual and group sessions to ensure a complete picture. Most of the data collected for the study covered the financial year stretching from 1 April 1998 to 31 March 1999. This approach allowed expenditure data to be linked to service data thus allowing the measurement of efficiency and unit costs. Analysis was however limited by the way that the financial systems is presently structured and how staffing is done. On the other hand, the availability of meticulously kept hospital data assisted the project. Gordonia Hospital acts as a district referral hospital also rendering some level 2 services. It has undergone intense transformation since 1996 and coped well. Although services continue as business as usual, management identified a need to have more comprehensive analysis of the services and performance to support their strategic management. Due to a successful district intervention of managing tuberculosis according to National Policy, the load on the radiology department dropped by 47%. The hospital was also able to desegregate services and is undergoing structural upgrading. Apart from these and other positive findings, the document supports the concern that management had that business as usual is covering inefficiencies. Absenteeism was a particular concerning factor aggravated by rosters that include staff attending training, making it difficult for wards to cope. Infection control will improve as soon as policies are communicated and the disposal of soiled ward refuse is properly dealt with. The medical records system experienced difficulty in retrieving files. It took on average 14 minutes to retrieve a file and in a survey done 50% of files was never found. (This has improved following an intervention.) Stores took up 22% of the hospital expenditure and was already identified by management as an important issue that requires attention. The situation analysis confirmed this. Other factors highlighted were maintenance management, aspects of quality patient care, hospital fees collection and general management issues. The introduction to the document describes the scope of the services provided in the hospital and the role the hospital plays within the district setting. Many districts in South Africa are yet to be clear on the role of the hospital within the District Health System and Gordonia has already moved a long way in clarifying this relationship. Section 2 focuses on the important aspect of management within the hospital. Management capacity is presently an important focus of government and this section attempts to analyse the situation at Gordonia Hospital. This is followed by section 3 describing patient care ward by ward. Some aspects of quality of patient care have been recorded in this section.

Clinical support services are described in section 4 with section 5 focusing on administrative and non-clinical support services. In both these sections an attempt was made to move beyond merely describing the situation, but also to stretch the groups to think of quality and standards. This should support the next steps in the continuous cycle for improved quality of care. The recommendations made at the end of the report serves to draw attention to key factors constraining progress and quality services. The key recommendations were to: Fill the post of assistant director administration Establish a culture of discipline Establish a shared vision and strategic planning with staff participating Establish and monitor indicators for management Establish quality management Improve the medical records system by further analysing the situation and applying remedial actions Establish a Health and Safety Committee Enhance stores and financial management
Acknowledgements
All the personnel at Gordonia Hospital are acknowledged for their participation in the project, particularly unit managers and heads of sections. The district manager, Mr Nico Fourie, Mrs. Witbooy, the Nursing Services Manager, Mr. Delie, who manages Financial and Support Services and Mrs. van der Westhuizen deserve special mention. John Gear and David McCoy from ISDS who assisted with editing of the document.
CONTENTS Section 1: Introduction
Page
1. 2. 3. 4.
Background Scope of services Gordonias role within the District Activity Measures
7 9 9 10
Section 2. Management
1. 2. 3. 4. 5. 6. 7. 8. 9.
Organisational Structures Strategic Planning Communication Human Resources Management and Development Financial Management Data Collection and Information Systems Quality Management Drug Management System Transport Management
12 14 14 14 17 18 19 20 20
Section 3: Patient Care 1. 2. 3. 4. 5. 6. 7. 8. 9. General Comments Outpatients/Casualty Female Ward Male Ward Childrens Ward Maternity Ward High Care Unit Theatres TB Unit 22 23 24 25 25 26 27 28 28
Section 4: Clinical support services 1. 2. 3. 4. 5. 6. Physiotherapy Occupational therapy Dietetics Services Radiography Services Laboratory Services Pharmaceutical Services 30 30 30 31 32 33
Section 5: Administrative and non-clinical support services 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Introduction Registry and general office services Personnel administration Financial administration and fees Medical Records and Admissions Catering Laundry Central sterilisation services department Stores Maintenance and workshop services Steam, incinerator and mortuary services Porters Nurses home and crche 35 35 35 36 37 39 40 41 42 43 44 45 45
Section 7: Recommendations
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Appendices 1. 2. 3. Links with PHC Staff establishment Rational drug use 50 51 52
Tables 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Activity measures for Gordonia Hospital April 1998-March 1999 Changes in service statistics from 1997 to 1998 Hospital performance indicators Strategic issues for 1999 Budget performance in 1998/99 financial year and the allocated amount for 1999/2000 financial year Wards in Gordonia Hospital Workload in Casualty and OPD Maternity service statistics (1998/99 financial year) Admissions to High Care Unit during the first five months of 1999 Theatre utilisation figures Radiography activities for the financial year Laboratory services and costs for the financial year The budget allocation and expenditure for drugs Expenditure per drug category for 1998/9 Revenue collection for 98/99 financial year Meals, cost of meals and productivity for catering services in the 1998/9 financial year. Laundry statistics for the previous financial year (1998/99):
Section 1: Introduction
1.
Background
Gordonia Hospital is a 189-bedded hospital that was opened in 1964 as a community hospital. It now serves as: A level one or district hospital for the Upington and Mier sub-districts of the Lower Orange Region or District. A referral hospital for the remaining four sub-districts in the Lower Orange Region namely Kakamas, Keimoes, Pofadder and Kenhardt. Each of these sub-districts has a district hospital or CHC (with inpatient beds). See the map below. A referral hospital for two additional regions namely Namaqualand and Hantam.
The population served by the hospital is estimated to be about 250 000, of whom 1 approximately 165 000 live in the Lower Orange District itself. Northern Cape Referrals. Source Northern Cape Informatics section and District manager.
Northern Cape Province
Rietfontein
Lower Orange District
Hartswater Kuruman Olifantshoek Danielskuil Postmasburg Jan Kempdorp
Port Nolloth
Warrenton Gordonia Barkly West Keimoes Griekwastad Pofadder Kakamas Kimberley Groblershoop Douglas Aggeneys Bloemfontein Kenhardt (Private) Prieska Brandvlei Loeriesfontein Calvinia Williston Hopetown
Springbok
Garries
Colesburg Carnarvon Victoria West Noupoort Richmond
Vosburg De Aar
Fraserburg Cape Town Sutherland

0 50 Kilometers 100
NGCF
The hospital provides a full range of first level hospital services as well as a limited range of secondary level services. Complex secondary level and tertiary level cases are usually referred to the regional hospital in Kimberley and, more occasionally, to Cape Town or Bloemfontein.
1
The terms District and Region are often used interchangeably in the Northern Cape Province

Since 1996, major changes have taken place within the hospital. These change processes have been driven both from outside and from within the hospital. Important changes include: Incorporation of the hospital into the District Health System Change of status from a community to a referral hospital with expanded scope of services to include provision of a limited range of secondary level services Desegregation of services and facilities Appointment of a new management team Change in racial composition of top management Changes in organisational structure Changes to a more decentralised and interactive management style Local GPs who ran the hospital on a part time basis replaced by a team of 8 full-time Cuban doctors since 1996 and 4 community service doctors since 1999
Overall Gordonia Hospital has coped well with this process of transformation and now enjoys a good reputation amongst both the community it serves and professional bodies. The hospital management must ensure that the transformation process is not a once-off event, but is the first step in an ongoing process of quality improvement. The framework developed by the medical superintendent is a tool for use in this process. It outlines the position in which the hospital found itself in 1995 as well as the position defined as Where we want to be. See the table below.
Issue
Hospital Management
Where are we now?
Where do we want to be?

189-bed district hospital Decentralised Interactive Bottom-up approach Integrated Comprehensive Equitable Adequate staff numbers Well trained Team development Responsible Sense of ownership New technology Evenly distributed Full-time physiotherapist Full-time pharmacist Social worker Training facilitator or tutor Integrated Comprehensive Patient-orientated Trusting Loyal Teamwork
189-bed community hospital. Centralised Rigid hierarchy Top-down approach Facilities Segregated Duplicated Unevenly distributed Personnel Understaffed Low morale Overworked Stagnating No responsibility No sense of ownership Equipment Out-dated Inadequate Support services No specialist services No pharmacist Part time physiotherapist No training department Services Segregated Fragmented Centred around staff Culture Suspicious Disrupting Selective friendships Disloyal Source: Medical Superintendent Disease profile of the Lower Orange Region
Accurate information regarding the disease profile in the region is not available. The region has one of the highest documented incidences of tuberculosis (TB) in the world (800 cases per 100 000 people). The incidence of trauma (often alcohol related) is also high. The HIV epidemic is in an earlier stage than most parts of South Africa. In a 1997 survey of women attending antenatal care in the district 7% tested positive. Health workers report a high

prevalence of chronic conditions such as hypertension, diabetes and arthritis in the community, but this has not been accurately documented.
2.
Scope of Services
The hospital is now operating as a district hospital where services provided are at the level of the general practitioner. A limited range of secondary level services is also available. Facilities and services therefore include: 189 beds divided into 5 wards: Male, Female, Childrens, Maternity and TB. 24 hour casualty Two theatres used weekly for emergency and general surgery (including orthopaedic, gynaecological and obstetric surgery). A visiting surgeon performs an ophthalmic list every six weeks. A High Care Unit. Weekly specialist outpatient clinics: these include medical, surgical, orthopaedic, paediatric, pain, gynaecology and antenatal clinics. Monthly to six weekly specialist outpatients clinics for oncology and ophthalmology Clinical support services including radiography, physiotherapy, pharmacy, dietetics and laboratory services
Over the past two years, acquisition of new medical staff and equipment has significantly improved the hospitals capacity to manage complex cases. Referrals to Kimberley have consequently been drastically reduced. The provincial office, together with hospital management has therefore decided that the range of services should be extended to include more secondary level services. In order to achieve a comprehensive secondary level service, Gordonia would need to offer specialised services for urology, ENT and plastic surgery. The development of the flying doctors scheme within the province may facilitate this. In addition, management estimates that a further R680, 000 of equipment would be needed to equip the hospital adequately to support that level of work. Limitations in nursing, non-medical support services such as the maintenance section and the central sterilising service department will also require improvement if any expansion of services is considered.
3.
Gordonias role within the District
As in many districts in South Africa, the role of the district hospital in the district itself is a thorny one. In general, a good relationship exists between the hospital and the district, although there is still room for improvement. At an organisational level, the hospital is fully integrated into the Lower Orange district. The hospital management forms part of the district management team and the hospital is funded through the district budget. Clear referral patterns have been established with few patients bypassing these systems (with the exception of a proportion of Upington residents who access the hospital OPD directly rather than through the local PHC clinics). The clinical support services of the hospital are shared with the district. Historically the hospital has not played a significant role in providing direct support to PHC services. For example, clinics in the area have received drug supplies directly from the provincial depot and ambulance services have been run separately by the Local Authorities. In both cases, the situation has recently changed. Ambulance services have been taken over by the province and a drug depot will be established within the d istrict. It is anticipated that staff based at Gordonia will play a larger role in managing and co-ordinating these systems. This provides excellent opportunities for integration of hospital and community-based services, but the process will need to be carefully managed. The personnel rendering clinical support services at the hospital such as physiotherapy, occupational therapy and pharmacy also have responsibilities for the whole district.

A gap still exists between the hospital patient care and PHC services. Appendix 1 offers a case history of how this gap is being narrowed.
4.
Activity Measures
The figures shown below where taken from the Business Status Reports (BSRs) which are completed on a monthly basis by hospital staff. Table 1: Activity measures for Gordonia hospital: April 1998 to March 1999: Month Inpatient Admissions (state and private) 791 814 743 756 753 754 794 862 920 908 788 1 146 10 029 836 Outpatient and casualty attendances (state and private) 2 079 1 998 2 022 2 026 1 942 2 146 2 550 2 447 2 313 2 395 2 258 2 669 26 845 2237 Theatre cases Deliveries
April 1998 May 1998 June 1998 July 1998 August 1998 September 1998 October 1998 November 1998 December 1998 January 1999 February 1999 March 1999 TOTAL Average / month
104 150 121 124 123 138 131 144 112 124 135 171 1 577 131
156 132 126 126 122 135 126 93 128 131 121 185 1581 133
Notes to table 1. There is a slight increase over time of outpatients/casualty attendance both in and out of hours. March seems to have been an extra-ordinary month and the trend from March onwards should be monitored The number of theatre cases appears to have remained stable over the period but with April and May 1998 and March 1999 being exceptions. The average time that the theatre was used per month was 119 hours. Table 2: Changes in service statistics from 1997 to 1998 (Source: Superintendent) Service Admissions Outpatients Deliveries X-rays Theatre cases Notes to table 2: Service statistics between 1997 and 1998 show an increase in in-patient load and some significant decreases in the X -ray load due to the implementation of the new t berculosis u treatment protocol. 1997 9 923 24 217 1 283 23 988 1 567 1998 10 997 26 186 1 409 12 538 1 379 Change 1074 (+10,8%) 1969 (+8,1%) 126 (+9,8%) -11450 (-47,7%) -188 (-12%)
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Table 3: Hospital performance indicators: Month In-patients referral rate (%) 1,9 1,5 1,9 1,8 2,4 2,8 9,6 61,8 59,0 53,8 78,4 64,8 28,3 Bed occupancy rate (%) 65 76 63 57 50 61 57 66 59 62 63 74 65 Inpatients >8 days (%) 7,7 9,0 9,8 9,0 11,4 8,3 7,7 7,9 7,0 7,1 9,6 6,5 8,4 Average length of stay (days) (ALOS) 4,7 5,6 5,1 4,3 4,0 4,6 4,4 4,5 3,8 4,4 4,2 4,0 4,5
April 1998 May 1998 June 1998 July 1998 August 1998 September 1998 October 1998 November 1998 December 1998 January 1999 February 1999 March 1999 AVERAGE Notes to table 3: -
The in-patient referral rate was recorded for the first 7 months as the referrals from Gordonia to higher levels of care and for that period it was on average 3,1%. Since November the definition for the indicator was changed and patients referred to the hospital from other centres were recorded. There was no clear reason why the hospital decided to change from an efficiency indicator to a referred patient profile measure. The bed occupancy rate stayed around 65% with March the highest. A bed occupancy rate of 80% is usually considered a well-occupied facility and efficient utilisation of the hospital. During the study some wards complained of overcrowding. We recommend that in future these occupancy rates be recorded per ward and not just for the whole hospital. The officially approved 189 beds were used in the calculations. Inpatients more than 8 days represents in-patients that stayed in hospital for more than 8 days as a percentage of the total in-patients for the month. This indicator should be read in conjunction with ALOS as this further qualifies the ALOS indicator. Although the average length of stay is 4,5 days, there are still on average 8,4% of patients staying longer than 8 days. As the hospital also caters for TB inpatients, the figure is good. As Multi-drug resistant TB cases will be admitted soon, this might change.
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Section 2. Management
1.
Organisational Structure
The official organogram of the hospital is as follows:
Medical Superintendent
Clinical services manager
Assistant director administration (vacant)
Assistant director nursing
Doctors Pharmacy Physiotherapy Radiography Occupational therapy Dietician
Financial administration Human resources administration Kitchen Laundry Workshop Reception Nurses home Stores Porters
CPN: Trai= ning
CPN: Childrens Ward Female ward Male ward
CPN: (vacant) ICU Casualty / OPD Theatre Gynaecol ogy Labour ward
CPN: TB Unit Regional TB coordinator
The hospital management team comprises Medical Superintendent Assistant Director Nursing Head: HR Department Senior Admin officer: Administration Nurse trainer TB Unit manager Dietician Crucially, the post of Assistant Director Administration (also called the Hospital Secretary) is currently vacant. This places an immense management burden on the Hospital superintendent (also the Clinical Service Manager) and the Assistant Director of Nursing. The assistant director nursing is often the only senior person available in the hospital as the medical superintendent is only a part-time position. He attends to hospital matters during the mornings and during the afternoons he is at his private surgery. Wards administrative and management tasks are shared between the assistant director for nursing and the CPN. The organisational design has multiple lines of communication and accountability. There is division of responsibilities between units that are functionally linked. This causes a crossing
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in lines of accountability and divided responsibility, resulting in an incoherent approach and frustration for both management and staff. The kitchen for example, reports technically to the dietitian, whilst administratively to the head of administration services. The dietician reports to the medical superintendent (head of clinical services). A matrix approach in management is required to ensure proper communication and coordination. This must still be implemented. Management Capacity Many staff at senior levels have received very limited management training and some have little previous experience at such senior levels. Strenuous efforts have been made to address the management deficiencies through formal training programmes. To date the Medical Superintendent has completed the Free State Universitys two-year Health Management Training course. Six senior staff are currently registered but a total of six senior personnel dropped out during the past 2 years. The high drop out rate raises important challenges around strengthening management capacity.
2.
Strategic Planning
Management initiated strategic planning and created a mission statement for the hospital. Each member of the management team drew up his or her own version, out of which a consensus draft was to emerge. During March 1999 a 3-day session was held where some key strategic issues were identified. The key components of the strategic plan can be summarised as follows: Table 4: Strategic issues for 1999: Strategic Objectives / activities issue Service delivery Expand services to include: Dentistry services, occupational therapy services, increase operations by 20%, operate on 200 eye patients. Reduce number of PHC patients by 30% by strengthening PHC clinics, by-pass fees collection Improve the quality of services by means of establishing a quality assurance programme, an infection control programme, staff training. Physical Refurbish labour ward, high care unit, childrens w ard, and establish a facilities private ward with amenity beds Human Establish a human resource department, have a functional disciplinary resource process, improve interaction with trade unions, promote health and safety in the workplace, introduce personnel evaluation programmes Administration Create user-friendly reception, improve patient record system, streamline internal communication system, and ensure adequate data collection. Community Establish a hospital board and actively promote the district hospital in participation local communities by means of monthly community meetings. and interaction Budget Promote better budget control, ensure income generation by improved fees collection, reduce spending on laboratory and pharmaceuticals, and investigate alternate sources of income.
Source: Strategic plan for the hospital
Comments on the strategic plan: Some objectives and targets have been determined, but baseline information to assist monitoring is lacking.
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It is not immediately clear what the priorities are. Key interventions identified by a group of 24 senior staff and management showed 38% of the group requesting urgent attention to the medical records section, 57% for improved management efficiency (financial management, personnel management and equipment) with 4,8% requesting treatment of patients at the correct level of care. An expansion of services is indicated, but the indicative figure of the budget available in March already showed that expansion would not be possible. This could raise unrealistic expectations and defeat the aim of planning. Focus on increased efficiency and quality is more appropriate in such a situation. The plan has not been communicated to all staff leaving them with little idea of where the hospital is heading.
3.
Communication
Gordonia has identified communication and the lack thereof as a priority issue that needs to be addressed. Although communication channels and regular meetings between various sections of the hospital have been established, it appears that the processes are not working optimally and that many staff still feel ignored and unaware of what is happening within the hospital and region as a whole. For example, many staff were unaware of the policy for action following exposure to blood. In theory, the communication cascade goes from the administrative block to each ward. The CPN signs to acknowledge receipt of documents received. Apart from the flowing of documentation, a system of cascading management meetings has been agreed to. Information should then flow up and down in the hospital structure. It was, however, found that not all units are adhering to these processes. Establishment of a staff newsletter is considered as a solution which may also benefit staff morale. Many positive developments are occurring throughout the hospital, such as the Baby Friendly Hospital Initiative (BFHI) and refurbishment. The knowledge that the hospital is not stagnating would be of great motivational benefit to staff.
4.
Human Resources Management and Development
4.1 Human Resource management Human resource management emerged as a major theme. Staff establishment The hospital has 257 approved posts. 26 of these posts are vacant. An additional 16 filled posts are held at the district office but based at the hospital, bringing the total filled posts at 267 and the total posts (filled plus vacant for hospital application) at 283. (The full establishment list is given as Appendix 2.) The filled posts held at the district office are: Chief dietician (1) Chief pharmacist (1) SASO (1) Porter (1) Medical Officer posts (12): Cuban doctors (8) Community service doctors (4) Medical staffing has undergone immense change over the past three years. Prior to 1996, fourteen South African private family practitioners worked sessions within the hospital, and between them, provided cover for all generalist services. The de-segregation of the hospitals two wings and other policy changes in 1996, however, prompted ten of them to resign; they have since established a private hospital in Upington. Their resignation co-incided with South
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Africas importation of Cuban doctors and so they were gradually replaced by a team of 7 fulltime Cuban doctors between 1996 and 1997. This team has now grown to eight with the appointment of a dedicated casualty doctor in October 1998. In January 1999, Gordonia received four community doctors as part of the newly introduced community service scheme whereby newly qualified doctors must complete one year working within the state system. These four doctors rotate between wards and also between the primary health care clinics in Upington. The staff turnover rate is monitored and a monthly list of vacancies is produced. Turnover however appears to be fairly low. Staff Absenteeism Although absenteeism is recognised as a major problem within the hospital, absenteeism levels are however not regularly monitored. The problem is rather dealt with on an individual basis through the disciplinary process. It is common knowledge amongst hospital staff that many people (both clinical and non-clinical staff) are constantly subject to the earlier stages of the disciplinary process but are aware of how to ensure that the later stages are never reached. An analysis of staff that are absent (both scheduled and unscheduled leave patterns) was made of two representative months, May and October, during 1998. (The tables and notes are attached as appendix 3.) This analysis revealed a significant difference in staffing levels. One reason why staffing levels are low in October in the example is because staff who are already scheduled to be on a training course during their shift are still included on the roster, the logic being that they are still working. Analysis of staffing problems One of the major features of the nursing management style at Gordonia is that it is very centralised. CPNs in charge of a ward have limited autonomy. Their staff are accountable to them, yet disciplinaries are conducted by a member of the senior nursing management team of CPNs based in the administrative block. Similarly, the nursing rosters for all wards are held centrally. Ward CPNs are not, and presently do not wish to be, involved in the performance appraisal, disciplinary procedures or deployment of staff and consequently do not have the scope to develop their management skills. This is mostly due to staff shortages according to the staff concerned. When a ward discovers that they are going to have a staff shortage during the day, the ward then phones through to the central nursing management to ask for help. The senior nursing staff then look through the roster to find a ward which is well staffed and can spare a nurse to transfer to the ward which is struggling. Another important factor is that of overtime: Overtime payment for d ays when a nurse is not scheduled to work, is one and two thirds payment, whilst if overtime is worked when scheduled, it is one and a third. This often has the effect that staff stay away when supposed to work and offer to work when not scheduled! The effects of the system described above are: It results in a great deal of resentment by wards that feel that they are constantly supporting others at the expense of the quality of care given to their own patients. Moreover, it creates a perverse incentive a nursing teams that are well motivated and s who have a low absence rate are punished by being repeatedly deprived of their staff. This does not encourage ward managers to take responsibility for motivating their team or dealing with repeated absenteeism Furthermore, the impact of this system on nursing staff is that there is less sense of loyalty to the teams with which they work. Rather than know that their colleagues will be
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struggling throughout the day, nurses know that their ward will receive help if they are absent. Nursing staff are frequently transferred to a different ward to cover for staff shortages. They therefore have little opportunity to develop their clinical skills and knowledge in one particular area and also do not receive continuous clinical supervision or feedback. Formal performance appraisal is difficult to implement, as there is so little stability of staffing. Effective nursing teams cannot be built due to the lack of continuity.
Disciplinary processes Staff disciplinaries are not handled directly by the personnel department but by the various heads of sections. Delegations are eagerly awaited to further some disciplinary actions that have started. There are, for example two offenders who have 36 charges against them. Labour relations There are four unions active within the hospital DENOSA, NEHAWU, HOSPERSA and PSA, of which NEHAWU has the most members. At present there are no regular meetings between unions and management but the hospital has offered NEHAWU r cognition rights e and it is expected that meetings will commence in the near future. Performance appraisal There is no formal system of performance appraisal in place within the hospital. Many nurses and staff at all levels cited a lack of recognition or praise for their hard work as a major cause of low morale. Most wards and departments said that they intended to introduce individual reviews for certain staff over the coming year. It will be seen in a years time whether any reviews have taken place and whether they have any beneficial effect upon morale and potentially even absenteeism. 4.2 Human Resource development: Nurse training The hospital training officer has recently been made responsible for nurse training in the region as a whole. The main training activities in Gordonia are as follows: Bridging course This course, which allows staff nurses to upgrade their qualification in order to register as professional nurses, has been the main training programme at Gordonia over the past few years since August 1997. Primary Health Care Course This is a one-year part-time post-basic course that is run by the nursing college in Kimberley but is now taught at Gordonia Hospital. Tutors from the nursing college travel to Upington for two days each month this consists of one day of theory and one day of practical. Perinatal Education Programme (PEP) The PEP course is run under the auspices of the Maternal, Child and Womens Health (MCWH) sub-directorate in Kimberley. All nurses in the Maternity section as well as other nurses have completed the course. Other short courses Nurses from Gordonia have attended numerous courses over the past few years these include courses on EPI, oncology, optometry, the Baby Friendly Hospital Initiative and drug management. Chronic disease training is currently being planned this will mainly target nurses in the clinics and in OPD.
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5.
Financial Management
The medical superintendent is to a large extent the person who determines the budget, although the various sections are requested to provide inputs. The method is mainly that of incremental historically based budgeting that merely builds on the allocations of a previous year. This has resulted in perpetuating problems. For example, a continued over-budgeting for administrative services whilst stores, equipment and professional services were repeatedly under-funded. The hospital experiences a general lack of financial management capacity. This is i.a. reflected in the fact that financial planning is not linked to service planning and there is no financial management committee or structure where financial management issues are discussed. Cash flow management is limited to the drawing of financial reports and submitting these to the district office and the medical superintendent. The Budget The total budget is allocated centrally from the Provincial Department of Health. For 1998/9, the total budget was R17.2 million. R18.8 million was spent with R13.2 million or 70% of total expenditure being spent on personnel salaries (Note that the personnel costs appearing on the budget and expenditure reports do not include the 16 posts from the district office). This is an important aspect to rectify, as 12 of these posts are medical officers, an expensive category. In theory the basic budget allocation covers only Gordonias district-level services. The hospital is supposed to receive additional funding from provincial level for provision of secondary level services. The hospital management team feels, however, that this system of re-imbursement is not working and that the hospital is losing out financially as a result of the expansion of services over the past two years. The Department of Public Works funds capital expenditure and maintenance of the estate and buildings. This expenditure for major renovations does not form part of the hospitals budget. The budget is structured according to standard line items and not according to service units such as wards. There are thus no cost centres yet. The allocated amount and expenditures for the previous financial year (April 1998 to March 1999) and the allocations for the 1999/2000 financial year are listed in table 6. Table 5: Budget performance in 1998/99 financial year and the allocated amount for 1999/2000 financial year. Standard item Personnel Administration Stores Equipment (current) Equipment (capital) Professional and special services Miscellaneus TOTAL Income Notes to table 5: Personnel (70% of total hospital expenditure) include salaries, allowances, pension, medical aid, overtime and home owners allowance. The doctors and other staff posts borrowed from the regional office (a total of 16 posts) are not included. Budget 1998/9 13 000 000 300 000 3 196 000 182 000 458 000 73 000 17 215 000 Expenditure 1998/9 13 209 422 185 925 4 121 658 207 768 11 265 769 415 204 026 18 829 947 568 303 % expenditure 1998/9 101,6 % (+ 1,6%) 61,9% (- 38,1%) 128,9% (+ 28,9%) 114,2% (+ 14,2%) 11 265,0% (+ 11265%) 167,9% (+ 67,9%) 279,5% 109,4% (+ 179%) ( 9,4%) Budget 1999/2000 13 859 000 290 281 3 114 719 50 000 507 000 247 000 18 068 000
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Administration (1% of total hospital expenditure) covers costs such as postal services, stationery, airfares, subsistence and travel. Stores (22% of hospital expenditure) represent most of the running costs of the hospital, for the following group of store items: Provisions 10% Medical and surgical needs ( including IV fluids and surgical antisepticals) 37% Drugs (Pharmaceuticals and vaccines) 18% General stores 1% Consumable items 24% Medical stores 11% (mostly for blood and blood products) Equipment (current) expenditure was equally shared between workshop needs and surgical and medical equipment. Professional and special services funds are mostly for laboratory costs, which were 68% of the professional costs. Miscellaneous: this represents mostly the stabilisation fund, a contribution made by the employer and employees towards the pension fund to account for the financing of yearly pension increases. Income for the hospital represents 3% of the hospital expenditure. It is generated through provision of inpatient care, mortuary services, the creche, accommodation, parking and orthopedic aides. In analysing the budget for 1998/99 some obvious examples of a lack of financial planning emerged. For example R73 000 was budgeted for the stabilisation fund and R207 026 spent. The formula for the stabilisation fund is set and 65% underbudgeting has major implications. The stores expenditure for 1998/99 was R4 121 658, exceeding the budget by 28,9%. No evidence could be found why the budget for 1999/00 is 25% less than that of 1998/99. Considering the an increase in many stores items, especially drugs, consumable items and surgical requirements, it is inevitable that an overexpenditure will happen again. The doubling of laundry, meals and laboratory costs during the financial year of 1998/99 was not considered in the financial planning process. Budgetary devolution The various sections do not have a budget of their own and show a lack of commitment to keeping within the budget, as they have no ownership to it. A comment was made that they do not have any control over it. The kitchen, wards and theatre should do it. Wards are asked to account for expenditure only in a limited manner, in that they are required to submit monthly reports of the value of their ordering of supplies/stocks/drugs /sundries etc. During the past year, ward CPNs and section heads were asked to suggest a reas in which savings on expenditure within their area might be made, but with little success. Income Generation The rate of revenue against accounts or expenditure was not available. All patients are asked to give their yearly income as part of standard admission details. Revenue collected is sent through to the Provincial office and does not directly benefit the hospital. There is therefore very little incentive to collect it. (See Section 5 on administrative support services regarding hospital fees collection.)
6.
Data Collection and Information Systems
The hospital has a system where monthly data from the various sections are captured in a single page, the Business Status Report. This report is submitted to the district and provincial offices in Kimberley. The processes of collection are compromised because the forms on which data are collected and the format in which it is submitted to the Provincial Office has changed twice in the last two years without appropriate training. In many cases, including that of the business status reports, the forms are completed by administrative staff (either ward clerks or central
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administration staff) who are not clinically trained, do not necessarily understand the technical terms involved and often cannot pick up statistics which seem out of place. There is also no guide available on how to complete the form or how to interpret or calculate certain figures. During 1998 it happened for example that peri-natal mortalities were recorded as maternal mortalities over a period of months. The findings regarding the information system can be summarised as follows: Data is collected but is not used for planning and evaluation either within the hospital or at provincial level. A limited information culture within the hospital the importance and power of information is not recognised. Staff having little understanding for the meaning or significance of the data that they collect. Staff has not been trained in completion of the various forms used to collect data.
7.
Quality Management
A quality management strategy is yet to be developed. This strategy should cover aspects such as quality management, clinical risk and adverse event management, complaints management, clinical audit and pro-active quality improvement activities. Sessions were held with the doctors in the hospital. Several recommendations resulted . A few are listed here: To have referral criteria guidelines To establish hand over sessions with the change of staff To have regular multidisciplinary academic meetings on clinical care and policy issues. To improve communication between clinics and the hospital To include doctors representative in the hospital management team Have doctors participating in morbi-mortality analysis. Clinical Risk and Adverse Event Management The hospital has a limited system in place but it is designed solely to deal with adverse events/accidents after they occur and does not attempt to prevent them or avoid reoccurrence. The hospital has no health and safety functionary at present and no health and safety representatives. This places it in a vulnerable legal position should any accidents occur to staff, patients or visitors. Management is aware that this is an area that requires urgent attention. Clinical Audit Although a strategy for clinical audit is lacking, several areas of the hospital demonstrate good practice in terms of recording clinical outcomes and using analysis of these, sometimes together with case studies, to improve clinical practice. This is particularly evident in Maternity, with regard to perinatal mortality, and within the TB Unit. Both these areas have received a particular impetus, additional training and external support (Maternity through the DEPAM course and TB through ISDS) which has facilitated and motivated these practices. Such training and support has thus clearly demonstrated to be valuable and effective. Several sources around the hospital and within the district expressed concern about prescribing practice within Gordonia. It was decided to ask for outside analysis of the problem on the basis of a random sample of ten TTO prescriptions taken from across the hospital on one day. The findings are summarised in appendix 4. Infection Control This is an area of particular concern. There is no policy document on infection control and no one person or team takes responsibility for it. Issues that are highlighted in this report such as
2
C Baez, ISDS. Report of visit 23/11/99.
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the refuse from the wards, the incinerator, policy on needle prick injuries and the handling of human tissue are all aspects that should be covered in such a policy. Complaints and client satisfaction The hospital has not yet developed a procedure nor a policy or any information telling patients how to complain or who to complain to. When complaints are however made, they are dealt with by management. The hospital has recently measured the level of satisfaction that patients have. The result is an average score of 49% measuring aspects such as: Tangibles (equipment and physical surroundings) Reliability (Waiting times, staff explaining diagnosis) Responsiveness (willingness to assist clients) Assurance (ability to inspire confidence and trust) Empathy (Ability to care and display compassion towards clients) Access (time and cost to access hospital) General satisfaction (general feeling about hospital) The fact that the hospital is very far from many communities negatively influenced the score. This criterion could not easily be changed by the hospital. Not considering the access criterion, the score would have been 58%.
3
8.
Drug Management System
As Gordonia hospital supplies drugs to most of the district, proper record keeping and stock level management are important. Due to the temporary nature of the position of the pharmacy during renovations, these actions have not been taken during the time of the survey. (See the section on pharmacy for more detail.)
9.
Transport Management
Transport management is a major issue that contributes to many of the hospitals problems. This is to be expected considering the vastness of the district that is almost as large as the Kwazulu-Natal Province. The location of Gordonia Hospital, 4km outside the towns centre, adds to the problem, as there is no public transport between the town centre and the hospital. As a result most patients walk the 4km, however ill they are. The main problem concerns patients who live outside Upington itself, either in other towns such as Kakamas or Pofadder, or in one of the many farms around the district. The hospital has one light delivery van. Patient transport Elective transport from the outlying areas to Gordonia has been available for the outpatient clinics that are offered on Wednesdays so patients can be guaranteed of being seen and transported home on that day. This situation has resulted in a marked reduction in unnecessary admissions. Gordonia thus at any one time still accommodates patients who do not actually require hospital care at all. These patients occupy beds and represent a cost to the hospital in terms of food and laundry. These patients are often not attended to, thereby increasing the medico-legal risk of the hospital. Ambulance services have only recently been taken over by the province increasing their ability to align it according to service needs. These services are managed from the district office.
3
M Smith, October 1999. Report: Developing a tool to measure client satisfaction in South Africa.
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Staff Transport The second issue around transport concerns staffing issues. Although the transport of staff to and from work is not the responsibility of the hospital, the difficulty that staff experience getting to and from work, negatively affects the service and staff availability. Staffing rosters are consequently designed according to staff availability. However difficult, the hospital needs to be run around the patients needs, not the staffs needs. Management cannot ignore this situation and some resolution should be sought.
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Section 3: Patient Care

The wards were initially given a set of questions to answer. The questions covered core quantitative issues: facilities, staffing, bed occupancy and activity rates, most commonly treated conditions and data collection. There were also more qualitative questions attempting to elicit some sense of the nursing staffs perspective of their current situation. In particular nursing staff were asked to identify what they saw as the strengths and weaknesses of the services which they provided. These were followed up with personal visits to the hospital. Further analysis of the case mix, ward specific occupancy, rates for morbidity and mortality and hospitalism (infections obtained in hospital) was not possible due to the unavailability of such data. This would have enriched the situation analysis. The wards at Gordonia are shown in the table below: Table 6: Wards in Gordonia Hospital. Unit Female Ward Male Ward Maternity Ward Neonatal beds Childrens Ward High Care / ICU TB Unit Casualty / OPD TOTAL Notes to table 6: The neonatal beds are not included in the official number of beds used to calculate bed occupancy or in planning. This could skew the picture and lead to insufficient data for planning. As the hospital also act as a referral hospital with a mix of level one and level two services, it was not possible to analyse the number of beds for the population served. The hospital should attempt to identify the number of level one and level 2 beds to assist them in their planning. Approved beds 40 40 13 50 2 38 6 189 Actual beds 40 40 13 19 50 2 38 6 208
General impressions The wards all appeared clean and tidy with a general air of orderliness and calm. Although some unit managers complained of shortages of linen this was not apparent when visiting the wards. Patient records are kept neatly in ring files which keeps them tidy. Visiting outside official visiting hours is enforced except in special cases. Management Although the professional nurse (PN) of each ward or unit has been designated as the unit manager, there does not appear to be a very clear understanding of what this role should and does entail. Most unit managers expressed pride and satisfaction in the work which they do, but felt that, although they accepted responsibility for day-to-day management of the ward, they did not have time to take on additional roles or tasks. The doctors expect the PN to accompany them on ward rounds and the sisters are expected to take bloods and put up drips. The sisters were extremely busy and it is difficult to imagine that a PN in the childrens ward can provide clinical care to 50 children and be actively
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involved in hospital and ward management. But this situation is at least due in part to the fact that many nurses were not on duty due to suspension (in one case), attendance at training courses and sick leave. All of the unit managers had been encouraged to enroll for the Management Training Scheme that is presently providing district level staff with management skills. Although a number of the unit managers had begun the course most had dropped out. The course takes them away from work once per month for three days. Data collection The following statistics are collected routinely by all wards: Anonymous AIDS notification Data regarding patients who are non-South Africans The weekly and monthly report
The weekly report contains information regarding midnight counts, admissions, discharges and deaths. It is used by the administrative staff to calculate the information necessary to complete the Business Status Report which the hospital must send to the Provincial Department each month. The monthly report contains a summary of each week. It contains the following data items: Number of patients Patient days Occupancy rate Consumable costs Pharmaceutical costs Cost per patient (not including staffing and overhead costs) In the past the number of staff shifts were also calculated as well as the staff : patient ratio. This has since been dropped as it was inaccurate and was not used by anyone in the wards or in management. There are still a number of problems with this method of reporting. Firstly the wards themselves do not use the information in any meaningful way. The bed-occupancy rate for instance is expressed as a fraction and not a percentage. In fact, as the admin staff use the daily counts to calculate bed occupancy rates it is unclear whether the information is used by anyone.
1. Casualty and Outpatients(OPD)

The Casualty and OPD departments are run as one unit. The Casualty is open 24 hours a day. It aims to provide a comprehensive emergency service and patients are referred from clinics and outlying hospitals to the department. Self-referred patients also present at Casualty during and after hours. There is a casualty theatre where minor procedures such as incision and drainage of abscesses, dental slates and insertions of underwater drains are performed. The OPD service is a relatively new one that has only been operating since the arrival of the Cuban doctors at the hospital. Specialised OPD clinics are held each weekday beginning at 9 a.m. The clinics are said to finish at about 2.30 or 3 p.m. It should be noted that there is no general OPD all such patients should be seen at the PHC clinics outside the hospital. Only referred patients are seen at the OPD clinics and approximately 20 patients are booked per clinic. The patients are mostly referred by doctors many visits are follow-up visits for patients who have been admitted to the hospital. Doctors who visit the local Upington clinics refer the other patients. One doctor is assigned to Casualty from 07:00 hours to 14:00 hours.
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Medical cover outside these hours is provided by the doctor-on-call. The OPD clinics are run by the doctors based in the relevant department both Cuban and community doctors. Because the majority of patients are Afrikaans speaking, nurses spend considerable time translating for the Cuban doctors. This is unproductive use of nursing time. Workload The figures for Casualty and OPD are shown below. It should be noted that the figures are collated for the two services and then broken down into In hours (which refers to weekdays) and After hours (which refers to night-time and for Saturdays and Sundays). The statistics therefore do not accurately reflect the workload distribution - this will need to be addressed in the future. TABLE 7: Workload casualty and outpatient department In hours visits 1906/ month After hours visits 317/ month
Average
During the 1998/1999 financial year there was an average of 1906 in hours visits per month. Although figures were not collected, it appears from the register that Casualty is fairly quiet during the week (often five or fewer patients are seen overnight). Strengths The staff feels that they work well as a team this includes both the nursing staff and the doctors. Staff are looking forward to moving into a newly renovated space Good communication with outlying hospitals the system of these hospitals having a dedicated OPD day is said to work well.
Problems Staff report that many patients bypass PHC facilities and come straight to the hospital particularly after hours. A brief review of the casualty register did not substantiate this view it appeared that few patients are seen after hours during the week. Other patients are said to attend OPD for daily dressings which hospital staff feel could be done at the clinics. This should be investigated, as the hospital is difficult and costly to access from most parts of Upington. Equipment such as a viewing box, a suction machine and ENT sets are required.
2.
Female Ward
Workload/utilisation As in most wards, information regarding bed occupancy rates was not readily available. A typical midnight count (headcount of inpatients at midnight) for a week in October 1998 was as follows: Sunday 32 Strengths Medical and nursing care is good considering the workload. Staff are doing their best to provide a good service. Monday 34 Tuesday 39 Wednesday 38 Thursday 36 Friday 23
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Problems Patients often stay in the ward for longer than is necessary this is usually due to shortage of transport to take the patients back to peripheral hospitals. In addition, some admissions, particularly over the weekend appear unnecessary. Number of patients with HIV/AIDS has increased dramatically. Patients who require basic care and who are not catered for in the PHC services. Male Ward
3.
Although there are officially 40 beds, additional beds have been placed in all the wards. This often results in cramped conditions for patients and staff alike. Workload Review of a weeks midnight head counts in October 1998 revealed the following figures: Sunday 32 Strengths Staff find it rewarding to see patients getting better The ward is always very clean this is due to the dedication of the Cleaners Monday 34 Tuesday 35 Wednesday 36 Thursday 36 Friday 36 Saturday 36
Problems Less than optimal standard of care due to lack of adequate time to spend with each patient for instance nurses do not have time to spend with patients who are dying. Nurses are often called upon to provide cover in other wards. Childrens Ward
4.
Although the official allocated beds are 50, some beds were lined in the passage during the investigation. The ward is sub-divided as follows: Large ward for children 4 12 years (for all conditions) TB ward Malnutrition ward Gastro ward Pneumonia ward Premature room Isolation room Workload and disease profile The following figures are available for the period September 1998 to March 1999. Condition No of children Diarrhoeal disease 469 Acute respiratory infections 186 Severe malnutrition* 36* Total 1236 * this covers the period April 1998 to March 1999 % of total 38% 15 % 100 %
The most common conditions treated in the ward are diarrhoeal disease (38%), pneumonia (15%) and malnutrition. Staff report however that the number of children with severe malnutrition has d ecreased and that fewer children are readmitted with severe malnutrition.
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This is thought to have resulted from the staffs decision to educate mothers proactively about good nutrition. Links with clinic-based nutrition programmes have also been strengthened. Burns are a common cause for admission particularly in winter. These are mainly due to paraffin lamps/stoves and candles, which are used to provide light in some of the poorer homes, where electricity is not available. The number of children with HIV-related illnesses is also gradually increasing and the nursing staff are very aware that this number will continue to increase. It was noted that there is a small increase in patients year on year. The highest activity levels (between 101 and 161%) appeared between March and May (due to gastro cases). Discharge arrangements and links with primary health care Although there are no formal links with the PHC services, the staff interacts with the clinic sisters about individual patients. Most children are referred to the PHC clinics or to the OPD Paediatrics Clinic on discharge. Children with diarrhoea return for a check up one week after discharge or within 3 days if they are under three months of age. Weaknesses The childrens ward has an acute over-occupancy problem. This is caused partly by the nature of the conditions involved (malnutrition, burns, TB) and also by the lack of a system to ensure timely discharges. The ward also suffers from a lack of equipment: there are no wall-attached oxygen machines, only canisters kept some distance away in the wards store cupboard. 3 of the 5 ward IVACS have broken during the time of the visit and have been sitting for many months in Kimberley waiting for repair. Finally, the staff is aware that their patients suffer from being kept for much of the day in their beds and cots, physically unexercised and mentally un-stimulated.
5.
Maternity Ward
The 13-bed maternity unit is responsible for all referred ante-natal, intra-partum and postnatal care of mothers and infants. This includes outpatient antenatal care (ANC) for high risk patients and other ANC patients referred to them. The gynaecologist and one of the advanced midwives usually run these. The unit is also responsible for terminations of pregnancy. Workload and performance Staff complain that the maternity ward is too small. In particular having only two delivery beds is a major problem. Mothers are kept for one night after delivery and for an average of three nights following delivery by caesarian section. The ward regularly reports a bed-occupancy rate in excess of 100%. The significance of these figures is however difficult to interpret mainly because neonates are counted as patients but the cots and incubators are not included in the number of beds. A previous consultant recommended this approach to the Northern Cape. This renders the statistics useless! Ante-natal care has been identified an important area of intervention for the whole district. The maternal service statistics for the 1998/1999 financial year supports this and are shown in Table 8.
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Table 8: Maternity Service Statistics (1998/1999 financial year) Total deliveries Average no of deliveries per month Maternal deaths Teenage pregnancy rate Caesarean section rate public patients Caesarean section rate private patients Stillbirth rate (Rate of stillborn babies per 1000 live births) Peri-natal mortality rate (Death of foetuses >28 weeks and within 7 days after birth) Low Birth Weight rate (Birth weight <2,5 kg) 1596 133 0 21 % 9% 53 % 38 per 1 000 60 per 1 000 22 %
It is encouraging to note that no maternal deaths were reported over the twelve-month period. However, the peri-natal mortality rate is extremely high. Stillbirths are particularly high and account for almost two-thirds of the peri-natal deaths. The Low Birth Weight and teenage pregnancy rates are high, but are approximately the same as those found throughout most of South Africa. The high caesarian section rate for private patients presents a challenge in private health care rendered in a public facility. Links with PHC Most ANC is provided by PHC clinics. Women with high-risk pregnancies are referred to the hospital ANC clinic. The advanced midwives are now holding regular peri-natal meetings with staff from the hospital and the local clinics. Weaknesses Staff feel that they are unable to monitor patients (particularly those in labour) adequately due to the high patient: staff ratio. Basic equipment is lacking the only fetal monitor was sent to Kimberley for repair in 1998 and has not been returned at the time of the study. There is no information about the numbers of referrals from each clinic or community hospital and the condition of the patient. This could be valuable to them as they could then liaise with clinics that repeatedly refer unnecessarily. Staff report anecdotally an increase in referrals but cannot explain exactly where from or why. They think that there are about 15 referrals a month of complicated deliveries from the community hospitals. However this does not appear to be a ward in which unnecessary information collection is a major problem. Infection control is a problem as the nursery is not isolated and staff cross from neonatal area to delivering mothers. The nursery is very small. The ward staff are aware that they are treating a catchment population of the hospital with an increasingly high HIV rate. In only very rare cases do they know that a woman is HIV positive when she is admitted.
6.
High Care Unit
Facilities The High Care Unit has two beds and is only opened when necessary. In general only adults are admitted children may be admitted for short periods of time but are usually transferred to Kimberley. The hospital has no facilities for ventilating newborn babies. Workload The majority of patients are admitted after trauma (head injuries, MVAs) or for post-operative care.
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Table 9: Admissions to High Care Unit during four of the first five months of 1999 Number of patients 8 14 5 4 Number ventilated 3 6 2 3 Bed occupancy 27,5 % 26,2 % 31,6 % 35,4 %
January February April May
Problems Lack of equipment the major problem is the lack of walled oxygen. As a result nurses have to wheel huge canisters of oxygen around the unit. Lack of training.
7.
Theatres
The theatre complex has two fully equipped operating theatres and a recovery room. The theatre also operates its own sterilisation section. The two theatres operate weekdays until 15:00 hours. After this they are opened only for emergencies. Workload Table 10: Theatre utilisation figures for the 1998/1999 financial year Public patients In Hours Emergencies 1297 280 1033 hours 308 hours Private patients In Hours Emergencies 46 5
Theatre cases Operating hours
Note: The hospital does not routinely collect data on the type of anaesthesia to allow an indication of the % of theatre cases done with general anaesthesia and those with local anaesthesia. This information would provide more background to comment of efficient utilisation of the theatre. Strengths Medical and nursing staff work well together. The Team is working hard to maintain standards despite problems.
Problems Autoclave machine is very old and not able to keep up with the demands placed on it. Although there are meant to be three professional nurses on duty, most of the time there are only two who are therefore both required in theatre. The unit manager has little time for administration and ordering, a very time-consuming task. No septic theatre therefore the theatre has to be cleaned after it has been used for dirty cases. Lack of equipment Limited time for training of staff.
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8.
TB Unit
The unit is housed in a separate two-storey building that has recently been renovated. It has 38 beds. Links with PHC The TB Unit forms an integral part of the districts TB control programme. Until 1997, all adult patients diagnosed as having TB were transferred from the wards to the unit and many were admitted for part or the whole of their treatment period. As part of the Regional TB control programme efforts were made to reduce the number of admissions. Strict admission criteria were applied and patients who did not require admission to the Unit were referred directly from the wards to the PHC services. As a result, the number of patients dropped dramatically. Furthermore there was spare capacity which allowed patients from other parts of the district who required admission to be admitted. During 1998, a decision was taken that multi-drug resistant (MDR) patients would no longer be transferred to Kimberley Hospital but would be admitted to Gordonia. Efforts would also be made to hospitalise all such patients in the initial phase of their treatment.
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Section 4: Clinical support services

The clinical support services are: Therapeutic services: Physiotherapy (PT), occupational therapy (OT) and dietetic services. Laboratory services. Pharmaceutical services. Radiography services. Both PT and OT provide services to the whole district with the physiotherapist on the staff establishment of the hospital and the occupational therapist on the establishment of the district office. Dietetic services are rendered by a part-time dietitician whilst radiography services are done by three radiographers. There is no radiologist. The laboratory service is provided by the South African Institure for Medical Research (SAIMR), a well established parastatal with a network of laboratories throughout the country.
1.
Physiotherapy (PT)
The PT services have been running since January 1996 on a full time basis and since April 1999 covers the whole regional, including facilities in Upington, Kakamas, Keimoes, Groblershoop and recently Springbok. The departments mission statement is: To equip people with disabilities with tools to achieve and maintain maximum functioning or independence and integration in order to fulfill their roles in the community. Service activities are recorded monthly and data for Gordonia hospital during the period April 1998 to March 1999 (previous financial year) are presented below: Total clients seen: 2218 with 66,8% as inpatients. 26% of the total patient load was new cases. 27,7% of these patients were for orthopaedics, 21,8% for burns and 18,3% medical. Problems The facility is very small and, as family members usually accompany patients, it is really unsatisfactory. Confidentiality is a problem. Staffing is extremely thin and with the vast area to be covered, a lot of time is spent on driving. In any given week, the physiotheropist spends about 3 days in the hospital. There is not yet a profile available listing people with disabilities in the region. Availability of assistive devices. Patients often need assistive devices at short notice either because they are new patients or when their devices are in for repair. There are no spares available. Repairs of wheelchairs: because there is a wide range of wheelchairs in the region, the workshop cannot keep a range of spares and repairs take very long. A policy of purchasing one type of wheelchair is in place, but there are still old types in circulation and often patients are discharged from other hospitals with a different of wheelchair.
2.
Occupational Therapy (OT)
OT services are rendered on a full time basis since June 1999. Prior to this the service was rendered from Kimberley every two months. Referrals to date have been mainly from the physiotherapist.
3.
Dietetic Services (DS)
There is a part-time dietitician. Her tasks include supervision and support of the catering services rendered by the kitchen. Her role is thus two-fold:
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Catering Responsible for the planning and ordering and for controlling the budget. Presently she keeps regular statistics and does other administrative tasks which will soon be delegated. She uses the routine statistics to plan and to monitor catering trends. (See Catering services for more detail on quality management and record keeping). Nutrition therapy She responds to referrals from doctors and participates in establishing a baby-friendly hospital, something that takes up most of her time. She gets betweem 2 and 5 referrals per week and intends to have rounds with each doctor at least once during the year to sensitise them to dietetic services and to enhance communication. She links to the community nutrition services and works very closely with the nutritionist in the community. The community team also include nutrition advisors that do follow-ups and do nutrition promotion. Nutrition clinics serving mostly diabetics and discharged malnourished patients are run.
4.
Radiography Services
The three radiographers are responsible for taking X-rays and keeping routine statistics. The darkroom assistant is responsible for the development of X-rays, keeping the section clean, and to render general support. Gordonia hospital has two Fischer machines. The older of the two is not in use as the head cannot rotate and the bed cannot slide, decreasing its ability to maneauvre for good X-raying. The equipment is serviced once per year at a cost of R17 000. The investigations most frequently done are orthopaedic and chest x-rays. They do not perform any barium or tomography investigations, nor transilluminations and swallows. Due to financial constraints the chest X-rays have been limited to an postero-antero view, unless the radiographer notes an abnormality. The registers show an average of 30-40 patients per day. The number of X-rays taken remained relatively constant on a month to month basis. Chest X-rays form about 60 % of all X-rays taken. Registers are kept for private and hospital patients, for out-patients, ward and for after-hours X-rays (after16:00in weekdays and over weekends). Table 11: Radiography activities for the 98/99 financial year. Average number of X-rays per month: referred from outpatients Average number of X-rays per month: refer from wards (inpatients) Average number of X-rays per month: Total (inpatients plus outpatients) Total number of X-rays for the year 607 266 873 10 489
Quality control measures have been implemented to ensure quality and effectiveness: Correct names: The radiographer is consciously checking that the number of plates for the investigation and the name of the patient are correct. Correct positioning: The radiographer checks for the right and left indicators on the films. Radiation control. The radiographers have registration with the Health Professionals Council of South Africa and the equipment is registered with the radiation council. Each radiographer has their own individual radiation dosage meter that is returned to the Radiation Council centre once per month. Chemicals and unused films are stored away from the radiation. Problems The facility is inadequate as it has no room for administration or tea and they have to wash the rollers in the wards as there is no place in the X-ray unit.
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The equipment for development and the drier are both old and breakdowns often occur.
5.
Laboratory Services (LS)
This SAIMR-run laboratory is part of the hospital, and is headed by a senior technologist. There is a person on call 24 hours per day. Range of services The laboratory at Gordonia Hospital provides services to the total district including all public hospitals and clinics and to the private sector (hospital and surgeries). They do an average of 34 000 units per month which includes haematological, biochemical and microbiological tests.Histological and hormonal studies are sent to Bloemfontein by overnight courier. The tests that are done most frequently are sputum microscopy for tuberculosis and a rapid syphilis test on samples from the clinics. Cost is calculated according to a tariff scale per unit with different scales for public and private patients. The unit price for the public sector (provincial and Local Authority facilities) is R1.99 per unit. Table 12: Laboratory services and costs for the financial year 1998/99: Average number of tests done per month Total tests done for the year Average cost per month Total cost for the year Note to table 12: The monthly data are not shown here, but when it was analysed it showed the number of tests increased from 2176 (value of R39 965) in April 1998 to 3644 (value of R68 041) in March 1999. This represents a 70% increase. The month to month detailed statistics were not evaluated to find out what are the exact tests that have increased and comparing the cost of certain tests. The rapid HIV test is for example twice as expensive as the Elisa test and not all healthworkers are often familiar with this fact. 2 587 31 052 R46 199.75 R554 396.94
Quality management Both internal and external quality management are done. Internal: The laboratory runs their own systems of controls for each investigation - one normal, one abnormal high or abnormal low. This is to ensure standardisation of results. This is done four to five times per day. External: SAIMR runs a quality management system whereby the laboratory is reviewed on a weekly and monthly basis.
Specific control measures Equipment: There are service contracts with 6-monthly servicing. A biohazard hood is used to ensure an enclosed environment with special filters to exclude airborne distribution during tests e.g. for TB. Patients names correct Each specimen gets a laboratory number with computerised patient stickers on each report and specimen.
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Chemicals availability The SAIMR mostly uses test kits from their own supply and have never experienced any shortages. The hospital supplies their own syringes and tubes. If the hospital runs out of stock, the laboratory assist them. Turn-around time Results are available on the day of receipt by the laboratory. All facilities have fax machines. This commitment is crucial to the success of the TB control programme.
The only problem experienced by the laboratory service is that laboratory results often have to be re-printed as the reports have been lost after leaving the laboratory.
6.
Pharmaceutical services
The pharmacy has one pharmacist who is also the district pharmacist who has to provide support to the clinics and nearby hospitals. Drugs are received monthly from Cape Town in trucks. Drugs that are urgently required outside this arrangement are obtained by ambulance from Kimberley. Budget Table 13 shows the budget performance for pharmacy stock. It is not clear where the expenditure for vaccines is recorded. To date the pharmacist has not played a role in budgetting but will in the future. Table 13: The budget allocation and expenditure for drugs: Allocation 98/99 R403 000 R126 000 R 20 000 R 2 000 Expenditure R762 673 R304 064 R 9 693 -R 51 % Expenditure 164.7 (+ 64,7%) 241.3 (+141,3%) 48.5 (-51,5%) 0
Pharmaceuticals IV Fluids Surgical antisepticals Vaccines Stock control
There is presently only limited stock control due to the cramped space. Basic stock recordkeeping is done. Rational use of drugs The pharmacist realised that nearly each treatment prescription has an antibiotic. Pain tablets are also very generally prescribed. Presently doctors use retail names and not generic names. The average number of items per script is 2,4 but the latest figures suggest an increase. There is a Therapeutic Committee (TC) that meets four times per year to look at standardising drugs and to develop policy on the use of certain drugs such as acyclovir and other medications. Prescribing patterns are not yet monitored, but it is foreseen that this will happen soon. Members of the TC plan to determine the various indicators for efficient drug management and drug prescribing. The Hospital EDL has been in place since March, and compliance is still not optimal. Record keeping Registers are kept for orders placed by the wards and those placed and received from the depot. Data provided as part of the accounts rendered to the hospital prove to be very useful for management purposes.
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An analysis was done of the use of drugs per category for the 1998/99 financial year. The data is not available on the printouts and had to be calculated manually. Table 14: Expenditure per drug category for 1998/9 (Total expenditure was R762 673): Category Catalogue 30 Catalogue 31 Catalogue 32 Catalogue 33 Catalogue 34 Catalogue 35 Catalogue 36 Catalogue 37 Catalogue 38 Catalogue 39 TOTAL Description Powders Schedule 6 and 7 drugs Injections Prepacks Test strips Ointments Suppositories Tablets Liquids and inhalers Schedule 5 drugs Average cost per month (R) 243 645 30 161 572 282 4 449 1 525 18 749 6 673 256 R63 556 % Share 0,4% 1,0% 47,3% 0,9% 0,5% 7,0% 2,4% 29,5% 10,5% 0,4% 100%
Notes to table 14: Nearly 50% of the drug expenditure is for injectables. The expenditure data includes the cost of the drugs plus an 8% levy for transport.
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Section 5: Administrative and non-clinical Support Services

1. Introduction
The Hospital Secretary (assistant director adminstration) post is vacant and the Administartive Support Section section has been headed by the senior administration officer (SAO) since March 1999. This vacancy is critical as certain delegations for administration are at the assistant directors level (such as the approval of leave, authorisation of the driver to go beyond Kakamas (80km) and for acquisitions more than R5 000). The SAO supervises and co-ordinates all the sections shown below: Personnel administration Financial administration Medical records including reception and admissions Laundry Catering / Kitchen Stores / warehouse Maintenance (workshop, grounds, mortuary, incinerator services, steam services) Porters service Nurses home and creche Although much routine data is collected by the various units in the section, only some units use these for service planning and service management. The kitchen uses the data to plan meals and look at costs. Excessive laboratory service costs are often discussed at clinical service meetings. On the other hand, the complex calculations done monthly to determine electricity and steam costs for the laundry are not used in planning or management (it is done in order to obtain refunds from other hospitals). Some offices have burglar proofing, but potential access to patient files is a major problem. The reception/admission section is temporarily housed and files are kept in the admissions office and in a container ouside the hospital building which lacks access control during official hours. The Role of the Administrative Support Section in the Hospital The role of the administrative section is to support efficient and effective health care and to enhance the image of the hospital. Important tasks include the availablility of functional equipment, correct and complete patient information and patient accounts, cleanliness of the hospital and the grounds, efficient use of resources such as at the laundry and the kitchen, and support to other facilities in the region (as demonstrated by the role of the stores). ASS primarily supports the nursing and medical staff and the hospital management team.
2.
Registry and general office services
The registry function is part of the responsibility of the secretary to the superintendent. There is a postal procedure that is followed for the collecting and opening of post and completing the necessary registers such as a remittance register for moneys received by post. The remittance register is locked away and weekly and monthly control checks are done. Post is collected on a daily basis with the key to the post bag locked away when not in use. There is a register for all faxes sent and photocopies made. The hospital filing system complies with the standardisation laid down for the Northern Cape.
3.
Personnel administration
This department will split in the near future to have a human resources department (HRD) and a personnel administration section. The need for the HRD was identified in 1997 and will focus on relationships between the employer and employees and their interests. Human resources development will not be co-ordinated by this section, but by the CPN for training.
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The personnel administration section provides support to all other facilities in the district this includes emergency services, all clinics, community health centres and all hospitals in the district except for Kakamas hospital who has the capacity to perform this function. Job descriptions are not yet available for all staff. The personnel administration section regard their key success areas as follows: Quick and complete handling of all personnel enquiries. Ensuring that important personnel administration tasks such as personnel evaluation and job descriptions are done. Observing need for confidentiality. Salary verification. Correct and up to date personnel information such as leave records, membership of personnel associations and medical aid. Immediate processing of resignations and new appointments. Rapid handling of salary advices. This is of particular importance to the Cuban doctors who have to submit these to their Embassy before the end of a month. Monitoring personnel indicators such as absenteeism.
4.
Financial Administration and Fees
This section is headed by a supervisor (a senior administrative officer) supported by two administration clerks responsible for the administration and payments of firms providing services to the hospital. Their role in financial management has not been clear up to now. Batch control is a key performance measure in the FMS system and a fundamental compliance criterium in the Treasury Instructions. Batches are presently typed by the regional data typist. Apart from delays in the data typing of the batches, numerous errors frequently occur resulting in incorrect payments, firms not being paid or firms receiving double payments. Correcting these errors is extremely time-consuming. Staff have to draw the journals, recall the cheques, write a letter of explanation and submit it to the Provincial Department of Finance for journalisation of the payments. It is clear that the unit could enter their own batch information. They have done this up to 1995 and see their way open to do it again. There is no policy for a commitment register system and expenditure information is mostly outdated, negatively influencing the ability of the hospital management to manage its finances efficiently. They have implemented a daily payment list for authorisation of payments to firms as an emergency measure until financial information appears in the system. (The budget information was not yet available on the system by June.) The name of the firm and the amount is sent to Kimberley for approval prior to payment. The finance section receives information from the laundry and the stores section to render payments and to ensure that other facilities in the district are journalised for expenses incurred providing them with linen and stores. Accounts Section (AS) The three administrative clerks in this section receive payments, handle patient accounts and collate routine hospital statistics in the business status report that are forwarded to the regional office and the provincial informatics section. Payments are also received after hours at service points. Accounts are managed using admission data and the TR70 system (which is perceived to be outdated). When the patient is discharged, the ward nurse signs the patient off and the TR70 page goes to the accounts section. The data is checked and is then sent via the network to Cape Town where accounts are raised. The lists of accounts raised are forwarded to the hospital and they start with the monitoring of payments. It usually takes between 20 and 80 days before the hospital has the printouts of the accounts.
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If a patient would like to pay immediately following hospitalisation, it is possible to calculate the accounts for public patients. For private patients, however, the accounts are more detailed and, as medical aids do not accept handwritten accounts, it is not possible to have these accounts immediately available for payment. Revenue reflects as income on the financial management system (FMS). During the study it was not possible to determine hospital fees collection rate due to the way in which the data is recorded. Table 15: Revenue collected for the 1998/99 Financial year: Mechanised account system Hospital fees H1 in-patients Hospital fees private in-patients Hospital fees out-patients TOTAL R 243 812 R 16 443 R 5 910 R 132 802 R 398 967
Data on accounts rendered was not complete and could not be used to determine the revenue collection rate. This should be a key task for the management. Key performance areas of the section are: Correct accounts rendered timeously Friendly services when payments are done or arrangements for payments are considered Improving on the revenue collection rate Timeous and correct monthly business status reports The problems that the accounts unit presently encounter are: accounts are often delivered late printed accounts cannot be provided when someone wants to pay immediately after hospitalisation having no computer to handle patient statistics or account data accounts often have double entries and this leads to a bad image of the unit and of efficiency of the hospital; and files and receipt books must be scanned manually to see which payments have been made and which are still due. The revenue generated by the hospital is a crucial efficiency performance indicator and management should address the problems as soon as possible (see recommendations section)
5.
Medical Records and Admissions (MRA)
The staff in this section open new or retrieve the medical records of patients who attend outpatients or who are admitted, collect money from out-patients and file investigation results. They estimate that each clerk can manage the medical records of about 80 patients per day. When patients are discharged the staff in the medical records section has to collect the file and see to it that the TR70 forms that are used to raise accounts are delivered to the fees section. During after hours shifts the staff are also responsible for the switchboard. The MRA sees their role as: portraying an image of efficiency and friendliness at the entry point to the hospital playing a key role in ensuring that correct medical file information accompanies each patient and that it is kept confidential. ensuring that correct tariffs are charged to patients.
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The medical record filing system When a patient file is opened the basic information of the patient (name, address, hospital file number and date) is entered in the register. The patient is provided with a hospital folder number and a card is handed to the patient to keep for future visits. For each admission a different in-patient number is also provided. Patients often lose the file number and then a card system is in place to find the number based on the estimated date of the last visit. When a patient visit the hospital after hours, the nurse on duty opens a patient record for each patient. The same admission procedures are not followed and fees are not collected. It is not known what the number of files presently open is, as inactive files are closed every five years, while the numbering continues. It is estimated that approximately 500 new files are opened each week. There is presently a moratorium on the destroying of files and all files are stored. The files have recently been moved into new storage space and it is hoped that this will facilitate a more efficient and secure system. Hospital fees paid are checked against the invoice book. The supervisor signs the invoice book. During off-duty times, the cash-book is locked away in the canister. The provincial hospital fees structure is adhered to. Bypass fees have not been implemented, but the clerks always refer patients to casualty if they do not come with referral letters. Until 1994, the hospital had two separate filing systems for medical records desegregation meant that many files were lost in the process of creating one system. Further problems include: There is little uniformity across records admission and progress notes vary from one ward to another. In general the standard of record keeping is poor many folders do not contain a diagnosis. Records are stored by number only and not by name and so cannot be easily found if a patient presents without his or her number. The admissions department is closed after 22.00 hours patients seen after this time are issued with a temporary folder. Some services, such as oncology, maintain entirely separate records. File retrieval is difficult as files are often not returned from the wards or the out-patient clinics. Patients often lose the card with their file number and retrieval is then based on unreliable information. As medical records does not function on Sundays, there are usually several files that must be filed on Monday mornings, contributing to a heavy workload on Monday mornings. Staff regard the following indicators as important for a well-functioning medical records section. An effective filing system with sufficient shelves. No filing back-log Admissions clerk able to trace files, even if it is in use elsewhere. An up to date and accurate outpatient register Clean section Short waiting times (the present waiting time has not been calculated). File retrieval rate- to be within 5 minutes. Friendly service Confidentiality Good working relations with the rest of the hospital staff.
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Although patient waiting times may be long, it takes them on average 14 minutes to retrieve 4 or open a new file. This, however refers only to the files that could be found. In a survey done it was found that 50% of files were not found during the survey exercise. Despite the problems, the staff handle the patients in a professional manner. They acknowledge that they often get tired and due to frustration are not as friendly to patients as they should or would like to be. Following an intervention of enhancing the efficiency of the system, the overall success rate in file finding improved to 80 % with the index card method and the time it takes to find a file with the index card system reduced to 2 minutes. A projected 98% success rate is possible.
6.
Catering
The catering services are supervised by the dietician and the kitchen manager, a food service supervisor. The balance of staff comprises seven food service assistants who work in shifts. They prepare 500 to 550 meals per day. The catering service aims to provide well-balanced, high quality and cost-efficient meals to hospital patients. The team regard efficient planning, preparing and dishing up the correct number of meals, acquiring the correct quantities of foodstuffs and monitoring the quality and the cost as key to efficient catering. The wards use the midnight count to request the diet list for breakfast. Standardised recipes are used and the menus rotate every 2 weeks. This will now change to an 8 day cycle (benefits unknown). The standardised recipes provide information to calculate the exact number of slices of bread, margarine, weight of meat and other foodstuffs to be prepared per patient. The preparation is in line with these recipes. Quality management The dietitian monitors the cost of meals per patient per day. The supervisor and the dietician have not yet been involved in financial planning and financial management. The dietitian is not clear how the budget for the financial year was derived. The dietitian often goes to the wards to assess patients satisfaction. Nursing staff also provides feedback to kitchen staff about the meals. Maintenance of equipment: As most of the equipment is old, frequent repairs are required. Weighing scales are gauged every 18 months. Hygiene control: The kitchen is divided into areas and allocated to a few kitchen aides responsible for a specific area. There is also a fumigation program for cockroaches. Floors are cleaned with biocide. Occupational health: Staff who are ill or who have open sores on their hands are utilised in the washing section or other sections where they do not handle food. The staff generally wear gloves when they handle food. They are entitled to influenza and Hepatitis B vaccinations. Stock control: stock counts are done weekly for foodstuffs and monthly for equipment. Any shortages of equipment result in an active search programme. There is, however resistance from the wards when they have to account for shortages.
Record keeping A monthly operational report is prepared for submission to the administrative head. The dietitian noticed an increase in meals since free health services were introduced. There are also more requests for salt restricted diets since 1995.
Albertse K, Hilder A. October 1999. Report: Medical Records System at Gordonia Hospital.
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Cost of meals The cost of a meals per patient per day is used as the cost-efficiency measure. It measures only the foodstuffs and no staff or overhead costs are included. The cost of meals per patient per day increased from R6,77 in April 1998 to R7.66 in April 1999. This represents a 40% increase. A norm was not available against which to compare the cost. Table 16: Meals, cost of meals and productivity for catering services in the 1998/9 financial year. Average cost of meals per patient per day Average number of meals per day R7.54 481
Problems The kitchen is small, with not enough worksurfaces and storage areas including freezer facilities are inadequate. Their performance is influenced by factors such as reliability of suppliers, the warehouse and the diet lists from the wards. The catering team regard the following as criteria for a well-functioning catering service: Meals should be hot, available on time, portions not too little or too big and prepared in a hygienic manner Equipment functional Staff should be sufficient in number, well-trained and motivated Standardised recipes Standardised scales Correct planning and placing of orders Efficienct catering budget management
7.
Laundry
The laundry provides a service to Gordonia hospital, Kakamas hospital and the ambulance service. The facility is fire and burglar protected. They regard good laundry service as : Maintaining good production. A low loss rate. Linen clean, well ironed and repaired. All linen clearly marked. Dirty linen removed from the wards by 8am There is a written linen stock control system and a procedure manual for stock control with counts every 3 months. The first time that laundry stock was recorded was in 1995 when a loss of R40 000 was registered. During the past 3 years that loss increased to R57 800 (R17 800 over a 3 year period-R5 933 per year on average). It is mostly nappies and towels that are missing, presumed stolen. All losses and condemned stock have to be replaced with hospital funds. Register The data from the registers kept in the laundry are summarised on the monthly laundry form and sent to the finance section where it is journalised. It is not used for planning or monitoring.
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Table 17: Laundry statistics for the financial year (1998/99): Average / month 52 899 19 136 kg R1 665 R3.17 Total 634 795 229 634 kg R 19 974
Pieces Weight Cost of laudry consumables Cost per 100 pieces
Notes to table 17: The number of pieces and weight of linen remained relatively constant during the year. The cost information does not include the costs for staff or overheads. The cost for consumables (from R1 188 to R2 619) as well as the cost per 100 pieces (from R2.15 to R4.22) doubled during the year . This is most probably due to the increased cost of consumables, water and electricity. The accounts office has a full set of detailed laundry costs per month. The document has 10 annexures: Salary costs for the month Laundry costs including the cost of steam, water and electricity. Consumables used and cost. Maintenance done and cost. Non-consumables used and cost. Miscellaneus expenditures. Transport used and cost. Condemned linen and cost. Monthly regional laundry return. Calculated cost for each of the other hospitals that receive laundry from Gordonia. This calculation is required to journalise the other hospitals. Problems experienced by the laundry: Infection control: They are supposed to use gloves when the sorting is done, but available gloves are too small. Floors are washed by hand. Equipment is old and is in frequent need of repairs. Parts are not readily available and then the machines are not in use. Both steam irons are broken.
8.
Central sterilisation service department (CSSD)
CSSD is overseen by a housekeeper supervisor. She caters for all needs for sterile instruments and packs apart from the theatre which has its own sterilisation unit. She is the only person responsible for the CSSD and is relieved by the housekeeper from the out-patient section when required. There is a policy outlining the times when the CSSD is open, the use of the packs, control and accountability measures. The stock control system is done by ensuring that all instruments which are signed out are returned. Wards must indicate their needs by 09.00 hours so that she can prepare the packs. She also does regular spot checks on ward stock ensuring that the information is correct. She has stock-taking every 3 months. There is a borrow out book where people have to sign for loose instruments that are collected. The purchasing of new instruments happens once per year. Good records are kept of instruments that are condemned. She is not aware of the budget, but keeps good record of what is lost and what needs replacement.
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Criteria for a well-functioning CSSD The Supervisor considers the following as important performance measures: Good stock control Availability of appropriate packs Packs correctly packed Proof of sterilisation checked (colour of strips) Problems according to the supervisor: Too few instruments Autoclaving equipment is old and according to the maintenance staff should all be replaced. The workshop staff are not allowed to work on the autoclaves as they are not registered as medical technicians. The efficiency is dependent on the availability of clean linen and especially on Mondays and Tuesdays it is a problem.
9.
Stores
The strores section provides support to all hospitals and clinics in the region. Previously it supplied only Gordonia hospital and Kakamas, but now also supplies a number of old age homes and clinics. The person in charge is a provisioning administration clerk Grade II who took over on 31 May 1999. There has, unfortunately, not been any orientation or training in stores management. The rest of the staff is one clerk, one general assistant and one driver. Because of limited space, only two-months supply can be kept at the store. There are five storage sections in the warehouse: Surgical supplies and bandages Cleaning materials Provisions Crockery Stationery Each shelf is marked with the respective catalogue number and description of the items. Total stock issued are recorded on the stock cards, with a stock card for each item. The supplies are then provided according to a specific programme. For example on Mondays consumables for wards and on Tuesdays cleaning materials and bandages are provided. Stock control The stores section is not computerised and a stock card system is in use. Good stock record keeping is best done by means of the stock control card system. The balance that is calculated from the stock received and stock issued should concur with the stock on the shelves. Spot checks should be done. Of 10 cards drawn during the visit only one card was correct. Staff are not sure how to correct the situation. There is no mechanism specifying the minimum and maximum levels of each item. The supply of essential items such as gloves, handwashing soap and chemicals for X-rays cannot be ensured. Items out of stock recently were liquid soap (supplier problem), surgical items, bandages and stationery. The level of cleaning materials and provisions are often lower than what they should be. When this happens, all requisitions and supplies are checked to see whether deliveries have been a problem. Stock counts are made every three months. Expired stock is not a problem as turn-around times are rapid.
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Problems The section requires a Chief Provisioning administration clerk and an extra provisioning administration clerk. Lack of training Inadequate space. Stock control and stock management. Problems with suppliers: Suppliers are often out of stock. Goods supplied are often of inferior quality, for example perishables. Surgical supplies are often out of stock. Written reports on the poor performance of suppliers have been forwarded to the Provincial Office, but the result has not been satisfactory. Problems with tenders: The tenders are arranged at provincial level, the hospital has no input in the process and complaints by the hospital have to go via the Provincial Office. Tenders are awarded at provincial level, but tender documents often do not reach the hospital timeously (or ever) making placing of orders and monitoring of specifications a problem.
10.
Maintenance and Workshop Services
The workshop is headed by an artisan foreman. The rest of the staff include: an electrician (also an artisan foreman), one general foreman, one tradesman aid and four groundsmen. The workshop reacts to requisitions. These are prioritised as they are received. When a repair will affect the patient or patient care it receives preferred attention. Due to a lack of staff and the high load of reactive work required, they do not have a programme of preventive maintenance. They are aware of painting that needs to be done and the potholes in the access road, but these could not as yet be incorporated into their work schedule. There is however preventive maintenance of equipment in the laundry, mortuary, steampipes and watercoolers. The team regards the following as indicators of a well-functioning workshop: Good workplanning and work of quality. Preventive maintenance programmes in place. Tools good and sharp. Safety measures followed when a job is done. Neatness. Staying within budget. Problems experienced There are no training programmes available. All repairs for the hospital, including the grounds, come from their budget. These include the servicing of incubators, anaesthestic machines, oxygen bank and theatres. They feel that some allocation of budget needs to go to the wards or theatre. Repairs to medical equipment are referred to Kimberley. Although communication was lacking in the past, it has since improved. Medical equipment has a high frequency of fault They have no training to do the repairs and are not registered to do so. There are also no guidelines available for the use and care of medical equipment. Service planning is difficult as they are expected to provide support to the wards where required. This may include the fetching of post or blood or the moving of furniture. They provide support to the laundry when some-one is on leave . They feel that their important role is not acknowledged. The appearance of the hospital is important, but they cannot get to it.
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Stock control There are yearly stock counts. The results of the records of these counts were not checked in this study. Each worker is responsible for his own equipment, which is locked away when they are not in. Gardeners have to sign out any equipment they use.
11.
Steam, incinerator and mortuary services
Steam services The steam services are provided daily and the staff shift starts at 03.00 hours. The three staff members responsible for the steam service work on a three-person shift system to cover the steam service, incinerator and mortuary for a 24 hour period. It is possible to calculate the monthly paraffin use from the steam service register. 20 000l of paraffin is used every 16 days. Apart from paraffin the engines also use 280 l oil per month as well as chemicals. The total cost is R34 000 per month. Incinerator services The incinerator is on the hospital grounds. The facility is not fenced off to keep stray animals or people away. The machine is a first stage burner and according to the Air Pollution Act (Act 45 of 1965) a temperature of 850 celcius should be maintained in the chimney. A recent visit by the chief air pollution control officer indicated that the temperature is lower than required. The machine is serviced on a weekly basis. The staff operating the incinerator are not full time. They load the 3 to 4 bags every 20 minutes and remove ash from the previous burning cycle. Material to be incinerated is in excess of the incineraters capacity. The supervisor, supported by hospital management, has circulated several circulars to request adherence to the policy of infectious, hazardous refuse management. Bags of different colours are used for the various types of refuse that are collected in the hospital. Infectious refuse such as placentas, foetuses and body tissue should go in red bags, yellow bags for drapes, sanitary towels and cotton wool and all sharp disposable instruments should be in special containers, even if it is a self-designed carton box. Black refuse bags should be used for ordinary refuse such as paper and tins. There is unfortunately poor adherence to this policy causing the incinerator to be overloaded. Not all bags can be handled in one day resulting in bags needing to be kept overnight. This is hazardous in terms of infectious diseases. There is also no control over the bags that are delivered at the incinerator as the worker is not stationed there. The hospital is now considering to paintmark the bags with a specific colour for each ward and to establish an occupational health and safety committee to oversee adherence to the policy. Mortuary During the previous financial year 473 bodies went through the mortuary. 77 of these were stillborn babies awaiting cremation. The bodies of the stillborn babies stayed extremely long in the mortuary, up to 9 months (average of 54 days). The other bodies are on average stored for 2,9 days. The unit was not aware of the Human Tissue Act and no policy was yet available for the handling of bodies. Problems Operational issues such as a lack of policy, nurses that do not complete the register, security officers accompanying bodies instead of ward nurses, bodies that often have an
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odour when they arrive from the wards, difficulty in tracing next of kin for collecting the bodies or for signing the authority form for cremation. Infection control concerns have been raised as only gloves are provided. No protective shoes or masks are provided and there is no policy on the handling of bodies where the patients died of AIDS or Haemorrhagic fever. The mortuary should have a freezer especially in the hot summer months. They regard this as an important requirement for changing to a level 2 hospital.
12.
Porters
There are three porters operating in shifts to cover a 24 hour service. A major constraint is the intercom system that does not work. Hospital staff complain that it is often difficult to locate the porters.
13.
Nurses home and Creche
The nurses home has 23 rooms. Only 7 nurses stay there, the other rooms are occupied by Cuban doctors, administrative staff and the radiographer on call. There are also three students. The creche caters for 25 children of staff members at a cost of R80 per month. This is regarded as a service to staff members who have no other means of care for their children. The children stay until they are 5 years of age and are cared for by 3 of the hospital cleaners. Management would like to separate the crche from the hospital to utilise cleaners again in the hospital.
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Section 7: Recommendations
The recommendations listed in this section will inevitably focus on rectifying some priority gaps identified. It must be mentioned, however, that the hospital has a long list of strong points that should continue to be strengthened. The hospital has survived an intense transformation since 1996 and the present refurbishment and the availability of this situation analysis document should be used as an opportunity to boost morale and market the hospital to the community. The most important asset of the hospital is its staff. They are mostly dedicated and competent. It is recommended that hospital management identify key priorities from the list of recommendations and see the implementation through.
1.

Management of the hospital

The management team should align their approach to cover key management aspects such as technical efficiency, quality control issues, drug management and continuity of care. Separate project committees may be established to oversee some of these aspects. Proper feedback from the various sections must be accommodated. Checklists for key performance and compliance areas should be developed to assist managers in their routine tasks. This is of particular importance to the hospital secretary functions. Define a minimum set of indicators of performance for the hospital and arrange regular (at least quarterly) sessions for monitoring. Record absenteeism separately for each ward/unit. Develop / update policies for issues around infection control, the mortuary, pharmaceuticals and patient care. Clarify and strengthen the role of unit managers. Wards should be managed as units, which will include the quality of services and the staff. Until finances have been devolved to the wards, the calculating of costs should be reconsidered as no evidence of its usefulness could be found yet it is time consuming and adds to the administrative load of staff. The Hospital Management needs to embark on a trust and team building exercise as a matter of urgency. This will strengthen the team, share the load and enhance the capacity to make the hospital an effective service provider.
2.

Management of wards
The daily involvement of senior managers in day-to-day staff deployment matters should be reduced. A bank-system whereby some nurses are available for flexible staff allocation could be considered. Rosters should be determined according to patient needs. Staff known to be on training courses should not be included in the rosters. Each section was very clear on their needs (not all of these have been captured in this document). These needs should be included in the strategic plan to put staff at ease that their needs are recorded and will be addressed.
3.

Financial management
All sections should be orientated in financial management and their role in financial management of the hospital should be clear. Financial performance must be monitored regularly. Cash flow at least weekly and overall performance on a monthly basis.
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Establish capacity in financial planning, cash flow management and reporting. Particular attention should be placed on ensuring that expenditure data is turned into management decisions. Revenue collection: The data for Gordonia should be available separately from the other hospitals. Present performance should be measured on a monthly basis. The rendering of accounts should be decentralised to the hospital. Staff allocation: All staff working in the hospital should be placed on the staff establishment of the hospital. Staff servicing the region must be on the regional staff establishment. Annual resource allocation and expenditure review: It is strongly recommended that a resource allocation and expenditure r view of hospital expenditures be conducted. This e will support the management team in establishing cost centres and in their strategic planning. This will also lay the basis for establishing benchmarks in financial performance. Stock management in the stores and pharmacy must be improved as a matter of urgency.
4.

Human resource management

Each staff member should have a job description and all new staff should be orientated into the Gordonia hospital culture, values and strategic focus. A system of staff appraisal should be implemented. The grievance procedure should be clarified and communicated Disciplinary protocols and procedures should be in place as a matter of urgency. The devolvement of authority to handle disciplinary cases at the hospital is necessary. The issue of absenteeism should be further investigated and analysed. Where required appropriate disciplinary action should be implemented without delay. A training programme according to staff needs must be available for each staff member. Priority attention should be given to stores management and workshop staff.
5.
Infection Control
The lack of infection control is a major concern for managers and staff. This is a crucial aspect and should receive priority attention. Aspects that highlights the problem are briefly listed below: Staff are exposed to body fluids, human tissue and needles (Incinerator, refuse system). The male ward has 2 towels for hand washing. Nursery and childrens ward inappropriate for the patient load Case mixing happens in childrens ward Action required: A detailed policy should be developed as soon as possible Establish a health and safety committee.
6.
Strategic planning:
It is recommended that the management should continue with their initiatives in this regard and establish a strategic vision and focused strategy towards improved management and quality of care. These should be captured in a strategic focus document and buy-in by all staff should be ensured. The following criteria for such a document are strongly recommended: The plan should initially focus on improving efficiency and effectiveness of existing services. The future role of the hospital must be clear so that upgrading of services can be planned in an incremental and contextualised manner. The hospital plan should be supported by a plan for each section where problems listed in this document, as well as performance indicators are refined. This should form the basis of continued improvement of quality.
47
Situation Analysis: Gordonia Hospital 7.

Organisational structure and staffing

The assistant director administration post should be filled as a matter of urgency. Revisit the organisation structure by first clarifying the functions that should be performed and then allocating staff accordingly. The existing fragmentation of management of human resources, the lack of clarity regarding the role of staff in financial management and the role of ward managers should be addressed during this exercise, with a focus on delegation and inclusion where appropriate. The role of each section should be clarified. This should include definition of clear communication channels and lines of authority. The staffing of the other sections should be compared against the staffing norms. This issue is of particular importance as the issue of staffing was recorded in all sections. A plan with a phased implementation strategy is required. Establish a culture of discipline by making it the responsibility of each manager and by empowering him or her to do so. Finalise the disciplinary actions of the staff with a record.
8. Hospital information system

From the report it is clear that unnecessary data is collected routinely whilst it is not really used. Important data that is collected is not presented in a format to assist decision-making or monitor trends. It is recommended that: A proper analysis of routinely collected data should be done and real management indicators can be measured. The packaging of data should be so that analysis and interpretation trends in routine information on health status, service activities expenditure information. Those who have to complete routine statistics should be trained available. streamlined so those is easy. This includes and support service and have guidelines
9.
Communication
Communication is a gap in most organisations and in situations of transformation the need for appropriate and regular communication to staff is even more crucial. The hospital should prioritise this and establish a task team to enhance the existing communication practices. The expectations of staff regarding communication from management should form part of this team`s assignment. Indicators to measure internal communication should be identified. Open staff meetings could be considered as a method for communication until the team has finalised their task. In terms of external communication the following is advised that the following should be considered: Liaison between the hospital and PHC and the community, The mission and complaints strategy as well as important aspects such as referral patterns should be displayed to the public. The admissions section should have space for confidential communication.
10.
Patient care
A system of clinical audit should be introduced. Introduction of basic clinical audit should be the responsibility of one member of senior management. There is no need to generate additional information for audit as plenty exists within the data already collected. It is suggested that each department identify one pertinent statistic and a relevant case study once a month and share this at an audit session. This process also maintains professional education. Some forums, such as the doctors forum could be used as a vehicle for clinical audit. Establish hand-over sessions with the change of staff. The hospital level EDL should be implemented together with a system for monitoring rational use of drugs (based on the EDL).
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Strengthen links with PHC. Use the TB control programme as a model and extend it to maternal health, AIDS care and malnutrition. Use morbidity and mortality data to establish district priorities. Maternity care should receive priority attention. Links with other sectors such as welfare and education should also be strengthened (alcohol-related trauma is a cause of high hospital attendance over weekends, several suicide attempts have been observed). A complaints policy should be developed and made public throughout the hospital in areas visible to patients and visitors. The policy needs to include: The fact that patients have the right to make a complaint How patients should go about making a complaint How the hospital will deal with the complaint
11.
Medical records
This system is of particular concern to management, ward staff and the staff in the medical records section. Implement and monitor performance of the medical records procedure manual. Monitor the improvement of confidentiality, retrieval rates and the efficiency of the system itself.
12.
Equipment and linen
Throughout the investigation mention is made of equipment that is broken or breaks down frequently as well as some equipment that needs urgent replacement. This is of particular concern, as the hospital will be expected to render more level 2 services in the near future. It is strongly recommended that a replacement and upgrading programme be effected as soon as possible. Linked to this is the need for guidelines and training of staff on the use and care of medical equipment.
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Appendices
Appendix 1: Strengthening links between PHC and the hospital
Perinatal Mortality Review an example of building links between Gordonia Hospital and PHC facilities As a component of their Advanced Midwifery course, two students are responsible for arranging and leading a monthly meeting based around a case study of a perinatal death. Medical and nursing staff from the hospitals maternity department and PHC nurses from the four Upington clinics attend the meetings. Its purpose is to improve antenatal care, labour practices and neonatal care so as to reduce the perinatal mortality rate. This is achieved firstly through consideration of the past months performance, measured by the Perinatal Mortality Rate, the maternal mortality rate and the emergency caesarian section rate. Secondly, a case study is considered. The meeting appears to be extremely valuable in that it: improves communication and familiarity between primary and secondary level staff thereby strengthening the team creates a forum where not only secondary, but also primary level staff can learn together with, and from, doctors develops a culture focusing on quality of care encourages ongoing clinical education increases interest and motivation
The model of improving primary care so as to prevent admissions at secondary level is an extremely good one and should be rolled out to other clinical areas such as malnutrition, HIV or diarrhoeal disease as the hospital sees fit.
Appendix 2: The staff establishment The total staff establishment is 267 posts with a further 16 posts filled at district office but operating in the hospital. The summary of the filled and vacant posts of the hospital is as follows: Post class Medical superintendent Pharmacist Radiographer Physiotherapist Assistant director nursing Chief professional nurses Professional nurses Staff nurses Nursing assistants Assistant director administration Senior administation officer Administration clerks Provisioning administration clerks SASO Operators Number of posts 1 1 3 1 1 19 26 26 46 1 1 18 2 3 6 2 Number of vacancies Comments Part-time appointment On district staff establishment Renders a service to the whole district
7 3 1
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Housekeeper Cleaners General worker Driver Seamstress Laundry supervisor Laundry assistant Messenger Porter Catering supervisor Foodaid Artisan supervisor Artisan Artisan assistant Groundworker General foreman Medical doctors Dietician Occupational Therapist 7 32 1 2 2 3 14 1 3 3 8 2 3 6 1 12 1 1
1 2
2 2 1 On district staff establishment
Appendix 3: Absenteeism May Day and night duty (night duty in italics and brackets).
Ward
Maternity Childrens ward Male w ard Total shifts Overtime Annual Leave Sick leave Training course Unauthorised Leave Absence rate
257 (105) 248 (105)
6 4 1 (1) 4 3
3 (1)
12 2 (5) 1 4
12% (0%) 2% (0,05%) 1% (0%) 4% (0,05%) 4% (0%) 2% (0%)
198 (126) 242 Female ward (105) 256 Outpatients/Ca (105) sualty
TB Unit
4 (4) 6 (3)
137 (72)
October Day and night duty (night duty in italics and brackets).
Ward Total shifts Over time Annual Leave Sick leave Training course Unauthorised leave Absence rate
Maternity Childrens ward Male ward Female ward Outpatients/ Casualty TB Unit
184 (101) 174 (86) 181 (85) 184 (82) 181 (84) 124 (70)
5 3 5 4 3 4 (2)
1 (14) 4
(1) 3 (1) 23 3 (2) 14 (1) (1) 3
6% (13%) 4% (1%) 4% (2%) 20% (2%) 4% (2%) 15% (4%)
7 (2) 1
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Notes to the Table: Comparison of the number of staff rostered to work nights during May and October demonstrates a significant difference in staffing levels. There is a marked decrease in shifts allocated for October. This decrease affects day and night shifts and all wards except the TB Unit. It is not explained by variations in occupancy rate as staff allocation is done independently of occupancy. For example 105 shifts were rostered at the childrens ward in May and only 86 in October; for the male ward, 126 shifts in May and only 85 in October; Female ward 105 in May but only 82 in October; and outpatients/casualty, 105 staff in May and 84 in October. One reason why staffing levels are low is because staff who are already scheduled to be on a training course during their shift are still included on the roster, the logic being that they are still working. This does not happen in all cases of in-service training; for example, the Maternity ward loses two students to the advanced midwifery course for weeks at a time and plans the roster accordingly. This training does not therefore show up as leave in the figures above. In practice, a heavy re-training burden accounts for a significant part of the staffing problems. The problem is severe because of the pressure upon the hospital to re-train all its enrolled nurses to registered nurse level by 2000 and because of the many short courses to which the hospital is required to send representatives, often at short notice.
Appendix 4: Rational drug use. Dr Catherine Orrell, who has been involved in much of the rational drug use training in the Lower Orange primary health sector, produced the report and recommendations below. Plan for Rational Drug Use in Gordonia Hospital, Upington The regional manager of the Lower Orange district has expressed concern about whether or not drugs are being used rationally at Gordonia Hospital. According to the total budget for the hospital, drugs costs constitute 6% of total expenditure. In October 1998 a sample of 10 outpatient scripts were taken for a brief analysis. If these scripts showed evidence for irrational prescribing then a plan would be made for further sampling, as 10 scripts are too few to be statistically significant, for identification of areas in which training is needed. Results: Indicator Number of drugs per script Number of drugs prescribed by generic name Number of drugs from the essential drugs list Correct prescription line Follow primary care treatment guidelines for stated diagnosis completely Result 3,6 0% 68% 68% 11% WHO ideal 1,2 to 2 100% 100% 100% 100%
On looking in detail at two of the scripts, both for treatment of hypertension, it was noted that the first used a potentially dangerous combination (which can cause fatal brady-arrythmias) of atenolol, a beta-blocker, and diltiazem, a calcium channel blocker. The other prescribed 5 different antihypertensive agents to the same patient. Neither practice falls within any guideline for the treatment of hypertension.
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Situation Analysis: Gordonia Hospital

Hospital Management in Gordonia District Hospital, Lower Orange District

Situation Analysis: Gordonia Hospital

A Situation Analysis of Gordonia District Hospital, Northern Cape Province.

Beth Engelbrecht, Lesley Bamford, Natalie Grazin and George Isaacs

Funded by the European Union via the National Department of Health

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

CONTENTS Section 1: Introduction

Situation Analysis: Gordonia Hospital

Appendices 1. 2. 3. Links with PHC Staff establishment Rational drug use 50 51 52

Situation Analysis: Gordonia Hospital

Northern Cape Province

Lower Orange District

Hartswater Kuruman Olifantshoek Danielskuil Postmasburg Jan Kempdorp

Colesburg Carnarvon Victoria West Noupoort Richmond

Fraserburg Cape Town Sutherland

Situation Analysis: Gordonia Hospital

Where are we now?

Where do we want to be?

Situation Analysis: Gordonia Hospital

Gordonias role within the District

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

The official organogram of the hospital is as follows:

Clinical services manager

Assistant director administration (vacant)

Assistant director nursing

Doctors Pharmacy Physiotherapy Radiography Occupational therapy Dietician

CPN: Trai= ning

CPN: Childrens Ward Female ward Male ward

CPN: TB Unit Regional TB coordinator

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Human Resources Management and Development

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Data Collection and Information Systems

Situation Analysis: Gordonia Hospital

C Baez, ISDS. Report of visit 23/11/99.

Situation Analysis: Gordonia Hospital

Drug Management System

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Section 3: Patient Care

Situation Analysis: Gordonia Hospital

1. Casualty and Outpatients(OPD)

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

High Care Unit

Situation Analysis: Gordonia Hospital

January February April May

Theatre cases Operating hours

Situation Analysis: Gordonia Hospital

Situation Analysis: Gordonia Hospital

Section 4: Clinical support services

Occupational Therapy (OT)