POC Operations Management
L. Brief Overview of the Philippine Orthopedic Center The Philippine Orthopedic Center, formerly known as the Manhandling Emergency Hospital and then the National Orthopedic Hospital, is a special tertiary hospital. It is a 700-bed capacity tertiary specialty hospital that is under the Department of Health. It is located at Maria Clara corner Banana Street, Santa Mesa Heights, Guenon City. The Philippine Orthopedic Center caters to a wide range of population, from pediatric to geriatric population. However, the patient clientele are usually of orthopedic and neuromuscular disorders.
It is also a major referral center for spinal injuries. Its main service division is the Medical Division consisting of Trauma Services, Adult Orthopedic Service, Children’s Orthopedic service, Tumor Unit, Hand service and Spine Surgery service. It also has Anesthesia, Rehabilitation Medicine, Radiology and Laboratory Departments. Other specialty services such as General Surgery, Neurosurgery, Urology, Neurosurgery, Internal Medicine (Pulmonary and Cardiology) and Diabetes Care are also available in providing care for all POCK patients. II. Vision, Mission and Values Vision
To provide comprehensive orthopedic care and rehabilitation, training and research utilizing world-class technology and expertise Mission To become the premier center of excellence in the art and science of orthopedic surgery and rehabilitation medicine responsive to needs of the nation and the international community. Values The Philippine Orthopedic Center has three main values. These are integrity, as they are committed to serve honesty; excellence, as they provide highest quality of medical care, training and education; and lastly, compassion, as they empathic with patients at all times.
Ill. Background on Orthopedic ERR Department Overview One of the medical services that the Philippine Orthopedic Center offers is the Trauma Service or the Emergency Department of the Hospital. The services in this department are offered by different teams of doctors (consultants and residents) assigned by a color (Pink, Green, Brown, Yellow and Red Service Teams). The ERR department serves the patients 24 hours a day and 7 days a week.
The services offered in the ERR department include casting of fractures, closed reduction of dislocations, emergency surgeries (like closed reduction pinning, wound flushing and abridgment, and amputation), application of external fixations, and elective surgeries (such as total/partial hip replacement, open reduction internal fixation of fractures, ethnography and skin grafting). The medical orthopedic staff within POCK is divided into 5 groups, Red, Green, Yellow, Pink and Brown, aside from specific services such as Child Orthopedic, Hand Service and Spine Service.
Each team is given a unique schedule that ensures that all stations within the hospital are manned. It also allows Tort a relatively lax duty issuance Tort ten resident pinnacles. A sample issuance Is hon.. In the table below. Given that majority of cases are due to trauma, the emergency room is one of the highlights of the hospital. The Emergency Department is housed in an 85 x 82 m edifice located near the Banana Street entrance. It contains its own quarters for doctors and nurses, Radiology section with an X-Ray machine, 2 treatment/minor Or’s, 1 clean operating room, 1 dirty operating room and a casting room.
General ERR Process There are specific processes depending on the assessment of a resident physician. For the purposes of discussion, a general outline of the flow in the ERR is described. Patients brought or who come in the ERR have to first stop by the reception/ registration booth to the right of the entrance to be given a hospital/case number and a chart. After which they then proceed to the area where consultations are made. They first hand their charts to the clerks and are interviewed regarding the nature of their complaint and are given a quick physical exam before their case is endorsed to any resident.
Depending on the nature of the complaint a resident may opt to re-interview or do a physical exam of their own. Being subjected to an X-Ray reoccurred is a must due to the nature of the cases brought to the hospital. After the initial consultation, the resident dictates to the clerk what diagnostics must be ordered for the patients. Clerks fill up the necessary forms and are the ones to instruct companions of the patient as to what must be done. It would either be Just an X-Ray or with an additional Gram Stain and Culture & Sensitivity in cases of open wounds.
As the companion of the patient tends to these requirements, the patient is left in the waiting or the patient area. If the patient is with a wound or laceration, the clerks will clean the wound. If the wound is of significant size and no fracture is suspected, the companion may also be asked to buy materials for suturing. Clerks often times are the ones to suture patients. After payments for the diagnostics, patients then undergo the ordered procedures. Results are then released and the residents assess what course of action must be done.
The patient is called by the clerk and is seen by the resident. The diagnosis and therapy is explained to the patient and the companion’s. Depending on the diagnosis, there may be options for therapy available. Often, the treatment requires materials which the resident asks he companion to buy from either the pharmacy within the hospital or at any of the other pharmacies around the area. When the necessary materials have been purchased, the patient is treated at any place within the ERR.
The resident once again talks to the patient and the companion’s regarding the dos and don’t and when to come back for a follow-up. They are then free to leave. The ERR Department of the POCK has many points of improvement in the process of patient evaluation and management. Management of time, physical and human resources can also be evaluated for further improvements. Improvement in the service time of the patients an increase patient satisfaction and quality of life which is why the focus of this paper is to evaluate on how to improve in the areas of patient service.
IV. Analysis Moments The analysis of the process in the POCK is based on the observation made by the clerks during their one-week rotation in the department. The main data collected for the analysis are the average time that is needed to finish a process. The following time were noted: patient’s arrival time, time for the patient to be interviewed, time to finish interview, time the patient is referred to a resident, start and end time of existent interview, time for obtaining x-ray, time to manage the patient (including casting and advising patients).
A limitation of this paper is that only the teams where the clerks were assigned are the only ones observed and included in the data analysis. Another limitation is that this paper only included patients who were managed on an out-patient basis and those admitted patients were not included . Data The data collected during the observation done by the students during rotation in the ERR department of POCK are the following: Number of patients observed: 36 Average time a clerk interviews a patient: 23 minutes
Average time a patient is referred to a resident: 6 minutes Average time a resident checks the patient: 14 minutes Average time a relative pays for diagnostics (x-ray or CSS) = 19 minutes Average time a patient obtains x-ray and results: 26 minutes Average time for casting patients: 65 minutes (N=27) Average time for advising and giving prescription to patients = 12 minutes Process Analysis Process analyses are one of the most effective ways of gaining an understanding of existing processes. Such analyses are intended to represent a process in such a way that it is easy to read and understand.
A process map is considered to be a visual aid for picturing work processes that show how inputs, outputs, and tasks are linked (Mansard, 1998). It has been described as being one of the “most important and fundamental elements of business process re-engineering. ” (Solomon, 1998) Process analyses have several benefits which include: giving a clearer explanation of a process; imparting an understanding of the tasks and problems faced within/by the organization; allowing participants involved in individual tasks to see the entire process and help clarify their interactions with others involved; and prompting new rain of thoughts.
Given the large number of potential stakeholders from varied backgrounds are present, it is pertinent that process analyses are transparent – the steps should be clear and understood by all parties involved. Fig. 1. Process flowchart in the POCK Emergency Room. Figure 1 illustrates the process flowchart of the emergency room in the Philippine Orthopedic Center. Four points within the process of the ERR have been identified to have room for improvements: Patients who undergo X-Rays are left in the waiting area while the companion is asked to go to the Radiology window Just by the waiting rear to show the X-Ray request.
At the window, after presenting the request they are glen a paper Tanat contains ten expense Tanat must De covered Dye ten patient. I née then have to present this paper at the cashier outside the ERR that is manned by 1-2 people. It takes less than 30 seconds to get to the cashier. The time spent in line however, is variable since it depends on the traffic currently being experienced in the ERR. This takes a few minutes up to 30 minutes. After which, companions are supposed to present the receipt at the window.
They then wait for the patient to be called. After the X-Ray is done, the patient’s name is called again and the companion retrieves the X-Ray plate’s and hands this to the clerk for review of the residents. The process regarding the X-Rays can be shortened or cut so that it would involve less effort on behalf of the patient and the companions. For one, it requires extra effort for the companions to leave the ERR and to walk back and forth. It is easier to have a cashier near or by the Radiology section.
This would cut the walking time and waiting in line in the outside cashier would be more pleasant and comfortable since there are seats near Just outside of Radiology. Once the plates are given to the companions and patients, often times they are at a loss of what to do. Service could be extended by having the radio technician be the one to hand the plates to the clerks and residents. This saves the companions from exerting extra effort to Just get the plates and to hand it to the clerks. Though this may not take a long time, it does reflect on the quality of service being given to the hospital visitors.
Points 2 and 3 that require improvement are related and can be crashed into 1 since they revolve around AS/CSS. Patients with open wounds routinely have the wound tested for any infections. The clerk prepares slides with swabs from the open wounds. They then give the slides to the companion and instruct them to take the ERR logbook for AS/CSS to the lab window outside of the ERR. They are asked to have the logbook signed. Once a companion does this, all AS/CSS slides for other patients cannot be submitted to the lab since the logbook must always accompany the slide.
This causes a backlog in lab submissions. Slides in the hands of the companion or left on the table while waiting for the logbook have the possibility of being lost. After the logbook and the slides have been vomited, the logbook can either be returned by the companion or the lab technicians. Times between the logbook leaving the ERR and returning are widely varied depending on the amount of patients being catered to. There is also no set protocol regarding who must return the logbook to the ERR.
This can cause some confusion which adds to time being extended between submissions of slides between different patients. Treatment revolving around orthopedic more often than not requires materials such as bandages, cement, metals, etc. When a treatment plan has been decided for the patient, they are asked to buy the materials outside of the ERR. This increases the time between the patient coming in and the patient receiving the treatment. At times when there is heavy patient traffic, patient areas and even companion waiting areas are overcrowded.
There is a long lag between assessment and the plan for the patients. This results in bottleneck especially when there are a high number of patients admitted in the ERR. Job Analysis The main human resources in the POCK ERR department are the residents-on-duty. Clerks, during this time, are also available, but not all throughout the year. Based on ten Interview AT ten residents Ana consul ants a , ten Ideal Coo ascription AT an orthopedic surgeon resident in the ERR department was analyzed using the EWE Framework.
Who What When Where Why The orthopedic resident staff consists of physicians assigned to the Hospital who are in an approved Postgraduate training program and are licensed to practice medicine or who meet the medical licenser requirements, and who meet the qualifications for and are accepted to the Philippine Orthopedic Center medical education program. The resident performs and documents a history and physical exam. Performs differential diagnosis and accurately diagnose the patient’s condition. After the diagnosis, the resident performs appropriate management for the patient.
The ERR department of POCK is open 24 hours a day and 7 day a week. The ERR department is located on the ground floor of the hospital in Banana SST. In Guenon City. To provide comprehensive orthopedic care and rehabilitation to emergency trauma patients. Service Analysis Several areas for pokey have been identified within the ERR process. Service quality in the ERR centers more on resolving the patient’s medical problem effectively and efficiently, leaving out other factors that should be under the umbrella of quality arrive.
Areas of service quality improvement are: When patients enter the hospital, often they are lost. Unless they ask the guards, they are not told where to go. As soon as the patient comes in to the ERR, they sometimes do not know what the first step is. Some proceed directly to the consultation area bypassing the registration. Some patients who do manage to go through registration are lost and wait within the area not knowing that they must go in to the consultation area and to hand their forms to the clerks since there is no instruction as to what should be done after registration.
The waiting area of the ERR contains Just 8 unblock benches an electric fan making the wait somewhat of an ordeal for patients and companions. When patients are called so that they may be seen, as said earlier, what is paramount is treatment of the patient, rapport and niceties are often forgotten and not bothered with. No extra effort is expended on things that will not contribute to treatment. As mentioned earlier in various steps in diagnostics for the patient, the companion or the patient himself is inconvenienced since they are the ones who must submit various requirements and diagnostics.
These are unnecessary efforts on their part. They take on some of the responsibilities for the care that the patient would receive in the ERR. After a patient is treated and advised on when to return. They simply leave the ERR and the hospital, again without any extra effort on the side of the hospital team. Service is basic and down to the bare diagnosing and treating and nothing else. The medical field also relies upon interpersonal skills which must be cultivated among the staff from guards to physicians. Good rapport is and should always be part of the medical service.
Patients who come do not only mom in for physical ailments, there is anxiety and fear which must be addressed. And always they are uncomfortable due to their illness and their mental state which requires medical staff to be more accommodating and to put the patients and also the companions at ease. Hectically Ana Layout Area Area A Entrance into the Emergency Room M Emergency Room Radiology B Reception/Registration N Radiology Window C Emergency Room Operating Room O Waiting Area D Minor Operating Room P Empty Room E Sink and Storage/Cleaning Area Q Residents’ Consultation Tables F Nurse’s Station R Consultants’ Tables
G Tables S X-Ray Illumination’s Box & Tables H Nurse’s/Female Doctor’s Quarters T Treatment Carts I Treatment Room U Benches J Casting Room V Patient Treatment Bed K Storage Room W Patient Areas L Doctor’s Quarters X Walkway Entering the emergency room, a patient should first stop by the receptions which is a small wooden booth about 2 x 3 m with 2 chairs and their own electric fan. There are no computers for registration but instead patients are given forms. The consultation area is separated somewhat from the rest of the space by lattice wall separators.
Towards the wall of radiology is a space often used for patients that re placed on beds and/or wheelchairs. Three to four patients on beds can be fitted in this space granted that they are facing towards the consultation tables. This depends on the wideness of the beds/gurneys. Beside this is the small 1 x 1 m window for radiology. To the left of it is the waiting area for all companions and some patients. It contains 8 unblock benches and 1 industrial sized electric fan. An unused room is the the south of the waiting area.
The main consultation area has 4 tables for residents and 3 tables for consultants and unblock chairs for the physicians and clerks. Behind the tables is the big view box for reviewing plates from Radiology. Due to the ERR being open, stray cats can often be found underneath the consultation tables, on or under the benches of the waiting area and sometimes, even on patient gurneys. The Emergency Room is housed within 85 x 82 m room. Attached to it is its own operating complex with 2 major operating rooms, 1 for dirty operations and another for clean operations, a room for minor operations, and 2 restrooms.
Each of the operating rooms contains their own operating bed, overhead light source and view box. The major OR’S also have their own anesthesia machines. Outside and inside the OR’S are cabinets and tables of stored materials for operations. There is one sink with 2 faucets for aseptic technique right outside the dirty OR. Each OR have 2 old wall type reconditions. Only one of each is to be used depending on the time of day. By ten lattices, Don In ten consultation area Ana outs ala AT It are treatment carts cleaning wounds or also for suturing.
Patients may be sutured or treated in any area within the ERR. Inside the Radiology department of the ERR are X-Ray machines located to the west. The east of the radiology room contains patient plates. The nurse’s station contains charts of patients who are to be conducted or are candidates for admission or stats surgery. This is also where most materials and equipment are kept since it is adjacent to the sink and storage area where most sterile tools are kept and cleaned. On the benches are logbooks for patients and for attendance of staff.
This is also where schedules for use of the ERR OR are posted. The nurse’s call room contains its own restroom with a toilet, sink and a faucet. A big plastic drum is kept over the floor drain so as to prevent any vermin from coming up. The call room itself contains 2 bunk beds, a table and 2-3 chairs. There is also reconditioning. The treatment room contains a tiled sink and a gurney. Equipment and materials are brought in depending on what the treatment will be done. There is no reconditioning in the room and so the 2 windows in the room are kept open.
Casting is not done within the casting room. It is where the plaster is prepared and most reduction and casting materials are kept. It is more of a store room and room for the mangos who are in charge of casting. Casting and reductions that require counteraction and finger traps are done on the bed found in the hallway inferno of he casting room. There are 2 benches found by the bed for companions or patients in line for treatment and casting. Along this hallway going to the west is another storage room.
Going further in the hallway are boxes and cabinets of old materials and equipment. At the end is the doctor’s call room where physicians and clerks eat. There are 4 bunk beds positioned like an ‘L’. The top bunks are used for storing bags. Only residents are allowed to sleep in the call room. Clerks sleep in the consultation area. There are 2 tables inferno of the beds where buffet meals are served. There is approximately 6 chairs. The rest of the people who are eating sit on the beds.
Inferno of the table are cabinets and a table. On the table is a small CRT TV with cable. Used plates are put on a small table inebriate the last bed and a sink. It is directly underneath the raccoon of the room which has lost its blades and is reportedly at some point an entryвЂўay for a rat. In between the cabinet and the sink is the door to the bathroom for the doctors. It contains a sink, a toilet and a shower. A big water drum is also left over the floor drain to prevent any rats from entering the room.