Action Learning Pilot Programme

Project Khaedu Rob Ferreira Hospital - preliminary findings

10 February 2005

Agenda

 Executive summary  Current situation  Complications  Some suggested resolutions Khaedu Rob Ferreira 2

Executive summary (1)

Situation

 Weak organisation structure and management structures at both hospital and provincial level delay decision-making, but most critically resolving the major human resources and industrial relations issues  Some important processes such as Outpatients need to be overhauled at both a macro (I.e. Province must engage) and a hospital level to solve excessive wait times (3-10 hrs)  While the unions appear obstructive, this is often due to lack of engagement and management attention to key issues

Complications

 Actual authority levels at the hospital level are very low, despite this being a R175 million*, 700-person operating unit  Significant confusion and duplication of effort and authority between Province, District and hospital  Absolute shortage of key professional and support staff, with very long lead times to fill Khaedu Rob Ferreira 3 *Including conditional grants

Executive summary (2) – some suggestions 1. Urgently review the decision-making processes between the 3 spheres of authority Consider delegating authority in critical areas like budget and HR down to the Hospital level 2. Reinforce the hospital management team Restructure roles and responsibilities Hire (even on a short-term contract) key IR, HR and technical skills 3. Engage with organised labour Remove key contentious issues such as career progression and training > Consider a one-off testing of staff seeking promotion Fill roles through promotion where possible Aggressive recruitment campaign headed by a dedicated hospital HR project manager 4. In outpatients, develop an overall strategy to move patients back to primary healthcare and/or spread the load of patients across the day by: Communication campaign at Province and District level Schedule repeat appointments in the afternoon Create a dedicate 0800 toll-free number for appointment scheduling Reengineer the registration process with particular regard to filing, where the process is collapsing (critical consequences) 5. Review budget priorities in the province (e.g. more wards being built while we are chronically short of staff to run existing) Khaedu Rob Ferreira 4

Agenda

 Executive Summary  Current situation  Complications  Some suggested resolutions Khaedu Rob Ferreira 5

Current situation – what we’ve seen and heard

Process and physical Organisation design People management     High volumes of patients, many of whom are primary healthcare patients and come from other areas Very long wait times in OPD - patients unhappy High occupancy rates (average of 86% last year) Long waiting lists for non-emergency functions (e.g 18 months for prostheses)      High level of centralisation at the provincial head office level - Limited branch delegation - Cumbersome with many delays Unclear mandate of the hospital as a tertiary health institution Severe shortage of professional and support staff for a long time (years) Executive management and professional staff levels and remuneration do not appear to match levels of responsibility CEO job overstretched with 3 hospitals over large geographical area       Staff at all levels frustrated and very demoralised Management lack credibility with staff Unions play very dominant (and sometimes obstructive) role - Ongoing resistance to PMDS Basic supervisory and management skills not sufficient to meet challenges - People management skills - Problem-solving skills - Communication Discipline a challenge No clear HR plan / strategy Financial and procurement    Hospital has limited autonomy and delegation - Centralised provincial procurement function appears to add little value and is cumbersome and slow Long delays in: - Procurement of equipment - Maintenance of facilities and equipment No Finance Director to drive alignment of budget with strategic objectives Khaedu Rob Ferreira 6

Despite a number of challenges, there are some positive elements

 Rob Ferreira continues to be perceived as the “hospital of choice” in the District -Many patients travel long distances to access facilities  Patients are happy with the treatment received and service from staff members  Many of the staff appear loyal and are trying their best despite the many frustrations  Good coordination with Home Affairs for births and deaths registration  Management making a concerted effort to turn things around Khaedu Rob Ferreira 7

Bed occupancy is consistently higher than other hospitals in the region…

Average bed occupancy 100% 80 60 40 20 0 1998 1999 2000 2001 2002 2003 2004 Themba* *Estimate from RF management – needs to be checked Source: DHIS, CIO: Rob Ferreira Hospital Khaedu Rob Ferreira 8

…and outpatient activities have been steadily rising

Outpatient numbers per month 6,000 5,237 5,373 4,000 4,717 Sp Clinics 4,909 Casualty 5,696 5,954 6,091 2,000 OP 0 1998 1999 2000 2001 2002 2003 2004 CAGR 0.5% 4.1% 5.4% Khaedu Rob Ferreira 9

…with a large proportion of patients being primary healthcare candidates from out of the area…

Average number of outpatients per day 250 200 203 Not attended to in the day 150 Secondary or tertiary patient 100 50 Primary Healthcare Patient 0 Number of OPD patients Target patient for Rob Ferreira Could be seen at local clinic Source: Note that this data is based on estimates of interviewed doctors Khaedu Rob Ferreira 10

…leading to bottlenecks and long wait times at OPD

Khaedu Rob Ferreira 11

Although patients are frustrated with the overall process and cleanliness of the facilities, they are happy with the treatment Patient responses to questionnaire 5 4 3 2 1 0 Waiting Time Cleanliness Overall process Access to Toilets Service of staff here Treatment received Avail.of

Medicines Khaedu Rob Ferreira 12

There appears to be a persistently severe shortage of staff Number of staff 1,500 1,000 737 500 0 Current staff complement 513 Support Nursing, Medical & Allied Health Vacancies 1,250 Support Nursing, Med & Allied Health Planned staff complement Khaedu Rob Ferreira 13

The CEO is stretched and management levels appear to not match the associated responsibility, resulting in difficulty attracting the right candidates Director

750 people organisation

CEO Dep. Director Hospital Manager Medical Manager (Superintendent) Nursing Service Manager (Senior Matron)

+

Themba Ass. Director Finance & Provisioning HRM Patient Admin 5 senior clerks attending to all HR matters incl. pensions and payroll Auxiliary Services (166) Bongani

245 people organisation (National DPSA)

DG CFO Chief Director Director Dep. Director Director: People Management Skills Development Director: Finance Labour relations People Management Internal Auditor Employee Helath & Wellness Khaedu Rob Ferreira 14

Staff are unhappy with the facilities, career progression, overall quality of management and level of training… Staff responses to questionnaire 5 4 3 2 1 0 Facilities Career Progression Overall Mgt Managers Professionals Support Staff Training Khaedu Rob Ferreira 15

…but are relatively happy with communication, their job content and competency of co-workers, and feel that they provide a good service to customers Staff responses to questionnaire 5 4 3 2 1 0 Communication Job Content Competency of co-workers Professionals Support Staff Managers Provide Service to Customers Khaedu Rob Ferreira 16

The application of the PMDS is a bone of contention  Resistance to the PMDS.

 Lack of understanding of the system -When asked about their responsibilities the subordinates response is: “This is not your farm”.

-Subordinates do not sign PAs as they have not received instruction from their provincial office.(A total misunderstanding).

-They want to be trained and receive performance incentives yet they do not want to sign PAs, which are the basis of training and development; salary progression and other performance incentives. -Other staff members who have signed and have been evaluated are discouraged because they have not received any feedback, they got the same evaluation mark(3) and the same percentage (1%) and are therefore not encouraged. Khaedu Rob Ferreira 17

Agenda  Executive summary  Current situation  Complications  Some suggested resolutions Khaedu Rob Ferreira 18

The outpatients process is cumbersome and slow Patient arrives at hospital and goes to OPD A Need to pay?

Previou s patient?

Yes No Join queue 2: Records Clerk take details of patient on dummy Join queue 1: Records Clerk registers new patient and creates file Yes Go to pay clerk and pay No Send dummy to filing room Retrieve file and replace with dummy Send file to clerk who calls patient & hands over file Send file to clerk who calls patient & hands over file A Walk to Outpatients and queue for doctor Consult with doctor Take file to dispensary and queue to wait for medicine Collect medicine Total process = 3-10 hrs Khaedu Rob Ferreira 19

Our patients arrive en masse in the morning

Number of patients 160 140 120 100 80 60 40 20 0 6:30 - 8am 8-10 10-12 12-2 2-4:30pm Khaedu Rob Ferreira 20

Other complications  Clarification of the mandate regarding the tertiary status of RF Hospital (and enforcement thereof) is likely to be a long-term resolution - Inherently political in nature - Requires a mind-set change from a large portion of the population (mostly poor and many rural) - Requires upgrading and improvement of primary healthcare clinics and secondary hospitals  Many are still suffering from the legacy of apartheid neglect  Role of provincial vs district vs hospital likely to be politically driven and also long term in nature - Any permanent change in the delegation and authority levels will have knock-on effects with other hospitals in the region  Change of levels (and remuneration) of management and professionals is likely to take a long time since this is likely to be a national decision  Changing attitudes of staff and improving the relationship with organised labour will be a challenge due to cynicism having set in, and distrust between management and unions  A major bottleneck is the current recruiting capacity of HRM departments at both hospital and provincial level - With the best will in the world, the current capacity is simply not able to efficiently handle the massive increase in recruiting requirements in the time frame required Khaedu Rob Ferreira 21

Agenda  Executive Summay  Current situation  Complications  Some suggested resolutions Khaedu Rob Ferreira 22

Prioritised recommendations 1. OPD 2. Organisation structure – macro and micro 3. Recruiting 4. Organised labour 5. People Management Khaedu Rob Ferreira 23

1. The OPD challenge There are 2 main problems to solve in OPD: 1. Reduce the volume of primary healthcare patients flooding the facility 2. Spread the volume of patients more evenly throughout the day to avoid bottlenecks These 2 problems should be attacked from all angles and the resolution will combine short-term with longer-term initiatives Khaedu Rob Ferreira 24

1. The OPD challenge Short-term Reduce Volume  Introduce Help-desk at reception point to inform patients of procedures Medium – long-term  Continue with provincial communication campaign  Introduce gate clinic  Improve facilities at clinics and district hospitals Spread volume  Improve management of file archives  Improve queue management - E.g. give patients numbers when they arrive to enable fair tracking  Appointment system - 0800 number to book times with Doctor (Switchboard will have to be upgraded) - Appointment desk at reception for repeat patients  Those who do not book have to wait  Investigate use of a WIP (work in progress) system to track location of files Khaedu Rob Ferreira 25

2. The organisation structure challenge Hospital Organisation Structure  Hospital management levels and remuneration commensurate with degree of responsibility - One CEO per hospital, with CEO level tied to the size of the hospital - Finance and HR reporting directly to the CEO - Different post levels and grades should allow high level responsibility and accountability  Align budget with strategic objectives  Need for balanced proportion between line (956) and staff (294) functionary - Workstudy in progress - Regular review of org structure based on new service delivery priorities/mandate  Link to HO’s vision and mission Role of province vs district vs hospital  Recommend that certain functions and delegations be decentralised down to hospital level to improve efficiency e.g.

- Recruiting and appointments - Provisioning - Labour relations - Establish disciplinary committee at hospital - Training and development - Batho Pele revitalisation strategy roll-out Khaedu Rob Ferreira 26

3. The Recruiting Challenge

Check list

•A costed strategic plan, the practical MTEF cycle and the annual action plan.

• Revised and re-aligned organogram •Clearly outline recruitment plan with time-frames , processes and priorities.

•Job description of each employee .

•Identify and Evaluate critical areas of employment that need immediate attention. • HR plan 2.

3.

4.

5.

Possible interventions.

1.

Appointment (outsourcing) of project manager to coordinate, monitor and implement recruitment plan and processes. Contract medical specialists with attractive packages For a long run benefit train more medical personnel (offering contractual bursaries) Recruitment strategy aligned to HR plan.

Retention strategy Khaedu Rob Ferreira 27

……..continue

CONSIDERATIONS PRIOR TO RECRUITMENT

•Nature of skill required •Head hunting for scarce skills •Employee Induction plan  How,when,what, who •Availability of physical resources •Budget to accommodate needs and benefits of new employees.

 Office space, computers, vehicles, furniture,clothing etc.

 Housing allowance, medical aid, training, s&t etc.

• Legislative mandate  Equity plan (gender, race,disability etc) • Is filing of some post a temporary need or permanent.

•A sound and realistic retention plan Khaedu Rob Ferreira 28

Plan to address the 513 posts Backlog

 Appointment (outsourcing) of contract project manager to coordinate, monitor and implement recruitment plan and processes.

 Appoint temporary staff in areas where there’s bottleneck parallel to the recruitment processes since funds are available for those posts.  Put clear time frames for wiping out the entire backlog (e.g to be completed in the MTEF cycle)  Consider over-time for packages for staff.

 Consider moonlighting of medical and support staff from neighbouring primary health care institutions.

Khaedu Rob Ferreira 29

4. The organised labour challenge

Use the “give-and-take” strategy to improve relationship with labour… i.e what are the key objectives of management and what can we give in return?

Management key objectives  Implement PMDS at all levels in the organisation  Improve discipline  More cooperation with open lines of communication What can management offer in return?

 Alleviation of staff shortages by May 05  Training and development of staff to improve upward mobility  Correct application of PMDS Khaedu Rob Ferreira 30

5. The people management challenge Recruitment and selection  Recruitment and selection of levels from Assistant Director downwards must be done at the hospital/CEO level to speed up process and reduce red-tape  All adverts must be specific about the signing of PA within three months  Orientation and induction (done immediately by a training officer who is conversant with all the legislative framework, BP and disciplinary procedures-Code of conduct to be signed by all employees Performance Management  Develop an annual consultative strategic plan - establish a good rapport with labour  All staff to be re-trained on the use of PMDS.

 PAs and Workplans to be signed by all staff by 30 April of each year-This will form the basis of evaluation, training and development, performance incentives.

 A labour relations committee must be set up to deal immediately with disciplinary hearings.

 Khaedu and Change Engagement programme to be undertaken by Executive management Retention and Maintenance  A good communication strategy with all staff must be developed. (Monthly management and staff meetings)  Reward good and punish poor performance Khaedu Rob Ferreira 31