MSc Thesis "Optimization of Emergency Departments in the Netherlands"

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MSc Thesis "Optimization of Emergency Departments in the Netherlands"

  1. 1. Optimization of emergency departments in the Netherlands Which variables influence the efficiency of an emergency department and how can these variables be used to create the optimal emergency department?Authors: Femke Lammerts (f.lammerts@msc19.nyenrode.nl) Elisa van Poelgeest (e.vpoelgeest@msc19.nyenrode.nl)Dissertation date: January 5th, 2012Defence date: January 12th, 2012First reader: Professor Dr. Willem BurggraafSecond reader: Drs. Hans ten RouwelaarCompany Supervisor: Professor Dr. Drs. L.H.L. WinterStraatweg 253620 AC BreukelenThe NetherlandsZiekenhuisweg 1008233 AA LelystadThe Netherlands
  2. 2. Executive summaryThe current healthcare system in the Netherlands is coming under increasing pressure due todemographic, socio-economic and technological developments within Dutch society. Demandand costs are rising, leading to savings and reforms in the healthcare sector. Consequently, anew approach towards acute care, with the focus on emergency departments (EDs) is to bedesired, as outlined in this research paper.The aim of this research was firstly to investigate which variables contribute to the efficiency ofan emergency department in the Netherlands and secondly how the latter contribute todeveloping the optimal emergency department (ED). The variables researched wereinfrastructure, technology, service, logistics, employees, financial system and patient satisfactionwithin an emergency department (ED). To arrive at recommendations, the following centralresearch question was posed:Which variables influence the efficiency of an emergency department and how can these variables be used to create the optimal emergency department?Qualitative research was chosen as the research method for different reasons. The nature of thecentral research question required descriptive, exploratory and explanatory informationexpressed in words, as well as a flexible means of data collection. Qualitative research enabledthe researchers to ask more in-depth questions during interviews and qualitative research wasalso preferable, as the aim of this research paper is to develop recommendations based on thecurrent situation in the twelve individual emergency departments (EDs). The population wasidentified as ‘complete’ EDs; 24/7 availability and incorporating eight compulsoryspecializations. From the 67 ‘complete’ EDs in the Netherlands, a sample size of 12 was foundwilling to co-operate. Location, category and willingness were three of the main selectioncriteria.The most important results were derived from the validation of the posed hypotheses by bothliterature and the results of the interviews. Firstly, the layout of an emergency department (ED)has been shown to have an effect on the long-term success of its processes (throughput timeand reducing overcrowding). The physical layout has an effect on patient satisfaction. Secondly,the processes within an ED will become more efficient if digitalization, a paperless system anda software system are applied in a uniform manner throughout the hospital. Thirdly, thepresence of an ED doctor at an ED is two-fold. Benefits include time-savings in terms ofspeed and number of diagnostic tests and reduction in waiting and turnaround times.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012
  3. 3. Disadvantages mentioned were the time lost in the supervision of doctor assistants. Theshortage of ED doctors in full ED employment, plus the lack of uniformity in trainingprograms make it difficult to measure the actual presence of an ED doctor. Fourthly, waitingtime can be reduced to eliminate bottlenecks by using the Theory of Constraints (TOC). Theimplementation of this theory can enhance the processes within the ED. Fifthly, it is difficultto determine the profitability of an ED. EDs are seen as costly, mainly due to theconsequences of their permanent availability function. On the other hand, the ED yieldsrevenue for the hospital through patient admissions and follow-up consultations. However, noclear overview of revenues generated by the ED exists as yet. Lastly, verbal communicationwith patients in the ED plays an important role in patient satisfaction, especially with regard towaiting times, the communication of information and the relation between patients and EDstaff. These are areas where major improvements can be made as Patient Centered Care (PCC)will become increasingly important in the 21st century.To briefly answer the central research question; literature has shown that the efficiency of anED is influenced by seven variables which can lead to optimization of an ED. The optimal EDdoes not exist, as factors such as resources, culture and location of the individual ED must betaken into account when designing the optimal ED. Accordingly, the seven variables must beapplied within an individual ED.Recommendations for further research would be to conduct more than twelve interviews andinvestigating the impact of cultural and regional differences within the Netherlands on theefficiency of an ED. The variables should also be applied in a practical setting to identify theireffect on efficiency within an ED. Hypotheses that could not be validated by research shouldalso be further investigated as to their impact on ED efficiency.The research in this paper was limited by the restrictions in terms of methodology, theoreticalframework and availability of data. Time constraint constituted the most important limitationas it was not possible to conduct extensive research within the timeframe. Moreover, thepopulation researched was relatively small making it more difficult to reach a generalconclusion.Recommendations for the person commencing this research, Loek Winter, are derived fromthe hypotheses that could be validated by literature and the results of the interviews. Theparticular circumstances of the ED at the MC|Groep should be taken into account, onlyincorporating those variables that add value to that ED.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012
  4. 4. AcknowledgementsThis research is conducted for and supported by Professor Dr. Drs. L.H.L. Winter, co-founder of the MC|Groep, and Professor Dr. Willem Burggraaf, connected to NyenrodeBusiness University. We would like to thank both for their time, effort and support duringthe writing of the thesis. Without the advice and resources of these parties, this thesiswould not have been possible. We would also like to thank all the people who wereinvolved in the process of this thesis and making their resources and contacts available tous. Lastly, a special thank you to all the interviewees at the different emergency departmentfor their co-operation, interesting conversations and openness in the exchange of ideas andinformation.Femke Lammerts and Elisa van Poelgeest, MSc 19January 2012Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012
  5. 5. Table of contents1. Introduction ................................................................................................................................... 8 1.1 Scientific and managerial relevance .................................................................................... 10 1.2 Structure ................................................................................................................................. 112. Conceptual model ....................................................................................................................... 123. Methodology ................................................................................................................................ 13 3.1 Introduction........................................................................................................................... 13 3.2 General overview .................................................................................................................. 13 3.3 Qualitative research .............................................................................................................. 15 3.4 Research subjects, population selection and sample size................................................ 16 3.5 Data collection: method of collection and choice for interviews .................................. 18 3.6 Analysis................................................................................................................................... 20 3.7 Reliability and validity .......................................................................................................... 21 3.8 Operational conceptual model............................................................................................ 234. Theoretical framework ............................................................................................................... 24 4.1 Introduction........................................................................................................................... 24 4.2 Emergency departments ...................................................................................................... 25 4.3 Efficiency and optimization ................................................................................................ 27 4.3.1 Efficiency ........................................................................................................................ 27 4.3.2 Optimization .................................................................................................................. 28 4.3.3 Relation between efficiency and optimization .......................................................... 28 4.4 The seven variables............................................................................................................... 28 4.4.1 Infrastructure ................................................................................................................. 29 4.4.1.1 Emergency department layout ............................................................................. 29 4.4.1.2 The Huisartsenpost................................................................................................ 32 4.4.2 Technology ..................................................................................................................... 34Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012
  6. 6. 4.4.2.1 Software and digitalization of patient data ......................................................... 35 4.4.3 Service ............................................................................................................................. 36 4.4.3.1 Quality and performance indicators .................................................................... 37 4.4.4 Employees ...................................................................................................................... 39 4.4.4.1 Emergency department doctors........................................................................... 39 4.4.4.2 Emergency department nurses, triage nurses and nurse practitioners ........... 40 4.4.5 Logistics .......................................................................................................................... 42 4.4.5.1 Triage process and triage systems ........................................................................ 43 4.4.5.2 Waiting times and processes in the emergency department ............................ 47 4.4.6 Finances .......................................................................................................................... 48 4.4.7 Patient satisfaction......................................................................................................... 52 4.5 Hypotheses ............................................................................................................................ 555. Results and analysis ..................................................................................................................... 56 5.1 Infrastructure .................................................................................................................... 56 5.1.1 Emergency department layout..................................................................................... 56 5.1.1.1 Results ...................................................................................................................... 56 5.1.1.2 Analysis .................................................................................................................... 59 5.1.2 The Huisartsenpost ....................................................................................................... 60 5.1.2.1 Results ...................................................................................................................... 60 5.1.2.2 Analysis .................................................................................................................... 63 5.2 Technology ........................................................................................................................ 63 5.2.1 Software and digitalization of patient data ................................................................ 64 5.2.1.1 Results ...................................................................................................................... 64 5.2.1.2 Analysis .................................................................................................................... 66 5.3 Service ................................................................................................................................. 67 5.3.1 Quality and performance indicators ........................................................................... 67 5.3.1.1 Results ...................................................................................................................... 67Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012
  7. 7. 5.3.1.2 Analysis .................................................................................................................... 68 5.4 Employees .......................................................................................................................... 69 5.4.1 Emergency department doctors .................................................................................. 69 5.4.1.1 Results ...................................................................................................................... 69 5.4.1.2 Analysis .................................................................................................................... 73 5.5 Logistics .............................................................................................................................. 74 5.5.1 Triage process and triage systems ............................................................................... 74 5.5.1.1 Results ...................................................................................................................... 74 5.1.1.2 Analysis .................................................................................................................... 75 5.5.2 Waiting time and processes in the emergency department ..................................... 75 5.5.2.1 Results ...................................................................................................................... 75 5.5.2.2 Analysis .................................................................................................................... 78 5.6 Finances .............................................................................................................................. 79 5.6.1 Financial system of the emergency department ........................................................ 79 5.6.1.1 Results ...................................................................................................................... 79 5.6.1.2 Analysis .................................................................................................................... 80 5.7 Patient satisfaction ......................................................................................................... 81 5.7.1 Patient satisfaction......................................................................................................... 81 5.7.1.1 Results ...................................................................................................................... 81 5.7.1.1Analysis ..................................................................................................................... 82 5.8 Overview of the hypotheses and their validation ............................................................ 836. Conclusion ................................................................................................................................... 85 6.1 Introduction........................................................................................................................... 85 6.2 Conclusion research questions............................................................................................ 85 6.3 Conclusion central research question ................................................................................ 89 6.4 Recommendations for the MC|Groep ............................................................................. 90 6.5 Limitations ............................................................................................................................. 91Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012
  8. 8. 6.6 Recommendations for further research............................................................................. 92Bibliography ..................................................................................................................................... 94Table of figuresFigure 1: Conceptual model ............................................................................................................. 12Figure 2: Research paths .................................................................................................................. 14Figure 3: Selection of research subjects .......................................................................................... 16Figure 4: Method of data collection ................................................................................................ 18Figure 5: Analysis process ................................................................................................................ 20Figure 6: Operational conceptual model......................................................................................... 23Figure 7: Position of emergency department ................................................................................. 25Figure 8: Position of efficiency and optimization .......................................................................... 27Figure 9: Position of the seven variables ........................................................................................ 28Figure 10: Position infrastructure variable...................................................................................... 29Figure 11: Position technology variable .......................................................................................... 34Figure 12: Position service variable ................................................................................................. 36Figuur 13: Position employee variable ............................................................................................ 39Figure 14: Position logistics variable ............................................................................................... 42Figure 15: Position finance variable ................................................................................................ 48Figure 16: Financing and funding structure in Dutch health-care system .................................. 49Figure 17: Position patient satisfaction variable ............................................................................. 52Figuur 18: Position infrastructure variable ..................................................................................... 56Figuur 19: Position technology variable.......................................................................................... 63Figuur 20: Position service variable................................................................................................. 67Figuur 21: Position employee variable ............................................................................................ 69Figuur 22: Position logistics variable............................................................................................... 74Figuur 23: Position finance variable ................................................................................................ 79Figure 24: Position patient satisfaction variable ............................................................................. 81Table of tablesTable 1: Overview emergency department layout.......................................................................... 58Table 2: Overview of the distribution of HAP integration ........................................................... 62Table 3: Overview of emergency doctors and opinion on their presence ................................... 72Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012
  9. 9. 1. IntroductionThe current healthcare system in the Netherlands is coming under increasing pressure dueto demographic, socio-economic and technological developments within Dutch society.The demand for care will become increasingly complex due to the rising number of elderlypeople and the increasing demand for personally tailored care. This will eventually lead tohigher healthcare costs. Consequently, the healthcare sector will have to deal with savingsand reforms (Bos, Koevoets, & Oosterwaal, 2011).The Dutch healthcare system consists of 3 pillars: primary, secondary and tertiary care.This was determined by the ‘structuurnota’ in 1974. The relationship between these pillarsoriginates from the patient perspective (Boot & Knapen, 2005). Primary care is defined ascare for which no referral is needed from a general practitioner (GP) and therefore patientscan refer themselves to specific healthcare (Bos, Koevoets, & Oosterwaal, 2011). Theemergency department (ED) forms part of the primary care pillar, but is situated withinsecondary care. The general practitioner (GP) plays an important role in the process ofreferring a patient to secondary care. Secondary care is only accessible by referral viaprimary care. Tertiary care entails highly-specialized care (Bos, Koevoets, & Oosterwaal,2011).Acute care, situated in both primary and secondary care, encompasses ambulance facilities,general practioners (GPs) and trauma care. ‘Vereniging Huisartsenposten Nederland’(VHN) defines acute care as medical problems and conditions for which treatment isneeded within a short period of time (van Baar, Giesen, Grol, & Schrijvers, 2007). Duringrecent years there have been reforms leading to the creation of general practitioners’ co-operations to organise acute care more efficiently. The following bottlenecks still existwithin the acute care sector:  There is no performance-based reimbursement: this indicates that general practitioners do not receive the same reimbursement for e.g. a sprained ankle as a specialist working in the emergency department (ED). Consequently, the general practitioner has no incentive to take over low acute care patients which makes acute care less efficient.  The differences in triage and treatment protocols induce non-efficient quality and processes.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 8
  10. 10. These bottlenecks will need to be adressed in the future in order to make acute care moreefficient. Within acute care, the emergency department (ED) has its own obstacles:  Shortage in the general practitioner’ (GP) care  The rise of the specialism as emergency department (ED) doctor  The increase in the number of centralized general practitioner (GP) co-operations  The decreasing number of doctor’s assistants in hospitals  Patients require more information and are less willing to accept lengthty waiting times  The multicultural society calls for another care model for consumers/patients (Nederlandse Vereniging Spoedeisende Hulp Verpleegkundigen, 2005)A new approach towards acute care, with the focus on emergency departments (EDs) is tobe desired, as outlined in this research paper. The closure of and pressure on emergencydepartments is currently a ‘hot topic’ so to speak, as is the worsening financial situationencountered in many hospitals. Controlling costs in an emergency department is complexas EDs have a 24/7 availability function (Baltesen, 2009). Costs, customer service andeliminating waiting time are key factors that should be addressed in any attempt to reformacute care. By focusing on results, a positive effect can be reached on quality, care andpatient satisfaction. Therefore, it is desirable to investigate which variables can be used tocreate an optimal emergency department, which is customer focused, improves efficiencyand has a sound financial foundation (Nederlandse Zorgautoriteit, 2008).The aim of this research is firstly to investigate which variables contribute to the efficiencyof an emergency department in the Netherlands and secondly how the latter contribute todeveloping the optimal emergency department (ED). Based on these results,recommendations on the optimal emergency department can be made. The variablesresearched are infrastructure, technology, service, logistics, employees, financial system andpatient satisfaction within an emergency department (ED). To arrive at recommendations,the following central research question is posed: Which variables influence the efficiency of an emergency department and how can these variables be used to create the optimal emergency department?Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 9
  11. 11. The central research question will be answered by means of the following sub-researchquestions: 1. What is the definition and what characterizes of an emergency department in the Netherlands? 2. What is the definition and characterizes efficiency in health care? 3. What is the definition and which are the optimization characteristics in health care? 4. How are efficiency and optimization interrelated? 5. Which variables contribute to the efficiency of an emergency department? 6. How does the variable infrastructure contribute to the efficiency of an emergency department? 7. How does the variable technology contribute to the efficiency of an emergency department? 8. How does the variable service contribute to the efficiency of an emergency department? 9. How does the variable logistics contribute to the efficiency of an emergency department? 10. How do the variable employees contribute to the efficiency of an emergency department? 11. How does the variable finance contribute to the efficiency of an emergency department? 12. How does the variable patient satisfaction contribute to the efficiency of an emergency department?In order to define the scope of the research, the first four sub-research questions willclarify the terms of the central research question. Sub-research question five will explainwhich variables, found in literature, contribute to the efficiency of an emergencydepartment. The last seven sub-research questions will answer, per variable, how eachvariable influences the efficiency of an emergency department. The twelve researchquestions form an extensive answer to the central research question, which will beanswered in the conclusion.1.1 Scientific and managerial relevanceThere are several reasons why this research has scientific and managerial relevance.Scientifically, there are very few research reports that investigate both the financialFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 10
  12. 12. perspective as well as the customer focus perspective in an emergency department. Therehas never been sufficient research done on customer focus in an emergency departmentsetting, as the main focus has been on the optimization of procedures and achieving higherquality. The customer satisfaction and focus in this paper will be achieved as a consequenceof optimizing the emergency department’ processes. The interviews have not beenvalidated in English, as this research investigates the optimization of Dutch emergencydepartments. This gives a better insight into the current situation of emergencydepartments in the Netherlands. By looking at the different variables and their contributionto the efficiency and optimization in an emergency department, the overall performance ofan emergency department could be improved. The new approach to the structure of anemergency department will also influence the managerial relevance. Market forces willbecome increasingly important, as well as distinguishing factors. Consequently, themanagerial approach should be adjusted in order to become more customer focused andprofitable. Finally, managers and other professionals can use the suggested variables as atool for change and improvement when thinking about their own acute care situation.1.2 StructureThis report is divided into six chapters. Chapter one is the introduction as presented above.Chapter two, shows and gives an explanation of the conceptual model used. This model isimportant for the total structure of this research paper, as it will function as a guidethrough all the subsequent chapters. The third chapter will discuss the methodology, inwhich qualitative research, data collection, research subjects, method of analysis, reliabilityand variability and the operational conceptual model will be discussed. The fourth chapterwill cover the theoretical framework. This chapter contains the literature on which thevariables are based. From this theoretical framework, hypotheses are developed. Thischapter is then followed by an overview of the results and an analysis (chapter five). Theresults describe the outcomes of the interviews held and they will test the validity of thehypotheses that emerged from the theoretical framework. The last chapter (chapter six) isthe conclusion, in which the central and twelve sub-research questions will be answeredand recommendations made. This chapter also contains the limitations of the research,recommendations for the MC|Groep and recommendations for further research. Thebibliography can be found at the very end. The appendices can be found in the confidentialbooklet, which is supplied separately to whoever it may concern.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 11
  13. 13. 2. Conceptual modelThe conceptual model shown in figure 1 is important for the structure and comprehensionof this research paper. It will guide the reader in a structured manner through the chapters.Every chapter and the subchapters will be introduced with the conceptual model, in whichthe specific part under discussion is highlighted in the model.The detailed methodology behind this conceptual model and the research paper will befurther elaborated on in chapter three (methodology). The foundation for the variables canbe read in the theoretical framework (chapter four).The conceptual model was developed with the central research question and twelve sub-research questions in mind, as it encompasses all the steps and terms needed to answerthese research questions and to reach a final conclusion. Figure 1 can be read andinterpreted as follows: The left box indicates the research subject. The emergencydepartment (ED) is the research subject, of which the head of the EDs are theinterviewees. In total twelve EDs were visited, divided into academic, teaching andregional. The middle box shows the seven variables that, based on literature, have an effecton the efficiency of an ED. These variables are interlinked. The right-hand box shows theaim of this research paper, namely recommendations for the optimal ED.Figure 1: Conceptual modelFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 12
  14. 14. 3. Methodology3.1 IntroductionChapter three discusses the methodology of this paper and is divided into eight parts. Thesecond section of this chapter (3.2) will give a general overview of the methodology bymeans of a model. The function of the model is to give a general and clear overview of thepaths followed in this research paper. The third part (3.3) discusses the reasons forchoosing qualitative research and the fourth part (3.4) elaborates on the research subjects.This is followed by the method of data collection (3.5), the method of analysis (3.6), thereliability and validity of the methodology (3.7) and concluded with the operationalconceptual model (3.8).3.2 General overviewThe figure on the next page, figure 2, gives an overview of the paths followed for thisresearch paper. The model can be interpreted as follows. The request by the personcommissioning this research, Loek Winter (co-founder of the MC|Groep), on theoptimization of emergency departments (EDs) in the Netherlands led to a pre-investigation. The pre-investigation consisted of gaining an awareness of the literature onEDs and optimization, in order to obtain knowledge and insight into the variablescontributing to the efficiency and optimization of EDs. From this study two products weredeveloped; the central research question and the twelve sub-research questions and avariables list for the interview. The list of variables can be found in appendix I of theconfidential booklet and its foundation is described in the theoretical framework (chapter4). The central research question and the twelve sub-research questions can be found inchapter 1. In order to answer the central and twelve sub-research questions, two paths wereselected.Path one (indicated by the arrow going up and digit one) shows the theoretical path.Following the pre-investigation literature study, further research was conducted into theliterature on variables contributing to the efficiency of EDs in order to establish thefoundation for the central and twelve sub-research questions. From the literature,hypotheses were deduced. The validation of some of these hypotheses could be tested bythe literature, other hypotheses not. This latter path will be further explained in theresearch path (path two, dotted red arrow in figure 2). The hypotheses that could beFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 13
  15. 15. validated by the literature were used in the analysis. In this analysis the theoreticalhypotheses were compared to the outcomes of the interviews in order to make a finalconclusion as to the validity of the hypotheses.Path two (arrow pointing down and digit two) indicates the practical part of this researchpaper. Twelve interviews were conducted and the variables list posed and investigated.Some of the unanswered hypotheses that issued from the literature path (path one) wereanswered by the outcomes of the interviews. The other unanswered hypotheses remainedunanswered, as they were not able to be answered within the scope of this paper. Theywere then placed as recommendations for further research.The main conclusion was reached by answering the central and twelve sub-researchquestions. This could be accomplished by integrating the information of the literatureresearch, the interviews and the analysis. This integration is indicated by the orange lines infigure 2 below.Figure 2: Research pathsFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 14
  16. 16. 3.3 Qualitative researchThis section will elaborate on the reasons for choosing qualitative research.There are three main reasons for choosing a qualitative research method: the design of thecentral research questions and twelve research questions, the need for in-depth informationand the aim of the research paper. These three reasons will be further elaborated on in thenext paragraphs.The design of the central research question and its twelve sub-research questions calls for aqualitative answer. The nature of the central research question requires descriptive,exploratory and explanatory information expressed in words, as well as a flexible means ofdata collection. The research questions have an open design and would benefit more fromqualitative research. In-depth information is preferred in order to answer the central andtwelve sub-research questions adequately. Interviews, as part of qualitative research, canfacilitate in the need for in-depth information. Also, qualitative research enables researchersto ask more in-depth questions during interviews when a certain topic is not clear or notelaborated on sufficiently. Quantitative research cannot contribute to this in the samemanner as qualitative research. The central research question does not prefer a quantitativeapproach, as the data would not be sufficiently extensive or in-depth to culminate in acomprehensive and complete answer.Qualitative research is also desirable, as the aim of this research paper is to developrecommendations based on the current situation in the twelve individual emergencydepartments (EDs). Qualitative research will be able to provide the tools to outline thedifferent processes within the EDs; the bottlenecks on the one hand and the successes onthe other as extensively and detailed as possible. Qualitative research can function as thefirst step in this research on the efficiency and optimization of EDs in the Netherlands.Further research could test the non-validated hypotheses in this research throughquantitative research.In conclusion, the central research question and twelve sub-research questions weredesigned according to the need for in-depth information, whereby the aim of the researchpaper led to the three main reasons for choosing quantitative research as the preferredmethod. The next section will elaborate on the research subjects, population selection andsample size.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 15
  17. 17. 3.4 Research subjects, population selection and sample size This methodology section identifies and discusses the research subjects (population), as well as the method and reasons for selecting this population. Figure 3 on the left gives a short overview of the selection process of the research subjects. The population for this research paper is the emergency department (ED) in the Netherlands. The central research question specifies that the research on the variables contributing to the efficiency and the optimization are focused in the ED. Since the person commissioning this work, Loek Winter (co-founder of the MC|Groep), is based in the Netherlands, the research is conducted in Dutch EDs. It is Figure 3: Selection assumed that interviews with foreign EDs do not add extra valuable of research subjects information for this particular research. Such an assumption is basedon the fact that healthcare systems and working methods in an ED abroad are different. Ifthe focus were to shift to include other countries the results may not be applicable to aspecific ED in the Netherlands.The interviewees functioned as representatives of the ED. These interviewees werequalified as the head or manager of the ED. The head of the ED has the knowledge andinsight to provide the data needed to answer the questions in the interview, as well ashaving access to documentation to support or add to the data in the interview. The head ofthe ED has a background as ED nurse or ED doctor and can thus provide practical andtheoretical information on the different categories incorporated in the interview. Acombination of practical examples and theoretical information are necessary and importantfor insight into the individual situation in a specific ED, as well as tools for thedevelopment of the optimal ED.The selection of the EDs was as follows. First the size of the population was defined as105 EDs in the Netherlands (RIVM, CBS, VHN, 2011). From these 105 EDs, 67 are seenas ‘complete’ EDs and were thus selected on the basis of the selection criteria. A completeED has a 24/7 availability and incorporates eight compulsory specializations (see chapter4.2). From these 67 EDs, a further selection took place according to category (academic,teaching, regional) and location, thus not on a random basis. The category was important asthe type of categorization can be different depending on processes and size, thusFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 16
  18. 18. comparisons can be made between the EDs. Location also formed part of the selectioncriteria, as the geographical location of an ED can reveal a difference in the mentality ofstaff and patients and the ‘loyalty’ element towards the general practitioner (GP) (Giesen,2006) (Olatunde, 2007). To obtain as diverse a view as possible of the EDs, these wereselected throughout the country and the ED choice within each area in the Netherlands(North, East, West and South) was chosen randomly. After selection, the sample size wasreduced to 20 EDs. As research has it, the number of interviews required to achievereliable data and feasibility has not been specifically set, but most in-depth and semi-structured interviews encompass a size of 10-20 interviews. It is also said that “Anappropriate sample size for a qualitative study is one that adequately answers the research question”(Marshall, 1996). Considering the latter and the time frame of the research, 20 interviewswas considered a maximum number.The head or manager of 20 EDs in the Netherlands were contacted by telephone, informedabout the research and asked to co-operate in an interview. In the end the willingness toco-operate was the determining factor in the choice for the final selection of the EDs.Twelve of the 20 EDs approached, were willing to cooperate (2 academic, 5 teaching and 5regional). This list can be found in appendix II. Reasons for the twelve EDs to co-operatewere (personal) interest in the research or a general willingness to help and participate. Theother eight EDs were either too busy at that point in time, did not respond to the requestor did not see the added value of co-operating in the research.As mentioned above, a list of the regions and co-operating EDs can be found in appendixII. The names and exact locations of the hospitals themselves are not mentioned due toprivacy reasons. The hospitals are coded from A-L; categorization was done independentlyof the sequence of the appointments.Concluding this section on the population of the EDs in the Netherlands, a sample size of12 was found willing to co-operate in an interview for this research. Location, category andwillingness were three of the main selection criteria. The next section will discuss the datacollection.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 17
  19. 19. 3.5 Data collection: method of collection and choice for interviews In this section of the methodology, the method of data collection will be discussed. First the method of obtaining the interviews will be described, followed by the choice for interviews and the execution of the interviews. The use of the variables list during the interviews will also be elaborated on. Figure 4 on the left shows the steps in the data collection. As mentioned in section 3.4, the head or manager of the 12 individual EDs agreed to co-operate in an interview. After setting a date for an appointment by telephone, a confirmation e-mail was sent together with the variables list (see next paragraph). The variables list was sent to the interviewees before the appointment itself, to give the Figure 4: Method of interviewees time to prepare. It was decided to visit the individual data collection EDs for a face-to-face interview, as this adds to the reliability andvalidity of the research. The interview lasted approximately one hour and was recordedwith a memo recorder. By recording the interview the focus could be on the collection ofdata and no time was wasted on writing down answers. Recording the interviews isimportant for the reliability of the research. During the interview, the structure of thevariables list acted as a basis and guide for the interview (see next paragraph). At the end ofthe interview, the recordings were transferred onto the computer to serve as a backup.Next to the interviews, some EDs offered a tour though the ED as complementary to theinterview. The tour through the ED, if possible within the time frame, was not recordeddue to potential interaction with other technology and privacy concerns. Information ofthe tour in the ED was written down afterwards in the form of bullet points and was usedas background information for the research itself.The type of interviews in this qualitative research was a combination of face-to-face semi-structured and face-to-face in-depth interviews. As mentioned in section 3.3, the nature ofthe central research question requires descriptive, exploratory and explanatory informationexpressed in words, as well as a flexible method of data collection. Interviews have thecapabilities and tools to accomplish this.Semi-structured interviews allow the interviewer to deviate from the variables list in orderto get the specific information needed in more detail or more concrete terms. In-depthFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 18
  20. 20. interviews have an exploratory and explanatory function. The combination of the twocontributes to ensuring all aspects of the variable list are covered (Saunders, 2007) and thecentral research question and twelve sub-research questions can be answered. Interviewswere conducted in Dutch, as this is the language used at most EDs. To conduct theinterviews in English would have hampered the process. Observation by the tworesearchers of this paper during their visit to the ED was considered as supplementary.Observation allows the information given by the interviewees to be verified by theinterviewers and can also be seen as an additional reason for a face-to-face interview.Observation for a longer period of time in a specific area of the ED was not recommendeddue to privacy concerns and the feasibility of receiving permission to conduct a prolongedobservation.Questionnaires or surveys were not considered as options for data collection, as thesemethods limit the quantity of information that can be collected. These methods are toorestrictive when descriptive, exploratory and explanatory information is needed to reach aconclusion (Saunders, 2007). Also, questionnaires and surveys are the slowest way of datacollection and respondents may not fill in all the fields (Staff, 2011). The interviews had tobe completed within three weeks, so time was scarce. Telephone interviews were not apreferred option, as they make the collection of data less reliable and valid (Saunders,2007). This is also why face-to-face and observation criteria were considered important inthe method of data collection.During the interview, the list of variables was used as a guide throughout the interview.The list of variables has the same structure and sequence as the conceptual model and wasderived from the literature (see chapter 4). Using the same structure throughout theresearch, facilitates the sorting of data. The interview questions are in the form of bulletpoints and not written out in full, this with a view to optimizing the flexibility of thecollection of data. It is easier to deviate from bullet points than questions written out infull, which is important for the descriptive, exploratory and explanatory informationneeded to answer the central research question and the twelve sub-research questions (see3.2 and 3.3). The list of variables can be found in appendix I in the confidential booklet.In summary, a combination of face-to-face semi-structured and in-depth interviews wasconducted at twelve different EDs. The next section will elaborate on the analysis of thedata.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 19
  21. 21. 3.6 Analysis This section will discuss the approach of the qualitative research analysis. Figure 5 on the left shows a summary of the analysis process. After each interview the recordings were transferred to the computer as a backup. Each interview recording was re-played and digitally summarized in Dutch. The reason for digitally summarizing the recordings was to obtain a quick overview of the most important data and save time compared to writing out summaries by hand. The summaries were written in Dutch, as the vast amount of text could affect reliability if translated into English. Figure 5: Analysis For the analysis of the results, the matrix method was used. Matrix process methods are often used in qualitative research for interviews with nofollow-ups. The matrix can distinguish two elements on the horizontal and vertical cellsand can interlink them (Groenland & Jansen, 2010). In this research the two elements werethe codes of the hospitals visited (horizontal) and vertically the variables. The informationfrom the digital summaries of the interviews was transferred using the matrix method. Anexample of this matrix can be found in appendix III of the confidential booklet. It wasopted to use Excel, as less can go wrong when copying information from the digitalsummary into Excel compared to handwritten matrices. Also, transferring data betweendigital systems is quicker than transferring handwritten data. The matrix in Excel followedthe same structure as the conceptual model, as using a uniform structure is easier for theresearcher to work with, as well as for the readers to interpret. The information was copiedinto the matrix in the Dutch language and then transferred to English. Translating fromDutch to English can have an effect on the reliability of the data, however the quantity oftext was limited thus the chance of misinterpretation is minimized. The data was thenwritten out per variable in the results chapter. The same structure as the conceptual modelwas used in the results chapter: the vast amount of information gathered would nottherefore be confusing to the readers. In the results, quotes were used from the digitalsummaries as a foundation for the results and tables were developed functioning as actualtextual elements. By so doing, readers can opt to read either of the two. Quotes from thedigital summaries of the interviews were given an alphabetical reference immediately, so itsFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 20
  22. 22. origin would be clear. However, these quotes, due to privacy reasons, were labeled from A-L (as stated in 3.3) and thus referenced in the same way. The results of the interviews andthe information of the theoretical framework are integrated in the analysis, as this supportsthe final conclusion and recommendations (Miles, 1994). In the analysis, the hypothesesfrom the theoretical framework are validated with information from both the literature andthe interviews or either of the two, if possible. The hypotheses that cannot be clearlyvalidated are used as recommendations for further research. All the information and datafrom the theoretical framework, results and analysis are integrated to answer the centralresearch question and the twelve sub-research questions in the conclusion.In conclusion, analysis is done by transferring the recordings into digital summaries andthen transposing them into a matrix in Excel. The written results are combined with quotesand the tables function as a quick overview and summary of the results. The conceptualmodel structure is used to create a coherent and comprehensive paper. The next sectiondiscusses the reliability and validity.3.7 Reliability and validityIn this section the reliability and validity are discussed.The list of variables was developed by data in literature researched in the pre-investigation.Scientific and academic databases used for the literature research, like EBSCO andPubMed. This makes the list of variables reliable and valid as it is based on prior researchpublished in scientific and academic databases.The number of respondents is twelve. As mentioned in section 3.4, the sample size is seenas valid by research when the number of interviews is between 10-20, or exceeding.Conducting twelve interviews is therefore a correct number, according to literatureresearch, to validate this research. If the time for conducting interviews would not havebeen as limited, as well as more willingness to co-operate by the different EDs, moreinterviews could have been conducted for a higher validity.The profile of the interviewees was similar in education and current function. By selectingsimilar interviewees’ profiles, it can be assumed that the knowledge of the organization issimilar as well as the level education of the interviewees. This has a positive effect on theoverall reliability and completeness of the answers, as well as the understanding of thequestions posed during the interview. Data collection, in the phase of conducting theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 21
  23. 23. interviews, was performed in Dutch. This makes the data obtained from the intervieweesmore valid and reliable as Dutch is the leading language in an ED. Collecting the data inDutch also made it easier for the possibility to ask in-depth questions. However, as Englishis the obligatory language for this research, the data was translated into English in thematrix. This could have affected the validity of the data.The data for this research was collected in twelve different EDs, in twelve differenthospitals throughout the Netherlands. Collecting data at different locations makes the databetter comparable with each other and more generalizable, as the variables are answeredtwelve times in different situations. Moreover, the chance of bias is reduced by notcollecting data solely in one organization, making the collected data more reliable.However, it must be taken into account that interviewees could have given social desirableanswers, due to for example not wanting to provide certain information or turning certaininformation in such a way that it is presented better than the actual situation at themoment. Also, not all interviewees were able to give the full data needed for certainvariables, as they were not entirely familiar in certain areas. Both reasons mentioned canreduce the reliability of the data, as completeness of the data is reduced.Data was collected in the same manner throughout the interviews, making the method ofdata collection more reliable. The variables list was used as a guide through the interviewsand additional in-depth information was derived by posing specific questions. Datacollected from the interviewees was therefore quite broad and only specific parts had to beselected to obtain the information needed to attain an answer on the different variables.This selection process was done as cautious as possible. However, it must be taken intoaccount that in this process data loss could have taken place. Semi-structured interviewsallowed for answers to be compared more easily, thus increasing the reliability of thecomparison. Also, face-to-face interviews increase the validity and reliability of the answersduring the interviews. Observation of the situation at the ED contributes to this.Data was recorded by means of a memo recorder and the two researchers of this paperwere always present at the interview. In this way the loss of data was reduced and digitalsummaries could be made more accurately. Both reasons add to the reliability of the data.The matrix method used in the analysis is a reliable and valid analyzing method whenhaving conducted interviews. This method provided a short and clear overview of the datacollected, in order to easily and reliably compare the data. The translation of the DutchFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 22
  24. 24. language into English when data was transferred to the matrix, might have affected itsvalidity.The following section will discuss the operational conceptual model.3.8 Operational conceptual modelFigure 6 below shows the operational conceptual model. The operational conceptual modelis comprised of the conceptual model as illustrated in chapter 2, with the methodologyintegrated in it. This model functions as a quick and brief overview of the methodology,indicated in orange.Figure 6: Operational conceptual modelFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 23
  25. 25. 4. Theoretical framework4.1 IntroductionThe theoretical framework is part of the theoretical path in this research, as illustrated infigure 2 in the methodology (chapter 3). In this chapter, each of the seven variables in theconceptual framework (chapter 2) will be researched via the available literature. Definitionswill be explained, as well as the foundation for the seven variables. The theoreticalframework was written with the central research question and the twelve sub-researchquestions in mind.The structure of this chapter is as follows. The theoretical framework consists of fivesections. The first section is the introduction, as presented here. The second section willelaborate on the definitions and characterizations of an emergency department, followed bythe third section on relations between efficiency and optimization. The fourth section willpresent the different variables that influence the efficiency of the emergency department.This section consists of the seven sub-sections, in which the seven variables as mentionedin the conceptual model (chapter 2) are discussed; infrastructure, technology, service,employees, logistics, financial system and patient satisfaction. The last section will give anoverview of the hypotheses that are deduced from the literature.Each section will be introduced showing a highlighted area of the conceptual model,indicating the variable that is being discussed and thus sustaining a clear structure. Allsections will start with an introduction, explaining the relevance of the section to thecentral research question and one or more of the sub-research questions. Each of the sevenvariables will end with a short conclusion and a hypothesis derived from that sub-chapter.These hypotheses will be further elaborated on in the results and analysis (chapter 5).Several abbreviations will be used throughout the paper for the sake of brevity andefficiency. These abbreviations will be expressed in full in the sub-chapter introductions.An explanatory list of these abbreviations can be found in appendix IV.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 24
  26. 26. 4.2 Emergency departments The following paragraphs will elaborate on the definition of an emergency department (ED), the division of the emergency departments (EDs) in the Netherlands and their patient categories. This section is related to research question 1. The position of this section in the conceptual model is indicated by figure 7 on the left.Figure 7: Position of emergency departmentThe ED is a multidisciplinary specialized department within a hospital organization. AnED provides medical and nurse related care to patients visiting the ED. These patientsarrive at the ED with traumas or acute health problems (RIVM, 2011). A definition of anED in the Medical Dictionary suggests: Emergency department: The department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care. Emergency department personnel may also respond to certain situations within the hospital such cardiac arrests. (Websters New World™ Medical Dictionary 3rd Edition, 2000)An ED can be classified as a ‘complete’ or full ED when it has 24/7 availability and thehospital itself comprises at least the following eight specific specializations: internalmedicine, surgery, gynecology/obstetrics, pediatric medicine, neurology, cardiology, ear-nose-throat (ENT) medicine and ophthalmology (RIVM, 2011). EDs are obliged toexamine every patient that visits an ED, a guideline stipulated by the Dutch Public HealthInspectorate (IGZ).In 2010 the RIVM indicated the presence of 105 EDs in the Netherlands and 128 HAPs(Huisartsenpost; general practitioner’s co-operations). In 2008 104 EDs were indicated ascomplete or full EDs. However, the RIVM has indicated that in 2010 only 67 could beclassified as a complete ED. Reasons for this were mergers between hospitals,concentrating multiple locations into one new location, the closure of hospitals and the lossof different specializations due to a decrease in demand for specific specializations (RIVM,2011).Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 25
  27. 27. Research indicates that many health problems can be treated by the HAP rather than theED. Therefore, EDs and HAPs are now trying to enhance their co-operation and worktogether. By setting the HAPs as primary caregivers for patients, this could make acute caremore effective as non-urgent patients can be redirected to more suitable locations toreceive care (RIVM, CBS, VHN, 2011). A detailed map of the location of EDs and theHAPs can be found in appendix V.Patients visiting the ED can be divided into the following categories:  Self-referrals  Patients referred by their general practitioner (GP)  Patients under treatment of a specialist  Patients who arrive by ambulance  Patients referred by others  Patients that have in the past visited the ED and come back for a back-up check (Nederlandse Vereniging Spoedeisende Hulp Verpleegkundigen, 2005)Annually, EDs in the Netherlands receive around 1.8 million patients. Approximately 20%of these patients are admitted to the hospital, 45% return for a follow-up, 30% returnhome with an appointment for the outpatient clinic, 15% receive subsequent treatment bytheir GP and 33% return home without any further follow-up. In general, 45% of thepatients visiting the ED are self-referrals, 28% are referred by the GP and 7% arrive byambulance. Nearly 29% of the self-referrals visit the ED with no necessity for acute careand are therefore considered as being in the wrong location (RVZ, 2003). However, thesepercentages are not applicable to every hospital as they are general numbers. It is clear thathospitals in the north and east of the Netherlands have a different ratio in self-referralsthan hospitals in the west, central Holland and in the cities (RVZ, 2003).In conclusion, the ED is a specialized department within a hospital providing medical careto trauma or acute patients visiting the ED. In the Netherlands 67 ‘complete’ EDs havebeen identified. Co-operation between the ED and HAP can redirect patients to moresuitable locations for non-urgent patients.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 26
  28. 28. 4.3 Efficiency and optimization Efficiency and optimization are terms used in the central research question and throughout this research paper. The relevance of this section lies in the importance of defining both terms properly, in order to use them correctly in this research paper to arrive at a conclusion. This section will provide the definitions of both terms and their relation to each other. Research questions 2, 3 and 4 are applicable. Figure 8 on theFigure 8: Positionof efficiency and left shows the position of this section in the conceptual model. optimization4.3.1 EfficiencyLiterature identifies many definitions of efficiency. The business dictionary definesefficiency as “The comparison of what is actually produced or performed with what can be achieved withthe same consumption of resources (money, time, labor, etc.). It is an important factor in the determinationof productivity” (Business Dictionary, 2011). Efficiency is also referred to the ‘how’ ofoperations and looks at inward processes, thus questioning whether the work is relevant,correct and delivered in the right way to achieve the strategic outcomes (Hubbell, 2007).Efficiency is geared towards individual processes within a system, stated in the literature asvariables. Definitions of efficiency related to healthcare are mostly cost or process oriented.In health care cost models, efficiency is defined as; the weighted sum of outputs forhospital A divided by the weighted sum of input by hospital A (Fulton, Lasdon, McDanielJr., & Nicholas, 2008). Palmer and Torgerson define efficiency in healthcare as “health careresources that are used to get the best value for money” (Palmer & Torgerson, 1999). The UnitedStates Government Accountability Office defines efficiency as “providing and ordering a level ofservices that is sufficient to meet patients’ health care needs, but not excessive, given a patient’s healthstatus” (McGlynn & Shekelle, 2008).Combining the definitions above, the following definition of efficiency in healthcare can bedeveloped: “Efficiency is to provide and order a level of service that is sufficient to meet the patients’ health-care needs,where operations and processes are questioned on their relevance to achieve the strategic outcomes and where the health-care resources are used in such a way as to get the best value for money”Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 27
  29. 29. 4.3.2 OptimizationOptimization in general is defined as “Finding an alternative with the most cost effective or highestachievable performance under the given constraints, by maximizing desired factors and minimizingundesired ones. Practice of optimization is restricted by the lack of full information, and the lack of time toevaluate what information is available” (Business Dictionary, 2011). Optimization aims toimprove or solve the identified problems in order to improve and maximize healthcareservices in the following areas in the best way: planning, delivery and management (Rais &Viana, 2011). In an optimization process, the goal is to design a system or process asfunctional and perfect as possible and the focus should be on the application of resourcesand balancing the individual areas in healthcare. Continuous improvement is important ashealthcare is a dynamic setting and it is seen as the progress towards optimization (Wayne,2008).4.3.3 Relation between efficiency and optimizationEfficiency and optimization are interrelated. Efficiency can be seen as the steps to achievean optimum situation. Optimization refers to the best possible way in which a system orprocess can be designed, in which the focus should be on the application of resources andbalancing the individual areas in healthcare (Wayne, 2008). In efficiency, the individualprocesses are questioned on their relevance and improved or changed to improve theirefficiency. By continuously improving and redesigning the efficiency of the system and itsindividual processes, progress is made towards an optimal situation (Wayne, 2008)(Hubbell, 2007).In conclusion, optimization can thus be achieved by making the system and its individualprocesses as efficient as possible, depending on the timeframe and possibilities of aparticular organization.4.4 The seven variables Based on the literature, seven different variables have been identified as having an effect on the efficiency of an emergency department (ED); infrastructure, technology, service, employees, logistics, finance and patient satisfaction. The seven variables will be discussed further individually in the following sub- section, as will their contribution to the efficiency of an emergency department (ED). These seven variables are related to research questions 6-12. Figure 9 Figure 9:Position of the indicates the position of this section in the conceptual model.seven variablesFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 28
  30. 30. 4.4.1 Infrastructure The first of the seven variables that contributes to an efficient emergency department (ED) is infrastructure. Infrastructure includes the sub-variables layout of the ED and the Huisartsenpost (HAP; general practitioner’s co- operation). Research question six is applicable here. Figure 10 indicates the position of this section in the conceptual model. Figure 10: Position infrastructure variable4.4.1.1 Emergency department layoutThe layout of an emergency department(ED) has an effect on the long-term success of itsoptimization. This will be further explained in the following paragraphs.Overcrowding is a major problem worldwide. It has been stated that building a new stateof the art ED or increasing personnel will not solve all the problems as the ED must firstidentify and investigate the bottlenecks in its processes. Internal reasons for overcrowdingcan be ED boarding1, inefficient registration and discharge processes. External factors canbe limited access to primary care, uninsured people and a growing ageing population(Toledo Business Journal , 2009) (Harking, 2011). However, overcrowding not only affectsthe ED but also the input (community), throughput (ED) and output (hospital). Problemsin all three elements must be identified and addressed to achieve improvement inovercrowding (Jarousse, 2011).Generally speaking, different notions have been expressed in research as to the physicallayout of an ED (Przybylowski Jr., 2010). Below are some examples.The ED should provide a safe and welcome setting. The first impression is important andwill determine the whole ED visit experience (Greene, 2002). Green, blue and naturalmaterials used for the interior seem to have a positive effect on the patient’s experience ofan ED visit (Straczynski, 2011). Also accessibility and parking at the ED play a role inpatient satisfaction (Jarousse, 2011). Safety is important, and examples are in the form ofclosed-off doors and security. Registration normally takes place at the entrance to the ED,however bedside registration through an electronic device (e.g. iPad) is on the increase in1Boarding: when a patient remains in the emergency department after the patient has been admitted to the facility, buthas not been transferred to an inpatient unit.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 29
  31. 31. order to save space in the waiting-room and speed up the registration process (Greene,2002).Waiting-rooms benefit from having a television, internet access (throughout the ED),refreshment facilities, games and reading material to keep the waiting patients and familysatisfied and calm (Zilm, 2003) (Romano, 2003). Questionable in research is whether to userows of chairs for safety reasons, or make the waiting-room more attractive by adding adifferent kind of seating configuration (Greene, 2002).The corridors and treatment rooms must be spacious (Toledo Business Journal , 2009).Lighting must preferably consist of natural light or indirect lighting. Attention must be paidto a quiet environment and good lighting (Wolf, 2010). The most important rooms forurgent care must be placed near the ambulance entrance (Peck, 2011). The materials forceiling, wall and floor must be easy to clean. Walls must contain sound insulation to reducenoise (Peck, 2011). It is important to prioritize what has to be an essential part of theclinical area (center) and the outside (periphery).To create visibility and a good overview of the ED, the ballroom layout is recommended.The ballroom setting means that the central nursing station is placed in the middle, with thetreatment rooms around it. This is beneficial to both patients and staff; easily accessibleand close proximity (Zilm, 2003). However, research has indicated that when the numberof treatment rooms exceeds 18, the ballroom setting is no longer effective. In the lattercase, either the ballroom setting should be duplicated and two ballroom areas created, orthe EDs should investigate linear units. In the linear setting the rooms are situated inparallel rows to make the area more ’expandable’. Also, less space is needed and theeffective walking time for staff is 25% less than that for a ballroom setting. The linearsetting is also compared to the shape of a thermometer, where patients are positionedaccording to quiet and busy periods (Zilm, 2003). The central nursing desk would benefitfrom partly glass covered surroundings. This creates an overview for the staff and patientsand is sound-isolating (Carolina, 2010). A digital board at the central desk in the ED isrecommended as it gives an overview of the situation within the ED itself: “With the whiteboard you didnt know the department was getting crowded until it was crowded” (Greene, 2002).Uniform treatment rooms create flexibility as to their use. Treatment rooms can be gearedtowards specific health issues. However, the treatment room can also be transformed into auniversal treatment room (Greene, 2002). To increase patient privacy and flexibility inFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 30
  32. 32. visualizing the patient, (sliding) doors with curtains are advised. Treatment rooms shouldbe separated from each other by means of walls to increase patient privacy (Peck, 2011), aswell as to reduce the risk of infection. For privacy reasons, most rooms should be singlepatient rooms. This also reduces the risk of wrong medication, incorrect treatment, cross-contamination, faulty follow-up or staff injury (Sprague, 2007). Semi-individual rooms,especially for orthopedic and geriatric patients, can have a therapeutic function and aretherefore to be preferred over single rooms (Sprague, 2007). For efficiency purposes, thetreatment rooms should only contain essential supplies. The use of mobile carts for othersupplies is recommended (Przybylowski Jr., 2010). Other research suggests keeping stocksof supplies and medicines in each treatment room to save treatment time (Wolf, 2010).Important information or graphics should be placed on the left or right wall from the bedso the patient can see it, rather than behind the bed, with the bed placed in the middle(Carolina, 2010). Indirect lighting is recommended, also above the bed. A flexible arm withdiagnostic light should also be present (Peck, 2011). A sink and a built-in garbage box mustbe included for hygienic reasons (Sprague, 2007). Questionable in research is whether ornot to place a telephone and/or television in the single patient rooms (Romano, 2003).A distinction between high-care and low-care patients must be made. High-care patientsshould be situated in the core of the ED, low-care patients must be located peripherally.The latter do not necessarily need a bed in which to wait; a waiting-room also suffices: “Werecognized that not all ED patients are sick enough to require beds the entire time they are there”(Przybylowski Jr., 2010). For non-urgent patients, the PDQ theory (Physician DirectingQueuing) can be used, whereby patients are divided into needing (additional) diagnostictesting and not needing it (Przybylowski Jr., 2010). The first group can undergo diagnostictests and wait in a special waiting-room for the results; the latter can be treated in theperipheral treatment rooms and then discharged. There should be a sufficient number offit-for purpose waiting-rooms in the ED, located adjacent to the main arrival waiting-room.An important premise as part of the process in an ED is that treatment rooms should notbe used as waiting-rooms (Przybylowski Jr., 2010). An example of this layout can be foundin appendix VI.For non-urgent patients a fast track or a RADIT program (Rapid Assessment andDischarge In Triage) could improve patient satisfaction and reduce waiting times. TheRADIT program was designed to be used in peak times, generally stated as being between2 pm and 10.30 pm. Non-urgent patients do not need to use a treatment room, but will beFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 31
  33. 33. provided with screening, examination and a diagnosis in the specifically designed RADITarea. If simple diagnostic tests are needed, patients can wait in the RADIT treatment areafor the results. The RADIT has been stated to achieve a 98% satisfaction rate amongpatients (Vega, 2007).Depending on investment opportunities and the availability or otherwise (lack) of specificemployees, the preferred location for diagnostic imaging would be located in or adjacent tothe ED for optimal efficiency: “The best of both worlds is to have the hospitals radiology departmentjust eight feet across a corridor from the ED so you can share staff” (Greene, 2002). The same appliesfor lab facilities (Przybylowski Jr., 2010). Due to the frequent requests for X-rays, a mobileX-ray device could be useful (Greene, 2002). Non-urgent patients should not wait fortransport, but walk to the diagnostic test rooms themselves: ‘We move less-sick patients throughthe system a lot faster’ (Harking, 2011). Digital information systems let physician’s accesspatient information also outside the ED, thus making this process more efficient (Zilm,2003).Concluding, the ED layout affects the long-term success of its processes. To avoidovercrowding it is desirable to have the correct layout. In order to create visibility and agood overview of the ED, the ballroom layout is recommended. To improve the process,diagnostics should be located within or next to the ED for optimal efficiency. Furtherliterature recommends making a distinction between urgent or high-care patients and non-urgent patients. High-care patients should be located around the nursing station and non-urgent patients can follow the RADIT program.The following hypothesis can be formulated, based on the literature in the section above: Hypothesis 1: the layout of the ED affects the long-term success of its processes.4.4.1.2 The HuisartsenpostThis section elaborates on the function of the HAP (Huisartsenpost) and its co-operationwith the emergency department (ED). This has an influence on the efficiency of theprocesses and procedures in an ED.The Dutch term HAP refers to a Huisartsenpost. A HAP is a center in, next to or locatedoutside the premises of an ED. General practitioner’s co-operate together in a center toprovide care outside working hours. In the literature a HAP is often translated as ‘out-of-Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 32
  34. 34. hours general practitioners’, ‘general practitioner’s organization’, a ‘general practitioners co-operation or the function of a GP in the ED as PCP (primary care provider) (Chew-Graham, 2004) (Winters, 2009) (Philips, 2010). The following quote defines that a HAP isavailable outside working hours for urgent medical care that cannot wait till the nextday:“Huisartsenposten zijn er voor acute vragen van patiënten buiten kantooruren en bieden medische zorgdie niet kan wachten tot de volgende werkdag” (Gijsen, 2010). During the day the patient can visithis/her own GP or one nearby. After working hours and in the weekend patients can visita HAP for less urgent medical care. The standard procedure for a patient is to call theregional HAP number, after which a secretary or assistant will triage the patient bytelephone. For this triage the NHG2 guidelines are used, which are almost identical to theNTS system (see 4.4.5.1; triage systems). The urgency code determines whether a visit tothe HAP is required (NHG, 2010) (Gijsen, 2010).Integration and co-operation between a HAP and ED is seen as an important factor for thesolution of the overcrowding in EDs and its provisions. Overcrowding is mainly caused bynon-urgent patients, accounting for 40% of the ED visits that could actually be seen by aGP (Van Uden, 2004). Dutch research on the integration of HAPs and EDs in theNetherlands concluded the following: “There was a shift of more than fifteen percent from secondarycare to primary care for emergency consultations and waiting/consultation times were shortened by morethan ten percent” (Kool, 2008). Research also stated that just over 25% of the patientspresenting themselves at the GP have unspecified problems and questions aboutmedication. Dutch health policy-makers believe that improvements in the efficiency andquality of care at a lower cost occur when HAPs and EDs are integrated and collaboratewell with each other (Moll, 2007). Research also questions the need for the ED, ambulanceand HAP to be active during hours when few patients make use of it due to inefficienciesand costs (Giesen, 2006). Three main advantages of a HAP are: ED diversion to alternativecare, care co-ordination to reduce the use of EDs and the accessibility of services (need tocreate awareness for this) (Harking, 2011): “Reducing inappropriate and unplanned hospitaladmissions enables services to work at optimum efficiency. This helps to ensure that the patients who trulyneed these services are seen as quickly as possible” (Winters, 2009).Advantages of good co-operation between the HAP and ED lie in the ‘redirection’ ofpatients. The discrepancy lies in the perception by clinical staff read healthcareprofessionals and patients as to what is ‘urgent’ (24% of self-referred patients think they2 NHG: Nederlandse Huisartsen GenootschapFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 33
  35. 35. need diagnostic tests). This discrepancy in perception impacts on the use of the ED andcan be dealt with by good co-operation between the HAP and ED as well as the provisionof good information to the patient on the specific tasks of the healthcare services.Information should include the availability of GPs, costs and explanatory texts as to thelack of the need for diagnostic tests in the case of many injuries (Philips, 2010) (Gill, 1996)(Lowe, 1997). Research suggests that the co-operation between HAP and ED could reducecosts and increase effective care. However it has not been substantiated that co-operationsubstantially reduces the total number of patients visiting the ED (Philips, 2010).Redirection to a HAP, located in an ED, on or offsite of the hospital complex, isconsidered effective as many patients visit the ED for non-urgent care. However, this isonly effective when the care needed by non-urgent patients can be done by a GP, withoutthe involvement of the facilities or staff of an ED. The location of the HAP in accordancewith the ED is not as important as the communication between the two (Harking, 2011).Speed and convenience are also factors that determine whether to visit the ED or HAP(Moll, 2007).In conclusion, by integrating the HAP with the ED, efficiency improves and the quality ofcare can be performed at a lower cost. There are several advantages when they both co-operate well. The most important advantage can be found in the redirection of patientsfrom the ED to the HAP. It is more effective as many patients visiting the ED are non-urgent patients, which can be treated by a GP. As such, the following hypothesis can beformulated: Hypothesis 2: the integration of a HAP and an ED improves the efficiency and quality of care at a lower cost.4.4.2 Technology This variable consists of 2 factors: software and digitalization. Research question seven is related to this variable and the figure on the left shows the position in the conceptual model. Figure 11: Positiontechnology variableFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 34
  36. 36. 4.4.2.1 Software and digitalization of patient dataDigitalization and the incorporation of a hospital-wide uniform system contribute to amore efficient way of accessing information, improving quality and minimizing medicalerrors.The role of ICT in hospitals has increased over the years. The main reasons for this are theincreasing digitalization processes in hospitals, rising software costs, an increase in thepossibilities and complexity within the different software, increasing integration of hospitalsystems, increase in the number of computers, dependence on software and personnelcosts. Software and personnel account for 70% of ICT costs. Internal auditing systemscould monitor and raise an awareness for the increasing costs, as well as lead to thestandardization of the applications and type of software used within hospitals (vanEekeren, 2011).Hospitals make use of different software programs. Well known software in theNetherlands is Chipsoft, SAP, iSoft, Xcare and PACS (digital imaging). The effectivenessof the software depends on the culture and structure of the ED and specific hospital(Busca, 2010). The Electronic Patient Record (EPD) is an integral part of this software. Initself the content is not complex, yet what is is to make all the processes around itinterchangeable and transparent for the different stakeholders. Although the system issimilar in every hospital, the usage method at both macro and micro levels is, as these differconsiderably per hospital. This is what makes integration at a macro and micro level morecomplex (van Eekeren, 2011) (Smits, 2010).Independently of the type of system that is used, research has shown that the usefulnessfor the user is more important than the number of functions available in the softwaresystem. Also, the planning and structure of the information must tie in with the structureof the ED (Busca, 2010). As Busca states in his research: “In short, for a computer application tobe capable of dealing with the complexity of an ED, it must incorporate three elements: operations insideand outside the service, apply intuitive and multiuser user interfaces, and be able to carry out an efficientmanagement of data at the macro, meso and micro levels” (Busca, 2010). Making use of informationand communication technology has also been stated to improve the professionaldevelopment of health professionals (Mugisha, 2009).The effect of ICT and digitalization is thought to have a major impact. The benefits willFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 35
  37. 37. only become apparent if the different software systems are incorporated in a systematicform, this in contrast to many hospitals worldwide. The benefits of a systematicincorporation are: more effective and rapid healthcare, accessibility of information, shift toevidence based medical care, improvement of the quality of patient care, a reduction induplication and minimizing medical errors (Anvari, 2007). Research has shown that apaperless environment can reduce transcription by 65% and charting by 85% (Hancock,2000). Besides, a full digital system results in greater and more efficient documentation ofthe patients’ data and results (Elder, 2010).Failure or less effective usage of a digital system lies in the lack of user focus, as the usageby different professionals can have an adverse effect on its supportive role in clinical work(Koch, 2003). In addition, some systems are less compatible with each other. Diagnosticimaging is one that is frequently referred to. Research has also revealed that moredocumentation can have a negative impact on the communication of new information andresults to the patient. A sound structure and a systematic approach are vital (Elder, 2010).In summary, the role and costs of ICT within the health sector have increased due todifferent factors. The effectiveness of the software that the hospital uses depends on thestructure and culture of the ED and the hospital itself. By using information andcommunication technology, improvements in professional development can be measured.To create these benefits, the system should be incorporated throughout the hospital.Based on the literature above, the following hypothesis can be derived: Hypothesis 3: digitalization of patient data has both a positive and negative effect on the processes in the ED.4.4.3 Service The third variable is service; this comprises on the one hand patient satisfaction and on the other quality of management and performance indicators. The patient satisfaction aspect of service will be dealt with in sub-chapter 7 (Patient satisfaction, variable 7). This sub-chapter on service focuses on the quality and performance indicators needed toFigure 12: Position maintain the standards of healthcare and compare these with each other service variable in order to improve the processes within the emergency departmentFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 36
  38. 38. (ED). Service relates to research question eight and the position of the service variable isindicated in figure 12 above.4.4.3.1 Quality and performance indicatorsQuality and performance indicators may have an effect on efficiency when comparingdifferent emergency departments (EDs), but only when these indicators are standardizedamong all EDs in the Netherlands. “Quality: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (El Sayed, 2011).Measuring the quality of care and performance in an ED is complex, as it is influenced bymany different factors. The need for higher quality at lower costs and improved patientcare co-ordination makes it important to continuously monitor processes and theireffectiveness, as well as develop and improve quality programs. Quality measurement andperformance indicators must be “[…] evidence-based performance indicators that can be nationallystandardized so that statewide and national comparisons can be made” (El Sayed, 2011). Evidence-based indicators are also important to measure the effectiveness of the ED system,especially patient outcomes and clinical conditions. The aim of quality management is theimprovement of the ED unit and patient satisfaction. Evaluation and comparison of qualityis challenging due to the lack of integration of the system, lack of uniformity in thecollection of data, lack of consensus on performance indicators and the lack of agreementin the assessment of its validity (Sobo, 2001) (Spaite, 1995). Specific training on qualitymanagement implementation is therefore advisable, for management and ED staff alike(Dellifrane, 2010). The level of quality and efficiency in the ED on weekdays or weekendsmay vary. Some research suggests an increase of quality and efficiency in the weekends;some show a decrease at the weekend. Reasons for this vary from the availability role of anED to staff expertise. Geographical location, patient ethnicity and patient categories play arole in this (Miro, 2004). Quality measurement can be divided into three levels (Laffel,1989) (Berwick, 1980): 1. Quality Assurance: inspection of services by internal and external parties 2. Continuous Quality Improvement: continuous improvement through set programs, guidelines and communication 3. Total Quality Management: quality improvement and the use of quality indicatorsFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 37

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