MSc Thesis "Optimization of Emergency Departments in the Netherlands"
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MSc Thesis "Optimization of Emergency Departments in the Netherlands" Document Transcript

  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. (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
  • 39. by front line-workers, as well as effective and committed leadershipThe goal of quality indicators is transparency and measurability of the quality in healthcare.The outcomes can be used to profile an organization or institute or improve quality. Thesupervision and monitoring of healthcare quality indicators in the Netherlands is theresponsibility of the IGZ, the Dutch Healthcare Inspectiorate. The IGZ publishes anannual report, per healthcare sector, on the quality indicators for the forthcoming year.Quality indicators in healthcare lack transparency, validity, uniformity and could nottherefore be compared with each other at national level.. The IGZ collaborates with theparties it monitors and as from 2007 also co-operates with ‘Zichtbare Zorg’ (transparenthealthcare). The latter started a program on transparent healthcare in 2007 and will as from2013 be known as the quality institute and all healthcare sectors will be responsible fordeveloping and maintaining quality indicators (IGZ, 2011) (Zichtbare Zorg, 2011).The report on basic quality indicators 2012, states that emergency processes, as in ED, donot have their own set of quality indicators (IGZ, 2011). An ED in the Netherlands has tocomply with the Kwaliteitswet Zorginstellingen (quality law re healthcare organizations).Three main pointers in this are (1) delivery of responsible healthcare, (2) a clear and soundpolicy as well as good communication, co-ordination and a clear division of tasks at alllevels of the organization, (3) monitoring and improving the quality of care and (4)evaluation and adjustment of the policy (SEH, 2009). Quality management in general canbe done internally and externally. Internally through for instance training, workshops andpeer reviewing. Training among staff both individually and as a team has been proveneffective for the reduction of errors, team behavior and staff attitudes. Communication anddigitalization of data also plays a role. This consequently has effect on the quality ofperformance of the ED, as well as patient satisfaction (Morey, 2002). Additionally, staffshould be qualified as ED doctor or ED nurse, according to the guidelines. External qualitymanagement through certification, accreditation and/or visitation. There are certain bodiesthat provide this to healthcare organizations. These bodies use quality norms as a basis.Examples of these bodies are (IGZ, 2011) (Zichtbare Zorg, 2011):  NIAZ (Nederlands Instituut voor Accreditatie in de Zorg): non-mandatory accreditation of health-care organizations by means of peer review (NIAZ, 2011).  HKZ (Harmonisatie Kwaliteitsbeoordeling in de Zorgsector): develops quality and safety norms and issues a HKZ certificate if the organization has met the norms. ItFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 38
  • 40. is non-mandatory and is qualified under the international ISO 9001 (HKZ, 2011).  ISO (International Organization for Standardization): the largest standard development organization in multiple sectors, bridging the public and private sectors (ISO, 2011).  VMS (Veiligheid Management Systeem): focused on patient safety and reducing the number of claims submitted by patients to hospitals. There are ten points that are most effective in increasing patient safety (VMS, 2011).As from December 31st 2012 all hospitals in the Netherlands must be either accredited orbe in a possession of a VMS certification (VMS, 2011).In conclusion, measuring the quality of care and performance in an ED is complex. Qualitymeasurement and performance indicators are conducted in order to improve the ED andpatient satisfaction. However, there is no standardized quality measurement in the ED.Several institutions are investigating the use of standardized quality indicators in order tocompare various hospitals with each other.This hypothesis stated below can be derived from the literature above: Hypothesis 4: standardized performance indicators enhance the quality of the processes of the ED.4.4.4 Employees The employees in an emergency department (ED) can contribute to the efficiency of an ED in different ways, depending on the type of employee. This sub-chapter will elaborate on emergency department doctors (ED doctors) and emergency departments nurses (ED nurses), including triage nurses and nurse practitioners (NPs). Research question nine is applicable Figuur 13: here and figure 13 on the left indicates the position in the conceptualPosition employee variable model.4.4.4.1 Emergency department doctorsEmergency doctors (ED doctors) have an effect on the efficiency on an emergencydepartment (ED). The reasons for this will be explained in the following paragraphs.In recent years, the discussion on the efficiency of ED doctors has been divided. There areadvocates and critics. Some endorse the idea, but criticize the fact that there are notFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 39
  • 41. sufficient ED doctors available to staff their services. In 2000, a small number of hospitalsin the Netherlands initiated training for ED doctors. To this day, there is still a debateabout the positioning, acceptance and responsibility of an ED doctor. Plexus MedicalGroup researched the effectiveness of ED doctors in the Catharina Hospital at Eindhoven.This was conducted by measuring the speed and number of requested diagnostic tests,customer focus and medical practices. This research showed that ED doctors are moreeffective in treatment time in three of the four urgency categories; thereby resulting in afaster treatment time. All of this can be explained through the special training for EDdoctors, specially geared towards the situation in EDs. It also means that they can treat thepatients independently without consulting specialists outside the ED. On the other hand,the doctor’s assistants do need to consult the specialist outside the ED before embarkingon a treatment. This element makes for significant time savings. Furthermore, it has beenshown that ED doctors have less extensive requests for additional diagnostic testing thanthe doctor’s assistant, in view of the former’s experience. Therefore, the ED doctors cansave time on the speed and the number of requested diagnostic tests as well in the medicalpractice itself (Maas, 2007). However, the advocates of ED doctors do have variouscriticisms. The organization determines the quality of the ED and not the type of doctor(Gans, kathan, ter Maaten, & van Offenbeek, 2008). The purpose of introducing EDdoctors to cut supervision and thus treatment times has not been affected. Moreover, it isnot confirmed that the quality of care performed by an ED doctor is superior to that of adoctor’s assistant and an ED doctor is considered more a generalist-type doctor comparedto the specialists consulted via an ED (Gans, kathan, ter Maaten, & van Offenbeek, 2008).Currently, not enough students are graduating to provide every ED with full-time EDdoctors. This poses difficulties in investigating the efficiency of ED doctors in an ED unit.In conclusion, the opinions as to the effect of an ED doctor on the efficiency in an ED arevery diverse. Those in favor mention time savings in various areas as a benefit, whilst thoseagainst question this. The shortage of ED doctors and their lack of specific training aremaking it difficult to validate their effect on the efficiency in the ED.4.4.4.2 Emergency department nurses, triage nurses and nurse practitionersThe efficiency of an emergency department nurse and triage nurse lies in the coordinationof patient care and their impact on the patient’s peace of mind.The ED nurse is important in the process of co-ordinating patient care and theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 40
  • 42. cooperation with physicians. 88% of all nurses work in hospitals and specialization anddifferentiation are becoming increasingly important, also as an ED nurse (Derlet, 2002).Qualified ED nurses must meet at least the following criteria: finalized the basic educationin nursing, obtained a specialized degree in ER nursing, completed triage training andregular training on TNCC (Trauma Nursing Core Course), BLAS (Basic and Advanced LifeSupport), ENPC (Emergency Nursing Pediatric Course) and the PALS (PediatricAdvanced Life Support). Maintaining the quality of the ED nurse is done throughregistration in the BIG register, the NVSHV (nursing organization), obtaining the abovequalifications and regular training updates and peer reviewing. For the quality of the ED,there must always be at least one ED nurse present with a qualification in pediatric careand trauma care (NVSHV, 1996) (NVSHV, 2005) (SEH, 2009).Literature is questioning whether the ED nurse should be assigned one particular task, astriage nurse, during certain shifts. In the Netherlands there is not one single specificmethod for this; some hospitals assign a specific triage nurse to ensure all the triages aredone in a separate room, some partly by the secretary or fully by an ED nurse in the EDitself. By not having one single method, it is more difficult to influence waiting times andturnaround times (SEH, 2009). Nurse triage has been widely adopted in the US and theUK; however, opinions as to effectiveness vary as per the literature. A triage nurse ensuresthat a patient receives the right urgency code and initial assessment. The effect a triagenurse has on waiting times, especially for urgent categories, is two-fold. Triage nurses doactually reduce the anxiety and frustration experienced by the patient (George, 1993).Triage must be started within five minutes after arrival, as this has a positive impact on thepatient who feels he/she is being attended to. Research shows this often increases to 10minutes, but the extra time taken has not been shown to have a negative impact on thepatient’s satisfaction. In addition, a triage nurse ensures that the patient is treated at theright level and location, making efficient use of the resources of an ED. A triage nurse isonly effective when triage is the primary focus and is not being delayed by non-primaryresponsibilities (Buckles, 1990) (Bailey, 1987) (Neades, 1997).There are varied opinions about the role of a nurse practitioner, a NP, in an ED. An EDnurse practitioner (NP) is seen as an efficient element within the setting of non-urgentpatients. NPs can reduce workload, reduce waiting times in the ED, improve patient care,safety, deal with (difficult) accompanying persons and reduce pressure on junior doctors(Rao, 1995) (Davies, 1994). The exact function of a NP is not uniform, but researchFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 41
  • 43. suggests a uniform profile would be more efficient for the procedures within the ED(Neades, 1997). The education program is generic, but hospitals often edit or add to theeducation to suit the culture and needs of a specific hospital or ward. Besides patient care,another option is for NPs to focus on protocols and quality management. Research showsconcerns about NPs and their substitute role as junior doctor and the inappropriateness ofthis. Substitution sometimes occurs when a hospital experiences financial pressure, whileon the other hand the cost-effectiveness of this transition has not as yet been proven.Besides the financial aspect, the education of a NP is not equal to a junior doctor and thelegal consequences are major (Neades, 1997): “Emergency Nurse Practitioner should not be viewedas a replacement for the role of the nurse in A&E junior doctor, but as a professional with qualities andskills which complement those of the medical staff in A&E. This is not a quick or cheap solution to theproblem of increasing A&E attendances” (Jones, 1994).A shift in ED staff responsibilities is seen as a one of the ways to challenge the problemconcerning increased waiting times, resource allocation and the increasing inflow of non-urgent patients. Research has suggested improving the efficiency of the ED and hospital byhaving a better combination of staff. Additionally, having a general practitioner (GP) in theED has proven to decrease referrals, prescriptions and the number of diagnosticinvestigations (Rao, 1995). The opinions as to the effect on the efficiency of an ED by atriage nurse vary, but similar opinions are shared regarding the idea that a triage nurseshould only focus on his/her primary responsibility.The following hypothesis can be formulated, based on the literature above: Hypothesis 5: the presence of an ED doctor at an ED has more advantages than disadvantages, but the effect on efficiency at an ED is difficult to substantiate.4.4.5 Logistics The fourth variable is logistics, which can be divided into the triage process and triage systems and waiting times. Both parts will be further elaborated on as well as explaining their relation to the efficiency in an ED. The logistics variable is related to research question ten. Figure 14 indicates its position in the conceptual model.Figure 14: Position logistics variableFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 42
  • 44. 4.4.5.1 Triage process and triage systemsA triage system is on the one hand patient-oriented and on the other organization-orientedand has an effect on patient acuity and resource allocation. Its effect on the efficiency willbe discussed further in this section. The different triage systems will be explained andwhich system is most appropriate for the Dutch emergency department (ED) setting.“Triage acuity is defined as the classification of patient acuity that characterizes the degree to which thepatient’s condition is life-threatening and whether immediate treatment is needed to alleviate symptoms”(Gilboy, 2005).The goal of a triage system is two-fold. On the one hand patient acuity, on the other theadequate assignment of resources. Windle once summarized the goal for triage as “to assesspatient acuity and assign available resources appropriately, both physical and personnel” (Windle, 2002)(Windle, 2001). The goals of triage can be divided into 2 categories, namely patient orientedand organization oriented (Coenen, 2005). A patient is prioritized according to clinicalurgency, so patients with the highest medical need are seen first (Janssen, 2011).Classification of a patient’s triage code is decided on by a triage nurse and will reflect the‘safeness’ of the time allowed before treatment. Depending on the triage code, the patientwill experience no waiting time, a short waiting time or longer waiting time (Janssen, 2011).The need for a triage system arose from a rise in overcrowded emergency departments, dueto the increase of ED visits. The latter part of this increase in ED visits resulted from self-referrals, but also the ageing population and the changing mentality towards first visitingthe general practitioner (GP) (Janssen, 2011) (Coenen, 2005). Also, the overcrowding ofEDs has indicated an increase in the number of aggression incidents, as well as an increasein longer waiting times for urgent patients with urgent medical problems. Added to that,most EDs in the Netherlands do not have a clear systematic procedure for the primary careof emergency patients (Coenen, 2005).The main advantage of a triage system is the immediate assessment of patients, the positiveeffect on waiting times in the waiting room, prioritization of care, placement of patients inthe correct treatment room or area and being able to start diagnostic tests. This all impactspositively on the anxiety of patients, their frustrations and concerns. This in turn isreflected in less written complaints and an increase in employee satisfaction (Blythin, 1983)(Jones, 1988) (Nuttall, 1986) (Grose, 1988).Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 43
  • 45. An important part of a triage system is continuous evaluation. Evaluation of the EDs triagesystem can lead to improvements such as the use and layout of a triage room, theresponsibilities of and permitted interventions by a triage nurse, content and developmentof pain protocols, optimization and further implementation of an ICT system and changingthe number of shifts of a triage nurses into 24/7 availability (Janssen, 2011) (Meijers, 2006)(Cheung, 2002). When using a triage system, it is important for there to be no discrepancybetween desirability, feasibility and reality. To avoid this discrepancy, it is important thatthe ED nurse has completed triage training and that triage is performed consistently(Coenen, 2005). There is an ongoing discussion as to whether patients who are referred bytheir GP or by ambulance personnel should be triaged. In general, research shows thatthese patients should be triaged upon arrival at the ED, as their medical situation canchange in the time taken between the GP visit and arrival at the ED (Coenen, 2005).EDs the world over use of different triage systems. Worldwide frequently used triagesystems are the ATS (Australian Triage Scale), CTAS (Canadian Triage and Acuity Scale),the MTS (Manchester Triage System) and the Emergency Severity Index (ESI) or alsoknown as the Boston Systems (Cronin, 2003). The NTS is a Dutch triage standard. Ingeneral it has been recommended that a triage system should meet the followingrequirements to be used by EDs in the Netherlands: the triage system must be valid,reliable, applicable in the Dutch setting, for all age categories, focuses on symptoms andcomplaints, follows the nursing methodology and must be usable in all circumstances(Coenen, 2005) (LAMP, 2003). The paragraphs that follow will explain the different triagesystems mentioned above.MTS (Manchester Triage System) - The MTS was introduced in 1997 and focuses on theclinical priority of the patient (Mackway J. K., 1997). It does not make use of medicaldiagnosis, is flow based and dynamic. Diagnosis-based models are perceived as dangerous,as triage must be concise and totally objective and comprehensive (Windle, 2001)(Zimmermans, 2001) (Windle, 2002). The MTS uses the reduction method and separatesthe clinical priority of the patient from the management aspects on the ward (Windle,2002). An advantage of the MTS is its sensitivity to identify different types of criticalpatients (Zimmermans, 2001). A disadvantage of the MTS is the attention and devotion to thevalue attached to the pain a patient is experiencing. Recognition of pain is important for patientsatisfaction and must be treated in the triage room (Windle, 2001) (Mackway J. K., 1997).Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 44
  • 46. ESI/Boston (Emergency Severity Index) - The ESI is also known as the Boston Triage System.It does not, as is the case of MTS, work with target times per triage code (Gilboy, 2003).The methodology is based on two items: urgency of a patient and resources needed.Symptoms and complaints are questioned according to the ABCD method and the PQRST(pain) method. An advantage is that the diagnostic tests are based on the ‘standards of care’and not the preferences of the doctor (Zimmermans, 2001) (Wuerz, 2000) (Wuerz, 2001).Also, the need for diagnostic tests can be better estimated (Ishove-Bolk, 2001).ATS (Australasian Triage Scale) - The ATS focuses on the clinical urgency of patients(Zimmermans, 2001). It describes acceptable time spent by the nurse, time by the doctorand also keeps track of Performance Indicator Thresholds (the percentage of patients thatmust be seen within the target times) (Considine, 2002). An advantage is that the ATS isregarded as a safer system than the CTAS (next paragraph), as the same category patientsare placed in a more urgent category in the ATS compared to the CTAS. A disadvantage isthat the ATS cannot be applied uniformly, as it is adjusted to regional circumstances. TheATS is also not yet fully developed and does not work according to a standardmethodology (Considine, 2002).CTAS (Canadian Triage and Acuity Scale) - The CTAS was derived from the ATS and hasbeen adapted to Canadian needs (Zimmermans, 2001). The CTAS uses the presumptivedisease diagnosis and is focuses on the symptoms and complaints of the patient. Thesystem works with target times and upgrading patients when the waiting time becomesunreasonable. The primary goal is for the patient to see the doctor within a certain timeperiod; the exact urgency code of a patient is not the prime factor (Beveridge, 1998). Adisadvantage is that the training and education behind the system is an unknown factor andthere is no methodological structure (Beveridge, 1998). There are also doubts about thesensitivity of the system in the case of complex patients (Zimmermans, 2001).NTS (Nederlandse Triage Standaard) - The NTS was introduced in 2005 and a pilot started in2007. The NTS is seen as a system that can contribute to one triage system; it positivelyaffects the co-operation between the different stakeholders in emergency care. It has beensaid that one triage system could positively affect the efficiency, safety, patient satisfaction,communication and co-operation within an integrated emergency care system. The NTS ismainly used by GPs at HAPs and triage through NTS can be done physically or over thephone. The NTS is focuses on determining the urgency, not the diagnosis (Jochems, 2006).Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 45
  • 47. The conclusion was that the NTS is a new concept in emergency care and still needs to beinvestigated further. There are questions about the its implementation method, thepossibility of having one triage system in an integrated emergency post, the difference ingoals between the NTS and the other triage systems used by EDs, the communication, co-operation and culture differences between GPs and ER staff and their working methodsand language aspects. These call for further investigation (Jochems, 2006) (Huibers, 2009).Some studies also indicated concern about the quality and safety of after working hourstelephone-based consultations. A study in the Netherlands indicated that the quality waspoor in all the centers investigated and that the outcomes of the triage were onlyappropriate in 58% of all calls. The underestimation of urgency was 41% (Derlx, 2008).International studies have also questioned the effectiveness and safety issues. Consultationby telephone did appear to reduce the number of face-to-face visits to a HAP by 50%, butuncertainty remains about the effect on the number of future visits. Patient satisfaction wasnot affected if a telephone consultation was used instead of a face-to-face visit (Bunn,2004) (Katz, 2008).For a system to be effective and to fit into the Dutch ED culture there must be aseparation between the medical and nursing language. It is difficult to state which triagesystem is the best in its performance, as there has not been enough research in this area(Nicholl, 2000). Research has indicated that the MTS would be most suitable to use in EDsin the Netherlands, as the symptoms and complaints of a patients are seen as moreimportant than the diagnosis itself. Also, the MTS is the only European triage system andcan be used in the Netherlands as healthcare is similar to the English system. The MTS tiesin better with the ED situation in the Netherlands in terms of reliability, validity, way ofthinking and applicability by ED nurses than the other triage systems mentioned above(Nicholl, 2000)(Zimmermans, 2001) (Windle, 2001).A triage system has different effects on the efficiency of processes in the ED itself as wellas on patient and employee satisfaction. For instance there is a decrease in complaintsfrom patients, reduced waiting times in the waiting room, prioritization of care, placementof patients in the correct treatment room or area and the ability to start diagnostic tests,where needed, at the earliest opportunity. Extrapolating the different triage systems, MTSis seen as being most compatible with the Dutch EDs.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 46
  • 48. The following hypothesis can be formulated, based on the section above: Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED.4.4.5.2 Waiting times and processes in the emergency departmentWaiting times influence logistics. If the logistics of an emergency department are well-established, this will decrease the waiting time for patients significantly. The next sectionwill elaborate on the botllenecks of the processes in the ED and how to eliminate these.Waiting time is perceived by patients as one of the most irritating aspects of a visit to theED. Yet, waiting time is one of the most difficult bottlenecks to eliminate. Many hospitalsuse the Theory of Constraints theory (TOC) of E. Goldratt in order to reduce thebottlenecks in their processes. It can also be used in the ED to reduce the turnaround timeof patients. The Theory of Constraints can be used as a method to increase profitabilityand volume (Noreen, Smith, & Mackey, 1995): “A constraint is anything internal or external tothe manufacturing process that limits a plant’s ability to generate throughput, the rate at which theproduction system generates money through the sale of products” (Kershaw, 2000, p. 2). In order tomaximize this throughput, the constraints should be identified and managed (Goldratt &Cox, 1992). By defining throughput in a healthcare setting, it can be changed to:“reimbursement rate less the cost of drugs and medical supplies for the number of patients seen and treated.”(Kershaw, 2000, p. 2) The steps of TOC can be found in appendix VII of the confidentialbooklet. The key factor in the TOC process is to expand the capacity of the constraint inorder to increase throughput. The ultimate target is to completely eliminate non-productivetime. The non-productive time in an ED can be decreased by reducing preparation time,the use of appropriate supplies, available and accesible information, as well asimplementing and performing the right procedures. Constraints can be eradicated by hiringmore staff or by procuring additional equipment (Kershaw, 2000). By implementing theTheory of Constraints, the processes within the ED become more efficient and effective.According to the literature, (Nicholl, 2000) there was no evidence that waiting times areshortened by implementing a simple triage system. However, time can be gained byimplementing an advanced triage system, whereby a nurse can already apply for diagnostictests, which in turn means that the test results are known by the first consultation. Byimplementing this advanced triage system, the efficiency of the care process improves as doturnaround times of patients by making effective use of the patient’s waiting time (Cheung,Heeney, & Pound, 2002). A triage system only has a positive impact if the role of a triageFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 47
  • 49. nurse is combined with extra tasks such as requests for examinations and extraorganizational adjustments (Edwards, 1999). On the other hand, the implementation oftriage does not have the desired outcome to solve all logistic problems. Therefore, varioushospitals are implementing care pathways to improve the logistic process in theiremergency departments. In 2005, Vlietland hospital developed a triage system as well ascare pathways. In these care pathways, the patient’s need for care is determined, as are theexaminations, treatment andtime span. Measurements show that the average turnaroundtime decreased by 40 minutes for cardiology patients. This is also partly due to the full-timeavailability of a cardiologist and the introduction of an observatory in the ED (Sterk, 2006).Concluding, waiting time can be eliminated by using the Theory of Constraints of E.Goldratt. In order to maximize throughput, constraints should be identified and managed.The aim of this theory is to completely eradicate non-productive time. Further waiting timecan be reduced by introducing an advanced triage system. However, this only has a positiveeffect if the triage nurse combines extra tasks such as examinations in combination withpatient triage.As such the following hypothesis is formulated, namely: Hypothesis 7: waiting time can be decreased by reducing the bottlenecks in the process.4.4.6 Finances An optimal emergency department (ED) cannot be developed without investigating its financial system. This section will elaborate on how the financial system works in the Netherlands and how it will function in the future. The finance variable entails research question eleven and figure 15 shows the position in the conceptual model. Figure 15: Position finance variableHospitals are currently financed and funded in different ways. Financing involvestemporarily making capital available, whereas funding encompasses making a financialcontribution to cover the costs, associated with the service provided (Bos, Koevoets, &Oosterwaal, 2010).Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 48
  • 50. The Dutch care authority (Nederlandse Zorgautoriteit – NZa) determines a budget forevery hospital in the Netherlands. They use a calculation method that is provided by theministry of health. The financing of hospitals is based on Diagnostic TherapyCombinations (DBC). This DBC contains all (care) activities of a hospital and of medicalspecialists, arising from the patients care demand (Bos, Koevoets, & Oosterwaal, 2010).The DBC includes the total route of the diagnosis until the treatment starts. The DBC-system gives hospitals and health insurers:  The possibility to negotiate on price and quality for certain hospital treatments. This offers health insurers better possibilities to procure better and more affordable care  Better insight into the costs of treatments. This leads hospitals to improve their management and thus deliver affordable and efficient care (NZa, 2011)The DBC codes are divided into two categories: the A-segment and B-segment. The A-segment contains approximately 66% of the hospital treatments (NZa, 2011). For theDBCs in this segment, there are fixed rates, determined by the Dutch care authority. Forevery diagnosis, the costs of the treatment are calculated in order to determine an averagetariff. This tariff incorporates various costs components such as: costs for specialists,nursing and X-ray photos. It also contains indirect hospital costs: costs of education,research and the ED itself (Ministerie van VWS , 2011). All this makes it difficult toaccurately trace the revenues and costs of an ED.In segment B, the DBC codes are subject to competition. The hospitals themselvesdetermine the tariffs for the treatments. Negotiations between hospitals and health insurersabout quality and price of DBCtreatments in the B-segment form thebasis of the B-segment (Bos, Koevoets,& Oosterwaal, 2010).In figure 16 on the right, the financingand funding of health-care is explained.As already stated above, there is adifference between financing andfunding. The funding contains the Figure 16: Financing and funding structure in Dutch health-care systemfunctional budget and the revenues of theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 49
  • 51. B-segment. The turnover of the hospital comprises these two components. By declaringthe DBC codes, the hospital receives money which is the financing part. They can declareDBC codes both in the A- as well as the B-segments. However, the revenues in the A-segment are fixed because of the budgeting system. In the B-segment, hospitals andinsurers can negotiate on price, volume and quality of the care (Belonen naar prestatie,2011).In 2012, the budgets for hospitals will disappear. Healthcare will be financed on the basisof the services delivered. In the B-segment, now changed to free market segment, thehealth insurers and care providers can freely negotiate on the quality, price and volume ofthe care. This includes care that is offered by many providers and can be translated intorecognizable performances. 70% of all treatments will now be based on free pricing underthis financing system. However, there will also be a regulated segment, where negotiationis possible at maximum rates. This contains care that is not suited to free negotiation.There will also be a fixed segment where there can be no negotiation on the care provided.This includes, for example, care that requires an enormous investment or where thenumber of patients fluctuates greatly. The ED will be financed under the first-named freesegment but can be eligible for reimbursement via the fixed segment (Belonen naarprestatie, 2011).This new system, DOT3, will provide higher quality and greater efficiency in healthcarebecause providers are rewarded based on the services they deliver. To make the systemwork, it is important that the services are well-defined. An innovative aspect of the newsystem is the way in which the various items of the care offered are grouped and declaredin the system. DOT has the following advantages:  Greater transparency: every stakeholder gets more insight into quality, care process and pricing;  Medical recognition: the extent to which the specialist can identify with the care product itself with respect to the actual care delivered;  Care burden: the complexity of care is better encapsulated in the care products;  Transcending specialisms: Not every specialism has its own DBC codes, but specialisms that deliver the same care, also declare the same care products;3 DOT = DBC op weg naar Transparantie: DBC towards TransparencyFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 50
  • 52.  More homogenous costs: the extent to which care costs are reimbursed to the patient.Care for the patient is grouped in a product based on the diagnosis. All possible careproducts together are called the care product structure. This structure is based on theInternational Classification of Diseases (ICD10) so that the classification is standardized inline with the rest of the world. The ICD10 has 22 chapters. These chapters are in turndivided into various diagnostic groups and these are again divided into several treatmentgroups. Finally, the treatment group is separated into care products. There areapproximately 3500 care products. An overview of the DOT system can be found inappendix VIII in the confidential booklet (Werken met DOT, 2011).Because of the social care system in the Netherlands, which indicates that every person isobligated to have health insurance, it is difficult to determine the profitability of an ED. Inconcrete, patients that visit the ED get a DBC code where the average price of a certaindiagnosis is inserted. Also the visit of the ED is incorporated in the DBC code of thatcertain diagnosis. The cost of the readiness and availability of an ED is a cost regardless ofthe patient volume (Taheri, Butz, Lottenberg, Clawson, & Flint, 2004).According to the literature, the low-care unit is profitable in the ED. These revenues areused to finance the medium and high-care unit of the ED (Schrijvers, Steeg, Schaaf,Hemrika, & Gussinklo, 2011). However, previous research does not give a clear perceptionof the financial situation of EDs in general. It merely states that they are cost centers.In conclusion, Dutch hospitals are financed and funded. These are two totally differentmethods. Hospitals receive a budget, but they can also reimburse costs. Reimbursementsare currently done by DBC codes. As from next year, these codes will be extended toDOT. This reimbursement system also makes it difficult to determine the profitability ofan ED. It is merely stated that the low-care unit of an ED is profitable.The following hypothesis can be formulated from the literature above: Hypothesis 8: it is difficult to determine the profitability of an ED.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 51
  • 53. 4.4.7 Patient satisfaction Patient satisfaction plays an important role in the efficiency of the process in the ED. A patient is only satisfied when the waiting time is minimal and when the service is good. Therefore patient satisfaction entails different factors that should be optimized. This section encompasses research question 12 and figure 17 on the left indicates theFigure 17: Position position in the conceptual model.patient satisfaction variable“Emergency physicians in Hong Kong have come up with a list of 10 Cs, helpful and applicable for qualityemergency care and risk management: competence, confidence, comfortable, careful attitude, compliance withprotocols, checklists, courtesy, being calm and controlled, compassionate, and considerate as well as timelyand appropriate communications…the same values we all strive for” (Lateef, 2011).In 2010 research was conducted in the Netherlands on the quality of care in the ED inrelation to patient satisfaction, using the CQ index (Consumer Quality Index). There arenine important steps that affect the satisfaction of a patient visiting the ED: (1) generalimpression, (2) pre-entering the ED, (3) reception ED, (4) professionals ED, (5) pain, (6)diagnostics and treatment, (7) departure ED, (8) ED in general and (9) the patient himself(Bos N. , 2011).In general, patients visiting the ED were satisfied about routing indication in the hospital tothe ED, the location of the ED, parking at the ED, consistency in information, being takenseriously by all staff, safety in the ED, privacy in the treatment room, trust in the expertiseand being listened to. Although patients seem satisfied with the latter points, these pointsare also ranked 30-39 in the top 39 improvement points (Bos N. , 2011). The ten majorpoints of improvement were about the co-decision of treatment, information from thesecretary and the nurse (concerning waiting time) and the information on sequence oftreatment and side effects to medicines, communicating the data transfer to the GP aboutthe ER visit, information about after care (activities, what to watch out for), eating anddrinking facilities in the ED and communicating who to contact when the patient isconcerned about a matter concerning his condition and treatment (Bos N. , 2011).The infrastructure, especially hygiene and comfort, play a role in patient satisfaction. Thepreferred location of the ER, integrated with a HAP or co-located, has not beenFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 52
  • 54. sufficiently investigated by research (Chalder, 2006). Patients are also influenced by thepatient-nurse or patient-physician relation (Hidalgo, 2011). Communication and courtesyplay a major role in this (Soleimanpour, 2011). Patients comply better with the physician ifthey have been given pain relief at the ED during their stay, all of which minimized theirdistress. This positively affects patient satisfaction (Downey, 2010).Patient Centered Care (PCC), is becoming increasingly important in the 21st century. PCCis focused on customized care. The patient becomes a partner in his/her own care andhealth ‘ownership’ is aligned with 21st century thinking. There are three major areas ofimportance: (1) respect for patient values, preferences, and expressed needs, (2) the co-ordination and integration of care and (3) information, communications, and education.The question is whether the ED will benefit from this approach. Research has shown thatit could be used, only if the approach is well planned in advance (Taylor, 2006) (Lateef,2011).“The two dimensions most strongly positively associated with global satisfaction were receiving the expectedmedical help and being treated well by the doctor’’ (Taylor C. , 2004). A patient’s expectations playa major role in relation to satisfaction and are not necessarily dependent on the triage code.It is not known in this situation whether the triage code or the waiting time itself affectssatisfaction (Taylor C. , 2004). Patients arrive at the ED with certain expectations, whichare either met or not by the physician. Failure to meet the expectation can result in anger oreven aggression. Negative comments about an ED or physician can also be circulatedpublicly. These patients will consequently not return for follow-up care, resulting possiblyin a loss of patients for the hospital. Managing expectations in an ED is complex, due tothe high anxiety and stress levels that are naturally present. This can only be achieved whena balance is found between the expectations of the patient, the perception of the physicianand the prioritization by the healthcare planners. Research suggests that communicationand building a good patient-physician relationship is crucial in this (Lateef, 2011) (Hidalgo,2011).Waiting times do not always affect the patient’s satisfaction negatively. Communicationregarding waiting times is essential. This can be done during triage, but also throughinformation screens in the waiting room (Kelly, 2010). The perceived waiting time does notnecessarily show a decrease with the introduction of the information screen (Papa, 2008).Communication plays a major role in the interaction aspects between nurse and patient, inFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 53
  • 55. which information and psychosocial exchange play a key role in satisfaction criteria (Kim,2010). Generally, communication in all areas between patients and staff and between staffamongst themselves has been indicated as a frequent sphere of improvement in patientsatisfaction. “Although it may be neither feasible nor desirable to meet all patient expectations, increasedfocus on wait times and staff communication may increase both ED efficiency and patient satisfaction”(Cooke, 2006). Communication about waiting times linked to the non-urgent character of apatient visiting the ED may have a positive impact on expectations and satisfaction(Olsson, 2001). Research has shown that communication skills workshops improve thecommunicational and therapeutic skills of physicians (Lau, 2000).When reviewing a patient population, younger people are most often the least satisfied andelderly people with no comorbidities most satisfied. A good education and bad healthstatus has a more positive impact on satisfaction than lower education and good healthstatus (Rahmqvist, 2010). When researching the appropriateness of seeking medical care,patients tend to think that other patients are wasting their time, but do not see themselvesin that same light. Patients tend to search for health-seeking rationales, yet their anxiety andsymptoms appear to be more like health-seeking behavior (Adamson, 2003).In conclusion, patient satisfaction is influenced by the efficiency in an ED. Importantfactors determining patient satisfaction are the layout of the ED and the verbalcommunication between patient and staff. A patient’s expectations can be turned intorealistic expectations, if the communication towards the patient is adequate. Patientsatisfaction and waiting times can also be influenced by verbal communication.The following hypothesis can be derived from the literature: Hypothesis 9: verbal communication towards a patient in the ED plays an important role in patient satisfaction.The foundations for the sub-research questions have been discussed in the sections above.The seven variables were elaborated on as well as their effect on the efficiency on an ED.The next section will give an overview of the hypotheses derived from the literature in thischapter.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 54
  • 56. 4.5 HypothesesBased on the theoretical framework, the following hypotheses were derived:  Hypothesis 1: the layout of the ED affects the long term success of its processes  Hypothesis 2: the integration of a HAP and an ED improves the efficiency and quality of care at a lower cost  Hypothesis 3: digitalization of patient data has both a positive and negative effect on the processes of an ED.  Hypothesis 4: standardized performance indicators enhance the quality of the processes of the ED  Hypothesis 5: the presence of an ED doctor at an ED has more advantages than disadvantages, but its effect on the efficiency at the ED is difficult to confirm  Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED  Hypothesis 7: waiting time can be decreased by eliminating the bottlenecks in the process  Hypothesis 8: it is difficult to determine the profitability of an ED  Hypothesis 9: verbal communication towards a patient in the ED plays an important role in patient satisfactionThese hypotheses will be tested on their validation through the results of the interviews inchapter 5.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 55
  • 57. 5. Results and analysisThis chapter will discuss the results and analysis. The results are based on the outcomes ofthe twelve interviews at different emergency departments (EDs) in the Netherlands. Theresults are discussed per individual variable. The analysis incorporates the hypothesesextrapolated from the literature (chapter 4, section 4.5) with the results of the interviewsand thus will determine the validation of those hypotheses from the literature. Hypothesesthat cannot be validated through our research will be postulated as recommendations forfurther research.The structure of the results and analysis is identical to that of the chapters above. Thestructure is based on the conceptual model (chapter 2. A figure at the beginning of eachvariable discussed will indicate which variable in the conceptual model is being elaboratedon. Each of the seven variables discussed will start with the results, followed by theanalysis. Quotes from the interviews will be used to substantiate the results or as evidence.Some sections show a table at the end of the section. Its function and how to read it will beexplained in that section.The final section of this chapter will give a short overview of the hypotheses and whetheror not they could be validated.5.1 Infrastructure The following chapter will discuss the results from the outcome of the interviews on the variable infrastructure. This variable is divided into the layout of an emergency department (ED) and the Huisartsenpost (HAP, general practitioners’ co-operation). The results are followed by an analysis of both, in which hypothesis 1 and 2 from the literature (chapter 4) will be Figuur 18: tested for validation. Figure 18 on the left shows the position of this Position infrastructure variable in the conceptual model. variable5.1.1 Emergency department layout5.1.1.1 ResultsThe results on the layout of the ED are discussed in the section below. Firstly, it isdiscussed if the EDs have a Computer Tomography scanner (CT-scanner) in thedepartment itself after which the results of the physical layout are discussed. Secondly, theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 56
  • 58. format of the treatment rooms is detailed. This is followed by a new topic that arose duringthe interviews, namely the acute admissions ward. Finally, a general conclusion on theresults of the layout of the ED is given. Table 1 gives an overview of this section.One out of twelve EDs has a CT scanner in the department itself. One ED will get a CT inthe future and two others would like to have an own CT but stated that the investmentrequired was proving to be a barrier at the moment. The trauma rooms are equipped withan X-ray device. Some have an extra X-ray room on the ED, including one ED with amobile X-ray device for the non- or less mobile patients.Two out of twelve EDs currently have the ballroom setting. Two have a partly ballroomstructure and three want to set up the ballroom setting in the future. The reason for thelatter is the functionality and overview it creates for both staff and patients; “Voor de patiëntis dit prettig, omdat hij aanspreekbaar is wanneer nodig. Het werkt voor de mensen prettig, het is dichtbijallemaal, heel functioneel” (Hospital I, 2011).Eight out of twelve EDs have uniform rooms, two a combination and two have a non-uniform configuration. The reason for uniformity stated elsewhere in this paper, is the easeof use and patient placement and allocation; “In de nieuwbouw willen we toewerken naar eenstandaard kamer waar alles gedaan kan worden. Momenteel is daar nu geen plaats voor. Nu moet ernagedacht worden wat de patient nodig heeft en welke kamers er dan ter beschikking zijn. Dat kost nuontzettend veel tijd omdat er vaak patiënten verplaatst moeten worden naar andere kamers” (Hospital B,2011). All rooms contain the standard layout resources: bed, monitor, computer (in mostEDs), mobile carts, small cupboard, sink, oxygen/air pressure and stool. Some are adaptedto suit a particular specialization as for example the ENT (ear, nose and throat specialist),urology and ophthalmology.Three EDs have an AOA (acute admissions ward) and three said they had plans for anAOA. Reasons mentioned in favor of an AOA are better logistics, flexibility and lessdisruption for other wards; “Enige afdeling waar patiënten heen gaan, werkt logistiek veel beter.Discussies met afdelingen zijn er uit, er is gewoon 1 centrale afdeling […] Maakt dat je flexibel bent enrust op andere afdelingen” (Hospital K, 2011). Contrasting ideas about the effectiveness statedare doubts as to its functionality and the number of patients; “Je moet voor jezelf duidelijkkijken wat het voor jezelf oplevert. Het kan een oplossing zijn voor een logistiek probleem maar niet voorhet bedden tekort” (Hospital C, 2011), “Ons patiënten volume is niet groot genoeg om een AOAFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 57
  • 59. rendabel te maken. Je moet er ook personeel neerzetten terwijl er misschien niemand wordt opgenomen”(Hospital G, 2011).Table 1 below provides an overview of the outcomes of the interviews. Horizontally in thecolumns, the elements of the layout variable can be seen. Vertically, the rows indicate theindividual hospital codes. Specific information on the elements in the columns perindividual ED can be obtained by reading the table horizontally. If the table is readvertically, each individual column can be linked to the different hospitals. Hospital Number of CT/X-ray on ED? Shape Room lay-out* code treatment rooms A 12 (2 trauma, 2 CT near ED Ballroom Uniform AED) X-ray on ED B 20 (2 trauma, 1 CT and X-ray on ED, -** Some uniform, some AED) ultrasound specific C 8 (1 trauma, 1 CT near ED, X-ray on ED - Uniform acute) D -(2 trauma) CT in 2013, X-ray next to ED Linear Uniform E 24 (2 trauma) CT near ED, X-ray on ED Partly Some uniform, some ballroom specific F 7 (1 trauma) X-ray on ED, CT near ED, - Uniform mobile X-ray device G 3 (1 trauma) Next to ED Ballroom in Not uniform future H 8 (2 crash) CT near to ED, X-ray on ED No real Uniform structure I 25 (2 trauma) CT near to ED, X-ray on ED Partly Uniform ballroom J 11 (1 trauma) CT near to ED , X-ray on ED Ballroom in Not uniform (separate room in new future situation) K 6 (1 trauma) CT near to ED, X-ray on ED Ballroom in Uniform future L 14 (2 trauma) CT near to ED, X-ray on ED Ballroom UniformTable 1: Overview emergency department layoutNote 1: * Standard layout: bed, monitor, computer, mobile carts, small cupboard, sink, oxygen/air pressure, stoolNote 2: ** A horizontal line indicates that the data in that field is unknownFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 58
  • 60. Concluding on the results above, the interviews have indicated that the ballroom layout isseen as functional and efficient for its processes as well as offering uniformity in the layoutof treatment rooms. The provision of diagnostic equipment for the ED is often consideredan investment issue and the location of such equipment affects the efficiency of theprocesses in an ED. Opinions about an AOA vary. Some indicate flexibility as anadvantage, others question its functionality.5.1.1.2 AnalysisFrom the literature the following hypothesis was derived: Hypothesis 1: the layout of the ED affects the long-term success of its processes.Literature has validated this hypothesis. According to the literature, layout plays asignificant part in the throughput of the emergency room (ED). This in turn makes forimprovement in overcrowding issues. The combination of these two factors makes the EDmore efficient. Efficiency in the long term can be achieved through various changes oradaptations in the physical layout. Firstly, implementing the ballroom layout createsvisibility of the ED and easy accessibility to the central nursing station for patients andstaff. However, research has indicated that when the number of treatment rooms exceeds18, the ballroom setting is no longer effective. The ballroom setting should then beduplicated and two ballroom areas created or the EDs should consider linear units.Secondly, uniformity in the layout of treatment rooms provides flexibility in patientplacement. This in turn can support the idea to centralize the primary processes and toplace other processes in the periphery. Research suggests for instance that high-carepatients should be located around the nursing station and non-urgent patients can followthe RADIT program, for instance. Optimal efficiency can also be enhanced by the rightlocation for diagnostic imaging equipment, either on the ED itself or located next to theED. Research is questioning whether registration of a patient should be handled by thesecretary at the front desk of the ED or via bedside registration. The latter is said to savespace in the waiting room and speed up the process within the ED itself.Hypothesis 1 can also be validated by the outcomes of the interviews in the results.Hospitals have acknowledged the functionality and advantages of the ballroom settingwhich also improves patient satisfaction. Hospital E and I have implemented a semi-ballroom layout, as is also suggested in literature when the number of treatment roomsexceeds 18. In addition to flexibility, the results have identified that the uniformity ofFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 59
  • 61. treatment rooms also provides ease of use and patient placement. Hospital L confirms inthe interview the efficiency and effectiveness of separating the central and peripheralprocesses. Several hospitals have indicated that not having diagnostic imaging equipmenton or near the ED constitutes as bottleneck in their processes. The interviews haveconfirmed that a distinction should be made between urgent and low-care patients, forinstance by placing urgent care patients near the nursing station and using a fast track forlow-care patients. In order to improve overcrowding and throughput in an ED, theinterviews have suggested the use of an ‘acute opname afdeling (AOA)’; an admissionsward which is part of the ED with a maximum stay of 24hrs, 48hrs or 72hrs. The efficiencyof this AOA to reduce overcrowding and make for greater throughput cannot beconfirmed by the literature in this research paper, thus further research on its effect onefficiency is to be recommended. The following hypothesis can consequently be derivedand used as a recommendation for further research (chapter 6): Hypothesis 1: an admissions ward has a positive effect on the overcrowding and throughput of an ED.The literature and outcomes of the interviews have shown that hypothesis 1 can bevalidated.5.1.2 The Huisartsenpost5.1.2.1 ResultsIn the interviews, the Huisartsenpost (HAP) was also discussed with the head of theemergency departments (EDs). The following section gives an overview of the results. Theresults will encompass the number of hospitals that are actually integrated. Furtherdiscussion will investigate the effects on efficiency if the processes were to be integrated,and if these can be validated. Finally, the literature found is linked to the interviews in orderto confirm or reject the hypothesis stated.Ten of the twelve hospitals interviewed state that the HAP is not integrated. There areseveral reasons why integration or co-operation has not yet taken place. One reason is thedifficulty in co-operating with the general practitioners (GPs) because of the differentreimbursement scales that general practitioners receive in comparison with the ED versusthe responsibilities they bear; “De HAP zit aan de SEH vast maar er zijn geen samenwerkingenmee. We zouden dat wel heel graag willen. Zeker als je kijkt naar het aantal patiënten dat wij zien en hetaantal patiënten dat de HAP ziet, want veel van hun patiënten worden toch nog doorgestuurd naar deFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 60
  • 62. SEH […] Alleen de huisartsen hebben nog koudwatervrees om samen te werken. Ze zijn bang dat ze hetdrukker gaan krijgen en dat ze niet een financiële compensatie voor krijgen” (Hospital G, 2011).Four hospitals do not have a HAP within the he hospital complex. However, three of themhave plans for future integration. Hospital B has no plans yet, stating that they have goodcollaboration agreements with the HAP. Patients can be redirected to the HAP, if they arenot urgent enough for the ED or the ED is full to capacity; “In die mate dat bij grote drukte, depatiënt bij ons getrieerd wordt en het echt een eerstelijnszorg vraag betreft en we kunnen die patiënt nietbinnen een redelijk termijn helpen, is er overleg met de HAP en de patiënt dat hij/zij daarnaar kandoorverwezen worden” (Hospital B, 2011).Of the four hospitals where a HAP is located in or next to the ED, but not integrated,three have expressed future plans for integration. Hospital D states that there is potentialfor having the HAP and ED under one roof, but that one desk (integration) would bemore efficient for the patient. However, legal matters and reimbursement discussions havenot yet been resolved; “Ze zitten dichterbij en er zijn kortere lijnen. Maar er is nog steeds tegenstandvanuit verschillende partijen. Er zitten nog heel veel mogelijkheden maar ook juridisch is het niet geregeld.[…]. De patiënt moet nu nog terug opnieuw ingeschreven worden als hij/zij doorverwezen wordt naar deSEH. Dat zou dus veel efficiënter kunnen geregeld worden door 1 balie neer te zetten” (Hospital D,2011).Seven of the EDs that are not integrated with the HAP, state as one of the reasons forfuture integration the benefits to the patients as there is communication between the HAPand ED about the placement of the patient; “Ik zie met name voordelen voor de patiënten. Als jekijkt vanuit de patiënt dan is het makkelijk dat de huisarts deze kan doorverwijzen naar de 2e lijnszorg.Een SEH kost meer dus je kan makkelijker afspraken maken met de huisarts welke patiëntendoorverwezen moeten worden” (Hospital H, 2011). Other reasons stated were better logistics,increase in patient satisfaction and a reduction in waiting times; “Alle acute zorg komt bijelkaar. Dat is efficiënt logistiek” (Hospital H, 2011), “De geïntegreerde HAP zorgt dat er mensen nietkomen op de SEH als ze er niet thuis horen. Zorgt dus dan ook voor minder wachttijden, meer tevredenpatiënten” (Hospital E, 2011). The thinking processes of the HAP and the ED aresignificantly different. At the HAP a patient is considered healthy until the contrary hasbeen diagnosed; at the ED the patient is ill until the contrary has been diagnosed; “Ja, datéén-loket model. Het gaat niet alleen om tijd. Het gaat ook om geld en als je in het ziekenhuis zit dan benje ziek tot het tegendeel bewezen is. En kom je bij de huisarts dan ben je gezond tot het tegendeel bewezenFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 61
  • 63. is. Dus eigenlijk is dat een hele andere insteek” (Hospital L, 2011).Obstacles and challenges for the integration of the HAP and ED can be found within thefinancial system (reimbursement vs. responsibilities) and legal matters; “We willen in detoekomst naar 1 entree met 1 functionaris die trieert. Vanuit daar kan de patiënt doorverwezen wordenofwel naar de HAP ofwel naar de SEH. Achter die balie blijven het wel 2 identiteiten. Dit komt omdatmedico-legaal dit nog niet is afgedekt en ook financieel is het niet afgedekt. Het verschil in financieringtussen 1e en 2e lijnszorg is nog te groot om dit te realiseren” (Hospital C, 2011). In addition, theportfolio of tasks and responsibilities is not clear nor does an integrated situation exist; “Erzijn ook nog vragen of we beide functionarissen beide systemen laten inkijken, wie die balie gaat bemannen.Het is heel moeilijk om ook de takenpakketen te bepalen. Een medisch secretaresse doet velen malen meerlogistiek dan een medewerker van de HAP” (Hospital H, 2011). The complexity and non-uniformity of the registration of patients plays a role. When patients change over from aHAP to ED or vice versa, the patients have to be re-registered; “Als er een patiënt staatingeschreven bij de HAP, dan kan deze niet gelinkt worden aan het systeem van de SEH. De patiënt moetopnieuw ingeschreven worden” (Hospital H, 2011).Table 2 gives an overview of the distribution of HAP integration. The left columndescribes the different situations of the integration of hospitals with EDs. The middlecolumn indicates the number of hospitals that can be apportioned according to thedifferent situations. Additionally, the last column connects the interviewed hospitals to thedifferent situations shown in the first column. Situation Number Hospital Code No integration 10 B, C, D, F, G, H, I, J, K, L No integration, HAP not on hospital complex 4 B, F, I, J No integration, HAP on hospital complex 2 G, H No integration, HAP in/next to ED in hospital 4 C, D, K, L Integrated HAP and ED 2 A, E Plans for integration in new/renovated/current 7 C, F, H, I, J, K, L buildingTable 2: Overview of the distribution of HAP integrationIn conclusion, most hospitals are still not integrated with a HAP. However, they do expressan intention to co-operate since there are many benefits. Challenges need to be addressedFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 62
  • 64. to make integration a success. These challenges are mostly related to the financial system,especially the mismatch of the reimbursements versus responsibilities. The hypothesis fromthe literature stated below is analyzed by searching for confirmation in the literature itselfas well as in the interview results.5.1.2.2 AnalysisThis subsection discusses the analysis of the premise that the integration of a HAP and anED improves the efficiency and quality of care and at a lower cost. The analysis is based onhypothesis 2, formulated in chapter 4 (theoretical framework):Hypothesis 2: the integration of a HAP and an ED improves the efficiency and quality of care at a lower cost.The literature states that the integration of a HAP and an ED can resolve overcrowdingproblems in the ED. This constitutes one of the most important advantages of co-operation, namely the redirection of non-urgent care patients. By redirecting those patientsto the HAP, this could reduce costs and increase effective care. Also Dutch policy makersconfirm that the efficiency and quality of care is improved when the HAP and ED areintegrated.The results of the interviews indicate that most hospitals are not integrated with the HAPbecause of the resistance of general practitioners. However, hospitals do see the advantagesof co-operation but the current lack of harmonization of reimbursements in line withresponsibilities makes it difficult to achieve this. There were insufficient interviews thatwere able to corroborate the efficiency of the integration of a HAP and an ED, so thehypothesis cannot be validated. Further research is recommended based on hypothesis 2.5.2 Technology This chapter will discuss the results from the outcomes of the interviews on the variable technology. Technology encompasses the software used on an ED and the digitalization of patient data. The results of the interviews are followed by an analysis. In the analysis, hypothesis 3 from the literature (chapter 4) will be tested for validation. Figure 19 shows the position of this Figuur 19: variable in the conceptual model. Position technology variableFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 63
  • 65. 5.2.1 Software and digitalization of patient data5.2.1.1 ResultsThe following paragraphs will show the results of the technology variable. The uniformityof software systems will be discussed, as will the effects of the digitalization of patient dataand their effects on the processes within an ED. The scope and impact of a paperlesssystem on an ED will also be examined.Eleven out of twelve hospitals work with the same software hospital-wide. Hospital L doesnot have a uniform software system. It was stated that iSoft has a special ED portfolio, towhich other specialists were not yet connected prior to 2004, due to the need foroptimization within the ED before opening it up to other specialists; “We hebben toen bewustniet gekozen om de specialisten mee te laten doen, omdat we dachten dan gaan we buiten de deuren van onzespoedeisende hulp. Dat ging alleen voor ellende zorgen, er zijn veel te veel mensen die er dan wat van vinden.Laten we eerst maar zorgen dat we het binnen onze afdeling voor elkaar krijgen” (Hospital L, 2011).The introduction of the system to other specialists and nursing wards has started but isregarded a slow and cumbersome process.Opinions regarding the notion for implementing a hospital-wide system vary considerably.Stated as positive is the sharing of information with other wards and specialists, especiallywhen a patient is admitted to a nursing ward from the ED; “Wij beschouwen ons als een bron,waarbij je start met de behandeling van de patiënt. De start van het contact met de patiënt in hetziekenhuis. Dus alle informatie willen we graag delen met anderen die er gebruik van willen maken”(Hospital L, 2011). Working with different systems makes for less time-saving; “Het kostnatuurlijk wel tijd door in meerdere systemen te moeten werken” (Hospital B, 2011). Others think thebenefits lie in a good transfer of information when admitting a patient to a nursing wardand not so much in having a uniform system; “Er is niet concreet winst te maken als het zelfdesysteem gebruikt wordt in het ziekenhuis. Er is altijd winst te halen als de overdracht gewoon goed gebeurt”(Hospital B, 2011).Two out of twelve EDs have a paperless system. Opinions about the possibilities of havinga fully paperless and digital system are contradictory; “Alles kan papierloos” (Hospital E,2011) or; “Nee. Dat gaat het nooit helemaal worden” (Hospital L, 2011). The effect ofdigitalization of hospital G was stated as very inefficient, whereas the ED system is fullypaperless; “Heel de digitale werking hier in het ziekenhuis is inefficient” (Hospital G, 2011).Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 64
  • 66. The benefits stated for a paperless system are the availability of information(“systeminformatie is onmiddellijk beschikbaar, je hebt alles in 1 opslag nu” (Hospital A, 2011)), time-saving (“Je hoeft niet alles een paar keer op papier te zetten” (Hospital A, 2011)), efficiency (“Ikdenk wel dat het efficiënter werkt. Vooral de specialisten vinden dat ze te lang bezig zijn met het invullenvan de statussen” (Hospital D, 2011)), possibilities for analyzing processes and insight into theareas of improvement as a result of condensing all statistical information in one system(“Je kunt er statistieken op loslaten” (Hospital L, 2011)) and less printing and printing costs(“Wij gaan niet meer uitprinten want alles is in principe digitaal beschikbaar” (Hospital G, 2011)).The disadvantages of a paperless system were stated as being the increase of functions vs.time consumption (“Bespaart werk, maar kost ook tijd door het aanklikken bijvoorbeeld. Door demeer mogelijkheden in het systeem, heeft men de neiging meer aan te klikken dan nodig is. Dat is eenleercurve.” (Hospital A, 2011)), accessibility during maintenance or breakdown periods(“Nadeel is dat je er niet altijd bij kan bij storingen of updates, dan worden de hoofdonderdelen uitgeprint.Maar bij SEH kan dat niet!” (Hospital E, 2011)), the loss of data during transfer to a nursingward (“Wij hebben nu een digitaal systeem die ophoudt bij de poort van de SEH dus er wordt wel eenuitdraai gemaakt van de SEH kaart. Maar je verliest dus wel informatie want daar staat niet alles op”(Hospital B, 2011)) and the conversion of a paper into a digital system in the start-upphase (“Tot voor kort waren alle dossiers nog dossiers, die zijn nu allemaal digitaal gekopieerd. Maar opdit moment wordt alles nog afgedrukt en in het dossier bijgevoegd” (Hospital G, 2011).The most frequently stated non-paperless documents are transfer documents from ED tothe nursing ward, radiology, diagnostic requests, documentation when patients are admittedto the ED by ambulance or GP, medicines, consultation documents and laboratoryrequests. GP letters can be sent digitally or given to the patient. The information containedin transfer documents is often transferred verbally. The physical condition of patients issubject to ongoing changes, whereas digitalization has not as yet been implemented;“Overdracht naar verpleegafdelingen: EPD is een belangrijke bron van informatie, maar je ontkomt nietaan een mondelinge overdracht (moment opname), maar bij sommige patiënten niet altijd nodig” (HospitalJ, 2011), “Kijk je naar de verpleegkundige, we hadden voorheen geschreven overdracht naar deverpleegafdeling. Nu draai je het digitaal uit. We printen het nog voor de afdeling, omdat ze op de afdelingnog onvoldoende elektronisch werken.[…] Nu hebben ze de overdracht en vanaf het moment dat wij deoverdracht meegeven, hebben we eigenlijk heel weinig vragen meer gehad. Alles staat er op” (Hospital L,2011). Sometimes it is stated that the reason not all papers can be digitalized is because thesoftware cannot as yet implement certain codes; “Alleen bepaalde formulieren als consulten,Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 65
  • 67. aanvragen is er wel maar nog niet op een goede manier ingebed. Dat krijgt langzaam zijn verbeteringen envoortgang” (Hospital I, 2011). A large amount of paper administration is involved forpatients that are admitted to the ED. Some EDs are scanning all the paper administrationto have all the information available in the digital system; “Er is ook nog een grote papierstroom.Dit is vooral het geval bij het opnemen van patiënten’ (Hospital B, 2011), “Alles wat de patiëntmeeneemt wordt gescand en toegevoegd aan het EPD” (Hospital C, 2011).The general idea is that there are advantages to be gained by a fully digital and paperlesssystem; “In de toekomst wil ik dat als ik een patiënt aansluit aan een monitor dat alle gegevens wordenverwerkt in de computer. Daar is zeker nog een efficiëntie slag te halen” (Hospital C, 2011).Digitalization has conflicting effects on the processes in an ED: there are advantages anddisadvantages. To improve the efficiency and time-savings on the ED, a uniform hospital-wide software system is preferred by some hospitals and specialists. Some intervieweeshave indicated that this is not always the case at the moment. Advantages of digitalizationare for example information transfer and sharing. Disadvantages mentioned by theinterviewees are the increase in time consumption due to the increase of functionsassociated with the digital system and the incompatibility between systems. Opinions onwhether a system can be fully digital vary among the interviewees.5.2.1.2 AnalysisFrom the literature, hypothesis 3 was formulated for the variable technology: Hypothesis 3: digitalization of patient data has both a positive and negative effect on the processes in the ED.Literature can validate this hypothesis as digitalization has been shown to have both apositive and to some extent a negative effect on the processes in an ED. Beneficial effectsof digitalization that have been stated in the literature are: a positive effect on the efficiencyof data management, creating more effective and rapid healthcare, the accessibility ofinformation, a shift to evidence-based medical care, improvement in the quality of patientcare and a reduction in the duplication of data. Digitalization also improves professionaldevelopment. A paperless environment reduces transcriptions and charting vast amountsof patient information and results. Research has however also shown a negative side todigitalization. It is not always possible to digitalize all documents and some systems are lesscompatible with one another. An example of the latter are the compatibility and integrationFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 66
  • 68. of the diagnostic imaging codes with the rest of the software. Also, the literature often perceives digitalization as being efficient, only if a uniform system is used hospital-wide. The incorporation of a hospital-wide uniform system contributes to greater efficiency in accessing information, improving quality and minimizing medical errors. Lastly, the lack of ease of use of digital systems can adversely affect the specialists’ clinical work in terms of its supportive function. Hypothesis 3 can also be validated by the results of the interviews. The opinions of the interviewees vary, as also stated in the literature analysis above. The benefits of a paperless system are availability of information, time-saving, efficiency, possibilities for analyzing processes and insight in areas of improvement due to statistical information in one system and less printing and reduced printing costs. As expressed in the literature, the interviewees have also stated that the reason not all papers can be digitalized is due to the incompatibility of codes in certain areas, like diagnostic imaging. Negative opinions on digitalization and its effect on the processes within an ED were reflected in the increase in time spent on importing patient data, the increase in options for importing data and the potential loss of data when a patient is admitted to a nursing ward where the software systems are not uniform or hospital-wide. The analysis above concludes that hypothesis 3 can be validated by both literature and the results of the interviews. 5.3 Service Service is one of the seven variables that was investigated during the interviews. In this section the results are discussed, followed by the analysis and based on hypothesis 4 (chapter 4). Figure 20 on the left shows the position of the service variable in the conceptual model.Figuur 20: Position service variable 5.3.1 Quality and performance indicators 5.3.1.1 Results This section will discuss the certification and the presence of quality and performance indicators in the hospitals. Ten out of twelve hospitals are NIAZ-certified. One has his own certification; another has Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 67
  • 69. decided to look into another accreditation organization as the NIAZ does not fit theorganization’s structure and management (Louwerse, 2011). Five out of twelve hospitalshave a collaboration agreement with Medirisk. Other items to maintain the quality of theED that were stated: internal and external accreditation, inspection of the IGZ, qualityhandbook for the ED, digitalize protocols, reporting incidents (VIM melding), peerreviews, coaching and training, staff qualifications, keeping portfolios of the staff updated,courses and workshops, technical checks, patient surveys, appointing a professional tomaintain quality, instituting a safety management system and setting quality indicators andmaking them transparent. No uniform decision has been taken on this latter point;“Indicatoren wordt steeds meer op gehamerd. Jammer dat ze nog niet NL breed geaccepteerd zijn, ligt al 5jaar een voorstel voor 50-60 indicatoren gesteld door een aantal beroepsorganisaties. Knoop wordt nietdoorgehakt. We worden pas de laatste 4-5 jaar resultaatgericht afgerekend en dan nog niet keihard. Omdater geen goede indicatoren zijn” (Hospital J, 2011), “Ik vind het vooral belangrijk dat er een intern goedauditsysteem komt en dat je niet afhankelijk bent van de inspectie die eens in de zoveel tijd langskomt”(Hospital D, 2011). Quality maintenance and improvement must involve everyone; “Iedereenkan betrokken worden in het kwaliteitsproces om dingen te verbeteren” (Hospital G, 2011).In conclusion, all hospitals do actually work with some sort of certification in order toguarantee the quality of care given. However, certification is not the only measure to ensureand maintain the quality of the ED. Other examples are inspections by the IGZ,digitalization of protocols, peer reviews, coaching and training and making the qualityindicators transparent. The latter measure has not been standardized which makes itdifficult to compare hospitals and to work according to a more results-oriented scheme.The next section will elaborate on the analysis of the quality and performance indicatorswhich is based on hypothesis 4.5.3.1.2 AnalysisThe following hypothesis was formulated based on the theoretical framework in chapter 4: Hypothesis 4: standardized performance indicators enhance the quality of the ED.Performance indicators need to be evidence-based and nationally standardized in order tocompare quality at a national level. They are important for measuring the effectiveness ofthe ED system to create transparency and measurability of the quality of healthcare.Performance indicators also play a role in patient outcomes and clinical conditions.However, it is difficult for EDs to compare themselves at a national level as theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 68
  • 70. performance indicators are not standardized. Furthermore, communication anddigitalization of data have an effect on the quality of performance of the ED. Additionally,the quality of the ED is maintained through external quality management: certification,accreditation or visitation.All hospitals have an internal and external quality management system. They use internaland external accreditation, are subject to inspections by the IGZ, digitalization ofprotocols, reporting incidents, peer reviews, qualifications of staff, courses and workshops,patient surveys, a safety management system and setting quality indicators and makingthem transparent. These measures serve to enhance quality. However, the standardizedperformance indicators are still not generally established which makes it difficult tocompare hospitals. Therefore, it cannot be confirmed that standardized performanceindicators enhance the quality of the ED. Yet it can be stated that performance indicatorsthat are established by the hospitals themselves improve the quality and performance of theED.In conclusion, performance indicators do enhance quality in general but this has not beenspecifically measured for an ED as there is no general standardization to date. However,quality is maintained through other internal and external quality management systems. Sohypothesis 4 can only be partially validated. Further research on the standardizedperformance indicators is recommended for further research.5.4 Employees The fourth variable is the employees. In this section the focus is on the emergency department (ED) doctor. A table is presented after the results, giving a short overview of the presence of and opinion on emergency (ED) doctors in the different emergency departments (EDs). The results in this chapter will be followed by an analysis, in which hypothesis 5 of the Figuur 21: literature will be tested for validation. Figure 21 on the left shows the Position employee position of the employee variable in the conceptual model. variable5.4.1 Emergency department doctors5.4.1.1 ResultsEmergency department doctors are present in ten of the twelve EDs visited. Theadvantages and disadvantages of the presence of an ED doctor on the processes in an ED,Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 69
  • 71. mentioned by the different interviewees, will be further elaborated on in the followingparagraphs.Only two out of twelve hospitals do not have ED doctors. Hospital D does not use EDdoctors because it is a teaching hospital that provides training for future trainee specialistsand because the general practitioners cannot refer to ED doctors since it is not aspecialization in those hospitals. They also believe they are functioning perfectly wellwithout ED doctors; “Wij werken niet met SEH artsen omdat we een opleidingsziekenhuis zijn diebestemd is voor de AIOS. Verder is een SEH arts een algemene arts en een huisarts kan alleendoorverwijzen naar een specialist. Het is ook nog steeds een probleem om de vacatures gevuld te krijgen. (...)Tot op heden functioneren we prima zonder SEH artsen.” (Hospital D, 2011).The other 10 hospitals do make use of ED doctors. In 9 hospitals, the number of EDdoctors present in the ED is exactly known. It is only known that hospital B and hospital Ihas a fulltime ED doctor in the emergency department. Five hospitals indicate that they donot have fulltime ED doctors. In the case of the other hospitals, the figures are not known.Six out of 12 hospitals indicate that there are not enough ED doctors to work on a fulltimebasis. According to hospital C, there are not enough ED doctors because of savings in themedical curriculum. They are starting an internal training study course for acute caredoctors;“De SEH artsen zijn niet te krijgen omdat er op de opleiding bezuinigd wordt. Wij starten nueen eigen opleiding tot arts geneeskunde.” (Hospital C, 2011). Hospital L confirms that there arenot enough ED doctors to have an ED doctor working full time in the emergencydepartment; “We kunnen de SEH nog niet 7 dagen in de week 24 uur per dag met SEH artsenbemannen. (…), maar SEH artsen zijn schaars. Ze zijn er gewoon niet.” (Hospital L, 2011).Nine of the twelve hospitals declare that they believe that ED doctors enhance efficiency inthe ED process. Three of these nine hospitals indicate that the turnaround time is reducedby employing an ED doctor. Hospital L even pointed out that their waiting time reducedby 4 minutes per patient; “De wachttijd gaat dan gemiddeld naar beneden. We begonnen met ongeveer120 minuten per patient en zitten nu op 116 minuten.” (Hospital L, 2011). Hospital F confirmsthat the waiting time is cut because of up-to-date protocols and because diagnostics aremore efficient and effective thanks to the presence of ER doctors on the ED; “Veelprotocollen zijn geactualiseerd en er zijn veel afspraken gemaakt met de afdelingen en medischebeeldvormende techniek en diagnostiek. Sommige diagnostiek wordt overgeslagen om een andere diagnostiekte doen om sneller resultaat te krijgen. (...) Doorlooptijd wordt bij aanwezigheid van SEH artsen korter.”Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 70
  • 72. (Hospital F, 2011).Another drawback to employing ED doctors in the emergency department is that theycannot perform the tasks they would like to make for greater efficiency. They are morepreoccupied with supervising doctor assistants or specialists in training. Hospital J statesthat the ED doctors do not have enough time to prepare a vision and define and institute aspecific policy. Their policy plan for 2015 specified that the ED needs to be anindependent unit where the ED doctor is formally in charge; “SEH artsen komen niet toe aanvisie, beleid en maatschap gesprekken. (…) Hier staat in het medisch beleidsplan dat in 2015 de SEHeen volledig zelfstandige eenheid moet zijn, waarbij de SEH arts de formele baas is” (Hospital J, 2011).Two out of 12 hospitals make use of a nurse practitioner (NP), namely hospital D andhospital J. Hospital J indicates that their NPs are performing in the fast track and that theyare acting independently in certain protocols. They can also be used for quality assessment.However, they believe that NPs should be given more responsibilities; “Ze doen hier de fasttrack, ze doen protocollair een aantal dingen zelfstandig. (…) Je kan ze ook gebruiken voorkwaliteitsbepaling (zorgpaden, protocollen, wachttijden). Ze moeten alleen meer doen dan fast track.”(Hospital J, 2011) On the other hand, hospital L declares that they are against the use ofNPs. They believe that an NP does not add to the efficiency of an ED. Nurse practitionerscan only perform a small number of extra procedures and these can be done by an EDnurse as well; “Omdat een nurse practitioner volgens mij niks toevoegt. (…) Er zitten hele lagen en denurse practitioner zou dan in een smalle bandbreedte zijn werk moeten doen. Ik denk niet dat we daargenoeg aanboed voor hebben, dat is één. En twee, ik zie er veel meer in dat je dat deel bij de spoedeisendehulp verpleegkundige neerlegt.” (Hospital L, 2011). They believe that the nurse practitionershould play a bigger role in the care of the chronically ill; “Ik denk dat zij een grote rol hebben inde chronische patiëntenzorg.” (Hospital L, 2011).Eight of the twelve hospitals worked or are working with volunteers specifically dedicated tothe needs of patients and their family. The use of volunteers or hosts and hostesses is mostlypositively evaluated. This enhances the quality of service to patients. In hospital D, they workwith patient-service employees to take away some of the workload of an ED nurse and to takeextra care of patients that have to wait; “De patientenservice medewerkers nemen een stuk van hetverpleegkundige werk af. Verder regelen zij ook een stuk patiëntenservice.” (Hospital D, 2011). Incontrast, hospital G stopped using volunteers because they found it difficult to define theirtasks and in the long run there was not enough work for them; “Wij werken met vrijwilligers maardit is niet positief geëvolueerd. Het probleem is dat het moeilijk is om hun takenpakket goed te definiëren. (...)Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 71
  • 73. kunnen weinig of niets doen omdat er geen patiënten zijn.” (Hospital G, 2011).All hospitals have the required training for their nurses and doctors. However, there arehospitals that provide extra training on specific topics like child abuse and customerfriendliness (Hospital G, 2011). Hospital D organizes symposia and case-study training;“Symposium en scholing, waarbij er ook verwacht wordt dat er wat mee gedaan wordt. (...) Vier keer perjaar casuïstiek bespreking met hele keten.” (Hospital E, 2011).Table 3 below shows an overview of the presence of ED doctors in the EDs at thedifferent hospitals, as well as the opinions relating to their presence at an ED. Whenreading the table horizontally, the presence of ED doctors is confirmed as well as theopinion regarding their presence per individual hospital. If the table is read vertically, thenthe situation of the presence of an ED doctor or the opinion on the presence of an EDdoctor can be read for all the hospital codes. Hospital ED Opinion code doctors A Yes Improvement quality/steady professionals B Yes Less consultations/improvement complex care C Yes Not enough ED doctors D No Not enough ED doctors E Yes Lower turnaround time F Yes More efficient shifts, lower turnaround G Yes More efficient process H No - I Yes Take control, central person in process, good support other professionals J Yes Should be their own boss on the ED, too much time on supervision K Yes Too much time on supervision, function not sufficiently incorporated in organization L Yes More efficient because of experience, waiting time cutsTable 3: Overview of emergency doctors and opinion on their presenceThe opinion on the presence of an ED doctor at an ED is two-fold. Advantages includereducing turnaround time, cutting waiting time and making the diagnostics process moreefficient. Disadvantages include the time spent on supervision and the time taken up byED doctors with secondary responsibilities.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 72
  • 74. 5.4.1.2 AnalysisHypothesis 5 was derived from the literature: Hypothesis 5: the presence of an ED doctor at an ED has more advantages than disadvantages, but the effect on efficiency at an ED is difficult to substantiate.Literature can validate this hypothesis. The opinions on the efficiency of ED doctors at anED differ. On the one hand, ED doctors can save time on the speed and quantity of thediagnostics as well on the medical practice. Due to their specific training for ED situations,ED doctors can economize on waiting and turnaround time by diagnosing and treatingwithout the involvement of other specialists as well as playing a role in policy- making.However, research also shows that organization itself determines the quality of the ED andnot the type of doctor. The lack of a uniform training program and the low number of EDdoctors currently employed makes it difficult to fully investigate their effect on theefficiency of an ED.The results of the interviews can validate the ‘twofold’ effect of the presence of an EDdoctor at an ED. The outcomes of the interviews have, as in the literature, confirmed thepositive factor of reducing waiting and turnaround times. Also, interviewees mentionedthat diagnostics are more efficient due to the presence of an ED doctor. The results havealso indicated the disadvantages of the presence of an ED doctor, namely the time spenton supervision and thus the time lost and taken up with tasks other than their primary tasksand responsibilities. The shortage of ED doctors is also confirmed by several interviewees,which makes it difficult to measure the overall efficiency of an ED. ED doctors, asexpressed by most interviewees, cannot be employed fulltime as an ED doctor. Also,hospitals develop their own training program to educate ED doctors, which confirms thenon-uniformity in training programs for ED doctors found in the literature. This alsomakes it difficult to measure the effect of ED doctors on the ED.Hypothesis 5 can be validated by both the literature and the results of the interviews.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 73
  • 75. 5.5 Logistics Logistics is the fifth variable that influences the efficiency of the processes. This section is divided into two subdivisions, namely the triage process and the waiting time and the process within the ED itself. In each subdivision, the results will be discussed as well as the analysis of the literature and interviews. In the analyses, hypotheses 6 and 7 stated in the theoretical framework (chapter 4) will be tested for validation. Figure 22 Figuur 22:Position logistics shows the position of the logistics variable in the conceptual model. variable5.5.1 Triage process and triage systems5.5.1.1 ResultsThese results contain the triage systems the hospitals use, as well as the time prior to triage.Eight out of twelve hospitals use the Manchester triage system. Only hospital H does notuse a triage system. They judge people based on a clinical view; “Wij bepalen patiënten nu opbasis van een klinische blik maar niet vanuit een methodiek” (Hospital H, 2011). Hospital K usesthe Nederlandse Triage standard (NTS) system for patient triage. They used to use theMTS but switched to NTS with the arrival of the integrated HAP. It was more efficient tomake use of one triage system; “Manchester hebben we gehad en met komst van spoedpost zijn weovergegaan op 1 systeem omdat het handiger is als je in één systeem werkt.” (Hospital K, 2011).However, hospital D declared that NTS does not work for their hospital since it triagespatients with a purpose other than that for a HAP; “Wij hebben gekozen voor een andere (triagesysteem) omdat wij met een ander doel triëren. Sowieso werkt het NTS niet voor een ziekenhuis.”(Hospital D, 2011). Ten of the twelve hospitals use a triage nurse to assess patients.However, hospital E uses a ‘co-ordination’ nurse that also does the triage instead of a triagenurse; “We hebben niet formeel een triage verpleegkundige, maar een coördinerend verpleegkundige die ookde triage doet.” (Hospital E, 2011).The time taken for triage to commence is stated as between 5-10 minutes. Most of the EDsmention it is feasible to start a triage within 5-10 minutes, unless it is very busy or thesoftware is not available throughout the ED. Waiting times then increase and in some casesassistance is requested from other ED staff; “Komt ook omdat het NTS nog niet geïntegreerd is,maar stand alone op 1 plek” (Hospital K, 2011), “De patiënten moeten binnen 10 minuten getrieerdworden. Dat halen we redelijk goed” (Hospital G, 2011).Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 74
  • 76. In conclusion, most hospitals make use of the Manchester triage system. However, it is notindicated by the hospitals as being the most efficient triage system. Finally, most of theEDs point out that triage starts within 5 minutes of a patient’s arrival.5.1.1.2 AnalysisThe following hypothesis was formulated in the theoretical framework for the sub-chapteron triage systems: Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED.In the literature, it can be found that the advantages of a triage system are the immediateassessment of patients, the positive effect on waiting times in the waiting room,prioritization of care, placement of patients in the correct treatment room or area andbeing able to start diagnostic tests. What’s more, the different triage systems have their ownadvantages and disadvantages and should be adjusted to the requirements of the hospitalsthemselves. From the different triage systems, MTS is seen as most compatible with theDutch EDs.The results do not give an indication as to whether the implementation of a triage systemmakes the processes of the ED more efficient. Therefore, hypothesis 6 cannot be validatedand should be considered in the recommendations for further research in line withhypothesis 6 below. Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED5.5.2 Waiting time and processes in the emergency department5.5.2.1 ResultsThe results state the different bottlenecks encountered in the processes within the ED.Firstly, the lack of diagnostic equipment is discussed, followed by the dependency ofspecialists that work in their own outpatients’ clinics. Further bottlenecks are thedeployment and inexperience of doctor assistants as well as the uncertainty concerning theallocation of a patient to a particular specialism. This latter bottleneck refers to theadmission of patients to the hospital. This is followed by a discussion of the results ofturnaround and waiting times at the various hospitals. Lastly, the peak patient flow timesare elaborated on.The interviewees at six hospitals indicate that the lack of diagnostic equipment in the EDFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 75
  • 77. creates bottlenecks in the process. Hospital F declared that it is difficult to make clearagreements with the radiology department to give priority to ED patients; “Het is somsmoeilijk afspraken te maken met de afdeling medisch beeldvormige techniek.Zij hebben ook hunprogramma’s en er is geen aparte kamer voor de SEH.” (Hospital F, 2011).Another bottleneck in the process is that emergency departments are dependent onspecialists who work in their own outpatients’ clinics. Six of the twelve hospitalsinterviewed indicate that this factor delays their processes significantly. According tohospital G, it takes up more time to work with specialists from outpatients’ clinics insteadof fixed specialists within the ED itself; “Wij werken met specialisten vanuit de poli’s, dat kan weleens extra tijd opleveren.” (Hospital G, 2011). This is confirmed by hospital L that declaresthat consultation by an ‘outside’ specialist, is more time-consuming; “En natuurlijk als je opeen specialist moet wachten, gaat er over het algemeen meer tijd overheen.” (Hospital L, 2011).According to hospitals D, F, G and J, the deployment and inexperience of doctorassistants, constitutes one of the factors influencing inefficiency in the process within anED. Hospital D states that doctor assistants merely have too many patients to treat.However, this situation is improved slightly by employing a fixed specialist in the ED itself;“Arts-assistenten hebben gewoon te veel patiënten te verwerken. We zien wel dat het verbeterd door hetinzetten van een specialist op de SEH, maar je kan het nooit helemaal wegnemen.” (Hospital D, 2011).Hospital F focuses on the fact that the doctor assistants are young and need extra trainingto function in the emergency department. This affects turnaround time; “Die (arts-assistenten)moeten ingewerkt worden voordat ze wat klinische ervaring hebben, en dat merk je in de doorlooptijden.”(Hospital F, 2011).Another bottleneck according to hospital G and I, is that sometimes it is not clear to whichspecialism the patient should be referred. As a result incorrect referral entails extraconsultations. Precisely speaking, Hospital I states that if the patient cannot be clearlyreferred to a particular specialism, then the ED doctor will determine the specialistdepartment of referral. This means that the ED doctor decides which specialism the patientshould be referred to. This leads to inefficiencies in the process; “Als een patiënt niet duidelijkis voor één specialisme, dan bepaalt de SEH arts voor welk specialisme de patiënt naar een bepaaldeafdeling gaat. De specialisten zoeken het daar maar uit.” (Hospital I, 2011).Two out of the 12 hospitals indicate that the bottleneck in the process is to be found at thepatient admissions procedure at the hospital. The waiting time of patients increases becauseFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 76
  • 78. of the lack of availability of staff to collect patients; “Als een patiënt opgehaald moet worden dooreen afdeling, dat moet dan binnen 15 minuten gebeuren. (…) Daar zitten we over het algemeen overheen.En dat heeft ook met de afdeling te maken die dan geen beschikbaarheid heeft.” (Hospital L, 2011).The turnaround time ranges from 5 minutes to 420 minutes, with the average timebetween 116 and 180 minutes. Hospital E has the lowest turnaround time, but also thehighest range. Turnaround time is influenced by the type of specialism; “Per specialisme heb jeook gemiddelden en je zou het eigenlijk per specialisme moeten bekijken” (Hospital E, 2011). Themultidisciplinary nature of a patient’s assessment and treatment is often stated as the majorimpact factor on turnaround time; “Als patiënten lang op de SEH moeten verblijven dan komt datvaak omdat het multidisciplinair is. Wij werken met specialisten vanuit de poli’s dat kan wel eens extratijd opleveren. Als dan blijkt dat de patiënt toch niet voor het juiste specialisme is aangemeld dan moeten erextra consulten gedaan worden. Dat kost gewoon efficiëntie” (Hospital G, 2011). Other influentialfactors stated are inexperienced doctor assistants, increasing patient complexity itselftogether with an increasing number of complex patients, misinformation from the GP tothe patient about waiting times at the ED, multidisciplinary consultations, admissions,waiting for diagnostic tests or results, dependency on third parties, non-urgent patientsvisiting the ED instead of the HAP and overcrowding; “30% zelfverwijzers, waarvan 15% op deSEH thuis hoort. Ongeveer 10 mensen per dag kon gewoon naar de huisarts” (Hospital I, 2011), “Decomplexiteit van wat wij aanbieden, ligt vrij hoog en daardoor is de doorlooptijd hoger” (Hospital C,2011), “De wachttijden lopen vooral op door de complexere zorg die patiënten vragen. De kamers die jewilt gebruiken voor laag complexe zorg worden nu bezet door patiënten die hoog complexe zorg vragen. Duspatiënten in een lagere urgentie categorie komen niet meer aan de beurt” (Hospital B, 2011), “Verdergebruiken specialisten de SEH om de patiënt verder in kaart te brengen omdat zij er geen tijd voor hebben.Daardoor moeten de arts-assistenten het hele onderzoek opnieuw doen. Dat kost tijd en vooral efficiëntie”(Hospital G, 2011). Solutions to cutting the stated waiting times were the use of an acuteadmissions ward (acute opname afdeling), using care paths, more responsibilities for thegeneral practitioner (GP), providing better and accurate information to patients beforeadmissions and during the ED process itself, better communication and co-operationbetween ED staff, fast track and a good overview of the patients and processes for the EDstaff (digital board) to monitor and give a clear picture of the situation and leave room forinitiative and anticipation; “De huisartsen hebben de rol om overbrugingszorg te bieden en zij denkendat als we dichter bij het ziekenhuis zitten dan wordt de drempel alleen maar lager. De SEH denkt echterdat veel patiënten geen echte eerste lijnszorg of tweedelijnszorg nodig hebben” (Hospital B, 2011), “ErFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 77
  • 79. valt meer efficiëntie te behalen in een vaste kern van arts assistenten op de SEH” (Hospital F, 2011),“Zorgpaden zijn niet de oplossing voor alles, maar met name voor een interdisciplinair proces is het handigom een zorgpad te hebben” (Hospital A, 2011), “Het EPD geeft gelijk een routingsscherm. Iedereenwerkt vanuit zo een routingsscherm. Het is heel handig. In één blik heb je in de gaten hoe druk het is enwat de belasting is” (Hospital I, 2011).The peak period is similar in all the EDs. Inflow starts around noon and dies down mid-evening. The busiest times are mentioned as Mondays and Fridays, because patients tend tovisit the GP just before the weekends or cannot get an appointment just after the weekend;“Dat zijn patiënten die na het weekend toch nog naar de huisarts of SEH gaan. En voor de vrijdag geldt danhetzelfde, alleen dan andersom. Voor het weekend ga je toch maar even naar de dokter” (Hospital L, 2011).In conclusion, different bottlenecks delay the processes within the ED and therefore alsoincrease the waiting time for patients. There are 5 bottlenecks indicated by the hospitalsinterviewed: the lack of diagnostic equipment in the ED, consultations by specialists thatwork in their own outpatients’ clinics which is most time-consuming, the inexperience ofdoctor assistants has a negative effect on turnaround time, no clear referral to a certainspecialism which could entail extra consultations and admission to the hospitals. All thesebottlenecks cause extra turnaround time in the ED process. Finally, peak periods at theEDs are generally the same, namely a normal distribution spread with a peak from aroundnoon until mid-evening. Busiest times are Mondays and Fridays.5.5.2.2 AnalysisThe following hypothesis was deduced from the research of the theoretical framework onwaiting times and processes within the ED: Hypothesis 7: waiting time can be reduced by eliminating bottlenecks.The waiting time is one of the most difficult bottlenecks to eliminate. The Theory ofConstraints (TOC) is often used to reduce bottlenecks in their processes. By implementingthis theory, the processes in the ED become more efficient and effective. Non-productivetime in an ED can be cut by reducing preparation time, the use of appropriate supplies,available and accessible information as well as performing the right procedures. The goal ofTOC is to completely eliminate non-productive time.Several bottlenecks were revealed during the interviews such as the lack of diagnosticequipment in the ED the dependency on specialists from outpatients’ clinics, theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 78
  • 80. deployment and supervision of inexperienced doctor assistants, extra consultations becauseof the ‘undifferentiation’ and non-specificity of patients and the admission of patients tothe hospital. These bottlenecks impact on waiting times. Measures designed to improve theelements expressed above will reduce waiting times.In conclusion, waiting times can be reduced but never completely eliminated. As such,hypothesis 7 can be validated.5.6 Finances Finance is one of the variables that influence the optimization of the processes in the emergency department (ED). The next section will first elaborate on the results of the interviews in the twelve hospitals. This is followed by an analysis based on hypothesis 8. Figure 23 shows the position of the finance variable in the conceptual model. Figuur 23:Position finance variable5.6.1 Financial system of the emergency department5.6.1.1 ResultsThe results in this section cover the financial systems that are used by the various hospitals.It also gives on overview of the opinions on the new DOT system that will be establishedas per 2012.The majority of the hospitals state that revenues are very difficult to calculate as patientsthat visit the ED and have repeat consultations cannot be traced as revenue for the ED;“Het is niet te berekenen hoeveel een SEH precies opbrengt. Het is niet duidelijk als patiënten terugkomenop de poli dat het de SEH is die geld opbrengt.” (Hospital G, 2011). This is confirmed byhospital G that indicates that an ED can calculate what the costs and revenues are up to acertain point. However, it is difficult to calculate what the ED generates via repeat orfollow-up consultations; “(..) SEH’s kunnen berekenen wat het kost en wat het opbrengt. Het is welmoeilijk om te berekenen wat het oplevert aan herhaal consulten.” (Hospital H, 2011).Hospitals C, E and K indicate that the ED is loss-making per definition because itconstitutes a cost center; “Elke SEH is per definitie verlieslatend want het is een kostencentrum.”(Hospital C, 2011). On the other hand, seven out of the twelve hospitals point out that theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 79
  • 81. ED generates money for the hospital elsewhere. The ED itself operates according to abudget construction so it cannot be ascertained just how much revenue it generates.However, the follow-up consultations at outpatients’ clinics do generate money for thehospital at specialist level; “De SEH heeft altijd een kostenbegroting en dan komt het geld elders inhuis binnen.” (Hospital D, 2011). According to hospital F, the ED does generate income.However, such income only appears at the specialist level via outpatient visits but not onthe ED balance sheet; “Wij genereren veel inkomsten door opname en het eerste poliklinische bezoek.Dit wordt terug gezien bij het specialist niveau, niet bij de SEH.” (Hospital F, 2011).Concerning the implementation of DOT, opinions vary from hospital to hospital.However, most hospitals state that they do not see any advantage in changing DBC intoDOT. Hospital B indicates that their products are not covered in DOT for complexityreasons; “Ik denk niet dat dit gaat helpen. Ten eerste zijn onze producten daarin niet goed gedekt. Diecomplexe zorg die wij leveren wordt daar niet in gedekt.” (Hospital B, 2011). According to hospitalH, the encoding of self-referred patients will become questionable; “DOT wordt op basis vaneen verwijzing gecodeerd. Als je weet dat éénderde bij ons zelfverwijzers zijn, dan is nog maar de vraag hoedeze zullen gecodeerd worden.” (Hospital H, 2011).In conclusion, hospitals state that it is difficult to calculate if the ED is generating money.The interviewees indicate that in itself the ED constitutes a cost center but also generatesrevenue for the hospital via follow-up consultations. Opinions about the implementationof DOT vary significantly per hospital. Generally, most hospitals do not believe that DOTwill create greater efficiency.5.6.1.2 AnalysisThe following hypothesis was stated in the theoretical framework on the financial system: Hypothesis 8: it is difficult to determine the profitability of an ED.According to the literature, the social care system in the Netherlands makes it difficult todetermine the profitability of EDs. There is no DBC code for the ED. Visits to the ED areincorporated in the DBC codes for specific diagnoses. In precise terms, this means that ifyou have appendicitis, a small part of the DBC code is apportioned to a visit to the ED. Itis also stated that the outlay for the costs of ‘readiness’ for and ED and being prepared isthe same regardless of patient volume (Taheri, Butz, Lottenberg, Clawson, & Flint, 2004).Neither does the literature give a clear perception of the financial situation of EDs inFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 80
  • 82. general. It is only stated that the low-care unit is profitable in the ED where revenues areused to finance the medium and high-care units. The only statement that can be found isthat EDs are cost centers that work with budgets.The results confirm that there is no clear overview of revenues generated by the ED. Themajority of the hospitals indicate that revenues are difficult to calculate because of follow-up consultations that cannot be traced as revenue for the ED. Follow-up consultations arebooked in under the DBC codes of specialists. The research does not confirm that EDs areloss-making since the department is generating money for the hospital elsewhere. Thefollow-up outpatient consultations do indeed generate money at the specialist level. Onlytwo hospitals indicate that EDs are loss-making per definition since the ED is itself a costcenter.In short, hypothesis 8 is confirmed by the literature as well by the results of the research.However, more research should be conducted in order to reach a general conclusion thatthere is no clear overview of ED-generated revenues. A hypothesis for further researchcould be: Hypothesis 8: An emergency department is profitable.5.7 Patient satisfaction This section gives an overview of the results of the interviews in the twelve hospitals. Hypothesis 9 is then tested for validation. Figure 24 on the left indicates the position of the patient satisfaction variable in the conceptual model.Figure 24: Positionpatient satisfaction variable5.7.1 Patient satisfaction5.7.1.1 ResultsThe nature of the complaints from patients is a reflection of a patient’s satisfaction. Thissection will elaborate on the complaints from patients and the role of volunteers in an ED.Of the three EDs with an annual complaints score under 10, two are EDs with anintegrated HAP (hospitals A and E). For those EDs with complaints amounting toFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 81
  • 83. between 20 and 30 annually, there is a plan for an integrated HAP and ED. The mostcommon complaints are courtesy, communication towards the patient during the entireprocess, wrong diagnosis/treatment, waiting times, receiving attention and the supply ofinformation; “Wat in ieder geval de bedoeling is is dat je bij de triage aangeeft wat de urgentie code is enhoe lang de wachttijd is. En als ze in het traject zitten, dat ze goed geïnformeerd worden waar ze zitten inhet traject. Als het heel druk is, dan gaat het daar mis […]het gaat om het bakkie koffie, om deaandacht, om de kleine dingen, om informatie, om hoe ze ontvangen zijn, hoe ze te woord gestaan zijn,bejegening, voelt de patiënt zich gehoord” (Hospital L, 2011). The interviews have indicated thatthe presence of a volunteer or ward assistant, who interacts with the patient and supportsthe nurse in certain tasks, has a positive influence on patient satisfaction; “Een gastvrouwmaakt ook deel uit waarom we zo weinig klachten hebben. Zorgt voor patiënt en familie. In piektijdenaanwezig en begeleiden het hele traject” (Hospital A, 2011). Hospital E has won a prize for theconcept of ‘room service’, in which the extras in addition to the expected treatment areseen as important impetus for satisfaction; “Service is heel belangrijk. De patiënt komt niet voor dekwaliteit want dat verwacht hij, hij komt voor de extra dingen” (Hospital E, 2011). Hospital Gdeclared it had experimented with using volunteers, but that reactions were not positive asthe tasks of the volunteers were not well-defined; “Wij werken met vrijwilligers maar het is nietpositief geëvolueerd. Het probleem is dat het moeilijk is om hun takenpakket goed te definiëren. De mensenkomen met de intentie om mensen te helpen maar dan komen ze hier en dan kunnen ze niets of weinig doenomdat er geen patiënten zijn. Ze willen wel andere dingen doen zoals kamers bijvullen maar dat moet dooreen verpleegkundigen gedaan worden. Wij werken ook niet met afdelingsassistenten” (Hospital G, 2011).To summarize, complaints in the twelve EDs mainly concerned courtesy, communicationtowards the patient during the entire process, wrong diagnosis/treatment, waiting times,receiving attention and the supply of information. The function and effect of volunteershas been generally experienced as having a positive effect on patient satisfaction.5.7.1.1AnalysisFrom the literature the following hypothesis was derived: Hypothesis 9: verbal communication towards a patient in the ED plays an important role in patient satisfaction.Literature can validate hypothesis 9. The CQ index (Consumer Quality Index) hasidentified nine important steps that affect the satisfaction of a patient visiting the ED. Thisliterature has indicated that communication is crucial at all stages and levels within the ED,Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 82
  • 84. especially concerning waiting times and information and communication between patientsand staff. Research has indicated that patients are also influenced by the patient-nurse orpatient-physician relationship, in which communication, courtesy and building a goodpatient-physician relationship are considered as crucial elements in the realization of thoserelationships. Communication between patient-staff and between staff themselves has beenpointed out as a frequent area for improvement in patient satisfaction. Also,communication about the stay at the ED, waiting times, after-care and consistency in thetreatment information were indicated as important verbal communication factors playing arole in patient satisfaction. Research has indicated the importance of patient-centered care(PCC), in which communication plays an important role in patient satisfaction. Also, thepresence of volunteers guiding the patients through the process in the ED is seen toenhance patient satisfaction.The results of the interviews can also validate hypothesis 9. The interviews revealedcomplaints frequently mentioned by patients such as a lack of communication towards thepatient during the entire process, communication relating to waiting times and the supplyof information. Improvements in these domains, as also mentioned in the literature above,will enhance patient satisfaction. Those interviewees working with a volunteer systemindicated that this has a beneficial effect on patient satisfaction.In conclusion, hypothesis 9 can be validated by both the literature as well as the results ofthe interviews.5.8 Overview of the hypotheses and their validationThe hypotheses below were validated by both literature and the results of the interviews.Some hypotheses could be validated, but also required more extensive research. Thesehypotheses are stated below, but reformulated for further recommendations:  Hypothesis 1: Hypothesis 1: the layout of the ED affects the long-term success of its processes.  Hypothesis 3: digitalization of patient data has both a positive and negative effect on the processes in the ED  Hypothesis 5: the presence of an ED doctor at an ED has more advantages than disadvantages, but the effect on efficiency at an ED is difficult to substantiateFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 83
  • 85.  Hypothesis 7: waiting time can be reduced by eliminating bottlenecks  Hypothesis 8: An emergency department is profitable  Hypothesis 9: verbal communication towards a patient in the ED plays an important role in patient satisfactionSome hypotheses could only be validated partially or not at all by the interviews. Some ofthese hypotheses were restated or left in their original state, depending on the validation.These hypotheses will be further elaborated on in the recommendation for further research(chapter 6): Hypothesis 1: an admissions ward has a positive effect on the overcrowding and throughput of an ED (reformulated from original hypothesis 1) Hypothesis 2: the integration of a HAP and an ED improves the efficiency and quality of care at a lower cost Hypothesis 4: standardized performance indicators enhance the quality of the ED Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED Hypothesis 8: An emergency department is profitable (reformulated from the original hypothesis 8)Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 84
  • 86. 6. Conclusion6.1 IntroductionThis chapter presents the answer to the central research question, as well as the answers tothe twelve related sub-research questions. As mentioned in chapter 1, the aim of thisresearch is firstly to investigate which variables contribute to the efficiency of an emergencydepartment in the Netherlands and secondly how the latter contribute to developing theoptimal emergency department (ED). Based on these findings, recommendations on theoptimal emergency department can be made for Loek Winter, co-founder of theMC|Groep. The following central research question is applicable:Which variables influence the efficiency of an emergency department, and how can these variables be used to create the optimal emergency department?To answer the central research question, the twelve research questions must first beanswered. These are discussed in the following paragraphs, after which the central researchquestion will be answered. This will be followed by recommendations for Loek Winter (co-founder MC|Groep) who commissioned the actual research. Finally, the limitations andrecommendations for further research will be discussed.6.2 Conclusion research questionsThe first research question was based on the literature and discussed the definition andcharacteristics of an ED. An ED can be classified as a fully operational ED when it has24/7 availability and the hospital itself comprises at least the following eight specificspecializations: internal medicine, surgery, gynecology/obstetrics, pediatric medicine,neurology, cardiology, ear-nose-throat (ENT) medicine and ophthalmology. The Dutchhealth inspectorate requires EDs to examine every patient that visits an ED. An EDprovides medical and nurse-related care to patients visiting the ED. These patients enter anED with traumas or acute health problems.The second, third and fourth research questions discussed the definitions relating toefficiency and optimization and their interrelation. Efficiency refers to the method ofoperations and is often referred to in the literature as the efficiency variable. From thevarious definitions in the literature, efficiency was defined as ‘the capability to provide andorder a level of service that is sufficient to meet the patients’ healthcare needs, whereFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 85
  • 87. operations and processes are questioned as to their relevance with a view to achievingstrategic outcomes and where the healthcare resources are used in such a way as to get thebest value for money’. The goal of optimization is to design a system or process asfunctional and perfect as possible. Continuous improvement is important as healthcare is initself dynamic and it is seen as the progression towards optimization. By continuouslyimproving and re-determining the efficiency of the system and its individual processes,progress is made towards an optimal situation. Thus, optimization can be achieved bymaking the system and its individual processes as efficient as possible.The fifth research question identified the variables that contribute to the efficiency of anED. Seven variables were extrapolated and identified from the literature; infrastructure,technology, service, employees, logistics, finance and patient satisfaction. The researchquestions relating to these variables will be discussed in the following paragraphs.The sixth research question discussed the relation between infrastructure and efficiency.Discussed were the layout of an ED and the presence of a HAP (general practitioners’ co-operation). The layout of an ED impacts on the efficiency of the processes in and overviewof an ED and so hypothesis 1 could be validated. These processes include the throughputtime and improvements in overcrowding. Literature and interviews have indicated thatphysical layout is also shown to have an effect on the efficiency of an ED, especially theballroom or linear layouts for the ‘transparency’ of the ED, easy accessibility to the centralnursing station for both patients and staff and also to enhance patient satisfaction. Inaddition, uniformity in treatment room layout makes for greater flexibility and ease ofpatient placement. The literature stated that centralizing primary processes and placingsecondary processes in the periphery can make ED processes more efficient. Interviewsvalidated this added there should also be a distinction made between urgent and non-urgent patients for example by means of a fast-track. Optimal efficiency can also beachieved by the right location for diagnostic imaging. Hypothesis 2, relating to theefficiency of integration between the ED and the HAP (general practitioners’ co-operation)could be validated in the literature, but not through the interviews themselves. Literaturehas proven that the efficiency of an integrated ED and HAP lies in the redirection of non-urgent patients which can in turn also improve the quality of care. However, interviews donot fully validate the efficiency of an integrated HAP, due to the resistance of generalpractitioners and the lack of sufficient specific data from the interviews. Concluding, thelayout has an effect on the processes of throughput time and reducing overcrowding, theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 86
  • 88. effect of presence of a HAP and the effect on efficiency have not been validated and willneed to be further investigated.The seventh research question related to technology and efficiency, in which its positiveand negative effects on the processes of an ED are validated by both literature andinterviews. Technology consists of the digitalization of patient data. Literature andinterviews state that efficiency in the digitalization of data can benefit the followingprocesses in an ED; data management efficiency, creating more effective and rapidhealthcare, the accessibility of information, a shift to evidence-based medical care,improvement in the quality of patient care and a reduction in the duplication of data.Digitalization can save time as it is accessible everywhere, but may also be time-consumingdue to problems in compatibility between systems and codes, the increase in the number offunctions that can be implemented by specialists and loss of data when data is digitalized.The processes within an ED will become more efficient if digitalization, a paperless systemand a software system are applied in a uniform manner throughout the hospital. Efficiencyin the latter is seen as contributing to a more efficient and cost-effective way of accessinginformation and minimizing medical errors.Research question eight elaborated on the quality and performance indicators. The impactof these indicators on efficiency issues could not be validated by the interviews. Literaturehas however indicated that standardized performance indicators enhance the quality of theED, as they create transparency and make national comparisons between EDs easier. Thusthe effectiveness and quality of an ED can be measured, bottlenecks can be identified andimproved and where possible resolved to make for greater efficiency throughout the ED.Quality and performance indicators for the EDs in the Netherlands have not yet beenstandardized, thus no conclusion can be reached as to their effect on the efficiency of theprocesses within the EDs. Quality in an ED is maintained through other internal andexternal quality management systems, where the internal systems are developed by thehospitals themselves.Research question nine elaborated on the relation between the presence of an emergencydepartment (ED) doctor and the impact on the ED’s efficiency. Literature and interviewsalike have revealed more advantages than disadvantages when there is an ED doctorpresent. The benefits of the presence of an ED doctor in relation to the efficiency of anED can be summed up as follows: time savings in terms of speed and number ofFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 87
  • 89. diagnostic tests, reduction in waiting and turnaround times, no need for repeatedconsultations with other specialists and time for policy-making. Disadvantages mentionedwere the time lost in the supervision of doctor assistants and the generalist nature of an EDdoctor compared to the specialists consulted by an ED. Interviews have indicated that inthe Netherlands, the beneficial effect of the presence of an ED-dedicated doctor on theefficiency in an ED is difficult to measure, in view of the scarcity of ED doctorsthemselves, the shortage of ED doctors in full ED employment plus the lack of uniformityin training programs.The tenth research question covered the logistics of an ED, divided into triage systems andwaiting times. According to the literature, the efficiency of triage systems lies in thefollowing processes; reduction in waiting-room times, prioritization of care and the correctplacement and allocation of patients. The Manchester Triage System (MTS) is consideredthe triage system as having being the most compatible with EDs in the Netherlands as perthe literature and as reflected in the fact that most of the interviewed EDs were using theMTS system. However, the effect of a triage system on the efficiency of the processes inthe ED did not become apparent during the interviews themselves. Concerning waitingtimes, both the literature and interviews have indicated that waiting times can be cut byeradicating bottlenecks in those ED processes that affect waiting time. Bottlenecksmentioned were the absence of diagnostic equipment located in the ED, dependency onspecialists outside the ED, supervision of inexperienced doctor assistants, extraconsultations due to non-specific patients and patient admissions procedure. Bottleneckscan be identified and reduced by using the Theory of Constraints (TOC). Theimplementation of this theory can enhance the processes within the ED.Research question eleven focuses on the financial system in an ED. Both the literature andthe interviews have shown that the determination of the profitability of an ED in theNetherlands is difficult. DBC codes for the ED are incorporated in the DBC codes for adiagnosis, thereby resulting in the non-transparency of ED visit costs. Low-care unitsfinance the medium and high-care units. 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,no clear overview of revenues generated by the ED exists as yet.The last research question explored the relation between patient satisfaction and efficiency.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 88
  • 90. Efficiency in the processes in an ED resulted in less complaints and a lack of efficiency ledto more complaints by patients. Here, verbal communication plays an important role,especially with regard to waiting times, the communication of information and the relationbetween patient and ED staff. These are areas where major improvements can be made.Verbal communication during the stay at the ED, after care and consistency in theinformation about treatment are also important factors contributing to patient satisfaction.By tackling the bottlenecks and the inefficiencies, patient satisfaction can be improved andthe number of complaints reduced. The importance of verbal communication will becomemore important in the 21st century owing to the new focus on Patient-Centered Care(PCC). The use of volunteers has proven to be a useful way to improve communicationtowards patients and between patient and staff.All the research questions have now been answered. The answer to the central researchquestion will be presented in the following paragraph.6.3 Conclusion central research questionEfficiency can be seen as the various steps needed to achieve an optimal situation. In thispaper, the definition of efficiency was defined as ‘providing and commissioning a level ofservice that is sufficient to meet a patient’s healthcare needs, where operations andprocesses are questioned and investigated as to their relevance to achieve the strategicoutcomes and where healthcare resources are used in such a way as to get the best value formoney’. Seven variables were identified as having an influence on the processes in an ED,thereby influencing its efficiency; infrastructure, technology, service, employees, logistics,finance and patient satisfaction. The manner in which these variables affect efficiency wasexpounded in the previous paragraph in which the research questions were answered.However, to create an optimal ED by using the seven variables, these variables must bemanipulated and used in such a way as to maximize their efficiency within the ED inrelation to the processes associated with those individual variables. Only when theprocesses are implemented efficiently will it be possible to develop an optimal ED.Continuous on-going improvement is vital. Only by first determining and thencontinuously improving a system’s efficiency and its individual processes, can progresstowards an optimal situation be achieved. This is where the Theory of Constraints (TOC)can contribute to reducing bottlenecks and make for a more efficient, effective and optimalED which is indeed the ultimate goal (of this paper). From a patient perspective, theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 89
  • 91. Patient Centered Care (PCC) should be adopted to improve patient satisfaction, as this isbecoming increasingly important in the 21st century. It must be noted however that theoptimal ED does not exist and is dependent on different factors. An ED can be designedas optimal as possible, only when taking into account the resources, culture and location ofthat individual ED.To answer the central research question in short; literature has shown that the efficiency ofan ED is influenced by seven variables and when manipulated in a different ways can addto an optimum situation in the ED. However, not all of these seven variables could bevalidated by the results of the interviews and should therefore be investigated in furtherresearch. The optimal ED does not exist, as resources, culture and location of theindividual ED must be taken into account when designing the optimal ED. In turn, theseven variables must be manipulated in an ED on an individual level accordingly.6.4 Recommendations for the MC|GroepIn the light of the answers to the central research and twelve sub-research questions, thefollowing recommendations can be posed for Loek Winter (co-founder of the MC|Groep).ED layout – It is recommended to pay sufficient attention to ED layout, taking intoaccount both physical layout and general appearance. Not only does layout impact onED’s processes, but also on patient satisfaction. A ballroom setting is recommended tocreate visibility, accessibility, overview and transparency for both patients and ED staff.Also, uniformity of treatment room layout, makes for flexibility in the placement ofpatients. Additionally, separating out the central and peripheral processes, as well as urgentand non-urgent patients, will add to the efficiency of an ED.Digitalization of data – It is recommended to use a uniform software system throughoutthe hospital and digitalize all patient data to make for a more efficient and cost-effectivemethod of accessing information and minimizing medical errors.ED doctor – Although it is difficult to measure the effects of efficiency to date, thebenefits extrapolated from the interviews became apparent. A pilot should be initiated totest the effects of the ED doctor within the ED itself.Waiting time – If not already implemented, it is recommended to use of the Theory ofConstraints (TOC) to identify bottleneck and enhance the processes within the ED,Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 90
  • 92. including the reduction of waiting times.Finances - EDs are seen as costly, mainly due to the consequences of their permanentavailability function. Before embarking on the process of making the ED more efficient, aclear overview of the costs and revenues should be obtained. By so doing, those areas thatare costly can be identified and further research conducted to investigate how to make theprocess more efficient whilst reducing costs. As the ED yields revenue for the hospitalthrough patient admissions and follow-up consultations, it is also recommended to paysufficient attention to patient satisfaction.Communication – As verbal communication towards a patient in the ED plays animportant role in patient satisfaction, this area should be continuously evaluated andimproved. Patient-Centered Care (PCC) will become increasingly important in the 21stcentury, especially the relation between patients and ED staff. Besides verbalcommunication, it is recommended to create a physical layout in the ED that providesenough facilities for the patient as well as offering a clean and bright appearance.Overall, it should be born in mind that the optimal ED does not exist. Yet, an ED can beoptimized to its maximum extent by introducing the seven variables as efficiently aspossible. In this process, the particular circumstances of the MC|Groep should be takeninto consideration and only those variables that add value to the ED incorporated. Finally,the recommendations mentioned in section 6.6 in which the hypotheses have not as yetbeen validated, should be taken into account. Further research on these particularhypotheses could be conducted by the MC|Groep itself, or an external party.6.5 LimitationsThis section discusses the limitations of this research paper. Starting with the limitations ofthe methodology used, followed by the limitations relating to the theoretical frameworkand lastly the limitations of data availability.The first limitation relates to the methodology used. Not every hospital in the Netherlandshas been interviewed and not every hospital wanted to co-operate, thereby restricting thepopulation for the actual research. Qualitative research also limits research outcomes. Itwould have been preferable to include quantitative research based on financial data had thisbeen possible. A further limitation is reflected in the answers given by the intervieweesduring the interviews. Some of these might have been desirable from a social angle. CertainFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 91
  • 93. questions were not answered fully, as the interviewees might not have wanted to provide allthe information requested by the researchers. Consequently, not all data was available foranalysis. Some interviewees could not answer all the questions precisely, resulting in gaps inthe data. This could be attributed to interviewees who might not have been in theirposition for long or lacked the necessary background information. It was not possible togather the missing information after the interviews. The translation of Dutch interviewsinto an English matrix in Excel could have an bearing on the content of the data. Such asituation would not have arisen if the interviews had been conducted in English.Theoretical research also has limitations. Time constraints made it impossible to researcheach variable extensively. Certain data was not researched sufficiently or the outcomes wereindecisive as in the case of acute admission wards (AOA). Data might also have been lostduring the transfer from the memo recorder to the actual writing up of the interviews, aswell as transferring data from the interview summaries into Excel. Interviews facilitated thegathering of extensive information, but misinterpretations is always a possibility whenprocessing data. It is difficult to eradicate such an effect. The optimal ED as recommendedin this paper cannot be applies to each ED, which must appraise its own situation andadapt the optimal ED to its individual circumstances and capacities.6.6 Recommendations for further researchThis section will elaborate on the recommendations for further research, based on thehypotheses that could only partially validated or not at all by the results of the interviews:  Hypothesis 1: an admissions ward has a positive effect on the overcrowding and throughput of an ED (reformulated from original hypothesis 1)  Hypothesis 2: the integration of a HAP and an ED improves the efficiency and quality of care at a lower cost  Hypothesis 4: standardized performance indicators enhance the quality of the ED  Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED  Hypothesis 8: an emergency department is profitable (reformulated from the original hypothesis 8)Hypothesis 1 above was derived from the original hypothesis 1; ‘the layout of anemergency department (ED) has an effect on the long-term success of its processes’.Although the latter hypothesis was validated by both the literature and the results from theFemke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 92
  • 94. interviews, the interviews indicated a preference for the presence of an acute admissionsward (AOA). The presence of an AOA was not researched in the literature, thus noconclusion could be reached in this respect in the paper. A recommendation would be toconduct specific research on the impact of an AOA on the efficiency of an ED.Hypotheses 2, 4 and 6 were stated in literature to as having a beneficial effect on EDefficiency. However, further research should conduct further investigate as to the impact ofthe presence of a HAP on ED efficiency and cost. As this could not be substantiated viathe results of the interviews. Hypothesis 4 could give rise to comparative research in thefuture, where the current effects of the efficiency of an ED are compared with a futuresituation. Future situation defined as the moment standardized ED performance indicatorsare introduced. Recommendations for hypothesis 6 could be in-depth research on theefficiency of a triage system.Finally, the newly formulated hypothesis 8 was derived from hypothesis 8 as originallyposed; ‘it is difficult to determine the profitability of an ED’. Although both literature andthe results of the interviews validated original hypothesis 8, more research should beconducted on the specific aspects of the financial system within an ED. Generally, the EDis thought to be loss-making due to its permanent availability function. However, facts andfigures on the real costs and revenues are lacking. Further research designed to make forgreater transparency and precision would therefore contribute to optimizing efficiency andcost-effective healthcare.Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012 93
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