MSc Thesis "Optimization of Emergency Departments in the Netherlands"

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, 2012

Defence date: January 12th, 2012

First reader: Professor Dr. Willem Burggraaf

Second reader: Drs. Hans ten Rouwelaar

Company Supervisor: Professor Dr. Drs. L.H.L. Winter

Straatweg 25

3620 AC Breukelen

The Netherlands

Ziekenhuisweg 100

8233 AA Lelystad

The Netherlands

Executive summary

The current healthcare system in the Netherlands is coming under increasing pressure due to
demographic, socio-economic and technological developments within Dutch society. Demand
and costs are rising, leading to savings and reforms in the healthcare sector. Consequently, a
new approach towards acute care, with the focus on emergency departments (EDs) is to be
desired, as outlined in this research paper.

The aim of this research was firstly to investigate which variables contribute to the efficiency of
an emergency department in the Netherlands and secondly how the latter contribute to
developing the optimal emergency department (ED). The variables researched were
infrastructure, technology, service, logistics, employees, financial system and patient satisfaction
within an emergency department (ED). To arrive at recommendations, the following central
research 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 the
central research question required descriptive, exploratory and explanatory information
expressed in words, as well as a flexible means of data collection. Qualitative research enabled
the researchers to ask more in-depth questions during interviews and qualitative research was
also preferable, as the aim of this research paper is to develop recommendations based on the
current situation in the twelve individual emergency departments (EDs). The population was
identified as ‘complete’ EDs; 24/7 availability and incorporating eight compulsory
specializations. From the 67 ‘complete’ EDs in the Netherlands, a sample size of 12 was found
willing to co-operate. Location, category and willingness were three of the main selection
criteria.

The most important results were derived from the validation of the posed hypotheses by both
literature 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 time
and 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 and
a software system are applied in a uniform manner throughout the hospital. Thirdly, the
presence of an ED doctor at an ED is two-fold. Benefits include time-savings in terms of
speed and number of diagnostic tests and reduction in waiting and turnaround times.

Femke Lammerts and Elisa van Poelgeest, MSc 19, January 2012

Disadvantages mentioned were the time lost in the supervision of doctor assistants. The
shortage of ED doctors in full ED employment, plus the lack of uniformity in training
programs make it difficult to measure the actual presence of an ED doctor. Fourthly, waiting
time can be reduced to eliminate bottlenecks by using the Theory of Constraints (TOC). The
implementation of this theory can enhance the processes within the ED. Fifthly, it is difficult
to determine the profitability of an ED. EDs are seen as costly, mainly due to the
consequences of their permanent availability function. On the other hand, the ED yields
revenue for the hospital through patient admissions and follow-up consultations. However, no
clear overview of revenues generated by the ED exists as yet. Lastly, verbal communication
with patients in the ED plays an important role in patient satisfaction, especially with regard to
waiting times, the communication of information and the relation between patients and ED
staff. 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 an
ED is influenced by seven variables which can lead to optimization of an ED. The optimal ED
does not exist, as factors such as resources, culture and location of the individual ED must be
taken into account when designing the optimal ED. Accordingly, the seven variables must be
applied within an individual ED.

Recommendations for further research would be to conduct more than twelve interviews and
investigating the impact of cultural and regional differences within the Netherlands on the
efficiency of an ED. The variables should also be applied in a practical setting to identify their
effect on efficiency within an ED. Hypotheses that could not be validated by research should
also be further investigated as to their impact on ED efficiency.

The research in this paper was limited by the restrictions in terms of methodology, theoretical
framework and availability of data. Time constraint constituted the most important limitation
as it was not possible to conduct extensive research within the timeframe. Moreover, the
population researched was relatively small making it more difficult to reach a general
conclusion.

Recommendations for the person commencing this research, Loek Winter, are derived from
the hypotheses that could be validated by literature and the results of the interviews. The
particular circumstances of the ED at the MC|Groep should be taken into account, only
incorporating those variables that add value to that ED.


Acknowledgements

This 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 Nyenrode
Business University. We would like to thank both for their time, effort and support during
the writing of the thesis. Without the advice and resources of these parties, this thesis
would not have been possible. We would also like to thank all the people who were
involved in the process of this thesis and making their resources and contacts available to
us. Lastly, a special thank you to all the interviewees at the different emergency department
for their co-operation, interesting conversations and openness in the exchange of ideas and
information.

Femke Lammerts and Elisa van Poelgeest, MSc 19
January 2012


Table of contents

1. Introduction ................................................................................................................................... 8

1.1 Scientific and managerial relevance .................................................................................... 10

1.2 Structure ................................................................................................................................. 11

2. Conceptual model ....................................................................................................................... 12

3. 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............................................................................................ 23

4. 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 ..................................................................................................................... 34


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 ............................................................................................................................ 55

5. 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 ...................................................................................................................... 67


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 ............................................................ 83

6. 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 ............................................................................................................................. 91


6.6 Recommendations for further research............................................................................. 92

Bibliography ..................................................................................................................................... 94

Table of figures

Figure 1: Conceptual model ............................................................................................................. 12
Figure 2: Research paths .................................................................................................................. 14
Figure 3: Selection of research subjects .......................................................................................... 16
Figure 4: Method of data collection ................................................................................................ 18
Figure 5: Analysis process ................................................................................................................ 20
Figure 6: Operational conceptual model......................................................................................... 23
Figure 7: Position of emergency department ................................................................................. 25
Figure 8: Position of efficiency and optimization .......................................................................... 27
Figure 9: Position of the seven variables ........................................................................................ 28
Figure 10: Position infrastructure variable...................................................................................... 29
Figure 11: Position technology variable .......................................................................................... 34
Figure 12: Position service variable ................................................................................................. 36
Figuur 13: Position employee variable ............................................................................................ 39
Figure 14: Position logistics variable ............................................................................................... 42
Figure 15: Position finance variable ................................................................................................ 48
Figure 16: Financing and funding structure in Dutch health-care system .................................. 49
Figure 17: Position patient satisfaction variable ............................................................................. 52
Figuur 18: Position infrastructure variable ..................................................................................... 56
Figuur 19: Position technology variable.......................................................................................... 63
Figuur 20: Position service variable................................................................................................. 67
Figuur 21: Position employee variable ............................................................................................ 69
Figuur 22: Position logistics variable............................................................................................... 74
Figuur 23: Position finance variable ................................................................................................ 79
Figure 24: Position patient satisfaction variable ............................................................................. 81

Table of tables

Table 1: Overview emergency department layout.......................................................................... 58
Table 2: Overview of the distribution of HAP integration ........................................................... 62
Table 3: Overview of emergency doctors and opinion on their presence ................................... 72


1. Introduction

The current healthcare system in the Netherlands is coming under increasing pressure due
to demographic, socio-economic and technological developments within Dutch society.
The demand for care will become increasingly complex due to the rising number of elderly
people and the increasing demand for personally tailored care. This will eventually lead to
higher healthcare costs. Consequently, the healthcare sector will have to deal with savings
and 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 pillars
originates from the patient perspective (Boot & Knapen, 2005). Primary care is defined as
care for which no referral is needed from a general practitioner (GP) and therefore patients
can refer themselves to specific healthcare (Bos, Koevoets, & Oosterwaal, 2011). The
emergency department (ED) forms part of the primary care pillar, but is situated within
secondary care. The general practitioner (GP) plays an important role in the process of
referring a patient to secondary care. Secondary care is only accessible by referral via
primary 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 is
needed within a short period of time (van Baar, Giesen, Grol, & Schrijvers, 2007). During
recent years there have been reforms leading to the creation of general practitioners’ co-
operations to organise acute care more efficiently. The following bottlenecks still exist
within 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.

8

These bottlenecks will need to be adressed in the future in order to make acute care more
efficient. 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 to
be desired, as outlined in this research paper. The closure of and pressure on emergency
departments is currently a ‘hot topic’ so to speak, as is the worsening financial situation
encountered in many hospitals. Controlling costs in an emergency department is complex
as EDs have a 24/7 availability function (Baltesen, 2009). Costs, customer service and
eliminating waiting time are key factors that should be addressed in any attempt to reform
acute care. By focusing on results, a positive effect can be reached on quality, care and
patient satisfaction. Therefore, it is desirable to investigate which variables can be used to
create an optimal emergency department, which is customer focused, improves efficiency
and has a sound financial foundation (Nederlandse Zorgautoriteit, 2008).

The aim of this research is firstly to investigate which variables contribute to the efficiency
of an emergency department in the Netherlands and secondly how the latter contribute to
developing the optimal emergency department (ED). Based on these results,
recommendations on the optimal emergency department can be made. The variables
researched are infrastructure, technology, service, logistics, employees, financial system and
patient 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?

9

The central research question will be answered by means of the following sub-research
questions:

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 will
clarify the terms of the central research question. Sub-research question five will explain
which variables, found in literature, contribute to the efficiency of an emergency
department. The last seven sub-research questions will answer, per variable, how each
variable influences the efficiency of an emergency department. The twelve research
questions form an extensive answer to the central research question, which will be
answered in the conclusion.

1.1 Scientific and managerial relevance

There are several reasons why this research has scientific and managerial relevance.
Scientifically, there are very few research reports that investigate both the financial

10

perspective as well as the customer focus perspective in an emergency department. There
has never been sufficient research done on customer focus in an emergency department
setting, as the main focus has been on the optimization of procedures and achieving higher
quality. The customer satisfaction and focus in this paper will be achieved as a consequence
of optimizing the emergency department’ processes. The interviews have not been
validated in English, as this research investigates the optimization of Dutch emergency
departments. This gives a better insight into the current situation of emergency
departments in the Netherlands. By looking at the different variables and their contribution
to the efficiency and optimization in an emergency department, the overall performance of
an emergency department could be improved. The new approach to the structure of an
emergency department will also influence the managerial relevance. Market forces will
become increasingly important, as well as distinguishing factors. Consequently, the
managerial approach should be adjusted in order to become more customer focused and
profitable. Finally, managers and other professionals can use the suggested variables as a
tool for change and improvement when thinking about their own acute care situation.

1.2 Structure

This 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 is
important for the total structure of this research paper, as it will function as a guide
through all the subsequent chapters. The third chapter will discuss the methodology, in
which qualitative research, data collection, research subjects, method of analysis, reliability
and variability and the operational conceptual model will be discussed. The fourth chapter
will cover the theoretical framework. This chapter contains the literature on which the
variables are based. From this theoretical framework, hypotheses are developed. This
chapter is then followed by an overview of the results and an analysis (chapter five). The
results describe the outcomes of the interviews held and they will test the validity of the
hypotheses that emerged from the theoretical framework. The last chapter (chapter six) is
the conclusion, in which the central and twelve sub-research questions will be answered
and recommendations made. This chapter also contains the limitations of the research,
recommendations for the MC|Groep and recommendations for further research. The
bibliography can be found at the very end. The appendices can be found in the confidential
booklet, which is supplied separately to whoever it may concern.

11

2. Conceptual model

The conceptual model shown in figure 1 is important for the structure and comprehension
of 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 which
the specific part under discussion is highlighted in the model.

The detailed methodology behind this conceptual model and the research paper will be
further elaborated on in chapter three (methodology). The foundation for the variables can
be 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 answer
these research questions and to reach a final conclusion. Figure 1 can be read and
interpreted as follows: The left box indicates the research subject. The emergency
department (ED) is the research subject, of which the head of the EDs are the
interviewees. In total twelve EDs were visited, divided into academic, teaching and
regional. The middle box shows the seven variables that, based on literature, have an effect
on the efficiency of an ED. These variables are interlinked. The right-hand box shows the
aim of this research paper, namely recommendations for the optimal ED.

Figure 1: Conceptual model

12

3. Methodology

3.1 Introduction

Chapter three discusses the methodology of this paper and is divided into eight parts. The
second section of this chapter (3.2) will give a general overview of the methodology by
means of a model. The function of the model is to give a general and clear overview of the
paths followed in this research paper. The third part (3.3) discusses the reasons for
choosing 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), the
reliability and validity of the methodology (3.7) and concluded with the operational
conceptual model (3.8).

3.2 General overview

The figure on the next page, figure 2, gives an overview of the paths followed for this
research paper. The model can be interpreted as follows. The request by the person
commissioning this research, Loek Winter (co-founder of the MC|Groep), on the
optimization of emergency departments (EDs) in the Netherlands led to a pre-
investigation. The pre-investigation consisted of gaining an awareness of the literature on
EDs and optimization, in order to obtain knowledge and insight into the variables
contributing to the efficiency and optimization of EDs. From this study two products were
developed; the central research question and the twelve sub-research questions and a
variables list for the interview. The list of variables can be found in appendix I of the
confidential booklet and its foundation is described in the theoretical framework (chapter
4). The central research question and the twelve sub-research questions can be found in
chapter 1. In order to answer the central and twelve sub-research questions, two paths were
selected.

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 the
literature on variables contributing to the efficiency of EDs in order to establish the
foundation for the central and twelve sub-research questions. From the literature,
hypotheses were deduced. The validation of some of these hypotheses could be tested by
the literature, other hypotheses not. This latter path will be further explained in the
research path (path two, dotted red arrow in figure 2). The hypotheses that could be

13

validated by the literature were used in the analysis. In this analysis the theoretical
hypotheses were compared to the outcomes of the interviews in order to make a final
conclusion as to the validity of the hypotheses.

Path two (arrow pointing down and digit two) indicates the practical part of this research
paper. Twelve interviews were conducted and the variables list posed and investigated.
Some of the unanswered hypotheses that issued from the literature path (path one) were
answered by the outcomes of the interviews. The other unanswered hypotheses remained
unanswered, as they were not able to be answered within the scope of this paper. They
were then placed as recommendations for further research.

The main conclusion was reached by answering the central and twelve sub-research
questions. This could be accomplished by integrating the information of the literature
research, the interviews and the analysis. This integration is indicated by the orange lines in
figure 2 below.

Figure 2: Research paths

14

3.3 Qualitative research

This section will elaborate on the reasons for choosing qualitative research.

There are three main reasons for choosing a qualitative research method: the design of the
central research questions and twelve research questions, the need for in-depth information
and the aim of the research paper. These three reasons will be further elaborated on in the
next paragraphs.

The design of the central research question and its twelve sub-research questions calls for a
qualitative answer. The nature of the central research question requires descriptive,
exploratory and explanatory information expressed in words, as well as a flexible means of
data collection. The research questions have an open design and would benefit more from
qualitative research. In-depth information is preferred in order to answer the central and
twelve sub-research questions adequately. Interviews, as part of qualitative research, can
facilitate in the need for in-depth information. Also, qualitative research enables researchers
to ask more in-depth questions during interviews when a certain topic is not clear or not
elaborated on sufficiently. Quantitative research cannot contribute to this in the same
manner as qualitative research. The central research question does not prefer a quantitative
approach, as the data would not be sufficiently extensive or in-depth to culminate in a
comprehensive and complete answer.

Qualitative research is also desirable, as the aim of this research paper is to develop
recommendations based on the current situation in the twelve individual emergency
departments (EDs). Qualitative research will be able to provide the tools to outline the
different processes within the EDs; the bottlenecks on the one hand and the successes on
the other as extensively and detailed as possible. Qualitative research can function as the
first 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 through
quantitative research.

In conclusion, the central research question and twelve sub-research questions were
designed according to the need for in-depth information, whereby the aim of the research
paper led to the three main reasons for choosing quantitative research as the preferred
method. The next section will elaborate on the research subjects, population selection and
sample size.

15

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 based
on the fact that healthcare systems and working methods in an ED abroad are different. If
the focus were to shift to include other countries the results may not be applicable to a
specific ED in the Netherlands.

The interviewees functioned as representatives of the ED. These interviewees were
qualified as the head or manager of the ED. The head of the ED has the knowledge and
insight to provide the data needed to answer the questions in the interview, as well as
having access to documentation to support or add to the data in the interview. The head of
the ED has a background as ED nurse or ED doctor and can thus provide practical and
theoretical information on the different categories incorporated in the interview. A
combination of practical examples and theoretical information are necessary and important
for insight into the individual situation in a specific ED, as well as tools for the
development of the optimal ED.

The selection of the EDs was as follows. First the size of the population was defined as
105 EDs in the Netherlands (RIVM, CBS, VHN, 2011). From these 105 EDs, 67 are seen
as ‘complete’ EDs and were thus selected on the basis of the selection criteria. A complete
ED has a 24/7 availability and incorporates eight compulsory specializations (see chapter
4.2). 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 as
the type of categorization can be different depending on processes and size, thus

16

comparisons can be made between the EDs. Location also formed part of the selection
criteria, as the geographical location of an ED can reveal a difference in the mentality of
staff 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 were
selected 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 was
reduced to 20 EDs. As research has it, the number of interviews required to achieve
reliable 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 “An
appropriate 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 interviews
was considered a maximum number.

The head or manager of 20 EDs in the Netherlands were contacted by telephone, informed
about the research and asked to co-operate in an interview. In the end the willingness to
co-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 5
regional). This list can be found in appendix II. Reasons for the twelve EDs to co-operate
were (personal) interest in the research or a general willingness to help and participate. The
other eight EDs were either too busy at that point in time, did not respond to the request
or 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 appendix
II. The names and exact locations of the hospitals themselves are not mentioned due to
privacy reasons. The hospitals are coded from A-L; categorization was done independently
of the sequence of the appointments.

Concluding this section on the population of the EDs in the Netherlands, a sample size of
12 was found willing to co-operate in an interview for this research. Location, category and
willingness were three of the main selection criteria. The next section will discuss the data
collection.

17

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 and
validity of the research. The interview lasted approximately one hour and was recorded
with a memo recorder. By recording the interview the focus could be on the collection of
data and no time was wasted on writing down answers. Recording the interviews is
important for the reliability of the research. During the interview, the structure of the
variables list acted as a basis and guide for the interview (see next paragraph). At the end of
the 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 the
interview. The tour through the ED, if possible within the time frame, was not recorded
due to potential interaction with other technology and privacy concerns. Information of
the tour in the ED was written down afterwards in the form of bullet points and was used
as 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 of
the central research question requires descriptive, exploratory and explanatory information
expressed in words, as well as a flexible method of data collection. Interviews have the
capabilities and tools to accomplish this.

Semi-structured interviews allow the interviewer to deviate from the variables list in order
to get the specific information needed in more detail or more concrete terms. In-depth

18

interviews have an exploratory and explanatory function. The combination of the two
contributes to ensuring all aspects of the variable list are covered (Saunders, 2007) and the
central research question and twelve sub-research questions can be answered. Interviews
were conducted in Dutch, as this is the language used at most EDs. To conduct the
interviews in English would have hampered the process. Observation by the two
researchers 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 the
interviewers 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 recommended
due to privacy concerns and the feasibility of receiving permission to conduct a prolonged
observation.

Questionnaires or surveys were not considered as options for data collection, as these
methods limit the quantity of information that can be collected. These methods are too
restrictive when descriptive, exploratory and explanatory information is needed to reach a
conclusion (Saunders, 2007). Also, questionnaires and surveys are the slowest way of data
collection and respondents may not fill in all the fields (Staff, 2011). The interviews had to
be completed within three weeks, so time was scarce. Telephone interviews were not a
preferred 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 in
the 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 was
derived from the literature (see chapter 4). Using the same structure throughout the
research, facilitates the sorting of data. The interview questions are in the form of bullet
points and not written out in full, this with a view to optimizing the flexibility of the
collection of data. It is easier to deviate from bullet points than questions written out in
full, which is important for the descriptive, exploratory and explanatory information
needed to answer the central research question and the twelve sub-research questions (see
3.2 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 was
conducted at twelve different EDs. The next section will elaborate on the analysis of the
data.

19

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 no
follow-ups. The matrix can distinguish two elements on the horizontal and vertical cells
and can interlink them (Groenland & Jansen, 2010). In this research the two elements were
the codes of the hospitals visited (horizontal) and vertically the variables. The information
from the digital summaries of the interviews was transferred using the matrix method. An
example of this matrix can be found in appendix III of the confidential booklet. It was
opted to use Excel, as less can go wrong when copying information from the digital
summary into Excel compared to handwritten matrices. Also, transferring data between
digital systems is quicker than transferring handwritten data. The matrix in Excel followed
the same structure as the conceptual model, as using a uniform structure is easier for the
researcher to work with, as well as for the readers to interpret. The information was copied
into the matrix in the Dutch language and then transferred to English. Translating from
Dutch to English can have an effect on the reliability of the data, however the quantity of
text was limited thus the chance of misinterpretation is minimized. The data was then
written out per variable in the results chapter. The same structure as the conceptual model
was used in the results chapter: the vast amount of information gathered would not
therefore be confusing to the readers. In the results, quotes were used from the digital
summaries as a foundation for the results and tables were developed functioning as actual
textual elements. By so doing, readers can opt to read either of the two. Quotes from the
digital summaries of the interviews were given an alphabetical reference immediately, so its

20

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 and
the information of the theoretical framework are integrated in the analysis, as this supports
the final conclusion and recommendations (Miles, 1994). In the analysis, the hypotheses
from the theoretical framework are validated with information from both the literature and
the interviews or either of the two, if possible. The hypotheses that cannot be clearly
validated are used as recommendations for further research. All the information and data
from the theoretical framework, results and analysis are integrated to answer the central
research question and the twelve sub-research questions in the conclusion.

In conclusion, analysis is done by transferring the recordings into digital summaries and
then transposing them into a matrix in Excel. The written results are combined with quotes
and the tables function as a quick overview and summary of the results. The conceptual
model structure is used to create a coherent and comprehensive paper. The next section
discusses the reliability and validity.

3.7 Reliability and validity

In 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 and
PubMed. This makes the list of variables reliable and valid as it is based on prior research
published in scientific and academic databases.

The number of respondents is twelve. As mentioned in section 3.4, the sample size is seen
as valid by research when the number of interviews is between 10-20, or exceeding.
Conducting twelve interviews is therefore a correct number, according to literature
research, to validate this research. If the time for conducting interviews would not have
been as limited, as well as more willingness to co-operate by the different EDs, more
interviews could have been conducted for a higher validity.

The profile of the interviewees was similar in education and current function. By selecting
similar interviewees’ profiles, it can be assumed that the knowledge of the organization is
similar as well as the level education of the interviewees. This has a positive effect on the
overall reliability and completeness of the answers, as well as the understanding of the
questions posed during the interview. Data collection, in the phase of conducting the

21

interviews, was performed in Dutch. This makes the data obtained from the interviewees
more valid and reliable as Dutch is the leading language in an ED. Collecting the data in
Dutch also made it easier for the possibility to ask in-depth questions. However, as English
is the obligatory language for this research, the data was translated into English in the
matrix. This could have affected the validity of the data.

The data for this research was collected in twelve different EDs, in twelve different
hospitals throughout the Netherlands. Collecting data at different locations makes the data
better comparable with each other and more generalizable, as the variables are answered
twelve times in different situations. Moreover, the chance of bias is reduced by not
collecting data solely in one organization, making the collected data more reliable.
However, it must be taken into account that interviewees could have given social desirable
answers, due to for example not wanting to provide certain information or turning certain
information in such a way that it is presented better than the actual situation at the
moment. Also, not all interviewees were able to give the full data needed for certain
variables, as they were not entirely familiar in certain areas. Both reasons mentioned can
reduce 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 of
data collection more reliable. The variables list was used as a guide through the interviews
and additional in-depth information was derived by posing specific questions. Data
collected from the interviewees was therefore quite broad and only specific parts had to be
selected 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 into
account that in this process data loss could have taken place. Semi-structured interviews
allowed for answers to be compared more easily, thus increasing the reliability of the
comparison. Also, face-to-face interviews increase the validity and reliability of the answers
during 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 paper
were always present at the interview. In this way the loss of data was reduced and digital
summaries 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 when
having conducted interviews. This method provided a short and clear overview of the data
collected, in order to easily and reliably compare the data. The translation of the Dutch

22

language into English when data was transferred to the matrix, might have affected its
validity.

The following section will discuss the operational conceptual model.

3.8 Operational conceptual model

Figure 6 below shows the operational conceptual model. The operational conceptual model
is comprised of the conceptual model as illustrated in chapter 2, with the methodology
integrated in it. This model functions as a quick and brief overview of the methodology,
indicated in orange.

Figure 6: Operational conceptual model

23

4. Theoretical framework

4.1 Introduction

The theoretical framework is part of the theoretical path in this research, as illustrated in
figure 2 in the methodology (chapter 3). In this chapter, each of the seven variables in the
conceptual framework (chapter 2) will be researched via the available literature. Definitions
will be explained, as well as the foundation for the seven variables. The theoretical
framework was written with the central research question and the twelve sub-research
questions in mind.

The structure of this chapter is as follows. The theoretical framework consists of five
sections. The first section is the introduction, as presented here. The second section will
elaborate on the definitions and characterizations of an emergency department, followed by
the third section on relations between efficiency and optimization. The fourth section will
present 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 mentioned
in the conceptual model (chapter 2) are discussed; infrastructure, technology, service,
employees, logistics, financial system and patient satisfaction. The last section will give an
overview 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. All
sections will start with an introduction, explaining the relevance of the section to the
central research question and one or more of the sub-research questions. Each of the seven
variables 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 and
efficiency. These abbreviations will be expressed in full in the sub-chapter introductions.
An explanatory list of these abbreviations can be found in appendix IV.

24

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
department

The ED is a multidisciplinary specialized department within a hospital organization. An
ED provides medical and nurse related care to patients visiting the ED. These patients
arrive at the ED with traumas or acute health problems (RIVM, 2011). A definition of an
ED 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.
(Webster's 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 the
hospital itself comprises at least the following eight specific specializations: internal
medicine, surgery, gynecology/obstetrics, pediatric medicine, neurology, cardiology, ear-
nose-throat (ENT) medicine and ophthalmology (RIVM, 2011). EDs are obliged to
examine every patient that visits an ED, a guideline stipulated by the Dutch Public Health
Inspectorate (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 as
complete or full EDs. However, the RIVM has indicated that in 2010 only 67 could be
classified as a complete ED. Reasons for this were mergers between hospitals,
concentrating multiple locations into one new location, the closure of hospitals and the loss
of different specializations due to a decrease in demand for specific specializations (RIVM,
2011).

25

Research indicates that many health problems can be treated by the HAP rather than the
ED. Therefore, EDs and HAPs are now trying to enhance their co-operation and work
together. By setting the HAPs as primary caregivers for patients, this could make acute care
more effective as non-urgent patients can be redirected to more suitable locations to
receive care (RIVM, CBS, VHN, 2011). A detailed map of the location of EDs and the
HAPs 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% return
home with an appointment for the outpatient clinic, 15% receive subsequent treatment by
their GP and 33% return home without any further follow-up. In general, 45% of the
patients visiting the ED are self-referrals, 28% are referred by the GP and 7% arrive by
ambulance. Nearly 29% of the self-referrals visit the ED with no necessity for acute care
and are therefore considered as being in the wrong location (RVZ, 2003). However, these
percentages are not applicable to every hospital as they are general numbers. It is clear that
hospitals in the north and east of the Netherlands have a different ratio in self-referrals
than 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 care
to trauma or acute patients visiting the ED. In the Netherlands 67 ‘complete’ EDs have
been identified. Co-operation between the ED and HAP can redirect patients to more
suitable locations for non-urgent patients.

26

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 the
Figure 8: Position
of efficiency and left shows the position of this section in the conceptual model.
optimization

4.3.1 Efficiency
Literature identifies many definitions of efficiency. The business dictionary defines
efficiency as “The comparison of what is actually produced or performed with what can be achieved with
the same consumption of resources (money, time, labor, etc.). It is an important factor in the determination
of productivity” (Business Dictionary, 2011). Efficiency is also referred to the ‘how’ of
operations 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 as
variables. 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 for
hospital A divided by the weighted sum of input by hospital A (Fulton, Lasdon, McDaniel
Jr., & Nicholas, 2008). Palmer and Torgerson define efficiency in healthcare as “health care
resources that are used to get the best value for money” (Palmer & Torgerson, 1999). The United
States Government Accountability Office defines efficiency as “providing and ordering a level of
services that is sufficient to meet patients’ health care needs, but not excessive, given a patient’s health
status” (McGlynn & Shekelle, 2008).

Combining the definitions above, the following definition of efficiency in healthcare can be
developed:

“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”

27

4.3.2 Optimization
Optimization in general is defined as “Finding an alternative with the most cost effective or highest
achievable performance under the given constraints, by maximizing desired factors and minimizing
undesired ones. Practice of optimization is restricted by the lack of full information, and the lack of time to
evaluate what information is available” (Business Dictionary, 2011). Optimization aims to
improve or solve the identified problems in order to improve and maximize healthcare
services 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 as
functional and perfect as possible and the focus should be on the application of resources
and balancing the individual areas in healthcare. Continuous improvement is important as
healthcare is a dynamic setting and it is seen as the progress towards optimization (Wayne,
2008).

4.3.3 Relation between efficiency and optimization
Efficiency and optimization are interrelated. Efficiency can be seen as the steps to achieve
an optimum situation. Optimization refers to the best possible way in which a system or
process can be designed, in which the focus should be on the application of resources and
balancing the individual areas in healthcare (Wayne, 2008). In efficiency, the individual
processes are questioned on their relevance and improved or changed to improve their
efficiency. By continuously improving and redesigning the efficiency of the system and its
individual 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 individual
processes as efficient as possible, depending on the timeframe and possibilities of a
particular 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 variables

28

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
variable

4.4.1.1 Emergency department layout

The layout of an emergency department(ED) has an effect on the long-term success of its
optimization. This will be further explained in the following paragraphs.

Overcrowding is a major problem worldwide. It has been stated that building a new state
of the art ED or increasing personnel will not solve all the problems as the ED must first
identify and investigate the bottlenecks in its processes. Internal reasons for overcrowding
can be ED boarding1, inefficient registration and discharge processes. External factors can
be limited access to primary care, uninsured people and a growing ageing population
(Toledo Business Journal , 2009) (Harking, 2011). However, overcrowding not only affects
the ED but also the input (community), throughput (ED) and output (hospital). Problems
in all three elements must be identified and addressed to achieve improvement in
overcrowding (Jarousse, 2011).

Generally speaking, different notions have been expressed in research as to the physical
layout of an ED (Przybylowski Jr., 2010). Below are some examples.

The ED should provide a safe and welcome setting. The first impression is important and
will determine the whole ED visit experience (Greene, 2002). Green, blue and natural
materials used for the interior seem to have a positive effect on the patient’s experience of
an ED visit (Straczynski, 2011). Also accessibility and parking at the ED play a role in
patient satisfaction (Jarousse, 2011). Safety is important, and examples are in the form of
closed-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 in

1Boarding: when a patient remains in the emergency department after the patient has been admitted to the facility, but
has not been transferred to an inpatient unit.

29

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 family
satisfied and calm (Zilm, 2003) (Romano, 2003). Questionable in research is whether to use
rows of chairs for safety reasons, or make the waiting-room more attractive by adding a
different 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 paid
to a quiet environment and good lighting (Wolf, 2010). The most important rooms for
urgent care must be placed near the ambulance entrance (Peck, 2011). The materials for
ceiling, wall and floor must be easy to clean. Walls must contain sound insulation to reduce
noise (Peck, 2011). It is important to prioritize what has to be an essential part of the
clinical 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 the
treatment rooms around it. This is beneficial to both patients and staff; easily accessible
and close proximity (Zilm, 2003). However, research has indicated that when the number
of treatment rooms exceeds 18, the ballroom setting is no longer effective. In the latter
case, either the ballroom setting should be duplicated and two ballroom areas created, or
the EDs should investigate linear units. In the linear setting the rooms are situated in
parallel rows to make the area more ’expandable’. Also, less space is needed and the
effective walking time for staff is 25% less than that for a ballroom setting. The linear
setting is also compared to the shape of a thermometer, where patients are positioned
according to quiet and busy periods (Zilm, 2003). The central nursing desk would benefit
from partly glass covered surroundings. This creates an overview for the staff and patients
and is sound-isolating (Carolina, 2010). A digital board at the central desk in the ED is
recommended as it gives an overview of the situation within the ED itself: “With the white
board you didn't 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 geared
towards specific health issues. However, the treatment room can also be transformed into a
universal treatment room (Greene, 2002). To increase patient privacy and flexibility in

30

visualizing the patient, (sliding) doors with curtains are advised. Treatment rooms should
be separated from each other by means of walls to increase patient privacy (Peck, 2011), as
well as to reduce the risk of infection. For privacy reasons, most rooms should be single
patient 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 are
therefore to be preferred over single rooms (Sprague, 2007). For efficiency purposes, the
treatment rooms should only contain essential supplies. The use of mobile carts for other
supplies is recommended (Przybylowski Jr., 2010). Other research suggests keeping stocks
of 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 bed
so 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 with
diagnostic light should also be present (Peck, 2011). A sink and a built-in garbage box must
be included for hygienic reasons (Sprague, 2007). Questionable in research is whether or
not 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 patients
should 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: “We
recognized 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 Directing
Queuing) can be used, whereby patients are divided into needing (additional) diagnostic
testing and not needing it (Przybylowski Jr., 2010). The first group can undergo diagnostic
tests and wait in a special waiting-room for the results; the latter can be treated in the
peripheral treatment rooms and then discharged. There should be a sufficient number of
fit-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 not
be used as waiting-rooms (Przybylowski Jr., 2010). An example of this layout can be found
in appendix VI.

For non-urgent patients a fast track or a RADIT program (Rapid Assessment and
Discharge In Triage) could improve patient satisfaction and reduce waiting times. The
RADIT program was designed to be used in peak times, generally stated as being between
2 pm and 10.30 pm. Non-urgent patients do not need to use a treatment room, but will be

31

provided with screening, examination and a diagnosis in the specifically designed RADIT
area. If simple diagnostic tests are needed, patients can wait in the RADIT treatment area
for the results. The RADIT has been stated to achieve a 98% satisfaction rate among
patients (Vega, 2007).

Depending on investment opportunities and the availability or otherwise (lack) of specific
employees, the preferred location for diagnostic imaging would be located in or adjacent to
the ED for optimal efficiency: “The best of both worlds is to have the hospital's radiology department
just eight feet across a corridor from the ED so you can share staff” (Greene, 2002). The same applies
for lab facilities (Przybylowski Jr., 2010). Due to the frequent requests for X-rays, a mobile
X-ray device could be useful (Greene, 2002). Non-urgent patients should not wait for
transport, but walk to the diagnostic test rooms themselves: ‘We move less-sick patients through
the system a lot faster’ (Harking, 2011). Digital information systems let physician’s access
patient 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 avoid
overcrowding it is desirable to have the correct layout. In order to create visibility and a
good 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. Further
literature 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 Huisartsenpost

This section elaborates on the function of the HAP (Huisartsenpost) and its co-operation
with the emergency department (ED). This has an influence on the efficiency of the
processes and procedures in an ED.

The Dutch term HAP refers to a Huisartsenpost. A HAP is a center in, next to or located
outside the premises of an ED. General practitioner’s co-operate together in a center to
provide care outside working hours. In the literature a HAP is often translated as ‘out-of-

32

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 is
available outside working hours for urgent medical care that cannot wait till the next
day:“Huisartsenposten zijn er voor acute vragen van patiënten buiten kantooruren en bieden medische zorg
die niet kan wachten tot de volgende werkdag” (Gijsen, 2010). During the day the patient can visit
his/her own GP or one nearby. After working hours and in the weekend patients can visit
a HAP for less urgent medical care. The standard procedure for a patient is to call the
regional HAP number, after which a secretary or assistant will triage the patient by
telephone. For this triage the NHG2 guidelines are used, which are almost identical to the
NTS system (see 4.4.5.1; triage systems). The urgency code determines whether a visit to
the HAP is required (NHG, 2010) (Gijsen, 2010).

Integration and co-operation between a HAP and ED is seen as an important factor for the
solution of the overcrowding in EDs and its provisions. Overcrowding is mainly caused by
non-urgent patients, accounting for 40% of the ED visits that could actually be seen by a
GP (Van Uden, 2004). Dutch research on the integration of HAPs and EDs in the
Netherlands concluded the following: “There was a shift of more than fifteen percent from secondary
care to primary care for emergency consultations and waiting/consultation times were shortened by more
than ten percent” (Kool, 2008). Research also stated that just over 25% of the patients
presenting themselves at the GP have unspecified problems and questions about
medication. Dutch health policy-makers believe that improvements in the efficiency and
quality of care at a lower cost occur when HAPs and EDs are integrated and collaborate
well with each other (Moll, 2007). Research also questions the need for the ED, ambulance
and HAP to be active during hours when few patients make use of it due to inefficiencies
and costs (Giesen, 2006). Three main advantages of a HAP are: ED diversion to alternative
care, care co-ordination to reduce the use of EDs and the accessibility of services (need to
create awareness for this) (Harking, 2011): “Reducing inappropriate and unplanned hospital
admissions enables services to work at optimum efficiency. This helps to ensure that the patients who truly
need these services are seen as quickly as possible” (Winters, 2009).

Advantages of good co-operation between the HAP and ED lie in the ‘redirection’ of
patients. The discrepancy lies in the perception by clinical staff read healthcare
professionals and patients as to what is ‘urgent’ (24% of self-referred patients think they

2 NHG: Nederlandse Huisartsen Genootschap

33

need diagnostic tests). This discrepancy in perception impacts on the use of the ED and
can be dealt with by good co-operation between the HAP and ED as well as the provision
of 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 the
lack 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 reduce
costs and increase effective care. However it has not been substantiated that co-operation
substantially 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, is
considered effective as many patients visit the ED for non-urgent care. However, this is
only effective when the care needed by non-urgent patients can be done by a GP, without
the involvement of the facilities or staff of an ED. The location of the HAP in accordance
with 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 of
care 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 patients
from 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 be
formulated:

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: Position
technology variable

34

4.4.2.1 Software and digitalization of patient data

Digitalization and the incorporation of a hospital-wide uniform system contribute to a
more efficient way of accessing information, improving quality and minimizing medical
errors.

The role of ICT in hospitals has increased over the years. The main reasons for this are the
increasing digitalization processes in hospitals, rising software costs, an increase in the
possibilities and complexity within the different software, increasing integration of hospital
systems, increase in the number of computers, dependence on software and personnel
costs. Software and personnel account for 70% of ICT costs. Internal auditing systems
could monitor and raise an awareness for the increasing costs, as well as lead to the
standardization of the applications and type of software used within hospitals (van
Eekeren, 2011).

Hospitals make use of different software programs. Well known software in the
Netherlands is Chipsoft, SAP, iSoft, Xcare and PACS (digital imaging). The effectiveness
of 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. In
itself the content is not complex, yet what is is to make all the processes around it
interchangeable and transparent for the different stakeholders. Although the system is
similar in every hospital, the usage method at both macro and micro levels is, as these differ
considerably per hospital. This is what makes integration at a macro and micro level more
complex (van Eekeren, 2011) (Smits, 2010).

Independently of the type of system that is used, research has shown that the usefulness
for the user is more important than the number of functions available in the software
system. Also, the planning and structure of the information must tie in with the structure
of the ED (Busca, 2010). As Busca states in his research: “In short, for a computer application to
be capable of dealing with the complexity of an ED, it must incorporate three elements: operations inside
and outside the service, apply intuitive and multiuser user interfaces, and be able to carry out an efficient
management of data at the macro, meso and micro levels” (Busca, 2010). Making use of information
and communication technology has also been stated to improve the professional
development of health professionals (Mugisha, 2009).

The effect of ICT and digitalization is thought to have a major impact. The benefits will

35

only become apparent if the different software systems are incorporated in a systematic
form, this in contrast to many hospitals worldwide. The benefits of a systematic
incorporation are: more effective and rapid healthcare, accessibility of information, shift to
evidence based medical care, improvement of the quality of patient care, a reduction in
duplication and minimizing medical errors (Anvari, 2007). Research has shown that a
paperless environment can reduce transcription by 65% and charting by 85% (Hancock,
2000). Besides, a full digital system results in greater and more efficient documentation of
the patients’ data and results (Elder, 2010).

Failure or less effective usage of a digital system lies in the lack of user focus, as the usage
by 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. Diagnostic
imaging is one that is frequently referred to. Research has also revealed that more
documentation can have a negative impact on the communication of new information and
results 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 to
different factors. The effectiveness of the software that the hospital uses depends on the
structure and culture of the ED and the hospital itself. By using information and
communication 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 to

Figure 12: Position maintain the standards of healthcare and compare these with each other
service variable
in order to improve the processes within the emergency department

36

(ED). Service relates to research question eight and the position of the service variable is
indicated in figure 12 above.

4.4.3.1 Quality and performance indicators
Quality and performance indicators may have an effect on efficiency when comparing
different emergency departments (EDs), but only when these indicators are standardized
among 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 by
many different factors. The need for higher quality at lower costs and improved patient
care co-ordination makes it important to continuously monitor processes and their
effectiveness, as well as develop and improve quality programs. Quality measurement and
performance indicators must be “[…] evidence-based performance indicators that can be nationally
standardized 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 the
improvement of the ED unit and patient satisfaction. Evaluation and comparison of quality
is challenging due to the lack of integration of the system, lack of uniformity in the
collection of data, lack of consensus on performance indicators and the lack of agreement
in the assessment of its validity (Sobo, 2001) (Spaite, 1995). Specific training on quality
management implementation is therefore advisable, for management and ED staff alike
(Dellifrane, 2010). The level of quality and efficiency in the ED on weekdays or weekends
may 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 an
ED to staff expertise. Geographical location, patient ethnicity and patient categories play a
role 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 indicators

37

by front line-workers, as well as effective and committed leadership

The 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. The
supervision and monitoring of healthcare quality indicators in the Netherlands is the
responsibility of the IGZ, the Dutch Healthcare Inspectiorate. The IGZ publishes an
annual report, per healthcare sector, on the quality indicators for the forthcoming year.
Quality indicators in healthcare lack transparency, validity, uniformity and could not
therefore be compared with each other at national level.. The IGZ collaborates with the
parties it monitors and as from 2007 also co-operates with ‘Zichtbare Zorg’ (transparent
healthcare). The latter started a program on transparent healthcare in 2007 and will as from
2013 be known as the quality institute and all healthcare sectors will be responsible for
developing and maintaining quality indicators (IGZ, 2011) (Zichtbare Zorg, 2011).

The report on basic quality indicators 2012, states that emergency processes, as in ED, do
not have their own set of quality indicators (IGZ, 2011). An ED in the Netherlands has to
comply with the Kwaliteitswet Zorginstellingen (quality law re healthcare organizations).
Three main pointers in this are (1) delivery of responsible healthcare, (2) a clear and sound
policy as well as good communication, co-ordination and a clear division of tasks at all
levels 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 can
be done internally and externally. Internally through for instance training, workshops and
peer reviewing. Training among staff both individually and as a team has been proven
effective for the reduction of errors, team behavior and staff attitudes. Communication and
digitalization of data also plays a role. This consequently has effect on the quality of
performance of the ED, as well as patient satisfaction (Morey, 2002). Additionally, staff
should be qualified as ED doctor or ED nurse, according to the guidelines. External quality
management through certification, accreditation and/or visitation. There are certain bodies
that 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. It

38

MSc Thesis "Optimization of Emergency Departments in the Netherlands"

MSc Thesis "Optimization of Emergency Departments in the Netherlands"

Recommended

Recommended

More Related Content

What's hot

What's hot (6)

Viewers also liked

Viewers also liked (20)

Similar to MSc Thesis "Optimization of Emergency Departments in the Netherlands"

Similar to MSc Thesis "Optimization of Emergency Departments in the Netherlands" (20)

Recently uploaded

Recently uploaded (20)

MSc Thesis "Optimization of Emergency Departments in the Netherlands"