HEALTHCARE QUALITY

IMPROVEMENT PROJECT

PROJECT TITLE ፡ Improving Or productivity and efficiency

REGION: Oromia
Health Facility: Haramaya General hospital
Date: January, 2023
Maya

By Harif A(M.sc.)
Background of Haramaya General Hospital
Haramaya Hospital is found in East Hararghe; Oromia
National Regional state; 507Km from Finfinne and 18 km
from Harar town
◦ It is established in 2005 Ethiopia calendar.
◦ It was upgraded from health centre
Then in 2009 it was expanded to a zonal hospital by the
Regional Health Bureau.

haramaya general Hospital cluster 1st Q report prp by HA

Cont…
◦ Now the Hospital have more than 172 beds and giving
health service for two towns and four districts for more
than 1.4 million people and also there is 27 Health centers
in the catchment and two lead health centre
◦ It has 340 employees; 186 health Professionals and the
rest supportive staff

haramaya general Hospital cluster 1st Q report prp by HA

Cont…
◦ On averages Daily 320-460 patients visit OPD
◦ It has specialty in psychiatry, eye, ART clinic, Youth
friendly service ,ophthalmic clinic, and TBL among other
services and also four referral clinic
◦ To promote quality service effectively the hospital has fully
utilized all health reform core processes, namely BPR,BSC,
HCF, HMIS/DHIS2/HPMI, EHSTG, SaLTS, CaTCH-IT,
HSTQ, IPD initiatives and EHAQ/EBC
haramaya general Hospital cluster 1st Q report prp by HA
Organization’s Mission, Vision, Scope
of Service
◦ Mission
Haramaya General Hospital plays a basic role to reduce morbidity, mortality and disability and improve the health
status of Haramaya hospital catchment population through providing and regulating a comprehensive package of
preventive, promotive, rehabilitative and basic curative health services via a decentralized and democratized health
system.
◦ Vision
To see healthy, productive, and prosperous Haramaya Hospital catchment population
Problem identification and prioritization Matrix

SN Lists of problems identified Prioritization criteria Rank

magnitude Feasibility Importance Total
1 Cancellation 4 3 3 9 2
2 Poor OR efficiency 3 3 4 10 1
3 SSI 3 2 3 8 3
4 Late start(unplanned delays) 3 2 2 7 4
Problem statement (prioritized for improvement)

Operating rooms (ORs) are some of the most important areas of hospitals that have significant impact on the overall picture
of a hospital’s performance.
Running an operating room is capital and labor intensive. When OR utilization is inefficient, it leads to wastage of time and
human resources, higher costs and fewer patients treated than planned. This constellation of issues results in financial
losses as well as decreased patient satisfaction.
As we assessed OR efficiency and report of operating room from August, 2014 to January, 2015 EFY that shows that many
existing operating rooms in our hospital are underutilized/inefficiency which is (47.3%)
Team’s Aim Statement (SMART)
◦ The aim of these project is to Improving operating room productivity and efficiency from (47.3% to 85%) at
January, 2023 to march, 2024
And also the aim of project to evaluate all five indicators of OR utilization: start time, finish time, turnover time and
total daily utilization, together with cancellation rate.
Specific aim of the project
◦ Maximize utilization of current theatre resources
◦ Reduce time lost due to late starts and changeover
◦ Reduce Cancellations
◦ Increase patient throughput
◦ Improve Satisfaction of Patients, Specialists, OR Staff
S taff/people Pro c e s s /p ro c e d u re
l ck of
a
S g u i d e l in e/protoc ol s
Sta ff s h o rta g e
L a c k a wa re n e s s o v e rru n

L a te a rri v a l o f p a ti e n ts Be d u n av ail ab il it y for ICU

n o i n i ati an ti me Ine ffic ie nc y ofOR

produ c tiv ity
L a c k ba si cd ia gn ostic te st/ a nal yse d

p l a n n i n g o f a p p ro p ri a te e q u i
Eq u i p m e n t ste ril i zat i on fa i lu re L a c k o f s e p a ra te d OR ta b l e s
c k b a s i c i n s tru m en t L a c k tra n s p o rt

Equipment En v i ro m e n t

F ISHBONE DIAGRAM
Cause & Effect Diagram: Cancellations on
the Day
Staff/People
Illness
Processes/Procedures
Bed unavailability:
‘Fasting’ guidelines/used
not understood by patients
Equipment

Unavailability
- Sick staff - ICU/general beds (use ‘nil by mouth’)

Staff attitude Overruns

Staff unavailable Breakdown
-not working out of
between Rostering Scheduling to fill the time &
hours
4.30pm and 6.00pm (safe hours) emergency cases intervene
- safe working hours Poor planning
/safe hours
required for/booking of
Lack of an emergency Non-worked up patients appropriate
Surgeons/staff theatre equipment
on holiday and PH
not notified Delayed starts Poor bed availability Effect
Causes
Cancellations on the
Inappropriate health day
Poor bed availability data questionnaire screening (for
day theatre) through PAC, eg. Pathology equipment/
Anaesthetists miss pieces of staff unavailable/
information (patient inappropriate
completed questionnaire) on the day Undiagnosed, sick
Poor predictive data re We don’t know patient (acute illness
length of operations whether beds after preparation)
& equipment required available

Emergencies
- management & semi-
No real time data re Equipment urgent cases
in-patients for theatre breakdown
who are fasting/nil by
Overruns
mouth

Data Technology Environment

Cause & Effect Diagram: Delays in Theatre
Staff/People Processes/Procedures
“Late culture” - Surgeons bookings Processes reliant on surgeon
How do we know
-Everything runs a little late from other hospitals (who didn’t start on time)
when surgeons
- No expectation to start ‘on time’
due?
Surgeons don’t want to wait around/be kept
Poor patient discharge
Medical, education teaching waiting with patients not ready
Start times do not
- scheduled deferred starts
relate to surgeons Are we scheduling to give
- skills mix
Poor booking of eg. surgeons enough time?
Staff availability/absences Pacemaker technician - lists are too full
eg. Monday technician - all day lists at Rosebud/one site?
No “team driver”
(sick leave) Effect
- surgeons are key in the process
Causes
Unplanned delays, late
starts
Poor forecasting of
Poor CSSD capacity &
equipment required
logistics: need a
Poor knowledge quicker cycle
Arthroscopy need digital of accurate list Theatre staff have People work on other things &
equipment increasingly Machines being sent to wait for surgeons are legitimately late
between sites, eg
Endoscopy equipment not On time theatre not a priority
Poor data re wards/ Overrun of other lists
ICU status (& beds), available until 9.00am earlier in the day Impact of emergencies
post 9.30am meeting Poor predicted times causes delays
of length of operation
- compounds as the day goes on Poor parking for staff Morning/night theatre overruns

Data Technology Environment

Change idea
Intervention
How will this change improve our service
1. Capacity building Update skills of OR staff
2. Prepare OR planning Conduct regular reviews and analysis of demand to ensure the appropriate allocation of
resources and funded sessions, Scheduling and booking processes and Communication
processes that ensure key stakeholders have access to planning documentation and are
notified of changes as they arise
3. Improve OR start time Starting a list on time and as planned will ensure the greatest opportunity to finish on time
(and thus minimise overtime costs), avoid unnecessary cancellations and maximise the use
of available theatre time to increase productivity
4. List scheduling By optimising the use of available theatre time and increasing throughput with the main
aspects of scheduling falling into one of three phases: Theatre List Planning, Theatre List
Bookings and Ordering Theatre Lists
5.Patient-Specific Ensure appropriate pre-anaesthetic and preoperative assessment processes are in place that
Requirements and adequately prepare patients for surgery and identify any resource and / or discharge
Preoperative Assessment requirements in advance
6. Changeover Infrastructure and layout of the theatre environment (e.g. access to equipment, distance
between
holding bay to operating theatre), Capability for parallel processing, Communication
processes (e.g. push / pull approach to notify next case ready to enter or exit OR),
Emergency cases in elective sessions and Case mix and / or anaesthetic complexity
Measures/Indicators
Aim Outcome measure Change Process measures Balancing
measures
stateme ideas
nt Indicator Numerator Denominator

Improve Start time average change .

Indicator overtime Sum of [‘Out OR’ - ‘In
Number of patients treated –
OR’] for all cases treated
Number of sessions
in an elective session

Sum (‘In Anaesthetic’ Number of 1st cases in

Improve OR Numerator Average Elective
to ‘Procedure Start’) elective sessions
efficiency Pre-Procedure
for 1st cases of an
Anaesthetic Care elective morning or all
Start Time day session

Denominator Average Late Start

Sum [In OR - Session
Number of sessions starting
Start] for sessions
Minutes late
starting late

Data Source
S What (Change Process Measure Where(service Who How(desc When (time table ) Remar
No. ideas) P of PDSA area) (responsib ription k
Aim improving OR efficiency le body) how to
deliver
Start date End date

activities

1 Improve OR start Start 1st case incinsion OR OR C, schedule Feb, 2023
time 8:00am SMT

2 Capacity building Give training for OR staff OR session Feb, 2023 March 2024

3 OR utilization Increase Proportion of time OR OR staff

within the working hours in
which a patient
was in the operating room
4 Changeover Turnaround time b/n cases 20 OR OR staff
minutes

5 Cancellation rate
P of PDSA…
Measurement Plan /data collection plan
AIM/Out Come Data source (Where) Data collection Time Responsible for
Indicator method (how) (When)
Improved OR efficiency Month/quarterly report Survey, questioner, From Feb 01, Quality officer
and productivity of OR, SRC, SW and observation and FGD 2023 to march and OR
register 1, 2024 coordinator
P of PDSA…
Measurement Plan /data collection plan
Process/Change idea Data source Data collection Time Responsible for
(Where) method (how) (When)
% Of average change overtime Register and Questioner and From jan, Chart audit team
report observation 2023 to with Quality
march, 2024 committee
Register and Questioner and “ Chart audit team
Average Elective Pre-Procedure Anaesthetic Care with Quality
Start Time report observation
committee
% Of supportive supervisions Register and Questioner and “ Chart audit team
and feedbacks given report observation with Quality
committee

Register and Questioner and “ Chart audit team

Average Late Start Minutes report observation with Quality
committee

Register and “ Chart audit team

Elective Cancellations on Day of Surgery report with Quality
committee
Do
◦ Test your change ideas one at a time
◦ Use Run chart to monitor your QI project over time.
Study
◦ Describe the measured results and how they compared to the predictions and baseline
Act
◦ Here describe what modifications to the plan will be made for the next cycle from what you learned
(Adapt, Adopt, Abandon)