Executive SummaryThis report provides an analysis from the operations management perspective of the Ford ward. The methods used in the aforesaid analysis are: performance objectives, the 3 operations dimensions, process transformation and process mapping. The report focuses on analysing two key processes: the medication rounds and human resource planning. The alignment of the Ford ward Performance Objectives with the aforementioned processes has also been an important part of the analysis.

The results show what aspects of the processes have not been properly addressed, such as medication shortages and the use of agency nurses. A brief discussion centring on the underlying causes of these issues has also been included.

Overall, a small package of recommendations has been proposed. As a result of the report’s limitations, they are not concrete solutions, instead they are general suggestions about which direction to follow in order to improve.

Table of contentsExecutive Summary.......................................................................................11. Ford Ward Internal Analysis......................................................................3

1.1 Introduction..........................................................................................31.2. Performance Objectives......................................................................31.3. The Three Operations Dimensions......................................................4

Volume.....................................................................................................4Variety.....................................................................................................5Visibility...................................................................................................5

2. Analysis......................................................................................................62.1. The Medication Rounds.......................................................................6

2.1.1. Process Mapping...........................................................................72.1.2. The timing.....................................................................................82.1.3. Observations..................................................................................9

2.2. Human Resources Planning................................................................92.2.1. The Capacity..................................................................................92.2.2. The Workforce...............................................................................92.2.3. The shifts.....................................................................................102.2.4. Agency Use..................................................................................102.2.5. Observations................................................................................11

3. Conclusions and Recommendations........................................................11

1. Ford Ward Internal Analysis1.1 IntroductionSt. Richard’s Hospital is a District General Hospital, located in Chichester, West Sussex. It is a public hospital and is part of the National Health Service, and has been running since 1938. It has 30 different wards and a workforce of about 2000 workers, with an approximate capacity of 430 beds.

The Ford ward specialises in haematology and has 41 workers and 26 beds. Their main responsibility is to take care of patients with blood diseases. However, they also have patients from general medicine, much like most of the other wards in the hospital. The patients usually come from the emergency floor, which is a temporary ward where new patients wait until a bed in a proper ward has been assigned. Additionally, some patients might come from other wards, usually after a mistake in the form of a misclassification of the patient by the bed managers, who manage the patients’ locations throughout the hospital.

The Ford ward treats all of the incoming patients while attending to their needs. In the majority of the cases, the patients improve and are qualified as medically fit for discharge. However, there are situations in which the patients are transferred to another ward or alternatively, for terminal patients palliative care is offered.

1.2. Performance ObjectivesThe 5 Performance Objectives are a method to define what should be the goals of the company’s operations. They are rated from the point of view of the customer.

Table 1. Performance Objectives

Performance

Objective

Rating (Scale of 1 to

10)Evidence

Quality 10

Quality is a key component of healthcare and, extensively, the Ford ward. For customers it is essential to know that they will receive the best care. It is important to ensure high levels of quality because a mistake in the Ford ward could potentially result in the death of a patient. When the outcome of a miscalculation is fatal, it is mandatory for the patients to know that they are receiving the best service.

Speed 7

Speed assessment might be a little tricky. A lot of customers could argue that this is the most important objective, however, this may not be accurate. The importance of speed only comes into play once quality has been assured. The Ford ward, like the whole NHS system, requires high-quality standards and assurance, and as a result speed is an issue. When faced with choosing between quality and speed, all of the customers will choose quality before speed. This is why speed has been rated pretty high but not as high as quality, even though it is known that the most criticised aspect of the healthcare system is its speed.

Performance

Objective

Rating (Scale of 1 to

10)Evidence

Dependability 8

Dependability and consistency is also an important performance objective of the Ford ward. For the customers, it is necessary to know that the right service will be received in time. They appreciate a trustworthy service, while knowing that they can get into the Ford ward at any needed time and that the service will be there, as good as it has always been.

Flexibility 6

The flexibility of the Ford Ward is quite an important performance objective. In the healthcare system, flexibility may not be as key as quality, but it is still important. The same applies to the Ford ward. Even though there are protocols for different patient situations, each person is different. The treatment may be distinct because of the nature of the patient. For example, the same drug may be perfect for one patient but give a different patient a headache. This is why flexibility is important. The patient with a headache will ask for another drug with different side effects.

Cost 7 Even though Performance Objectives have been rated from the point of view of the patient, it is different for cost. As the patients do not pay directly for the service, the cost might not be relevant for them. This is why cost is rated from the government’s point of view, as in the end, they pay for health expenses. In the past NHS expense

tended to increase year on year, however now this period has passed. Since the beginning of the economic and financial world crisis, the expenditure has frozen. In fact, they have been trying to reduce it since then. Or at least, to keep the same expenditure even when the number of patients rises every year. This is why cost has been rated with a 7.

1.3. The Three Operations DimensionsIn order to analyse the operations process the 3 V model has been used. Measuring the Volume, Variety and Visibility dimensions is crucial in understanding the nature of the Ford ward operations. By linking them with the 5 performance objectives, an overall picture of the business’s operations will be created.

Volume The Volume has been rated as low. The reasons behind this decision are multiple. Firstly, the capacity of the Ford ward is pretty low (26 beds). It is also known because of the Performance Objectives that the key issue is the quality. As a rule, high quality and low capacity will lead to low volume. Moreover, the Ford ward specialises in haematology patients, which means that the patient often stays in the Ford ward for a considerable amount of time. Patients that are hospitalised for shorter durations stay for approximately 1 week, whereas patients that require longer-term treatments are in the hospital for a period between 2 and 3 months. Overall, the average period is 3 weeks, which leads to a low patient rotation. This reality fits with the speed rating from the Performance Objectives section. Even though it is important for the customers, it is not the focus for the Ford ward.

VarietyThe Variety dimension has been rated as low-medium. In general, variety in the healthcare system is usually low. As the Ford ward has patients not only from haematology, but also from general medicine, the variety is a little bit higher. It is also important to note that, as it was explained in the PO section, the workers in the Ford ward need to be a little flexible. It is because of these reasons that Variety has been rated as low-medium instead of low.

Figure 1. The three V Dimensions

VisibilityIn the Ford ward, the Visibility dimension is extremely high. The vast majority of operations are done in front of the patients, which means a high level of Visibility. All of the workers from the Ford ward spend their shifts working with the patients. Nurses, doctors, administrative staff, cleaners and housekeepers all carry out their work in front of the patients. One point of contrast from the English healthcare system (compared to other European healthcare systems) is the capacity of the rooms. In the Ford ward, the majority of the beds are situated in shared rooms called bays. Therefore, visibility is even higher than in a ward with individual rooms, because the patient can see and hear the workers even when they are not taking care of him or her.

1.4. Transformation ProcessThe Transformation process of the Ford ward is quite simple. The inputs are the workforce, the medical supplies, the Ford ward facilities and the information (coming from other wards, hospitals, the patient, etc.). As usually happens with service companies, their main input is the people. For the Ford ward, the most important input is the patients.

With regards to the transformation process, it is both physical and psychological. The main processes are the medical ones, which include examinations, medication or monitoring. However, there are a lot of

underlying processes, usually less medical and more personal, that are incredibly important for improving the patient's experience.

It is crucial to underline that not all of the patients get better and leave the ward or the hospital. Some of them are terminal patients and it is the responsibility of the Ford ward to offer them palliative care. This end of life care is also an important part of the outputs of the transformation process. It is commonly assumed that healthcare is about curing people, however, it mustn’t be forgotten that end of life care is just as important. A high-quality service is crucial when approaching this issue, as was explained in the Performance Objectives section.

Figure 2. Transformation Process

2. Analysis

2.1. The Medication RoundsDuring a typical shift in the Ford ward, one of the more time-consuming processes is the medication rounds. It is a process carried out by the nurses 5 times per day, where usually one nurse does the medication rounds for one bay. In the Ford ward, there are 3 bays, with 7 beds each, and 5 individual rooms. Therefore, 4 nurses are needed (1 per bay and 1 per individual room) to do the medication rounds.

2.1.1. Process MappingIn order to make the process more understandable, a process mapping has been created. The activities are marked with rectangles (rounded

rectangles for cases at the start and end of the process), the movements are marked with arrows and the decisions are marked with diamonds. As the process is conducted in three different spaces (the bay, Ford ward warehouse and general warehouse), the map has been divided into three parts. Although it is not supposed to happen, frequently the drugs needed are not available in the Ford ward warehouse. When this happens, the nurse must go to the general warehouse to look for the drug. The drug is often disposable, in which case the nurse can pick it up and go back to the bay. However, what can also happen is that the drug might be unavailable in the general warehouse. When this is the case, the nurse creates an order for the medicine. The responsibility for taking this order and supplying the missing drug lies with the Pharmacy. Once the order has been created, the nurse moves on with their job.

As a result of these regular shortages, the process possesses three different paths: when there is no shortage, when it can be solved by going to the general warehouse and when it cannot be solved at that moment.

Figure 3. Medication process mapping

2.1.2. The timingAll of the activities from the mapping process have been timed. For this purpose, the three processes have been called Process 1 (P1), Process 2 (P2) and Process 3 (P3). In Table 2, they have been timed. As there are different possibilities form the same process, the majority of the activities are shared.

When the nurses cannot find the demanded drug in the Ford ward warehouse, they go to the general warehouse (the hospital has 3 general warehouses). As shown in Table 2, the time that the nurse needs to spend fixing this problem is about 10 minutes and 40 seconds. If the shortage also occurs in the general warehouse, the nurse spends 15 minutes and 40 seconds more. However, in the last case, the problem is not really solved because the pharmacy usually needs several hours or days before delivering the missing drugs.

Table 2. Medication process timing

Activity Description TimeP1 P2 P3

Check drug needs from the ERP

Open the laptop from the bay and look for the concrete bay

and patient.04:00

Mvmt. (bay to Ford ward warehouse)

Walk from the Bay to the Ford ward warehouse. 01:15

Take the trolley Find an available trolley from the Warehouse. 00:20

Collect drugs Locate the drug’s whereabouts from the trolley laptop. 05:00

Mvmt. (Ford ward to general warehouse)

Walk from the Ford ward warehouse to the general

warehouse.- 03:20

Look for the missing drugs

Read the drug’s location from the trolley laptop and collect

the drugs.- 04:00

Mvmt. (general warehouse to Ford ward warehouse)

Walk from the general warehouse to the Ford ward

warehouse.- 03:20

Order the drugs from the pharmacy

Create an order in the ERP and a manual one (stays at the

warehouse).- - 05:00

Mvmt. (Ford ward warehouse to bay)

Walk from the Ford ward warehouse to the bay. 01:15

Patient condition consultation

Ask the patient about how he is feeling in order to corroborate

the drug’s use.03:00

Look for the patient file in the ERP

Look for the concrete bed in the ERP and check the patient’s

01:30

details.

Check patient identityCheck the name and the

hospitalisation number from the bracelet.

03:00

Prepare the medication

Take the needed drugs from the trolley and prepare the patient’s mix in a glass.

03:30

Give the medication to the patient

Make sure that the patient takes the mix of drugs. 02:30

TOTAL 25:20

36:00 41:00

Difference 0 +10:40

+15:40

The process’s analysis has been done for 1 patient. Obviously, the nurse overseeing the bay always has more than 1 patient. For estimating the overall time needed for an average number of patients, the last 5 activities will need to be repeated for each patient. These activities together add 13 minutes and 30 seconds. If we have 6 patients, the overall time will be:

P1(time)=25min+20 sec+5 ·(13min+30 sec)=1h32minutes50 seconds

P2 ( time )=36min+5 ·(13min+30 sec )=1h43minutes30 seconds

P3(time)=41min+5 ·(13min+30 sec)=1h 48minutes30 seconds

It can be said that the medication process takes between 1 hour and a half and 2 hours to be completed (the nature of each patient will add little variations to the timing, resulting in about a 5% error).

2.1.3. ObservationsThe causes of this constant shortage are difficult to highlight because the rest of the hospital is involved. However, this fact directly affects three of the POs. The quality and the dependability of the services are compromised when the Ford ward cannot provide the drug that the patient needs. Furthermore, the cost is also indirectly affected. The medication process has proved to not be operationally efficient, meaning that more could be done with less.

2.2. Human Resources Planning

2.2.1. The CapacityThe capacity in the healthcare system is usually measured by the number of beds available. Taking into account that it is indispensable to have a free bed for welcoming a new patient, it makes sense to use this indicator. The Ford ward has 3 bays and 5 individual rooms. A bay is a room which is able to have a group of patients allocated to it. Concretely, the Ford ward’s bays have 7 beds each. Adding these 21 beds to the 5 individual rooms, it makes 26 beds. Therefore, they can allocate a maximum of 26 patients at the same time.

The capacity utilisation in the Ford ward is pretty high. In a normal day, they usually have between 0 and 2 free beds in each bay and just one individual room empty. This means that the average number of patients is approximately 22. Consequently, it can be said that the capacity utilisation is somewhere around 80% and 90%.

2.2.2. The WorkforceOf course the beds by their own do not treat patients. A group of different professionals are needed in order for the patients to be taken care of. For the Ford war, the workforce is formed by 41 professionals. In table 3, there is a detailed list of all of the professionals working in the Ford ward.

Table 3. Workforce in the Ford ward

Professional Description Quantity

NurseThe nurses plan and provide nursing care to adults suffering from a wide variety of medical conditions and illnesses, supporting their treatment, recovery and well-being.

15

Health Care Assistant

The HCA take care of patients by helping them with basic needs: personal hygiene, mobilising and general activities for daily living.

15

Ward Clerk The ward clerk provides general administrative, clerical, and support services for the Ford ward. 1

House Keeper The housekeepers are coordinating non-clinical ward services: catering, drinks rounds. 3

ConsultantThe consultant is the senior doctor, who has completed the specialist training. The consultants accept ultimate responsibility for the care of all of the patients referred to them.

4

Junior Doctor The junior doctors are medical practitioners who have completed their training. They help and learn from the consultant to make the best decision for the

3

patients.Total 41

Taking into account that the average number of patients is 22 and the workforce is 41, it can be calculated that for each patient almost 2 workers are needed. It is commonly known that one of the bigger spending categories in the NHS is the wages of those professionals. As it was said in the POs, the importance of cost has been increasing in recent years. Accordingly, the proper management of this resource is key in terms of cost.

2.2.3. The ShiftsEven though the workforce is formed by 41 people, they never work at the same time. In the Ford ward the shifts are organised in a different manner than in the rest of the hospital. For the majority of the workers (nurses, health care assistants and housekeepers), the day is divided into three shifts. As shown in Figure 4, they call them early, late and night. However, shifts are organised by what they call "long days", meaning that they work for 2 whole shifts in a row. For the rest of the workers (consultants and doctors), the shifts are much easier: they all work from 09:00 to 17:00. During a long day shift, the staff working in the Ford ward consist of: 5 nurses, 4 healthcare assistants, 2 consultants, 3 junior doctors, 1 ward clerk and 1 housekeeper.

Figure 4. Ford ward shifts

2.2.4. Agency UseEven though the majority of the nurses from the United Kingdom work for the National Health Service (NHS), some of them work for private agencies. For the NHS, these Agencies are a good source of part-time workers. Their wage, when working for the NHS, is about 2 times the equivalent for other workers in the public system. The Ford ward, as part of the NHS, uses them to fulfil the human resources needs when there is an unexpected shortage of public workers. Or at least, that is the theory. The reality, however, is slightly different.

During a long day shift there usually are 4 or 5 nurses in the Ford ward. From those, normally 1 or 2 are from an agency. During the night shift, the proportion is even higher: there are 3 nurses, 2 of them being agency nurses. Therefore, it can be said that the ratio of agency nurses is between 20% and 50% during the day and 66% during the night.

2.2.5. ObservationsAs previously mentioned in the POs, for many years cost was not a priority in the NHS. They focused a lot on having a high quality and dependable system rather than a cost-efficient one. Once the financial crisis arrived, in 2008, the situation changed. Suddenly, the Government felt the need to not only stop increasing the budget year after year but reducing the overall expenditure. This fact led to a forced workforce reduction and a general premise: staff expenditure could not be increased. However, the United Kingdom’s population, and consequently the people using the NHS, has been increasing year after year. This divergent trend (between the medical staff and the patients) has caused more stress to the NHS system. In order to deal with this pressure, agency use has increased year after year.

3. Conclusions and Recommendations

The analysis done in this report has focused on two issues: the medication process and human resources planning. The conclusions arising from this analysis and the recommendations are as follows:

Conclusions The shortage of drugs causes an important increase in the time

needed by the nurses to carry out the process. Even though the effect might be hidden behind the fact that the majority of the time is spent in giving the medication to the patients, the time lost because of the shortage is significant.

The shortage of drugs has an important impact on some of the most important POs of the Ford ward. Quality and dependability are compromised when the patients cannot receive their medication on time. The cost is also affected because it is not cost-efficient to walk from warehouse to warehouse in order to find the drugs.

Human resources planning has proved to not be accurate enough. The number of agency nurses working in the Ford ward every day is far too high. This reality has a direct and huge impact on staff expenditure.

Recommendations The stock management will never work smoothly while the Ford

ward workers are not compromised in using the ERP. An analogic stock management is not efficient, but half of the staff using the ERP and half not is much worse. The solution might be more related to managing the change resistance than anything else.

There are two different approaches to solve the human resources planning conundrum. Firstly, hire more full-time staff. Secondly, improve the efficiency in order to do more with the same resources. In the case of both of these approaches, it isn’t okay to keep using a high level of agency staff, as costs increase with agency use. They cannot keep relying on high agency use due to the overspending that results from such use.