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 ([email protected])

Elisa van Poelgeest ([email protected])

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

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

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.


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


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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.


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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



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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


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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.


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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


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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


14

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


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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.


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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

assumed that interviews with foreign EDs do not add extra valuable

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

Figure 3: Selection of research subjects


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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.


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3.5 Data collect ion: 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

interviewees time to prepare. It was decided to visit the individual

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

Figure 4: Method of data collection


19

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.


20

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.

For the analysis of the results, the matrix method was used. Matrix

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

Figure 5: Analysis process


21

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


22

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


23

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


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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.


25

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.

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).

Figure 7: Position of emergency department


26

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.


27

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

left shows the position of this section in the conceptual model.

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”

Figure 8: Position of efficiency and

optimization


28

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

indicates the position of this section in the conceptual model. Figure 9:

Position of the seven variables


29

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.

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

1 Boarding: 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.

Figure 10: Position infrastructure

variable


30

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


31

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


32

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-


33

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


34

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


35

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


36

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

maintain the standards of healthcare and compare these with each other

in order to improve the processes within the emergency department Figure 12: Position

service variable


37

(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


38

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


39

is non-mandatory and is qualified under the international ISO 9001 (HKZ, 2011).

ISO (International Organization for Standardization): the largest standard

development organization in multiple sectors, bridging the public and private

sectors (ISO, 2011).

VMS (Veiligheid Management Systeem): focused on patient safety and reducing the

number of claims submitted by patients to hospitals. There are ten points that are

most effective in increasing patient safety (VMS, 2011).

As from December 31st 2012 all hospitals in the Netherlands must be either accredited or

be in a possession of a VMS certification (VMS, 2011).

In conclusion, measuring the quality of care and performance in an ED is complex. Quality

measurement and performance indicators are conducted in order to improve the ED and

patient satisfaction. However, there is no standardized quality measurement in the ED.

Several institutions are investigating the use of standardized quality indicators in order to

compare various hospitals with each other.

This hypothesis stated below can be derived from the literature above:

Hypothesis 4: standardized performance indicators enhance the quality of the processes of the ED.

4.4.4 Employees

The employees in an emergency department (ED) can contribute to the

efficiency of an ED in different ways, depending on the type of employee.

This sub-chapter will elaborate on emergency department doctors (ED

doctors) and emergency departments nurses (ED nurses), including triage

nurses and nurse practitioners (NPs). Research question nine is applicable

here and figure 13 on the left indicates the position in the conceptual

model.

4.4.4.1 Emergency department doctors

Emergency doctors (ED doctors) have an effect on the efficiency on an emergency

department (ED). The reasons for this will be explained in the following paragraphs.

In recent years, the discussion on the efficiency of ED doctors has been divided. There are

advocates and critics. Some endorse the idea, but criticize the fact that there are not

Figuur 13: Position employee

variable


40

sufficient ED doctors available to staff their services. In 2000, a small number of hospitals

in the Netherlands initiated training for ED doctors. To this day, there is still a debate

about the positioning, acceptance and responsibility of an ED doctor. Plexus Medical

Group researched the effectiveness of ED doctors in the Catharina Hospital at Eindhoven.

This was conducted by measuring the speed and number of requested diagnostic tests,

customer focus and medical practices. This research showed that ED doctors are more

effective in treatment time in three of the four urgency categories; thereby resulting in a

faster treatment time. All of this can be explained through the special training for ED

doctors, specially geared towards the situation in EDs. It also means that they can treat the

patients independently without consulting specialists outside the ED. On the other hand,

the doctor’s assistants do need to consult the specialist outside the ED before embarking

on a treatment. This element makes for significant time savings. Furthermore, it has been

shown that ED doctors have less extensive requests for additional diagnostic testing than

the doctor’s assistant, in view of the former’s experience. Therefore, the ED doctors can

save time on the speed and the number of requested diagnostic tests as well in the medical

practice itself (Maas, 2007). However, the advocates of ED doctors do have various

criticisms. The organization determines the quality of the ED and not the type of doctor

(Gans, kathan, ter Maaten, & van Offenbeek, 2008). The purpose of introducing ED

doctors to cut supervision and thus treatment times has not been affected. Moreover, it is

not confirmed that the quality of care performed by an ED doctor is superior to that of a

doctor’s assistant and an ED doctor is considered more a generalist-type doctor compared

to the specialists consulted via an ED (Gans, kathan, ter Maaten, & van Offenbeek, 2008).

Currently, not enough students are graduating to provide every ED with full-time ED

doctors. This poses difficulties in investigating the efficiency of ED doctors in an ED unit.

In conclusion, the opinions as to the effect of an ED doctor on the efficiency in an ED are

very diverse. Those in favor mention time savings in various areas as a benefit, whilst those

against question this. The shortage of ED doctors and their lack of specific training are

making it difficult to validate their effect on the efficiency in the ED.

4.4.4.2 Emergency department nurses, triage nurses and nurse practitioners

The efficiency of an emergency department nurse and triage nurse lies in the coordination

of patient care and their impact on the patient’s peace of mind.

The ED nurse is important in the process of co-ordinating patient care and the


41

cooperation with physicians. 88% of all nurses work in hospitals and specialization and

differentiation are becoming increasingly important, also as an ED nurse (Derlet, 2002).

Qualified ED nurses must meet at least the following criteria: finalized the basic education

in nursing, obtained a specialized degree in ER nursing, completed triage training and

regular training on TNCC (Trauma Nursing Core Course), BLAS (Basic and Advanced Life

Support), ENPC (Emergency Nursing Pediatric Course) and the PALS (Pediatric

Advanced Life Support). Maintaining the quality of the ED nurse is done through

registration in the BIG register, the NVSHV (nursing organization), obtaining the above

qualifications and regular training updates and peer reviewing. For the quality of the ED,

there must always be at least one ED nurse present with a qualification in pediatric care

and trauma care (NVSHV, 1996) (NVSHV, 2005) (SEH, 2009).

Literature is questioning whether the ED nurse should be assigned one particular task, as

triage nurse, during certain shifts. In the Netherlands there is not one single specific

method for this; some hospitals assign a specific triage nurse to ensure all the triages are

done in a separate room, some partly by the secretary or fully by an ED nurse in the ED

itself. By not having one single method, it is more difficult to influence waiting times and

turnaround times (SEH, 2009). Nurse triage has been widely adopted in the US and the

UK; however, opinions as to effectiveness vary as per the literature. A triage nurse ensures

that a patient receives the right urgency code and initial assessment. The effect a triage

nurse has on waiting times, especially for urgent categories, is two-fold. Triage nurses do

actually reduce the anxiety and frustration experienced by the patient (George, 1993).

Triage must be started within five minutes after arrival, as this has a positive impact on the

patient who feels he/she is being attended to. Research shows this often increases to 10

minutes, but the extra time taken has not been shown to have a negative impact on the

patient’s satisfaction. In addition, a triage nurse ensures that the patient is treated at the

right level and location, making efficient use of the resources of an ED. A triage nurse is

only effective when triage is the primary focus and is not being delayed by non-primary

responsibilities (Buckles, 1990) (Bailey, 1987) (Neades, 1997).

There are varied opinions about the role of a nurse practitioner, a NP, in an ED. An ED

nurse practitioner (NP) is seen as an efficient element within the setting of non-urgent

patients. NPs can reduce workload, reduce waiting times in the ED, improve patient care,

safety, deal with (difficult) accompanying persons and reduce pressure on junior doctors

(Rao, 1995) (Davies, 1994). The exact function of a NP is not uniform, but research


42

suggests a uniform profile would be more efficient for the procedures within the ED

(Neades, 1997). The education program is generic, but hospitals often edit or add to the

education to suit the culture and needs of a specific hospital or ward. Besides patient care,

another option is for NPs to focus on protocols and quality management. Research shows

concerns about NPs and their substitute role as junior doctor and the inappropriateness of

this. Substitution sometimes occurs when a hospital experiences financial pressure, while

on the other hand the cost-effectiveness of this transition has not as yet been proven.

Besides the financial aspect, the education of a NP is not equal to a junior doctor and the

legal consequences are major (Neades, 1997): “Emergency Nurse Practitioner should not be viewed

as a replacement for the role of the nurse in A&E junior doctor, but as a professional with qualities and

skills which complement those of the medical staff in A&E. This is not a quick or cheap solution to the

problem of increasing A&E attendances” (Jones, 1994).

A shift in ED staff responsibilities is seen as a one of the ways to challenge the problem

concerning increased waiting times, resource allocation and the increasing inflow of non-

urgent patients. Research has suggested improving the efficiency of the ED and hospital by

having a better combination of staff. Additionally, having a general practitioner (GP) in the

ED has proven to decrease referrals, prescriptions and the number of diagnostic

investigations (Rao, 1995). The opinions as to the effect on the efficiency of an ED by a

triage nurse vary, but similar opinions are shared regarding the idea that a triage nurse

should only focus on his/her primary responsibility.

The following hypothesis can be formulated, based on the literature above:

Hypothesis 5: the presence of an ED doctor at an ED has more advantages than disadvantages, but the

effect on efficiency at an ED is difficult to substantiate.

4.4.5 Logistics

The fourth variable is logistics, which can be divided into the triage

process and triage systems and waiting times. Both parts will be further

elaborated on as well as explaining their relation to the efficiency in an

ED. The logistics variable is related to research question ten. Figure 14

indicates its position in the conceptual model.

Figure 14: Position logistics variable


43

4.4.5.1 Triage process and triage systems

A triage system is on the one hand patient-oriented and on the other organization-oriented

and has an effect on patient acuity and resource allocation. Its effect on the efficiency will

be discussed further in this section. The different triage systems will be explained and

which system is most appropriate for the Dutch emergency department (ED) setting.

“Triage acuity is defined as the classification of patient acuity that characterizes the degree to which the

patient’s condition is life-threatening and whether immediate treatment is needed to alleviate symptoms”

(Gilboy, 2005).

The goal of a triage system is two-fold. On the one hand patient acuity, on the other the

adequate assignment of resources. Windle once summarized the goal for triage as “to assess

patient acuity and assign available resources appropriately, both physical and personnel” (Windle, 2002)

(Windle, 2001). The goals of triage can be divided into 2 categories, namely patient oriented

and organization oriented (Coenen, 2005). A patient is prioritized according to clinical

urgency, so patients with the highest medical need are seen first (Janssen, 2011).

Classification of a patient’s triage code is decided on by a triage nurse and will reflect the

‘safeness’ of the time allowed before treatment. Depending on the triage code, the patient

will experience no waiting time, a short waiting time or longer waiting time (Janssen, 2011).

The need for a triage system arose from a rise in overcrowded emergency departments, due

to the increase of ED visits. The latter part of this increase in ED visits resulted from self-

referrals, but also the ageing population and the changing mentality towards first visiting

the general practitioner (GP) (Janssen, 2011) (Coenen, 2005). Also, the overcrowding of

EDs has indicated an increase in the number of aggression incidents, as well as an increase

in longer waiting times for urgent patients with urgent medical problems. Added to that,

most EDs in the Netherlands do not have a clear systematic procedure for the primary care

of emergency patients (Coenen, 2005).

The main advantage of a triage system is the immediate assessment of patients, the positive

effect on waiting times in the waiting room, prioritization of care, placement of patients in

the correct treatment room or area and being able to start diagnostic tests. This all impacts

positively on the anxiety of patients, their frustrations and concerns. This in turn is

reflected in less written complaints and an increase in employee satisfaction (Blythin, 1983)

(Jones, 1988) (Nuttall, 1986) (Grose, 1988).


44

An important part of a triage system is continuous evaluation. Evaluation of the EDs triage

system can lead to improvements such as the use and layout of a triage room, the

responsibilities of and permitted interventions by a triage nurse, content and development

of pain protocols, optimization and further implementation of an ICT system and changing

the number of shifts of a triage nurses into 24/7 availability (Janssen, 2011) (Meijers, 2006)

(Cheung, 2002). When using a triage system, it is important for there to be no discrepancy

between desirability, feasibility and reality. To avoid this discrepancy, it is important that

the ED nurse has completed triage training and that triage is performed consistently

(Coenen, 2005). There is an ongoing discussion as to whether patients who are referred by

their GP or by ambulance personnel should be triaged. In general, research shows that

these patients should be triaged upon arrival at the ED, as their medical situation can

change in the time taken between the GP visit and arrival at the ED (Coenen, 2005).

EDs the world over use of different triage systems. Worldwide frequently used triage

systems are the ATS (Australian Triage Scale), CTAS (Canadian Triage and Acuity Scale),

the MTS (Manchester Triage System) and the Emergency Severity Index (ESI) or also

known as the Boston Systems (Cronin, 2003). The NTS is a Dutch triage standard. In

general it has been recommended that a triage system should meet the following

requirements to be used by EDs in the Netherlands: the triage system must be valid,

reliable, applicable in the Dutch setting, for all age categories, focuses on symptoms and

complaints, follows the nursing methodology and must be usable in all circumstances

(Coenen, 2005) (LAMP, 2003). The paragraphs that follow will explain the different triage

systems mentioned above.

MTS (Manchester Triage System) - The MTS was introduced in 1997 and focuses on the

clinical priority of the patient (Mackway J. K., 1997). It does not make use of medical

diagnosis, is flow based and dynamic. Diagnosis-based models are perceived as dangerous,

as triage must be concise and totally objective and comprehensive (Windle, 2001)

(Zimmermans, 2001) (Windle, 2002). The MTS uses the reduction method and separates

the clinical priority of the patient from the management aspects on the ward (Windle,

2002). An advantage of the MTS is its sensitivity to identify different types of critical

patients (Zimmermans, 2001). A disadvantage of the MTS is the attention and devotion to the

value attached to the pain a patient is experiencing. Recognition of pain is important for patient

satisfaction and must be treated in the triage room (Windle, 2001) (Mackway J. K., 1997).


45

ESI/Boston (Emergency Severity Index) - The ESI is also known as the Boston Triage System.

It does not, as is the case of MTS, work with target times per triage code (Gilboy, 2003).

The methodology is based on two items: urgency of a patient and resources needed.

Symptoms and complaints are questioned according to the ABCD method and the PQRST

(pain) method. An advantage is that the diagnostic tests are based on the ‘standards of care’

and not the preferences of the doctor (Zimmermans, 2001) (Wuerz, 2000) (Wuerz, 2001).

Also, the need for diagnostic tests can be better estimated (Ishove-Bolk, 2001).

ATS (Australasian Triage Scale) - The ATS focuses on the clinical urgency of patients

(Zimmermans, 2001). It describes acceptable time spent by the nurse, time by the doctor

and also keeps track of Performance Indicator Thresholds (the percentage of patients that

must be seen within the target times) (Considine, 2002). An advantage is that the ATS is

regarded as a safer system than the CTAS (next paragraph), as the same category patients

are placed in a more urgent category in the ATS compared to the CTAS. A disadvantage is

that the ATS cannot be applied uniformly, as it is adjusted to regional circumstances. The

ATS is also not yet fully developed and does not work according to a standard

methodology (Considine, 2002).

CTAS (Canadian Triage and Acuity Scale) - The CTAS was derived from the ATS and has

been adapted to Canadian needs (Zimmermans, 2001). The CTAS uses the presumptive

disease diagnosis and is focuses on the symptoms and complaints of the patient. The

system works with target times and upgrading patients when the waiting time becomes

unreasonable. The primary goal is for the patient to see the doctor within a certain time

period; the exact urgency code of a patient is not the prime factor (Beveridge, 1998). A

disadvantage is that the training and education behind the system is an unknown factor and

there is no methodological structure (Beveridge, 1998). There are also doubts about the

sensitivity of the system in the case of complex patients (Zimmermans, 2001).

NTS (Nederlandse Triage Standaard) - The NTS was introduced in 2005 and a pilot started in

2007. The NTS is seen as a system that can contribute to one triage system; it positively

affects the co-operation between the different stakeholders in emergency care. It has been

said that one triage system could positively affect the efficiency, safety, patient satisfaction,

communication and co-operation within an integrated emergency care system. The NTS is

mainly used by GPs at HAPs and triage through NTS can be done physically or over the

phone. The NTS is focuses on determining the urgency, not the diagnosis (Jochems, 2006).


46

The conclusion was that the NTS is a new concept in emergency care and still needs to be

investigated further. There are questions about the its implementation method, the

possibility of having one triage system in an integrated emergency post, the difference in

goals between the NTS and the other triage systems used by EDs, the communication, co-

operation and culture differences between GPs and ER staff and their working methods

and language aspects. These call for further investigation (Jochems, 2006) (Huibers, 2009).

Some studies also indicated concern about the quality and safety of after working hours

telephone-based consultations. A study in the Netherlands indicated that the quality was

poor in all the centers investigated and that the outcomes of the triage were only

appropriate in 58% of all calls. The underestimation of urgency was 41% (Derlx, 2008).

International studies have also questioned the effectiveness and safety issues. Consultation

by telephone did appear to reduce the number of face-to-face visits to a HAP by 50%, but

uncertainty remains about the effect on the number of future visits. Patient satisfaction was

not affected if a telephone consultation was used instead of a face-to-face visit (Bunn,

2004) (Katz, 2008).

For a system to be effective and to fit into the Dutch ED culture there must be a

separation between the medical and nursing language. It is difficult to state which triage

system is the best in its performance, as there has not been enough research in this area

(Nicholl, 2000). Research has indicated that the MTS would be most suitable to use in EDs

in the Netherlands, as the symptoms and complaints of a patients are seen as more

important than the diagnosis itself. Also, the MTS is the only European triage system and

can be used in the Netherlands as healthcare is similar to the English system. The MTS ties

in better with the ED situation in the Netherlands in terms of reliability, validity, way of

thinking and applicability by ED nurses than the other triage systems mentioned above

(Nicholl, 2000)(Zimmermans, 2001) (Windle, 2001).

A triage system has different effects on the efficiency of processes in the ED itself as well

as on patient and employee satisfaction. For instance there is a decrease in complaints

from patients, reduced waiting times in the waiting room, prioritization of care, placement

of patients in the correct treatment room or area and the ability to start diagnostic tests,

where needed, at the earliest opportunity. Extrapolating the different triage systems, MTS

is seen as being most compatible with the Dutch EDs.


47

The following hypothesis can be formulated, based on the section above:

Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED.

4.4.5.2 Waiting times and processes in the emergency department

Waiting times influence logistics. If the logistics of an emergency department are well-

established, this will decrease the waiting time for patients significantly. The next section

will elaborate on the botllenecks of the processes in the ED and how to eliminate these.

Waiting time is perceived by patients as one of the most irritating aspects of a visit to the

ED. Yet, waiting time is one of the most difficult bottlenecks to eliminate. Many hospitals

use the Theory of Constraints theory (TOC) of E. Goldratt in order to reduce the

bottlenecks in their processes. It can also be used in the ED to reduce the turnaround time

of patients. The Theory of Constraints can be used as a method to increase profitability

and volume (Noreen, Smith, & Mackey, 1995): “A constraint is anything internal or external to

the manufacturing process that limits a plant’s ability to generate throughput, the rate at which the

production system generates money through the sale of products” (Kershaw, 2000, p. 2). In order to

maximize this throughput, the constraints should be identified and managed (Goldratt &

Cox, 1992). By defining throughput in a healthcare setting, it can be changed to:

“reimbursement rate less the cost of drugs and medical supplies for the number of patients seen and treated.”

(Kershaw, 2000, p. 2) The steps of TOC can be found in appendix VII of the confidential

booklet. The key factor in the TOC process is to expand the capacity of the constraint in

order to increase throughput. The ultimate target is to completely eliminate non-productive

time. The non-productive time in an ED can be decreased by reducing preparation time,

the use of appropriate supplies, available and accesible information, as well as

implementing and performing the right procedures. Constraints can be eradicated by hiring

more staff or by procuring additional equipment (Kershaw, 2000). By implementing the

Theory of Constraints, the processes within the ED become more efficient and effective.

According to the literature, (Nicholl, 2000) there was no evidence that waiting times are

shortened by implementing a simple triage system. However, time can be gained by

implementing an advanced triage system, whereby a nurse can already apply for diagnostic

tests, which in turn means that the test results are known by the first consultation. By

implementing this advanced triage system, the efficiency of the care process improves as do

turnaround times of patients by making effective use of the patient’s waiting time (Cheung,

Heeney, & Pound, 2002). A triage system only has a positive impact if the role of a triage


48

nurse is combined with extra tasks such as requests for examinations and extra

organizational adjustments (Edwards, 1999). On the other hand, the implementation of

triage does not have the desired outcome to solve all logistic problems. Therefore, various

hospitals are implementing care pathways to improve the logistic process in their

emergency departments. In 2005, Vlietland hospital developed a triage system as well as

care pathways. In these care pathways, the patient’s need for care is determined, as are the

examinations, treatment andtime span. Measurements show that the average turnaround

time decreased by 40 minutes for cardiology patients. This is also partly due to the full-time

availability of a cardiologist and the introduction of an observatory in the ED (Sterk, 2006).

Concluding, waiting time can be eliminated by using the Theory of Constraints of E.

Goldratt. In order to maximize throughput, constraints should be identified and managed.

The aim of this theory is to completely eradicate non-productive time. Further waiting time

can be reduced by introducing an advanced triage system. However, this only has a positive

effect if the triage nurse combines extra tasks such as examinations in combination with

patient triage.

As such the following hypothesis is formulated, namely:

Hypothesis 7: waiting time can be decreased by reducing the bottlenecks in the process.

4.4.6 Finances

An optimal emergency department (ED) cannot be developed without

investigating its financial system. This section will elaborate on how the

financial system works in the Netherlands and how it will function in the

future. The finance variable entails research question eleven and figure 15

shows the position in the conceptual model.

Hospitals are currently financed and funded in different ways. Financing involves

temporarily making capital available, whereas funding encompasses making a financial

contribution to cover the costs, associated with the service provided (Bos, Koevoets, &

Oosterwaal, 2010).

Figure 15: Position finance variable


49

The Dutch care authority (Nederlandse Zorgautoriteit – NZa) determines a budget for

every hospital in the Netherlands. They use a calculation method that is provided by the

ministry of health. The financing of hospitals is based on Diagnostic Therapy

Combinations (DBC). This DBC contains all (care) activities of a hospital and of medical

specialists, arising from the patients care demand (Bos, Koevoets, & Oosterwaal, 2010).

The DBC includes the total route of the diagnosis until the treatment starts. The DBC-

system gives hospitals and health insurers:

The possibility to negotiate on price and quality for certain hospital treatments.

This offers health insurers better possibilities to procure better and more affordable

care

Better insight into the costs of treatments. This leads hospitals to improve their

management and thus deliver affordable and efficient care (NZa, 2011)

The DBC codes are divided into two categories: the A-segment and B-segment. The A-

segment contains approximately 66% of the hospital treatments (NZa, 2011). For the

DBCs in this segment, there are fixed rates, determined by the Dutch care authority. For

every diagnosis, the costs of the treatment are calculated in order to determine an average

tariff. This tariff incorporates various costs components such as: costs for specialists,

nursing and X-ray photos. It also contains indirect hospital costs: costs of education,

research and the ED itself (Ministerie van VWS , 2011). All this makes it difficult to

accurately trace the revenues and costs of an ED.

In segment B, the DBC codes are subject to competition. The hospitals themselves

determine the tariffs for the treatments. Negotiations between hospitals and health insurers

about quality and price of DBC

treatments in the B-segment form the

basis of the B-segment (Bos, Koevoets,

& Oosterwaal, 2010).

In figure 16 on the right, the financing

and funding of health-care is explained.

As already stated above, there is a

difference between financing and

funding. The funding contains the

functional budget and the revenues of the Figure 16: Financing and funding structure in Dutch health-care system


50

B-segment. The turnover of the hospital comprises these two components. By declaring

the DBC codes, the hospital receives money which is the financing part. They can declare

DBC codes both in the A- as well as the B-segments. However, the revenues in the A-

segment are fixed because of the budgeting system. In the B-segment, hospitals and

insurers can negotiate on price, volume and quality of the care (Belonen naar prestatie,

2011).

In 2012, the budgets for hospitals will disappear. Healthcare will be financed on the basis

of the services delivered. In the B-segment, now changed to free market segment, the

health insurers and care providers can freely negotiate on the quality, price and volume of

the care. This includes care that is offered by many providers and can be translated into

recognizable performances. 70% of all treatments will now be based on free pricing under

this financing system. However, there will also be a regulated segment, where negotiation

is possible at maximum rates. This contains care that is not suited to free negotiation.

There will also be a fixed segment where there can be no negotiation on the care provided.

This includes, for example, care that requires an enormous investment or where the

number of patients fluctuates greatly. The ED will be financed under the first-named free

segment but can be eligible for reimbursement via the fixed segment (Belonen naar

prestatie, 2011).

This new system, DOT3, will provide higher quality and greater efficiency in healthcare

because providers are rewarded based on the services they deliver. To make the system

work, it is important that the services are well-defined. An innovative aspect of the new

system is the way in which the various items of the care offered are grouped and declared

in the system. DOT has the following advantages:

Greater transparency: every stakeholder gets more insight into quality, care process

and pricing;

Medical recognition: the extent to which the specialist can identify with the care

product itself with respect to the actual care delivered;

Care burden: the complexity of care is better encapsulated in the care products;

Transcending specialisms: Not every specialism has its own DBC codes, but

specialisms that deliver the same care, also declare the same care products;

3 DOT = DBC op weg naar Transparantie: DBC towards Transparency


51

More homogenous costs: the extent to which care costs are reimbursed to the

patient.

Care for the patient is grouped in a product based on the diagnosis. All possible care

products together are called the care product structure. This structure is based on the

International Classification of Diseases (ICD10) so that the classification is standardized in

line with the rest of the world. The ICD10 has 22 chapters. These chapters are in turn

divided into various diagnostic groups and these are again divided into several treatment

groups. Finally, the treatment group is separated into care products. There are

approximately 3500 care products. An overview of the DOT system can be found in

appendix VIII in the confidential booklet (Werken met DOT, 2011).

Because of the social care system in the Netherlands, which indicates that every person is

obligated to have health insurance, it is difficult to determine the profitability of an ED. In

concrete, patients that visit the ED get a DBC code where the average price of a certain

diagnosis is inserted. Also the visit of the ED is incorporated in the DBC code of that

certain diagnosis. The cost of the readiness and availability of an ED is a cost regardless of

the patient volume (Taheri, Butz, Lottenberg, Clawson, & Flint, 2004).

According to the literature, the low-care unit is profitable in the ED. These revenues are

used to finance the medium and high-care unit of the ED (Schrijvers, Steeg, Schaaf,

Hemrika, & Gussinklo, 2011). However, previous research does not give a clear perception

of the financial situation of EDs in general. It merely states that they are cost centers.

In conclusion, Dutch hospitals are financed and funded. These are two totally different

methods. Hospitals receive a budget, but they can also reimburse costs. Reimbursements

are currently done by DBC codes. As from next year, these codes will be extended to

DOT. This reimbursement system also makes it difficult to determine the profitability of

an ED. It is merely stated that the low-care unit of an ED is profitable.

The following hypothesis can be formulated from the literature above:

Hypothesis 8: it is difficult to determine the profitability of an ED.


52

4.4.7 Patient satisfact ion

Patient satisfaction plays an important role in the efficiency of the

process in the ED. A patient is only satisfied when the waiting time is

minimal and when the service is good. Therefore patient satisfaction

entails different factors that should be optimized. This section

encompasses research question 12 and figure 17 on the left indicates the

position in the conceptual model.

“Emergency physicians in Hong Kong have come up with a list of 10 Cs, helpful and applicable for quality

emergency care and risk management: competence, confidence, comfortable, careful attitude, compliance with

protocols, checklists, courtesy, being calm and controlled, compassionate, and considerate as well as timely

and appropriate communications…the same values we all strive for” (Lateef, 2011).

In 2010 research was conducted in the Netherlands on the quality of care in the ED in

relation to patient satisfaction, using the CQ index (Consumer Quality Index). There are

nine important steps that affect the satisfaction of a patient visiting the ED: (1) general

impression, (2) pre-entering the ED, (3) reception ED, (4) professionals ED, (5) pain, (6)

diagnostics and treatment, (7) departure ED, (8) ED in general and (9) the patient himself

(Bos N. , 2011).

In general, patients visiting the ED were satisfied about routing indication in the hospital to

the ED, the location of the ED, parking at the ED, consistency in information, being taken

seriously by all staff, safety in the ED, privacy in the treatment room, trust in the expertise

and being listened to. Although patients seem satisfied with the latter points, these points

are also ranked 30-39 in the top 39 improvement points (Bos N. , 2011). The ten major

points of improvement were about the co-decision of treatment, information from the

secretary and the nurse (concerning waiting time) and the information on sequence of

treatment and side effects to medicines, communicating the data transfer to the GP about

the ER visit, information about after care (activities, what to watch out for), eating and

drinking facilities in the ED and communicating who to contact when the patient is

concerned about a matter concerning his condition and treatment (Bos N. , 2011).

The infrastructure, especially hygiene and comfort, play a role in patient satisfaction. The

preferred location of the ER, integrated with a HAP or co-located, has not been

Figure 17: Position patient satisfaction

variable


53

sufficiently investigated by research (Chalder, 2006). Patients are also influenced by the

patient-nurse or patient-physician relation (Hidalgo, 2011). Communication and courtesy

play a major role in this (Soleimanpour, 2011). Patients comply better with the physician if

they have been given pain relief at the ED during their stay, all of which minimized their

distress. This positively affects patient satisfaction (Downey, 2010).

Patient Centered Care (PCC), is becoming increasingly important in the 21st century. PCC

is focused on customized care. The patient becomes a partner in his/her own care and

health ‘ownership’ is aligned with 21st century thinking. There are three major areas of

importance: (1) respect for patient values, preferences, and expressed needs, (2) the co-

ordination and integration of care and (3) information, communications, and education.

The question is whether the ED will benefit from this approach. Research has shown that

it could be used, only if the approach is well planned in advance (Taylor, 2006) (Lateef,

2011).

“The two dimensions most strongly positively associated with global satisfaction were receiving the expected

medical help and being treated well by the doctor’’ (Taylor C. , 2004). A patient’s expectations play

a major role in relation to satisfaction and are not necessarily dependent on the triage code.

It is not known in this situation whether the triage code or the waiting time itself affects

satisfaction (Taylor C. , 2004). Patients arrive at the ED with certain expectations, which

are either met or not by the physician. Failure to meet the expectation can result in anger or

even aggression. Negative comments about an ED or physician can also be circulated

publicly. These patients will consequently not return for follow-up care, resulting possibly

in a loss of patients for the hospital. Managing expectations in an ED is complex, due to

the high anxiety and stress levels that are naturally present. This can only be achieved when

a balance is found between the expectations of the patient, the perception of the physician

and the prioritization by the healthcare planners. Research suggests that communication

and building a good patient-physician relationship is crucial in this (Lateef, 2011) (Hidalgo,

2011).

Waiting times do not always affect the patient’s satisfaction negatively. Communication

regarding waiting times is essential. This can be done during triage, but also through

information screens in the waiting room (Kelly, 2010). The perceived waiting time does not

necessarily show a decrease with the introduction of the information screen (Papa, 2008).

Communication plays a major role in the interaction aspects between nurse and patient, in


54

which information and psychosocial exchange play a key role in satisfaction criteria (Kim,

2010). Generally, communication in all areas between patients and staff and between staff

amongst themselves has been indicated as a frequent sphere of improvement in patient

satisfaction. “Although it may be neither feasible nor desirable to meet all patient expectations, increased

focus on wait times and staff communication may increase both ED efficiency and patient satisfaction”

(Cooke, 2006). Communication about waiting times linked to the non-urgent character of a

patient visiting the ED may have a positive impact on expectations and satisfaction

(Olsson, 2001). Research has shown that communication skills workshops improve the

communicational and therapeutic skills of physicians (Lau, 2000).

When reviewing a patient population, younger people are most often the least satisfied and

elderly people with no comorbidities most satisfied. A good education and bad health

status has a more positive impact on satisfaction than lower education and good health

status (Rahmqvist, 2010). When researching the appropriateness of seeking medical care,

patients tend to think that other patients are wasting their time, but do not see themselves

in that same light. Patients tend to search for health-seeking rationales, yet their anxiety and

symptoms appear to be more like health-seeking behavior (Adamson, 2003).

In conclusion, patient satisfaction is influenced by the efficiency in an ED. Important

factors determining patient satisfaction are the layout of the ED and the verbal

communication between patient and staff. A patient’s expectations can be turned into

realistic expectations, if the communication towards the patient is adequate. Patient

satisfaction and waiting times can also be influenced by verbal communication.

The following hypothesis can be derived from the literature:

Hypothesis 9: verbal communication towards a patient in the ED plays an important role in patient

satisfaction.

The foundations for the sub-research questions have been discussed in the sections above.

The seven variables were elaborated on as well as their effect on the efficiency on an ED.

The next section will give an overview of the hypotheses derived from the literature in this

chapter.


55

4.5 Hypotheses

Based on the theoretical framework, the following hypotheses were derived:

Hypothesis 1: the layout of the ED affects the long term success of its processes

Hypothesis 2: the integration of a HAP and an ED improves the efficiency and

quality of care at a lower cost

Hypothesis 3: digitalization of patient data has both a positive and negative effect

on the processes of an ED.

Hypothesis 4: standardized performance indicators enhance the quality of the

processes of the ED

Hypothesis 5: the presence of an ED doctor at an ED has more advantages than

disadvantages, but its effect on the efficiency at the ED is difficult to confirm

Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED

Hypothesis 7: waiting time can be decreased by eliminating the bottlenecks in the

process

Hypothesis 8: it is difficult to determine the profitability of an ED

Hypothesis 9: verbal communication towards a patient in the ED plays an

important role in patient satisfaction

These hypotheses will be tested on their validation through the results of the interviews in

chapter 5.


56

5. Results and analysis

This chapter will discuss the results and analysis. The results are based on the outcomes of

the twelve interviews at different emergency departments (EDs) in the Netherlands. The

results are discussed per individual variable. The analysis incorporates the hypotheses

extrapolated from the literature (chapter 4, section 4.5) with the results of the interviews

and thus will determine the validation of those hypotheses from the literature. Hypotheses

that cannot be validated through our research will be postulated as recommendations for

further research.

The structure of the results and analysis is identical to that of the chapters above. The

structure is based on the conceptual model (chapter 2. A figure at the beginning of each

variable discussed will indicate which variable in the conceptual model is being elaborated

on. Each of the seven variables discussed will start with the results, followed by the

analysis. Quotes from the interviews will be used to substantiate the results or as evidence.

Some sections show a table at the end of the section. Its function and how to read it will be

explained in that section.

The final section of this chapter will give a short overview of the hypotheses and whether

or not they could be validated.

5.1 Infrastructure

The following chapter will discuss the results from the outcome of the

interviews on the variable infrastructure. This variable is divided into the

layout of an emergency department (ED) and the Huisartsenpost (HAP,

general practitioners’ co-operation). The results are followed by an analysis

of both, in which hypothesis 1 and 2 from the literature (chapter 4) will be

tested for validation. Figure 18 on the left shows the position of this

variable in the conceptual model.

5.1.1 Emergency department layout

5.1.1.1 Results

The results on the layout of the ED are discussed in the section below. Firstly, it is

discussed if the EDs have a Computer Tomography scanner (CT-scanner) in the

department itself after which the results of the physical layout are discussed. Secondly, the

Figuur 18: Position

infrastructure variable


57

format of the treatment rooms is detailed. This is followed by a new topic that arose during

the interviews, namely the acute admissions ward. Finally, a general conclusion on the

results of the layout of the ED is given. Table 1 gives an overview of this section.

One out of twelve EDs has a CT scanner in the department itself. One ED will get a CT in

the future and two others would like to have an own CT but stated that the investment

required was proving to be a barrier at the moment. The trauma rooms are equipped with

an X-ray device. Some have an extra X-ray room on the ED, including one ED with a

mobile X-ray device for the non- or less mobile patients.

Two out of twelve EDs currently have the ballroom setting. Two have a partly ballroom

structure and three want to set up the ballroom setting in the future. The reason for the

latter is the functionality and overview it creates for both staff and patients; “Voor de patiënt

is dit prettig, omdat hij aanspreekbaar is wanneer nodig. Het werkt voor de mensen prettig, het is dichtbij

allemaal, heel functioneel” (Hospital I, 2011).

Eight out of twelve EDs have uniform rooms, two a combination and two have a non-

uniform configuration. The reason for uniformity stated elsewhere in this paper, is the ease

of use and patient placement and allocation; “In de nieuwbouw willen we toewerken naar een

standaard kamer waar alles gedaan kan worden. Momenteel is daar nu geen plaats voor. Nu moet er

nagedacht worden wat de patient nodig heeft en welke kamers er dan ter beschikking zijn. Dat kost nu

ontzettend veel tijd omdat er vaak patiënten verplaatst moeten worden naar andere kamers” (Hospital B,

2011). All rooms contain the standard layout resources: bed, monitor, computer (in most

EDs), mobile carts, small cupboard, sink, oxygen/air pressure and stool. Some are adapted

to suit a particular specialization as for example the ENT (ear, nose and throat specialist),

urology and ophthalmology.

Three EDs have an AOA (acute admissions ward) and three said they had plans for an

AOA. Reasons mentioned in favor of an AOA are better logistics, flexibility and less

disruption for other wards; “Enige afdeling waar patiënten heen gaan, werkt logistiek veel beter.

Discussies met afdelingen zijn er uit, er is gewoon 1 centrale afdeling […] Maakt dat je flexibel bent en

rust op andere afdelingen” (Hospital K, 2011). Contrasting ideas about the effectiveness stated

are doubts as to its functionality and the number of patients; “Je moet voor jezelf duidelijk

kijken wat het voor jezelf oplevert. Het kan een oplossing zijn voor een logistiek probleem maar niet voor

het bedden tekort” (Hospital C, 2011), “Ons patiënten volume is niet groot genoeg om een AOA


58

rendabel te maken. Je moet er ook personeel neerzetten terwijl er misschien niemand wordt opgenomen”

(Hospital G, 2011).

Table 1 below provides an overview of the outcomes of the interviews. Horizontally in the

columns, the elements of the layout variable can be seen. Vertically, the rows indicate the

individual hospital codes. Specific information on the elements in the columns per

individual ED can be obtained by reading the table horizontally. If the table is read

vertically, each individual column can be linked to the different hospitals.

Hospital

code

Number of

treatment

rooms

CT/X-ray on ED? Shape Room lay-out*

A 12 (2 trauma, 2

AED)

CT near ED

X-ray on ED

Ballroom Uniform

B 20 (2 trauma, 1

AED)

CT and X-ray on ED,

ultrasound

-** Some uniform, some

specific

C 8 (1 trauma, 1

acute)

CT near ED, X-ray on ED - Uniform

D -(2 trauma) CT in 2013, X-ray next to ED Linear Uniform

E 24 (2 trauma) CT near ED, X-ray on ED Partly

ballroom

Some uniform, some

specific

F 7 (1 trauma) X-ray on ED, CT near ED,

mobile X-ray device

- Uniform

G 3 (1 trauma) Next to ED Ballroom in

future

Not uniform

H 8 (2 crash) CT near to ED, X-ray on ED No real

structure

Uniform

I 25 (2 trauma) CT near to ED, X-ray on ED Partly

ballroom

Uniform

J 11 (1 trauma) CT near to ED , X-ray on ED

(separate room in new

situation)

Ballroom in

future

Not uniform

K 6 (1 trauma) CT near to ED, X-ray on ED Ballroom in

future

Uniform

L 14 (2 trauma) CT near to ED, X-ray on ED Ballroom Uniform

Table 1: Overview emergency department layout

Note 1: * Standard layout: bed, monitor, computer, mobile carts, small cupboard, sink, oxygen/air pressure, stool

Note 2: ** A horizontal line indicates that the data in that field is unknown


59

Concluding on the results above, the interviews have indicated that the ballroom layout is

seen as functional and efficient for its processes as well as offering uniformity in the layout

of treatment rooms. The provision of diagnostic equipment for the ED is often considered

an investment issue and the location of such equipment affects the efficiency of the

processes in an ED. Opinions about an AOA vary. Some indicate flexibility as an

advantage, others question its functionality.

5.1.1.2 Analysis

From the literature the following hypothesis was derived:

Hypothesis 1: the layout of the ED affects the long-term success of its processes.

Literature has validated this hypothesis. According to the literature, layout plays a

significant part in the throughput of the emergency room (ED). This in turn makes for

improvement in overcrowding issues. The combination of these two factors makes the ED

more efficient. Efficiency in the long term can be achieved through various changes or

adaptations in the physical layout. Firstly, implementing the ballroom layout creates

visibility of the ED and easy accessibility to the central nursing station for patients and

staff. However, research has indicated that when the number of treatment rooms exceeds

18, the ballroom setting is no longer effective. The ballroom setting should then be

duplicated and two ballroom areas created or the EDs should consider linear units.

Secondly, uniformity in the layout of treatment rooms provides flexibility in patient

placement. This in turn can support the idea to centralize the primary processes and to

place other processes in the periphery. Research suggests for instance that high-care

patients should be located around the nursing station and non-urgent patients can follow

the RADIT program, for instance. Optimal efficiency can also be enhanced by the right

location for diagnostic imaging equipment, either on the ED itself or located next to the

ED. Research is questioning whether registration of a patient should be handled by the

secretary at the front desk of the ED or via bedside registration. The latter is said to save

space in the waiting room and speed up the process within the ED itself.

Hypothesis 1 can also be validated by the outcomes of the interviews in the results.

Hospitals have acknowledged the functionality and advantages of the ballroom setting

which also improves patient satisfaction. Hospital E and I have implemented a semi-

ballroom layout, as is also suggested in literature when the number of treatment rooms

exceeds 18. In addition to flexibility, the results have identified that the uniformity of


60

treatment rooms also provides ease of use and patient placement. Hospital L confirms in

the interview the efficiency and effectiveness of separating the central and peripheral

processes. Several hospitals have indicated that not having diagnostic imaging equipment

on or near the ED constitutes as bottleneck in their processes. The interviews have

confirmed that a distinction should be made between urgent and low-care patients, for

instance by placing urgent care patients near the nursing station and using a fast track for

low-care patients. In order to improve overcrowding and throughput in an ED, the

interviews have suggested the use of an ‘acute opname afdeling (AOA)’; an admissions

ward which is part of the ED with a maximum stay of 24hrs, 48hrs or 72hrs. The efficiency

of this AOA to reduce overcrowding and make for greater throughput cannot be

confirmed by the literature in this research paper, thus further research on its effect on

efficiency is to be recommended. The following hypothesis can consequently be derived

and used as a recommendation for further research (chapter 6):

Hypothesis 1: an admissions ward has a positive effect on the overcrowding and throughput of an ED.

The literature and outcomes of the interviews have shown that hypothesis 1 can be

validated.

5.1.2 The Huisartsenpost

5.1.2.1 Results

In the interviews, the Huisartsenpost (HAP) was also discussed with the head of the

emergency departments (EDs). The following section gives an overview of the results. The

results will encompass the number of hospitals that are actually integrated. Further

discussion will investigate the effects on efficiency if the processes were to be integrated,

and if these can be validated. Finally, the literature found is linked to the interviews in order

to confirm or reject the hypothesis stated.

Ten of the twelve hospitals interviewed state that the HAP is not integrated. There are

several reasons why integration or co-operation has not yet taken place. One reason is the

difficulty in co-operating with the general practitioners (GPs) because of the different

reimbursement scales that general practitioners receive in comparison with the ED versus

the responsibilities they bear; “De HAP zit aan de SEH vast maar er zijn geen samenwerkingen

mee. We zouden dat wel heel graag willen. Zeker als je kijkt naar het aantal patiënten dat wij zien en het

aantal patiënten dat de HAP ziet, want veel van hun patiënten worden toch nog doorgestuurd naar de


61

SEH […] Alleen de huisartsen hebben nog koudwatervrees om samen te werken. Ze zijn bang dat ze het

drukker gaan krijgen en dat ze niet een financiële compensatie voor krijgen” (Hospital G, 2011).

Four hospitals do not have a HAP within the he hospital complex. However, three of them

have plans for future integration. Hospital B has no plans yet, stating that they have good

collaboration agreements with the HAP. Patients can be redirected to the HAP, if they are

not urgent enough for the ED or the ED is full to capacity; “In die mate dat bij grote drukte, de

patiënt bij ons getrieerd wordt en het echt een eerstelijnszorg vraag betreft en we kunnen die patiënt niet

binnen een redelijk termijn helpen, is er overleg met de HAP en de patiënt dat hij/zij daarnaar kan

doorverwezen worden” (Hospital B, 2011).

Of the four hospitals where a HAP is located in or next to the ED, but not integrated,

three have expressed future plans for integration. Hospital D states that there is potential

for having the HAP and ED under one roof, but that one desk (integration) would be

more efficient for the patient. However, legal matters and reimbursement discussions have

not yet been resolved; “Ze zitten dichterbij en er zijn kortere lijnen. Maar er is nog steeds tegenstand

vanuit verschillende partijen. Er zitten nog heel veel mogelijkheden maar ook juridisch is het niet geregeld.

[…]. De patiënt moet nu nog terug opnieuw ingeschreven worden als hij/zij doorverwezen wordt naar de

SEH. Dat zou dus veel efficiënter kunnen geregeld worden door 1 balie neer te zetten” (Hospital D,

2011).

Seven of the EDs that are not integrated with the HAP, state as one of the reasons for

future integration the benefits to the patients as there is communication between the HAP

and ED about the placement of the patient; “Ik zie met name voordelen voor de patiënten. Als je

kijkt vanuit de patiënt dan is het makkelijk dat de huisarts deze kan doorverwijzen naar de 2e lijnszorg.

Een SEH kost meer dus je kan makkelijker afspraken maken met de huisarts welke patiënten

doorverwezen moeten worden” (Hospital H, 2011). Other reasons stated were better logistics,

increase in patient satisfaction and a reduction in waiting times; “Alle acute zorg komt bij

elkaar. Dat is efficiënt logistiek” (Hospital H, 2011), “De geïntegreerde HAP zorgt dat er mensen niet

komen op de SEH als ze er niet thuis horen. Zorgt dus dan ook voor minder wachttijden, meer tevreden

patiënten” (Hospital E, 2011). The thinking processes of the HAP and the ED are

significantly different. At the HAP a patient is considered healthy until the contrary has

been diagnosed; at the ED the patient is ill until the contrary has been diagnosed; “Ja, dat

één-loket model. Het gaat niet alleen om tijd. Het gaat ook om geld en als je in het ziekenhuis zit dan ben

je ziek tot het tegendeel bewezen is. En kom je bij de huisarts dan ben je gezond tot het tegendeel bewezen


62

is. Dus eigenlijk is dat een hele andere insteek” (Hospital L, 2011).

Obstacles and challenges for the integration of the HAP and ED can be found within the

financial system (reimbursement vs. responsibilities) and legal matters; “We willen in de

toekomst naar 1 entree met 1 functionaris die trieert. Vanuit daar kan de patiënt doorverwezen worden

ofwel naar de HAP ofwel naar de SEH. Achter die balie blijven het wel 2 identiteiten. Dit komt omdat

medico-legaal dit nog niet is afgedekt en ook financieel is het niet afgedekt. Het verschil in financiering

tussen 1e en 2e lijnszorg is nog te groot om dit te realiseren” (Hospital C, 2011). In addition, the

portfolio of tasks and responsibilities is not clear nor does an integrated situation exist; “Er

zijn ook nog vragen of we beide functionarissen beide systemen laten inkijken, wie die balie gaat bemannen.

Het is heel moeilijk om ook de takenpakketen te bepalen. Een medisch secretaresse doet velen malen meer

logistiek dan een medewerker van de HAP” (Hospital H, 2011). The complexity and non-

uniformity of the registration of patients plays a role. When patients change over from a

HAP to ED or vice versa, the patients have to be re-registered; “Als er een patiënt staat

ingeschreven bij de HAP, dan kan deze niet gelinkt worden aan het systeem van de SEH. De patiënt moet

opnieuw ingeschreven worden” (Hospital H, 2011).

Table 2 gives an overview of the distribution of HAP integration. The left column

describes the different situations of the integration of hospitals with EDs. The middle

column indicates the number of hospitals that can be apportioned according to the

different situations. Additionally, the last column connects the interviewed hospitals to the

different situations shown in the first column.

Situation Number Hospital Code

No integration 10 B, C, D, F, G, H, I, J, K,

L

No integration, HAP not on hospital complex 4 B, F, I, J

No integration, HAP on hospital complex 2 G, H

No integration, HAP in/next to ED in hospital 4 C, D, K, L

Integrated HAP and ED 2 A, E

Plans for integration in new/renovated/current

building

7 C, F, H, I, J, K, L

Table 2: Overview of the distribution of HAP integration

In conclusion, most hospitals are still not integrated with a HAP. However, they do express

an intention to co-operate since there are many benefits. Challenges need to be addressed


63

to make integration a success. These challenges are mostly related to the financial system,

especially the mismatch of the reimbursements versus responsibilities. The hypothesis from

the literature stated below is analyzed by searching for confirmation in the literature itself

as well as in the interview results.

5.1.2.2 Analysis

This subsection discusses the analysis of the premise that the integration of a HAP and an

ED improves the efficiency and quality of care and at a lower cost. The analysis is based on

hypothesis 2, formulated in chapter 4 (theoretical framework):

Hypothesis 2: the integration of a HAP and an ED improves the efficiency and quality of care at a lower

cost.

The literature states that the integration of a HAP and an ED can resolve overcrowding

problems in the ED. This constitutes one of the most important advantages of co-

operation, namely the redirection of non-urgent care patients. By redirecting those patients

to the HAP, this could reduce costs and increase effective care. Also Dutch policy makers

confirm that the efficiency and quality of care is improved when the HAP and ED are

integrated.

The results of the interviews indicate that most hospitals are not integrated with the HAP

because of the resistance of general practitioners. However, hospitals do see the advantages

of co-operation but the current lack of harmonization of reimbursements in line with

responsibilities makes it difficult to achieve this. There were insufficient interviews that

were able to corroborate the efficiency of the integration of a HAP and an ED, so the

hypothesis cannot be validated. Further research is recommended based on hypothesis 2.

5.2 Technology

This chapter will discuss the results from the outcomes of the interviews on

the variable technology. Technology encompasses the software used on an

ED and the digitalization of patient data. The results of the interviews are

followed by an analysis. In the analysis, hypothesis 3 from the literature

(chapter 4) will be tested for validation. Figure 19 shows the position of this

variable in the conceptual model. Figuur 19: Position

technology variable


64

5.2.1 Software and digitalization of patient data

5.2.1.1 Results

The following paragraphs will show the results of the technology variable. The uniformity

of software systems will be discussed, as will the effects of the digitalization of patient data

and their effects on the processes within an ED. The scope and impact of a paperless

system on an ED will also be examined.

Eleven out of twelve hospitals work with the same software hospital-wide. Hospital L does

not have a uniform software system. It was stated that iSoft has a special ED portfolio, to

which other specialists were not yet connected prior to 2004, due to the need for

optimization within the ED before opening it up to other specialists; “We hebben toen bewust

niet gekozen om de specialisten mee te laten doen, omdat we dachten dan gaan we buiten de deuren van onze

spoedeisende hulp. Dat ging alleen voor ellende zorgen, er zijn veel te veel mensen die er dan wat van vinden.

Laten we eerst maar zorgen dat we het binnen onze afdeling voor elkaar krijgen” (Hospital L, 2011).

The introduction of the system to other specialists and nursing wards has started but is

regarded a slow and cumbersome process.

Opinions regarding the notion for implementing a hospital-wide system vary considerably.

Stated as positive is the sharing of information with other wards and specialists, especially

when a patient is admitted to a nursing ward from the ED; “Wij beschouwen ons als een bron,

waarbij je start met de behandeling van de patiënt. De start van het contact met de patiënt in het

ziekenhuis. Dus alle informatie willen we graag delen met anderen die er gebruik van willen maken”

(Hospital L, 2011). Working with different systems makes for less time-saving; “Het kost

natuurlijk wel tijd door in meerdere systemen te moeten werken” (Hospital B, 2011). Others think the

benefits lie in a good transfer of information when admitting a patient to a nursing ward

and not so much in having a uniform system; “Er is niet concreet winst te maken als het zelfde

systeem gebruikt wordt in het ziekenhuis. Er is altijd winst te halen als de overdracht gewoon goed gebeurt”

(Hospital B, 2011).

Two out of twelve EDs have a paperless system. Opinions about the possibilities of having

a fully paperless and digital system are contradictory; “Alles kan papierloos” (Hospital E,

2011) or; “Nee. Dat gaat het nooit helemaal worden” (Hospital L, 2011). The effect of

digitalization of hospital G was stated as very inefficient, whereas the ED system is fully

paperless; “Heel de digitale werking hier in het ziekenhuis is inefficient” (Hospital G, 2011).


65

The benefits stated for a paperless system are the availability of information

(“systeminformatie is onmiddellijk beschikbaar, je hebt alles in 1 opslag nu” (Hospital A, 2011)), time-

saving (“Je hoeft niet alles een paar keer op papier te zetten” (Hospital A, 2011)), efficiency (“Ik

denk wel dat het efficiënter werkt. Vooral de specialisten vinden dat ze te lang bezig zijn met het invullen

van de statussen” (Hospital D, 2011)), possibilities for analyzing processes and insight into the

areas of improvement as a result of condensing all statistical information in one system

(“Je kunt er statistieken op loslaten” (Hospital L, 2011)) and less printing and printing costs

(“Wij gaan niet meer uitprinten want alles is in principe digitaal beschikbaar” (Hospital G, 2011)).

The disadvantages of a paperless system were stated as being the increase of functions vs.

time consumption (“Bespaart werk, maar kost ook tijd door het aanklikken bijvoorbeeld. Door de

meer mogelijkheden in het systeem, heeft men de neiging meer aan te klikken dan nodig is. Dat is een

leercurve.” (Hospital A, 2011)), accessibility during maintenance or breakdown periods

(“Nadeel is dat je er niet altijd bij kan bij storingen of updates, dan worden de hoofdonderdelen uitgeprint.

Maar bij SEH kan dat niet!” (Hospital E, 2011)), the loss of data during transfer to a nursing

ward (“Wij hebben nu een digitaal systeem die ophoudt bij de poort van de SEH dus er wordt wel een

uitdraai gemaakt van de SEH kaart. Maar je verliest dus wel informatie want daar staat niet alles op”

(Hospital B, 2011)) and the conversion of a paper into a digital system in the start-up

phase (“Tot voor kort waren alle dossiers nog dossiers, die zijn nu allemaal digitaal gekopieerd. Maar op

dit moment wordt alles nog afgedrukt en in het dossier bijgevoegd” (Hospital G, 2011).

The most frequently stated non-paperless documents are transfer documents from ED to

the nursing ward, radiology, diagnostic requests, documentation when patients are admitted

to the ED by ambulance or GP, medicines, consultation documents and laboratory

requests. GP letters can be sent digitally or given to the patient. The information contained

in transfer documents is often transferred verbally. The physical condition of patients is

subject to ongoing changes, whereas digitalization has not as yet been implemented;

“Overdracht naar verpleegafdelingen: EPD is een belangrijke bron van informatie, maar je ontkomt niet

aan een mondelinge overdracht (moment opname), maar bij sommige patiënten niet altijd nodig” (Hospital

J, 2011), “Kijk je naar de verpleegkundige, we hadden voorheen geschreven overdracht naar de

verpleegafdeling. Nu draai je het digitaal uit. We printen het nog voor de afdeling, omdat ze op de afdeling

nog onvoldoende elektronisch werken.[…] Nu hebben ze de overdracht en vanaf het moment dat wij de

overdracht meegeven, hebben we eigenlijk heel weinig vragen meer gehad. Alles staat er op” (Hospital L,

2011). Sometimes it is stated that the reason not all papers can be digitalized is because the

software cannot as yet implement certain codes; “Alleen bepaalde formulieren als consulten,


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aanvragen is er wel maar nog niet op een goede manier ingebed. Dat krijgt langzaam zijn verbeteringen en

voortgang” (Hospital I, 2011). A large amount of paper administration is involved for

patients that are admitted to the ED. Some EDs are scanning all the paper administration

to have all the information available in the digital system; “Er is ook nog een grote papierstroom.

Dit is vooral het geval bij het opnemen van patiënten’ (Hospital B, 2011), “Alles wat de patiënt

meeneemt wordt gescand en toegevoegd aan het EPD” (Hospital C, 2011).

The general idea is that there are advantages to be gained by a fully digital and paperless

system; “In de toekomst wil ik dat als ik een patiënt aansluit aan een monitor dat alle gegevens worden

verwerkt in de computer. Daar is zeker nog een efficiëntie slag te halen” (Hospital C, 2011).

Digitalization has conflicting effects on the processes in an ED: there are advantages and

disadvantages. To improve the efficiency and time-savings on the ED, a uniform hospital-

wide software system is preferred by some hospitals and specialists. Some interviewees

have indicated that this is not always the case at the moment. Advantages of digitalization

are for example information transfer and sharing. Disadvantages mentioned by the

interviewees are the increase in time consumption due to the increase of functions

associated with the digital system and the incompatibility between systems. Opinions on

whether a system can be fully digital vary among the interviewees.

5.2.1.2 Analysis

From the literature, hypothesis 3 was formulated for the variable technology:


ED.

Literature can validate this hypothesis as digitalization has been shown to have both a

positive and to some extent a negative effect on the processes in an ED. Beneficial effects

of digitalization that have been stated in the literature are: a positive effect on the efficiency

of data management, creating more effective and rapid healthcare, the accessibility of

information, a shift to evidence-based medical care, improvement in the quality of patient

care and a reduction in the duplication of data. Digitalization also improves professional

development. A paperless environment reduces transcriptions and charting vast amounts

of patient information and results. Research has however also shown a negative side to

digitalization. It is not always possible to digitalize all documents and some systems are less

compatible with one another. An example of the latter are the compatibility and integration


67

of the diagnostic imaging codes with the rest of the software. Also, the literature often

perceives digitalization as being efficient, only if a uniform system is used hospital-wide.

The incorporation of a hospital-wide uniform system contributes to greater efficiency in

accessing information, improving quality and minimizing medical errors. Lastly, the lack of

ease of use of digital systems can adversely affect the specialists’ clinical work in terms of

its supportive function.

Hypothesis 3 can also be validated by the results of the interviews. The opinions of the

interviewees vary, as also stated in the literature analysis above. The benefits of a paperless

system are availability of information, time-saving, efficiency, possibilities for analyzing

processes and insight in areas of improvement due to statistical information in one system

and less printing and reduced printing costs. As expressed in the literature, the interviewees

have also stated that the reason not all papers can be digitalized is due to the

incompatibility of codes in certain areas, like diagnostic imaging. Negative opinions on

digitalization and its effect on the processes within an ED were reflected in the increase in

time spent on importing patient data, the increase in options for importing data and the

potential loss of data when a patient is admitted to a nursing ward where the software

systems are not uniform or hospital-wide.

The analysis above concludes that hypothesis 3 can be validated by both literature and the

results of the interviews.

5.3 Service

Service is one of the seven variables that was investigated during the

interviews. In this section the results are discussed, followed by the

analysis and based on hypothesis 4 (chapter 4). Figure 20 on the left shows

the position of the service variable in the conceptual model.

5.3.1 Quality and performance indicators

5.3.1.1 Results

This section will discuss the certification and the presence of quality and performance

indicators in the hospitals.

Ten out of twelve hospitals are NIAZ-certified. One has his own certification; another has

Figuur 20: Position service variable


68

decided to look into another accreditation organization as the NIAZ does not fit the

organization’s structure and management (Louwerse, 2011). Five out of twelve hospitals

have a collaboration agreement with Medirisk. Other items to maintain the quality of the

ED that were stated: internal and external accreditation, inspection of the IGZ, quality

handbook for the ED, digitalize protocols, reporting incidents (VIM melding), peer

reviews, coaching and training, staff qualifications, keeping portfolios of the staff updated,

courses and workshops, technical checks, patient surveys, appointing a professional to

maintain quality, instituting a safety management system and setting quality indicators and

making them transparent. No uniform decision has been taken on this latter point;

“Indicatoren wordt steeds meer op gehamerd. Jammer dat ze nog niet NL breed geaccepteerd zijn, ligt al 5

jaar een voorstel voor 50-60 indicatoren gesteld door een aantal beroepsorganisaties. Knoop wordt niet

doorgehakt. We worden pas de laatste 4-5 jaar resultaatgericht afgerekend en dan nog niet keihard. Omdat

er geen goede indicatoren zijn” (Hospital J, 2011), “Ik vind het vooral belangrijk dat er een intern goed

auditsysteem komt en dat je niet afhankelijk bent van de inspectie die eens in de zoveel tijd langskomt”

(Hospital D, 2011). Quality maintenance and improvement must involve everyone; “Iedereen

kan betrokken worden in het kwaliteitsproces om dingen te verbeteren” (Hospital G, 2011).

In conclusion, all hospitals do actually work with some sort of certification in order to

guarantee the quality of care given. However, certification is not the only measure to ensure

and maintain the quality of the ED. Other examples are inspections by the IGZ,

digitalization of protocols, peer reviews, coaching and training and making the quality

indicators transparent. The latter measure has not been standardized which makes it

difficult to compare hospitals and to work according to a more results-oriented scheme.

The next section will elaborate on the analysis of the quality and performance indicators

which is based on hypothesis 4.

5.3.1.2 Analysis

The following hypothesis was formulated based on the theoretical framework in chapter 4:

Hypothesis 4: standardized performance indicators enhance the quality of the ED.

Performance indicators need to be evidence-based and nationally standardized in order to

compare quality at a national level. They are important for measuring the effectiveness of

the ED system to create transparency and measurability of the quality of healthcare.

Performance indicators also play a role in patient outcomes and clinical conditions.

However, it is difficult for EDs to compare themselves at a national level as the


69

performance indicators are not standardized. Furthermore, communication and

digitalization of data have an effect on the quality of performance of the ED. Additionally,

the quality of the ED is maintained through external quality management: certification,

accreditation or visitation.

All hospitals have an internal and external quality management system. They use internal

and external accreditation, are subject to inspections by the IGZ, digitalization of

protocols, reporting incidents, peer reviews, qualifications of staff, courses and workshops,

patient surveys, a safety management system and setting quality indicators and making

them transparent. These measures serve to enhance quality. However, the standardized

performance indicators are still not generally established which makes it difficult to

compare hospitals. Therefore, it cannot be confirmed that standardized performance

indicators enhance the quality of the ED. Yet it can be stated that performance indicators

that are established by the hospitals themselves improve the quality and performance of the

ED.

In conclusion, performance indicators do enhance quality in general but this has not been

specifically measured for an ED as there is no general standardization to date. However,

quality is maintained through other internal and external quality management systems. So

hypothesis 4 can only be partially validated. Further research on the standardized

performance indicators is recommended for further research.

5.4 Employees

The fourth variable is the employees. In this section the focus is on the

emergency department (ED) doctor. A table is presented after the results,

giving a short overview of the presence of and opinion on emergency

(ED) doctors in the different emergency departments (EDs). The results

in this chapter will be followed by an analysis, in which hypothesis 5 of the

literature will be tested for validation. Figure 21 on the left shows the

position of the employee variable in the conceptual model.

5.4.1 Emergency department doctors

5.4.1.1 Results

Emergency department doctors are present in ten of the twelve EDs visited. The

advantages and disadvantages of the presence of an ED doctor on the processes in an ED,

Figuur 21: Position

employee variable


70

mentioned by the different interviewees, will be further elaborated on in the following

paragraphs.

Only two out of twelve hospitals do not have ED doctors. Hospital D does not use ED

doctors because it is a teaching hospital that provides training for future trainee specialists

and because the general practitioners cannot refer to ED doctors since it is not a

specialization in those hospitals. They also believe they are functioning perfectly well

without ED doctors; “Wij werken niet met SEH artsen omdat we een opleidingsziekenhuis zijn die

bestemd is voor de AIOS. Verder is een SEH arts een algemene arts en een huisarts kan alleen

doorverwijzen naar een specialist. Het is ook nog steeds een probleem om de vacatures gevuld te krijgen. (...)

Tot op heden functioneren we prima zonder SEH artsen.” (Hospital D, 2011).

The other 10 hospitals do make use of ED doctors. In 9 hospitals, the number of ED

doctors present in the ED is exactly known. It is only known that hospital B and hospital I

has a fulltime ED doctor in the emergency department. Five hospitals indicate that they do

not have fulltime ED doctors. In the case of the other hospitals, the figures are not known.

Six out of 12 hospitals indicate that there are not enough ED doctors to work on a fulltime

basis. According to hospital C, there are not enough ED doctors because of savings in the

medical curriculum. They are starting an internal training study course for acute care

doctors;“De SEH artsen zijn niet te krijgen omdat er op de opleiding bezuinigd wordt. Wij starten nu

een eigen opleiding tot arts geneeskunde.” (Hospital C, 2011). Hospital L confirms that there are

not enough ED doctors to have an ED doctor working full time in the emergency

department; “We kunnen de SEH nog niet 7 dagen in de week 24 uur per dag met SEH artsen

bemannen. (…), maar SEH artsen zijn schaars. Ze zijn er gewoon niet.” (Hospital L, 2011).

Nine of the twelve hospitals declare that they believe that ED doctors enhance efficiency in

the ED process. Three of these nine hospitals indicate that the turnaround time is reduced

by employing an ED doctor. Hospital L even pointed out that their waiting time reduced

by 4 minutes per patient; “De wachttijd gaat dan gemiddeld naar beneden. We begonnen met ongeveer

120 minuten per patient en zitten nu op 116 minuten.” (Hospital L, 2011). Hospital F confirms

that the waiting time is cut because of up-to-date protocols and because diagnostics are

more efficient and effective thanks to the presence of ER doctors on the ED; “Veel

protocollen zijn geactualiseerd en er zijn veel afspraken gemaakt met de afdelingen en medische

beeldvormende techniek en diagnostiek. Sommige diagnostiek wordt overgeslagen om een andere diagnostiek

te doen om sneller resultaat te krijgen. (...) Doorlooptijd wordt bij aanwezigheid van SEH artsen korter.”


71

(Hospital F, 2011).

Another drawback to employing ED doctors in the emergency department is that they

cannot perform the tasks they would like to make for greater efficiency. They are more

preoccupied with supervising doctor assistants or specialists in training. Hospital J states

that the ED doctors do not have enough time to prepare a vision and define and institute a

specific policy. Their policy plan for 2015 specified that the ED needs to be an

independent unit where the ED doctor is formally in charge; “SEH artsen komen niet toe aan

visie, beleid en maatschap gesprekken. (…) Hier staat in het medisch beleidsplan dat in 2015 de SEH

een volledig zelfstandige eenheid moet zijn, waarbij de SEH arts de formele baas is” (Hospital J, 2011).

Two out of 12 hospitals make use of a nurse practitioner (NP), namely hospital D and

hospital J. Hospital J indicates that their NPs are performing in the fast track and that they

are acting independently in certain protocols. They can also be used for quality assessment.

However, they believe that NPs should be given more responsibilities; “Ze doen hier de fast

track, ze doen protocollair een aantal dingen zelfstandig. (…) Je kan ze ook gebruiken voor

kwaliteitsbepaling (zorgpaden, protocollen, wachttijden). Ze moeten alleen meer doen dan fast track.”

(Hospital J, 2011) On the other hand, hospital L declares that they are against the use of

NPs. They believe that an NP does not add to the efficiency of an ED. Nurse practitioners

can only perform a small number of extra procedures and these can be done by an ED

nurse as well; “Omdat een nurse practitioner volgens mij niks toevoegt. (…) Er zitten hele lagen en de

nurse practitioner zou dan in een smalle bandbreedte zijn werk moeten doen. Ik denk niet dat we daar

genoeg aanboed voor hebben, dat is één. En twee, ik zie er veel meer in dat je dat deel bij de spoedeisende

hulp verpleegkundige neerlegt.” (Hospital L, 2011). They believe that the nurse practitioner

should play a bigger role in the care of the chronically ill; “Ik denk dat zij een grote rol hebben in

de chronische patiëntenzorg.” (Hospital L, 2011).

Eight of the twelve hospitals worked or are working with volunteers specifically dedicated to

the needs of patients and their family. The use of volunteers or hosts and hostesses is mostly

positively evaluated. This enhances the quality of service to patients. In hospital D, they work

with patient-service employees to take away some of the workload of an ED nurse and to take

extra care of patients that have to wait; “De patientenservice medewerkers nemen een stuk van het

verpleegkundige werk af. Verder regelen zij ook een stuk patiëntenservice.” (Hospital D, 2011). In

contrast, hospital G stopped using volunteers because they found it difficult to define their

tasks and in the long run there was not enough work for them; “Wij werken met vrijwilligers maar

dit is niet positief geëvolueerd. Het probleem is dat het moeilijk is om hun takenpakket goed te definiëren. (...)


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kunnen weinig of niets doen omdat er geen patiënten zijn.” (Hospital G, 2011).

All hospitals have the required training for their nurses and doctors. However, there are

hospitals that provide extra training on specific topics like child abuse and customer

friendliness (Hospital G, 2011). Hospital D organizes symposia and case-study training;

“Symposium en scholing, waarbij er ook verwacht wordt dat er wat mee gedaan wordt. (...) Vier keer per

jaar casuïstiek bespreking met hele keten.” (Hospital E, 2011).

Table 3 below shows an overview of the presence of ED doctors in the EDs at the

different hospitals, as well as the opinions relating to their presence at an ED. When

reading the table horizontally, the presence of ED doctors is confirmed as well as the

opinion regarding their presence per individual hospital. If the table is read vertically, then

the situation of the presence of an ED doctor or the opinion on the presence of an ED

doctor can be read for all the hospital codes.

Hospital

code

ED

doctors

Opinion

A Yes Improvement quality/steady professionals

B Yes Less consultations/improvement complex care

C Yes Not enough ED doctors

D No Not enough ED doctors

E Yes Lower turnaround time

F Yes More efficient shifts, lower turnaround

G Yes More efficient process

H No -

I Yes Take control, central person in process, good support other

professionals

J Yes Should be their own boss on the ED, too much time on supervision

K Yes Too much time on supervision, function not sufficiently incorporated in

organization

L Yes More efficient because of experience, waiting time cuts Table 3: Overview of emergency doctors and opinion on their presence

The opinion on the presence of an ED doctor at an ED is two-fold. Advantages include

reducing turnaround time, cutting waiting time and making the diagnostics process more

efficient. Disadvantages include the time spent on supervision and the time taken up by

ED doctors with secondary responsibilities.


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5.4.1.2 Analysis

Hypothesis 5 was derived from the literature:

Hypothesis 5: the presence of an ED doctor at an ED has more advantages than disadvantages, but the

effect on efficiency at an ED is difficult to substantiate.

Literature can validate this hypothesis. The opinions on the efficiency of ED doctors at an

ED differ. On the one hand, ED doctors can save time on the speed and quantity of the

diagnostics as well on the medical practice. Due to their specific training for ED situations,

ED doctors can economize on waiting and turnaround time by diagnosing and treating

without the involvement of other specialists as well as playing a role in policy- making.

However, research also shows that organization itself determines the quality of the ED and

not the type of doctor. The lack of a uniform training program and the low number of ED

doctors currently employed makes it difficult to fully investigate their effect on the

efficiency of an ED.

The results of the interviews can validate the ‘twofold’ effect of the presence of an ED

doctor at an ED. The outcomes of the interviews have, as in the literature, confirmed the

positive factor of reducing waiting and turnaround times. Also, interviewees mentioned

that diagnostics are more efficient due to the presence of an ED doctor. The results have

also indicated the disadvantages of the presence of an ED doctor, namely the time spent

on supervision and thus the time lost and taken up with tasks other than their primary tasks

and responsibilities. The shortage of ED doctors is also confirmed by several interviewees,

which makes it difficult to measure the overall efficiency of an ED. ED doctors, as

expressed by most interviewees, cannot be employed fulltime as an ED doctor. Also,

hospitals develop their own training program to educate ED doctors, which confirms the

non-uniformity in training programs for ED doctors found in the literature. This also

makes it difficult to measure the effect of ED doctors on the ED.

Hypothesis 5 can be validated by both the literature and the results of the interviews.


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5.5 Logistics

Logistics is the fifth variable that influences the efficiency of the

processes. This section is divided into two subdivisions, namely the triage

process and the waiting time and the process within the ED itself. In each

subdivision, the results will be discussed as well as the analysis of the

literature and interviews. In the analyses, hypotheses 6 and 7 stated in the

theoretical framework (chapter 4) will be tested for validation. Figure 22

shows the position of the logistics variable in the conceptual model.

5.5.1 Triage process and triage systems

5.5.1.1 Results

These results contain the triage systems the hospitals use, as well as the time prior to triage.

Eight out of twelve hospitals use the Manchester triage system. Only hospital H does not

use a triage system. They judge people based on a clinical view; “Wij bepalen patiënten nu op

basis van een klinische blik maar niet vanuit een methodiek” (Hospital H, 2011). Hospital K uses

the Nederlandse Triage standard (NTS) system for patient triage. They used to use the

MTS but switched to NTS with the arrival of the integrated HAP. It was more efficient to

make use of one triage system; “Manchester hebben we gehad en met komst van spoedpost zijn we

overgegaan op 1 systeem omdat het handiger is als je in één systeem werkt.” (Hospital K, 2011).

However, hospital D declared that NTS does not work for their hospital since it triages

patients with a purpose other than that for a HAP; “Wij hebben gekozen voor een andere (triage

systeem) omdat wij met een ander doel triëren. Sowieso werkt het NTS niet voor een ziekenhuis.”

(Hospital D, 2011). Ten of the twelve hospitals use a triage nurse to assess patients.

However, hospital E uses a ‘co-ordination’ nurse that also does the triage instead of a triage

nurse; “We hebben niet formeel een triage verpleegkundige, maar een coördinerend verpleegkundige die ook

de triage doet.” (Hospital E, 2011).

The time taken for triage to commence is stated as between 5-10 minutes. Most of the EDs

mention it is feasible to start a triage within 5-10 minutes, unless it is very busy or the

software is not available throughout the ED. Waiting times then increase and in some cases

assistance is requested from other ED staff; “Komt ook omdat het NTS nog niet geïntegreerd is,

maar stand alone op 1 plek” (Hospital K, 2011), “De patiënten moeten binnen 10 minuten getrieerd

worden. Dat halen we redelijk goed” (Hospital G, 2011).

Figuur 22: Position logistics

variable


75

In conclusion, most hospitals make use of the Manchester triage system. However, it is not

indicated by the hospitals as being the most efficient triage system. Finally, most of the

EDs point out that triage starts within 5 minutes of a patient’s arrival.

5.1.1.2 Analysis

The following hypothesis was formulated in the theoretical framework for the sub-chapter

on triage systems:

Hypothesis 6: a triage system has an effect on the efficiency of processes in the ED.

In the literature, it can be found that the advantages of a triage system are the immediate

assessment of patients, the positive effect on waiting times in the waiting room,

prioritization of care, placement of patients in the correct treatment room or area and

being able to start diagnostic tests. What’s more, the different triage systems have their own

advantages and disadvantages and should be adjusted to the requirements of the hospitals

themselves. From the different triage systems, MTS is seen as most compatible with the

Dutch EDs.

The results do not give an indication as to whether the implementation of a triage system

makes the processes of the ED more efficient. Therefore, hypothesis 6 cannot be validated

and should be considered in the recommendations for further research in line with

hypothesis 6 below.


5.5.2 Waiting time and processes in the emergency department

5.5.2.1 Results

The results state the different bottlenecks encountered in the processes within the ED.

Firstly, the lack of diagnostic equipment is discussed, followed by the dependency of

specialists that work in their own outpatients’ clinics. Further bottlenecks are the

deployment and inexperience of doctor assistants as well as the uncertainty concerning the

allocation of a patient to a particular specialism. This latter bottleneck refers to the

admission of patients to the hospital. This is followed by a discussion of the results of

turnaround and waiting times at the various hospitals. Lastly, the peak patient flow times

are elaborated on.

The interviewees at six hospitals indicate that the lack of diagnostic equipment in the ED


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creates bottlenecks in the process. Hospital F declared that it is difficult to make clear

agreements with the radiology department to give priority to ED patients; “Het is soms

moeilijk afspraken te maken met de afdeling medisch beeldvormige techniek.Zij hebben ook hun

programma’s en er is geen aparte kamer voor de SEH.” (Hospital F, 2011).

Another bottleneck in the process is that emergency departments are dependent on

specialists who work in their own outpatients’ clinics. Six of the twelve hospitals

interviewed indicate that this factor delays their processes significantly. According to

hospital G, it takes up more time to work with specialists from outpatients’ clinics instead

of fixed specialists within the ED itself; “Wij werken met specialisten vanuit de poli’s, dat kan wel

eens extra tijd opleveren.” (Hospital G, 2011). This is confirmed by hospital L that declares

that consultation by an ‘outside’ specialist, is more time-consuming; “En natuurlijk als je op

een specialist moet wachten, gaat er over het algemeen meer tijd overheen.” (Hospital L, 2011).

According to hospitals D, F, G and J, the deployment and inexperience of doctor

assistants, constitutes one of the factors influencing inefficiency in the process within an

ED. Hospital D states that doctor assistants merely have too many patients to treat.

However, this situation is improved slightly by employing a fixed specialist in the ED itself;

“Arts-assistenten hebben gewoon te veel patiënten te verwerken. We zien wel dat het verbeterd door het

inzetten van een specialist op de SEH, maar je kan het nooit helemaal wegnemen.” (Hospital D, 2011).

Hospital F focuses on the fact that the doctor assistants are young and need extra training

to function in the emergency department. This affects turnaround time; “Die (arts-assistenten)

moeten ingewerkt worden voordat ze wat klinische ervaring hebben, en dat merk je in de doorlooptijden.”

(Hospital F, 2011).

Another bottleneck according to hospital G and I, is that sometimes it is not clear to which

specialism the patient should be referred. As a result incorrect referral entails extra

consultations. Precisely speaking, Hospital I states that if the patient cannot be clearly

referred to a particular specialism, then the ED doctor will determine the specialist

department of referral. This means that the ED doctor decides which specialism the patient

should be referred to. This leads to inefficiencies in the process; “Als een patiënt niet duidelijk

is voor één specialisme, dan bepaalt de SEH arts voor welk specialisme de patiënt naar een bepaalde

afdeling gaat. De specialisten zoeken het daar maar uit.” (Hospital I, 2011).

Two out of the 12 hospitals indicate that the bottleneck in the process is to be found at the

patient admissions procedure at the hospital. The waiting time of patients increases because


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of the lack of availability of staff to collect patients; “Als een patiënt opgehaald moet worden door

een afdeling, dat moet dan binnen 15 minuten gebeuren. (…) Daar zitten we over het algemeen overheen.

En dat heeft ook met de afdeling te maken die dan geen beschikbaarheid heeft.” (Hospital L, 2011).

The turnaround time ranges from 5 minutes to 420 minutes, with the average time

between 116 and 180 minutes. Hospital E has the lowest turnaround time, but also the

highest range. Turnaround time is influenced by the type of specialism; “Per specialisme heb je

ook gemiddelden en je zou het eigenlijk per specialisme moeten bekijken” (Hospital E, 2011). The

multidisciplinary nature of a patient’s assessment and treatment is often stated as the major

impact factor on turnaround time; “Als patiënten lang op de SEH moeten verblijven dan komt dat

vaak omdat het multidisciplinair is. Wij werken met specialisten vanuit de poli’s dat kan wel eens extra

tijd opleveren. Als dan blijkt dat de patiënt toch niet voor het juiste specialisme is aangemeld dan moeten er

extra consulten gedaan worden. Dat kost gewoon efficiëntie” (Hospital G, 2011). Other influential

factors stated are inexperienced doctor assistants, increasing patient complexity itself

together with an increasing number of complex patients, misinformation from the GP to

the patient about waiting times at the ED, multidisciplinary consultations, admissions,

waiting for diagnostic tests or results, dependency on third parties, non-urgent patients

visiting the ED instead of the HAP and overcrowding; “30% zelfverwijzers, waarvan 15% op de

SEH thuis hoort. Ongeveer 10 mensen per dag kon gewoon naar de huisarts” (Hospital I, 2011), “De

complexiteit van wat wij aanbieden, ligt vrij hoog en daardoor is de doorlooptijd hoger” (Hospital C,

2011), “De wachttijden lopen vooral op door de complexere zorg die patiënten vragen. De kamers die je

wilt gebruiken voor laag complexe zorg worden nu bezet door patiënten die hoog complexe zorg vragen. Dus

patiënten in een lagere urgentie categorie komen niet meer aan de beurt” (Hospital B, 2011), “Verder

gebruiken specialisten de SEH om de patiënt verder in kaart te brengen omdat zij er geen tijd voor hebben.

Daardoor moeten de arts-assistenten het hele onderzoek opnieuw doen. Dat kost tijd en vooral efficiëntie”

(Hospital G, 2011). Solutions to cutting the stated waiting times were the use of an acute

admissions ward (acute opname afdeling), using care paths, more responsibilities for the

general practitioner (GP), providing better and accurate information to patients before

admissions and during the ED process itself, better communication and co-operation

between ED staff, fast track and a good overview of the patients and processes for the ED

staff (digital board) to monitor and give a clear picture of the situation and leave room for

initiative and anticipation; “De huisartsen hebben de rol om overbrugingszorg te bieden en zij denken

dat als we dichter bij het ziekenhuis zitten dan wordt de drempel alleen maar lager. De SEH denkt echter

dat veel patiënten geen echte eerste lijnszorg of tweedelijnszorg nodig hebben” (Hospital B, 2011), “Er


78

valt meer efficiëntie te behalen in een vaste kern van arts assistenten op de SEH” (Hospital F, 2011),

“Zorgpaden zijn niet de oplossing voor alles, maar met name voor een interdisciplinair proces is het handig

om een zorgpad te hebben” (Hospital A, 2011), “Het EPD geeft gelijk een routingsscherm. Iedereen

werkt vanuit zo een routingsscherm. Het is heel handig. In één blik heb je in de gaten hoe druk het is en

wat de belasting is” (Hospital I, 2011).

The peak period is similar in all the EDs. Inflow starts around noon and dies down mid-

evening. The busiest times are mentioned as Mondays and Fridays, because patients tend to

visit the GP just before the weekends or cannot get an appointment just after the weekend;

“Dat zijn patiënten die na het weekend toch nog naar de huisarts of SEH gaan. En voor de vrijdag geldt dan

hetzelfde, alleen dan andersom. Voor het weekend ga je toch maar even naar de dokter” (Hospital L, 2011).

In conclusion, different bottlenecks delay the processes within the ED and therefore also

increase the waiting time for patients. There are 5 bottlenecks indicated by the hospitals

interviewed: the lack of diagnostic equipment in the ED, consultations by specialists that

work in their own outpatients’ clinics which is most time-consuming, the inexperience of

doctor assistants has a negative effect on turnaround time, no clear referral to a certain

specialism which could entail extra consultations and admission to the hospitals. All these

bottlenecks cause extra turnaround time in the ED process. Finally, peak periods at the

EDs are generally the same, namely a normal distribution spread with a peak from around

noon until mid-evening. Busiest times are Mondays and Fridays.

5.5.2.2 Analysis

The following hypothesis was deduced from the research of the theoretical framework on

waiting times and processes within the ED:

Hypothesis 7: waiting time can be reduced by eliminating bottlenecks.

The waiting time is one of the most difficult bottlenecks to eliminate. The Theory of

Constraints (TOC) is often used to reduce bottlenecks in their processes. By implementing

this theory, the processes in the ED become more efficient and effective. Non-productive

time in an ED can be cut by reducing preparation time, the use of appropriate supplies,

available and accessible information as well as performing the right procedures. The goal of

TOC is to completely eliminate non-productive time.

Several bottlenecks were revealed during the interviews such as the lack of diagnostic

equipment in the ED the dependency on specialists from outpatients’ clinics, the


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deployment and supervision of inexperienced doctor assistants, extra consultations because

of the ‘undifferentiation’ and non-specificity of patients and the admission of patients to

the hospital. These bottlenecks impact on waiting times. Measures designed to improve the

elements expressed above will reduce waiting times.

In conclusion, waiting times can be reduced but never completely eliminated. As such,

hypothesis 7 can be validated.

5.6 Finances

Finance is one of the variables that influence the optimization of the

processes in the emergency department (ED). The next section will first

elaborate on the results of the interviews in the twelve hospitals. This is

followed by an analysis based on hypothesis 8. Figure 23 shows the position

of the finance variable in the conceptual model.

5.6.1 Financial system of the emergency department

5.6.1.1 Results

The results in this section cover the financial systems that are used by the various hospitals.

It also gives on overview of the opinions on the new DOT system that will be established

as per 2012.

The majority of the hospitals state that revenues are very difficult to calculate as patients

that visit the ED and have repeat consultations cannot be traced as revenue for the ED;

“Het is niet te berekenen hoeveel een SEH precies opbrengt. Het is niet duidelijk als patiënten terugkomen

op de poli dat het de SEH is die geld opbrengt.” (Hospital G, 2011). This is confirmed by

hospital G that indicates that an ED can calculate what the costs and revenues are up to a

certain point. However, it is difficult to calculate what the ED generates via repeat or

follow-up consultations; “(..) SEH’s kunnen berekenen wat het kost en wat het opbrengt. Het is wel

moeilijk om te berekenen wat het oplevert aan herhaal consulten.” (Hospital H, 2011).

Hospitals C, E and K indicate that the ED is loss-making per definition because it

constitutes a cost center; “Elke SEH is per definitie verlieslatend want het is een kostencentrum.”

(Hospital C, 2011). On the other hand, seven out of the twelve hospitals point out that the

Figuur 23: Position finance

variable


80

ED generates money for the hospital elsewhere. The ED itself operates according to a

budget construction so it cannot be ascertained just how much revenue it generates.

However, the follow-up consultations at outpatients’ clinics do generate money for the

hospital at specialist level; “De SEH heeft altijd een kostenbegroting en dan komt het geld elders in

huis binnen.” (Hospital D, 2011). According to hospital F, the ED does generate income.

However, such income only appears at the specialist level via outpatient visits but not on

the ED balance sheet; “Wij genereren veel inkomsten door opname en het eerste poliklinische bezoek.

Dit wordt terug gezien bij het specialist niveau, niet bij de SEH.” (Hospital F, 2011).

Concerning the implementation of DOT, opinions vary from hospital to hospital.

However, most hospitals state that they do not see any advantage in changing DBC into

DOT. Hospital B indicates that their products are not covered in DOT for complexity

reasons; “Ik denk niet dat dit gaat helpen. Ten eerste zijn onze producten daarin niet goed gedekt. Die

complexe zorg die wij leveren wordt daar niet in gedekt.” (Hospital B, 2011). According to hospital

H, the encoding of self-referred patients will become questionable; “DOT wordt op basis van

een verwijzing gecodeerd. Als je weet dat éénderde bij ons zelfverwijzers zijn, dan is nog maar de vraag hoe

deze zullen gecodeerd worden.” (Hospital H, 2011).

In conclusion, hospitals state that it is difficult to calculate if the ED is generating money.

The interviewees indicate that in itself the ED constitutes a cost center but also generates

revenue for the hospital via follow-up consultations. Opinions about the implementation

of DOT vary significantly per hospital. Generally, most hospitals do not believe that DOT

will create greater efficiency.

5.6.1.2 Analysis

The following hypothesis was stated in the theoretical framework on the financial system:

Hypothesis 8: it is difficult to determine the profitability of an ED.

According to the literature, the social care system in the Netherlands makes it difficult to

determine the profitability of EDs. There is no DBC code for the ED. Visits to the ED are

incorporated in the DBC codes for specific diagnoses. In precise terms, this means that if

you have appendicitis, a small part of the DBC code is apportioned to a visit to the ED. It

is also stated that the outlay for the costs of ‘readiness’ for and ED and being prepared is

the same regardless of patient volume (Taheri, Butz, Lottenberg, Clawson, & Flint, 2004).

Neither does the literature give a clear perception of the financial situation of EDs in


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general. It is only stated that the low-care unit is profitable in the ED where revenues are

used to finance the medium and high-care units. The only statement that can be found is

that EDs are cost centers that work with budgets.

The results confirm that there is no clear overview of revenues generated by the ED. The

majority of the hospitals indicate that revenues are difficult to calculate because of follow-

up consultations that cannot be traced as revenue for the ED. Follow-up consultations are

booked in under the DBC codes of specialists. The research does not confirm that EDs are

loss-making since the department is generating money for the hospital elsewhere. The

follow-up outpatient consultations do indeed generate money at the specialist level. Only

two hospitals indicate that EDs are loss-making per definition since the ED is itself a cost

center.

In short, hypothesis 8 is confirmed by the literature as well by the results of the research.

However, more research should be conducted in order to reach a general conclusion that

there is no clear overview of ED-generated revenues. A hypothesis for further research

could be:

Hypothesis 8: An emergency department is profitable.

5.7 Patient satisfaction

This section gives an overview of the results of the interviews in the twelve

hospitals. Hypothesis 9 is then tested for validation. Figure 24 on the left

indicates the position of the patient satisfaction variable in the conceptual

model.

5.7.1 Patient satisfaction

5.7.1.1 Results

The nature of the complaints from patients is a reflection of a patient’s satisfaction. This

section will elaborate on the complaints from patients and the role of volunteers in an ED.

Of the three EDs with an annual complaints score under 10, two are EDs with an

integrated HAP (hospitals A and E). For those EDs with complaints amounting to

Figure 24: Position patient satisfaction

variable


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between 20 and 30 annually, there is a plan for an integrated HAP and ED. The most

common complaints are courtesy, communication towards the patient during the entire

process, wrong diagnosis/treatment, waiting times, receiving attention and the supply of

information; “Wat in ieder geval de bedoeling is is dat je bij de triage aangeeft wat de urgentie code is en

hoe lang de wachttijd is. En als ze in het traject zitten, dat ze goed geïnformeerd worden waar ze zitten in

het traject. Als het heel druk is, dan gaat het daar mis […]het gaat om het bakkie koffie, om de

aandacht, om de kleine dingen, om informatie, om hoe ze ontvangen zijn, hoe ze te woord gestaan zijn,

bejegening, voelt de patiënt zich gehoord” (Hospital L, 2011). The interviews have indicated that

the presence of a volunteer or ward assistant, who interacts with the patient and supports

the nurse in certain tasks, has a positive influence on patient satisfaction; “Een gastvrouw

maakt ook deel uit waarom we zo weinig klachten hebben. Zorgt voor patiënt en familie. In piektijden

aanwezig en begeleiden het hele traject” (Hospital A, 2011). Hospital E has won a prize for the

concept of ‘room service’, in which the extras in addition to the expected treatment are

seen as important impetus for satisfaction; “Service is heel belangrijk. De patiënt komt niet voor de

kwaliteit want dat verwacht hij, hij komt voor de extra dingen” (Hospital E, 2011). Hospital G

declared it had experimented with using volunteers, but that reactions were not positive as

the tasks of the volunteers were not well-defined; “Wij werken met vrijwilligers maar het is niet

positief geëvolueerd. Het probleem is dat het moeilijk is om hun takenpakket goed te definiëren. De mensen

komen met de intentie om mensen te helpen maar dan komen ze hier en dan kunnen ze niets of weinig doen

omdat er geen patiënten zijn. Ze willen wel andere dingen doen zoals kamers bijvullen maar dat moet door

een verpleegkundigen gedaan worden. Wij werken ook niet met afdelingsassistenten” (Hospital G, 2011).

To summarize, complaints in the twelve EDs mainly concerned courtesy, communication

towards the patient during the entire process, wrong diagnosis/treatment, waiting times,

receiving attention and the supply of information. The function and effect of volunteers

has been generally experienced as having a positive effect on patient satisfaction.

5.7.1.1Analysis

From the literature the following hypothesis was derived:

Hypothesis 9: verbal communication towards a patient in the ED plays an important role in patient

satisfaction.

Literature can validate hypothesis 9. The CQ index (Consumer Quality Index) has

identified nine important steps that affect the satisfaction of a patient visiting the ED. This

literature has indicated that communication is crucial at all stages and levels within the ED,


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especially concerning waiting times and information and communication between patients

and staff. Research has indicated that patients are also influenced by the patient-nurse or

patient-physician relationship, in which communication, courtesy and building a good

patient-physician relationship are considered as crucial elements in the realization of those

relationships. Communication between patient-staff and between staff themselves has been

pointed out as a frequent area for improvement in patient satisfaction. Also,

communication about the stay at the ED, waiting times, after-care and consistency in the

treatment information were indicated as important verbal communication factors playing a

role in patient satisfaction. Research has indicated the importance of patient-centered care

(PCC), in which communication plays an important role in patient satisfaction. Also, the

presence of volunteers guiding the patients through the process in the ED is seen to

enhance patient satisfaction.

The results of the interviews can also validate hypothesis 9. The interviews revealed

complaints frequently mentioned by patients such as a lack of communication towards the

patient during the entire process, communication relating to waiting times and the supply

of information. Improvements in these domains, as also mentioned in the literature above,

will enhance patient satisfaction. Those interviewees working with a volunteer system

indicated that this has a beneficial effect on patient satisfaction.

In conclusion, hypothesis 9 can be validated by both the literature as well as the results of

the interviews.

5.8 Overview of the hypotheses and their validation

The hypotheses below were validated by both literature and the results of the interviews.

Some hypotheses could be validated, but also required more extensive research. These

hypotheses are stated below, but reformulated for further recommendations:

Hypothesis 1: Hypothesis 1: the layout of the ED affects the long-term success of

its processes.

Hypothesis 3: digitalization of patient data has both a positive and negative effect

on the processes in the ED

Hypothesis 5: the presence of an ED doctor at an ED has more advantages than

disadvantages, but the effect on efficiency at an ED is difficult to substantiate


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Hypothesis 7: waiting time can be reduced by eliminating bottlenecks

Hypothesis 8: An emergency department is profitable

Hypothesis 9: verbal communication towards a patient in the ED plays an

important role in patient satisfaction

Some hypotheses could only be validated partially or not at all by the interviews. Some of

these hypotheses were restated or left in their original state, depending on the validation.

These hypotheses will be further elaborated on in the recommendation for further research

(chapter 6):

Hypothesis 1: an admissions ward has a positive effect on the overcrowding and

throughput of an ED (reformulated from original hypothesis 1)

Hypothesis 2: the integration of a HAP and an ED improves the efficiency and quality

of care at a lower cost

Hypothesis 4: standardized performance indicators enhance the quality of the ED


Hypothesis 8: An emergency department is profitable (reformulated from the original

hypothesis 8)


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6. Conclusion

6.1 Introduction

This chapter presents the answer to the central research question, as well as the answers to

the twelve related sub-research questions. As mentioned in chapter 1, 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 findings, recommendations on the

optimal emergency department can be made for Loek Winter, co-founder of the

MC|Groep. The following central research question is applicable:

Which variables influence the efficiency of an emergency department, and how can these variables be used to


To answer the central research question, the twelve research questions must first be

answered. These are discussed in the following paragraphs, after which the central research

question will be answered. This will be followed by recommendations for Loek Winter (co-

founder MC|Groep) who commissioned the actual research. Finally, the limitations and

recommendations for further research will be discussed.

6.2 Conclusion research questions

The first research question was based on the literature and discussed the definition and

characteristics of an ED. An ED can be classified as a fully operational 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. The Dutch

health inspectorate requires EDs to examine every patient that visits an ED. An ED

provides medical and nurse-related care to patients visiting the ED. These patients enter an

ED with traumas or acute health problems.

The second, third and fourth research questions discussed the definitions relating to

efficiency and optimization and their interrelation. Efficiency refers to the method of

operations and is often referred to in the literature as the efficiency variable. From the

various definitions in the literature, efficiency was defined as ‘the capability to provide and

order a level of service that is sufficient to meet the patients’ healthcare needs, where


86

operations and processes are questioned as to their relevance with a view to achieving

strategic outcomes and where the healthcare resources are used in such a way as to get the

best value for money’. The goal of optimization is to design a system or process as

functional and perfect as possible. Continuous improvement is important as healthcare is in

itself dynamic and it is seen as the progression towards optimization. By continuously

improving and re-determining the efficiency of the system and its individual processes,

progress is made towards an optimal situation. Thus, optimization can be achieved by

making the system and its individual processes as efficient as possible.

The fifth research question identified the variables that contribute to the efficiency of an

ED. Seven variables were extrapolated and identified from the literature; infrastructure,

technology, service, employees, logistics, finance and patient satisfaction. The research

questions relating to these variables will be discussed in the following paragraphs.

The sixth research question discussed the relation between infrastructure and efficiency.

Discussed were the layout of an ED and the presence of a HAP (general practitioners’ co-

operation). The layout of an ED impacts on the efficiency of the processes in and overview

of an ED and so hypothesis 1 could be validated. These processes include the throughput

time and improvements in overcrowding. Literature and interviews have indicated that

physical layout is also shown to have an effect on the efficiency of an ED, especially the

ballroom or linear layouts for the ‘transparency’ of the ED, easy accessibility to the central

nursing station for both patients and staff and also to enhance patient satisfaction. In

addition, uniformity in treatment room layout makes for greater flexibility and ease of

patient placement. The literature stated that centralizing primary processes and placing

secondary processes in the periphery can make ED processes more efficient. Interviews

validated this added there should also be a distinction made between urgent and non-

urgent patients for example by means of a fast-track. Optimal efficiency can also be

achieved by the right location for diagnostic imaging. Hypothesis 2, relating to the

efficiency of integration between the ED and the HAP (general practitioners’ co-operation)

could be validated in the literature, but not through the interviews themselves. Literature

has proven that the efficiency of an integrated ED and HAP lies in the redirection of non-

urgent patients which can in turn also improve the quality of care. However, interviews do

not fully validate the efficiency of an integrated HAP, due to the resistance of general

practitioners and the lack of sufficient specific data from the interviews. Concluding, the

layout has an effect on the processes of throughput time and reducing overcrowding, the


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effect of presence of a HAP and the effect on efficiency have not been validated and will

need to be further investigated.

The seventh research question related to technology and efficiency, in which its positive

and negative effects on the processes of an ED are validated by both literature and

interviews. Technology consists of the digitalization of patient data. Literature and

interviews state that efficiency in the digitalization of data can benefit the following

processes in an ED; data management efficiency, creating more effective and rapid

healthcare, the accessibility of information, a shift to evidence-based medical care,

improvement in the quality of patient care and a reduction in the duplication of data.

Digitalization can save time as it is accessible everywhere, but may also be time-consuming

due to problems in compatibility between systems and codes, the increase in the number of

functions that can be implemented by specialists and loss of data when data is digitalized.

The processes within an ED will become more efficient if digitalization, a paperless system

and a software system are applied in a uniform manner throughout the hospital. Efficiency

in the latter is seen as contributing to a more efficient and cost-effective way of accessing

information and minimizing medical errors.

Research question eight elaborated on the quality and performance indicators. The impact

of these indicators on efficiency issues could not be validated by the interviews. Literature

has however indicated that standardized performance indicators enhance the quality of the

ED, as they create transparency and make national comparisons between EDs easier. Thus

the effectiveness and quality of an ED can be measured, bottlenecks can be identified and

improved and where possible resolved to make for greater efficiency throughout the ED.

Quality and performance indicators for the EDs in the Netherlands have not yet been

standardized, thus no conclusion can be reached as to their effect on the efficiency of the

processes within the EDs. Quality in an ED is maintained through other internal and

external quality management systems, where the internal systems are developed by the

hospitals themselves.

Research question nine elaborated on the relation between the presence of an emergency

department (ED) doctor and the impact on the ED’s efficiency. Literature and interviews

alike have revealed more advantages than disadvantages when there is an ED doctor

present. The benefits of the presence of an ED doctor in relation to the efficiency of an

ED can be summed up as follows: time savings in terms of speed and number of


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diagnostic tests, reduction in waiting and turnaround times, no need for repeated

consultations with other specialists and time for policy-making. Disadvantages mentioned

were the time lost in the supervision of doctor assistants and the generalist nature of an ED

doctor compared to the specialists consulted by an ED. Interviews have indicated that in

the Netherlands, the beneficial effect of the presence of an ED-dedicated doctor on the

efficiency in an ED is difficult to measure, in view of the scarcity of ED doctors

themselves, the shortage of ED doctors in full ED employment plus the lack of uniformity

in training programs.

The tenth research question covered the logistics of an ED, divided into triage systems and

waiting times. According to the literature, the efficiency of triage systems lies in the

following processes; reduction in waiting-room times, prioritization of care and the correct

placement and allocation of patients. The Manchester Triage System (MTS) is considered

the triage system as having being the most compatible with EDs in the Netherlands as per

the literature and as reflected in the fact that most of the interviewed EDs were using the

MTS system. However, the effect of a triage system on the efficiency of the processes in

the ED did not become apparent during the interviews themselves. Concerning waiting

times, both the literature and interviews have indicated that waiting times can be cut by

eradicating bottlenecks in those ED processes that affect waiting time. Bottlenecks

mentioned were the absence of diagnostic equipment located in the ED, dependency on

specialists outside the ED, supervision of inexperienced doctor assistants, extra

consultations due to non-specific patients and patient admissions procedure. Bottlenecks

can be identified and reduced by using the Theory of Constraints (TOC). The

implementation of this theory can enhance the processes within the ED.

Research question eleven focuses on the financial system in an ED. Both the literature and

the interviews have shown that the determination of the profitability of an ED in the

Netherlands is difficult. DBC codes for the ED are incorporated in the DBC codes for a

diagnosis, thereby resulting in the non-transparency of ED visit costs. Low-care units

finance the medium and high-care units. 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.

The last research question explored the relation between patient satisfaction and efficiency.


89

Efficiency in the processes in an ED resulted in less complaints and a lack of efficiency led

to more complaints by patients. Here, verbal communication plays an important role,

especially with regard to waiting times, the communication of information and the relation

between patient and ED staff. These are areas where major improvements can be made.

Verbal communication during the stay at the ED, after care and consistency in the

information about treatment are also important factors contributing to patient satisfaction.

By tackling the bottlenecks and the inefficiencies, patient satisfaction can be improved and

the number of complaints reduced. The importance of verbal communication will become

more important in the 21st century owing to the new focus on Patient-Centered Care

(PCC). The use of volunteers has proven to be a useful way to improve communication

towards patients and between patient and staff.

All the research questions have now been answered. The answer to the central research

question will be presented in the following paragraph.

6.3 Conclusion central research question

Efficiency can be seen as the various steps needed to achieve an optimal situation. In this

paper, the definition of efficiency was defined as ‘providing and commissioning a level of

service that is sufficient to meet a patient’s healthcare needs, where operations and

processes are questioned and investigated as to their relevance to achieve the strategic

outcomes and where healthcare resources are used in such a way as to get the best value for

money’. Seven variables were identified as having an influence on the processes in an ED,

thereby influencing its efficiency; infrastructure, technology, service, employees, logistics,

finance and patient satisfaction. The manner in which these variables affect efficiency was

expounded in the previous paragraph in which the research questions were answered.

However, to create an optimal ED by using the seven variables, these variables must be

manipulated and used in such a way as to maximize their efficiency within the ED in

relation to the processes associated with those individual variables. Only when the

processes are implemented efficiently will it be possible to develop an optimal ED.

Continuous on-going improvement is vital. Only by first determining and then

continuously improving a system’s efficiency and its individual processes, can progress

towards an optimal situation be achieved. This is where the Theory of Constraints (TOC)

can contribute to reducing bottlenecks and make for a more efficient, effective and optimal

ED which is indeed the ultimate goal (of this paper). From a patient perspective, the


90

Patient Centered Care (PCC) should be adopted to improve patient satisfaction, as this is

becoming increasingly important in the 21st century. It must be noted however that the

optimal ED does not exist and is dependent on different factors. An ED can be designed

as optimal as possible, only when taking into account the resources, culture and location of

that individual ED.

To answer the central research question in short; literature has shown that the efficiency of

an ED is influenced by seven variables and when manipulated in a different ways can add

to an optimum situation in the ED. However, not all of these seven variables could be

validated by the results of the interviews and should therefore be investigated in further

research. The optimal ED does not exist, as resources, culture and location of the

individual ED must be taken into account when designing the optimal ED. In turn, the

seven variables must be manipulated in an ED on an individual level accordingly.

6.4 Recommendations for the MC|Groep

In the light of the answers to the central research and twelve sub-research questions, the

following recommendations can be posed for Loek Winter (co-founder of the MC|Groep).

ED layout – It is recommended to pay sufficient attention to ED layout, taking into

account both physical layout and general appearance. Not only does layout impact on

ED’s processes, but also on patient satisfaction. A ballroom setting is recommended to

create visibility, accessibility, overview and transparency for both patients and ED staff.

Also, uniformity of treatment room layout, makes for flexibility in the placement of

patients. Additionally, separating out the central and peripheral processes, as well as urgent

and non-urgent patients, will add to the efficiency of an ED.

Digitalization of data – It is recommended to use a uniform software system throughout

the hospital and digitalize all patient data to make for a more efficient and cost-effective

method of accessing information and minimizing medical errors.

ED doctor – Although it is difficult to measure the effects of efficiency to date, the

benefits extrapolated from the interviews became apparent. A pilot should be initiated to

test the effects of the ED doctor within the ED itself.

Waiting time – If not already implemented, it is recommended to use of the Theory of

Constraints (TOC) to identify bottleneck and enhance the processes within the ED,


91

including the reduction of waiting times.

Finances - EDs are seen as costly, mainly due to the consequences of their permanent

availability function. Before embarking on the process of making the ED more efficient, a

clear overview of the costs and revenues should be obtained. By so doing, those areas that

are costly can be identified and further research conducted to investigate how to make the

process more efficient whilst reducing costs. As the ED yields revenue for the hospital

through patient admissions and follow-up consultations, it is also recommended to pay

sufficient attention to patient satisfaction.

Communication – As verbal communication towards a patient in the ED plays an

important role in patient satisfaction, this area should be continuously evaluated and

improved. Patient-Centered Care (PCC) will become increasingly important in the 21st

century, especially the relation between patients and ED staff. Besides verbal

communication, it is recommended to create a physical layout in the ED that provides

enough facilities for the patient as well as offering a clean and bright appearance.

Overall, it should be born in mind that the optimal ED does not exist. Yet, an ED can be

optimized to its maximum extent by introducing the seven variables as efficiently as

possible. In this process, the particular circumstances of the MC|Groep should be taken

into consideration and only those variables that add value to the ED incorporated. Finally,

the recommendations mentioned in section 6.6 in which the hypotheses have not as yet

been validated, should be taken into account. Further research on these particular

hypotheses could be conducted by the MC|Groep itself, or an external party.

6.5 Limitations

This section discusses the limitations of this research paper. Starting with the limitations of

the methodology used, followed by the limitations relating to the theoretical framework

and lastly the limitations of data availability.

The first limitation relates to the methodology used. Not every hospital in the Netherlands

has been interviewed and not every hospital wanted to co-operate, thereby restricting the

population for the actual research. Qualitative research also limits research outcomes. It

would have been preferable to include quantitative research based on financial data had this

been possible. A further limitation is reflected in the answers given by the interviewees

during the interviews. Some of these might have been desirable from a social angle. Certain


92

questions were not answered fully, as the interviewees might not have wanted to provide all

the information requested by the researchers. Consequently, not all data was available for

analysis. Some interviewees could not answer all the questions precisely, resulting in gaps in

the data. This could be attributed to interviewees who might not have been in their

position for long or lacked the necessary background information. It was not possible to

gather the missing information after the interviews. The translation of Dutch interviews

into an English matrix in Excel could have an bearing on the content of the data. Such a

situation would not have arisen if the interviews had been conducted in English.

Theoretical research also has limitations. Time constraints made it impossible to research

each variable extensively. Certain data was not researched sufficiently or the outcomes were

indecisive as in the case of acute admission wards (AOA). Data might also have been lost

during the transfer from the memo recorder to the actual writing up of the interviews, as

well as transferring data from the interview summaries into Excel. Interviews facilitated the

gathering of extensive information, but misinterpretations is always a possibility when

processing data. It is difficult to eradicate such an effect. The optimal ED as recommended

in this paper cannot be applies to each ED, which must appraise its own situation and

adapt the optimal ED to its individual circumstances and capacities.

6.6 Recommendations for further research

This section will elaborate on the recommendations for further research, based on the

hypotheses that could only partially validated or not at all by the results of the interviews:

Hypothesis 1: an admissions ward has a positive effect on the overcrowding and

throughput of an ED (reformulated from original hypothesis 1)

Hypothesis 2: the integration of a HAP and an ED improves the efficiency and

quality of care at a lower cost

Hypothesis 4: standardized performance indicators enhance the quality of the ED


Hypothesis 8: an emergency department is profitable (reformulated from the

original hypothesis 8)

Hypothesis 1 above was derived from the original hypothesis 1; ‘the layout of an

emergency department (ED) has an effect on the long-term success of its processes’.

Although the latter hypothesis was validated by both the literature and the results from the


93

interviews, the interviews indicated a preference for the presence of an acute admissions

ward (AOA). The presence of an AOA was not researched in the literature, thus no

conclusion could be reached in this respect in the paper. A recommendation would be to

conduct specific research on the impact of an AOA on the efficiency of an ED.

Hypotheses 2, 4 and 6 were stated in literature to as having a beneficial effect on ED

efficiency. However, further research should conduct further investigate as to the impact of

the presence of a HAP on ED efficiency and cost. As this could not be substantiated via

the results of the interviews. Hypothesis 4 could give rise to comparative research in the

future, where the current effects of the efficiency of an ED are compared with a future

situation. Future situation defined as the moment standardized ED performance indicators

are introduced. Recommendations for hypothesis 6 could be in-depth research on the

efficiency of a triage system.

Finally, the newly formulated hypothesis 8 was derived from hypothesis 8 as originally

posed; ‘it is difficult to determine the profitability of an ED’. Although both literature and

the results of the interviews validated original hypothesis 8, more research should be

conducted on the specific aspects of the financial system within an ED. Generally, the ED

is thought to be loss-making due to its permanent availability function. However, facts and

figures on the real costs and revenues are lacking. Further research designed to make for

greater transparency and precision would therefore contribute to optimizing efficiency and

cost-effective healthcare.


94

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ED.

msc thesis "optimization of emergency departments in the netherlands"

Health & Medicine