چكيده به لاتين
Emergency systems of the hospital are considered as one of the most important centers for rendering medical services, where patients with critical conditions who need urgent medical cares are admitted. One of the major risks of the treatment domain is the inefficiency of the emergency wards in rendering timely services to the emergency patients due to the overcrowding, congestion, long waiting time and long staying of the patients in the ward.
The present research has focused on improvement of efficiency of emergency systems through identification of the inefficiency factors of the ward and their impacts on the system and suggestion of mechanisms toward improvement of these factors. The first step of the research deals with recognition of these factors, their impacts on medical systems and recommended mechanisms in the course of time with the purpose of improving these negative impacts. To this end and upon examination of the previous studies, all the findings have been classified within a systematic framework consisting of independent variables as the causes of decreasing the efficiency of emergency wards; dependent variables or effects as the issues and problems which are the outcomes of the inefficiency in emergency ward; mechanisms as encounters with difficulties and inefficiencies of emergency wards in the previous researches; and ultimately, indexes of efficiency measurement as a tool for measurement of the efficiency or inefficiency of the system.
To define the issue, two emergency wards of Imam Khomeini Hospital and Dr. Shariati Hospital were chosen and put in the agenda from among all the emergency wards in Tehran as the case study during a non-probable sampling and a combination of targeted and easily obtainable sampling. An approach to improve the efficiency of hospital systems was put in the agenda based on the plans compiled by the Ministry of Health, Treatment and Medical Education within the Health Development Project under the title of development and optimization of the emergency ward of Dr. Shariati Hospital and construction of the new emergency ward of Imam Khomeini Hospital (Mahdi Clinic).
The main objective of defining the two above-mentioned projects is to introduce a general framework along with local mechanisms to improve the efficiency of the emergency ward and efficacy of the previously routine methods in the face of planning, designing and re-designing of treatment spaces. In the course of achievement of the afore-mentioned objectives the research was faced with three essential questions: What are the biggest bottlenecks of the ward which hinder the optimal execution of the treatment processes and what are the effects of these bottlenecks on the efficiency of the ward and standard indexes? What plan and design mechanisms do help to control and solve these bottlenecks and what kind of effects do these mechanisms leave on the current processes of the ward and the indexes of measuring their efficiency and what economic load do they put on the medical system?; and ultimately, what are the best mechanisms to control and solve the bottlenecks in consideration of the weight of the indexes and the costs they impose on the system?
To achieve the objectives and to answer the questions asked in the research both the quantitative and qualitative research methodology as well as the main method of “simulation of system behavior based on the mathematical algorithms” has been used in view of the types of variables. From the point of view of the objective it is an applied research toward improvement of efficiency of the emergency ward within a particular period of time. Depending on the objective of the research, content analysis method, Delphi method, survey method to discover the characteristics, method of distribution of the statistical community and comparative causal method toward perception of the quantitative relation between cause and effect and influence of the change of variables with numerical values on the effect through behavior simulation and multi-standard decision making systems have been used in different stages.
In order to identify the mechanisms of efficiency rise and the measurement indexes in this research all the mechanisms and indexes proposed in the previous similar researches were extracted and by means of the Delphi method seven mechanisms, namely: “Establishment of split procedure flows for different patients with different intensity grades of illness toward traffic management of entries of the department along with establishment of subsidiary and internal spaces for these split flows to control the non-return to the main waiting spaces and their interference with each other (split flow and sub-waiting/internal waiting area); “planning for an express care unit”; “planning for a discharge lounge”; “planning for an intensive care unit at the emergency department”; “planning for an observation unit”; “Planning for a trauma unit”; ”planning for a holding area”; and four indications, namely, “Bed occupancy rate”; ”period of time between completion of triage and the beginning of the first visit by the doctor (triage to doctor time); “Bed turnover rate”; and “period of stay of patients at the department (length of stay); together with economic indexes including “ cost of capital and semi-capital equipments of the department”, “number of human resources needed by the department”, and “amount of profits the department should yield” were selected. Based on the introduced mechanisms, in consideration of the strategic and long-term planning of the emergency department toward future changes and orientations, and through different combinations of the selected mechanisms 6 scenarios for improvement of the efficiency of the emergency department of Dr. Shariati Hospital within its development and renovation project, and 4 scenarios for improvement of the efficiency of the emergency department of Imam Khomeini Hospital in its new site were put to trial and their impacts on the efficiency of the departments were measured. The proposed quantitative indexes serve as the basis of the measurement of the system efficiency.
The numerical indexes extracted from the simulation model were pluralized upon exerting process changes in relation with each mechanism so that the most optimized mechanism would be selected and executed in consideration of the weight of the indexes and economic standards within the process of multi-standard decision making AHP and Topsis. When indexes were obtained from execution of the simulation models, the sixth scenario for the emergency department of Dr. Shriati Hospital with combination of the mechanisms of “establishment of split procedure flows for different patients with different intensity of illnesses toward traffic management of entries to the department along with establishment of subsidiary and internal spaces for these split flows to control the non-return of patients to the main waiting spaces and interference with each other”; “planning for trauma unit”; “planning for express care”; planning for discharge lounge”; and planning for observation unit” with a decrease of 20 percent in the index of period of stay of patients in the department along with lower expenses in resources and equipments as the superior scenario comparing with the other scenarios; and the third scenario for the emergency department of Imam Khomeini hospital with combination of the mechanisms of “establishment of split procedural currents for different patients with different intensity of illnesses toward traffic management of entries to the department along with establishment of subsidiary and internal for these split flows to control the non-return of patients to the main waiting spaces and interference with each other”; “planning for trauma unit”; “planning for intensive care unit“; “planning for express care”; planning for discharge lounge”; and planning for observation unit” with a decrease of 41 percent in the period of stay of patients were selected as the superior scenario.
