Going Solo
The transformation of Africa’s biggest hospital is being closely watched by the Gauteng Department of Health, Department of Public Service and Administration and trade unions to see whether it can be a model for change countrywide.
Empowering the hospital CEO and clinicians to take control over the operation of Chris Hani Baragwanath is at the heart of the project, with the hospital’s massive surgical division acting as the guinea pig for new operating system.
A few months back, the Gauteng Health Department made the country’s first ever appointment of a hospital CEO with decentralised powers to appoint his own staff and draw up his own budget, when it appointed Arthur Manning.
The CEO’s lack of power, with the province retaining control over virtually all operations, has been a key frustration for those seeking to transform the massive 2 800-bed hospital.
‘The delegation of power [from the province] to the CEO are being further delegated down to the surgical division so that it can take control of procurement, budgeting and cost control, human resources and so on,’ says Karl von Holdt, one of the consultants working on the project.
This is only possible because of the willingness of the new MEC, Brian Hlongwa, to adopt an ambitious vision and take bold steps to support it, according to Von Holdt.
The surgical division, with 700 beds over 15 wards, is the size of a medium sized hospital itself.
‘We are now going full speed implementing the new model of empowered and integrated management in the surgical division, with the number one priority being supporting improved patient care and clinical outcomes, number two priority improving work satisfaction,’ say Von Holdt.
The idea, says Von Holdt, is that ‘nurses and clinicians are being empowered to take control of the clinical and healthcare domains and manage them effectively’.
At present, healthcare at the unwieldy Chris Hani Baragwanath Hospital is ‘a bit of a hit and miss’, ranging from top-class to life-threatening care, according to one of the hospital’s top medical officers.
‘You can have operations here that you would have in the best hospitals in the world,’ says Professor Martin Smith, head of the surgical division and the transformation project.
‘But if you get here on the wrong day, when there are not enough nurses in the ward, or you don’t have a bed, or your operation gets cancelled or you get managed by someone who isn’t skilled enough to look after you, or the lab hasn’t done the blood results properly, you’re endangering your life.’
Earlier this year, healthworkers took desperate measures to save CHB’s transformation project, started in 2001 but stymied by government’s failure to release R10-million it had promised to fund the changes.
Protests organised by the National Education, Health and Allied Workers Union (Nehawu) were supported by virtually all CHB staff, from professors to porters.
At a march, Professor Rudo Mathivha, chairperson of the CHB transformation forum, said that staff would ‘no longer keep quiet about the state of the hospital’.
Since the protests, the Gauteng health department has released R5-million and appointed trade union think-tank Naledi to manage the transformation for a year.
Von Holdt, who is part of Naledi, says that the project is back on track and going at full speed.
CHB’s main problems are staff shortages (about a third of posts are vacant), huge workloads for health workers, dysfunctional management and a completely inadequate budget.
‘We’ve recognised for many years at the hospital that the quality of care and the clinical outcomes have not been what we believe is appropriate and adequate,’ says Smith. ‘Everything we’re trying to do [with the transformation project] is to improve patient care.’
The overall aims of the project, supported by all staff including management, are four-fold:
- to ensure that the Gauteng health department delegates enough power to the hospital managers to enable them to fulfil their responsibilities.
- to develop a human resource strategy to support and develop overburdened staff.
- to reorganise wards and departments to ensure that staff ‘ management, doctors, nurses and support staff ‘ work together as one unit, rather than in ‘silos’
- to ensure that the budget is sufficient, based on the needs of the hospital not on what has been allocated historically to CHB.
The budget is a sore point, with apartheid-era inequalities still plaguing CHB, according to Karl von Holdt, from the trade union think-tank Naledi.
‘CHB’s budget [two years back] had about R330 000 per bed per annum. But Johannesburg General has a budget of about R730 000 per bed per annum, which is more than double,’ says Von Holdt, whohas been involved in the project from the start.
‘What we are seeing is simply the perpetuation of the apartheid budgetary legacy where a formerly black hospital receives roughly half the budget of a formerly white hospital.
‘The net result is that poor patients who go to CHB really can expect a lower level of treatment because there’s fewer staff to treat them, there’s less resources, less equipment, and so on. And this is an untenable situation.
‘What it means is that staff are working under appalling workloads, impossible workloads, staff are burnt-out, demoralised, frustrated and they can’t work to full capacity and many of them resign and leave.’
A number of dramatic changes have taken place in the surgical division, the most important being the appointment of 100 additional nurses funded from vacant posts in the hospital.
‘We were able to open the band of payments, so if people had skills that we thought warranted a slightly higher salary, we were empowered to offer them that,’ says Smith.
Sister Ruth Kgesa, chief professional nurse in surgery, says that the additional nurses have meant that ‘there’s hope at the end of the tunnel’.
‘We are now, at least, doing what we are supposed to do as professional nurses as compared to last time where we found ourselves doing non-nursing duties that had a negative impact on patient care,’ says Kgesa.
Smith believes that the changes in the surgery department have made patient care ‘far better’.
‘We have nurses doing ward rounds with doctors now. In the past, this didn’t happen because there weren’t enough nurses. They were too busy doing mundane things that were either unrelated to nursing such as feeding and carrying patients.’
But Fikile Majola, General-Secretary of Nehawu, says there is still a long way to go.
‘What is sad is we still have patients sleeping on the floors here,’ says Majola. ‘Patients are being sent back home when they have not been properly treated because they can’t be kept in the hospital because of shortage of staff and other equipment. We still have very long queues, and it is because there’s more than 70 percent vacancy rate of pharmacists in this hospital.’
In addition, there are only 18 intensive care unit (ICU) beds and 8 high-care beds that are always full and doctors fight with each other for these, yet Mathivha says ‘we actually need about 200 critical care beds’.
The effect of staff shortages and the massive patient load on those working at CHB have been studied by Professor Helen Schneider of the Wits School of Public Health.
Schneider and her team observed the hospital’s medical and paediatric departments for six weeks.
They found that one in five patients admitted to the medical ward died. About 44% of admissions were HIV-related, and about a quarter of HIV positive patients died.
In the paediatric wards, about one third of admissions were related to HIV and about one in 10 little patients died. A quarter of HIV positive children died.
‘This, by any standards is a very, very high mortality rate,’ said Schneider.
‘Part of the reason for that is the HIV epidemic and an absolute shortage of beds,’ she said.
‘With time, what has happened is that the hospital selects the most ill people for admission. Everyone with a milder illness has been shifted to an out-patients service. So, if you’ve got a mild pneumonia or even a mild heart-attack your chances of being admitted now are very slim.’
Using an international measure for burnout, Schneider found that one in six doctors (out of 57) in the medical wards reported high levels of burnout while one in six of the nurses (out of 207) reported emotional exhaustion.
‘I think the HIV-related component of it and the very, very high experience of death and dying has a very big part to play in high experiences of burnout,’ said Schneider.
For a number of years, the province has planned to build district hospitals to alleviate the pressure on CHB, but until that happens staff will continue to feel the pressure of working in one of the busiest hospitals on the continent.
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