Since the establishment of the Hospital Authority (HA), there has always been a conscious effort to improve the quality of services provided, while at the same time, making every effort to ensure efficiency and cost effectiveness. In 1993, the concept of productivity gains was introduced and by 1995, hospitals were required to quantify the notional savings achieved through CQI (Continuous Quality Improvement) or re-engineering and to identify how the savings could be used to implement new services or improve existing services. Some of the successful programmes implemented included re-organisation of domestic and cleansing services, rationalisation of laundry services and re-engineering of nursing practice, etc.  

With the formal launch of the Enhanced Productivity Programme (EPP) announced by the HKSAR Chief Executive in his 1998 Policy Address, the HA, like Government bureaux and departments and other subvented bodies, is required to achieve 5% savings over the operating expenditure in real dollar terms by 2002-03.  

To meet this new challenge, the HA has decided to make a headstart to require 1% real savings in the current financial year i.e. 1999-2000. By this means, a sum of money will be available centrally to fund an "Invest to Save" Programme over the next 2 years. Hospitals will be bidding for seed money from the "Invest to Save" capital to finance projects which can realise real recurrent savings in the future provided that the pay back period is within 5 years. 
 

The Pamela Youde Nethersole Eastern Hospital (PYNEH) has implemented various measures to achieve the EPP targets. What the PYNEH has undergone is not unique. All the 40 odd hospitals under the HA have adopted various measures to achieve productivity savings.  

The most important step for successful implementation of enhanced productivity with sustained or improved quality is to institute the correct culture and core values for the organisation and its staff. At the PYNEH, we have achieved this by introducing our hospital mission, core values, goals and a new management philosophy. The new culture of our hospital is modeled after that of the HA which emphasises patient-centred quality care, team work, accountability, efficiency and cost effectiveness.  

The management philosophy for our hospital is that every staff in every department must do their best to support the core services i.e. providing direct health care for the patients. Every staff must be aware of how their role in the hospital contributes to patient care. If they are not involved in direct patient care, they must identify their internal customers and explore ways to serve them better so as to release valuable time for the health care professionals such as doctors and nurses to serve their patients better.  

We have adopted EIGHT strategies to achieve higher productivity. Catering services are used as a case study to illustrate the application of these strategies. 

1.Restructuring of Services   

Previously, dietitians managed food purchase and food production, hospital foremen organised food trolley distribution, while nursing officers managed tray preparation, portioning, tray distribution and collection, dishwashing and even waste disposal. After restructuring, the entire food chain is managed by the catering manager. As a result, we have achieved better accountability and control of service standards, as well as higher efficiency. Figures 1a and 1b illustrated what happened before and after restructuring.  
 

Figure 1a

Figure 1b

To enable successful role re-delineation, detailed job analysis of various ranks and grades must be done first. A survey of the activities of nurses discovered that 28% of their duty hours were spent in doing non-nursing activities such as catering (15%), managing drug stock (5%) and housekeeping (5%), etc. By re-delineating the role of nurses, we have successfully released nurses from all non-nursing activities. You can see from Figure 2 that after role re-delineating, nurses concentrate on patient care duties. 

Figure 2

Departments are required to review all their processes and devise better and more cost effective ways to do the work. To quote one example, we have implemented ISO 9001 quality system together with the HACCP system - HACCP stands for Hazard Analysis of Critical Control Points - an internationally recognised system for Food Safety. By careful redesign, documentation of work processes and by putting in adequate controls at critical points, we could achieve higher standards of food quality and safety as well as more cost-effective use of resources.  

4. Use of Modern Technology   

Significant productivity gains can be achieved by using modern technology. In the catering example, we have adopted a computerised system to automate manual processes for diet order, nutrient analysis, menu planning and production. We have also invested in a lot of automated equipment to assist central food plating, dishwashing and waste disposal. The two pictures below show the use of tray belt for central plating and the central dishwasher. This dishwasher, together with only 3 workmen, can wash and dry all the utensils for the whole hospital in 2 hours.  

Tray Belt for Central Plating 

Central Dishwasher 

Since 1998, we have adopted a new cook-chill system to replace conventional cooking for the production of high quality food in large quantities. With this technique, the food is cooked to the peak of flavor, packaged at pasteurisation temperature and rapidly chilled to 3C. Food produced in this way can be stored up to 4 weeks. Therefore, without any increase in manpower, we are able to triple our production capacity.  

5. Economy in Resources Utilisation    

Even before the implementation of cook-chill technique, we had been able to achieve greater economy in the use of manpower resources. Before we restructured the catering team, there was a significant amount of idle time for the catering staff in-between meals of 20% to 40%. After restructuring and role re-delineation, the catering staff also took up meals plating, meal service, trolley distribution and dishwashing so that idle time had been reduced to 5%. After adopting the cook-chill technique, idle time has now been reduced to zero because we are also cooking for receptor hospitals as shown in Figures 3a & 3b.

As a result, total cost per meal day has decreased from $47.2 in 1993 to $27.2 in 1998 while the number of meals produced per staff per day has increased from 32 in 1993 to 92 in 1998 - an almost 3-fold increase.  

Figure 3a

Figure 3b

We require staff from various disciplines to come together and work out different processes required to bring the right meal to the right patient in an integrated and seamless manner. Now, doctors, nurses, dietitians and catering staff all utilise the Dietetics and Catering Computer software to ensure an integrated and efficient workflow.  

7. Collaboration with Cluster/ HA Hospitals   

Due to the increased food production capacity, we are able to collaborate with other HA hospitals to provide cook-chilled food to 5 other hospitals, namely Cheshire Home (Chung Hom Kok), Fung Yiu King, Our Lady of Maryknoll, Bradbury Hospice and Nam Long Hospital. Through the "Invest to Save" Programme, we have obtained funding to further increase our production capacity and more receptor hospitals will join in the future.  

8. Partnership with Outside Organisations  

Finally, if HA does proceed with the plan to build a large central food production centre, we may have spare capacity to produce food for outside organisations. By teaming up with outside organisations, our capacity can be utilised to the full.  

Master Plan  

The above demonstrates how we achieve productivity gains in respect of catering services. To respond to the challenge of EPP, we have worked out a master plan to achieve 5% reduction in our recurrent budget by 2002-03, amounting to $60 million (Figure 4).  

Through the revenue generation programme in food production, X-ray equipment maintenance, laboratory automation and rental charges, we aim to achieve $10.5 million savings. Energy conservation programme will yield $10 million, terminating our management contracts for housekeeping and transportation will achieve $ 6 million, reduction in improvement works budget, another $10 million savings. By implementing supply chain management, we hope to achieve $11.5 million savings and by contracting out housekeeping services in common areas, we will realise $2 million savings. Reduction in administrative overheads-particularly targeting facilities and equipment maintenance and consumption of consumables will also bring about $10 million savings. We are confident that we will be able to deliver the EPP targets.  

Productivity Plus Quality  

There may be some concern that productivity savings are achieved at the expense of quality. This proves to be unfounded because in tandem with the increase in efficiency, we have in fact been able to improve and maintain the quality of our services. This is reflected by the number of complaints and appreciations received. In 1998, we received per 10 000 discharges, 47.58 appreciations and 0.83 complaints, which is better than the HA's average of 18.73 appreciations and 1.76 complaints.  

In conclusion, with concerted efforts to develop the culture and capabilities of our staff, by careful planning and change implementation, enhanced productivity can be achieved with sustained and even increase in quality of services provided. 
 

Figure 4