An evaluation of an enterprise framework for performance improvement in the Emergency Department of a rural District General Hospital

• Main Author: Turner, Paul
• Published: University of Lincoln 2016
• Subjects: L431 Health Policy
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.692529

An Enterprise Culture, which looks to replicate improvements to quality and efficiency demonstrated in the private sector, has evolved from health care policy in the English NHS. The aims of this research were to explore the theory underpinning the application of the policy and to challenge and test if the Enterprise Culture has provided a framework for performance improvement in a rural District General Hospital (DGH). The evolution and characteristics of the Enterprise Culture resulting from the convergence of political policy relating to health care revealed a centralised command and control approach to performance expectations and a decentralised means of achieving them through managers and competitive markets. Using a mixed methodology with a dominant quantitative, less dominant qualitative emphasis, this research examined the theory through a critical comparison of the Enterprise Culture present in a single case study of a rural DGH with the Purpose, Process, People (PPP) framework which has led to private sector success. Firstly, the study looked to understand the nature of the central Enterprise Culture target for hospital emergency care: that patients spend less than four hours in the Emergency Department. A quantitative analysis of service demand from patients found that attendance patterns offered opportunity to use PPP techniques to meet the four hour target, but that greater data availability would be necessary to make detailed calculations. A quantitative analysis of the resources provided revealed that capacity was not calculated, planned or monitored to meet demand. Furthermore, an ethnographic study of the operational activities of the hospital’s emergency care system uncovered a lack of defined process and competent actors, departmental barriers and reactionary decisions leading to poor performance against the four hour wait target. Secondly, an intervention was introduced to examine the Enterprise Culture’s ability to generate efficiency and quality improvements. The intervention (care plans and drug chart provision for patients who required clinical observation) addressed a need, specific to the case site and was identified and implemented by clinicians and managers within the hospital’s emergency care system. Practical barriers to conducting research in rural a DGH were encountered during the intervention and its evaluation. The intervention 2 also revealed that although the Enterprise Culture enabled an improvement intervention to meet local needs, pressure from the central target and the competence of people enacting the process did not support its continued efficacy. In conclusion, in my contributions to subject knowledge, I argue that the Enterprise Culture present in the case site does not support the policy aims for generating quality and efficiency. The central four hour target remains too influential and causes reactionary operational activities. Processes and staff competent in following them are not adequate to meet the demands placed on the service of the emergency care system studied. Finally, the whole emergency care system has a great influence on the Emergency Department’s performance and should be considered when evaluating its performance and decisions about service structure.