# Why go to A@E with flue



## W200 (27 Jan 2016)

I see today that Leo Veradker warned that patient levels in A@E will peak within the next two weeks due to the high FLUE levels . Now I have absolutely no medical qualifications but why do the terms A@E and FLUE appear in the same sentence much less in the same location


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## Purple (27 Jan 2016)

I agree. If people went to their GP before they got very bad then there should be far less need for attending A&E.


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## Thirsty (27 Jan 2016)

> FLUE


Chimney repairs?


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## Leo (27 Jan 2016)

If you have a condition such as CF, compromised immunity, etc., then flu can be life threatening.

That said, still too many people see A&E as an easy option.


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## Purple (27 Jan 2016)

Thirsty said:


> Chimney repairs?


In that context it makes it even harder to understand!


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## W200 (27 Jan 2016)

Thirsty said:


> Chimney repairs?



Think I was off sick with flu when I should have been learning to spell in school


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## Purple (27 Jan 2016)

W200 said:


> Think I was off sick with flu when I should have been learning to spell in school


Just blame spell check like the rest of us.


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## Thirsty (27 Jan 2016)

@W200 - this is 'letting off steam'  - don't take it to heart, only a bit of fun


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## Leper (29 Jan 2016)

'Flu in A + E?, fair question.  Many GP's do not operate after 8.00pm.  You have a medical card and think you have the 'flu; go to A + E, sure it won't cost you anything and you have a chance of appearing on the News.


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## Purple (29 Jan 2016)

Leper said:


> 'Flu in A + E?, fair question.  Many GP's do not operate after 8.00pm.  You have a medical card and think you have the 'flu; go to A + E, sure it won't cost you anything and you have a chance of appearing on the News.


That's your most cynical post ever (I love it!).


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## W200 (29 Jan 2016)

An interesting statistic to obtain would be the numbers that ATTEND A@E as opposed to those that are ADMITTED or told to return for further treatment


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## Purple (29 Jan 2016)

W200 said:


> An interesting statistic to obtain would be the numbers that ATTEND A@E as opposed to those that are ADMITTED or told to return for further treatment


Plenty of people who attend A&E but are not admitted should still be there.

Broken bones, cuts which require stitching (and yes, I know GP’s should do that), knocks on the head which may be concussion, sick children who need fluids and an anti-biotic (and yes, I know GP’s should do that as well) etc can all be treated and released without admission.


Most of what presents at A&E departments should be treatable at primary care units but Irish GP’s, despite all the sanctimonious moaning from them, do not do nearly as much as their counterparts in the UK or most of Western Europe.


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## geri (29 Jan 2016)

In my experience, GP's prescribe antiobiotics or write referral letter to hospitals.


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## johnwilliams (29 Jan 2016)

geri I agree
we had a gp years ago ,would check you over and solve problem there and then so to speak
current gp sits in front of computer, swear he is googling for the answer for whats wrong


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## Leper (30 Jan 2016)

Regarding of who should attend at A&E, especially for 'flu like symptoms we need to change the way we think of our entire health system.  When we lived in Spain, the first port of call when you were sick was the local pharmacy.  The pharmacist would speak with you (and with extensive local knowledge) immediately know what you needed.  Without prescription from a GP you would be supplied with whatever was required.  You paid for what was supplied, went home and probably cured within a few days.  Only if the XXXXXXXXXXXXXXXXXXXX/syrup didn't work were you to attend the local GP. This appears to be working for many years in Spain. OK! Over the past few years medical people in this part of europe are trying to ensure the system in Spain is changed. It's all about money.

Years ago, we (in Ireland) were promised that we would have nurses who could write prescriptions for patients.  This was challenged strongly by our doctors.  Of course, their power was being somewhat reduced and their earning power reduced.  I see no reason why our pharmacists in the pharmacies could not be used to a greater extent.  They cost less, cure more and have the confidence of many. 

So, until we have a great change of mindset we continue to visit bacteria infested A & E facilities where we have a greater chance of becoming sicker than toddling down to the local pharmacist.


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## mathepac (30 Jan 2016)

Anyone with cold of 'flu-like signs or symptoms attending a crowded environment packed with potentially vulnerable people should be shot (figuratively). The national GP out of hours services, referred to as "GPOOH" within the HSEs, is the appropriate first point of contact. All the numbers are on the HSEs' site.

Maybe as a consequence of your positive experience you'd like to nominate your local HSE for a Health Service Excellence Award this year. Well if you're a HSE "client", or tea-break spoiler as we're called by the HSEs, you can't.  Only people "working" within a HSE can do that. Have you ever heard anything so ridiculous. They give each other strokes because if the were waiting for Sean or Sheila Citizen to do it I suspect they'd be waiting.

[broken link removed]


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## Leper (1 Feb 2016)

Hold on Lads! You have a medical card, your GP doesn't need to see you - he gets paid your part in his medical card capitation list whether he sees you or not.  The GP does not want to see you on a Friday night while his private patients are lined up in the waiting room clutching a fifty spot while holding a tenner in reserve, just in case it's more.  

Meanwhile, back at the A&E ranch the queue of sneezing, sweating medical card holders (+ more) are waiting.  While they are there our Gardaí have no other choice than to deliver some ossified drunks like a conveyor belt provides tins of beans.  The road traffic accident victims are delivered by ambulance and add to this some domestic violence victims.  All these people do not come alone, they have their friends with them.  New mothers arrive with their newborn who cannot keep down the feed.  The suspected heart attack patients wait patiently too.  

I am not saying that all of these do not need treatment. I am saying though, many are there because they can be there and at no cost other than to the Irish taxpayer. The country needs to change the way colds and 'flu are dealt with and something drastic needs to be done with the flow of violent people delivered to A&E. The obvious start is to get the pharmacists involved before the point of entry.  If it works in Spain, it should work here.


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## Purple (1 Feb 2016)

Leper said:


> Hold on Lads! You have a medical card, your GP doesn't need to see you - he gets paid your part in his medical card capitation list whether he sees you or not.


 Yea, but if he, or more likely she, puts your visit down as a house call they get paid extra. Oh, put I'm sure that never happens, just like GP's don't skim off some of the cash they take in.


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## Leo (1 Feb 2016)

mathepac said:


> Maybe as a consequence of your positive experience you'd like to nominate your local HSE for a Health Service Excellence Award this year. Well if you're a HSE "client", or tea-break spoiler as we're called by the HSEs, you can't.



Many companies and organisations, including my own run similar schemes. They serve to encourage and reinforce the behaviours of individuals or teams that are doing a good job. There's a lot wrong with the HSE, but this isn't among them.


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## mathepac (1 Feb 2016)

Good organisation design principles allow for feedback from the environment in which the organisation operates to measure its effectiveness, assuming of course that the organisation operates as an open system. Seeking and acting principally on internal messages regarding effectiveness will tend to insulate the organisation from its key stake-holders and its purpose then becomes solely to fulfil specialised internal goals and to ignore its wider environmental purpose or act against it. With the HSEs, I rest my case. Along with other large organisations, they have attempted several failed "restructuring" drives (who reports to whom), ignoring the fact that experts like Prof Charles Handy list "structure" as only one of more than 60 attributes of successful organisation design.

Walk around some of these organisations and you'll see they probably have "mission statements" plastered on their walls, long-winded statements that confuse rather than clarify. They are usually meaningless, costly attempts to pay lip-service to good OD principles and do more harm than good.


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## Leo (1 Feb 2016)

Not disagreeing with any of that, but why is it ridiculous for such an organisation to seek internal feedback or look to highlight examples of good service/ performance? Why can't such a mechanism form part of an overall feedback/assessment model? Those inside the system are best placed to identify smaller pockets of high performing individuals or teams. To say that any such feedback is ridiculous does nothing to encourage rising standards.


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## Leper (1 Feb 2016)

Some of my colleagues worked in A&E as reception/clerical people.  During the daylight hours the environment is difficult enough in which to work, but come the night and especially weekend nights nobody knows what's ahead in the next hour never mind the whole night.  Our Gardaí will deliver any case they see fit.  They are  not going to lock some drunk/drug abuser into a Garda Cell just to spend the night.  If anything untoward happens the Garda is left out on a limb, so he/she will bring the person to A&E.  This will happen several times per night nearly every night.  Many of these patients "come around" during the night an walk out (forget about even discharging themselves). Usually, they do not supply information of even who they are or where they live (probably in fear of receiving a bill). It is not unusual for some of these people to become aggressive and threatening during the night also. 

Many people see themselves as the most deserving cases and insist on jumping the queue. Also, you have plenty of the public advising why their people should be seen first and even object to any length of time on a trolley.  Doctors, nurses, clerical staff get fed up with the phrase "I'm a taxpayer . . ." Some of these people think a hospital trolley is a wheelbarrow. You will be contacted by political peole  during the day and night also to be seen representing their constituents.  These guys don't care what they say or what rank they pull just to ensure the patient hears that his political representative is dropping everything for patient welfare.

No two nights are the same.  Flu outbreaks, big sports events, festivals, holiday periods, weather, ice, etc can influence immediate huge increases in demand of the service.  We can all shout about the service.  Internally, the staff shouts about the service too.  We need a whole change of mindset regarding minor medical care and until some sort of power is released to nurses to write prescriptions or pharmacists to advise and dispense drugs accordingly we might as well be sneezing against the wind and our Accident & Emergency facilities will continue to be overcrowded.


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## Purple (1 Feb 2016)

Leper, I'm always glad to see that life has not made you cynical


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## Sophrosyne (1 Feb 2016)

Leper said:


> We need a whole change of mindset regarding minor medical care and until some sort of power is released to nurses to write prescriptions or pharmacists to advise and dispense drugs accordingly we might as well be sneezing against the wind and our Accident & Emergency facilities will continue to be overcrowded.



Leper,

I think you are on the right track, not just in relation to A & Es but also to hospital clinics.

An acquaintance of mine read your posts and very kindly let me reproduce an email she sent to Mary Harney, Health Minister in April 2006, to which she did not receive the courtesy of a reply.

"Dear Minister,

Some years ago, I developed a thyroid problem.

I was referred to a consultant who unfortunately died.

Until I could be referred privately to another consultant, I had to attend a public hospital clinic.

I made maybe 6 or 7 visits to this clinic. The waiting time to see a doctor was usually 3 hours plus. On one of the visits it was over 5 hours. On each occasion the consultation with the doctor (I never actually saw a consultant) lasted less than 10 minutes.

Before each visit, I had to have a blood test, which was looked at during the consultation.

Apart from the first visit, when my thyroid was examined, the only matter considered during the consultation was my blood test. My physical presence during the consultation seemed unimportant. In fact, on two occasions, the doctor had no idea who I was, my medical history or my personal status.

The result of the consultation was to either increase or reduce my medication dosage.

During each of my visits to the clinic, there were in excess of 100 other patients who all appeared to have appointments at the same time as mine.

Most of the patients I spoke to said that my experience was the norm - queue for hours, see usually a junior doctor for a few minutes, who will tweak around with medication dosages and tell you to come back in 6 weeks.

What I could not understand during my experience with public clinics was that if the only thing that mattered was my blood test, *why did I need to be there.* Through travelling to and from the hospital and the unreasonable queue time I was absent from work for 5 to 6 hours per day.

There seems to be two problems,

Firstly, the lack of adequate consultants in public clinics is false economy. I was later referred privately to a consultant, who cured my thyroid problems after *two* visits. Had this not happened, I would probably still be attending the public clinic and my thyroid problem would at this stage be extremely serious. The appointment system is obviously not working. It is not possible for anyone to treat more than 100 people all at once. Naturally, the most serious cases will be prioritized. But this allows others, like myself, who could be cured if proper attention was given early on, to become progressively worse.


Secondly, is it necessary, in this day and age, to force people to queue for hours in the dismal surroundings of a public clinic, many of whom have to bring their children with them. If it is simply to examine a patient's blood, surely this does not always require the presence of the patient. Where I live there are umpteen, clean and pleasant pharmacies who if provided with *competent* nurses, could have taken my blood and sent it to the hospital for examination. If the dosage needed to be amended the hospital could telephone or mail me or arrange an appointment if they needed to see me."


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## mathepac (2 Feb 2016)

Leo said:


> ... but why is it ridiculous for such an organisation to seek internal feedback or look to highlight examples of good service/ performance? Why can't such a mechanism form part of an overall feedback/assessment model? Those inside the system are best placed to identify smaller pockets of high performing individuals or teams. To say that any such feedback is ridiculous does nothing to encourage rising standards.


In the case of the HSEs quite simply because 

a) they have no mechanism that seeks direct feedback about treatment effectiveness from their clients
b) their systems of care, recruitment, control and financial accountability are broken beyond any hope of repair

If standards were rising within the HSEs, I'd agree that self-praise might have value. However, as standards are demonstrably falling, they need to focus on client perception and expectations not indulge their internal Narcissus.


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## Leo (2 Feb 2016)

mathepac said:


> a) they have no mechanism that seeks direct feedback about treatment effectiveness from their clients



External 'client' feedback is a completely unrelated matter. To rule out inexpensive internal peer recognition programs such as this just because there is no external feedback makes no sense. Besides, there are existing user feedback systems in place, never used them, but they're there.



mathepac said:


> b) their systems of care, recruitment, control and financial accountability are broken beyond any hope of repair



Agree there, it's a mess of multiple antiquated systems all jumbled up and thrashed out with unions over the years so even those trying to work with it day to day are left frustrated and demotivated. 



mathepac said:


> If standards were rising within the HSEs, I'd agree that self-praise might have value. However, as standards are demonstrably falling, they need to focus on client perception and expectations not indulge their internal Narcissus.



It's when standards are falling that the need for such systems is greatest.

I'm no fan of the HSE, I think it's a complete administrative and logistical mess that wastes vast amounts of taxpayer money. Attacking everything they do regardless of merit isn't likely to encourage anyone to try fix it from within.


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## mathepac (2 Feb 2016)

The only "thing" that gives an organisation any validity is its purpose - what was it set up to do - the end-product it was supposed to deliver to its clients.

I would venture to suggest that the purpose of the HSEs is "to deliver healthcare to the population of Ireland". How well, or indeed if, it does that can only be measured by their clients - the people to whom they deliver healthcare. Nothing else matters. 

Systems which fail to deliver on their purpose will eventually wither and die. They will have no purpose and the first signs of this happening is when the wagons start to circle and those employed within the system will begin criticising their clients, their sponsors (government in the case of the HSEs) in fact their entire environment for their on-going failures. 

In the case of commercial organisation they will eventually close or be bought up if they have products or other assets that might be valuable. In the case of the HSEs the alternative will be privatisation and the breaking of the unions whose playthings the HSEs have become. Neither Government nor what passes for management within the HSEs have been able to get control of the monsters they have become. Money hasn't fixed the problems, multiple "restructurings" have failed and all the trophies awarded to each other by staff internally won't change what the organisations have become. They will be closed and the work (not the facilities, not the management, not the personnel with their current contracts) will be will be undertaken by private enterprise.

My family and I have been clients of various health boards and HSEs for decades. Not once has anyone approached us to provide feedback on how we experienced the services provided or if we saw any opportunity for improvements or if our expectations had been met. The arrogance is just mind-boggling.

Seeking feedback about effectiveness (how well it achieves its purpose) is expensive for any organisation. Not doing so as we are seeing with the HSEs is unmitigated disaster.


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## Leo (2 Feb 2016)

I fail to see how any of that makes an internal recognition tool ridiculous. Particularly when that tool has nothing to do with end user feedback.

The feedback tools are available, if you feel so strongly, perhaps you should look them up and have your voice heard. Letting off steam here may make you feel better, but will change nothing.


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## mathepac (2 Feb 2016)

Believe me we have used them. They achieve nothing other than generate paper.

If the general population in the country doesn't know enough to stay away from A&E with 'flu and/or don't have or know about alternatives, how does a shiny plastic trophy exchanged between speech therapists or hospital porters in an area change that disgraceful situation? Shut the HSEs down. According to the Dail PAC they may even pose a very real danger to the people they are meant to care for.


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## W200 (2 Feb 2016)

Leper said:


> We need a whole change of mindset regarding minor medical care and until some sort of power is released to nurses to write prescriptions or pharmacists to advise and dispense drugs accordingly we might as well be sneezing against the wind and our Accident & Emergency facilities will continue to be overcrowded.



I think you have squarely struck the nail on the head with that comment. There has to be a better way to establish what exactly is an accident or emergency without the actual A@E department being the first port of call.


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## Purple (3 Feb 2016)

I cut my finger quite badly a few days ago. My hand slipped when I was slicing veg on a mandoline and I ended up with a long flap of skin hanging off the side of my finger from the top knuckle into the back of my nail. I know that doctors don’t stitch that sort of injury so I wrapped it up and went around the corner to the pharmacy. €20 on disinfectant spray, plastic stitches (steri-strips), a bandage and some pain killers and I was sorted. I did bleed all over the floor of the pharmacy but they were ok with that. If I’d gone to A&E it would have cost me €100 and 5 or 6 hours and I would have ended up with the same thing. OK, I would not have had to clean and dress the cut myself but so what. I don’t understand why people go to hospital for minor injuries and the like when they should be able to sort them out themselves. Should we teach first aid in schools? Would that help?


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## geri (3 Feb 2016)

My local doctor used to have a walk in clinic, but no longer operates it.  Sometimes you  have to wait days for an appointment. Now, instead, I regularly go to the chemist for minor ailments for myself and my son.  Our local chemist is lovely, private consulting room , free of charge, no need for an appointment.The things I have gone to the chemist with were, a suspected veruca on my sons foot. One of the staff members had training in foot therapy.  She examined it in the private room and said it was actually a corn, for which she gave me treatment. I have also had one of my children in with hand, foot and mouth disease.  No treatment available for this, either prescription or non-prescription, advised to wait it out  which we did.  Also, I went myself with a sore eye, drops given by chemist, which cleared it up.  Of course, if a condidtion persists, I would go to GP, but its ages since I needed a doctor.  I would love to see them be given a bit more responsibility, and recognition as a practical and knowledgeble front line medical person.


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## Leo (4 Feb 2016)

mathepac said:


> If the general population in the country doesn't know enough to stay away from A&E with 'flu and/or don't have or know about alternatives, how does a shiny plastic trophy exchanged between speech therapists or hospital porters in an area change that disgraceful situation?



It won't. It's not supposed to. It's completely unrelated so expecting it to do so makes no sense.


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## Gerry Canning (4 Feb 2016)

mathepac, I like your comment on (mission) statements. AIB used to have them?
Leo, I also agree with you that in general mission statements, if enforced, help.
............................................................................................................
A&E is driven by an uncertain demand ,and twits thinking their scratch requires immediate attention.
 A&E needs to be taken out of (political/airways) cycle of unusual cases  and we then decide do we tolerate the Saturday Night Drunks or the other resource wasters whilst trying to be fair ,
Its a tough one .


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## Marion (4 Feb 2016)

www.undertheweather.ie

The above is a very useful website

Marion


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## mathepac (5 Feb 2016)

Leo said:


> It won't. It's not supposed to. It's completely unrelated so expecting it to do so makes no sense.


You keep missing, or ignoring, my key point. Any activity that is not aimed at improving the HSEs' services for the benefit of their clients is a waste of time, effort and money. Our money, my money. I can almost guarantee that the activities associated with the award of trophies occur during work-hours, just like the time and cost of reworking the HSEs' web-site for competition and awards was paid for by us.

@Marion that's a very useful web-site. Is there a link to it from the HSEs' main site or is it stands-alone?


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## Leper (5 Feb 2016)

Purple said:


> I cut my finger quite badly a few days ago. My hand slipped when I was slicing veg on a mandoline and I ended up with a long flap of skin hanging off the side of my finger from the top knuckle into the back of my nail. I know that doctors don’t stitch that sort of injury so I wrapped it up and went around the corner to the pharmacy. €20 on disinfectant spray, plastic stitches (steri-strips), a bandage and some pain killers and I was sorted. I did bleed all over the floor of the pharmacy but they were ok with that. If I’d gone to A&E it would have cost me €100 and 5 or 6 hours and I would have ended up with the same thing. OK, I would not have had to clean and dress the cut myself but so what. I don’t understand why people go to hospital for minor injuries and the like when they should be able to sort them out themselves. Should we teach first aid in schools? Would that help?



There was Purple always talking, running the country, pointing his fingers at bearded ones and not concentrating at what he was doing and nearly mutilated himself with a kitchen mandolin.  But, being probably afraid to show himself to some Public Service people, felt threatened and self diagnosed and self cured and saved himself some time, money and carpark fees, not to mention possible infection and the certainty of him pulling out his hair when he might see some thoughtless people in attendance of A + E just because it was "free" for them.  

Next time Purple points the finger it will be a reminder of what can happen if not fully concentrating.  To answer his question we should be teaching first aid in schools and perhaps minor injuries will cease to be treated in A+E.


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## Leo (5 Feb 2016)

mathepac said:


> You keep missing, or ignoring, my key point. Any activity that is not aimed at improving the HSEs' services for the benefit of their clients is a waste of time, effort and money. Our money, my money. I can almost guarantee that the activities associated with the award of trophies occur during work-hours, just like the time and cost of reworking the HSEs' web-site for competition and awards was paid for by us.



I'm not, I have seen the benefit of similar low-cost schemes over the years for end users/customers. I'm not sure why you can't accept that the improvement of services to end users can be achieved internally, and provide much better value for our money.


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## mathepac (5 Feb 2016)

Examples please of those schemes and the the improvements they have provided for specific health services supplied to clients.


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## Leo (5 Feb 2016)

Where did I say my examples related to health services? I don't work in the HSE, so don't have access to such information. Where I do work, they work really, really well. If you want to effect lasting change in any significant org, there's only so much diktats or schemes promoted from the top will ever achieve. Look at how Japan took over the manufacturing world through Kaizen and lean practices. They all embrace schemes such as these, done well they're a hugely cost effective means of improving the end product.


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## Marion (7 Feb 2016)

@mathepac there is a link on the right hand side of Www.hse.ie home page.

Marion


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## Purple (8 Feb 2016)

Leo said:


> Where did I say my examples related to health services? I don't work in the HSE, so don't have access to such information. Where I do work, they work really, really well. If you want to effect lasting change in any significant org, there's only so much diktats or schemes promoted from the top will ever achieve. Look at how Japan took over the manufacturing world through Kaizen and lean practices. They all embrace schemes such as these, done well they're a hugely cost effective means of improving the end product.


I think it’s a stretch to suggest that there is or even could be any correlation between the culture of quality in the HSE, and the State sector in general, and the Shinto influenced Japanese culture of excellence.

As for Lean and Kaizen (both methods developed by Americans, not Japanese), they require adaptability, decision making at a local level, employee engagement and empowerment and labour flexibility. None of these are present at the required level in the HSE.


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## Leo (8 Feb 2016)

Purple said:


> I think it’s a stretch to suggest that there is or even could be any correlation between the culture of quality in the HSE, and the State sector in general, and the Shinto influenced Japanese culture of excellence.



We'll both agree there's very little chance of that kind of culture ever permeating the HSE. It would take a seismic shift neither the administrators, unions, nor government want to contemplate. My point in this thread is just because the system is rotten, we shouldn't discourage everyone within trying something that might pay dividends. There are good people working in the system, some are trying to bring about change from within, if we knock them down at every opportunity, things will only get much worse. 



Purple said:


> As for Lean and Kaizen (both methods developed by Americans, not Japanese), they require adaptability, decision making at a local level, employee engagement and empowerment and labour flexibility. None of these are present at the required level in the HSE.



The Lean term was coined by John Krafcik in a paper on his experience as a quality engineer with Toyota and TPS. The history of waste elimination/ quality goes back nearly as far as industrialisation itself, but my point was how Japan embraced these after WW2 to very quickly move into a position of dominance.


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## Firefly (8 Feb 2016)

Irish Times:

http://www.irishtimes.com/news/health/new-curbs-on-hse-recruitment-to-be-introduced-1.2526177 

New curbs on HSE recruitment to be introduced
Confidential memo by HSE chief Tony O’Brien warns rate of hiring cannot continue

*Rise in health service employment*
_Rise since Dec 2014 by staff group

Care 993_
*Clerical and administrative 669*
_HSPC other 660
NCHDs 379_
*Staff nurse 317*
_Nurse manager 296
Management 291
Therapists (OT, Physio, SLT) 209
Nurse specialist 128
Consultants 92
Public health nurse 55
Support 46
Ambulance 30
Nursing student 16
Medical other 8_


Given the shortages of beds & nurses in hospitals around the country and the long waiting lists in general, does anyone else think that hiring more than TWICE the number of Clerical / Administrative staff compared to nurses makes sense? 

Also the numer of nurse managers almost matched the number of staff nurses - could it be inferred that the nurse managers were promotions and the staff numbers were replacements? If so, we have the same number of nurses but more management!

Also, I like to know what _HSPC other _refers to since it was the 3rd highest ? 



Time to really think about the HSE. Bring back the nuns!!!
Firefly


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## Purple (8 Feb 2016)

Leo said:


> The Lean term was coined by John Krafcik in a paper on his experience as a quality engineer with Toyota and TPS. The history of waste elimination/ quality goes back nearly as far as industrialisation itself, but my point was how Japan embraced these after WW2 to very quickly move into a position of dominance.


I know it well. This is the paper in question. If you applied the same principles to the healthcare industry, or just look at the bottlenecks within the sector in the light of Lean then many of the solutions become obvious, if not easy. It also becomes abundantly clear that money is not the problem.


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## Leo (8 Feb 2016)

Purple said:


> It also becomes abundantly clear that money is not the problem.



Absolutely, and all that is lost in the business of politicians looking to score points and quick fixes.


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## Sophrosyne (8 Feb 2016)

It is not that simple. Flu can be lethal, especially to those with serious underlying medical conditions and sometimes to those who do not.

Already this year, tragically, a 5-year-old boy, who had no underlying medical conditions, has died in Crumlin Hospital from swine flu. Many other children and babies have been hospitalised with the same condition.

Certain flu sufferers may, quite rightly, be referred to A & E by their GPs.

A & Es are reactive. Who knows how many patients will present with whatever conditions on any one day/week/month/year.

In other words, their work is not predictable. They are not making widgets, cars or mobile phones.

Should everyone have attended A & E? Who knows?

To form an opinion, one way or another, one would need and have to start with qualitative statistics from each A & E service.


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## mathepac (8 Feb 2016)

Interesting that Lean / 6 Sigma should be discussed here in the context of the HSEs. For those not familiar with the terms, here are the 7 underlying principles:

Focus on the customer 
Identify & understand how the work gets done 
Manage, improve & smooth the process flow
Remove Non-Value-Added steps & waste
Manage by fact & reduce variation
Involve & equip the people in the process
Undertake improvement activity in a systematic way
In the case of the HSE no 1. is what needs to happen, ASAP. Anything that diverts from this is a distraction. Rewarding each other with plastic trophies and dummy awards is, as I've said already, a serious distraction from the changes that need to happen and might even lead to staff believing that are doing a great job, just because they can point to a trophy they awarded themselves.

Let me give a simple example of how far removed from customer focus staff in the HSEs are. When nurses get to within 4 or 5 years of retirement age, irrespective of business need, they are automatically placed back on restored duties. The purpose of this is to increase their reckonable salaries for pension purposes. Rostered duty allowances are reckonable as salary for pension purposes, thereby inflating final salary and pension. This does nothing to improve services or patient care and proves that staff and unions use the HSEs as cash cows and have lost sight of their purpose.

Staff at all levels collude in this kind of expensive waste e.g. multiple employees from a single location due to attend a central event will all take their individual cars and  charge mileage. The reason this nonsense goes on is because they, staff and "management" are all members of the same unions and no-one can afford to break ranks.

I should point out that I have extensive manufacturing experience and have also worked as a clinician in the Health Boards / HSEs / Service Providers.


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## Purple (8 Feb 2016)

Good post mathepac.
I have worked as a quality engineer in industry (medical device manufacturing) and previously as a manufacturing engineer. My current role includes new process design and implementation and we apply Lean to just about everything we do.
Buy-in and empowerment of staff is critical. This is a major stumbling block in the protected sectors of the economy as employees think that they deserve a pay increase for any improvements they are part of. In the open sector employees see such improvements as providing a competitive advantage for their employer and therefore an improvement in their job security. 
As long as the parasites in the unions prevent major process improvements by attempting to blackmail their employer into diverting resources from patient care into wage increases there is no real prospect of reform.


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## Deiseblue (8 Feb 2016)

Kaizen/Lean is seen by Unions as an attack on long held , hard fought for practices such as job demarcations , job classifications & seniority rights which if successful would see a return to the days when management exercised full prerogative unimpeded by Union recognition .

I do realise that many would welcome such a scenario but the reality is that such a system is not going to be implemented in the HSE as long as the Unions represent management as well as staff .

Nor , it must be said , has any Irish Government as employer shown any interest in introducing such a system in the public sector - possibly because of the strong adverse reaction it would provoke.


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## Purple (8 Feb 2016)

Deiseblue said:


> Kaizen/Lean is seen by Unions as an attack on long held , hard fought for practices such as job demarcations , job classifications & seniority rights which if successful would see a return to the days when management exercised full prerogative unimpeded by Union recognition .
> 
> I do realise that many would welcome such a scenario but the reality is that such a system is not going to be implemented in the HSE as long as the Unions represent management as well as staff .
> 
> Nor , it must be said , has any Irish Government as employer shown any interest in introducing such a system in the public sector - possibly because of the strong adverse reaction it would provoke.


Very honest post Deiseblue. I agree and it's a shame because it should result in a better workplace and empowered and therefore satisfied employees. The problem is that the people in charge in the HSE seem to be the ones who need to change most so the main winners could be the "consultants" who spend years trying to work around the Unions. 

Enterprise Ireland have an excellent Lean team. I wonder if they, as another state body, could be used here?


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## Sophrosyne (8 Feb 2016)

Purple said:


> Good post mathepac.
> I have worked as a quality engineer in industry (medical device manufacturing) and previously as a manufacturing engineer. My current role includes new process design and implementation and we apply Lean to just about everything we do.


 

Lean and 6 Sigma or a combination of both has many guises and is implemented in different ways.

How would you see this put into practice in, say, A & Es?


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## Gerry Canning (9 Feb 2016)

Deise Blue,

Lean and 6 Sigma are used by Ge ,a large American Conglomerate.
They applied lean/6 Sigma on their finance wings , upshot was finance wing bailed out by US government ?
That does not mean lean/6 Sigma are bad but Purple saying 6 sigma/lean may mean (empowered workplace) is putting too much faith in a system.

Simply (in my opinion) most workplace issues comes down to weak management.
To hang blame on Unions is too simplistic.
With no unions ,poor managers would still foul up.
Could it be that in many cases Unions stop poor management , at least that is what history has shown us.


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## Deiseblue (9 Feb 2016)

Gerry , I totally agree with you .
I am totally of the opinion that Kaizen/Lean disempowers employees & should be resisted at all costs.
I should have clarified that when I  stated previously that such a system could not be introduced in the HSE as both management & staff were members of Unions I did not mean that as a criticism rather I see such all encompassing Union membership as desirable.


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## mathepac (9 Feb 2016)

So @Deiseblue do you see the examples I gave as desirable because they are the status quo or do you believe they are even sustainable in the medium term? 

Never yet has the big HSE at a corporate level or the other HSEs at operational levels met their budget numbers, either in man-power or monetary terms. Other targets about lead-times, response-times, wait-times are being missed daily, weekly and monthly. They have closed beds in the belief that beds create costs - they don't. Like any service organisation the HSEs' biggest costs are people costs. They cut staff to reduce costs and to meet whole-time equivalent numbers, but cheated and blow more budgets by hiring back the staff they had cut at inflated agency rates and lower productivity levels and still incurred additional man-power costs as the agency staff would not work week-ends or rostered duties.

6 Sigma, 5 Ss, Lean, Kaizen, Quality Circles, JIT, Kanban, Ishikawa Diagrams for problem solving, in fact any technique where the outcome is to maintain the status quo is destined to failure, you have what used to be called a day-one deviation.

A&Es are not fit for purpose for dozens of reasons, they are down-right dangerous places to be but that won't change unless they are designed from the ground up to work for their clients.


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## Sophrosyne (9 Feb 2016)

I have been looking at these A & E statistics.

Are these the latest available?

I note that there were 1,278,522 Emergency Dept attendances in 2012 and that this number is typical for the years displayed – (2003 – 2012).

In 2012 the population was 4.587m. I appreciate that the figure of 1,278,522 includes repeat attendances.

Are there any more granular statistics available on the 1,278,522?

For instance, do we know how many individuals were involved, why did they present, etc.?


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## mathepac (10 Feb 2016)

I've tried the Dept of Health site and it's a nightmare - lots of tables and reports stored as PDFs & XLSs, all at leat 5 years old, all qualified in some way "acute hospitals only, excluding non-residents", or "no numbers available for 200X due to changes in tabulation methods" or "we are no longer responsible for those data, look elsewhere", anything to enable obfuscation.

Interestingly, I did find a report called "eHealth-Strategy-for-Ireland.pdf" which quotes this strategy's purpose as:-

*"Bringing improved population wellbeing, health service efficiencies and economic opportunity through the use of technology enabled solutions"
*
the usual buzz-word stuff which could be prècised as "Saving money and improving health, using IT" which is only seven words long and saves time, money and printing costs.

Unfortunately this whole initiative sounds like PPARS all over again, just bigger, and has identified a dependency on a Deliverable from the Dept of Health the "Individual Health Identity Number"  to be used instead of our existing PPSN. At least three other "strategic programmes" designed to replace the PPSN with this "IHIN" have failed but you can't criticise the determination, even if it is misplaced.

This document talks openly about the dismantling of the HSE, but gives no indications as to how many more mini-HSEs will replace it.

I deleted all the "fluff", blank pages and page-sized coloured photos leaving 67 A4 pages of "content" (see above 7-word strategy statement versus their 17). In those 67 pages, work design gets less than half a page, and I quote:

"_4.5 Re-designing Work Practices

eHealth deployments by their very nature are disruptive and international experience has shown that their success can be measured by an organisation’s ability to adapt work practices and processes. eHealth needs to be viewed as a process reengineering activity facilitated through the use of information systems rather than a ’pure’ ICT project per se. The distinction here is important, because the decision to utilise eHealth solutions and the consequent planning and execution needs to be based on the recognition of a business need, the understanding and acceptance of any potential change management implications, the identification and provision of the required resources and the establishment of an authoritative governance and project management structure. In addition, the importance of stakeholder engagement and in particular clinical engagement is obvious in order to achieve a successful eHealth project in which full benefits are realised by all parties. Figure 4.2 outlines the key elements insuch an eHealth project.

The importance of process reorganisation and adaptation of work practices must be re-emphasised as failure to do so will result in
an even more confused and costly system than before. Hal Wolf of Kaiser Permanente in the USA (one of the earliest and most successful adapters of eHealth technologies) summarises this as follows;

NT + OO = COO

New Technology + Old Organisation  = Costly Old Organisation

Issues such as skills and training of staff therefore are as important as pure technical competency when it comes to integrating eHealth technologies and redesigning work practices and processes._"

I think you can understand my scepticism

Hidden in all the flannel and fluff and stuff copied and pasted and quoted from other sources is this gem, this moment of insight around development and delivery:-

_"3 Outsource the delivery entity

Outsourcing (through a tender process) of the entire eHealth delivery function to a third party with previous successful experience of implementation.

Pros:

*» Decoupled from perceived public scepticism of the Health Services ability to deliver major eHealth initiatives.*"
_
No mention found yet of simple, up-to-date, un-massaged stats for A&E specifically but I'll continue looking.


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## Leper (10 Feb 2016)

Would somebody change "Flue" to "'Flu" in the title of this thread before I attack the offices of AAM and have us all in Accident and Emergency?


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## Delboy (10 Feb 2016)

mathepac said:


> Never yet has the big HSE at a corporate level or the other HSEs at operational levels met their budget numbers, either in man-power or monetary terms. Other targets about lead-times, response-times, wait-times are being missed daily, weekly and monthly. They have closed beds in the belief that beds create costs - they don't. Like any service organisation the HSEs' biggest costs are people costs. They cut staff to reduce costs and to meet whole-time equivalent numbers, but cheated and blow more budgets by hiring back the staff they had cut at inflated agency rates and lower productivity levels and still incurred additional man-power costs as the agency staff would not work week-ends or rostered duties.


Marian Finucane had a Consultant from St Vincents I think it was on last weekend. He works in both Private and Public.
He said when he's in the Private, he has targets...so may surgeries, so many follow ups. All measured and recorded. Reviews on results with Senior Mgmt.
When he's in the Public, no body chases him. Operations are cancelled at the last minute...staff availability, room/equipment availability. No shows by Patients for consultations etc. And it's left at that. Never seems to be much of a push to improve the system.

The entire Health System is broken and the ongoing patches applied every 5 years by a new Govt are a waste of time, money and resources. The entire system needs to be redesigned on paper...what would an ideal system look like. Then a timetable for implementation set out and if any self-serving/self interest Grouping decide to nuke it, then show them up for the greedy carefree luddites that they are. Yes, there may/would be strikes and a lot of strife but eventually you'll get the 21st century system that is needed. Short term pain for long term gain


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## Sophrosyne (10 Feb 2016)

mathepac said:


> I've tried the Dept of Health site and it's a nightmare - lots of tables and reports stored as PDFs & XLSs, all at leat 5 years old, all qualified in some way "acute hospitals only, excluding non-residents", or "no numbers available for 200X due to changes in tabulation methods" or "we are no longer responsible for those data, look elsewhere", anything to enable obfuscation.
> 
> No mention found yet of simple, up-to-date, un-massaged stats for A&E specifically but I'll continue looking.


 
Hi Mathepac,

I'm having the same difficulty.

The pity of it is that people are probably entering valuable data that is going nowhere.

Even if systems are being changed, information should still be extractable. Surely this data would be necessary for annual reports, governmental briefings, etc., not to mention internal assessment.

Many large organizations, including govenment departments, have IT systems in constant stages of upgrade, which does not impede access to essential information.

I see your point that use of the Individual Health Identity Number seems ridiculous.

I am thinking of situations where people are receiving health care from a  combination of the HSE and also from the Social Protection Dept., which uses the PPSN.

And you are right, you have to pick your path through the promotional waffle!


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## mathepac (10 Feb 2016)

I'm reminded of the time Gerry Robinson (Sir Gerry) looked at a small bit of the NHS to try to understand its brokenness. While some initiatives went nowhere, he looked at a surgical clinic that seemed to have longer delays and wait-times than seemed appropriate. He discovered that an operating theatre only opened for business from Monday to Thursday. No-one could explain why it didn't operate to a 5-days-per-week schedule like others. With agreement from surgeons, nurses, admin etc they started using this expensive facility to it's full capacity. Suddenly wait-times reduced, delays disappeared and overall there was less stress and frustration in the system as patients got treatment sooner. It made for good telly at the time (I thought).

There's a lot to be said for the stranger's eye, the naive view. On the other hand the HSEs seem to have free rein to continue navel-gazing.


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## Gerry Canning (10 Feb 2016)

Valuable Data , Hmn!

Statistically, piracy increased since we saw global warming , ergo Global Warming is a big cause of piracy.??
..........................................................................................................................................
Problems are cured by people with the will to continue to challenge those small narks that build up into waffle .
The issue is, will the system support challengers ?

Maybe the idea of putting in a Health Czar for 10 years to make implementable/fast decisions could cut through the layers ?


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## Purple (10 Feb 2016)

Sophrosyne said:


> Lean and 6 Sigma or a combination of both has many guises and is implemented in different ways.
> 
> How would you see this put into practice in, say, A & Es?


I don't know enough about the specific needs but I have see the success they bring in organisations. Many small and inexpensive changes can add up to a major improvement in overall outcomes. There is rarely one big "silver bullet" solution to organisational problems. The big fix is in fact usually lots of small fixes. The best people to identify and implement those are the people who work there. That should then inform an overall cultural change. The prerequisites are a workforce who wants to be empowered and a management which is competent and confident enough to listen and accept that other people might have the best ideas.
If unions think that it will make things worse for their members then they don't understand it. If anyone things that the outcome is just to tweak a broken system them they don't understand it either.


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## Sophrosyne (10 Feb 2016)

Gerry Canning said:


> Valuable Data , Hmn!
> 
> Statistically, piracy increased since we saw global warming , ergo Global Warming is a big cause of piracy.??
> ..........................................................................................................................................
> ...


 
I don’t understand your point Gerry. Are you saying that in a huge country-wide organization, such as the HSE, that data is unnecessary?


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## Leper (11 Feb 2016)

Purple said:


> I don't know enough about the specific needs but I have see the success they bring in organisations. Many small and inexpensive changes can add up to a major improvement in overall outcomes. There is rarely one big "silver bullet" solution to organisational problems. The big fix is in fact usually lots of small fixes. The best people to identify and implement those are the people who work there. That should then inform an overall cultural change. The prerequisites are a workforce who wants to be empowered and a management which is competent and confident enough to listen and accept that other people might have the best ideas.
> If unions think that it will make things worse for their members then they don't understand it. If anyone things that the outcome is just to tweak a broken system them they don't understand it either.



Finally, a post that is somewhat on the money. (The likes of Lean and Sigma have well been used up over and over). When everything else is failing, ask all the guys who are on the spot. I mean all the guys including receptionists, clerical, medical, physio, nursing, attendant, security, porters, care assistants etc.  And if workable solutions can be found, then even reward them and not with plastic trophies or A4 printed fill-in-the-blank certificates.


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## Leo (11 Feb 2016)

Leper said:


> Finally, a post that is somewhat on the money. (The likes of Lean and Sigma have well been used up over and over). When everything else is failing, ask all the guys who are on the spot. I mean all the guys including receptionists, clerical, medical, physio, nursing, attendant, security, porters, care assistants etc.  And if workable solutions can be found, then even reward them and not with plastic trophies or A4 printed fill-in-the-blank certificates.



Exactly. So something like the Staff Excellence Awards that accepts input from all staff is perfect in this regard. Rewards high achievement and publicises their work internally helping to set standards. It's certainly a very long way from instilling a culture of continuous improvement, but there are so many archaic practices to overcome without a seismic change that culture will never prevail there.


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## Firefly (11 Feb 2016)

I remember a few years ago during the first of two really cold winters, there was a huge pothole somewhere in North Cork. There was a YouTube clib of a guy swimming in it. It went public and the council filled it in the next day. That's what we need for our A&E departments - an effective public feedback loop. I note that the [broken link removed] site is run by the irishhealth website and it nice & pasteurised - you even have to register & supply an email address to post! A simple YouTube channel where patients on trolleys could upload to, would really shake things up I would imagine. It would be public and global - foreign press could even pick up on it.

With respect to Lean / Sigma, it might work well in some organisations, but in the HSE it would, I believe, just add another layer of fat where more and more staff would be taken away from treating patients to attend a course they will never use. 

Regarding the public / private hospitals, I performed consultancy work for a private hospital in the past 3 years. Honestly, you wouldn't believe the stats they gather and use. And I really mean _use_....everything is analysed and anything outside set ranges is followed up on. Granted, the hospital is private and therefore profit is important but I really think it is time to start privatising _some_ of the functions that the HSE performs, particularly A&E where private hospitals could be paid by the state to treat everything that is currently treated and open 24x7.


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## Leo (11 Feb 2016)

The majority of those within the system already know what's broken. External feedback won't change that, and external people are usually not aware of the bureaucracy or antiquated systems used internally that contribute to the disfunctional state. Anonymous feedback is worthless in any system. 

The public shaming approach didn't work too well for the pothole campaigner from Cavan with the threat of jail hanging over him. Patients on trolleys uploading clips to YouTube could soon find themselves in court also.


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## Purple (11 Feb 2016)

Firefly said:


> With respect to Lean / Sigma, it might work well in some organisations, but in the HSE it would, I believe, just add another layer of fat where more and more staff would be taken away from treating patients to attend a course they will never use.


 6 Sigma is essentially a statistical management tool and that requires considerable training and could suck up resources. Lean and Kaizen are simple and very adaptable tools and don't require much training at all. Once people understand the concept and know that they will be listened to a lot of the low hanging fruit can be picked with little or no cost or disruption.


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## Gerry Canning (11 Feb 2016)

Sosphy. Data is very valuable , my point was that data is very prone to bad -use.(I was being a bit sarky!)

Purple . Agree IF people are listened to = great.


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## Purple (11 Feb 2016)

Gerry Canning said:


> Purple . Agree IF people are listened to = great.


If people aren't listened to then it's not kaizen. Lean is an output; your process ends up being Lean. If enough processes are Lean then you can say that your organisation will end up being Lean.


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## Leper (11 Feb 2016)

Great! We're now going to have patients and their friends wielding mobile phones in A+E facilities threatening global fame for all the wrong reasons on Youtube if Padser on the trolley is not treated within 10 seconds. Mobile phones are banned even in GAA dressing rooms in underage occasions.  How long will it be before all staff in A+E refuse to work in front of such threats? I haven't even mentioned more patient distress as a result. 

Better again, we can bring in some advising company to implement Lean and a plethora of other systems.  I am sure Padser's worries will be eased as he continues his horizontal life on the trolley.

And of course, we can continue to ignore those working in such places. We can let morale slide more into the abyss of cynicism.
Doctors will doctor, nurses will nurse, admin will admin, care assistants will care assist and what does Seosamh Ó Galúnach think -only the obvious i.e. teamwork and a decent set of workable ground-rules would matter so much. Let's not dismiss the obvious; if teamwork works, then let it work.


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## mathepac (12 Feb 2016)

Eddie Molloy and the retiring head of HIQA say it well http://www.independent.ie/opinion/c...s-ever-responsible-for-mistakes-34428484.html

To paraphrase, no-one cares because no-one is accountable.


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## Sophrosyne (12 Feb 2016)

mathepac said:


> Eddie Molloy and the retiring head of HIQA say it well http://www.independent.ie/opinion/c...s-ever-responsible-for-mistakes-34428484.html
> 
> To paraphrase, no-one cares because no-one is accountable.



Perhaps this should be a new thread, but from the same article, which makes for depressing reading:

“Following last year's HIQA report into infant deaths in Portlaoise hospital, there were calls for sanctions against personnel who had failed "to take seriously" the evidence of repeated catastrophic failures that were brought to their attention.

The best that the CEO of the HSE, Tony O'Brien, could offer when he was pressed about sanctions was to appoint HR consultants from the UK to advise on how these serious failures by several layers of management could be handled.

*Here, we have the biggest employer in the country, with over 100,000 staff, which doesn't have an effective performance-management and disciplinary system,* *one that includes, when required, the legal instruments and industrial relations machinery to impose sanctions on managers guilty of the most egregious lapses. *[Emphasis mine]

Questioned before the Public Accounts Committee this week, Mr O'Brien explained how he was powerless to take effective action and, turning the spotlight on his interrogators, he then added wryly: *"Because of rules set in this place." *[Emphasis mine]

To what rules is he referring?


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## Leper (13 Feb 2016)

We are all talking like we were at a meeting in which our duty is to solve all the problems in Accident and Emergency (and perhaps in the entire HSE). We are talking management systems, union participation, strong management, bought-in staff etc. 

Newsflash Guys! - We are wasting each other's time and all of us would be better off sharing a bar table to watch the Six Nations.

But, the problems especially in Accident & Emergency are about to be resolved in their entirety. (You heard it here first). From where I sit, it appears only a matter of a few short years before our Health System is privatised.  And yes, we are getting what we all wish for. (Another round of drinks there, Paddy, the match is about to start!).

So Seosamh Ó Galúnach is jumping all over the place with joy.  He will be able to go to A&E receive treatment within minutes and will be cured of all ills. Great! But, Seosamh, bring hard cash or at least a plastic credit card or you can stay outside unseen in the rain if you are not covered by expensive Medical Insurance.  And yes, come Monday to Friday, 9.00am - 5.30pm and you will be seen by one of our caring doctors (who works in only three other hospitals and four GP Centres). 

Seosamh and his buddies will learn quickly that most ills can now be treated free at any of our Pharmacies.  Even if he has private health insurance, the insurance companies will be introducing No Claims Bonus etc. We will have a hospital service rivalling any great hospital in Manhattan. Whether Seosamh likes it or not the government has done a Pontius Pilate job (washed their hands) on the public health facilities and all our hospitals are now private. There will be no delays in Accident & Emergency.  We will have a much poorer population.  And Seosamh will learn that all he can do now is whistle Dixie.  But, Seosamh got what he wished for.


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## mathepac (13 Feb 2016)

Leper said:


> We are all talking like we were at a meeting in which our duty is to solve all the problems in Accident and Emergency (and perhaps in the entire HSE).


I see it as my duty as a citizen to try and ensure that those who need medical care in this country get the best we can supply. The current offering falls far short of that.


Leper said:


> Newsflash Guys! - We are wasting each other's time and all of us would be better off sharing a bar table to watch the Six Nations


Feel free to opt out at any stage and watch telly.


Leper said:


> But, the problems especially in Accident & Emergency are about to be resolved in their entirety. (You heard it here first). From where I sit, it appears only a matter of a few short years before our Health System is privatised.


Yes it will be privatised but that solution was mentioned long ago in this thread by me amongst others. Sorry you missed that from your seat in from of the telly.


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## Leper (13 Feb 2016)

mathepac said:


> I see it as my duty as a citizen to try and ensure that those who need medical care in this country get the best we can supply.



Now my mind is at ease.  Mathepac is taking up the mantle of responsible citizen.  All our problems are about to cease.  Now back to the telly . . . and Paddy, another pint and a ball of malt there for Mathepac.


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## ajapale (13 Feb 2016)

W200 said:


> why do the terms A@E and FLUE appear in the same sentence much less in the same location


In the north of England you go to "obs & gynae" with FLUE problems!


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