Admission Policy Analysis in Princess Basma Hospital

(	Asem Ahmed Abdalrahim Correspondence: Asem Ahmed Abdalrahim, RN, MSN Lecturer- Faculty of Nursing Hashemite University Phone: +962796328487 Email: asemalhmoud@yahoo.com

Admission Policy Analysis in Princess Basma Hospital
Being admitted to hospital may be a stressful, if not frightening experience for any individual (Protocol on Admission to Hospital in Shetland, 2004). The purpose of the current paper is to use a systematic method and analytical approach to analyze the admission policy in Princess Basma Hospital and to develop the best solutions for the problems that are identified in the policy based on a pre established criteria. The policy analysis will include six steps policy analysis criteria, as the following steps: Verifying, defining and detailing the problem, establishing evaluation criteria, identifying alternative policies, Assessing alternative policies, displaying and distinguishing among alternatives, and implementing, monitoring, and evaluating the policy.

1. Verifying, Defining and Detailing the Problem
The basic problem in the admission policy of Princess Basma Hospital is related to the patient's safety and feeling of being secure. Although the admission policy in the Princess Basma Hospital mentioned that its major purpose is to admit the patient in an easy and safe way, the safety precautions were not mentioned clearly. The extent of safety problems identified in the policy includes psychological and physical aspects.

Before explaining these aspects, it is important to mention that all admitted patients to Princess Basma Hospital must be provided with standard precautions and information to achieve feeling of being secure in the environment. However, some deficits in the current policy may hinder patients from feeling secure in the environment. For example, any newly admitted patients will be advised to report directly to the main reception. The patient will be directed by the receptionist to the relevant ward. If the patient is unfamiliar with the hospital or requires any other assistance, the receptionist will make arrangements to assist the patient to the relevant ward area (Protocol on Admission to Hospital in Shetland, 2004). Then, a member of the ward team will meet and greet the patient and take them to their allocated bed. The process on each ward will vary according to ward philosophy and workload, but the following principles will be always applied when admitting patients: such as introducing fellow patients; patient's doctor will be informed of his/her arrival on the ward, promoting prompt assessment, clinical examination and the ordering of any relevant tests; and orienting to the local environment, persons, and procedures including toilets, washing facilities, nurse call bell system, time of food, taking of details by health care professionals, routine observations, blood test, visiting times, introduce the patient to others in the ward, introducing to health care professionals by name and title e.g. doctor, nurse (Protocol on Admission to Hospital in Shetland, 2004).

Therefore, applying these steps during admission will make the patient feel safe in the environment. In addition, hospitals are responsible for ensuring that appropriate procedures and records are maintained to facilitate accurate reporting, and to justify the admission (Victorian Hospital Admission Policy, 2011).

Patients may have fear from an unknown future because the policy did not mention an approximate length of time they can expect to stay in the hospital. Furthermore, patients are not involved in their plan of care or informed of their progress. Therefore, these may hinder patients from feeling secure in the hospital environment (Protocol on Admission to Hospital in Shetland, 2004).

In addition, the identification of the patient is not mentioned. Other admission policies for example, Peterborough and Stamford Hospitals (2008) mentioned that all admitted patients or those undergoing treatment must have 1 wrist band detailing the following: Full name, date of birth and patient number. Moreover, Protocol on Admission to Hospital in Shetland, (2004)
specified that wrist bands must be in specific colors such as red, for example, if the patient was reported to have an allergy. However, the policy in the Princess Basma Hospital does not include that, and patients are still up till now without wrist band for identification. This will cause serious challenges in emergency situations especially if the health care professionals need to response quickly for an urgent situation such as patient loss of consciousness if the health care professional does not remember the name of the patient to follow instructions in patients file.

Protocol on Admission to Hospital in Shetland (2004) cited that patients need to understand that family and carers have the opportunity to interact and support the patient during admission and prior to discharge, inclusive of participation in the leave and discharge by planning processes with the consent of the patient to feel safe and secure in the environment. In addition, the clients and recognized carers should have the opportunity to discuss any issues encountered during admission and as part of the discharge. They can also share the planning process with their treating medical officer and members of the treating team. The admission policy in Princess Basma Hospital did not provide any data about that and focused mainly on the process of admission.

As identified by the previous discussion, our objectives in the following analysis will focus on admitting the patient in an easy and safe way by working to provide the least restrictive environment that supports patients to feel safe and secure during admission. This will be achieved by using a more client-centered approach in addition to providing the most effective inpatient treatment and care. These objectives are consistent with the general purposes of Princess Basma Hospital admission policy.

It is very important for patients to feel secure and safe during the admission into any .health facility. This will keep the patient calm, relaxed and decrease the risk of other harm such as violence toward health care professionals and other patients. However, our major concern is including actions that aim to enhance patients feeling of being secure. This concern is usually expected by patients and their families in addition to health care providers because they know that the patient will experience a lot of stressors during admission and need to feel secure and safe. This can be achieved by adding some aspects in the admission policy such as all patients are treated as individuals and that their needs are met in a manner that recognizes this; all patients, and where appropriate their relatives and carers, are involved in planning their care from the moment they are admitted to hospital; the admission process is as quick and efficient as possible; the importance of early planning to facilitate a smooth discharge is recognized, therefore this process will begin as soon as practical after admission; an immediate explanation is offered for any delays that occur during the admission process, and that all possible steps will be taken to rectify the situation; and any concerns patients and, where appropriate relatives and carers have regarding the progress of their admission will be listened to where appropriate, and action will be taken to address these concerns (Protocol on Admission to Hospital in Shetland, 2004).

Patients and their families have less power than the health care providers to achieve the expected outcomes related to patients' feeling of safety and security during admission. This is because health care providers have some legal authority related to their position.

Estimation of resources needed to solve the problems that have been explained previously reveals that we mainly need human resources. The human resources include the chief nurse executive who is working on the policy to identify the limitations related to patient's safety and modifying or adding the new suggestions to the current policy, and the nurses who are responsible for applying the policy and evaluating the outcomes.

2. Establishing Evaluation Criteria
The major goal for the current policy is to admit the patient in an easy and safe way. The policy has not included explanations for the method in which outcomes will be measured and evaluated. However, the effectiveness of the current policy to achieve the expected outcomes was measured by two major criteria; the content of the policy, and reports of patients, families, and health care providers.

The first criterion focused on the content of the policy. The content of the current admission policy didn't include many actions that are needed to admit patients safely and make patients feel secure in the environment, such as orientation to the local environment, persons and procedures, including toilets, washing facilities, nurse call bell system, time of food, taking of details by health care professionals, routine observations, blood test, visiting times, introducing the patient to others in the ward, introduction to health care professionals by name and title e.g. doctor, nurse, presence of identification band and mentioning to the patient an approximate length of time they can expect to stay in hospital.

The second criterion focused on the reports of patients, families, and health care providers. Most reports of patients, families, and health care providers either by their verbalization or objective assessment, mentioned that the patients aren't satisfied about the current policy for feeling safe and secure in the environment.

As the policy has a major goal to admit the patients in an easy and safe way, the desirable outcomes of applying the current policy are to provide safety for patients, satisfy feelings of being safe and secure in the environment, and using the least restrictive approaches to achieve these outcomes as reported by patients, families, and health care providers.

The most important criterion is the effectiveness of achieving the desired goals appropriately. Other important criteria include administrative ease of the policy. This can be measured by using solutions that do not require more new structures, staff, or other resources. Cost is another important criterion; this can be measured by identifying the cost of implementing solutions on taxpayers, such as the cost of implementing solutions in the term of staff, equipment, operating expenses, benefits paid.

In addition to the previously mentioned criteria, other criteria include the net benefits, equity, legality, and political acceptability. Net benefit is the benefits that can be achieved if compared with the costs, equity refers to the distribution of the benefits equally on the service users, legality includes the presence of authority to implement the proposed solution, and political acceptability refers to being the proposed solution acceptable to political leaders or popular among general citizens.

3. Identify alternative policies
To identify alternative policies, brainstorming and obtaining solutions using alternative policies developed by experts, were used. However, considering the status quo or no-action alternative, was applied.

The first option to stay with the status quo or no-action alternative. This option includes leaving the current policy free from any additional instructions that enhance patients' ability to feel safe and secure in the environment.

The second option is including specific actions in the policy that enhance patients' ability to feel safe and secure in the environment. This option is derived from Protocol on Admission to Hospital in Shetland (2004) which included specific instructions, for example:

• Each patient arriving at the hospital must be greeted by a member of staff who must introduce themselves by name and title e.g. doctor, nurse. An outline of the admission process must be described. The name of the doctor under whom the patient has been admitted must be given and details of any routine procedures, i.e. taking of details, routine observations, blood test, must be explained.
• The patient must be orientated to the local environment including toilets, washing facilities and nurse call bell system.
• On arrival to the allocated bed, it must be considered if it is appropriate to introduce the patient to others in the bay.
• The ward routine must be explained. A copy of the generic hospital booklet 'Welcome to Princess Basma Hospital' must be made available to the patient and in addition local information relevant to the ward area should be shared and supported with a local booklet detailing, for example, ward round times, meal times and any other specific information.
• Visiting times must be explained clearly, highlighting the reasons for restrictions and these details should be highlighted to any accompanying person.
• The patients must be asked if they have any particular needs to be addressed during their hospital stay. At this point it is important to establish if the patients have any communication requirements.
• On admission each patient must be made aware of the approximate length of time they can expect to stay in hospital.
• Each patient must be involved in their plan of care and must be kept informed of their progress.
• Each patient must be informed that if they wish to raise concerns or are unhappy with any aspect of their care, they may raise the matter with any member of staff so their problem can be resolved quickly.
• All patients admitted or undergoing treatment must have 1 wrist band detailing the following:
• Full name
• Date of birth
• Patient number
• The wrist bands must be red if the patient is reported to have an allergy. All details must be checked with the patient or accompanying person prior to application.

The third option is including general actions in the policy that enhance the patient's ability to feel safe and secure in the environment. This option is derived from admission to inpatient services policy by the Health Boards Executives in its Project Guideline (2003) which included general instructions, for example:

• Provide the best available evidence practice and treatment within a safe environment for consumer, staff, carers and visitors
• The consumer and recognized carers should have the opportunity to discuss any issues encountered during admission, during any period of leave and as part of the discharge planning process with their treating medical officer and members of the treating team.
• Extended access to rapid assessment clinics and outpatient radiology and pathology services.
• Rapid assessment and extended access to diagnostics (unnecessary delays in admitting and/or discharging patients from hospital may arise from avoidable delays in patient assessment by specialists, duplication of tests or the absence of high or low dependency beds).
• Early Senior Medical decision making available at the point of admission.
• Close multidisciplinary team work.
• National agreed standardized triage processes to ensure clinical prioritization of patients on their arrival in the Emergency Department and to ensure timely and appropriate care is delivered.
• Patients should be streamed into the following categories:
i. Resuscitation;
ii. Minor illness and injury stream (patients who are unlikely to be admitted);
iii. Pediatric cases;
iv. Specialized medical/surgical team assessment for patients who may require admission; psychiatric case assessment service.
• Care pathways to minimize delays in the Emergency Department if admission is definite.
• These pathways should be developed in consultation with the relevant professionals and stakeholders.
• Rapid access facilities such as Medical Assessment Units (MAU) requiring robust, specific and auditable operational policies.
• Protocols for transfer of patients within and between regional areas and tertiary units to continue to be developed and implemented with pre-hospital emergency care, trauma teams and other relevant parties.
• Short Stay observation wards or Clinical Decision Units (CDUs) are advocated in emergency patient care. Such units should be directly adjacent to the Emergency Department and should be supervised by Consultants in Emergency Medicine. The length of stay should not be greater than 24 hours.
• Chest Pain Clinics, geriatric, respiratory clinics and in-house specialist services should be used to fast track patient management where possible.
• Information Systems should be used to provide comprehensive comparable and reliable data on activity waiting times. While a least restrictive approach is used this must also be balanced against an emphasis on safety for consumers, staff, carers, visitors and that of the general public.
• An information sheet as to the consumers rights is to be provided to the consumer along with an explanation of the purpose of admission and an indication as to the plan of care that has been developed to respond to the consumers needs inclusive of an explanation about any prescribed medication.

The fourth option is providing handbooks for patients that describe all general and specific instructions and patients' rights that enhance patients to feel safe and secure in the environment. This option, however, was developed using brainstorming and includes some nurses' work in Princess Basma Hospital.

4. Assess alternative policies

Option 1:
The first option is the staying with the status quo or no-action alternative. This option includes leaving the current policy free from any instructions that enhance the patient to feel safe and secure in the environment. This policy is currently applied. The expected outcomes of applying this policy are that the patient will be admitted in an easy way. However, patients who are admitted according to the current policy do not feel completely safe. Patient usually feels "shocked" because of the new environment and many aggressive incidents occur.

This is a direct result of not being oriented to the surrounding environment. The expected outcomes for applying this option are not fully consistent with the desired policy goal which aims to admit patients easily and safely into the hospital.

This option however does not satisfy patients' needs for safety. It may need to be discarded, but we need it as a base line for comparison between the other options.

Option 2:
The second option is including specific actions in the policy that enhance patient's ability to feel safe and secure in the environment. This option aims at including many specific instructions that enhance patients' feelings of safety such as orientation to the local environment, persons, and procedures, including toilets, washing facilities, nurse call bell system, time of food, taking of details by health care professionals, routine observations, blood test, visiting times, introduce the patient to others in the ward, introducing to health care professionals by name and title e.g. doctor, nurse, presence of identification band and mentioning to the patient an approximate length of time they can expect to stay in hospital.

This option has an opportunity to be applied. The expected outcomes of applying this policy are that the patient will be admitted in an easy and safe way. Safety will not be limited to the physical aspect, but the patient will feel psychologically relaxed in the new environment.
This is a direct result of applying client centered policy within the new environment. The expected outcomes for applying this option are fully consistent with the desired policy goal which aims to admit patients easily and safely into the hospital.

Option 3:
The third option is including general actions in the policy that enhance the patient's ability to feel safe and secure in the environment. This option aims at including some general instructions that enhance patients' feelings of safety, such as mentioning that the care should be provided during admission within a safe environment for consumer, staff, carers and visitors and that the patient and recognized carers should have the opportunity to discuss any issues encountered during admission, any period of leave and as part of the discharge planning process with their treating medical officer and members of the treating team. Another example is that of an orientation to the physical layout of the unit and unit programs and routines, but without mentioning them specifically.

This option has an opportunity to be applied. The expected outcomes of applying this policy are that the patient will be admitted in an easy and safe way. Safety will not be limited to the physical aspect, but the patient can feel psychologically relaxed in the new environment. However, although this policy can be described as client centered, the application of the policy may differ according to the staff's general understanding of the policy because it has general statements. This can hinder some important actions needed to enhance the feeling of being safe and secure within the new environment. The expected outcomes for applying this option are partially consistent with the desired policy goal which aims to admit patients easily and safely into the hospital.

Option 4:
The fourth option is providing handbooks for patients that describe all general and specific instructions in addition to patient's rights that enhance feeling safe and secure in the environment. Each patient must have a copy of this book. This option aims at including general and specific instructions that enhance patients' feelings of safety that are a compensation of instructions in option two and three. The hand book will be explained to the patient who cannot read by a staff nurse or a family member. This option has a difficulty in application because it will be costly. However, the expected outcomes of applying this policy are that the patient will be admitted in an easy and safe way. Safety will not be limited to the physical aspect, but the patient can feel psychologically relaxed in the new environment. The expected outcomes for applying this option are fully consistent with the desired policy goal which aims to admit patients easily and safely into the hospital.

5. Display and distinguish among alternative policies
After generating four policies, it is necessary to narrow the options to choose the policy that is most consistent with the evaluation criteria. To compare the alternative policies, a table of matrices will be applied. This table describes and compares the policies using scenario comparison and identifies strengths and weaknesses of each alternative according to the evaluation criteria.

Click here for Scenario table for admission policy in the Princess Basma Hospital focusing on the problem of safety

The most important criterion for comparison between alternative policies is the effectiveness of policy and achieving the desired goals appropriately. As identified by this table, the most effective policy is policy option 2. However, the worst and least effective policy for achieving the desired goals is policy option 1. The policy options 3 and 4 can be effective but less than policy option 2. Other concerns for the policy options 3 and 4 is that policy option 3 is general and vague and policy option 4 can be costly.

As inferred from the previous discussion, the best option for making patients feel safe and secure in the environment is policy option 2 which aims at adding specific actions (described on page 7 and 8) to the current policy that enhance the patient's ability to feel safe and secure in the environment.

6. Implement, Monitor, and Evaluate the Policy
As there is a quality management office in Princess Basma Hospital, implementation of the current policy will be with coordination with the quality management office. Implementation will include adding specific instructions to the current policy to obtain client centered policy that enhances feelings of safety and security during admission. These instructions should be included in a separate section called safety insurance section. The following are specific instructions that will be added and include:

• Each patient arriving at the hospital must be greeted by a member of staff who must introduce themselves by name and title e.g. doctor, nurse. An outline of the admission process must be described. The name of the doctor under whom the patient has been admitted must be given and details of any routine procedures, i.e. taking of details, routine observations, blood test, must be explained.
• The patient must be orientated to the local environment including toilets, washing facilities and nurse call bell system.
• On arrival to the allocated bed, it must be considered if it is appropriate to introduce the patient to others in the bay.
• The ward routine must be explained. A copy of the generic hospital booklet 'Welcome to the Princess Basma Hospital must be made available to the patient and in addition local information relevant to the ward area should be shared and supported with a local booklet detailing for example, ward round times, meal times and any other specific information.
• Visiting times must be explained clearly, highlighting the reasons for restrictions and these details should be highlighted to any accompanying person.
• The patient must be asked if they have any particular needs to be addressed during their hospital stay. At this point it is important to establish if the patient has any communication requirements.
• On admission, each patient must be made aware of the approximate length of time they can expect to stay in hospital.
• Each patient must be involved in their plan of care and must be kept informed of their progress.
• Each patient must be informed that if they wish to raise concerns or are unhappy with any aspect of their care, they may raise the matter with any member of staff so their problem can be resolved quickly.
• All patients admitted or undergoing treatments must have 1 wrist band detailing the following:
- Full name
- Date of birth
- Patient number
• The wrist bands must be red if the patient is reported to have an allergy. All details must be checked with the patient or accompanying person prior to application.

After including these instructions in the current policy, the new policy will be announced and applied. Nurses will be trained to apply this policy. The monitoring system will include a check list including each of the new instructions. The check list will be filled in by the patient and saved in the patient's file. Patients will have the right to put a question mark on items that were not explained or applied for them.

Evaluation of the policy will depend mainly on achieving the intended outcomes by making patients feel safe and secure within the environment. Achieving the intended outcomes will be measured using a semi structured interview with the patients and staff and comparing them with the base line data regarding safety. After that, the implementation of the new policy will be applied for the first six newly admitted patients. The result will measure the achieving the intended outcomes.

Conclusion
The policy remains a live document and will be refined, updated and expanded following implementation, evaluation and the introduction of any new alternative or legislation relating to admission policy. It is our aim to ensure that the patient's journey through the admission process and subsequent hospital stay and discharge, are as smooth and trouble free as possible.

References
Health Boards Executives in its Project Guideline: admission and discharge policy (2003).
Retrieved from http://www.dohc.ie/issues/health_strategy/action84.
pdf?direct=1
Peterborough and Stamford Hospitals Admission Policy (2008). Retrieved from
http://www.peterboroughandstamford.nhs.uk/_files/policies/1212020admissions20policy.pdf
Protocol on Admission to Hospital in Shetland (2004). Retrieved from
http://www.shb.scot.nhs.uk/documents/pphandbook/documents/
HospitalAdmission.pdf
Victorian Hospital Admission Policy (2011). Retrieved from
http://www.health.vic.gov.au/hdss/vaed/adm_policy_1_Jul2011.pdf