Introduction
There is a problem related to emergency departments in Dubai governmental hospitals. Despite numerous models of care that have been developed to reduce overcrowding and processing time in the emergency room, the current situation is not as favourable as it can be. Therefore, this problem has a negative impact on both patients and medical staff. An extensive number of patients and the absence of the facilities necessary to provide qualified emergency procedures produce adverse outcomes (Kader, 2019). One possible reason is a lack of studies using quantitative and qualitative methods to investigate the extent of issues regarding the lack of resources that directly impact the level of healthcare. Such examinations could result in a reliable overview of the problem and an implementation of a remedy for the issue of inefficient management resulting in overcrowding.
Policy problem
Despite numerous models of care that have been developed to reduce overcrowding and processing time in the emergency room, the current situation in the government healthcare sector of Dubai revealed numerous problems associated with the emergency departments, having a negative impact on both patients and health care workers (Appendix A). The problem directly impacts the quality of service provided by healthcare workers and causes significant disruption to both patients and medical staff, as well as increases infection rates. An extensive number of patients and the absence of the facilities necessary to provide qualified emergency procedures produce adverse outcomes (Kader, 2019). Researchers have examined these issues and found a maximization in violations during the last years, which correlates with the idea that Dubai requires additional safety measures and improvements (Al-Alawy et al., 2021a). Moreover, researchers mention that Dubai healthcare facilities will benefit from developing performance measures and specific regulations that address problems within organizational outcomes and patient satisfaction (Al-Alawy et al., 2021b). A study examining the same domain concluded that patients seeking healthcare services in Dubai are unsatisfied with the waiting time caused by significant influxes of people aiming to receive medical advice or treatment (Aburayya et al., 2020). The evidence proves that the city in question is the location that is most affected by overcrowded emergency departments.
The resolution of the overcrowded emergency departments issue in Dubai is also relevant. It aligns with the Social Development Goal 3 (SDG-3), achieving good health and well-being for all ages. The United Nations established Seventeen SDGs in 2015 to gain a better future for all. Since the United Arab Emirates aims to diversify its income sources and become a more attractive tourist destination, especially with cities like Dubai, meeting SDGs is considered one of the country’s priorities. There are 13 targets and 28 indicators that reflect the progress in achieving SDG-3 (Sundewall & Forsberg, 2020). Some of them can only be met in case the overcrowding in emergency departments issue is solved. For example, target 3.5 to reduce mortality from cardiovascular diseases and suicide, target 3.6 to reduce road injuries and deaths. In other instances, emergency departments also play a pivotal role in reducing mortality if proper care is delivered on time.
The primary issue is overcrowding of patients in emergency departments in Dubai governmental hospitals. One of the causes of this issue is extensive amount of time taken in the emergency department. Most patients take more time than required in obtaining health care services. One of the reasons for the extensive time taken in the department is the lack of numbers of adequate medical staffing. (Chang et al. 2018). The lack of adequate training is another issue related to the extensive time taken in the departments. This results in delays in service delivery. There is a lot of documentation in the emergency departments, and this results in a significant amount of time taken to attend to patients.
Another significant issue of overcrowding in emergency departments in Dubai governmental hospitals is the visit of non-urgent patients who insist on being seen in an emergency department instead of being treated in Primary Health Care (PHC). According to the research conducted by Idil et al. (2018), among non-urgent patients, most of which do not have a chronic disease and have health insurance, the most common reasons to prefer an emergency department are “to get examined quicker (36.4%), and not being able to book early appointments with alternative health units (30,9%)” (p. 72). The factor that contributes to the main cause is the lack of medical insurance, which results in patients rushing to the emergency departments in Dubai governmental hospitals. According to ASPE (2021), “The proportion of emergency department visits generally reflected changes in rates of health insurance coverage” (p. 8). It implies that unaffordable costs of insurance lead to an increase in the number of non-urgent patients visiting emergency departments.
Finally, the second main cause of the problem is the understaffing in hospitals which prevents the effective management of an increased number of patients. It has already been mentioned that patients complain about the inability to book an early appointment in a hospital that contributes to the overcrowding of emergency departments (Idil et al., 2018). Simultaneously, according to Morley (2018), “nursing staff shortages as a cause of emergency department crowding was highlighted in exploratory fieldwork undertaken with 158 emergency department directors in Canada” (Input section). This fact evidences the significance of understaffing as a cause of emergency departments overcrowding. The discussed problem can lead to additional issues such as poor quality of health care services, medical staff’s burnout, medical errors, and dissatisfaction in patients and health care workers (Appendix B).
Importance of Government Intervention
The government should consider the following problem due to its contribution to social issues, lack of regulations, and market failures.
UAE Vision 2020 specifically emphasizes the importance of having a world-class healthcare system, which directly correlates with improving patient satisfaction and risk mitigation (Salim & Rahman, 2017). Since the government illustrates the significance of addressing this domain, contributing to a more organized emergency department is one of the initial concerns that require improvement. In terms of social collapse, the issue elevates morbidity and mortality rates resulting in public health load. Moreover, the emerging obstacle of an increase in medical errors led to the burden associated with civil lawsuits and regulations issues (Strzelecka et al., 2021).
Moreover, Economists use the term market failure to categorize situations or conditions that lead to an inefficient allocation of services in the free market because the observed equilibrium deviates. The health department in Dubai experiences many problems in the emergency department, one of which is the hospital failure in the market. Economists, in essence, acknowledge that market failure leads to a net loss (Lumenlearning, 2019). Regarding healthcare and hospitals, the reasons for market failure also include price discovery. It is when clients, or in this case patients, are able to know the price before receiving treatment. Secondly, there is no economic competition between emergency departments because it is impossible to predict the number of patients and the cost of their treatment. Finally, the healthcare industry globally and in the UAE also experiences a shortage of nurses and physicians (Cherian et al., 2018). Hence, there is no constant equilibrium between patients and healthcare providers. Therefore, the normal logic of economic processes does not entirely apply to hospitals, even though they are private.
Market failure in healthcare is an important topic, as it poses challenges of rising costs of services as well as supplying a sufficient amount of healthcare professionals that would match the demand. The problem is even more complex for emergency departments due to its unpredictable cost of operations and constantly growing demand. In Dubai, most hospitals are private, with only 6 out of 38 facilities being government hospitals. Therefore, providing free treatment to stabilize the state can be financially problematic to some hospitals, so they do not expand their emergency departments. This is why market failure in hospitals in UAE is an important issue.
Market failure in the healthcare department manifested through delayed treatment, stretched resources, and leads to poor patient outcomes. Also, it may lead to ambulance diversion because patients may leave before being checked by the physician. Again, an overcrowded emergency creates a high risk of medical errors that threaten the patient’s safety. Critically ill patients have to wait for long hours in the overcrowded emergency departments where they are boarded therefore deteriorating their conditions (Arnould & DeBrock, 1986, p. 288). For this reason, the hospital markets fail due to the stiff competition implied by the other hospitals. Due to the poor services, patients will choose better hospitals that do not have an overcrowded emergency, reducing the hospital’s economic status because the occupancy level will reduce and minimize output. Therefore, market failures are the primary reasons the government intervenes in the healthcare market (Nichols, 2012, p. 555). The government can intervene by providing services and direct funding to the healthcare services (Wallis & Dollery, 1999, p. 9). Besides, the hospital should use the funds provided by the government to expand its capacity. Secondly, avoiding boarding patients admitted in the emergency department, providing alternatives for primary care, and providing care to patients with emergency cases will reduce overcrowding in the emergency department, hence improving the hospital’s market.
The reasons why the government should intervene to solve the problem include the disruptions caused by overcrowding in Dubai governmental hospitals. Firstly, it could lead to high morbidity and mortality levels associated with emergencies, including traumas and operations. Secondly, patient management procedures could be delayed due to the increased load on the medical staff. Thirdly, the overcrowded emergency departments issue could increase the waiting time, which is highly undesirable in emergency and acute situations. Fourthly, the professional burnout and dissatisfaction of healthcare workers are associated with the medical staff’s stress and anxiety at a period of high workload (Kader, 2019). Finally, overcrowding and overload lead to common medical errors; high workload and stressful environment result in mistaken procedures starting from documentation to diagnosis identification.
Governmental support and intervention are required because of the effect on the healthcare system of Dubai city. If this tendency continues, it will harm the image of healthcare workers in Dubai government healthcare facilities (Muslim, 2019). Moreover, the issues mentioned above, such as poor quality of healthcare services, professional burnout, dissatisfaction, an increased number of medical errors, will ruin the Dubai healthcare system (Muslim, 2019). Government should take action as the quality of the healthcare services will affect the quality of life of the general population (Muslim, 2019). Moreover, this issue could create a private emergency healthcare sector leading to financial loss in medicine.
Policy Objectives
The Dubai government is facing the problem of overcrowded emergency rooms in the government health sector, and therefore, there is an immediate need to set important targets for the development of a policy plan.
The policy objectives are:
- To increase the awareness of the public about PHC facilities for non-emergency cases.
- To reduce the burden on the medical staff.
- To improve the quality of healthcare service.
- To decrease mortality and morbidity rate with infection rate.
- To develop strategies between ambulance and ED
Policy Context and scope
The offered policy is a unique approach to the existing problem of overcrowded emergency departments in Dubai governmental hospitals. According to the UAE Healthcare Department (n. d.), a similar strategy has never been implemented prior. A similar model based on identical desired outcomes was proposed in Iran in 2015, aiming at effective overcrowding management (Babatabar-Darzi et al., 2020). Successful experience of the neighbouring countries and Western models could help cope with the issue in question by acting as real-life examples and helpful information that can give an overview of the potential future.
The scope of measures that will be considered to address overcrowding are:
- Community awareness.
- Creating a list of critical diseases directed towards paramedics in case patients in the red zone contact physicians.
- Giving doctors in the emergency department triaging training.
- Encouraging the community to visit PHC by making access easy.
- Increasing the number of PHC clinics in the community.
- Connecting emergency doctors and PHC with the paramedics to develop policies.
- Planning strategies to manage physicians’ professional burnout.
- Ensuring instantaneous and appropriate responses to emergency cases.
- Providing protected emergency care services.
The policy will be implemented in Dubai city and be available for all patients delivered to a government emergency department.
High Level Information Requirement
This is a new policy directed to improve the quality and satisfaction of patients and medical staff. As this strategy was not implemented before in the given region, it requires careful investigation and research. The central strategic development will rely on the experience of a foreign country and will be adapted to the local lifestyle. The existing platform that has adequate measures regarding quality patient care is the Joint Commission of International Accreditation (JCIA). Another system that will be utilized is the Canadian Triage. The method illustrates the acuity of the patient’s state.
Stakeholder Engagement Plan
Stakeholder Identification
The selection and analysis of the stakeholders relevant to the proposed policy have been conducting using PESTEL and SWOT analyses (See Appendices C and D). Overall, nine stakeholders have been identified, including patients, medical staff (physician/nurse), emergency department, Government hospital (DHA), primary health care centers, governmental institutions, Healthcare Department of the government hospitals in Dubai, Joint Commission International Accreditation (JCIA), World Federation of Public Health Associations (WFPHA).
Emergency department overcrowding contributes to problems for patients by increasing their waiting time, length of stay, and morbidity and mortality (Salway et al., 2017). The policy proposal will address patient needs and aim to improve the quality of health care services in Emergency Departments and Healthcare Centers. The policy proposal will reduce the overburden on the medical staff, which justifies the assumption that this group will support it. The proposed policy recommends adequate strategies after analysing the current situation and addresses the issues associated with overcrowding in emergency departments, such as difficulties in bed management and poor patient flow in emergency departments.
DHA will be involved in the policy implementation process as the health care regulator. Overcrowding in primary health care centers results in increased waiting times, prolonged patients’ length of stay, poor access to services, financial losses, as well as dissatisfaction in patients and staff (Salway et al., 2017). The overcrowding problem decreases the quality of care, thus interfering with the government’s objective to maintain the high standards of medical services (Bahadori et al., 2017). The Healthcare Department of governmental hospitals in Dubai will benefit from developing performance measures and specific regulations. JCI can assist in developing and implementing high standards-driven policy to improve the quality and safety of care in Dubai city. WFPHA can contribute to the development of the proposed policy since it aims at encouraging partnerships among public health professionals that promote health care safety and quality through action and collaboration.
Stakeholder Analysis
The stakeholder analysis indicates that it is important to involve a group of stakeholders with high levels of both influence and interest. This group includes Government hospitals (DHA) and governmental institutions (See Appendix E). The group of stakeholders that should be monitored includes WFPHA; it is essential to manage the Healthcare Department of the government hospitals in Dubai and JCIA. Finally, patients, medical staff (physician/nurse), emergency department, and primary health care centers should be acknowledged when implementing the policy.
Stakeholder Participation Plan
Patients
Dubai is one of the cities in the UAE that harbour a significant population of individuals from different regions. Therefore, emergency department overcrowding contributes to problems for patients by increasing their waiting time, length of stay, morbidity, and mortality (Salway et al., 2017). The policy proposal will address patient needs and aim to improve the quality of health care services in Emergency Departments and Health Centers. Hence, it is expected that this group of stakeholders will support the change. Printed and electronic communication channels will be utilized to inform patients about the policy options, and surveys will be conducted to obtain data to improve patient satisfaction and allow patients to express their concerns. Among the possible risks associated with the participation of this group of stakeholders are communication risks, lack of data, and insufficient feedback. Clear and open communication must be ensured to encourage patient involvement.
Medical Staff (Physician/Nurse)
Patient overload poses an imminent effect on medical practitioners due to the persistence in maintaining high standards under stressful conditions. The current policy problem implies medical staff burnout and dissatisfaction, which, in turn, contribute to occupational illnesses, poor work-life balance, the possibility of developing unhealthy coping strategies, and medical errors (Bahadori et al., 2017). The policy proposal will reduce the overburden on the medical staff, which justifies the assumption that this group will support it. Medical staff will be informed about the policy options and engaged in the process to promote proposals on improving the quality of care in emergency departments. Team meetings, clinical workshops, and surveys will be used to gain the staff’s opinion and support for the policy. Organizational and communication risks and the lack of support and commitment are considered threatening. Medical staff’s involvement must be promoted as a source of insight into addressing the problem.
Emergency Departments
The central role of the healthcare management team enshrines advocating for timely care for customers to avoid the risk of complications. Emergency Departments in Dubai are affected by the overcrowding problem. The proposed policy recommends adequate strategies after analysing the current situation. It addresses issues associated with overcrowding in emergency departments, such as difficulties in bed management and poor patient flow. Therefore, it is expected that emergency care providers will support the suggestion. Electronic communication channels and phone calls with emergency departments will be ensured to keep the stakeholders informed and involved in the collaborative process to improve the quality of health care. It is essential to reach out to emergency departments to involve them in the project initiative.
Governmental Hospitals (Dubai hospital and Rashid hospital)
Governmental hospitals will be involved as the entity regulating the health care industry. Its positive response with regard to the initiative is crucial, and clear communication will be ensured through electronic channels and phone calls to reach the desired outcomes. Careful planning is critical for required equipment and materials for the overcrowding problem elimination.
Primary Health Care Centers
There is an interdependent relationship between sustainability and the medical care index across the public domain. Overcrowding in primary health care centers results in increased waiting times, prolonged patients’ length of stay, poor access to services, financial losses, and dissatisfaction in patients and staff (Salway et al., 2017). The support of this group is expected since the policy proposal aims to provide all necessary equipment and materials necessary to eliminate the problem. Communication with primary health care centers will be ensured through electronic channels and phone calls to keep the stakeholders informed and allow for their involvement and contribution to the problem-solving process. It is essential to reach out to primary health care centers to involve them in the project initiative.
Governmental Institutions (DHA)
Patient protection is a prominent factor across the Dubai environment, hence involving the administrative organs in the outlying conditions. The primary purpose of the Dubai Health Authority (DHA) is to protect public health and ensure an accessible and efficient health care system. DHA will be involved in the policy implementation process as the health care regulator. Furthermore, it is crucial to raise public awareness and encourage the population’s trust in the healthcare system. Governmental institutions will be contacted through electronic and phone communication channels for collaboration and direct involvement in policy implementation. It is critical to obtain this stakeholder’s support to ensure the success of the initiative. Clear communication and well-defined processes are required to ensure efficient change management.
Joint Commission International Accreditation (JCIA)
Different stakeholders focus on the implementation of strategies that elevate the welfare of the personnel. Joint Commission International (JCI) provides the service of international health care accreditation to medical facilities worldwide. JCI can assist in developing and implementing high standards-driven policy to improve the quality and safety of care in the UAE. Healthcare Department of the government hospitals in Dubai. In this case, JICA’s involvement fosters significant attribution of dynamism in the perspective of the proposal. JCIA will be reached through electronic communication channels to seek collaborative effort in standards-driven policy implementation. Its purpose of improving the quality and safety of care in medical facilities worldwide aligns with the proposed policy’s objectives, which implies possible fruitful cooperation. Although no substantial risks are expected, it is necessary to ensure that a strong commitment to quality patient care in Dubai is demonstrated to ensure efficient collaboration with JCI.
World Federation of Public Health Associations (WFPHA)
The plan on alleviating the issue of overcrowding in the facilities in Dubai renders the importance of the entity’s participation in the practice to assert international standards. This non-governmental organization aims at encouraging partnerships among public health professionals that promote health care safety and quality through action and collaboration. Hence, WFPHA can contribute to the development of the proposed policy. It is crucial to include the institution cause of the prominent effect of the adversities to the global population. WFPHA will be involved through electronic communication channels to encourage international collaboration and exchange for health care quality promotion. No substantial risks are expected from the involvement of this stakeholder in the policy implementation.
Figure (3): Theory of change
Policy Theory of Change summary
Patient overcrowding in the emergency department is a major public health issue due to deterioration in care quality such as (missing and delay treating critically ill patients, prolong stay in ED). also, it led to loss resources and increase the cost. Therefore, the policy first aims are reducing patients overcrowding in emergency department, by encourage the population to use the PHCs for the non-emergency situation through increase public knowledge about the PHCs availability as a policy outcome and raise public awareness through campaign as an output. The second impact of the policy is to reduce the mortality and morbidity rate through minimalize the medical error by increasing the medical staff satisfaction, decrease the staff burnout and reducing the number of patients per each medical staff though diversion the non-emergency cases to the PHCs, increase the number of PHCs and build PHC near the overcrowding hospital. Decrease the health risk and the infection risk are the third impact in our policy which can be achieved through decrease the patients waiting time by keeping expert triage staff in triage area and provide the staff with proper training and proper technology. The final impact is to enhance the quality of services, by retaining the qualified staff and prevent the resignation and sustain the emergency department financial stability and prevent loss the resources through triage away the non-emergency cases to the nearest PHCs, which will lead to distribute the workload in a more efficient way among health care units. The output in this situation is implementing standard triage system between the emergency department and PHCs and implementing the law that forces the employer to offer health insurance to all employee. Finally, the Inputs are integral elements of the planned work towards achieving the intended results. The project initiative suggests providing of technologies and the number of medical staff, Furthermore, it is proposed to build more hospital, increase the number of (PHCs), train more family physicians, add triaging doctors in emergency department, and provide additional training workshops to medical staff, all can be achieved through funding and training.
Identifying and appraising policy options
Selecting the short list of policy options
Conclusion
Resources, such as new health care facilities and personnel, are vital in addressing the problem of overcrowding (DHA, 2018). along with financial resources, including expenses associated with training of family physicians and triage system training for ED nurses. The hypothesis for dealing with overcrowding patients in emergency departments is to implement many changes in the system, beginning with providing health insurance to all UAE citizens so they can access medical services in PHC and overload the emergency depart ,increasing the use of advanced technologies, increasing the number of medical staff, and building more hospitals, increasing the number of primary care clinics and training more family medicine physicians, and increasing public awareness about the problem.Implements these changes need time and it will take at least 6-12 months to see some result for example adding triaging doctor we can measure the effect statistically bun ember patient seen per shift, day and month, KPI measurement also will help monitor the improvement and can measure the patient’s satisfaction.
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Appendices
Appendix A. Issue Tree Diagram
Appendix B. Causes Tree Diagram
