Commissioning New Hospital Facilities

in

South Africa

A Manual of Good Practice

Commissioning new hospital facilities in South Africa

Commissioning new hospital facilities in South Africa

COMMISSIONING NEW HOSPITAL FACILITIES IN SOUTH AFRICA

A Manual of Good Practice

Second edition

Andrew Butcher

May 2002

HLSP Consulting, London, 2002 First edition, 1999 Second edition, 2002

Supported by a grant from the United Kingdom Department for International Development (DFID)
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Acknowledgements
The assistance of many colleagues in the drafting of this manual is acknowledged with gratitude. Those involved in managing and commissioning the new academic hospitals in Durban, Pretoria and Umtata have helped to work through the practical detail here. Those who contributed to the workshop in Durban in July 1999 will see some of their efforts reflected in these pages. Tim Wilson, Thabo Sibeko and Nico den Oudsten in the South Africa National Department of Health have encouraged the production and given guidance. Particular thanks are due to Malcolm Kilvington who has helped and advised me on much of the detail here. He has shared the material which he is developing as part of his work with the South African Departments of Health and hospitals. This work is currently being piloted in the Eastern Cape by Sydney Mafu, Deputy Director of Health Facilities Planning in the Directorate of the Policy, Planning, Information and Research. The list of contents of the workbook is included as Appendix 1. The front cover photograph of the new Nelson Mandela Academic Hospital, Umtata, was supplied by Malcolm Kilvington. I am grateful to all for their assistance. The UK Governments Department for International Development (DFID) has funded my work in South Africa from 1998 - 2002 through a contract with the Health and Life Sciences Partnership (HLSP). DFID has also funded the design and printing costs of this manual. The European Union has funded Malcolm Kilvingtons work. This funding is acknowledged with gratitude. I would be glad to receive comments from anyone using the manual. Comments should be sent to: Andrew Butcher HLSP Consulting 27 Old Street London EC1V 9HL England phone: fax: e-mail: +44 20 7253 5064 +44 20 7251 4404 andrew.butcher@ts21.org

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Contents
Acknowledgements Preface An overview of commissioning Introduction Project direction The Commissioning Team Strategic and business planning Project planning Hospital management Operational policies and procedures Equipping Workforce planning Public Private Partnerships (PPP) Facilities Management Building handover and building commissioning Opening sequence The costs of commissioning The costs of sustaining the investment Risks and impediments Ten key tasks and challenges 2 4 5 8 9 9 11 11 12 13 13 15 18 18 20 21 22 22 22 23

Appendices
1. Integrated Hospital Capital Investments Commissioning Workbook - List of contents 2. Job description and person specification for Commissioning Director 3. Operational Policies and Procedures 4. Inkosi Albert Luthuli Central Hospital - Employee Transfer Strategy 24 26 29 34

Biographical details

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Preface
The material contained in this manual is based on experience gained at three very different hospital building projects in South Africa, each of which has been underway in recent years.

Inkosi Albert Luthuli Central Hospital

The Inkosi Albert Luthuli Central Hospital (IALCH) has been built on a greenfield site. Not only is it a brand new building, it is also a brand new facility in the sense that it has no predecessor hospital. It comprises 850 beds providing quaternary and tertiary services to the whole province of KwaZulu Natal and part of the East and North East of the Eastern Cape. It will be a postgraduate teaching hospital for all professions. The new hospital will open to patients in 2002.

Pretoria Academic Hospital

The new building at the Pretoria Academic Hospital (PAH) will replace the existing hospital, which first opened to patients in 1932 as the Pretoria General Hospital. It has gone through various additions over the years but because of the deterioration of the buildings, plans were developed for a replacement. Construction commenced in 1997 of a 777 bedded hospital due for completion in 2004.

Nelson Mandela Academic Hospital, Umtata, Eastern Cape

The project will provide a 480 bedded hospital in Umtata for secondary and tertiary level services. It is being built alongside an existing hospital, the Umtata General Hospital, part of which will continue to provide some services. Construction of the new hospital commenced in November 1998. The first patients will be admitted in 2002. The commissioning work for the three projects was considered at a workshop in Durban on 30 June and 1 July 1999. It was attended by representatives of the three projects and of the national Department of Health. The workshop had three objectives. 1. To introduce those involved in commissioning significant hospital projects 2. To identify and share good practice in commissioning 3. To develop networks which will allow for joint working in the future Some of the material in this manual was first presented at the workshop. Other material has been gathered as the three projects have developed since then.

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An overview of commissioning
Purpose
This Commissioning Manual is written primarily for those with overall responsibility for organising and funding commissioning rather than those embroiled in the detail of a complex project. It will also prove useful to those moving into commissioning for the first time and to those working in other parts of health care who need to know about commissioning in overall terms.

The importance of commissioning

Each and every new hospital building must be commissioned, ie brought into use. Without commissioning the new building will remain an empty shell or stumble into inappropriate use which is just as problematic and a waste of capital funds. Commissioning is required to turn the new facility into a dynamic, functioning organisation that provides a planned and improved service to the community. The commissioning process has to be well led and managed. This manual cannot just be taken off the shelf with a guarantee of trouble free commissioning. The detail here must be tailored to the particular circumstances of each individual project. Each commissioning project must be kept under review. It will not just happen of its own accord. The ideal time to begin the commissioning process is during the planning stage. From this point onwards, equipment suppliers will bombard the Commissioning Team with information and offers. Design teams will request detailed specifications, makes and models for some medical equipment so that appropriate mechanical services (drains, data connections, etc) can be incorporated in the correct room and position. At this stage, Commissioning Teams should only provide typical layouts and generic specifications to avoid being forced into guessing which specific equipment will be the final choice.

Commissioning - who leads it

Commissioning is a project management process and by definition must be time managed, be task driven and objective driven - this can only happen if the strategic direction has been agreed at the start. Good commissioning requires purposeful and constant management attention. It must be led by someone with sufficient seniority and authority to ensure decisions are taken when required, to ensure the team members perform to the standard expected, to ensure those outside of the Commissioning Team required to make a contribution do so and to ensure that timescales are maintained.

These considerations mean that the person heading the commissioning process must operate at a strategic level and have a personal track record of delivering results through a complex process. In this manual the person heading the function is referred to as the Commissioning Director. The use of the term Director should not be taken as an indication of their grade in the public sector.
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The Commissioning Director must report direct to the most senior hospital manager, either the Chief Executive Officer (CEO) or the Chief Medical Superintendent. This is to ensure the necessary direction is given for the commissioning process and to ensure speedy decision making.

Commissioning - what it is
Commissioning is bringing into use, on time, a facility that has been designed in consultation with those who will use it. It starts at the onset of a project, ie before building on site commences. It finishes with evaluation after the project has been completed and the facilities brought into use.

All aspects of a hospitals operation are likely to be affected by the commissioning process. Some work may not all be carried out by the Commissioning Team itself, but the process should be planned and managed by a dedicated Commissioning Director to ensure proper co-ordination and time management. Most major projects will require at least one full time dedicated and experienced Director to carry out the process. It is likely that the team will grow in size as the project progresses. A number of key tasks are to be undertaken by team members or by others whose work is co-ordinated by them. Project planning and project management Co-ordination of user input into the briefing and design processes Preparation of operational policies and procedures Identification and procurement of equipment Identification of staffing needs and recruitment Oversight of building handover Determination of the opening sequence

The development of whole hospital and departmental operational policies and business plans must be an integral part of the process. These are likely to take an immense amount of time. If the opportunity is taken in planning the new facilities to introduce new or changed working practices and staff skill mix, then commissioning is a still larger process.

Commissioning - what it is not

Commissioning is not only about equipment It is not only about engineering services Nor is about macro strategic planning Most importantly it is not a spare time role for the disorganised
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Although equipment costs do represent a significant component of the total cost of a new facility, Commissioning is about far more than equipment.

Commissioning - the context

The objective of the process is to bring into effective use the facilities, systems and staff of a new or refurbished healthcare building. The commissioning process starts after the strategic plans have been agreed It must be included as a function and cost in any Business Case It runs in parallel with design and construction It is a specialist function in major projects The Commissioning Director reports to the most senior hospital manager who should be the Chief Executive Officer or the Chief Medical Superintendent A multi-disciplinary Commissioning Team reports to the Commissioning Director The Commissioning Director prepares the commissioning project plan The commissioning plan defines, allocates and monitors tasks Commissioning requires co-ordination, teamwork and attention to detail

The main stages of a building project are shown in Figure 1. The diagram illustrates the important point that operational commissioning starts as soon as the decision has been taken to proceed with the project. Figure 1: Main stages of a building project.
Provincial strategic plan Decision

Facility business plan Decision

Design

Build

Commission Manage

Time

Commissioning is not something to be left to the end of a project. The Commissioning Team can only do their jobs if the strategic and political problems that affect the process are anticipated and resolved without delay. Strong business orientated management at an institutional level remains a major factor in successful commissioning.

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Introduction
Hospital Rehabilitation and Reconstruction Programme
A very substantial job has commenced in renewing and improving health facilities in South Africa through the Hospital Rehabilitation and Reconstruction Programme (HR&R). The programme itself was initiated as a result of the Health Facilities Audit undertaken by the Centre for Scientific and Industrial Research (CSIR) in the mid 1990s. The audit covered all health facility buildings in the country and demonstrated that there was a huge need to replace and renovate many of the buildings being used. Cabinet approved the HR&R programme in 1997 with an expected duration of ten years. The objective of the programme is to improve the equity of distribution and access to health facilities in the country. The budget allocated for HR&R in 2001/02 was R500m.

Hospital Revitalisation Programme

The HR&R programme is now being subsumed into a broader Hospital Revitalisation Programme. The principles of Hospital Revitalisation have been agreed within the national DOH and the level of funding is being finalised. The aims of the programme are broader than the building programme of the HR&R. They are to improve: a) the access of the poor and disadvantaged to hospital; b) the efficiency of public hospitals; and c) the quality of care in public hospitals. It is envisaged that the programme will consist of four parts: 1. 2. 3. 4. Revitalisation of public hospital buildings Improvements to the quality of care Strengthening hospital capacity for management and policy development Developing capacity for project management and evaluation

Funds will be made available for building infrastructure and equipment but only if each scheme is linked to quality improvements and organisational development for the hospital. The HR&R and Hospital Revitalisation programmes are in transition between the one and another. National expenditure on HR&R is tapering off whilst expenditure on Hospital Revitalisation is expected to increase, assuming Treasury approval of a major increase in year on year expenditure.

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Project direction
It is vital to determine who leads the project from the perspective of the relevant Health Department and, therefore, who has overall responsibility for its success. It is expected that this person will be the most senior hospital manager, either the Chief Executive Officer (CEO) or Chief Medical Superintendent. For the sake of consistency in this manual, this person is referred to as the CEO. The province will have a legitimate role in large projects and it is likely that the national DOH will have one as well. The province will undoubtedly have to appoint specialist hospital design and construction specialists. The provincial Departments of Public Works have traditionally managed this process on behalf of Health Departments. Provision of an accurate brief to the design team, payment of certified accounts and acceptance of the finished building will generally remain the responsibility of provincial Health Departments as the client body. The national DOH interest follows from it providing capital funds plus setting norms and standards guidance. It will also have an on-going interest if the new facility provides tertiary services as it will provide revenue funding through a conditional grant. However, both the national DOH and province should delegate overall responsibility for commissioning to the CEO who should be based at the hospital site. The key reasons for this are that the national and provincial staff will have many other projects with which they are concerned whereas the local CEO will be single minded about one. The CEO will also have continuing responsibility for running the facility once opened and therefore has a strong vested interest in ensuring it is built and commissioned to a high standard. The CEO must establish with adequate resources an organisational structure for commissioning which is appropriate for the task. He or she must recruit the Commissioning Director and determine the reporting mechanisms that must be followed. In addition the CEO must keep holding the Commissioning Team to account for performance and for maintaining timescales.

The Commissioning Team

A Commissioning Team is required to work under the direction of the CEO to bring the building which is handed over from the architect and contractor into operation as a hospital. The team must be headed by a Commissioning Director, who will report directly to the CEO, and who must be responsible for the day to day functioning of the team including the achievement of deadlines in the timetable. A copy of the detailed job description and person specification first drawn up for the Durban project in 1998 is included in Appendix 2. Other areas of expertise required in the team are: Project management, including a monitoring and evaluating role Equipment scheduling and procurement Engineering and building maintenance

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Human resource development Publicity/public relations PA, secretarial and administrative staff It is assumed that financial planning will be undertaken as part of the broader hospital and provincial management team. Human resource planning and development may also be undertaken as part of the wider organisation. The team needs to be provided with networked computers, which have, software installed to facilitate the inter-related tasks. Figure 2 shows a division of responsibilities between the hospital management and the Commissioning Director under the CEO. Figure 2: The division of commissioning responsibilities

CHIEF EXCECUTIVE OFFICER

HOSPITAL MANAGEMENT TEAM

COMMISSIONING TEAM

Operational management of existing and new facilities Financial planning Human resource planning and development Decisions about facilities management Public relations NB - Some functions will be undertaken jointly with the province

Project Management Co-ordination of user input to briefing Preparation of operational policies and procedures. Equiping Oversight of building handover Determination of the opening sequence.

During the course of the project or towards the end of it the team may need to be augmented by specialist staff. These may include medical, nursing or IT professionals who may be brought in from outside the hospital or who may be seconded from the hospital organisation itself. It must be understood that those seconded from the hospital organisation will continue to have regular duties there but they must be committed members of staff recruited for what in many cases will be a one-off chance to shape a new development and service.
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Strategic and business planning

Whilst commissioning is in some respects a set of tasks which on their own will lead to the opening of a new facility, they cannot be undertaken in isolation from the broader strategic context within which the building was planned in the first place. The new buildings are there for a purpose and that purpose has to fit into a framework for health care. Building from new or upgrading a hospital facility is a dynamic process. Treatment practices change over time and will do so during the life of any hospital building project. Therefore the CEO must have an active involvement in the project from the outset and have sufficient authority to be able to take critical decisions in respect, for instance, of finances, scheduling and usage. Decisions relating to changes in plans during the construction, will have to be managed strictly according to the rules laid down for approval of variation orders (VOs) and communication protocols. Otherwise project costs, claims for delay and abortive work will be incurred. During 2001, the national DOH implemented a strategic Integrated Health Planning Framework. A national model has been developed as a component of this framework and each province has to review its need for health facilities using the model. Outputs include the provincial Strategic Position Statement (SPS) and the identification of priority projects for inclusion within the revitalisation programme. No project will be included within the Revitalisation Programme without a business plan. This will describe the strategic context for the hospital and set out the implications for clinical workload, staffing and finances as well as indicate the knock on impact on existing services and buildings. It is essential to keep under review the detailed clinical content of the hospital, given the inevitable changes in medical technology and care regimes that take place during the life of a project. Changes may well occur in the strategic organisation of health care, with a consequent impact on levels of care and referral patterns. The new facility may be being planned at a time when other associated institutions are developing their own plans. For example a medical school or nursing college may be expanding or developing its curriculum. In such cases the hospital must be planned in conjunction with and not in isolation from its partner organisations.

Project planning
The commissioning process is task orientated and must fit into an overall timetable. As such it lends itself to a project management approach. The different components of commissioning fall into categories comprising: the definition of the overall strategy the definition of the individual deliverable projects the division of the individual deliverable projects into sub-projects the identification of the key tasks for sub-projects the division of the key tasks into activities the setting of achievable milestones the assignment of responsibilities tracking of progress
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There are several software products which can be used for project planning and management. Whatever product is chosen, its features must permit: the definition of time scale and milestones the definition of tasks the allocation of tasks the recording of progress with tasks & executive reporting the highlighting of problems and the effect on the programme the linking of tasks to determine optimum sequencing

The software is likely to produce the Gantt charts, which are a key tool for successful project planning, monitoring and reporting. They show recorded progress against planned progress with overall percentage completion. Reports can be generated at different levels of detail. The Commissioning Team itself will need considerable detail but the CEO needs a compressed or collapsed view of all tasks showing only the main project phases. These charts can be somewhat unpopular as they are time consuming to set up and keep up to date. They do, though, define the lead, order and time allowance for all the tasks to be done and if updated regularly and linked properly, will demonstrate if the project is slipping behind target dates, offering the opportunity to re-plan on paper or computer. If they are found to be too complicated for a particular product, there will still be a need for a visual timeframe showing critical paths and the timeframe will need to be kept up to date.

Hospital management
The CEO will need to review the management arrangements of the hospital. For a project which does not result in a significant increase in running costs, he may need to strengthen the hospital management temporarily. For a project that does increase the hospitals size, he is likely to have to increase on-going management resources with, perhaps, a change in management structure. Decisions about the longer term will have to be taken during the course of the project so they will have been implemented before completion. The financial consequences of any project will be significant even if they are only short-term onsequences lasting the life of the project. There are likely to be longer term revenue costs as well, though. The CEO must ensure all the costs are fully and accurately assessed, and that they can be met. Similarly, he or she must ensure the staffing implications are considered and plans made to meet them. There will be issues of both staff numbers and staff skills. In implementing such plans, numbers of staff may have to be reduced, where a project brings a more efficient or smaller building, or they may have to be increased. Training needs must be identified. Implementation of these plans, particularly where there are training implications, may take a number of years. Therefore it is also vital to secure and maintain strong links with local education institutions. It may be necessary to increase training places for undergraduate or postgraduate courses for a short or longer period of time. These changes will need to be planned and negotiated.

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The CEO will need to ensure the new facility benefits from good publicity. In part this is external to the hospital so that the public is informed during the course of the project. In part it is internal, as staff have to be both informed and prepared for the changes. There may well be a knock on effect onto other hospitals in the surrounding area when the new facility opens. These may be in the areas of clinical services, financial planning or in the use of the workforce. The CEO must be able to assess these issues, produce plans to address them, gain support for any necessary changes and ensure implementation.

Operational policies and procedures

A single policy and procedure statement is required for each department. This will incorporate two types of document, firstly, whole hospital polices - describing aspects of the hospital that are common to all departments and, secondly, departmental procedures which are concerned with the day to day management, organisation and function of each department. Writing operational policies and procedures for each department and function is a necessary part of planning. Without a coherent set of policies and procedures work in the hospital will not be properly co-ordinated, nor will incoming staff have an adequate basis for their induction training. Patient, staff and visitor safety will also be compromised if emergency procedures are not defined and known to staff. The policies and procedures should be written by those involved in running an existing department. Someone from the Commissioning Team should oversee the process to ensure consistency. It is essential to have a small committee established to resolve any uncertainties, disagreements or inconsistencies. Each policy and procedure must cover practical implementation and build in quality assurance, compliance with statutory standards and health and safety. A considerable amount of development work on operational procedures has been undertaken at the Pretoria Academic Hospital and at the Nelson Mandela Academic Hospital. The overall ontents list of each procedure at Pretoria is included in Appendix 3a. The various whole hospital operational policy headings for a typical health facility based on Umtata are included in Appendix 3b.

Equipping
The importance of equipping
Between 15% and 45% of the total cost of a project may be spent on the purchase of furniture and equipment. This task is a significant part of the commissioning process and is directly linked to briefing, design and to a lesser extent operational policies. It is very time consuming especially if new facilities bring new and changed working practices or different skill mix arrangements.

Technology needs assessment

The strategic planning phase of the project requires a technology needs assessment to ensure that high cost, highly specialised technologies such as MRI and Radiotherapy are not duplicated or
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known to be included before detailed design starts. A technology audit of the existing facilities is an integral part of business planning. The national DOH has developed and piloted computerised protocols.

Key tasks
At the briefing stage of a project, the equipping strategy must be considered. This is also the right time to ensure that construction tender documents reflect which items of fixed furniture, equipment and storage shelving are to be supplied through the main contract. The Commissioning Team must draw up location lists for these items and ensure the availability of data / telephone points. Then the key tasks of equipping are: identify and list the required equipment - a generic wish list identify and list items available and suitable for transfer from existing facilities, co-ordinating items purchased through conditional grant or donor procurement that may be managed outside commissioning ensure departmental ownership of the list ensure affordability against budget prepare specifications and tenders manage tender procedures prepare for delivery, acceptance testing, commissioning and training schedule ordering and deliveries receive equipment and place in the correct location create an inventory and asset register

Room data sheets

Specialist software is available to assist with the equipping tasks. The equipment lists for the 1,500 rooms at the Nelson Mandela Academic Hospital were generated using the UKs Activity Data Base (ADB) briefing system, which has been edited and priced for the South African context. The Room Data Sheets (RDS) developed for Umtata reflect South African indicative furniture and equipment prices (2002) and generic equipment descriptions. These data sheets are matched to appropriate project space, i.e. room layouts, and elevations. The National Department of Health or the Eastern Cape Health Planning and Policy Unit will make paper copies available to Commissioning Teams pending development of national norms and standards. Individual Umtata Room Data Sheets can be selected to match schedules of accommodation in other projects and assist project teams at briefing and sketch layout stages to determine typical layouts, mechanical and electrical services needs and equipping budgets. Given that equipment suppliers will bombard the Commissioning Team with information and offers from the onset of a project, Commissioning Teams would be well advised to prepare RDS using generic equipment specifications and so defer supplier pressure until the procurement phase. This also allows the project to take advantage of the latest technology rather than be locked into models which are out of date. Design teams will also request detailed specifications for some medical equipment so that appropriate mechanical services (drains, data connections etc) can be incorporated in the correct
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room and wall positions. Again, the advice is only provide typical layouts and generic specifications to avoid being forced into guessing which equipment, make and model, will be the final choice. X-ray rooms are usually specified with a ceiling incorporating flexible steel struts and suspended floors, which can be adjusted to accept a range of machines.

Stages of the equipping process

The process of moving from a generic equipment database, on which budgets are based, to detailed tender specifications is complicated, time consuming and requires specialist input from users, medical engineers and procurement. CEOs and equipment procurement approval committees also have an important procurement role to play in standardisation, selection of accessories, availability and cost of consumables and avoidance of duplication. Table 1, below, illustrates the computerised RDS procedure utilised in Umtata to determine a generic furniture and equipment open database, which was used to confirm the budget and produce the procurement and asset registration documentation. By being an open database, the software can be adapted into another database or spreadsheet to suit the particular circumstances and needs of an individual project. The approach outlined above assumes that all furniture and equipment for the facility will be purchased direct from local agents or manufacturers by the Commissioning Team according to relevant tender regulations. Alternative procurement approaches are available including using a specialist procurement company as a single source of supply and leasing rather than purchasing.

Alternative equipping approach

The use of a Public Private Partnership has been adopted in the case of IALCH in Durban. This approach transferred the project equipping budget to the Facilities Management consortium. The consortium undertook to purchase all the required equipment in return for an annual service charge over a 15 year contract. The agreement provides an on site maintain, repair and replace service to be managed as part of a wider Facilities Management agreement. Leasing avoids spending a large capital sum at the outset. It can incorporate maintenance contracts and allow for replacements in the case of longer-term contracts. Leasing is especially attractive with laboratory and other equipment that uses large amounts of expensive consumables, where rapid technology change is expected or shared use is possible such as, for example, a mobile CT scanner.

Workforce planning
A brand new hospital building will be of no use without the appropriate staff. Workforce planning is that process which assesses the appropriate level and quality of staff and then ensures their availability. In short, workforce planning is defined as identifying and securing the right numbers of staff with the right mix of skills organised in the most effective way. The planning part of the process can be undertaken in one of two ways. Where an existing facility is being upgraded, the existing staffing numbers and skill mix can be assessed incrementally.
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Table 1 Use of a Computerised Furniture and Medical Equipment Database based upon Room Data Sheets (RDS) Step 1 2 3 Stage Strategic Site master planning Business Case Development Task and Software Output/Reports Confirm project beds, service profile & highly specialised technology equipment Use general RDS room layouts to aid room sizing and relationships Undertake technology audit Identify furniture and equipment transfers Prepare schedules of equipment by room Prepare equipping budget Prepare schedules of accommodation

Tender Documentation

Identify which items are to be supplied by the construction contract Identify generic mechanical and electrical requirements and sizes of equipment Create unique room number, add to RDS Review RDS with users o Confirm room name, use & activity o Confirm built in & fixed items o Confirm telephone & data points o Confirm special room services o Confirm equipment generic schedules & quality o Confirm drawing room layouts & relationships o Ensure new items are coded correctly o Add purchase group code to each item Create procurement database, comprising: o Purchase group reports (i.e. tables, X-ray etc) o Distribution reports (same items & locations) o Departmental lists o State Tender Board items o Individual item purchase sheets Specify individual items & accessories for open tender Update database to add actual procurement data (order no, model, manufacturer, supplier, unit price) Ensure suppliers mark delivery boxes with item code Generate departmental RDS sets for room inspections Update database to add delivery date Export data to Asset Register software Use distribution report (same items & locations) Provide department RDS sets for users

Construction

Procurement

7 8 9 10 11

Handover Receipt & delivery Asset registration Distribution Orientation

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Relevant considerations will include whether there are enough staff, and whether skills need upgrading because equipment or services to be offered are being enhanced. The likelihood is that the existing group of staff will transfer into the new facility making this a relatively straightforward change. However, where a brand new building adds to the existing facilities, a more theoretical approach to workforce planning may be required initially. Some Provinces within South Africa are developing models based on an assessment of workload matched with staffing ratios to indicate staffing levels. These models are based on staffing norms and may include the cost of individual posts allowing the overall staffing costs to be identified quickly and different options to be appraised rapidly. Having different options available is essential for scenario planning or for undertaking risk assessments. Any proposed pattern of staffing must be tested in three key ways. This is true whether the model is purely theoretical or the pattern has been derived incrementally. The first test is of affordability. Can the suggested pattern of staff be afforded within the budget available for the hospital? If not, further financial allocations must be found or the staffing costs must be reduced or a mixture of both must be agreed. The second test is of availability. Are the numbers of staff with the skills required available to be employed? If not, can more staff be trained and, if they are trained, are they likely to remain available to the public sector in the country? The third test is of acceptability. Do senior, professional staff and the staffing organisations accept that the pattern of staff will provide the service required? If the preferred pattern passes the three tests, workforce planning moves on to practical aspects. The identification of training needs for existing staff The identification of additional training posts Recruitment The planning and delivery of induction training The availability of suitable accommodation, especially in rural areas and outreach facilities The assessment of employment consequences for other hospitals The first four of these practical aspects will involve short term costs for the project. The last may have serious implications for other hospitals which must be identified and considered. For example, if the new, well equipped building is near to another older facility, staff are going to be attracted to the new hospital. Recruitment at the older hospital will be adversely affected. The potential knock-on impact has been considered in Durban. The managers of the new hospital have drawn up an employee transfer strategy in conjunction with the province and other neighbouring hospitals. The strategy has three objectives: To provide guidelines for the transfer of employees affected by the rationalisation of services within the Durban area To ensure that the transfer process takes place within the framework agreed by the provincial bargaining chamber
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To ensure the timeous development and implementation of the workforce transfer plan for the new hospital The strategy itself is included in this manual as Appendix 4.

Public Private Partnerships (PPP)

A Public Private Partnership is a contractual arrangement between a public sector organisation and a private sector company for a defined period of time. The private sector company performs a function, or more usually functions, for the public sector organisation. The functions are defined by written specifications. The public sector retains control by regularly monitoring performance but transfers risks to the public sector. In any case of multiple functions, the private sector company is likely to be a consortium of ompanies specifically set up for the project and typically comprising a service provider, consultancy firm and financing organisation. In cases involving a new building project it will also include a construction company. These partnerships are organised within the national regulatory framework of the Public Finance Management Act, 1999, and the Treasury Regulations, May 2000. Authorisation is given by the Treasury through six phases starting with project initiation and concluding with project implementation and monitoring. The Treasury PPP Unit has issued written guidelines which must be followed.

Facilities Management
Core and non-core services
Facilities management is the co-ordination of the performance of the physical building and environment with the people and work of the organisation. It is an approach based on the notion that an organisations departments and functions can be divided into core and non-core services. Core services are those directly related to the key purpose of the organisation. In a hospital these will include the wards, outpatient departments and operating theatres. Non-core services are those services which support the key purpose. These will include maintenance, laundry services and security.

Providing non-core services

Traditionally, most non-core services at a hospital have been carried out by staff employed by the hospital. Over recent years many non-hospital organisations have contracted these services to specialist providers and some hospitals have contracted out some services to the private sector. Security services are a particular example of this. During the course of a building project, managers at province and hospital level need to decide how to provide these services. Non-core services can be provided by an in-house department, or by contract to a number of external companies, or to just one external company which will provide all the services required.

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Whichever method is selected, hospital managers must draw up a high quality specification detailing the level of service required as well as the standards to be met. By retaining the services in-house, the hospital will keep a greater ability to make variations in the level and type of services. It will retain the responsibility to recruit and train sufficient numbers of staff. It will need to employ experts in managing the services and a means of keeping up to date with developments. By outsourcing some or all of the non-core services, the hospital can transfer the responsibility and therefore the risk for recruitment to another company. This arrangement may well secure access to better expertise through a contract with a specialist firm and it can lead to better control of costs depending on the adequacy of the contract agreed.

Considerations and choices

In deciding which route to follow, hospital managers need to consider a number of issues. These include: What services are non-core? What expertise can we draw on to prepare specifications? Are we able to recruit and retain the numbers of staff required? Are we able to train our staff to a sufficient level of ability? Do we have access to sufficient levels of expertise? Do we keep good control of our costs? A hospital can decide to adopt different approaches for different services. Some can be provided in-house and some can be outsourced. Such decisions can be based on judgements of principle or after testing the market through tendering, ie a service can be offered for tender and be secured by the in-house department.

Working with external companies

If contracts are outsourced, a contract with one external company will be easier to manage from the hospitals perspective. It will certainly ensure easier co-ordination of the services. A hospital and FM company should seek to establish and build a partnership relationship. The specification should cover the concept of continuous quality improvement and it should require the FM company to have a focus on the hospitals clients. It must be noted, though, that unrealistic under-performance fines may result in bidders raising their service charges to cover possible non-compliance. It is also recommended that utility charges be settled directly by the hospital management, although the opportunity must not be lost to ensure that utility conservation and management measures are incorporated into the FM contract. The hospital will be wise to ensure ready access to professional, registered and experienced engineers for advice and guidance. This is required from the start to cover negotiations, whilst setting service agreements and through to an active role in monitoring contractors performance. Ideally, this advice would be provided by an in house professional who is familiar with the site and services design, possibly as part of a wider regional facilities management role.

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Both the hospital advisor and his counterpart at the PPP consortium should possess the following qualities: Business orientation Technical competence Customer service orientation Good communication and negotiation skills Given the acute shortage of clinical engineers within the public hospital sector, a medical equipment on site, parts and labour equipment maintenance service should be considered for inclusion in FM contracts. Variations on this basic level of service that could be incorporated include: 1. Maintenance and supply of all furniture and non-medical equipment with replacement by the hospital 2. Maintenance, supply and replacement of all furniture and equipment 3. Maintenance of transferred and newly purchased furniture and equipment Any combination of the above to suit local needs can be adopted although there will be large variations in annual service fees for the different examples. Whether or not a PPP is chosen for maintenance, an institution will have to identify at an early stage what items of high tech equipment will need specialist contract servicing and the likely annual operating and life cycle costs. Briefing and Commissioning Teams will have to consider what accommodation a Facilities Management organisation will require. This will include, for example, location, separate utility monitoring, offices, call centres, training rooms, technical libraries and workshops (including satellite or departmental workshops). The hospital will have to delay providing furniture and equipment for these areas until it is known what arrangements for service provision are to be made.

Building handover and building commissioning

A common problem with building contracts is the contractual completion date, which requires the whole contract to be completed at once. This is clearly an almost impossible task and inevitably contract completion dates are not met for one reason or another. Commissioning Teams must consider the implications of any delay in providing a clear brief and information to the design team, given that common reasons for delay are client changes or awaiting client instructions. These cost money and ensure that late completion penalty payments are often not collected. The handover process is managed by the lead architect and involves a detailed inspection of all the civil, architectural, mechanical and electrical services within the building and grounds. The hospitals professional design team, resident engineers and Clerk of Works are all involved in the preparation of snagging lists in the weeks approaching the contract completion date. These snags should be rectified before the building is offered by the main contractor for first delivery. The Commissioning Team should resist the temptation to become involved in snagging in this very hectic and somewhat dangerous period as any suggestions of changes or problems will be picked by the main contractor and could be used as the basis of a claim for extension of time. User groups will have previously been escorted around the building and any design or major
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problems reported to the Commissioning Director. Also, members of the Commissioning Team should have attended all the site meetings during the course of the building project. The Commissioning Team and engineering advisors from the Department of Public Works or the Health Departments independent consultants will work with the lead architect to consider if the first delivery of the building is acceptable. If the building is accepted, a certificate of practical completion is issued and the Health Department is immediately liable for security, fire and insurance of the new facility. 50% of the contract retention sum is also released at this time. The inspection duties of the Commissioning Team will include checking each and every user and clinical space and confirming against the commissioning and or architectural Room Data Sheets that the space is fit for purpose. This would include appropriate finishes, sockets, type and quantity of gas outlets, special ventilation and vision panels. The engineering advisors will check the hidden services and ensure that all plant is operating with appropriate controls and monitoring. They will ensure that as built drawings are available together with all technical data, drawings and parts lists for each and every maintainable item of building plant. Key components of this technical library are the engineering commissioning and test data sheets together with the design team representative or client engineer witness certificates, which record that the design specification has been met. This is essential for reference purposes. It will assist in establishing an Asset Register and in drawing up schedules for Planned Preventative Maintenance. Generally the main contractor has 3 weeks to complete outstanding snags. He then hands the building over to the Department of Public Works which in turn hands it on to the Department of Health. At this point the 12-month warranty period for all plant and equipment starts. The contractor generally has to provide 6 months of maintenance during which the client should ensure that the facility maintenance team is in place to take instructions from the plant installers. The hospital begins to incur running costs, eg electricity and security, from this point.

Opening sequence
Unless the new facility is a single department, it is highly unlikely that the new facility will open in its entirety on one day. Certainly a whole new hospital will be brought into use gradually over a period of several weeks or even several months as new services are developed and specialist staff recruited. Those moving in first will generally be the Commissioning Team, security personnel, hospital management, facilities management, engineering and clinical workshops, stores and logistics, cleaning and IT. IALCH chose to commission its new laundry in advance of the main hospital as this department serves a number of other institutions. Umtata could well operate its new laundry, CSSD and kitchens to serve the existing hospital before the new hospital opens to patients. It is only after the building is handed over that the huge task can begin of distributing the furniture, and of installing and testing the specialised equipment. Operating theatres have to be tested by the Microbiology Department, medical gas deliveries organised, gas outlets double-checked and stores filled.
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New and existing staff will have to be orientated with the new facility and procedures, and training carried out in the use of new medical equipment as it is commissioned. It is only when these key tasks have been completed that it is possible to begin moving clinical services into the new building. There are no firm guidelines as to which comes first, although an early introduction of outpatient clinics would allow clinical support services to be tested and built up incrementally. IALCH in Durban has no existing hospital on site and can be more flexible in its clinical start up process. It has helped by having good staff accommodation and an excellent location, which assist in staff recruitment. Umtata has a more difficult task to staff its major new referral hospital and it must continue to run a large district hospital on the adjacent site during a time of major upgrading.

The costs of commissioning

It is very difficult to be specific about the costs of commissioning. Each project differs one from another and some are more complex than others. In some small scale projects, a province or hospital may be able to support the process with existing staff. In any large project, it will not. As a guideline, commissioning costs can be expected to total about 1% of the total building costs, ie fees, construction and equipping. This was the expectation in both Durban and Umtata. Assessing the costs of commissioning is complicated, however, by choices about how the commissioning tasks are managed. For example, in Umtata Commissioning Team members were seconded from the hospital and salaries were still charged to that budget. In Durban, increased costs were incurred towards the end of the project through the recruitment of the CEO, management team and support staff.

The costs of sustaining the investment

The business case prepared for a project sets out the arguments for the capital investment to be made. One of the key areas, which should have been addressed at the outset, is the resource consequence of proper Facilities Management of the new facility. The capital cost of a new structure is relatively small (R370m in Umtata) over the life of a building compared with the full operating costs, (estimated at approximately R240m per year in Umtata). A comprehensive Facilities Management budget will be required each year and this should be estimated initially at 6-8% of the annual operating budget. This estimate is likely to turn out to be higher if PPPs are used to address the lack of experienced hospital and medical engineers within the public sector.

Risks and Impediments

Commissioning is no easy task. Any hospital is a complex environment. As such, commissioning requires skilled direction and experienced change management input. The more complex the hospital in terms of size or services, the more highly skilled direction and the more experienced the change management required.
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Delayed or partial opening of a facility will represent a failure to secure the full benefits of an investment, part at least of which will have been wasted. Failure to identify the knock on impact on other hospitals of the opening of a facility and failure to plan to overcome the impact will mean that other hospitals will function less effectively than they should and therefore not work fully in support of the new facility. Unless workforce planning is undertaken thoroughly staff to run the new facility will not be available in sufficient numbers or with sufficient skills. A new facility will encounter double running costs in the period up to and during the opening. This will prove an additional demand on budgets and could well be an impediment to hospitals releasing staff for training. Commissioning will take senior management time at the highest levels of the province, hospital and other organisations involved.

Ten Key Tasks and Challenges

There are considerable challenges to be met in opening a hospital on time. The key tasks and challenges include: 1. 2. 3. 4. 5. 6. 7. 8. 9. Ensuring purposeful direction for the project. Agreeing the clinical content of the hospital. Agreeing the educational function of the hospital. Establishing the on-going management of the hospital. Approving the on-going finances of the hospital. Developing the workforce plan for the hospital and recruiting staff. Commissioning the whole hospital. Assessing and counteracting the knock-on effect on other hospitals. Deciding on the appropriate computer system for the hospital and installing it.

10. Handling the commissioning task alongside the already full agenda of key decision makers.

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Appendix 1

DEPARTMENT OF HEALTH, SOUTH AFRICA and EUROPEAN UNION INTEGRATED HOSPITAL CAPITAL INVESTMENTS COMMISSIONING WORKBOOK
Malcolm Kilvington, European Union Technical Assistant, DOH Pretoria, and Sydney Mafu, Deputy Director of Health Facilities Planning, Eastern Cape

Contents
Project Commissioning Sequence - Strategic, Business Case, Briefing, Design Project Management - Typical Project Organisation Chart Strategic Planning CSIR Health Facilities Strategic Plan 1999 Province Map Development Plan Province Map Land Use Region Map Population Region Map Health Facilities and Current Beds CSIR Health Facilities Strategic Plan Health Facilities Audit Site Plan Building Condition Health Partners SA Human Resource, Activity and Bed Utilisation Report Project Description Location Scope of Work - Current and Proposed Beds by Specialty Scope of Work - Schedule of Accommodation Current Hospital Service, Activity and Staff in Post - Support & Outpatients Clinical Case Mix and Level of Care Survey Report Form (Current & Proposed) Briefing Room Data Sheets Health Briefing Room Data Sheets - Blank for copying and project use Health Briefing Room Data Sheet 1 - Room Activity and Use Health Briefing Room Data Sheet 2 - Environment Health Briefing Room Data Sheet 3 - Design and Maintenance Health Briefing Room Data Sheet 4 - Selected Fixtures & Medical Equipment Medical Equipment Schedule Medical Equipment Room Distribution Schedule - Asset Register Data Project Total Cost Analysis (Prepared by QS) Total Estimated Cost Breakdown Outline BC Stage Estimate Pre-tender Stage Update Post-tender Total Project Life Cost Breakdown Commissioning Budget Total Project Life Cash Flow by Month and Year Estimate (Completed by QS) At Pre-tender Estimate Stage At Post-tender Award

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Operating Costs Current Budget Future Budget Future Maintenance Budget Hospital Policy and Management Capacity Current Management Structure Proposed Management Structure Technology Situation Report Options and Strategy Equipment Audit Mini Medical Equipment Condition Survey Report Maintenance Management Structure including Medical Maintenance - Public Private Partnerships (PPP) Maintenance - Buildings, Plant and Grounds Information Technology Situation Report Options and Strategy Hardware, Software Audit Environmental Impact Assessment Situation Report Options and Strategy Total Quality Management Situation Report Options and Strategy Operational Commissioning Project Programme - Gantt Chart Project Documents Options considered - block plans Agreed Master Plan - All phases Fire Plan Architectural, Mechanical, Electrical and Equipment Room Data Sheets Whole Hospital Operational Policies Departmental Operational Procedures Guidance Climatic Regions of South Africa R581 Regulation Minimal Requirements for Physical Facilities (draft) Eastern Cape Standard Room Layout & Coordinated Room Data Sheets (draft) Eastern Cape Mechanical and Electrical Design Guides (in development) CSIR Design Guides Commissioning New Hospital Facilities in South Africa KPMG Business Planning Model DoH Ten Point Plan Hospital Strategy Project Report Health Sector Strategic Framework Integrated Health Planning Framework UK NHS Estates Briefing and Design Guidance ECR1 Medical Equipment Product Comparison Guide ECR1 Medical Equipment Specification Guide
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Appendix 2

SAMPLE JOB DESCRIPTION, PERSON SPECIFICATION AND ADVERT FOR THE POST OF COMMISSIONING DIRECTOR Job Description
Summary
The Commissioning Directors post is being established as a contract appointment to be responsible for bringing the ... Hospital into operation. Purpose To manage the commissioning process for the hospital and in particular to undertake the project management function Equivalent to Director Four years Chief Executive Officer, ... Hospital Members of the Commissioning Team ...

Grade Term Responsible to Responsible for Location

Main responsibilities
1. 2. To manage the work of the Commissioning Team and oversee any supporting working groups set up to undertake detailed work. To draw up, obtain the approval of the Management Committee, implement, and then monitor and control the detailed commissioning project plan, including preparing the opening sequence and timetable. To be a member of the Management Committee and prepare a written report on progress for each meeting of the committee. To liaise closely with the Project Manager for the construction of the new hospital to ensure the construction and commissioning processes are well co-ordinated. To establish detailed operational procedures, standards and systems for the health care, cademic and support functions to be accommodated within the hospital. To identify and where possible resolve conflicts which arise in the commissioning process. To direct the work of the Equipment Team ensuring that furniture and equipment is listed, specified, costed, purchased within budget, placed and commissioned. To organise the transfer of staff and services into the hospital. To plan and organise the decommissioning of redundant facilities on other sites.

3. 4. 5. 6. 7. 8. 9.

10. To support fully the Chief Executive Officer in his or her duties so that the hospital opens on time.
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Person Specification
Education
A first degree or equivalent qualification

Experience
1. At least five years working at management level in health care or other comparable complex and large-scale organisation. Experience of hospital management and particularly of financial and procurement practices. Responsibility for planning, implementing and maintaining a complex project management plan. Experience of handling consultation and negotiation within an organisational setting.

2. 3.

4.

Skills and Knowledge

The appointee will demonstrate managerial competence including: 1. project management, including co-ordination of tasks and functions 2. delegating, motivating and influencing 3. inter-personal relationships and conflict resolution 4. building and leading teams 5. political sensitivity 6. numerical reasoning and literacy 7. planning and negotiating 8. health care management

Personal Qualities
The successful candidate will demonstrate the following qualities: 1. 2. 3. 4. 5. 6. 7. a record of achievement a clear vision of the way forward a proactive style a highly motivated approach confidence with people ambition for success ability to gain trust and confidence

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Advertisement
DEPARTMENT OF HEALTH, KWAZULU NATAL COMMISSIONING DIRECTOR NEW DURBAN ACADEMIC HOSPITAL
Negotiable Contract @ R ? pa
The Department of Health is seeking to appoint the Commissioning Director for the prestigious New Durban Academic Hospital, currently under construction. The hospital, which is being built in a single phase on a greenfield site, will comprise 850 beds and associated facilities. It will provide high technology tertiary and quaternary level treatment. It will be the premier postgraduate centre for health professionals in KwaZulu Natal. The person appointed will be responsible for the commissioning of the hospital. The ideal candidate will have a first degree or equivalent qualification, and at least five years working experience at management level in a health care or other comparable large-scale and complex organisation. He or she will be able to demonstrate a significant record of achievement. The appointment will be made on the basis of a four year period contract renewable annually based on performance. In addition to the salary, the package will include competitive benefits with regard to a thirteenth cheque, homeowners allowance, motor vehicle allowance and medical assistance. Application is by letter accompanied by curriculum vitae and certified copies of qualifications, which are to be forwarded to: ... More information can be obtained from: ... Closing date for applications: ...

Format for Curriculum Vitae

Name, date of birth, address, telephone numbers, qualifications and awards Career history with most recent post listed first including details of financial, procurement and project management responsibilities, and including significant achievements Achievements outside of work and personal interests A statement in no more than 500 words as to how your skills and experience qualify you to be the Commissioning Director of the New Durban Academic Hospital The names of three referees who may be approached for personal references

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Appendix 3a

Pretoria Academic Hospital Headings for Departmental Operational Policies

1. 2. 3. 4. Philosophy of the department Mission of the department A short description of the department Planning Personnel: proposed staffing establishment current staffing needs job descriptions and work plans categories of staff organisational structure by level of care

Beds:

Relationships to adjacent areas 5. Work procedures specific to the area relevant legislation 6. Support functions (each having its own narrative for the hospital as a whole) waste disposal cleaning communications archives computer security maintenance catering administration 7. 8. 9. 10. 11. Internal and external liaison Loose and fixed equipment Costing Organisational standards Annexes - as required
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Appendix 3b

Nelson Mandela Academic Hospital, Umtata

Whole hospital operational policies are required for the following departments
IT AND COMMUNICATION SYSTEMS Telephones Internal communications Staff location systems Patient radio and television Personal attack alarms Clock systems Central alarm monitoring Computers Data processing (automatic)

MANAGEMENT OF THE ESTATE

Management and operational systems Building maintenance Engineering maintenance Grounds Works emergency plan Fuels In-house External Shared Central on site Dispersed on site For whom Sanitary facilities Locker system Locally or centrally Distribution system Frequency Stock level Storage at departmental level

EDUCATION AND TRAINING

STAFF CHANGING

STORES

SOCIAL WORK / LOCAL AUTHORITY LIAISON

Organisation Service Facilities Shared Dedicated/consecrated Range of facilities

RELIGIOUS FACILITIES

ACCOMMODATION FOR MANAGEMENT AND OTHER SERVICES

Organisation Location and general relationships Central Management

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Senior Management various disciplines Medical Staff Medical common rooms RESIDENTIAL ACCOMMODATION On call Medical Nursing Professional and technical Ancillary Security In-house or contract In-house or contract Produced on-site or elsewhere Type and storage of provisions, eg cook-chill Meals service In-house or contract Scope and extent of service Storage of equipment Distribution system Frequency Stock level Storage at departmental level Organisation Service Facilities General Points of entry Disabled people Pedestrians Bicycles/cars/ambulances Goods/public transport Fire-fighting vehicles Helicopters Traffic control Car parking Signposting General Disabled Goods Night access Patients Staff Visitors Goods Internal signposting

CATERING

DOMESTIC SERVICE

LINEN, LAUNDRY AND UNIFORMS

OCCUPATIONAL HEALTH

SITE ACCESS AND SITE TRAFFIC

ACCESS TO BUILDINGS

INTERNAL TRAFFIC WITHIN BUILDINGS

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SECURITY AND SAFETY

Theft Vandalism Violence Cost-effectiveness Current guidelines General considerations Structural precautions Means of escape Training Observation beds A&E Isolation facilities separate unit or single rooms on general wards Control of infection procedure Access by GPs Facilities for adolescents Emergency Referral system Non-urgent Day cases Major disaster plan Short term storage Disposal Policy Secretarial services Tracking accidents Appointments Master index system Statistics Disposal Distribution Storage Supply In-house/ bought in Standardisation Stock holding and turnaround time

FIRE PRECAUTIONS

CLINICAL POLICIES

ADMISSIONS

MEDICAL RECORDS AND PATIENT ADMIN SYSTEMS

MATERIALS HANDLING

STERILE SERVICES

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Departmental Policy Content

PHILOSOPHY OF SERVICE Functions Relationships UTILISATION SPECIFIC EXCLUSIONS TO SERVICE SPECIFIC DESIGN REQUIREMENTS Engineering Services Environmental Conditions Finishes Variances Normal Waste Goods Patients Visitors Staff Any which do not apply - noted to avoid omissions Those which are modified Which apply Relationships with other accommodation or services For storage For staff For patients For activities Method of calculation Function unit x No. required

HOURS OF OPERATION

FLOW PATTERN

RELATIONSHIP TO WHOLE HOSPITAL POLICIES

ACCOMMODATION REQUIRED

FUNCTIONAL CONTENT

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Appendix 4

INKOSI ALBERT LUTHULI CENTRAL HOSPITAL EMPLOYEE TRANSFER STRATEGY

OBJECTIVES: - To provide guidelines for the transfer of employees affected by the rationalization of services within the DFR, to IALCH. - To ensure that the transfer process takes place within the framework agreed by a sub committee of the provincial bargaining chamber. - To ensure a timeous development and implementation of the Workforce Transfer Plan for the IALCH. PROCESS 1. Senior Managers draw up their proposed departmental workforce plans and job descriptions and submit them to the C.E.O. for approval. The pre-commissioning working groups submit their workforce plans and job descriptions to the HR manager. Workforce plans are compared with the indicative plans to ensure that they are within the cost boundaries agreed for purposes of affordability. The C.E.O. approves departmental and pre commissioning workforce plans, and submits them to the Provincial Health Department for evaluation (where appropriate), and creation. Approved plans are submitted to the Provincial Finance Department to assist with the development of budgets and budget transfer. Both workforce plans and budget transfer plans are communicated to the transferring hospitals. The approved workforce plans, together with pre-commissioning plans and timetable are communicated to the Provincial Bargaining Chamber sub committee. Staff affected by transfer are identified through the HR Departments of the transferring hospitals. Working together with their Heads of Department and the HR Dept of the IALCH hospital, a transfer plan will be drawn up, based on the commissioning plan. The Provincial HR Dept will be sent a copy of the agreed transfer plan. Steps 1 to 7 above are carried out on an incremental basis, in line with the plan for commissioning. The criteria for staff transfer will be as per the agreement between the Department of Health and organized labour, utilizing the following criteria:

2.

3.

4.

5.

6.

7.

8.

9.

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Suitability for Transfer Specialized knowledge and experience Qualifications Level of Training Merit Efficiency Representivity State Interest Serving employees receiving preference.

10. Filling of charge posts will be subject to an internal recruitment and selection process within the Durban hospitals to ensure that the most suitable candidates are selected to fill the positions. 11. Where the number of posts to be filled is greater than the number of staff available, the remaining vacancies will be advertised in line with Provincial Policy. 12. Where the number of posts to be filled is less than the number of staff available, those staff in hospitals directly affected by the transfer process will be offered interviews in limited competition. Selection will be based on the criteria set out in paragraph 9, above. 13. In the event that no staff identified in (11) above are suitable, or, do not apply, the posts will be advertised in limited competition in other hospitals within Durban. 14. Only in the event that posts remain unfilled after step 12, will authority be sought from the Provincial Health Dept to advertise in open competition on a national basis. 15. All staff identified for transfer will be subject to a skills audit and appropriate training must be given, either prior to, or within three months of transfer. 16. All staff identified for transfer must receive comprehensive induction training within 4 weeks of transfer.

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Biographical Details
Andrew Butcher
Andrew Butcher has been advising the South African national Department of Health since June 1998. He has had detailed involvement with commissioning the major hospital building projects in Durban, Pretoria and Umtata and he has worked closely with the provincial administrations in KwaZulu Natal, Gauteng and the Eastern Cape as well as with the hospital managements. He has had an extensive career of over 25 years in the English National Health Service. He has worked in major hospitals in London, Oxford, East Anglia and the West Midlands. He has been Chief Executive of a large Health Authority and been a senior general manager at regional level. Andrews current interests in the UK include workforce planning and management consultancy. He is Honorary Fellow at the University of Birminghams Health Services Management Centre. He has a BA from London University, an MBA from Henley Management College and is a Fellow of the Chartered Management Institute.