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Ministry of Higher Education
College of Business
-194123323215(Corporation Training Final Report)
Second semester 2018
NGHA PACS section main problems and their impact on work progress
Training place:
King Abdulaziz Hospital Al-Ahsaa
Prepared by:
Mariam M. Al-Omair
Academic Number:
00(Corporation Training Final Report)
Second semester 2018
NGHA PACS section main problems and their impact on work progress
Training place:
King Abdulaziz Hospital Al-Ahsaa
Prepared by:
Mariam M. Al-OmairAcademic Number:

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Table of Contents
TOC o “1-3” h z u 1.Introduction PAGEREF _Toc513456852 h 31.1 Report Summary PAGEREF _Toc513456853 h 32.Theoretical framework PAGEREF _Toc513456854 h 62.1 Description of the workplace: PAGEREF _Toc513456855 h 62.2 Theoretical framework and studies PAGEREF _Toc513456856 h 83.Methodology PAGEREF _Toc513456857 h 124.Results PAGEREF _Toc513456858 h 135.Recommendations PAGEREF _Toc513456859 h 145.1Comparing the results: PAGEREF _Toc513456860 h 145.2 Recommendations PAGEREF _Toc513456861 h 166.References PAGEREF _Toc513456862 h 17

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Introduction1.1 Report SummaryThis report is aimed to focus on Ministry of National Guard Health Affairs (NGHA) in Al-Ahsaa major problems including; the problem of office design and location, the shortage in number of employees, main and backup servers and server overloads which are affecting the PACS (picture archiving and communication system) department workflow in specific. More on, the motivation behind choosing these problems and how they are affecting the PACS department performance. In addition, an overview of the business history and practices are mentioned. Furthermore, other studies with similar related problems will be discussed. Research methodologies and results will be displayed. Finally, the findings will be discussed and solutions will be suggested for the problems.

1.2 Problem statement
Every company or business normally faces problems no matter how big or small they are they sure affect them in some way. In this section we will be mentioning some main problems that PACS department in NGHA in Al-Ahsaa are facing.
Major department problems:
Offices design and locations:
Most offices in NGHA are small specially for PACS department. The head of the department’s office for example has no space to have a guest. He can open the door while he is sitting because there is no space to move in, he is just able to turn around. He also does not have any place to put his personal belongs, no drawers or cabinets to keep his stuff, all papers and documents are in front of him. More on, the head of the department’s office is in the hospital’s building, where the other department team members are isolated in a small unqualified workplace. Here we should also consider that the isolated small unqualified workplace is far from all of the PACS servers which are located in the hospitals’ building and far away from their boss. Also, one member’s office is open which lacks privacy. In addition, they do not have a meeting room.

Shortage in number of employees:
The PACS department uses and manages more than 15 systems. All these systems are managed and controlled by only 3 employees. The department is trying to handle the most important systems with little focus and attention to less important systems. Some systems are neglected due to the work pressure. The systems neglected will surly help to improve the department’s performance if they were not neglected.

Main and backup servers:
As a hospital, patient’s information is an extreme, important and private asset to the hospital. For that, the hospital has servers which are located in the information services department in the hospital to save and store all data. As mentioned, patients’ information is the most valuable asset in the hospital. Therefore, they have main servers to store the data and backup servers. These backup servers are used to store and save a backup of the stored data in the main servers. The problem to mention here is the location of these backup servers. They are located in the same rom as the main servers. As a result, if any physical disaster happens in the room all servers may be lost. As a PACS department, they should be terrified to lose their patients images. As well as their servers.
Servers overload:
Hospitals are considered to be using systems more often than any other corporation or business due to the need to access patient information and make updates continually. The number of cases handled by doctors daily or number of system users are uncountable. More on, the hospital information system (HIS) for NGHA is called BEST care. This system is used by all NGHA hospitals around the kingdom. All hospitals connect to the same central server in Riyadh. Accordingly, we can conclude that there will be an overload on the server. For that, the system will be slow, users will not be served as needed and the work progress will be affected. However, PACS servers are separated for each hospital. But they need to communicate with BEST care system which affects PACS work progress.

1.3 Motivation
Any problem could affect a company no matter how big it is. Mentioning the problems above were just some facts that I noticed during my 4 months training. Each of these problems affects the work quality and improvement.

Offices design and locations:
As an employee in a hospital, work hours are around 8 hours a day. this reveals that most of their day is spent in their office. For that, any problem affects them. More on, the PACS department offices are separated from each other. Which makes it more difficult to communicate. As a department it is normal to communicate to other members within the department daily at least 6 to 9 times a day. Accordingly, the PACS department are forced to communicate to each other by phone or get out of the office to another place to meet. Not being available in the office or letting the phone on busy in case someone else trays to reach any member of the department is another problem. Moreover, the office design is considered as a powerful element to focus on since it affects the employee’s productivity. BNet business dictionary defines office design as “the arrangement of workspace so that work can be done in the most efficient way” (1). We can conclude here that productivity will be improved as the office design is improved and considered as an important factor.

Shortage in number of employees:
Now days, it is more difficult to find a job that fills some requestors wants and needs but some request any job that just fills their life and get paid for. Joanne Smikle says, “It should first be noted that an unfilled position is better than a poorly filled position” (2). To have a good team they should hire the best. that could be what they are following or it’s just a financial issue. As I saw in the PACS department they only have three employees. We can see here that the department is having a shortage in employees where 3 people are dealing with more than 15 systems. Dealing with all these systems by three people only is so exhausting. Besides that, they can never focus on all as they should and errors may occur. Making an error in a department as PACS is a big problem since it is all related to patient’s health life. As a result, they will be neglecting some systems. Above all, the pressure they have to deal with will not able them to professionalism the work. For a big hospital, the quality of work should be high specially if we are dealing with patients. So, having this shortage of employees will affect them and affect the work quality.

Main and backup servers:
Having a backup is necessary in case anything happens to the main server for example: the server’s disk failure due to time, viruses could corrupt server’s security leading to a shutdown, fail upgrades and updates and physical disaster (3). Physical disasters are our main problem here because we have the main and backup servers’ in the same room. Exposure to fire, flood or electricity failure will surly damage the main and backup servers. Having a backup in the same location will be risky in the case of physical disasters because losing all servers will lead to losing all data which reveals the improper handling and managing of backup servers.
Servers overload:
As I mentioned previously that the PACS systems are related to the BEST care, due to the overload of the BEST care the business will go slow. Having updated information of a patient is necessary immediately specially if there is something critical. In case a system goes slow, many patients’ information could be delivered late for that his life could be in danger. For example, sending an important report could be lost due to a software shutdown or trying to send an important diagnosis of a patient’s image to be treated will be late if there is an overload. To serve more patient we cannot have a system that slows down the process in a situation where more than one patient can be served if no overload exist instead of serving one in the same amount of time due to the overload and slowness of the system.
Theoretical framework2.1 Description of the workplace:National guard health affairs (NGHA) provides health care in more than one geographical area in Saudi Arabia. The CEO of ministry of NGHA is Bandar Al Knawy. Until now, NGHA has six main hospitals which are mainly exist to serve national guard personals and their eligible dependences. NGHA has passed the requirements for accreditation under the (JCI) Joint Commission International standards with excellent performance in December 2006. The six hospitals are distributed as following:
Hospital’s name City Foundation year Privileges
King Abdulaziz Medical City Riyadh May 1983 KAMC emergency center considered to be the best trauma center in Saudi Arabia
?King Abdulaziz Medical CityJeddah July 1982 It interacts and indulges in the medical bases practice amongst the institutional, local, regional, national and international collegial community.

King Abdulaziz Hospital
Al-Ahsa 2002 the hospital consists of Housing buildings for its employees which cover a 24,000 square/meter area that has a lot of main and basic facilities such sports and recreation centers.

Imam Abdulrahman Al Faisal Hospital
Dammam October 2002. considered one of the leading hospitals in the Eastern Region due to the international accreditation from JCIA for its recognized efforts.

Prince Mohammed Bin Abdul Aziz HospitalAl Madinah 2007 King Abdullah Specialist Children Hospital Riyadh Jun 2008 the first medical referral institute that serves children

NGHA is meant to take care of high quality patient health. To achieve that they produce and work on many projects including: king Abdullah international research center, BEST Care the hospital’s information system(HIS) and more. The Health Information System “BESTCare” project was implemented through several stages, beginning with an intensive search for a system that meets the requirements of Ministry of National Guards – Health Affairs. BESTCare was introduced and selected by an international South Korean company, in order to acquire and localize the hospital information system.
Information Services DepartmentISD in NGHA Al-Ahsa is divided to many sections to offer the best technology services, support, maintenance and enhancement of all computer and information technology issues to the ministry. The sections of ISD are divided as the following:PACS Team Section: responsible for the support of the day-to-day applications level of RIS/PACS system and all other image based work including modality workflow, image archiving, quality assurance of data, troubleshooting, data integrity and other related activities. The team also administrates and manages clinical operations and technical aspects of PACS, including user accounts, documentation of procedures, definition and implementation.Application Section: handles all business application programs provided in the organization including: HIS-CPR (BEST Care), Oracle, Attendance System, and more. They are mainly responsible in maintaining and enhancing all in-house application system that have been developed for administrative use as well as intranet service.Data Center Section: a facility used to house computer systems and associated components such as telecommunications and storage systems.  It generally includes redundant backup power supply, redundant data communications connections, and environmental control. Data Center Section is in fact a combination of Networks (LAN, WLAN, WAN), Systems, Technical Support and IT operation.

Network and Technical Support Team: manages the entire hospital network, installing and configuring automated tools to track network configuration; monitor network status and performance; detect, diagnose, and resolve network problems; network connectivity between hospital & PHC satellites clinic and global connectivity of organization affiliates; intranet/internet connection; and network security system.

Office Automation: optimizing existing manual tasks into electronic procedures by utilizing information technology for processing information, and communication technology that focus on the movement of information from one place to another, and give support for multi non-medical system (4).
2.2 Theoretical framework and studies
Many problems are common around the world with similar and different environments. Every company tries to provide the best comfortable environment for their employees. In this section we will discover other researchers’ thoughts and studies around the selected problems:
Offices design and locations:
Companies should pay more attention on office design to improve the productivity of their employees. A research firm showed a research on US workplace environment (Gensler, 2006). In March 2006, they conducted a survey by taking a sample size of 2013. The research was focused on; workplace designs, work satisfaction, and productivity. 89 percent of the respondents rated design, from important to very important. Almost 90 percent of senior officials revealed that effective workplace design is important for the increase in employees’ productivity. As a result, the firm suggested that businesses would increase their employees’ productivity by improving the workplace design. Furthermore, they discovered that a well-designed workplace will enhance the employees’ performance by 22 percent.

Another study by (Gensler, 2006) shows that 40 percent of the employees believe that the reason behind bad office design is because companies want to keep their costs low and 46 percent of employees think that the priority list of their company does not have workplace design on top. 90 percent declared that their attitude about work is affected by the quality of their workplace environment. Finally, 89 percent blamed their working environment for their job dissatisfaction.
The relationship between Office Design and Productivity is conducted by the American Society of Interior Designers (ASID, 1999). The study revealed that the physical workplace design is one of the top three factors, which affect performance and job satisfaction. The study results showed that 31 percent of people were satisfied with their jobs and had pleasing workplace environments. 50 percent of people were seeking jobs and said that they would prefer a job in a company where the physical environment is good.

Brill et al. (1984) ranked factors, which affect productivity according to their importance. The factors are sequenced based on the significance: Furniture, Noise, Flexibility, Comfort, Communication, Lighting, Temperature and the Air Quality. Springer Inc (1986) stated that “an insurance company in a study revealed that the best ergonomic furniture improved performance by 10 to 15 percent (5).

According to the previous studies, we can strongly agree that the office design and workplace environment absolutely affects employee’s productivity therefor to the businesses performance at the end.
Shortage in number of employees:
Low number of employees are more likely to suffer high stress levels. Which also have lower engagement and less productivity, according to a research from professional services firm Towers Watson. The Global Benefits Attitudes survey found that levels of workplace disengagement significantly increase when employees experience high levels of stress.  The study of 22,347 employees across 12 countries including the UK and US, revealed that over half of those employees stating to be experiencing high stress levels reported they were disengaged. The proportion of employees claiming high levels of workplace stress was 30% in the US, slightly lower than the 34% in the UK. These numbers reveal how high stress with pressure results in lower productivity. As a result, having a shortage in employees increases stress which decreases productivity.
The research clearly shows the link between high levels of stress and reduced productivity, remarked Rebekah Haymes, senior consultant and wellbeing specialist at Towers Watson. “A third of respondents said they are often bothered by excessive pressure in their job and this can lead to higher instances of disengagement and absenteeism –clear indicators of low productivity in the workplace.”
The causes of high stress levels were also explored in the research.  More than half of employees cited inadequate staffing as the biggest cause of stress in the workplace.  Globally, few employers considered this to be a major problem with only 15% of senior managers acknowledging this as a cause of stress in their organization.  However in the US, employers agreed that inadequate staffing was the second largest cause of workplace stress after ‘lack of work-life balance’ (6).

As mentioned above, poor staffing could be a factor which increases stress. However, in my opinion, having the few best people is better than more unqualified workers who will increase stress. Working in a hospital is more critical than elsewhere. Having unqualified workers will not only increase stress. But may also cause inaccurate data entry.
Main and backup servers:
Backup servers are used to save all data from a device to another. Devices included in the backup servers may include disk, CD-ROM, floppy, Zip drives, and tape. The study of Norman C. Hutchinson declared the following facts: The benefits of backups are: simplicity and speed. It is simple Because every bit from the source device is copied to the destination; the format of the data is irrelevant to the backup procedure. It is fast because it is able to order the accesses to the media in whatever way is most efficient (7).

According to this old study, in my perspective, even if we had sum limitations, the backup servers are strongly necessary specially for patient’s data. We can also be sure that technology has evolved during the past years which insures a better backup infrastructure.

Ruchir Shastri, points how important It is to have a backup. Data backup importance could come in various cases:
Accidental delete of files / folders – In case the developer accidentally delete a file or folder, we can easily jump to the backup console and restore it without the requirement to rebuild it.

Compromised files – In case the server is infected by a virus or malware which has modified or scrambled files, we will need to restore these files to the original version in addition to removing the virus or malware from the server.

Bad server Update – In case the server is hit by a bad server update which breaks things, we will need to restore it back to a state where it was running smoothly.
Hardware issue with server – In case the server hardware or storage devices (HDD, SSD, RAID controller, etc.) fail for some reason, we will be looking at complete data failure with immediate requirement to restore data to a working state. Appropriate data backups in place help immensely in this scenario, so that we can move the system to a state before hardware crash.

No one can really predict when they will need data from their backup copy, but it is highly important for the reasons above to ensure that having backups in place which are monitored regularly. The data center should also know what their requirements are to provide them (8).
In conjunction, Djas Djati explains how a server can be down for many reasons. Pointing that some are predicted and some are out of our control to fix or protect. Focusing on the physical conditions of a server room, the following could face any server room:
The server is physically off by:
No electricity power.

Hardware crash.

Wrong room temperature.


Natural disasters.

And more.

The server is not connected to the network, cable or network card issues or an entire network shutdown (9).
After reading about the importance of backups and the reasons of losing servers we can see how important it is to have the backup servers somewhere far from the server’s room. Losing the server room for any reason from the listed above probably will cause the loss of the backup server as well.
Servers overload:
Mike Ulrich from Google company discusses some reasons for servers overload that any company could face including the following:
Increased number of requests, because requests take longer time to handle, more requests are handled concurrently (up to a possible maximum capacity at which queuing may occur).
Excessively long queue lengths, if there is insufficient capacity to handle all the requests at steady state, the server will saturate its queues.
Thread starvation, when a thread can’t make progress because it’s waiting for a lock, health checks may fail if the health check endpoint can’t be served in time.
CPU or request starvation, internal watchdogs in the server detect that the server isn’t making progress, causing the servers to crash due to CPU starvation, or due to request starvation if watchdog events are triggered remotely and processed as part of the request queue (10).

All reasons mentioned above could happen to the servers in NGHA. But having their servers affected could cost the hospital the patient’s data and health.

In a published paper for Evan Jones a software engineer at Bluecore, he shares his experience of dealing with server overload. The problem he was dealing with was that requests to a server were timing out. They needed to add servers when old servers stopped serving. This problem kept happening so their solution was temporary. Jones suggests people having similar problem to “Limit the number of concurrent requests in all servers to avoid cascading failures. Jones says “You need the limit to be well below the “catastrophic” failure point for your service, but setting it too low will limit the throughput of your system “.

Another suggested solution by Jones, is Queue policies. The most common queue policy seems to be “first in first out” (FIFO), where arriving requests are dropped when the queue is full (sometimes called drop tail). This is probably not the best policy for overloaded servers. Imagine our server is processing a burst of requests, with a request arriving every 5 milliseconds. It has a queue of 3 messages. At steady state, 50% of the requests are dropped immediately, and the others are processed with 40 MS latency (11).
As we can see from above, overload servers will disrupt the business workflow. According to Jones he suggested many solutions but he is still unsatisfied with any of them and he wishes if there is a better and easier solution. However, latency in business workflow results in affecting patients’ data and lives in some cases.
MethodologyThis report is aimed to highlight some of the NGHA problems and for the PACS section in specific. In my opinion and from my direct observation I noticed the previous discussed problems. In addition, a survey was conducted as well as an interview with the PACS section employees totaling in a sample size of 3.
The survey was made for the four problems mentioned earlier. Questions included basic personal information in addition to their personal thoughts and experience.

ResultsThe survey and questionnaire findings:
Offices design and locations:
Question Strongly Agree Agree Neutral disagree Strongly disagree
You are satisfied with your job? 100% You are ok with the office design? 33% 66%
You have enough space to keep your belongs? 33% 33% 33%
Changing the office or the design will increase your productivity? 66% 33% You have communication problems with each other? 100% You tried to talk to someone responsible about your workplace and there was a response? 66% 33% As shown, all participants are 100% satisfied with their job and 66% strongly dislike their office design. 66% strongly agree that changing the office design will increase their productivity.

Shortage in number of employees
Question Strongly Agree Agree Neutral disagree Strongly disagree
You are satisfied with the number of employees in the department? 33% 66%
You think that some systems are neglected because of the low number of employees? 100% You Are facing more pressure because you are 3 employees only? 100% It is negatively affecting you that you are 3 employees only? 33% 66% You prefer to have more employees with you in the department? 100% The quality of work is affected due to number of employees? 33% 66% Respondents 100% strongly agree they face more pressure due to the shortage in employees and 100% strongly agree they need more employees. Also, 100% agree that some systems are neglected.

Main and backup server’s locations:
Question Strongly Agree
In your opinion it is ok to have the main and backup servers in the same room? 100%
You see that backup servers should be moved to another place? 100%
All strongly agree that servers must be moved to other location and having them in the same room is a serious problem. Also, supportively according to an interview with the administrator of the data center, he also agrees that they must be separated. The administrator of the data center adds that 20% of the use of backup servers is needed because of human errors which highlights the need of backup servers.

Servers overload:
Question Strongly Agree Agree Neutral disagree Strongly disagree
You experience a slowness when using best care 33% 66% This slowness effects PACS department Work? 66% 33% You face slowness in one of PACS systems? 33% 66% The big number of users using the system is the main reason for the slowness? 66% 33% 66% of respondents agree there is a slowness in BEST Care which affects PACS department and there is a slowness in the Universal View (UV) system according to an interview with PACS administrator.
RecommendationsComparing the results:
Offices design and locations:
According to the related questions from the interview and survey on this topic, we can reveal that they have been working in NGHA with an average of 9 years which helps to show their experience. They are satisfied with their current jobs but not satisfied with their offices design and size appealing that most don’t have enough space for their personal belongs. All respondents agree their productivity and passion to work will increase if they had bigger and better offices. Two of respondents work at a different unqualified building (responders strongly agree they work in an unqualified office) somehow they prefer to move to a better office near the head of the department and near the servers related to their section. One major problem they complained about during the interview is they are sometimes forced to make meetings at parking areas. Respondents tried to reach someone responsible to look into their case, but the respond was; there are no enough resource to meet their requirements. The administrator of PACS department highlights that the most important thing is to have an office near their servers and their end users to serve them as fast as possible. As a result, we can conclude they need to be near their servers and end users and have a better office design to be more productive with a bigger office to keep their belongs and have meetings.
Shortage in number of employees:
In this section, respondents agree that there is a shortage in the number of the employees in this department resulting in; exposing more pressure, neglecting some systems where some systems are forgotten how to be used by some and the decline in the quality of their work. This problem will never help them to improve, work harder and focus more to have better outputs.
Main and backup servers:
Having the main and backup server in the same room is a strongly agreed issue and must be separated in different location. In NGHA in Al-Ahsa the servers never went down for physical problems. In the other hand, in NGHA Al-Dammam all server with the backups are also in the same room. In Al-Dammam, they experienced a problem in the temperature of the room which led to heating servers then shutting them all down more than once. Whereas, the last shutdown continued for three days; this can be considered a disaster. In conclusion, NGHA in Al-Ahsaa may experience any disaster in the server room as in Al-Dammam resulting in losing data.
Servers overload:
Respondents have experienced slowness in using BEST Care (HIS) which affects the PACS department workflow. Where luckily they have not experienced slowness in most PACS related system. One of the respondents’ states that human error could cause in systems shutdown. respondents suggest to increase the license number of system users, have a faster network, bigger database and more servers.
5.2 RecommendationsThis research study highlights four basic problems firms can be expose to. These problems were discussed and some solutions and recommendations are suggested. Wishing some could be applied to decrease the effect of these problems.
Some recommended solutions:
Offices design and locations:
Have a décor designer to design employees offices.

Have more green plants to have more oxygen and fresh air to have better atmosphere.

Have closed offices to have a more comfortable and quite environment.

Have all PACS employees in the same building.

Change the furniture once in 5 years.
Shortage in number of employees:
Employ more employees.

Assign specific tasks for each employee.

Set a schedule to check all systems weekly.

Set assistants for simple tasks.

Have longer brake hours to release stress and pressure.

Main and backup servers:

Move all backup servers in a different building.

Have all PACS offices in the same location of main servers.

Move backup servers to a different room; at least in the basement.
Make periodic maintenance on servers to discover any issues.

Servers overload:
Limiting the number of requests handled at the same time.

controlling network traffic.

Offer server pools which is logically an autonomous region that contains one or more physical servers.

virtual machine server (VM server) hosts or runs virtual machines for testing software in different environments without getting the hardware.

Bnet Business dictionary (2008).

Joanne Smikle, Smikle Training Services Inc. The Labor Shortage
 Eric Henderson Rocket IT Hameed, Shehla Amjad, (January 2009) Impact of Office Design on Employees’ Productivity: A Case Study of Banking Organizations of Abbottabad, Pakistan Article.
Karen Higginbottom , , sept 2014Workplace Stress Leads To Less Productive Employees.
Norman C. Hutchinson,1999, Logical vs. Physical File System Backup.
Ruchir Shastri, 2015, Importance of Data Backup Services For Servers. Djas Djati, , 2018, What does it mean when a server goes ‘down’? Why does it go down?.

Mike Ulrich, 2017, Google chapter 22-Addressing Cascading Failures.
Evan Jones, 2017, preventing server overload: limit requests being processed.

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