Outpatient Department (OPD)

A brief description of OPD of a hospital, with waiting-time management

1. Colonel Zulfiquer Ahmed Amin M Phil, MPH, PGD (Health Economics), MBBS Armed Forces Medical Institute (AFMI) DEPARTMENT

2. Definition OPD is defined as a part of the hospital with allotted physical facilities and medical and other staffs, with regularly scheduled hours, to provide care for patients who are not registered as inpatients. A hospital department where patients receive diagnosis and/ or treatment but do not stay overnight.

3. Rising cost of hospital care. Shortage of hospital beds. Economic constraints. To allow the patients to maintain social obligations. To avoid inconveniences of separation from family and society arising from hospital admission.

4. ● It provides 30–35% of hospital revenue by ways of consultation fees, diagnostic tests etc (For Private Hospitals). ● It is point of entry for more than 50% of IPD patients. ● It is a screening point (triage) for patients according to treatment need .

5. Magnitude of OPD Services ●

6. ● For each hospital bed, about 500 out-patients per year are given s ervices. ● In a hospital, usually 1.5-3 patients attend the OPD per day per hospital bed

7. History of OPD

8. Ambulatory Care Centre Polyclinic Health Centre Walk-in Clinic Day Hospital Dispensary etc

9. - Ambulatory care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and procedures . - A polyclinic is a clinic that provides both general and specialist examinations and treatments to outpatients and is usually independent of a hospital . - A health center is a type of clinic staffed by a group of general practitioners and nurses providing healthcare services to people in a certain area. Typical services covered are family practice and dental care.

10. A walk-in clinic accept patients on a walk-in basis and with no appointment required . A day hospital is part of a hospital that offers therapeutic services, where patients usually attend all day but go home or to a hospital ward at night . - A dispensary is an office in a school, hospital , industrial plant, or other organization that dispenses medications , and medical supplies. In a traditional dispensary set-up, a pharmacist dispenses medication as per prescriptions of qualified doctors.

11. OPD has functional and administrative links with the hospital of which it is a part. It may also be linked with Health Centers, Satellite Clinics and Dispensaries dependent on it. Expected demand should be determined basing on catchment area and population to be served. Should include curative, preventive and promotive health services

12. Requirements for OPD Size: 1 sq feet per patient visit or 60 sq m per bed OPD: 12 %-18 % of hospital area. Entrance zone: 2 sq m per bed Ambulatory zone (Clinical Area) : 10 sq m per bed Diagnostic zone: 6 sq m per bed 60% of area should be for waiting and corridors Seats for 1/3 of daily attendance @ 8 sq ft /pt. Consultation room – 150 sq ft Attached examination room – 80 sq ft

13. Projection of OP Load For every hospital bed, 1.5 to 3 patients attend OPD. 1-10 visits per capita per year of the dependent population basis

14. Design Consideration

15. 1 millimeter = 0.003 feet

16. Administrative Areas: - Admin Office - Business Office - House Keeping - Storage Facility - Security Point ATM Card Booth Clerical Point Physical Facilities

17. Circulation Areas (30% of all area ): - Corridors , Stairs, Lifts - Easy Accessibility of elevator - Corridor- 1.8 m wide

18. ● Family Planning and Immunization

19. Public relations practice is the planned and sustained effort to establish and maintain goodwill and mutual understanding between an organization and its publics. Public relations are the management function which evaluates public attitudes , identifies attitudes and procedures of an Individual and organization with the public interest , and executes p rograms of action to accomplish public interest and acceptance.

20. Improved public relations activities are steadily becoming one of the most important activities hospitals can engage. This increased emphasis is fueled by increased competition within the health care market where consumers are becoming more selective and using health-related information to make informed choices. In addition, patients have become better informed and more accountable consumers of health care services and want to become more active participants in decisions regarding the treatment process.

21. Organizational Components of OPD Auxiliary Nurse M idwife (ANM)

22. General Problems: 1. Insufficient number of doctors : This is mainly due to insufficient number of doctors to serve as compared to the number of patients arrive the clinic. 2. Absence of appointment system: Makes planning to manage patients impossible. 3. Inappropriate appointment system: Appointment-patient has no priority over non-appointment patient. Two types of patients follow the same process. Therefore, appointment-patients are likely to ignore their appointment time and tend to arrive the clinic very early. This causes congestion in the clinic during the beginning of the day.

23. 4 . Long waiting time at Registration, Consultation and Dispensary : Patients have to spend significant amount of time at all the contact points of OPD. 5 . Shortage of facilities. 6 . Insufficient training of medical personnel concerning ambulatory care. 7 . Fragmentation of care, poor communication and inadequate understanding of their demands. 8 . Resistance to change .

24. Specific Problems: 9. Inappropriate documentation. 10. Staffs sometimes misbehave with the patients. 11. There is absence of visible serial number . 12. Interruption of consultation or investigation by attending telephone calls, receiving guests, or attending VIPs. 13. Lack of privacy. 14. Advices are not clearly spelled out. 15. Illegible hand-writing of the doctors. 16. Poly-pharmacy. 17. Prescription of too much antibiotics.

25. 18. Long queues. 19. Prescribed medicines are not always available at pharmacy. 20. Use of trade-name of medicines by the doctors. 21. No clear advice about when, how and how long to take the medicines. 22. Sometimes, wrong medicines are given by the pharmacists. 23. Insufficient and un-cleaned toilets. 24. Undue influence of local political leaders. 25. Absence of practice of ‘triage’ at OPD . 26. Lack of respect and trust towards the professionals. 27. Too many patients.

26. Patient Waiting Time is “the time that the patient spends waiting for service in a facility” per visit and is calculated from the time the patient enters the facility ( taking into consideration the official opening time of a facility) to the time the patient leaves the facility. Patient clinic waiting time is an important indicator of quality of services offered by hospitals . Most patients found a waiting time of less than 30 minutes acceptable while more than 60 minutes was reported as not acceptable. The Institute of Medicine (IOM) recommends that patients should be attended to within 30 minutes of their arrival to the facility. Institute of Medicine : A nonprofit organization in USA established in 1970 that works outside the framework of government to provide evidence-based research and recommendations for public health and policy.

27. Causes of Long Queues - Too many p atients , not e nough hospitals. - In many health facilities demands for services is greater than the capacity at hand. - Where the demand exceeds capacity, appointments are postponed – these postponements increase the queues. - In instances where average capacity matches the demand, a mismatch between daily demand and daily capacity causes long queues. - Irregular pattern of inflow of patients in different time.

28. - Existence of ‘bottle-necks’ at some points of service-delivery - Not all patients are in equal need of care. Some patients are coming in for a follow-up visit. Others queue up for a general check-up or, as it often happens, “just to ask a quick question”. - Without an automated system, this adds to the chaos of a hospital wait room. Absence of dissemination of information. Scarcity of providers. Absence from work of service-providers. Inappropriate design of OPD.

29. How to solve long waiting-time -Introduction of appointment system. -Anyone needs emergency treatment (To by-pass appointment system), should report to only Emergency and Casualty Department. -It should be ensured that most health services are provided throughout the entire operational time of a facility. -Some of the services can be provided through outreach or visitation programs to reduce hospital load. -There must be sufficient staff members available during high pressure times. Tea and lunch breaks may be staggered throughout the day. -Maintaining r eferral pathways. -Identify the bottle necks by keenly observing the ‘ basic flow chart ’.

30. -Various mechanisms such as health education that empowers patient to understand their health conditions and subsequently take relevant precautions where necessary without the need to frequently visit facilities must be employed. -Partnering with local media and other public platforms should be used to provide relevant health education to the public. -Online and mobile-based medical help for minor ailments (Tele-health solution). -Organizing separate provisions for chronic disease conditions, requiring regular follow-ups, through local Central Chronic Medicine Distribution and Dispensing ( CCMD) . -Patients whose health conditions are stable and do not require regular observations and examinations in health facilities, should receive their chronic medications from CCMD .

31. -Signage indicating the location of various service areas should be visibly displayed at strategic areas . -Help / Information desk should be consistently manned to provide relevant information and guidance to needy patients . -Triage area should be consistently manned by knowledgeable clinicians who will direct and prioritize patients in line with their health conditions to appropriate service areas . -A staff member should be assigned to monitor queues and ensure that patients who need urgent attention are attended to urgently. -Meetings and in-service trainings should be held during the time of the day when the influx of patient is low.

32. -Doctors should be assigned to commence duties in OPDs as early as the time it officially opens. -Flexi-time should be considered for pharmacy staff, so to be responsive to high influx of patients. -Keep multiple counters during the peak patient-flow time. -Delegate documentation to other trained staff: Physicians’ time should be focused on interacting with patients, instead of completing time-consuming documentation. -The infrastructural design of new or renovated OPDs must ensure that service areas are in close proximity to one another to prevent time wasted through walking distance.

33. Psychological Approach -Sometime , it is not the duration of time, but how patients perceive the length of time of waiting, is important. -Introduction of a token and patient calling system with electronic display, to enable patients to sit and relax while waiting for their turn. -Provide a comfortable reception area. -Keep employees not serving the customers out-of-sight . -Inform customers of what to expect . -Try divert customer’s attention when waiting . -People always remember the last part of service. So provide a satisfying end of services. -Make waiting-lines bent, so that they don’t see a long line of queue always ahead of them. Give them hope . -A pleasant, personalized hospital experience drastically reduces perceived wait time.

34. Queuing theory is the mathematical study of the congestion and delays of waiting in line. Queuing theory (or " queueing theory") examines every component of waiting in line to be served, including the arrival process, service process, number of servers, number of system places and the number of " customers“. Queueing theory was pioneered by Agner Krarup Erlang when he created models to describe the Copenhagen telephone exchange . The ideas have since seen applications including telecommunication , traffic engineering , in the design of factories, shops, offices and hospitals, as well as in project management.

35. The waiting lines are formed due to the inefficiency of the service system to render immediate services to the customer when they arrive. The waiting time can be lessened by increasing the service capacity, or enhancing the efficiency of the existing elements in the service systems. But however, adding too much capacity may be a costly affair as it may lead to the increased idle time on the part of the server in case of a few or no customers. Also, the setup cost would be too high. Therefore, a manager has to decide the optimal level of service which is neither too high nor too low.

36. Queuing theory predicts, that congestion in any activity can be manipulated by: Influencing arrival process: Disperse number of people across time to arrive. Influencing queue structure: Make queue tolerable, comfortable, interesting. Apply psychological concepts. Influence service mechanism: Increase number of service providers, or increase points of service.

37. The basic formula behind queuing theory is Little’s Law . It may be defined as “the average number of items in a queuing system equals the average rate at which items arrive multiplied by the average time that an item spends in the system .” So, to minimize a waiting time: Reduce the rate of entry. By encouraging people to come through entire operational time of the facility. Use appointment system. Reduce the average time the customer will remain in the system. By increasing automation, efficiency, maintaining undisturbed flow etc.

38. Normal Queue System Make queue attractive. Keep provision of visible token-number; so that one can predict his turn of appointment.

39. Single queue, and multiple service points

40. Multiple queues, and multiple service points

41. To facilitate appointment system: -Automated reminders in the form of SMS, WhatsApp messaging and electronic mail systems. -Reminder calls especially to those with high risk conditions. -Telephone or physical notification of a facility by the patient in case the patient is unable to honour the appointment and requires alternative appointment.

42. Results of a Survey Top Strategies for Minimizing Patient Wait-Time Frustrations