WAITING TIME REDUCTION IN OUTPATIENT SERVICES - ANALOGY TO HEART FAILURE THERAPY

Transcription

1 WAITING TIME REDUCTION IN OUTPATIENT SERVICES - ANALOGY TO HEART FAILURE THERAPY Vijaya Bharat *, Bijoya Mohanty**, NKDas *** ABSTRACT Long waiting time in hospitals causes discontent among patients. Such delays in industrial hospitals can lead to man-hour loss and interfere with production. Crowded out-patient department (OPD) of the Cardiology section of Tata Main Hospital, Jamshedpur shared some commonality with chronic congestive heart failure on account of the volume overload and inefficient disposal in both the situation. Therefore, the principle of congestive heart failure therapy was applied to solve this problem. Crowding due to all the patients coming at the same time was overcome by giving appointment to chronic patients on regular visits. Efficiency was improved by increasing the availability of doctors and introduction of practice guidelines. Scheduling elective procedures after the OPD and starting a pacemaker clinic led to better time management. After two months of implementing these measures, the average waiting time for consultation decreased from 58.6 minutes to 7.7 minutes without any additional manpower or resources. I. INTRODUCTION Consultations in general hospitals are often without prior appointment and associated with significant waiting time. Such delays in industrial hospitals can lead to manhour loss and interfere with production. In Cardiology Department of Tata Main Hospital, Jamshedpur, by applying the principles of Congestive Heart Failure Therapy, this chronic problem was solved. II. MATERIAL AND METHODS Study Organization - Tata Main Hospital attached to Tata Iron and Steel Company offers free comprehensive medical services to its employees and their families. It caters to patients referred from other industries and the society in general. The Cardiology Department offers intensive care, pacemaker implantation and non-invasive tests like echocardiogram, stress test, holter monitoring etc. Its outpatient department (OPD) functions on Tuesdays, Thursdays, and Saturdays from 8.00 to AM with three doctors helping in consultation, screening patients for invasive cardiological procedures, and their follow up. In its pursuit for excellence, the management directed the hospital to achieve customer satisfaction by attending to at least 80% of the patients within 30 minutes of their arrival in the OPDs. MATERIAL Waiting time was calculated in 258 patients attending the Cardiology OPD on 4 days in March-April The OPD attendant gave chit papers with time of arrival to patients and the respective doctors noted the time of consultation and diagnosis. All the work done by each doctor before and after the OPD timing was noted for the above 4 days. Conditions in the existing system leading to long waiting time was identified by brain storming and grouped. Patient related causes - Patients used to come early since they were seen in a first come first seen basis. The OPD attendant used to collect their medical papers, enter names in a register, distribute them among the doctors, and then call the patients. The patients attending the OPD belonged to one of the three groups: 1) Those with chronic and stable illnesses, coming every month to collect medicines; 2) Patients undergoing evaluation or having unstable disease pattern requiring frequent visits and longer contact time. This category included patients with prosthetic heart valves, pacemakers, dyslipidaemia, etc; and 3) Referred cases with suspected cardiovascular problem, some of them requiring one time consultation only. Doctor related causes - The earlier practice of ward rounds by all the doctors before coming * Sr Specialist, ** Sr Medical Officer, *** Head of the Department, Dept of Cardiology 30

2 to the OPD had a snow balling effect on the waiting time in OPD. Elective procedures like discharge, case summary, investigations, pacing, pacemaker check up and emergency during OPD hours also increased the waiting time. METHOD A comparison was drawn between the causes and effects in congestive heart failure and the crowded OPD 1 (Table 1). A commonality was found due to volume overload and inefficient disposal in both the situations. Since patients with congestive heart failure benefit from treatment aimed at preload reduction, improvement in cardiac performance and afterload reduction the same principle was applied to solve the problem of crowded OPD as well. a) Preload reduction: Patients were staggered by giving appointment to those attending OPD on a regular monthly basis on any one of the 4 Tuesdays, 4 Thursdays, 4 Saturdays of every month. Five patients were called at 15 minutes interval from 8.00 to AM (every first Tuesday at 8.00 AM, every third Thursday at 9.30 AM etc). Convenience of patients was given preference. Patients were assured that they would be seen even if they come on an unscheduled day, by the same doctor beyond the appointment hours or by another doctor without delay. b) Improve cardiac performance: By rescheduling ward rounds, the availability of doctors in the OPD was improved. At least one doctor started the OPD in time, the rest joining after rounds in their respective wards. Practice guidelines for common problems were introduced for quick reference and uniformity like anticoagulant therapy, pacemaker follow up, prophylaxis for rheumatic fever, management of dyslipidaemia etc. The number of patients per doctor was fixed by giving appointment for one hour each in a cascading fashion (8.00 to 9.00 AM, 9.00 to AM and to AM). By this system at least 2 doctors at any given time could see the patients coming without appointment. 31 c) Afterload reduction: All elective works like combined rounds, discharges, case summaries, elective pacing, echocardiogram and other tests were postponed beyond the OPD hours. A new service - pacemaker clinic was started on the 5th Tuesday, Thursday or Saturday of the month since regular appointments were not given on such days. III. RESULTS The baseline data on waiting time calculated in 4 outpatient days in March-April 1998 is shown in Table 2. The mean waiting time was 58.6 minutes. Only 8.7% of the patients were seen within 30 minutes of their arrival in the hospital. In order to reduce overcrowding of patients, the type of cases, their contact time and the frequency of visits needed to be identified (Table 3). Patients with ischemic heart disease and hypertension constituted 70.5% of the total. Their average contact time was three minutes. Patients with rheumatic heart disease, prosthetic heart valves and pacemakers formed 16% but their average contact time was longer - 10 minutes. The rest 13.5% had varying contact time based on their illnesses. Reorganization of the OPD services and compliance of patients to the appointment system occurred in a consistent manner over two months. The impact on waiting time was calculated on 8 outpatient days from July 1998 to June Figure 1 shows significant reduction in waiting time from the base line level of 58.6 minutes to 7.7 minutes in June By giving appointment to about 50% of the patients attending the OPD, the entire group benefitted. The percentage of patients seen within 30 minutes increased from a mere 8.7% to 100% exceeding the target of 80% (Figure 2). This improvement occurred despite an increase in the average OPD attendance of 64 patients per day in March 1998 to 85 per day in June IV. DISCUSSION In most Indian hospitals, patients come to the OPD without prior appointment and wait for long. However, long waiting time in any

3 service sector is considered as an indicator of poor quality needing improvement. Increasing the number of staff and OPD hours are apparently simple but expensive solutions and do not address the problem. The concept of preload, contractility and afterload had remarkably improved the quality of life of patients with chronic congestive heart failure. The same concept applied in principle to the chronic problem of long waiting time in a Cardiology OPD produced equally impressive results! By reorganizing the work and introducing appointment to regular patients, the average waiting time was reduced within the available resources. Other benefits accrued from this effort were better compliance, improved contact time, and reduced noise level in the OPD. The employees who used to take leave for coming to hospital or make two visits to leave their wards and come again 2-3 hours later, stopped doing so after the new system was introduced. Instead they take a short break of 30 to 60 minutes from the work place, attend the hospital and return. Even elderly patients and those without any formal education could understand the simple one time appointment as per the fixed day of the month, which they mark in a calendar. Clear practice guidelines and instruction pamphlets improved patient care. A new facility like pacemaker clinic could be introduced for better follow-up. V. CONCLUSION It is possible to streamline the OPD services of hospitals through customer focus and optimum utilization of the resources. Industrial hospitals offering free medical aid to a captive population can adopt this method and achieve customer satisfaction by adding value to the services in a cost-effective manner. REFERENCE 1. Teres Daniel: Civilian triage in the ICU: The ritual of the last bed, Critical Care Medicine, 1993; 21; Reproduced with permission from the Editor Indian Journal of Occupational and Environmental Medicine, Vol 3, No 4, Oct- December 1999 Table 1: Analogy Between Congestive Heart Failure and Crowded OPD Cause Increase in preload (volume overload) Reduced contractility (inefficient disposal) Increase in afterload (vascular resistance) Effect in congestive heart failure Raised jugular veins Tender hepatomegaly Over stretched muscle Fibers Less contractile units Effect in crowded OPD Over crowding Noise and discontent More patients per doctor Less number of doctors cardiac contraction against Elective work and emergency resistance, increased valvular during OPD hours causing regurgitation into the heart interference and delay Table 2: Study of Waiting Time on 4 Out Patient Days (March-April 1998) Day 1 Day 2 Day 3 Day 4 Doctors Patients Average waiting time Range Patients seen within 30 minutes min minutes 4 (6.6%) min 10-80minutes 9(16.36%) min 2-105minutes 6(9.09%) min 5-102minutes 2(2.59%) 32

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