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.

5. ● 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.

6. Magnitude of OPD Services
●

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

8. History of OPD

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

14. - 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.

15. - 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.

18. • 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

19. 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

20. 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

22. Design Consideration

26. 1 millimeter = 0.003 feet

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

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

36. ● Family Planning and Immunization

39. 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
programs of action to accomplish public interest and acceptance.

40. 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.

42. Organizational Components of OPD
Auxiliary Nurse Midwife (ANM)

43. 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.

44. 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.

45. 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.

46. 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.

48. 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.

49. Causes of Long Queues
- Too many patients, not enough 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.

50. - 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.

52. 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 referral pathways.
-Identify the bottle necks by keenly observing the ‘basic flow chart’.

53. -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.

54. -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.

55. -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.

56. 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.

57. 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.

59. 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.

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

61. 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:
1. Reduce the rate of entry. By encouraging people to come through
entire operational time of the facility. Use appointment system.
2. Reduce the average time the customer will remain in the system.
By increasing automation, efficiency, maintaining undisturbed
flow etc.

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

63. Single queue, and multiple service points

64. Multiple queues, and multiple service points

65. 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.

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