patient flow management in opd

PATIENT FLOW MANAGEMENT IN OPD


Project submitted to Osmania University towards the partial fulfilment of the award of Masters Degree in Hospital Management

Submitted by

TEJASWI KOCHERLAKOTA

Enrol no: 140413676035

BATCH-19 (2013-15)

Academic year 2013- 2014

APOLLO INSTITUTE OF HOSPITAL ADMINISTRATION

APOLLO HEALTH CITY CAMPUS, JUBILEE HILLS

HYDERABAD – 500 096



DECLARATION

I hereby declare that the Project Report entitled “PATIENT FLOW

MANAGEMENT IN OPD” submitted by me to the Department of

Business Management, Osmania University, Hyderabad, is a bonafide work

carried out by me and is original and not submitted to any other University or

Institution for the award of any Degree/Diploma/Certificate or published any

time before.

PLACE: Hyderabad Signature:

DATE: Name: TEJASWI.K

Roll No.:140413676035



CERTIFICATION

This is to certify that the Project Report entitled “PATIENT FLOW

MANAGEMENT IN OPD” submitted in partial fulfilment for the award of

M.D.H.M programme of Osmania University, Hyderabad, was carried out by

Ms. TEJASWI KOCHERLAKOTA under my guidance. This has not been

submitted to any other University or Institution for the award of any degree/

diploma/certificate.

Signature of the Internal Guide Signature of the Principal

Name: M. Krishna Kartheek (with stamp)



ABSTRACT

Ensuring efficient and safe patient flow through the hospital system is a consistent problem in

healthcare settings. As demand and patient complexity increases small in efficiencies and

errors in health care delivery can cause hospital overcrowdings and service delay. An

inefficient layout may also create problem concerning patient supervision may increase the

travel time and waiting time. This may give patients a poor overall impression of the setting.

Reducing delays and making sure that patients receive the right care at right time will have a

significant beneficial effect on the quality of care patients receive.

To accomplish the above criteria the objectives are set which include, to

understand the problems which the outdoor patients encounter like long standing queues,

improper maintenance of patient traffic at the out patient department section, to find the

bottlenecks, reasons and solutions for the problems encountered. A random sampling

technique is followed to collect the data. A sample of 300 patients is selected randomly

from out patient department i.e., OP consultation patients, patients in casuality or

emergency department and from the diagnostics. The data is collected by observation

method and by preparing a format in which time slots are given to each activity i.e., waiting

time for op registration, waiting time for doctor consultation, waiting time for diagnostic

billing, testing and dispatch of reports. Data is analysed by plotting graphs and histograms.

The average time taken for OP registration is 5.5 minutes, waiting time for doctor

consultation is 37.1 minutes, for diagnostic billing it is 5.0 minutes, for diagnostic

procedures it is 14.1 minutes and for dispatch of reports it is63.1minutes. The inferences

made from the above analysis is the waiting time is more for doctor consultation and

dispatch of reports. As dispatch of reports is delayed, by the time the patient gets the report

the doctors may not be available in OP. This is due to improper scheduling of consultants

and radiologist. So, some suggestions are recommended to improve the patient care

delivery.

This project will help to optimise patient’s flow that is necessary to understand

how the system is currently working by reviewing existing process and determining weak or

broken links of the system.



ACKNOWLEDGEMENT

The success and final outcome of this project required a lot of guidance and assistance from

many people and I am fortunate to have got this all along the completion of my project work.

Whatever I have done is only due to such guidance and assistance and I would not forget to

thank them.

I respect and thank Dr.Satish Reddy (Managing Director) for giving me an

opportunity to do the project work in Prime Hospitals, Ameerpet and I am also thankful to the

hospital staff for providing me the support and guidance which made me complete the project

on time.

I would also like to thank my Principal Prof.D.Obul Reddy and Internal Guide

Prof.M.KrishnaKartheek without whom the project would have been a distant reality.

I owe my profound gratitude to my project guide Dr.Sarath (Senior Medical

Director),who took keen interest in my project work and guide all along, till the completion

of my project work by providing a the necessary information.

I take this opportunity to acknowledge the services provided by the library sir, lab sir

and everyone who collaborated in producing this work.

I also wish to thank specially my husband, family members and well wishers who has

always been supportive in successful completion of my project.



Table of Contents

S.No Description Page No

1. Introduction 1 - 9

Patient Flow 1

Principles of patient flow management 3

Bottlenecks 4

Research problem 7

Sources of information 9

2. Literature Review 10 - 15

Types of literature review 10

Literature review on patient flow management 11

Case Study-1 11

Case Study-2 12

Case Study-3 13

Case Study-4 14

3. Organization 16 - 38

History of Prime Hospitals 16

Directors vision 16

Services 17

Hospital Branches 17

Certifications, Quality policy and objectives 20

Strengths of the hospital 23

Outpatient department 23

OP and IP Registration 24

Diagnostics billing 24

Diagnostics 25

Emergency department / Casuality 32

Organograms 33

Patient flow processes 35

4. Data Analysis 39 - 45

Waiting time for OP registration 39

Waiting time for Doctor Consultation 40



Waiting time for Diagnostics billing 41

Waiting time for Diagnostics 42

Total waiting time at various stages in patient flow process 43

Average waiting time at various stages in patient flow process 44

5. Inferences 46

6. Summary and conclusions 47

Bibliography48

Appendix 49

1. List of Figures Page No

Figure 1.1 Process Bottlenecks 6

Figure 3.1 Prime hospital 17

Figure 3.2 Services 17

Figure 3.3 Prime Hospital Ameerpet 18

Figure 3.4 Prime hospital Kukatpally 19

Figure 3.5 National certification Board 20

Figure 3.6 ODC standard certification 21

Figure 3.7 Objectives and policies 22

Figure 3.8 Organo gram of Prime hospitals 33

Figure 3.9 Organo gram for Aarogyasree department 34

Figure 3.10 Patient flow process for emergency patients 35

Figure 3.11 Patient flow process for direct and appointment patients

36

Figure 3.12 Patient flow process for Aarogyasree patients 37

Figure 3.13 Process flow in X-Ray department 38

2. List of Charts Page No

Chart 4.1 No of patients vs. OP registration time 39

Chart 4.2 No of patients vs. Doctor consultation time 40

Chart 4.3 No of patients vs. Diagnostics billing time 41

Chart 4.4 No of patients vs. Diagnostics time 42

Chart 4.5 Total waiting time in various stages 43

Chart 4.6 Average waiting time in various stages 44



CHAPTER-1

INTRODUCTION

As there are numerous technological advances in diagnostics, medications, procedures and

modifications in healthcare reimbursement plans, the mode of healthcare has been gradually

shifting away from the inpatient setting to the outpatient basis.

Blockage in the flow can increase waiting time. When patient flow is handled well, it is

represented by short wait at the registration, examination, diagnostic testing, surgery, placement in

beds and discharge.

PATIENT FLOW

What is it and how can it help me?

More and more people are using the term ‘patient flow'. The term flow describes the progressive

movement of products, information and people through a sequence of processes. In simple terms,

flow is about uninterrupted movement, like driving steadily along the motorway without

interruptions, or being stuck in a traffic jam.

In healthcare, flow is the movement of patients, information or equipment between departments,

staff groups or organisations as part of a patient's care pathway. Patient flow means movement of

patients through multiple stages of care.

PATIENT FLOW MANAGEMENT

It represents ability of healthcare system to serve patients quickly and efficiently as they move

through stages of care.

This is an operational or process view of patient flow. A clinician may have a different

focus. Their focus could be on the progression of a patient's health status, disease progression

and/or the clinical knowledge and understanding of both. The clinical focus naturally allows for

appropriate waits, for example ‘watchful waiting'.

APOLLO INSTITUTE OF HOSPITAL ADMINISTRATION 1


There has to be a close relationship between both the operational and clinical perspectives. What

happens to a patient clinically will dictate his or her movement through different steps and

settings, as well as the movement of associated information, equipment, samples etc.

One way to engage and ensure that patient flow incorporates the clinical view is to include

clinicians in mapping sessions, i.e. where teams map out patient pathways and associated

processes. If you find it difficult to engage clinical staff, you may find it helpful to start from their

viewpoint - and then see how processes fit around this.

Reducing delays and making sure that patients receive the right care at the right time will have a

significant beneficial effect on the quality of care patients receive. In turn, this will improve

patient outcomes and reduce the cost of care.

When does it work best?

Patients referred to and treated in hospitals and systems that ‘keep the flow' and ‘keep things

moving' will have quicker referral to treatment times. Any waits that occur will be necessary;

either for clinical reasons or due to patients choosing to wait (for example, the time needed to

make a decision about whether or not to have a treatment).

How to use it?

This is useful to structure the overall approach to improving patient flow, and thereby reducing

delays. It links up to tools and other guides that provide more detail. The approach is based on two

main improvement strategies: the theory of constraints and Lean thinking; and a body of practical

knowledge - clinical systems improvement and clinical micro-systems.

It's useful to start from these theories as they provide health services with proven approaches to

improvement, as well as the tools and techniques which we know work. Despite the origins of

patient flow being in the manufacturing industry, there are many ideas and concepts that can be

borrowed and adapted to help manage health services.

Patient flow in context?

Improving patient flow is one way of improving health services. Evidence suggests that enhancing

patient flow also increases patient safety and is essential to ensuring that patients receive the right



care, in the right place, at the right time, all of the time (reliability). However, it is important that

patient flow does not improve at the expense of safety or system reliability.

Factors affecting patient flow:

Volume of patients on daily basis.

Types of patients seen in terms of stage care.

Clinic policies on frequency of the patient visits.

Type of provider they should see.

Size and composition of providers and staffing models.

Reasons for delay in patient flow:

Waiting for a doctor or a test result.

Waiting for investigations performed outside or for a specialist from outside.

Waiting to find a hospital bed or to go to a hospital bed.

Waiting for an ambulance or patients attendants for patient admission.

Principles of patient flow management:

Lengabeer in his book health care operation management a quantitative approach to

business and logistics points, there are five principles for improving operational efficiency

during hospital design.

Observe the movement pattern, volume, distance travelled and analyse length of time to

move staff, supplies and other resources.

Focus on interdependent movement and decreasing geographical distance from patient

examination room to minimize number of trips.

Use optimization to minimize costs.

Separate patient flow from staff reduces over crowing.



Physical and visual accessibility of spatial layout have the ability to improve

operational efficiency and maximize patient satisfaction by moving patients and

resources efficiently through the units by minimizing wait and transport time.

Spatial attributes included are visibility, accessibility, connectivity and path distance.

BOTTLENECKS:

A bottleneck is any part of the system where patient flow is obstructed causing waits and delays.

It interrupts the natural flow and hinders movement along the care pathway, determining the pace

at which the whole process works. You cannot make changes to improve the care process if you

don’t tackle the bottleneck. Any service improvement is unlikely to succeed because the patient

will be accelerated into the queue, only to be halted further along the pathway by the bottleneck.

Keep a look out for bottlenecks (usually identified by finding a queue). In the whole patient

journey, from visiting the GP to discharge after treatment, it is very likely that there will be at

least one.

Start by analysing the patient's journey to identify the location of any bottlenecks. The aim is to

identify where the flow is slowed within the overall process of care. This typically requires

developing a patient process flow map.

Reducing current waiting times requires a reduction in backlog of patients at every

stage of the journey. Matching capacity and demand is a key approach to removing some

of the visible and hidden backlogs along the patient pathway.

A bottleneck is usually caused by something - this is known as the constraint. The

constraint is the part of the process which ultimately restricts the amount of work that can

be done. By concentrating on the bottlenecks, you can accurately manage demand and

capacity and therefore keep the flow of patients moving, which will in turn reduce overall

waiting times.

Concentrate on the bottlenecks to reduce delays:



Look very carefully at the process map (a guide to mapping patient journeys - process

mapping, a conventional model) and identify stages in the patient journey where patients

have to queue or are put on a waiting list - this is a bottleneck.

Map that part of the process in more detail to make sure you really understand what is

going on. Map to the level of what one person does, in one place, with one piece of

equipment, at one time.

Look carefully for the true constraint. This is often a lack of availability of a specific skill

or piece of equipment. Queues tend to occur before the bottleneck in the patient journey,

and clear after the patient has gone past the stage with the constraint.

Measure at the bottleneck to really understand the capacity and demand. These guides will

help you: quick introduction to demand and capacity and comprehensive guide to demand

and capacity.

Begin to test and implement the relevant change ideas as a result of what the measurement

shows you.

Keep asking ‘why?’ (Five whys) to try to discover the real reason for the delay. For

example, if your starting point is ‘the clinic always overruns and patients have to wait for a

long time’, ask why? At least five times. Possible responses might be that the consultant

doesn’t have time to see all their patients in clinic as they have to see everyone who

attends, including first visit assessments and follow up patients.

Create templates of the processes (process templates), begin to schedule these templates

and watch the whole process improve.

Keep a look out for other bottlenecks. In the whole patient journey there is likely to be at

least one bottleneck.

Different types of bottlenecks:

Bottlenecks are the parts of the healthcare system with the smallest capacity relative to the

demand. There are two different types of bottlenecks: process bottlenecks and functional

bottlenecks.

1. Process bottlenecks are the stage in a process that takes the longest time to complete. Process

bottlenecks are often referred to as the ‘rate limiting step or task’ in a process.



Figure1.1

In the example above, activity 3 is the process bottleneck as it takes the longest time. This may be

the consultant seeing the patient in outpatients.

2. Functional bottlenecks are caused by services that have to cope with demand from several

sources. Radiology, pathology, radiotherapy, and physiotherapy are often functional bottlenecks

in healthcare processes. Functional bottlenecks cause waits and delays for patients because:

One process, such as ENT surgery, might share a function, such as imaging with other

processes, e.g. orthopaedic surgery, and medicine

A surgeon may be called to theatre when he is also needed in outpatients.

This type of bottleneck causes a disruption to the flow of all patient processes. Functional

bottlenecks act like a set of traffic lights, stopping the flow of patients in one process while

allowing the patients in another process to flow unheeded. Where you have a bottleneck, there is

usually a queue i.e. a delay that the patient will experience.

Methods for reducing the effect of bottlenecks:

Ensure that the bottleneck has no idle time, for example, have a list of stand by patients

who can be called at short notice in the event of idle capacity

Put inspection or checking tasks in front of the bottleneck (e.g. if the bottleneck is the

doctor in clinic, check that all test results are available at the clinic)

Don't allow the room or clinical area to be the bottleneck

Distribute the work amongst the clinical team so that everyone works to their highest level

of skill and expertise, for example take administration away from rehabilitation nurses and

give it to appropriate clerical staff



If experts are the bottleneck they should only be doing work for which an expert is needed

e.g. the development of nurse initiated transfer from critical care

Separate responsibilities for clinical care and paper flow

To increase the capacity of the bottleneck, give some of the work to non-bottleneck areas,

even if it is less efficient for these areas.

RESEARCH PROBLEM:

The research problem is to study the patient flow management in outpatient department.

NEED FOR STUDY:

As the patient flow increases there may be increase in bottlenecks, which gives a poor overall

impression for the patient. So to avoid this, reasons for increase in waiting time is analysed to

enhance patient satisfaction.

SIGNIFICANCE OF THE PROJECT:

Significance of the project is to analyse the inefficiencies and bottlenecks to improve patient care

delivery.

OBJECTIVES:

To understand the problems which the outdoor patients encounter like:

Long standing queues

Limited number of counters for patient registration and enquiries

Improper maintenance of patient traffic at the out patient department section.

To find the reasons and solutions for the problems encountered.

METHODOLOGY:

o Sampling method is followed for determining the patient flow process.

o Random sampling technique is followed



o The details of patients and time of his/her entry, the time for which the patient moves

through various departments till either exit of the patient or IP admission is noted.

o After the data collection is done the data is analysed for any delays in patient flow process

and they are resolved.

SAMPLE DESIGN:

The total monthly new OP is 1600-1650.A sample of 300 patients is selected which is 18% of the

whole population. The sample is selected by simple random sampling technique. The sample

represents the whole population.

SCOPE OF THE REPORT:

The project includes patient flow regarding only out patient department and the patient

management in various departments in out patient department i.e., registration process, in patient

admission, casualty/emergency department, diagnostic billings, diagnostics services.

SOURCES OF INFORMATION:

Primary sources:

o Survey method

o Relevant file study

Secondary sources:

o Internet used as a source of theoretical information.

o Registers and records of hospital.

TOOLS AND TECHNIQUES OF ANALYSIS:

For data collection:

o Personal observation: direct and indirect observation

o Interviews with staff



o Quantitative method of analysis

For data analysis: Mean

STRUCTURE OF THE STUDY:

Current study includes the literature review of other studies done on patient flow management,

historical aspect of the organisation in which project is done and outpatient department is selected,

data is collected, analysed and inferences are given.

CHAPTER-2

LITERATURE REVIEW

A literature review is a text of a scholarly paper, which includes the current knowledge including

substantive findings, as well as theoretical and methodological contributions to a particular topic.

Literature reviews use secondary sources, and do not report new or original experimental work.

Types of literature review:

Most often associated with academic-oriented literature, such as a thesis, dissertation or peer-

reviewed journal article, a literature review usually precedes the methodology and results section.

Literature reviews are also common in a research proposal or prospectus (the document that is

approved before a student formally begins a dissertation or thesis). Its main goals are to situate the

current study within the body of literature and to provide context for the particular reader.

Literature reviews are a staple for research in nearly every academic field.


http://en.wikipedia.org/wiki/Research_proposal

http://en.wikipedia.org/wiki/Dissertation

http://en.wikipedia.org/wiki/Thesis

http://en.wikipedia.org/wiki/Secondary_sources


A systematic review is a literature review focused on a research question, trying to identify,

appraise, select and synthesize all high quality research evidence and arguments relevant to that

question. A Meta analysis is typically a systematic review using statistical methods to effectively

combine the data used on all selected studies to produce a more reliable result.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time

to conduct research, literature reviews can give you an overview or act as a stepping stone. For

professionals, they are useful reports that keep them up to date with what is current in the field.

For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer

in his or her field. Literature reviews also provide a solid background for a research paper’s

investigation. Comprehensive knowledge of the literature of the field is essential to most research

papers.

Who writes these things?Literature reviews are written occasionally in the humanities, but mostly in the sciences and social

sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a

literature review is written as a paper in itself.

LITERATURE REVIEW ON PATIENT FLOW MANAGEMENT:

There was a lot of research work done on patient flow management by many scholars since many

years on various issues like patient flow in hospitals, patient flow in the emergency department,

patient flow analysis to improve patient visit efficiency, improving patient flow—In and Out

of Hospitals and Beyond etc.,

Some of those studies are given below:

CASE STUDY 1:

Patient Flow in Hospitals:

Understanding and Controlling It Better

Carolharaden, PhD and Androgerresar, M.D.


http://en.wikipedia.org/wiki/Meta_analysis

http://en.wikipedia.org/wiki/Systematic_review


Summary: Because waits, delays, and cancellations are so common in Healthcare, patients and

providers assume that waiting is an inevitable, but regrettable, part of the care process or years,

hospitals responded to delays by adding resources more beds and buildings or more staff as the

only way to deal with an increasingly needy population. Furthermore, as long as payment for

services covered the costs, more construction and more staff allowed for continued inefficiencies

in the system. Today, few organizations can afford this solution. Moreover, recent work on

assessing the reasons for delays suggests that adding resources is not the answer. In many cases,

delays are not a resource problem they are a flow problem. The Institute for Healthcare

Improvement has worked with more than 60 hospitals in the United States and the United

Kingdom to evaluate what influences the smooth and timely flow of patients through hospital

departments and to develop and implement methods for improving flow. Specific areas of focus

include smoothing the flow of elective surgery, reducing waits for inpatient admission through

emergency departments, achieving timely and efficient transfer of patients from the intensive care

unit to medical/surgical units, and improving flow from the inpatient setting to long-term-care

facilities.

CASE STUDY 2:

Analysis of patient flow in the emergency department and the effect of an

extensive reorganisation:

Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain Correspondence to: Dr Ò Miró, Emergency Department, Hospital Clinic, Villarreal 170, 08036 Barcelona, Catalonia, Spain.

Abstract:

Objectives: To evaluate the different internal factors influencing patient flow, effectiveness, and

overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on

these indicators.



Methods: The study compared measurements at regular intervals of three hours of patient arrivals

and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and

2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for

each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related

to ED itself; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself;

and (4) factors related to neither ED nor hospital. The study measured the number of patients

waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the

percentage of time that ED was overcrowded, as judged by numerical and functional criteria.

Results: Effectiveness of ED was closely related with some ED related and hospital related

factors. After the reorganisation, patients who remained in ED because of hospital related or non-

ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients

waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001).

Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in

numerical and functional terms respectively. After the reorganisation, these figures were reduced

to 8% and 15% respectively (p<0.001 for both).

Conclusions: ED effectiveness and overcrowding are not only determined by external pressure,

but also by internal factors. Measurement of patient flow across ED has proved useful in detecting

these factors and in being used to plan an ED reorganisation.

CASE STUDY 3:

Use of patient flow analysis to improve patient visit efficiency by decreasing

wait time in a primary care-based disease management programs for

anticoagulation and chronic pain: a quality improvement study

Nicholas M Potisek, Robb M Malone, Betsy Bryant Shilliday, Timothy J Ives, Paul R Chelminski,

Darren A DeWalt and Michael P Pignone.

Abstract:

Background:

Patients with chronic conditions require frequent care visits. Problems can arise during several

parts of the patient visit that decrease efficiency, making it difficult to effectively care for high

volumes of patients. The purpose of the study is to test a method to improve patient visit

efficiency.

Methods:



We used Patient Flow Analysis to identify inefficiencies in the patient visit, suggest areas for

improvement, and test the effectiveness of clinic interventions.

Results:

At baseline, the mean visit time for 93 anticoagulation clinic patient visits was 84 minutes (+/- 50

minutes) and the mean visit time for 25 chronic pain clinic patient visits was 65 minutes (+/- 21

minutes). Based on these data, we identified specific areas of inefficiency and developed

interventions to decrease the mean time of the patient visit. After interventions, follow-up data

found the mean visit time was reduced to 59 minutes (+/-25 minutes) for the anticoagulation

clinic, a time decrease of 25 minutes (t-test 39%; p < 0.001). Mean visit time for the chronic pain

clinic was reduced to 43 minutes (+/- 14 minutes) a time decrease of 22 minutes (t-test 34 %; p <

0.001).

Conclusion:

Patient Flow Analysis is an effective technique to identify inefficiencies in the patient visit and

efficiently collect patient flow data. Once inefficiencies are identified they can be improved

through brief interventions.

CASE STUDY 4:

Work pressure and patient flow management in the emergency department: findings from

an ethnographic study.

Nugus P, Holdgate A, Fry M, Forero R, McCarthy S, Braithwaite J.


http://www.ncbi.nlm.nih.gov/pubmed?term=Braithwaite%20J%5BAuthor%5D&cauthor=true&cauthor_uid=21996069

http://www.ncbi.nlm.nih.gov/pubmed?term=McCarthy%20S%5BAuthor%5D&cauthor=true&cauthor_uid=21996069

http://www.ncbi.nlm.nih.gov/pubmed?term=Forero%20R%5BAuthor%5D&cauthor=true&cauthor_uid=21996069

http://www.ncbi.nlm.nih.gov/pubmed?term=Fry%20M%5BAuthor%5D&cauthor=true&cauthor_uid=21996069

http://www.ncbi.nlm.nih.gov/pubmed?term=Holdgate%20A%5BAuthor%5D&cauthor=true&cauthor_uid=21996069

http://www.ncbi.nlm.nih.gov/pubmed?term=Nugus%20P%5BAuthor%5D&cauthor=true&cauthor_uid=21996069


Author information : Centre for Clinical Governance Research in Health, Australian Institute of Health

Innovation, Faculty of Medicine, University of New South Wales, Sydney, Australia.

[email protected]

Abstract:

Objectives :

In this hypothesis-generating study, we observe, identify, and analyse how emergency clinicians

seek to manage work pressure to maximize patient flow in an environment characterized by

delayed patient admissions (access block) and emergency department (ED) crowding.

Methods:

An ethnographic approach was used, which involved direct observation of on-the-ground

behaviours, when and where they happened. More than 1,600 hours over a 12-month period were

spent observing approximately 4,500 interactions across approximately 260 emergency physicians

and nurses, emergency clinicians, and clinicians from other hospital departments. The author’s

content analysed and thematically analysed more than 800 pages of field notes to identify

indicators of and responses to pressure in the day-to-day ED work environment.

Results :

In response to the inability to control inflow, and the reactions of inpatient departments to whom

patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions;

negotiated and determined patients' admission-discharge status early in their trajectories; pursued

predetermined but coevolving pathways in response to micro- and macro flow problems; and

exercised flexibility to reduce work pressure by managing scarce time and space in the ED.

Conclusions :

To redress the linearity of most literature on patient flow, this study adopts a systems perspective

and ethnographic methods to bring to light the dynamic role that individuals play, interacting with

their work contexts, to maintain patient flow. The study provides an empirical foundation,

uniquely discernible through qualitative research, about aspects of ED work that previously have

been the subject only of discussion or commentary articles. This study provides empirical

documentation of the moment-to-moment responses of emergency clinicians to work pressure


http://www.ncbi.nlm.nih.gov/pubmed/21996069


brought about by factors outside much of their control, establishing the relationship between

patient flow and work pressure. We conceptualize the ED as a dynamic system, combining socio

professional influences to reduce and control work pressure in the ED. Interventions in education,

practice, policy, and organizational performance evaluations will be supported by this systematic

documentation of the complexity of emergency clinical work. Future research involves testing the

five findings using systems dynamic modelling techniques.

CHAPTER-3

ORGANIZATION

HISTORY OF PRIME HOSPITALS:

Prime Hospitals situated in Ameerpet and Kukatpally, are one of the pioneer

corporate health care hospitals in the state of Andhra Pradesh. Since its inception, Prime

hospitals have been in the forefront in offering International standard corporate health care

facilities. As leaders in super specialty healthcare in the state of Andhra Pradesh.

Prime Hospitals is a private, full-fledged multi-speciality hospital with 250

beds of which 75 are ICU beds in Ameerpet and also 110 beds of which 30 are ICU beds

in Kukatpally centres.

The hospital has expert and renowned doctors, state of the art medical

infrastructure which includes the advanced Cath Lab, CT Scan, Colour Doppler,



Ultrasound and other diagnostic services with fully equipped labs. All these combine to

provide round the clock prompt and accurate treatment.

As a leading healthcare provider, the hospital provides patients with the latest

technological innovations for diagnosis and treatment of the most acute clinical conditions.

This is made possible by the compassionate care and expertise of doctors providing the

"Healing Touch" to the patient.

The Hospital has trained staff including nurses; full time doctors and support

staff to provide round the clock personalized attention and care leading to faster recovery

of patient.

DIRECTORS' VISION

We are pleased to introduce you to the world of the Prime Hospitals. We reinvented ourselves as

a group in 2007. We entered into the service sector enterprise to what I call "The Place Of

Care". Earlier, it was known as the Mythri Hospital, but renamed it as Prime Hospitals because

"Prime" symbolizes the location of the hospital, the quality of our services and the expertise of

our faculty.

Figure 3.1

As we know "Prevention is better than cure". So, Prime gives clear cut guidelines for prevention

of disease by its experts and experienced personnel.

We are actively involved in social service through Rajeev Aarogyasree services.

Our vision is to deliver world class health care with a sensitive focus by creating an institution

committed to the highest standards of medical and service excellence, patient care, scientific



knowledge and motivational approach.

We have set ourselves the mission of creating unparalleled standards and outcome. Our aim is to

be first in care providing as well as in patient's choice of home for care.

SERVICES:

Figure 3.2

» We provide a large range of consultative, diagnostic and surgical services to people

whose health complaints do not warrant hospitalization through our Out-Patient Dept.

» Quick registration procedures, extensive tie-ups with medical insurance organizations and

corporate world - credit cards are accepted for payment.

» An Emergency Medical service takes care of all emergency patients which has got

telephone access and round the clock red alert team along with all concerned specialities.

PRIME HOSPITALS

We have Two Branches in Hyderabad. Super Speciality Services at Ameerpet & Kukatpally.

Ameerpet:



Figure3.3

The Hospital is centrally located in Hyderabad at Ameerpet and accommodated in a building with

state-of-the-art medical equipment coupled with modern amenities. The Hospital houses all the

routine and the latest diagnostic facilities that are very important to enable quick and accurate

diagnosis to facilitate quality treatment.

Prime Hospitals is equipped with the latest facilities which function round-the-clock including

Cath Lab, T.M.T, ECG, PFT, CAT scan, Ultrasound-Ray and laboratory and five State-of-the-art

Operation Theatres. And with advantage of being centrally located and easily accessible, Prime

Hospitals provides 24 hours emergency care by experienced doctors in their respective specialities

including trauma care.

Kukatpally:

Figure3.4

The Hospital is air conditioned in all the patient care areas, providing the right ambience for

psychological and physical comfort. The well equipped four State-of-the-art Operation Theatres

can take-up all surgeries ranging from Laparoscope to Cardiothoracic surgeries. The intensive



care / acute medical care units are centrally monitored and are truly world-class. We have 4 OT's

with 24/7 coverage for any Emergencies.

SPECIALITIES IN PRIME HOSPITALS:

1. Anaesthesiology. 11.Plastic Surgery

2. Cardiology 12.Nephrology

3. Critical care 13.Gynaecology

4. Obstetrics 14.Metabolic Surgery

5. Internal Medicine 15.Advanced Laparoscopy

6. Neuro Surgery 16.Bariatric Surgery

7. Orthopaedics 17.ENT

8. Paediatrics 18.General Surgery

9. Radiology 19.Gastroenterology

10.Urology



CERTIFICATIONS:

The certifications given for prime hospitals are NABH, Indian Health Organisation and ODC

standards certification.

NATIONAL ACCREDITATION BOARD

Figure3.5



ODC STANDARDS CERTIFICATIONS:

Figure3.6



PRIME HOSPITALS QUALITY POLICY AND OBJECTIVES:

Figure3.7



STRENGTH OF THE HOSPITAL:

The strength is its dedicated, committed and sincere multidisciplinary team approach of

medical, paramedical, non medical personnel and administrators who are committed to

continue to provide the highest quality care in an emergency.

The training of staff and research continue to meet the needs of patients.

Their focus is on patient care and patient safety.

Working together the staff provides comprehensive diagnosis and coordinated

treatment.

Proximity of outpatient department with lab facilities and other diagnostics ensure well

coordinated care.

Statistical information:

Yearly OP range from 14000-15000

Yearly IP range from 4800-5000

Yearly diagnostics range from 30,000-35,000

Monthly OP range from 1000-1500

Monthly IP range from 3000-4000

Monthly diagnostics range from 250-500

Daily OP range from 30-40

Daily IP range from 10-12

Daily diagnostics range from 90-120

OUTPATIENT DEPARTMENT: Outpatient department is very important wing of

hospital serving as mirror. This department is visited by large section of community which is the

first point of contact between patient and hospital staff. The human relation skills/public relation

functions are utmost important. OPD is related with other departments like emergency,

diagnostics etc, This includes front office and emergency department.

Front office:



It contains reception, admissions, billing, diagnostics billing.

The work that goes on in a hospital front office vary depending on the size of the hospital and

the number of employees that work there. In general the hospital front office includes a reception

desk to greet patients and visitors as they enter the hospital and provide information where to go

or the services that are provided.

Functions of front office :

Function of front office are OP registration, IP registration, making site for the patients, making

bed occupancy, to minimise waiting time for all patients, to satisfy patients/visitors by proper

guidance, to organise consultant chambers as per their op timings, to minimise billing errors and

counselling of patients. The purpose of front office is to provide assistance for people when they

first enter the hospital.

OP and IP registration:

OP registration services are also available in the front office of the hospital. Patients can

provide their name and contact information, as well as any other information such as emergency

contact details. Certain administrative work is also done in front office such as maintenance of

records and paper throughout the hospital.

Staff: 08 Nos

No. of Shifts: 3 Shifts

Shift timings:

8am-5pm

11am-8pm

8pm-8am

Diagnostics billing : All the tests performed for op patients billing is done at this counter.

Staff: 2 Nos

No. of Shifts: 2 Shifts

Shift timings:

8am-5pm

11am-8pm



From 8pm-8am the diagnostic billing is done at op registration desk .IP admissions from

8am-11am are also done at this desk.

Diagnostics :

Radiology department:

Location: Radiology department is located in ground floor close to out patient department.

Radiology department includes x-ray, ultra sound scan and CT scan.

Sources of data:

Primary source:

Personal observation

Secondary source:

Radiology department files

Department Employees.

Radiology department:

The Radiology is a medical specialty that employs the use of imaging to both diagnose and treat

disease visualized within the body. Radiologists use an array of imaging technologies such as X-

ray radiography, ultrasound, computed tomography (CT),nuclear medicine, positron emission

tomography (PET) and magnetic resonance imaging (MRI) to diagnose or treat diseases.

Interventional radiology is the performance of (usually minimally invasive) medical procedures

with the guidance of imaging technologies.

Staff:

X-ray department staff -2 and incharge-1.

Ultra sound staff-2.

CT scan staff-3

Shifting boys-2, one in the morning and other in the night

Typists – 2.

Radiologists -2.


http://en.wikipedia.org/wiki/Invasiveness_of_surgical_procedures

http://en.wikipedia.org/wiki/Interventional_radiology

http://en.wikipedia.org/wiki/Magnetic_resonance_imaging

http://en.wikipedia.org/wiki/Positron_emission_tomography

http://en.wikipedia.org/wiki/Positron_emission_tomography

http://en.wikipedia.org/wiki/Nuclear_medicine

http://en.wikipedia.org/wiki/X-ray_computed_tomography

http://en.wikipedia.org/wiki/Ultrasound

http://en.wikipedia.org/wiki/Radiography

http://en.wikipedia.org/wiki/Medical_imaging

http://en.wikipedia.org/wiki/Medical_specialty


Shift timings: For x-ray and CT scan staff- 3shifts.

8am-2pm

2pm-8pm

8pm-8am

For typists: 8am-5pm and 11am-8pm

For ultrasound staff: 8am-5pm and 2pm-8pm

Radiologist timings:

10 am – 4pm

6pm – 8pm

Inventory management:

Indent for the required stock is given weekly once.

The stock is obtained from the stores and pharmacy.

Sufficient stock is maintained for the whole week as indent should be given only once in a

week.

Per week around 200 films are used in x-ray department.

Per month around 200-300 films are used in CT scan department.

Departmental orientation:

Newly joined staff has orientation classes by quality department staff and for old staff training

classes are conducted regularly. All the staff are qualified and efficient.

Patient management:

The x-ray and CT scan departments are open for both IP and OP patients round the clock.

(24hrs)

For IP patients who cannot be shifted to x-ray room, a portable x-ray machine is there

which is used at bed side.



X-ray:

Procedure:

The radiographer shall strictly monitor all the results of the patients undergoing

radiography procedures.

From 9am till 8pm if he/she finds that any findings is of a critical value, he/she shall report

the same to the radiologist. The Radiologist will confirm the critical result and will inform

the referring consultant. From 8pm till 9am the radiographer will inform the critical result

to duty medical officer.

The x-ray film is given to patient within 5minutes for cash patients and for Aarogyasree

patient’s film is not given. Either doctor comes to x-ray department and see the x-ray or x-

ray image is given on a scanned paper.

The image which is present in the system is saved and sent for report preparation.

The radiologist sees the image and prepares the report.

The report is given after 2 to 3 hrs.

The film is given immediately in case of emergency patients and for patients who are

referred to other hospitals.

The radiologist verifies the number of x-rays taken per day and number of films used.

Preparation of patients:

Clean hospital gown is provided for patients to undress. A separate cabin is provided to

patients for changing the dress.

Preparation of the machine/room:

The biomedical department holds the responsibility of all the machinery in x-ray

department.

They check the machines and their working conditions every morning.

In case of defects in the machines the biomedical department informs to the engineering

department to rectify the defect.

Critical results in x-ray imaging department:



All the critical results will be reported to the treating consultant within 10 minutes after

completing the investigation.

In case of emergency or code blues, the x-ray technician informs to the radiologists and

the process flow during this situation is as follows:

During nights x-ray imaging of critical cases like intra venous pyelogram (IVP) are not

done only in case of emergency it is done under supervision of anaesthetist as

radiologist will not be available.

Written consent is taken for IVP patients.

Radiology quality and safety parameters in prime hospitals:

To minimize repeat exposures.

To ensure that adherence to safety precautions of patient and employees are met.

To minimize number of reporting errors.

To reduce turn around time.

Radiation monitoring for staff:

Proper precautionary measure has to prevent from radiation like radiation absorbent

aprons, TLD batches etc.

TLD badges are to be worn during working hours to monitor their occupation radiation

dose.


patient in emergency condition during x-ray imaging

patient is stabilised and shifted to casuality immediately under anesthetist supervision

code blue is announced

code blue team arrives and do the needful treatment


These batches are sent to BARC at Bombay for every 3months to know the radiation

exposure, by the employees.

Radiation protection for patients:

Usually x-rays are not taken for pregnant women .only in case of emergency and

under prescription of doctor it is done.

Lead aprons are given in case if x-rays are to be taken for pregnant women.

Ultrasound scanning department:

The radiologist shall strictly monitor all the results of the patients undergoing scanning

procedures.

The radiologist will confirm the result and will dictate to the typist. The report is typed

and given to patient.

Scanning during nights is done only for emergency cases.

In case of emergency or code blues, the process flow is as follows:

Various other procedures are carried in ultrasound department called as interventional

radiological procedures. This includes ultrasound guided fine needle aspiration technique,

biopsy, pleural effusion. Doppler studies of veins and arteries.

Written consent is taken for any interventional procedures and also for other high risk

cases.


patient in emergency condition during scanning,informed to respective consultant

patient is stabilised and shifted to casuality immediately under anesthetist supervision




For pregnant women scanning procedures like early pregnancy scan, TIFFA scan etc,

CT scan:

Procedure:

The CT technician shall strictly monitor all the results of the patients undergoing

radiography procedures.

From 8am till 8pm if he/she finds that any findings is of a critical value, he/she shall report

the same to the radiologist. The Radiologist will confirm the critical result and will inform

the referring consultant. From 8pm till 10am the technician will inform the critical result to

duty medical officer and to the radiologist.

In case of emergency or code blues, the CT scan technician informs to the respective

consultant and the process flow during this situation is as follows:

Blood sample collection:

This is a medical specialty that employs the blood sample collection to both diagnose and treat

disease within the body.

Process flow in sample collection:

Identify the patient.


patient in emergency condition during CT scanning

informed to anesthetist,pateint is given emergency drugs and airway maintained



patient is shifted to casuality immediately under anesthetist supervision

http://en.wikipedia.org/wiki/Medical_specialty


Assess the patient’s physical disposition.

Check the requisition from for requested tests, patient information and any special

requirements.

Select a suitable site for venipuncture.

Prepare the equipment, the patient and the puncture site.

Perform the venipuncture.

Collect the sample in the appropriate container.

Recognise complications associated with the phlebotomy procedure.

Assess the need for sample collection or rejection.

Label the collection tubes at the bedside or drawing area.

Statistical information of sample collection : 20 – 30/day

Staff:

Number of staff:2

Shifts:2 shifts

Timings : 7:30am – 4:30pm and 11am – 8pm

During night after 8pm sample collection is done in the laboratory.





week.



classes are conducted regularly.



Emergency Department/Casuality:

Patients who need emergency care is directly bought into the emergency department. After

the initial care is given then they are shifted into the required ward i.e., ICU or AMCU or

general ward or step down.

Staff: There are two nursing staff and one DMO available round the clock. During day time all

the consultants are available according to their given schedule.

During nights consultants are available on call as per their schedule

Shifts timings:

There are 3 shifts for nursing staff and DMO.

8am-2pm

2pm-8pm

8pm-8am





week.



classes are conducted regularly.



ORGANOGRAM OF PRIME HOSPITALS

Figure 3.8


Managing Director

Senior Medical Superintendent

NS

ANS

Nursing Supervisor

Nursing Incharge

Nursing Staff

CSO

Security

Consultant Specialist

DMO

Administrat

ive staff

Manager

PRO

Manager

Floor Incharge

Medical Superintendent


ORGANOGRAM FOR AAROGYASREE DEPARTMENT

Figure 3.9

They are in coordination with government deputed Aarogyasree employees.


Managing Director

Medical superindent

HOD of aarogyasree department

Executive

Emergency patients

Enters Casuality

Patients Stabilized

OP Registration

IP Admission

Investigations

Send to ICU/AMCU


PATIENT FLOW PROCESS IN PRIME HOSPITALS:

Patients arriving at the hospital may be 3 kinds.

They are appointment patients, direct patients, emergency patients.

PATIENT FLOW PROCESS FOR EMERGENCY PATIENTS:

Figure 3.10

PATIENT FLOW PROCESS FOR DIRECT AND APPOINTMENT PATIENTS


Appointment Patients

OP Registration

Doctor Consultation

Doctor takes history from patients

Direct Patients

Diagnostics Billing Done

Diagnostic Procedures Done.

Reports Collected

Meet the Doctor

Patient reports at Admission Counter

Admission Done.

Admission Required

YES

NO Prescribes medication

Purchase Medicine from Pharmacy

Leaves the Hospital

Follow up

Investigation Required

YES NO


Figure 3.11

PROCESS FLOW FOR AAROGYASREE PATIENTS


Goes to Aarogyasree counter gets the op card and OP Registration done at the registration counter

Doctor Consultation

Aarogyasree Patients

Diagnostics Billing Done

Diagnostic Procedures Done.

Reports Collected

Meet the Doctor

Patient goes to the Aarogyasree department and confirms the eligibility for admission

Goes to admission counter and Admission Done.

Admission Required

YES

NO Prescribes medication

Purchase Medicine from Pharmacy

Leaves the Hospital

Follow up

Investigation Required

YES NO


Figure 3.12

PROCESS FLOW IN X-RAY DEPARTMENT



Figure 3.13


Receiving patient bill with the required test

Arrival of the patient

Explaining the procedure to the patient

Preparation of the patient

Area of interest is made free from metal objects

Preparation of the machine

Required accessaries are made ready

Machine is kept ready with approppriate technical exposure

Exposure done

Film is processed using automatic film exposure

Film is obtained


CHAPTER-4

DATA ANALYSIS

A sample of 300 patients is selected for data collection.

Sample represents the whole population.

The data is collected in a format in which the time slots are given at each step i.e., at OP registration counter, in waiting area for doctor consultation, diagnostic billing counter and for dispatch of reports.

The OP registration waiting time is represented graphically:

Patien

t 1

Patien

t 4

Patien

t 7

Patien

t 10

Patien

t 13

Patien

t 16

Patien

t 19

Patien

t 22

Patien

t 25

Patien

t 28

Patien

t 31

Patien

t 34

Patien

t 37

Patien

t 40

Patien

t 43

Patien

t 46

Patien

t 49

Patien

t 52

Patien

t 55

Patien

t 58

Patien

t 61

Patien

t 64

Patien

t 67

Patien

t 70

Patien

t 73

Patien

t 76

Patien

t 79

Patien

t 82

Patien

t 85

Patien

t 88

Patien

t 91

Patien

t 94

Patien

t 97

Patien

t 100

0

5

10

15

20

25

30

35

40

No. of Patients vs OP registration Time (Mins)

OP registration Time (Mins)

The approximate time taken for op registration is 5-7 minutes. (Chart 4.1)



Waiting time for doctor consultation as in graphical representation:

Patien

t 1

Patien

t 4

Patien

t 7

Patien

t 10

Patien

t 13

Patien

t 16

Patien

t 19

Patien

t 22

Patien

t 25

Patien

t 28

Patien

t 31

Patien

t 34

Patien

t 37

Patien

t 40

Patien

t 43

Patien

t 46

Patien

t 49

Patien

t 52

Patien

t 55

Patien

t 58

Patien

t 61

Patien

t 64

Patien

t 67

Patien

t 70

Patien

t 73

Patien

t 76

Patien

t 79

Patien

t 82

Patien

t 85

Patien

t 88

Patien

t 91

Patien

t 94

Patien

t 97

Patien

t 100

0

50

100

150

200

250

300

350

No. of Patients vs Doctor Consultation Time (Mins)

Dr. consultation Time (Mins)

The approximate time taken for doctor consultation is 30-40 minutes. (Chart 4.2)



Waiting time for diagnostics billing as in graphical representation:

Patien

t 1

Patien

t 4

Patien

t 7

Patien

t 10

Patien

t 13

Patien

t 16

Patien

t 19

Patien

t 22

Patien

t 25

Patien

t 28

Patien

t 31

Patien

t 34

Patien

t 37

Patien

t 40

Patien

t 43

Patien

t 46

Patien

t 49

Patien

t 52

Patien

t 55

Patien

t 58

Patien

t 61

Patien

t 64

Patien

t 67

Patien

t 70

Patien

t 73

Patien

t 76

Patien

t 79

Patien

t 82

Patien

t 85

Patien

t 88

Patien

t 91

Patien

t 94

Patien

t 97

Patien

t 100

0

2

4

6

8

10

12

No. of Patients vs Diagnostics Billing Time (Mins)

Diagnostics billing (Mins)

The approximate waiting time for diagnostic billing is 4 to 6 minutes. (Chart 4.3)



Waiting time for diagnostics procedures as in graphical representation:

Patien

t 1

Patien

t 4

Patien

t 7

Patien

t 10

Patien

t 13

Patien

t 16

Patien

t 19

Patien

t 22

Patien

t 25

Patien

t 28

Patien

t 31

Patien

t 34

Patien

t 37

Patien

t 40

Patien

t 43

Patien

t 46

Patien

t 49

Patien

t 52

Patien

t 55

Patien

t 58

Patien

t 61

Patien

t 64

Patien

t 67

Patien

t 70

Patien

t 73

Patien

t 76

Patien

t 79

Patien

t 82

Patien

t 85

Patien

t 88

Patien

t 91

Patien

t 94

Patien

t 97

Patien

t 100

0

10

20

30

40

50

60

70

No. of Patients vs Diagnostics Time(Mins)

Diagnostics

The approximate waiting time for diagnostic procedures is 10 to 30 minutes. (Chart 4.4)



Waiting Time at Various Stages in Patient Flow Process:

546

3602

222 165 130 180 95 135

2095

390

660

Total waiting time at various stages in Patient Flow Process

Registration Time Consultation Pharmacy Diagnostic Billing X-Ray Ultrasound Sample ECG Reports Not Consulted IP Admission

Hence it is concluded that maximum time consumption is for “Doctor Consultation”. (Chart 4.5)



5.5

37.1

7.45.0

10.8

22.5

7.9

15.0

63.5 65.0

94.3

Avg. waiting time at various stages in Patient Flow Process

Registration Time Consultation Pharmacy Diagnostic Billing X-Ray Ultrasound Sample ECG Reports Not Consulted IP Admission

The average waiting time is maximum for the IP admission. (Chart 4.6)



The average time for dispatch of reports is

Sample collection 2-3 Hrs

X-ray 4-5 Hrs

Ultrasound 20-30minutes.

For cash patients IP admission requires 15-30 minutes, in case of non availability of beds

2-6 hrs.

For credit patients admission requires 30-40 minutes if they get clearing from the

insurance company.

If credit patients does not get clearing from insurance company and the, if the patient is willing

to admit on cash basis, admission is done and treatment is continued. If patient is not willing to

admit on cash basis, patient is discharged and billing is done.

In OP, doctors are available 9am – 4pm and 5pm-8pm. On call doctors arrive within 20

minutes.

Duty roasters are given all medical and paramedical staff.

Patients referred from other hospitals are also accepted.

Patients from prime hospitals are also referred to other hospitals.



CHAPTER-5

INFERENCES

In unduly cases, doctor consultation time varies from 1 to 4 hrs due to non-availability of

doctors in OP.

Reasons for this may be

Doctors may be in OT during OP time.

Surgeries in other branches.

Doctors in rounds.

This is due to the improper scheduling of doctor timings

Front office staff at OP registration are unable handle properly the patients.

There is no separate help desk or enquiry.

Time of reports dispatch is greater in X-Ray department, as there is only one radiologist

during day time for ultrasound, CT scanning and X-Ray.

Sampling test for IP and OP patients are done simultaneously so delay may occur in

reports despatching.

There is no separate reports dispatch counter as there is only one counter for dispatch and

billing.

Admission of patients is delayed due non-availability of beds and lack of nursing staff in

wards, which cause delay in arrangements.

There is no MRI facility available.

As reports despatched is delayed, by the patient gets the report the doctors may not be

available in OP.

There is lack of nursing staff in casuality and the equipments are not under proper

working condition.

Duplication of work occurs in front office, due to wrong entry of patient information.



CHAPTER-6

SUMMARY AND CONCLUSIONS

Thus the major requirements of out patient department are:

Patient registration with complete information of the patient.

Check doctor availability.

Patient case history record should be visible and should include the package deals

for a patient at a fixed cost.

Consultation reminders need to send to patient on periodical basis, through

various modes like telecal, SMS, e-mail etc.

Having improved the situation at one bottleneck, others may emerge as rate limiting

steps in the patient journey. Bottleneck management is, therefore, a process of

continual improvement.

Thus improving patient flow is one way of improving healthcare services.

RECOMMENDATIONS:

Training classes for front office staff is to be conducted.

Consultant timings is to be properly scheduled.

Recruitment of new radiologist and other required consultants is to be done.

Duplication of work by the front office staff is to be avoided.

Nursing staff should be recruited.

Bed occupancy should be properly managed.

A separate help desk and report dispatch counters are recommended.

LIMITATIONS OF THE STUDY:

Project work was done in a small hospital.

Sample size may be insufficient.

The study was concerned with only outpatient department, so it does not include the

details of other department.

Study was done for short duration.

Due to improper time scheduling, was unable to consult with doctors.



BIBLIOGRAPHY:

Hospitals: Facilities Planning and Management G. D. Kunders

Patient Flow - NHS Institute for Innovation and Improvement.html

Work pressure and patient flow management in ... [Academe Med. 2011] - PubMed –

NCBI.

Managing-patient-flow-keep-lines-communication-open.html

Barriers-remedies-to-optimizing-patient-flow

Maximizing_Throughput_and_Improving_Patient_Flow.html

ManagingpatientflowSmoothingORschedulecaneasecapacitycrunchesresearcherssay.aspx

Profdavidben-tovim-131003191932-phpapp01

Frontiers.pdf

Analysis of patient flow in the emergency department and the effect of an extensive

reorganisation -- Miró et al. 20 (2) 143 -- Emergency Medicine Journal.html

In Focus Improving Patient Flow—In and Out of Hospitals and Beyond - The

Commonwealth Fund

Bottlenecks - NHS Institute for Innovation and Improvement.html

Root Cause Analysis Using Five Whys - NHS Institute for Innovation and

Improvement.html

Theory of Constraints - NHS Institute for Innovation and Improvement.htm

Radiology - Wikipedia, the free encyclopedia.html

Literature review - Wikipedia, the free encyclopedia.html

Literature Reviews - The Writing Center.html

Welcome to Prime Hospitals.html

Referred old reports from library.

APPENDIX:


http://www.google.co.in/search?tbo=p&tbm=bks&q=inauthor:%22G.+D.+Kunders%22


The following format was prepared for data collection:

Patient name:

Entry time:

Op registration time:

Dr Consultation time:

Diagnostic billing time:

Time at diagnostics:

Reports dispatch time:

Dr Consultation time:

IP admission time:

Or

Time at OP pharmacy:

Exit time:


patient flow management in opd

Healthcare

patient flowmanagement

safe patient flow

patient complexity

patient supervision

patient caredelivery

waiting time

project work

patient department section