Outpatient Services Notes

Outpatient Services

Introduction

  • Historically, outpatient services were provided by "Dispensaries" run by government and other organizations.
  • These dispensaries lacked diagnostic support.
  • The current century has seen outpatient services become integral to hospitals.
  • The focus in medical care has shifted from inpatient to outpatient services.

Definition

  • Ambulatory care is given to patients not confined to bed in various settings.
  • Outpatient care is ambulatory care rendered at a hospital's outpatient department (OPD).
  • The outpatient department is a part of the hospital with facilities, staff, and scheduled hours for patients not registered as inpatients.

Importance

The importance of the outpatient department lies in:

  1. First point of contact with the hospital and entry into the healthcare system.
  2. An inseparable link in the hierarchical chain of healthcare facilities.
  3. Contributes to reducing morbidity and mortality.
  4. A stepping stone for health promotion and disease prevention.
  5. Reduces admissions to inpatient wards, conserving beds.
  6. Acts as a filter for inpatient admissions.
  7. It is the "shop window" of the hospital.

Definitions of Outpatient Types

  • Outpatient: A person receiving diagnostic, therapeutic, or preventive service without being registered as an inpatient.
  • Outpatients are grouped into three categories:
    • Emergency Outpatient: Requires immediate care due to sudden illness or accident. The perception of "emergency" may vary between patients and physicians.
    • Referred Outpatient: Referred by a private practitioner or other physicians for specific procedures or opinions, who then return to the referring physician.
    • General Outpatient: Comes to the outpatient clinic without referral for non-emergency conditions. They often regard the hospital as a dispensary and may come for minor ailments due to lack of alternative care.

Outpatient Visit

  • Outpatient Visit: A person's visit to the OPD to receive service.
    • New Outpatient Visit: First-time visit.
    • Repeat Outpatient Visit: Subsequent visit.
  • Unit of Service: A measurable part of the volume of service rendered, expressed in terms of time and quantity.
  • Service Time: Time taken by the doctor for diagnosis, instruction, history, examination, case notes, prescriptions, and requisitions.

Planning of Hospital Outpatient Services

  • Demand for outpatient care is expressed on a 'per capita per year basis,' ranging from 1 to 10 visits, including revisits.
  • No standard to measure OPD service demand exists; it varies depending on:
    • Cost to the patient
    • Distance
    • Transportation
    • Degree of urbanization
    • Socioeconomic status of the community
    • Level of facilities and staff
    • Quality of care

Planning Considerations

After determining expected demand:

  1. Range of outpatient services and OPD functions.
  2. Daily and hourly capacity required.
  3. Number of staff needed by category and tasks.
  4. Possible service time per patient (average and distribution).
  5. Flow of patients and work.
  6. "Holding capacity" and "lifting capacity."
  7. Furniture and equipment requirements.
  8. Layout of the department.

Defining the Range and Scope of Outpatient Services

  • The range of services depends on patient characteristics (sex, age, socioeconomic status) and hospital accessibility.
  • Staff level (junior, senior, specialist) influences services.
  • Decide the proposed scope and range of services:
    • Preventive
    • Diagnostic
    • Therapeutic
    • Follow-up
    • Rehabilitative
    • Scheduled and unscheduled
  • Continued demand for sophisticated and expensive medical equipment is important.

Daily and Hourly Capacity Envisaged

  • Clinics should be scheduled for specific times and durations.
  • A simple method is calculating room hours needed based on expected visits or determining the number of rooms based on “possible service time”.
  • Room hours = (Number of examination rooms) x (Number of scheduled clinic hours).
  • Average service time (in minutes) = 60 ÷ (Average visits per room hour).

Staff Organization and Tasks

  • Medical staff should be the same in inpatient and outpatient departments.
  • Permanent OPD staff should be drawn from hospital staff, not separately employed.
  • Nursing staff is headed by a senior sister in charge who supervises nurses and paramedical workers.
  • Continuity of care is maintained by staff rotation between inpatient and outpatient departments.
  • For specialty clinics (ENT, eye, pediatrics, psychiatry), it’s advantageous for ward nursing staff to work in respective OPD clinics.

Possible Service Time per Patient and Distribution

  • It's hard to determine the specific amount of time a physician should spend per outpatient.
  • Service time differs from clinic to clinic and physician to physician.
  • Physician and clinic staff may assess service time for new and return visits.
  • The sequence of physician activity impacts patient turnover.

Flow of Patients and Work Scheduling

  • Patient flow is usually predictable: Enquiry → Registration → Waiting → Examination room → Investigation facilities.
  • Drawing a flowchart of activities and movements guides the planning process for facility locations.

Holding Capacity and Lifting Capacity

  • Holding capacity: the physical capacity of the OPD to hold the maximum expected number of people (patients, friends, relatives) at any one time in waiting areas and clinics.
  • Lifting capacity: capacity for vertical transportation in high-rise OPD blocks taking into consideration the traffic of patients and companions, staff, and stores during OPD hours.
  • At least one lift should be large enough for a stretcher trolley.
  • Planning a bank of two lifts together is functionally more efficient.

Sitting Accommodation and Physical Facilities

  • The OPD should be located so that diagnostic and treatment facilities are easily accessible but separate from inpatient areas with an independent approach.
  • It is desirable for the OPD to be on the ground floor. In larger teaching hospitals it may be more advantageous to have inpatient and outpatient departmental activities on contiguous floors.

Flow Pattern

  • Poorly planned physical relationships in the OPD increase staff workload and cause unnecessary patient movements.
  • The area required should be adequate for:
    • Reception and waiting hall
    • Waiting rooms
    • Registration and medical records
    • Clinics
    • Toilet facilities
    • Injection and dressing room
    • Pharmacy
    • Minor OT and circulation routes.

Ancillary Services

Additional facilities that increase functional efficiency:

  • Injection Room: For outpatients needing injections.
  • Dressing Room: Space for chairs, an examination table, a desk, a sink, and storage. Staffed by a nurse trained in dressing wounds, ulcers, etc.
  • Minor Operating Theatre: For ambulatory surgery.
  • Dispensary: Handles prescriptions. Includes storage, preparation, and dispensing areas, with waiting space for patients.
  • Laboratory Sample Collection Centre: A specimen collection room in the OPD where a technician receives urine and stool samples and draws blood specimens.
    • Specimens are taken to the hospital laboratory. This center should have separate toilets for male and female.
  • Outpatient Radiology: An essential part of investigations. Planning considerations include volume, workload, capacity, area, and timing.

Common Problems in Outpatient Services

Problems can be grouped as:

  1. Operations: Long queues, queue jumping, inadequate service time, unanswered queries, and punctuality.
  2. Resources: Adequacy and competence of staff, availability of drugs and supplies.
  3. Efficiency.
  4. Physical facilities and layout.
  5. Quality of care.
  6. Patient and staff satisfaction.

Solutions

  1. Queuing and Waiting Time Problems:
    • Appointment System
    • Filter Clinics
    • Satellite Clinics
    • Selective Service Charge
    • Starting OPD in Time and Prolonging OPD Timings
  2. Physical Facilities Problems:
    • Sufficient waiting spaces with toilets, water fountains, and seating.
    • Adequate number of examination cubicles.
    • Minor modifications to improve patient flow, such as adding a door, shifting a wash basin, partitioning a room, widening a passage, etc.
    • In-depth study of each problem using flow charts and work study (time and motion study, method study, activity sampling).
  3. Resource Problems:
    • Reduce costs and improve efficiency, especially in the use of drugs, radiographic films, and other expendable items.
    • Prescription of commonly used drugs under brand names, and prepacking of drugs for issue through pharmacy.
  4. Coordination Problem:
    • ‘Unity of command’ by one person over all OPD operations.

Other Measures

  • A record librarian is essential to train staff in maintaining OPD records.
  • Ensure adequate space and filing racks with identification numbers.
  • Augment staff during busy hours at enquiry and registration.
  • Continuously monitor the working of supportive services (injection room, specimen collection center, pharmacy, radiodiagnosis).
  • Develop a reasonable standard of efficiency in utilizing staff and facilities.

Conclusion

Scope for improving OPD operations exists in most hospitals, even if some problems require higher authority support. Efforts should be made by:

  • Simplification
  • Combination
  • Improved organization
  • Delegation
  • Task allocations and job descriptions
  • Communication
  • Improved motivation
  • Discipline