Patients waiting time at out Patient’s Department at the National Hospital Sri Lanka

At the Out Patient Department (OPD) patients have to wait for minutes to hours at each step of this process. The time duration which counts from the patient arrives to the OPD till patient actually leaves the OPD is defined as Patients’ waiting time at the OPD. The objectives of this study were to describe the patients’ waiting times at the OPD; to identify the factors affecting waiting times of patients at the OPD; and to give recommendations to improve the quality of healthcare deliver to patients and to reduce waiting time at the OPD. This study was an institution based prospective descriptive study. The Principal Investigator (PI) used direct observation and key informant interviews to collect data at the OPD. Patients’ waiting time was assessed in three steps. The time spent by a patient at each step was as follows; time spent between arrival to the OPD and leave at registration desk: Median = 24 minutes, time spent between leave at registration desk and enters to the doctor’s consultation room: Median = 42 minutes, time spent between the patient going to the OPD pharmacy queue and patient leaves the OPD: Median = 97 minutes. It was found that on average, patients spent nearly two hours in the OPD, with waits during peak times increasing to between 03 to 04 hours. This study showed that patients spent a significant amount of time at the OPD to get the registration and to get medicines.


Introduction
The Out Patient Department (OPD) is a place where patients receive healthcare servicesas out patient basis for minor disease conditions which could be managed without admitting patient to the hospital. The National Hospital OPD consits of a general OPD, admission and an Emergency Treatment unit [1]. The figure 01 shows the flow of series of processes undergo by OPD patients at the department. (Figure 1) These processes do not run smoothly without any frustration to the patients. OPD patients have to wait for minutes to hours at each step of this process which is unavoidable in every hospital. The time duration which counts from the patient arrives to the OPD till patient actually leaves the OPD is defined as Patients' waiting time at the OPD. Figure 2 describes the "Waiting" of an OPD patient at the OPD. Every one at the OPD has to wait at some point of receiving of healthcare. The first patient's impression on the healthcare delivery from the hospital begins at the OPD [2,3]. In several studies done at OPDs found that long queues at the OPD found with unnecessary visits, increase demand, lack of resources to cater large number of patients, ignorance of OPD procedures and due to lack of proper referral system [1,4-6].

Objectives
To describe the patients' waiting times at the OPD; To identify the factors affecting waiting times of patients at the OPD; To give recommendations to improve the quality of healthcare deliver to patients and to reduce waiting time at the OPD.

Methodology
Study Design: The study design was a cross-sectional descriptive study.

Study Setting:
The study setting was at the general OPD, NHSL.

Study Period:
The study period was from 05th July to 05th Au-gust 2015.

Study Population:
The study population was the patients attended to the general OPD, NHSL during the study period.
Study Sample: Approximately, 12,000 patients are seen at the OPD every month. Based on that, the sample size was calculated using the standard formula. The calculated sample size was 180 but as limited time permits for The study, the PI decided to use a convenient sample of 150 for the study. Therefore, it was decided to collect data from 5 patients per day for 30 days during the study period. Patients were randomly selected from the patient's register at the registration counter each day.

Data Collection
First the PI had key informant interviews with different level staff members at the OPD. The PI used the direct observation method to collect data from patients at the OPD. The PI first explained the purpose of the study and got the consent from patients when they arrived to the OPD. For the convenience on data collection the PI decided to follow patients during the process of treatment in steps numbered as 1 to 4 ( Figure 3). Volume 1; Issue 03

Data Analysis
The PI used a stop watch to calculate the time spend at each step. The data entry to the excel sheet was totally done by the PI. The data analysis was done using the excel spread sheet.
The patients' waiting time was assessed in steps 1, 2, 3 and 4 as follows; Step 1: Time spent between arrival to the OPD and getting a number from the registration desk.
Step 2: Time spent between getting a number at the registration desk and time at which patient enters in to the doctor's consultation room.
Step 3: Time spent between patient entering into the doctor's consultation room and time patient comes out from the doctor's consultation room (Time spent in the consultation room).
Some patients were directly gone to the OPD pharmacy after seen by a doctor while some patients were sent for investigations/ X-ray/ ECG/ injection room or dressing room and they returned back to the doctor before going to the pharmacy. Due to the complexity of the assessment these steps were removed from the assessment.
Step 4: Time spent between patient going to the OPD pharmacy and patient leaves the OPD

Situation analysis
The hospital OPD staff suggested that the main bottlenecks happened at the OPD registration counter and due to lack of proper directions to the patients. They found that patients arrived in large numbers between 6.00 a.m. And 7.00a.m. The usual starting time of the clinics was 7.00 a.m. Therefore, patients arrive at 6.00 a.m. have to spend one hour before they could be attended to. They spent one hour and more waiting to be given their files and again waiting for the vital signs to be taken by the nurses and finally be examined by the doctors. Doctors start seeing patient at around 8.30 a.m. Some doctors do not arrive on time. Even though the doctors arrive at 8.30a.m., because of delay at the reception area doctors have to wait for the first patient to arrive in the consultation rooms.

The assessment of patient's waiting time
The patients waiting time was assessed in four steps as follows; Step 1: Time spent between arrival to the OPD and leave at registration desk: Median = 24 minutes.
Step 2: Time spent between leave at registration desk and enters to the doctor's consultation room: Median = 42 minutes.
Step 3: Time spent in the doctor's consultation room: Median 12 minutes.
Step 4: Time spent between the patient going to the OPD pharmacy queue and patient leaves the OPD: Median = 97 minutes.
It was found that on average, patients spent nearly two hours in the OPD, with waits during peak times increasing to between 03 to 04 hours. Patients at the OPD found it difficult to locate some important places such as injection room, dressing room, OPD surgical room and even OPD dispensary by first comers due to lack of directions given at the OPD. Patients waiting at the inquiry desk were unnecessary and avoidable. At the same time the PI found that, there were patients waiting at the OPD without a reason.
This study showed, the patients spent a significant amount of time at the OPD to get the registration. These patients also spent a significant amount of time to get medicines from the OPD pharmacy. Patient's waiting at some places like injection room, X-ray room, ECG room were unavoidable. The National Hospital of Sri Lanka (NHSL) was always criticized for long queues and prolonged waiting times in the Out-patient Department. This affects patients' impression on satisfaction of the healthcare received by the hospital.

Recommendation
Significant reduction in waiting time at the front desk can achieved in the outpatient services by implementing an efficient inquiry counter at the front desk. Establishing one more registration counter at peak hours could result in reduction of patients' waiting time at the registration desk at the OPD Proper directions should be given to the patients by direction boards, thus improve the quality of the OPD service and reduce patients' time spending to inquire about places. The OPD Pharmacy needs to be upgraded with quality and productivity improvement activities. Patients can be given appointment numbers and scheduling time of issue medicine accordingly. The OPD pharmacy can be introduced with computerized medicine issuing system so that dispensers easily can find out what drugs available and what not available at the OPD pharmacy.