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WELCOME TO

M.S. RAMAIAH MEMORIALHOSPITAL

OUT PATIENT DEPARTMENT

By - Dr. Vinay Vatsayan Dept. Of Hospital Administration M.S. Ramaiah Medical College Email- drvinayv@gmail.com

OPD: Origins
Originated in mid 17th century by Sir George Clark In hotel Dieu in Paris: 6 Physicians were detailed for regular session on Wednesday or Saturday advising poor individually, in turn which introduced the idea of OP clinic. Modern OPD services emerged in 1850 in USA from frame work of dispensaries. General Practitioner ~ Physician ~ Specialist opinion ~ Institutional Care V/s Domiciliary Care.

OPD
Section of the hospital with allotted physical facilities Regularly scheduled hours and personnel in adequate numbers, assigned for established hours, To provide care for patients who are not registered as inpatients while receiving Health services.

Importance of OPD Services
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First point of contact It is the shop window of hospital Makes or mars the hospital image A good OPD service can reduce the load on in-patient services It is a place for implementing preventive & promotive health activities. Facilitates teaching About twice the in-patients attend OPD every day

Functions of OPD
Early diagnosis, curative, preventive & rehabilitative care on ambulatory basis Effective treatment on ambulatory basis Screening for admission to hospital Follow up care & care after discharge Promotion of health by health education Rendering of preventive health care Promotion of health through health education

Functions…
Training of medical / nursing students Keeping upto date records for future treatment, medical education, epidemiological & social research

Preventive Health activities
Well baby clinics ANC, marriage counseling, planned parenthood etc School health clinic. Control of communicable diseases Early diagnosis & detection of chronic diseases like Cancer, TB, RHD etc. Health education & nutritional advice Rehabilitation & prevention of disabilities & handicaps

Types
OUT PATIENT Any person given general or emergency diagnostic, therapeutic or preventive health care and who at that time is not registered as an in-patient in the hospital Two types of OP Services
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Centralized Outpatient Services : All services are provided in a compact area which includes all diagnostic and therapeutics facilities being provided in the same place. Decentralized Outpatient Services : Services are provided in the respective departments.

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CONTD..
GENERAL OUT PATIENT All the patients other than emergencies who report directly to the OPD EMERGENCY OUT PATIENT A person given emergency medical care for condition which is real or perceived emergency. REFERRED OUT PATIENT A person referred to an OPD by his attending medical/dental practitioner for specific diagnostic/treatment procedure.

Staffing
Staffing depends upon objectives of department and volume of work load. Ancillary staff in OPD e.g X-Ray, EEG & ECG technicians. Clerical staff to carry out registration patient billing, cashiering etc. In teaching hospital interns and residents assisting physicians. Receptionist & other volunteer staff . Availability of Administrator for planning, organizing, supervising, evaluating, coordinating and improving out patient services.

Planning Considerations
Location
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Separate entrance Easily accessible Should have approach from main road Adjacent to supportive facilities, x-ray & laboratory Amenable for Expansion

ENTRANCE

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EXIT

EASY TO LOCATE

Principles of Planning Layout
Principles: Patient flow should move in one direction to avoid undue back traffic. Sharing with the IPD, All Diagnostic facilities, such as X-Ray & pathology laboratory. Should be amenable for expansion without serious dislocation of work.

Layout:
Double loaded single corridor with rooms on each side of the corridor. Double corridor for entry from the opposite sides of the room. Triple corridor which provides two rooms of examination treatment rooms on each side of a staff corridor.

Size Of OPD
Type & number of specialist clinics Timings of OPD Number of daily OPD patients Number of attendants accompanying the patient Availability of space Plans for future expansion Some Recommendations A/c to BIS(Bureau of Indian Standzards): For Entrance Zone - 2 sq.meter/bed. Ambulatory Zone - 10 sq.meter/bed. Diagnostic Zone - 6 sq.meter/bed. Total hospital area - 60 sq.meter/bed.

Physical Facilities
Physical facilities categorized into 4 groups:
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Public Areas(Entrance zone) Clinical Areas(Ambulatory zone and Diagnostic zone) Administrative Areas Circulation Areas

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Entrance : Should be Easily accessible, with wide door and have ramps and steps Reception and Information : A desk or a counter located within the public area. Registration and Records Area : Should be located near the entrance. 100 cm high and with work surface 60 cm wide and with file drawers. One desk for 20 patients/hours. 2 square meters per bed for OP records. Waiting Area : Main waiting area should be adjacent to registration area, sub-waiting area in each clinical department. Area- 4 sq.meter with min. of 0.1 sq.meter/patient.

Public Areas (Entrance Zone)

Contd..
Public toilets & washrooms: One for each 200 patients & visitors separate for males & females. Snack bar: Should be located near the main waiting area.

Clinical areas
OPD include:
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Surgical , Dental , Opthalmic , ENT. Obstetric & gynecological Pediatric , Medical, Psychiatric Dermatology & Venerology Ortho & emergency department SUPER SPECIALITY LIKENeuro , Cardio , Urology.

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PATIENT’S WAITING AREA

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MINOR O.T AREA

PATIENT’S WAITING LOUNGE

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PLAY AREA

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PROCEDURE ROOM

DOCTOR’S CHAMBER & EXAMINATION ROOM

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RECEPTION AREA

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PATIENT’S WAITING AREA

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General requirement

Sub-waiting area: Should be 1/3rd of total patients visiting clinic /day Consultation room: Space for doctor’s chair, patient’s stool, follower seat ,wash basin, examination couch , equipment for examination. Area – 15-17 Sq.meter.& each clinic should handle 100 cases /day. Special examination room : Required for certain departments.

Ancillary facility
Injection room : It should be with waiting area for 1020 patients with 0.6-0.8 sq.meter/patient. Area may vary from 12 to 40 sq.meter depend on work load. Treatment & dressing room: About 12-16 sq.meter. Pharmacy : It should accommodate 5% of total clinical visits to OPD in one session

Auxiliary facilities
Laboratory – Should be able to serve IP&OP Patients with 2 (male & female) washrooms & toilets – 15 sq.meter. Bleeding room – 15-20 sq.meter with two or more examining tables. Radiology – Should serve both IP & OP PATIENTS. Blood Bank

Contd…
Health Education Facilities – Min. area required is 15 sq.meter. Medical Social Service Facilities – should be located in OPD with suitable cubicle for each social worker/Counselor. Screening Clinic – required in teaching or tertiary hospital & should be located near reception area having one or more cubicle with 12 sq.meter area for each cubicle

Administrative Areas
Administrative Office : For 100 bed hospital -15 sq.meter Business Office : Office for personnel section requisition, making reports etc. House keeping : Janitor’s closet, for house keeping and cleansing material with size of 4 sq.meter Storage Facility :
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General stores Drug stores Linen Stores : On each floor a closet with shelves, for storage of daily supply linens with area of 2 sq.meter

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Circulation areas
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This includes corridors, stairs, lifts etc. Occupies about 30% of total building area, easy accessibility of elevator specially for obstetrics and cardiac pt. Corridor should be 1.8 meter wide. Security check post at strategic location. Availability of STD/ISD facility.

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Equipment
Equipment related to specialty examination should be available in concerned room. Each consultation cum examination room should have- Work table, physician’s desk, wall mounted cabinets, X-ray view box, revolving stool, wash basins, instrument trolley, chairs beside examination couch. All OPD should have equipment for resuscitation of patients collapsing suddenly.

Work load.
The no.of patients visiting OPD depend on many factors 1. Location of hospital 2. Community needs 3. Programme & resources 4. Season of the year 5. Transport & Communication

Out Patient visits
New out patient visit Repeat out patient visit Ratio between New : Repeat = Varies between 1:1 TO 1:2

CONTD….
DAILY OPD ATTENDANCE: Usually 4 per In-patient bed or 10 per daily admission. THUMB RULE: 4 patients for every bed each day about 40% new & 60% old. PROBLEMS IN OPD: Patients overcrowding Long waiting time PROBABLE REASONS: o Wrong planning of departments o Restricted registration time o Absence of appointment system o Shortage of staff

WORK FLOW {Out Patient Flow Chart}
ENTRANCE RECEPTION & ENQUIRY REGISTRATION RECORDS SUB-REGISTRATION & WAITING EXAMINATION & TREATMENT INVESTIGATION ADMISSION PHARMACY HOME

Organization and Managerial Considerations
Policy – The policy should be able to achieve continuity of high quality patient care with modern techniques & methods. Procedures Managerial Considerations Public Relations OPD timing Management structure Waiting time (Queuing theory, Patient Scheduling) Flow of patient should be smooth , easy & quick

Monitoring and Evaluation
Volume :
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Clinic/department wise statistics of new and repeat visits on monthly and yearly basis. Percentage change in new and repeat visit. Fluctuation in visit by day of week(month)-average, high and low.

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Utilization and vital statistics : Average number of visit per person/year, vital statistics of population(age & sex). Visit Levels : (New & old visits) Costs and revenues : Cost of each service should match with revenue Gender wise calculation of patient Calculation of PEDIATRIC & GERIATRIC visits.

Hospital utilization statistics
The statistics pertaining to OPD services as follows: Number of new cases. Number of repeat cases. Specialty wise break-up cases. Unit wise break-up of cases. Age & Sex distribution of cases. Diagnostic statistics.

CONTD…
Daily average out patient attendance:
Total no. of OPD attendance during the period No. of OPD working days during the period Average outpatient attendance per patient: (average duration of the spell of sickness treated in OPD) Total no. of OPD attendance Total no. of New cases

Queuing theory definitions

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(Bose) “The basic phenomenon of queuing arises whenever a shared facility needs to be accessed for service by a large number of jobs or customers.” (Wolff) “The primary tool for studying these problems [of congestions] is known as queuing theory.” (Klein rock) “We study the phenomena of standing, waiting, and serving, and we call this study Queuing Theory." "Any system in which arrivals place demands upon a finite capacity resource may be termed a queuing system.” (Math world) “The study of the waiting times, lengths, and other properties of queues.”

Little’s Law
System Arrivals Departures

Little’s Law: Mean number tasks in system = mean arrival rate x mean response time Observed before, Little was first to prove Applies to any system in equilibrium, as long as nothing in black box is creating or destroying tasks

Characteristics of queuing systems
Arrival Process

The distribution that determines how the tasks arrives in the system. The distribution that determines the task processing time Total number of servers available to process the tasks

Service Process

Number of Servers

Queuing technique
Determination of waiting time, cost of waiting time & its reduction, identification of bottlenecks. This technique is used to analyze alternatives & arrive at solutions to many of all these problems. Data necessary to know – how often patients arrive? How long it take to serve them? The order in which patients are served? With all these data queuing problem can be solved. A simple method of studying queue line is: A multiserver queue in service area is represented by: counter 1 Arrivals counter 2 counter 3

The following observations are made at intervals of selected unit time:
Time (Hrs/Min) T Unit Time Queue Length (Person waiting) Q Number Served in Unit Time N Number of Counters Open C

From these observations following can be calculated: 1. Individual service time (I.T) T X C (E.T.XC.) N 2. Effective service time (E.T) T (Minutes) N 3. Waiting time (W.T) Q X E.T 4. Capacity (C) 60 Min. E.T

Prevalent System in OPD
Consultation chamber no: 1 Patients 2 3 4 5 1-8 9-17 18-26 27-35 36-43

Modified System in OPD
n n

Consultation chamber no: 1 Patients allotted as per arrival : 1 6 11

2 2 7 12

3 3 8 13

4 4 9 14

5 5 10 15..

The queuing technique can be applied in various Patient areasOPD ,Radio diagnosis ,Imaging ,Operations (surgery)etc…

Example application of queuing theory
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In many retail stores and banks multiple line/multiple checkout system  a queuing system where customers wait for the next available cashier We can prove using queuing theory that : Output improves when queues are used instead of separate lines

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Example application of queuing theory Click to edit Master text styles
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