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Journal of the Academy of Hospital Administration

Process Re-Engineering in a Tertiary Hospital Single Window Concept for Efficient Service

Author(s): K. Ravi Babu* G. Vijay Kumar**

Vol. 17, No. 2 (2005-01 - 2005-12)

Key Words
Single window, Patient satisfaction, Outpatient department, Multi tasking

Key Messages

  • Efficency can be enhanced by multitasking the employee at some nodes
  • Single window concept in OPD'S can increase efficencey and result in better patient satisfaction.

Abstract:

With increasing competition in the health care industry improvement of satisfaction of patient and staff is the need of the hour. Along with customer satisfaction, maintaining the sustainability and enhancing the profitability of organization is also equally important. In the hospital, the Out Patient Department is often called "shop window" and the reputation of the hospital can be made or marred by its Out Patient Department. Poor patient satisfaction leads to drift in both new and repeat customers, which hinders the sustainability of any hospital in long run.

Organization efficiency can be enhanced by multi tasking by the employee at some nodes in the value chain. Here is the prospective study to explain how to improve patient service at out patient division of the hospital by implementing the single window system which results in less number of patients in queue, equal work distribution among employees and increased rate of transactions per man hour.

INTRODUCTION

Increasing competition in health care sector has made it necessary to improve satisfaction of patients and staff, and the out patient department (OPD) often called "shop window" becomes a key area which can made or mar the reputation of the hospital. (1,2)

In today's fast growing world, customer is looking for hassle free and quick services. Meeting the customer requirements by the medical institutes with its limited resources is the challenge. This is only possible with optimum utility of the resources, through multi tasking in a single window system in the OPD for better services (3,4)

This study was prompted by the unduly long queues (5) and prolonged delay observed in each of the pre consultation activities in out patient department namely registration, billing and cash collection in the out patient area of the tertiary level multi speciality hospital. The queue in front of the registration counters starts forming in Out patient department very early. Whilst the registration counters are opened at 8AM, excess patient density in the waiting line is due to the inability to cope up with the available service facilities and patient arrival rate. Most often it is observed that this resulted in denying registration to considerable number of patients when the registration counters were compelled to be closed by about 12 Noon. It was felt that numerous counters and the personnel were not having equitable distribution of workload. The Nizam's Institute of Medical Sciences is quasi government super speciality medical institute. This has a grown from a 350-bedded hospital in the year 1988 to a 967 bedded super speciality hospital by 2005. Coping up with the quantum leap in various super specialities and the clientele base with its limited resources is becoming very important task for the administration. The existing facility of out patient department is unable to support required services for the patients, as the out patient registration counters setup is not changed according to the increase in specialities and other services. Even though computerization had taken place a decade ago due to limited access to the activities by the staff is one of the contributing factor for delayed services.

OBJECTIVES OF THE STUDY

This study was under taken in out patient department with the following objectives:

  1. To observe and record the functioning of various counters as they existed.
  2. To calculate the waiting and service time.
  3. To study the factors influencing the delayed services.
  4. To study the effect of the proposed and implemented system.

METHODOLOGY

The following study was conducted in two phases for a period of 2 months:

  • Phase I: Study of existing functioning of Out Patient Department for a period of one month (Nov. 2004)
  • Phase II: Study of functioning of proposed and implemented system (single window) for a period of one month (April 2005)

In both the phases study comprises of

  • Observation of patient waiting time
  • Service time i.e number of transactions per man-hour.
  • Workload distribution.

Modus operandi of Old System

There were 8 different counters in Out Patient Department for handling 6 different tasks. The total number of manpower deployed is 10, functioning of old system resembles single channel multi phase system.

Missing Image

Table 1: Number of Counters for various tasks and manpower deployment in old system

Code Task No. of Counters Man power
New Registration Counter for New Paying Cases 1 2
Old Registration Counter for Old Paying Cases 1 2
Cash Cash collection counters 2 2
Billing Billing counters (Cash and Credit counters) 2 2
W C H Low Income Group (W.C.H.) Counter 1 1
CGHS C.G.H.S Credit Beneficiary Counter 1 1

Missing Image

Fig. 2: Flow chart of various tasks in old system

Functioning of the Out Patient department starts with registration, billing and cash collection, followed by single channel multiple phase Queuing model. Every patient had to go through at least 3 administrative counters as shown in the above figure. Some of the patients, who wanted white card concessions, had to attend additional counter of white card registration. The patient / attendant had to wait repeatedly at all these counters.

Modus operandi of implemented system (single window) In the single window concept all the counters are capable of multitasking. Every counter can serve all the purposes of out patients. Total number of counters functioning are 7 with manpower of 7 in number, there by avoiding the need for different queues for different functions and the repeated waiting in these queues. Each counter can register New / Old consultation, raise the bills for investigations and also collect the cash. This will also result in more equitable distribution of work on the counters and reduce the overall waiting time of the clientele.

Missing Image

Fig: 3 Flow Chart of single window system

Table - 2 Work distribution in old system (Source: Database of NIMS HIS)

Time Interval New Old Billing Cash Total
8 am - 9 am 36 41 75 29 182
9 am - 10 am 41 36 118 48 242
10 am - 11 am 38 32 151 61 282
11 am - 12 noon 22 18 139 60 239
12 noon - 1 pm 5 4 115 51 175
1 pm - 2 pm 0 0 0 0 25 39 64
Total 142 132 623 287 1185
Missing Image

Fig 4: work distribution in old system

RESULTS

Table No. 2 depicts the Daily Average Number of transactions registered Counter wise with respect to time during the period of old system of functioning at Out Patient Department.

Patient waiting time:
Maximum patient waiting time in case of old system of Out Patient Department was 40 minutes. This was calculated by averaging the 250 observations over a period of one month. This was observed during the peak time i.e 8 a.m to 11 a.m.

Service time:
Daily average transactions were 1185 with 10 number of people at 8 counters and the total man-hours are 60. Averageservicing time per transaction is 3 minutes.

Table No. 2 shows the Daily Average Number of transactions registered Counter wise with respect to time during the period of single window system of functioning at Out Patient department.

Patient waiting time:
Maximum patient waiting time in case of new system of Out Patient Department was 25 minutes .This was calculated by averaging the 250 observation over a period of one month. This was observed during the peak time i.e 8 a.m to 11a.m.

Service time:
Daily average transactions are 1255 with 7 number of people at 7 counters. And the total man hours were 42. Average servicing time per transaction was 2 minutes.

DISCUSSION

In case of existing functioning system of Out patient department distribution of work among counters is skewed.

Table 3: Work load distribution of counters in new system

Time Interval O P 1 O P 2 O P 3 O P 4 O P 5 O P 6 O P 7 Total
8 am - 9 am 29 26 21 37 26 19 15 174
9 am - 10 am 33 31 34 48 40 34 15 236
10 am - 11 am 34 35 41 56 52 43 14 275
11 am - 12 noon 24 33 43 53 53 43 7 256
12 noon - 1 pm 14 27 31 43 42 35 4 196
1 pm - 2 pm 3 9 13 30 36 26 1 118
Total 139 161 183 267 250 200 56 1255

Transactions load is very high (52%) at billing followed by cash, new and old registration counters (Fig 4). The total man-hours required to function the Out Patient Department was 60 hours. Where as in case of single window system transaction load is equally distributed over 7 counters. And the toal number of man-hours required to function the single window system was 42 hours.(Table 3)

During peak hours of patient arrival patient waiting time is 40 minutes in old system of functioning, whereas in single window system it had come down to 25 minutes.

Service time i.e time taken for completion of one transaction by staff had come down to 2 minutes in single window system against the old system of 3minutes. Staff number came down to 7 in single window system against 10 in existing system of Out Patient department functioning. However, there resistance to change from various quarters as mentioned below

From Front office staff

  • Reluctance to do any additional duties than the existing duties
  • Strong opposition for decentralization of counters and sharing duties.
  • Staff at present are not willing to take the responsibility for cash collection.
  • Fear of transfers to other departments in future if the new system is accepted.

From Administration (Finance & Audit)

  • Objection for financial clearance for Software & Hardware
  • Clearance for generating Registration fee receipt & Investigation receipt from the same terminal
  • Audit objection for generating receipt numbers in serial order.

From Technical Staff

  • Lack of software knowledge
  • Reluctant to redesign the software program to single menu
  • Ignoring the repeated request for changed menu
  • Fear of outsourcing software program

CONCLUSION

By adopting the Single Window System, the total average waiting time for each patient has been brought down to a maximum of 25 minutes as against 40 minutes, which has definitely improved the clientele satisfaction besides bringing in some order in to the system. This has also resulted in reduction of one counter and three persons and also in equal distribution of workload at all counters.

REFERENCES:

  1. Syed Amin Tabish, "Hospital and Health Services Administration Principles and Practice" Oxford University Press 2001.
  2. J.R. Mc Gibony "Principles of Hospital administration" G.P.Putnam's Sons, New York , 1969.
  3. The web sites of Andhra Pradesh Government www.eseva.online.com & Kerala State Government www.ksidc.org.
  4. Gower, "Hand book of management "1992.
  5. Miller and Starn, "Executive decisions and operational research". Second edition Prentice Hall of India Private Ltd, New Delhi, 1973.

* Senior Resident, Department of Hospital Administration, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad,A.P.
* Medical Superintendent & Head Department of Hospital Administration, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, A.P.

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