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REDUCING PATIENT WAITING TIME AT OUT PATIENTS’DEPARTMENT AT KAWOLO GENERAL HOSPITAL.

BY

SILVIO ABIRIA,MSC-HM, BA (SS) Dip SCN and Dip MN

SALIMA KABISE, Certificate Medical Records, CCA,CCNA

HARRIET NANGOBI, Dip. Comp. Nursing.

MEDIUM-TERM FELLOWS (HEALTH SERVICE IMPROVEMENT)

MENTORS

HARUNA WAMALA

DR MAYANJA ROBERT

FEBRUARY2015

M A K E R E R E U N I V E R S I T Y

SCHOOL OF PUBLIC HEALTH (MakSPH-CDC FELLOWSHIP PROGRAM)

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TABLE OF CONTENTS

TABLE OF CONTENTS..............................................................................................................................2

DECLARATION .......................................................................................................................................... 3

FELLOWS’ ROLE IN PROJECT IMPLEMENTATION............................................................................ ii

ACKNOWLEDGEMENT. .......................................................................................................................... iii

ACRONYMS ............................................................................................................................................... iv

OPERATIONAL DEFINITIONS................................................................................................................. v

EXECUTIVE SUMMARY ......................................................................................................................... vi

INTRODUCTION AND BACKGROUND.................................................................................................. 1

About Kawolo Hospital ............................................................................................................................2

STATEMENT OF THE PROBLEM ............................................................................................................3

Problem Identification .............................................................................................................................3

Problem Prioritization..............................................................................................................................4

PROJECT OBJECTIVES .............................................................................................................................6

General Objective ..................................................................................................................................... 6

Specific Objectives.................................................................................................................................... 6

COUNTER MEASURES .............................................................................................................................7

PROJECT OUTCOMES.............................................................................................................................10

LESSONS LEARNT AND CHALLENGES EXPERIENCED .................................................................11

RECOMMENDATION AND NEXT STEPS ............................................................................................12

REFERENCES ...........................................................................................................................................14

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DECLARATION

I, Silvio Abiria, Salima Kabise and Harriet Nangobi, do hereby declare that this end of project

report entitled; Reducing Patient Waiting Time at Out Patients’ Department At Kawolo

General Hospital, has been prepared and submitted in fulfillment of the requirements of the

Medium-term Fellowship Program at Makerere University School of Public Health and has not

been submitted for any academic or non-academic qualifications.

Signed ………………………………………………. Date ………………………………………

Silvio Abiria, Medium-term Fellow

Signed ……………………………………………….. Date ………………..……………………

Salima Kabise, Medium-term Fellow

Signed ……………………………………………… Date ………………………………………

Harriet Nangobi, Medium-term Fellow

Signed ………………………………………………. Date ………………………………………

Haruna Wamala, Institutional Supervisor

Signed ………………………………………………… Date …………………………………….

Dr Mayanja Robert, Academic Mentor

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FELLOWS’ ROLE IN PROJECT IMPLEMENTATION

The team from Kawolo Hospital consisted of three members and each played a very important

role in the implementation of the project as indicated below;

1. Silvio Abiria- Team leader: Oversaw the entire implementation exercise and was also the

contact person responsible for liaising with the MakSPH-CDC Fellowship program, as

well as the institutional and academic mentors.

2. Salima Kabise -Secretary and records manager: Ensured proper documentation of the

activities, progress and outcome related with implementation of the project activities.

3. Harriet Nangobi - Coordinator: Was responsible for the overall coordination of the

activities implemented in the project, ensuring that all the other health workers within the

Hospitals work harmoniously with the trained team members to implement project

activities. She also led the dissemination of project results to stakeholders.

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ACKNOWLEDGEMENT.

We would like to thank the staff of Makerere University College of Health sciences, School of

Public Health, especially Dr.Violet Gwokyalya, Mr.J.B Matovu, Ms. Rose Baryamutuma and

Ms. Farida Mbambu for their valuable technical support and guidance throughout the entire

training period. We also acknowledge all stakeholders who participated in the different activities

during project implementation. Lastly, we are indebted to our families for the support they

rendered to us during the busy period of project implementation.

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ACRONYMS

OPD Out Patient Department

MOH Ministry of Health

SUSTAIN Strengthening Uganda’s Systems by Treating AIDS Nationally

DHT District Health team

IP Implementing Partner

TB Tuberculosis

ANC Antennal Clinic

ART Anti Retroviral Therapy

MakSPH Makerere University School of Public Health

CDC Centers for Disease Control and Prevention

HCQI Hospital Continuous Quality Improvement.

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OPERATIONAL DEFINITIONS

Waiting time in this report is defined as the total time spent from when the patient enters OPD to

the time he/she leaves OPD after receiving the required services.

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EXECUTIVE SUMMARY

Patient waiting time is one of the measures of the quality of health services from a client’s

perspective. Kawolo Hospital had a persistent problem of long waiting time at the outpatient

department. An assessment to determine the amount of time patients took to exist the facility

revealed that patients were waiting for an average of 4 hours. This was way above the 2 hours

recommended by the Ministry of health. Following meetings with the relevant stakeholders at the

hospital, it was agreed that the support from Makerere University School of Public Health CDC

fellowship program towards implementation of a QI project be focused on this service problem.

The project was designed with the overall objective of reducing patient waiting time at OPD at

Kawolo General Hospital from 4 to 2 ½ hours within 5 months.

In order to achieve this set objective, relevant counter measures were adopted which included;

strengthening support supervision, reducing staff absenteeism and streamlining patient flow

among others. After six months of project implementation, both direct and indirect outcomes

were registered. Overall, patient waiting time reduced from 4 to 3 hours, staff absenteeism

reduced significantly because of the involvement of administration and transferring some of the

basic laboratory tests for HIV and malaria from the congested laboratory to a separate testing

area which greatly reduced turnaround time for test results. In addition, patient comfort was

improved by the creation of another waiting place for those awaiting test results.

Through this project we learnt; the importance of team work, innovation to improve health

service provision and involvement of administration in QI interventions to ensure successful

implementation. We recommend that hospital administrators be trained in quality improvement

to enable them provide more support to the staff. The Ministry of health should also strengthen

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supervision in the public health facilities and maintain adequate staffing levels to enable timely

service delivery to clients.

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INTRODUCTION AND BACKGROUND

The time patients spend at health facilities is a key performance indicator for health facilities

especially for outpatient clinics. The effect of long waiting time on utilization of health services

is well documented (Fernandes et al., 1994; dos Santos et al., 1994) and has been associated with

poor utilization of available health care services (Kurata et al., 1992). Out Patients Departments

(OPD) act as windows to hospital services and they reflect the quality of services in the other

departments. A patient’s impression of the hospital begins at the OPD. This impression often

influences the patient’s sensitivity to the hospital and it is therefore essential to ensure that OPD

services provide an excellent experience for patients. When well organized and professionally

run, OPD can help avoid confusion, frustration and regulate the flow of patients in the hospital.

Additionally, waiting time becomes a factor in retaining current users of the service as well as

attracting new users. Throughout the world, patient waiting time has increased most especially in

the developing countries where it is compounded by poor health systems (Willcox et al., 2007;

Siciilian and Hurst 2004).

Studies have revealed that patient satisfaction is highly correlated with waiting time (Maitra and

Chikhani, 1992). A study done in United Kingdom revealed that prolonged waiting times led to a

substantial number of patients not receiving services at Out Patients Departments (Fernndes et al,

1994). Although sometimes long waiting times may have little medical impact, excessive delays

may be detrimental to patients’ (CIHR 2007). Wait times for health care services arise because

capacity does not match demand, or either capacity or demand is not well managed. Having

observed the importance of OPD, hospitals are making changes on various `fronts to streamline

this area (Sonal Shukla 2007).

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Against this background, a team of medium term fellows undertook to reduce patient waiting

time at Kawolo hospital following training on Health Services Improvement at the Makerere

University CDC Fellowship program. A quality Improvement project was designed with the

overall objective of reducing patient waiting time at the OPD. A number of strategies were

adopted and are elaborated further under relevant sections.

About Kawolo Hospital

Kawolo General Hospital is a public health facility, established by MOH in 1968. It is located

45kms along Kampala - Jinja highway in Kikaula Ward, Lugazi Town Council, Buikwe District.

It serves the districts of Buikwe, Buvuma and Mukono. The Catchment population is 441,199

(Sub National Projection Report 2013). The facility offers preventive, curative and rehabilitative

services both on outpatient and in-patient basis. On average 250 clients are seen daily in the

outpatient department which has a staffing of 33 health care workers as represented in Table 1

below.

Table 1:staffing level of the OPD of Kawolo General Hospital

OPD StaffingCadres NumberClinicians 8Nurses 10Lab Staff 6Pharmacy 5Dental 2Orth/Phsio 2

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STATEMENT OF THE PROBLEM

Kawolo General Hospital had experienced persistent outcry from patients regarding long waiting

times at OPD. On 26th December, 2013, there was a demonstration by patients about the long

waiting they had to go through to receive the required services. This demonstration was

broadcasted on national Television (“Agataliko Nfuufu 26th December, 2013). Following this

incidence, SUSTAIN an implementing partner with the hospital conducted a study to establish

the number of hours patients took to receive services at OPD. Using a pre designed tool, baseline

data taken on 1500 patients in March 2014 revealed that 1335 (89%) spent 4 hours and above to

go through the different service points which is way above the recommended time (2hrs)

according to the MoH guidelines. A similar survey of client satisfaction conducted by UPMB -

2012, confirmed length of entire visit in OPD as four (4) hours. A survey carried out by SUSTAIN

Project in March 2013 following the client demonstration mentioned above also revealed that

clients took four (4) hours in the OPD of Kawolo General Hospital instead of the recommended

two (2) hours. It was against this background that a quality improvement (QI) project was

designed and implemented at Kawolo Hospital with the overall goal of reducing this patient

waiting time at the OPD.

Problem Identification

Identification of the problem was done in line with QI principle that recommends participation of

relevant stakeholders. In this regard, a meeting was held with the District Health Team (DHT),

Implementing Partners and Health Facility Management. The purpose of this meeting was to

build consensus and get buy in from the various departments, to ensure successful

implementation of the project. The meeting also provided a forum for brainstorming on the

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different problems facing the hospital so as to select the one that was manageable with the

available resources. Some of the problems identified in that meeting are listed below;

Too many attendants in the ward

Long waiting time for patients in OPD

Documentation gaps in primary tools (registers) of the various wards

Poor emergency management

Low TB case detection rate

Poor infection control measures

Absenteeism among health workers

Problem Prioritization

The identified problems were subjected to a voting system whereby the problem with the highest

number of votes in terms of effect on the facility and the clients was selected for the QI project.

The results of the voting exercise are shown in table: 2 below.

Table 2:problem prioritization

Problems Tallies

Too many attendants in theward

Long waiting time for patientsin OPD

Documentation gaps in primarytools (registers)

Poor emergency management

Low TB case detection rate

Poor infection control measures

Absenteeism among healthworkers

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From the voting, patient waiting time was identified as the priority problem that could be

addressed because the causes were process related and could be influenced. Consequently,

further analysis was done using the Fish Borne tool to establish the actual cause of long waiting

hours at OPD. The results of the analysis are reflected in Figure 1below;

Fishbone showing root cause analysis of long patient waiting time

Few skilled staff

Many clinics

No salary forsome staff

Poor staffattitude

Inadequate staffaccommodation

Lack of support supervision

Lack of space

Lack of aDirection chart

No labels on theservice points

Patients not usingthe lower levelhealth facilities

Lack ofperformancefeedback

Infrastructure Patients

AdministrationHuman resource

Long patientwaiting time atOPD of KawoloGen. Hospital

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PROJECT OBJECTIVES

General Objective

To reduce patient waiting time at Kawolo Hospital OPD from 4 to 2.5 hours by December, 2014.

Specific Objectives

1. To strengthen support supervision systems and structures at the kawolo hospital.

2. To re-organize patient flow at Kawolo Hospital OPD by August 2014.

3. To build a sustainable system to monitor and evaluate OPD patient waiting time.

In order to achieve the project objectives and set targets, a number of counter measures were

adopted as reflected in Figure 2: below.

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COUNTER MEASURES

Figure 2: Counter measure matrix

Reducing staff absenteeism

In order to reduce staff absenteeism, a number of strategies were adopted as explained below;

Strengthened the staff clocking in system; before the project there was little focus from the

administration on the time staffs arrived and left the facility. With the new clocking system,

staffs were required to register both at the reception and their respective work stations. A red line

system was used to track staff who come in beyond the recommended time. Subsequently, data

in the clocking system would then analyzed at the end month and acted on accordingly.

Longpatientwaitingtime inOPD

No clear client flow

Late coming andabsenteeism

No supportSupervision fromthe administrators

Lack of space

Underutilization ofthe peripheral healthunits

Streamline client flow

Strengthening the clockin system.

Involvement ofadministrators in theCQI projectimplementationDecentralization of Lab& Pharmacy

Utilizing the redundantMedical Officers’ roomfor another clinician tosee clients.

Continuoussensitization of patientson the use of peripheralhealthFacilities

Draw and display bothclient flow & directioncharts

Monitoring andsummarizing monthlystaff attendance.Sharing information withthe District leadership.

Develop staff weeklyduty roster&departmental rounds inshifts.

Decentralize rapiddiagnostic testing andmedicine dispensing toother care points.

Use of a tent forcounseling & waitingarea to decongest OPDhence easing client flow

Problem

Counter measures

Root causes

Practical methods

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Support supervision structures were put in place whereby weekly duty rosters were developed to

conduct support supervision and keep reports within the department.

Figure 3: Showing Staff Absenteeism with relevant Percentages Before and After the

Project

0

5

10

15

20

25

30

35

july august sept nov dec

a graph showing staff absenteeism on a monthlybasis

staff absent

percentage

Improving patient flow and streamlining triage. A patient flow chart was developed clearly

indicating service provision points both in English and Luganda. Also, labels were placed at

various services provision points indicating services offered.

A volunteer from Red Cross who was in charge of patient registration was oriented on the patient

sorting. A standard operating procedure was developed to guide patient sorting at OPD.

Oriented the OPD staff on the use of the modified MoH MF5 to continuously monitor patient

waiting time and act accordingly when the hours are longer.

Deployment plans were reviewed and displayed and a client flow chart developed as reflected in

figure 4. Below.

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Patient flow chart sNO

YES

NO

YES

YES

NO

NO

YES

ARRIVAL

Patient Stable

REGISTRAION

CLINICIAN

PATIENTSTABLE

YES

EMERGENCYROOM

INVESTIGATIONS LAB,SCAN,XRAY

PRESCRIPTIONRECORDINGIN-PATIET

WARD

PHARMACY

HOME

. Figure 4: Client Flow Chart Developed by the QI team at Kawolo Hospital

Decentralizing laboratory services. Some laboratory services for malaria (RDT) and HIV (HCT)

were decentralized to reduce congestion in the central laboratory. A waiting tent for lab results

was introduced outside the main OPD.

Lastly, the QI team held monthly meetings to review progress and performance of the QI project.

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PROJECT OUTCOMES

The implementation of the QI project resulted in a number of outcomes as explained below

under relevant sub- section;

The introduction of the clocking system greatly improved staff attendance. This was as a

result of the systematic interventions from the administration on non-adhering staff

members.

Patient sorting eased patient flow and hence contributing to the reduction on waiting

time. This is because little time was spent between different service provision points.

Decentralization of some lab tests for malaria and HIV also reduced the volume of tests

done at the central laboratory, hence reducing the patient waiting time at the laboratory.

Overall the project resulted in the reduction of patient waiting time at Kawolo hospital from an

average of 4 to 3 hours by the end of the project. Figure 4 below shows the situation before and

after implementing the QI project. The figure below shows ccomparison of waiting time

before and after implementing the QI at Kawolo Hospital.

A graph showing changes in Kawolo hospital OPD waiting time

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LESSONS LEARNT AND CHALLENGES EXPERIENCED

A number of lessons were drawn from the experience as described below;

Close supervision by heads at all levels is necessary for effective service delivery in the

public health sector.

Administration involvement and understanding of quality improvement is very key for

successful implementation of CQI projects.

Table: 2 Challenge solution matrix

Challenge SolutionResistance by other staff Orientation of staff in CQI concepts and

motives of the project

Lack of support from the administration A team from MakSPH –CDC fellowshipprogram met with facility administration andably informed them the motives of the project

Multi-tasking by the same staff Prioritization was important

Challenges of identifying the right staff forthe different service points.

Reviewing performance and re-assigningresponsibility

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RECOMMENDATION AND NEXT STEPS

To MakSPH-CDC Fellowship Program

The District capacity building program should focus at training the top leadership of the

Districts followed by the facility heads before looking at the grass root heath workers.

Money for project implementation should be channeled directly to the fellows to reduce time

wastage because of the beurocracy followed when money is channeled through district

accounts.

To Kawolo Hospital

The administrators should continue with close support supervision and monitoring of staff

attendance, reporting time and duty coverage.

Disciplinary measures should be put in place such that habitual absentees and late comers are

subjected to disciplinary action.

To Ministry of Health

The Ministry of health should strengthen supervision in the public health facilities, recruit

and maintain adequate staffing levels and puts in place measures to stop patient self-referrals.

Sustainability plans and Next steps (dissemination plan, follow-up/scale-up strategy)

Some of the tested changes have been adopted by the Antenatal clinic

We intend to continue monitoring the project and we call upon the district administration to

also strengthen support supervision to the health facility.

If supported, we intend to scale up to the other public health facilities within our sub-district

and finally to the entire district of Buikwe.

The project has been incorporated in the hospital quality improvement work plan.

The human resource officer took up the responsibility of ensuring that updated duty rosters

for support supervision are in place.

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We oriented the OPD staff on the use of the modified MoH MF5 to monitor patient waiting

time.

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ART

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Arch

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