Pragmatics

Outpatient services are increasingly recognised as an important component of health care provision and may be improved through the application of modern management techniques. We have performed a time and role audit of consultation and waiting times in two medical clinics using different queuing systems: namely, a serial processing clinic where patients wait in a single queue and a quasi-parallel processing clinic where patients are directed to the shortest queue to maintain clinic flow. Data collected were used to construct a computer simulation of patient flows in clinic. Assessment of patient satisfaction in the clinic process was determined using a self-administered questionnaire. Mean waiting time was shorter in the quasi-parallel processing clinic: 26 (SD 17) minutes compared with 36(24) minutes in the serial processing clinic. In the serial processing clinic 61% of patients waited more than 30 minutes compared with 41% in the quasi-parallel processing clinic. In the serial processing clinic 8% of 142 patients surveyed complained of the time spent waiting. The computer simulation we produced was able to determine waiting times with different clinic structures. The simulation showed that reductions in waiting time up to 30% might be achieved by changing our serial processing clinic to a quasi-parallel processing one. Performance of medical outpatient clinics can be improved by examining and changing clinic management. Computer simulation of outpatient clinics offers a means of assessing the impact of such changes on waiting time in clinic and on waiting lists.     

Cluster randomized trial of a guideline-based open access urological investigation service

BACKGROUND: Out-patient services are trying to achieve effective and efficient health care in overcrowded, busy clinic settings. "One stop" and "open access" clinics have been advocated as a way of improving out-patient services. OBJECTIVES: Our aim was to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service. METHODS: General practices were randomized to receive either referral guidelines and access to the investigation service for lower urinary tract symptoms (LUTS) or referral guidelines and access to the investigation service for microscopic haematuria (MH). The study population comprised 66 general practices in the Grampian region of Scotland referring 959 patients. The outcome measures were compliance with guidelines (number of recommended investigations completed), number of general practice consultations, the number and case mix of referrals, waiting time to initial hospital appointment, and the number of patients with a management decision reached at initial appointment and discharged by 12 months after referral. RESULTS: GPs' compliance with referral guidelines increased (difference in means 0.5; 95% confidence interval 0.2-0.8, P < 0.001). Approximately 50% of eligible patients were referred through the new system. The number and case mix of referrals were similar. The intervention reduced the waiting time from referral to initial out-patient appointment (ratio of means 0.7; 0.5-0.9, patients with LUTS only) and increased the number of patients who had a management decision reached at initial appointment (odds ratio 5.8; 2.9-11.5, P < 0.00001, both conditions). Patients were more likely to be discharged within 12 months (odds ratio 1.7; 0.9-3.3, P = 0.11). There were no significant changes detected in patient outcomes. Overall the new service was probably cost saving to the NHS. CONCLUSIONS: The guideline-based open access investigation service streamlined the process of out-patient referral, resulting in a more efficient service with reduced out-patient waiting times, fewer out-patient and investigation appointments and release of specialist and clinic time.     

Patient attitude towards waiting in an outpatient clinic and its applications.

Patient waiting time in outpatient clinics is often the major reason for patients' complaints about their experiences of visiting outpatient clinics. Therefore, patient satisfaction with waiting time plays a crucial role in the process of health quality assurance or quality management. This paper reports the results of a survey on patient attitude towards waiting in an outpatient surgery clinic. Generally patients appear reasonably satisfied if they wait no more than 37 minutes when arriving on time, and no more than 63 minutes when late for appointments. Patients coming up to 15 minutes early are prepared to take full responsibility for the extra waiting caused, but the patients coming even earlier intend to be seen earlier and are only prepared to wait 15 minutes longer than otherwise. The potential applications of patient attitude towards waiting in the quality assurance process, ie setting up waiting time limits and designing patient dispatching rules, are also discussed.     

One-stop postmenopausal bleeding clinics reduce patient waiting times and theatre costs

BACKGROUND: Postmenopausal bleeding (PMB) is a common problem and reason for referral to gynaecology clinics. AIMS: The aim of this study was to compare patient management and outcomes from a newly developed one-stop clinic for women with PMB with traditional gynaecology outpatient clinics. METHODS: Retrospective studying running from January to July 2003 comparing the one-stop clinic with four traditional consultant-led outpatient gynaecology clinics also seeing women with PMB running concurrently in the same hospital. RESULTS: In the study period, 95 and 51 women were seen in each type of clinic. There was no difference in patient demographics but the time from referral tfirst consultation was shorter in the PMB clinic (p < 0.00 ) and women had fewer visits (p < 0.001). The mean time from first consultation to definitive treatment or discharge was also shorter (p < 0.001). Fewer hysteroscopies were generated from the PMB clinic (p < 0.0001) and yet there was no difference in the rates of abnormal histology between the two groups. CONCLUSIONS: This study demonstrated that one-stop investigation of PMB, compared to traditional outpatient clinics, reduced waiting times and theatre costs by reducing the number of hysteroscopies.     

医院门诊流程优化的调研统计分析与对策

目的 为了解门诊服务流程的现状和问题,进一步改善医疗服务质量,优化医院门诊服务流程。方法 现场统计“2013年2月第一周”和“2015年7月第一周”两个时段连续一周每天来四川大学华西医院门诊就诊的患者,每半小时统计一次,分析就诊各环节人流情况,进一步采取措施,优化就诊流程、强化分层就诊,整合窗口,细分号源预约时段和就诊时段。结果 门诊流程优化前,现场办卡、现场挂号、预约挂号、收费窗口及各候诊区人流量较大,尤其是候诊区等候的人群最高峰达3 720人,拥挤时间主要集中在9:00～11:30;门诊流程优化后,各窗口人流拥挤情况得到一定改善,患者满意度由原来的90.0%上升至93.5%。结论 医院门诊流程优化应根据患者的需求,关注细节,减少流程中的往返时间,缩短患者的等候时间,简化手续,才能改善患者的就医体验,最终提高患者满意度。     

Reducing non-attendance at outpatient clinics.

Outpatient non-attendance is a common source of inefficiency in a health service, wasting time and resources and potentially lengthening waiting lists. A prospective audit of plastic surgery outpatient clinics was conducted during the six months from January to June 1997, to determine the clinical and demographic profile of non-attenders. Of 6095 appointments 16% were not kept. Using the demographic information, we changed our follow-up guidelines to reflect risk factors for multiple non-attendances, and a self-referral clinic was introduced to replace routine follow-up for high risk non-attenders. After these changes, a second audit in the same six months of 1998 revealed a non-attendance rate of 11%--i.e. 30% lower than before. Many follow-up appointments are sent inappropriately to patients who do not want further attention. This study, indicating how risk factor analysis can identify a group of patients who are unlikely to attend again after one missed appointment, may be a useful model for the reduction of outpatient non-attendance in other specialties.     

儿科门诊候诊时间及其影响因素分析

目的深入挖掘影响儿科门诊候诊时间过长的影响因素,为改善门诊候诊状况提供方法学上的借鉴.方法收集某三级甲等医院2018年儿科门诊的就诊信息,采用方差分析及多元线性回归筛选候诊时间过长的影响因素.结果多元线性回归结果显示,年龄、病人来源、民族、医保类型、月份、星期、预约方式、挂号类别对候诊时间的影响有统计学意义.结论通过对影响候诊时间主要因素的分析,提示医院管理部门针对主要的影响因素实施弹性排班、分时段预约等措施,减少患者的候诊时间.     

Successfully reforming orthopaedic outpatients

Since 2005, Barwon Health has successfully reformed its orthopaedic outpatient service to address the following issues: increasing number of referrals, inefficient referral management and triage, long waiting times for non-urgent appointments, high 'Did Not Attend' (DNA) rates and poor utilisation of conservative therapies before referral to surgeon. Numerous strategies have been implemented including: waiting list audits, triage guidelines, physiotherapy-led clinics, a DNA policy, an orthopaedic lead nurse role and a patient-focussed booking system. There has been a 66% reduction in the number of patients waiting for their first appointment; an 87% reduction in the waiting time from referral to first appointment; a 10% reduction in new patient DNAs; and more efficient referral management and communication processes. Patients are now seen in clinically appropriate time frames and offered earlier access to a wider range of conservative treatments.     

Outpatient clinic: where is the delay?

In outpatient clinics, consultation times are often eroded by extraneous activities. We measured the components of each outpatient episode in 167 patients attending a general urology follow-up clinic. 41% of time in the clinic was spent away from the patient-administration 17%, disturbances 15%, finding results 9%. The inefficiencies had changed little since a study in the same setting thirteen years earlier. Since then, parallel nurse-practitioner-run clinics have been introduced in the hope of giving consultants longer with the patient; however, time with each patient is now 4.8 min compared with a previous 7.6 min. The most easily addressed inefficiencies are those relating to missing information, such as radiology reports.     

The effect of telemedicine on consultation time

We have implemented an 'evidence-based referral' for primary care patients in dermatology, cardiology and peripheral vascular disease. Telemedicine clinics bring together a district nurse, patient and vascular surgeon to discuss diagnosis, management and care. During a 30-month study, a total of 30 patients participated in telemedicine clinics. The mean consultation time fell from 23 to 10 min. In parallel, the type of consultation changed from dermatology to vascular surgery. Nineteen patients participated in vascular telemedicine clinics over the last 16 months of the study. The average consultation time was 10 min (SD 1), which included discussion of the case and negotiation of its management. The average consultation time in the equivalent outpatient clinic in the same hospital for the same consultant was 15 min. The acquisition of the relevant information in primary care could lead to a reduction of 75% in outpatient clinic appointments.     

数字医疗门诊信息系统的建设与应用

目的：为提升患者对医院的满意度,利用先进的现代化数字技术手段,在节约门诊信息系统建设成本的同时,达到提高资源利用率、门诊诊疗效率与品质的目的。方法：优化流程管理,完善门诊信息系统的基础信息化建设,同时建立新信息系统和完善旧信息系统的改造。结果：通过系列数字改造后门诊业务流程得到了进一步的优化,缩短了患者在门诊各类流程的排队等待时间,进而提升了患者对医疗服务的满意度。结论：医院门诊数字化建设和改造,对加快门诊数字化建设和尽早实现全院性数字化医院可起到关键性作用。     

Chemotherapy appointment scheduling under uncertainty using mean-risk stochastic integer programming

Oncology clinics are often burdened with scheduling large volumes of cancer patients for chemotherapy treatments under limited resources such as the number of nurses and chairs. These cancer patients require a series of appointments over several weeks or months and the timing of these appointments is critical to the treatment’s effectiveness. Additionally, the appointment duration, the acuity levels of each appointment, and the availability of clinic nurses are uncertain. The timing constraints, stochastic parameters, rising treatment costs, and increased demand of outpatient oncology clinic services motivate the need for efficient appointment schedules and clinic operations. In this paper, we develop three mean-risk stochastic integer programming (SIP) models, referred to as SIP-CHEMO, for the problem of scheduling individual chemotherapy patient appointments and resources. These mean-risk models are presented and an algorithm is devised to improve computational speed. Computational results were conducted using a simulation model and results indicate that the risk-averse SIP-CHEMO model with the expected excess mean-risk measure can decrease patient waiting times and nurse overtime when compared to deterministic scheduling algorithms by 42 % and 27 %, respectively.     

Patient satisfaction with nurse-led telephone follow-up in women with lower urinary tract symptoms

We assessed the clinical effectiveness and patient satisfaction with nurse-led telephone follow-up of women with lower urinary tract symptoms. Participants were offered telephone follow-up with a nurse instead of a conventional outpatient appointment. Suitability was decided by the doctor who saw the women at her last visit. The consultation was conducted using the same principles as a routine clinic visit. Patient satisfaction was evaluated by postal questionnaire and they were also sent a standard urinary continence questionnaire, the Kings Health Questionnaire (KHQ), to evaluate their current symptoms. In total, 116 women were included. The mean number of telephone consultations was 2 (range 1-12). The mean overall satisfaction score was 77 (maximum 100, where a higher score indicates greater satisfaction). Only 16 patients (17%) did not prefer telephone follow-up to a clinic visit. Women who had been discharged via the telephone follow-up clinic expressed similar mean satisfaction scores to those whose next visit was a clinic visit (80 and 82, respectively). The KHQ also indicated that the patients had been appropriately discharged or given a further follow-up appointment. Nurse-led telephone follow-up is associated with high satisfaction and has the advantages of consistent follow-up by the same clinician, convenience to the patient and cost-savings.     

系统动力学在医院门诊预约患者管理中的应用研究

目的 从患者角度分析预约就诊过程,为提高医院门诊预约服务质量和服务效率提供支持.方法 采用系统动力学方法,分析预约就诊过程中的关键性因素及因素之间的关系,建立系统动力学模型.结果 将医务人员数量、患者候诊时间、诊疗时间等作为反映医院服务质量和服务效率的重要变量,构建系统动力学模型,根据模型提出缓解预约就诊困难的管理策略...     

应用品管圈活动对缩短门诊高峰期患者取药等候时间的探讨

目的探讨品管圈活动在缩短门诊高峰期患者取药等候时间中的应用效果。方法以2018年9月-2019年8月在我院门诊药房取药的20000人为研究对象,成立品管圈,确定圈名、圈徽,通过选定主题、拟定活动计划、设定目标、分析原因、制定对策,对活动前后门诊高峰期患者取药的等候时间进行统计和比较,确认活动效果,从而制定规范化、标准化的工作流程。结果有形成果:活动前门诊西药房患者等候时间为14.2min,活动后患者取药等候时间为7.6 min,达到目标值8 min。无形成果:通过实施品管圈活动,提高了圈员的解决问题能力、沟通协调能力、团队凝聚力,增强了圈员责任心和积极性,改善了品管手法,和谐度更高。结论通过实施品管圈活动,缩短了门诊高峰期患者等候取药的时间,大大提高了门诊的药学服务质量。     

Acuity-based nurse assignment and patient scheduling in oncology clinics

The oncology clinics use different nursing care delivery models to provide chemotherapy treatment to cancer patients. Functional and primary care delivery models are the most commonly used methods in the clinics. In functional care delivery model, patients are scheduled for a chemotherapy appointment without considering availabilities of individual nurses, and nurses are assigned to patients according to patient acuities, nursing skill, and patient mix on a given day after the appointment schedule is determined. Patients might be treated by different nurses on different days of their treatment. In primary care delivery model, each patient is assigned to a primary nurse, and the patients are scheduled to be seen by the same nurse every time they come to the clinic for treatment. However, these clinics might experience high variability in daily nurse workload due to treatment protocols that should be followed strictly. In that case, part-time nurses can be utilized to share the excess workload of the primary nurses. The aim of this study is to develop optimization methods to reduce the time spent for nurse assignment and patient scheduling in oncology clinics that use different nursing care delivery models. For the functional delivery model, a multiobjective optimization model with the objectives of minimizing patient waiting times and nurse overtime is proposed to solve the nurse assignment problem. For the primary care delivery model, another multiobjective optimization model with the objectives of minimizing total overtime and total excess workload is proposed to solve the patient scheduling problem. Spreadsheet-based optimization tools are developed for easy implementation. Computational results show that the proposed models provide multiple nondominated solutions, which can be used to determine the optimal staffing levels.     

Patient referral by telemedicine: effectiveness and cost analysis of an Intranet system

The clinical effectiveness and costs of telemedicine in improving the referral process from primary to secondary care were examined in an eight-month prospective, comparative study with one-year follow-up. The internal-medicine outpatient clinics of two Finnish district hospitals were compared--Peijas Hospital (PH) with telemedicine and Hyvink?? Hospital (HH) without it. The three primary-care centres studied referred a total of 292 adult patients to the outpatient clinics. The population-based number of referrals to PH (7.5/1000) from primary-care centres was twice that to HH (3.8/1000). Thirty-seven per cent of referrals to PH included requests from general practitioners for on-line medical advice (teleconsultation). Forty-three per cent of the total number of intranet referrals resulted in outpatient visits at PH, compared with 79% in the outpatient clinic at HH. Only 18% of the patients receiving a teleconsultation ended up in the outpatient department of PH within one year. These visits were mainly due to progression of chronic disease. No deaths or missed diagnoses could be attributed to telemedicine, but one diagnosis was delayed. The direct costs of an outpatient clinic visit in internal medicine (EU211) were seven times greater per patient than for an e-mail consultation (EU32), with a marginal cost decrease of EU179 for every new intranet consultation. A cost-minimization analysis of the alternative interventions showed a net benefit of EU7876 in favour of the teleconsultation process. General practitioners sought an outpatient visit for 130 of their patients, and advice only for another 77. On-line advice was nonetheless given in 108 cases, and only 88 patient visits were arranged. Eleven referrals were declined. The cost difference between giving on-line medical advice for the 108 cases and a visit to the outpatient clinic for the other 88 was less costly (by EU4140) than investigating the 124 patients whose original clinic referrals to the PH were not declined. Productivity in the hospital increased over threefold by using e-mail consultations instead of traditional outpatient visits. The wide interactive use of the intranet referral system between secondary and primary care improved clinical effectiveness, lowered direct costs, increased productivity and was cost-effective.     

Using no-show modeling to improve clinic performance

'No-shows' or missed appointments result in under-utilized clinic capacity. We develop a logistic regression model using electronic medical records to estimate patients' no-show probabilities and illustrate the use of the estimates in creating clinic schedules that maximize clinic capacity utilization while maintaining small patient waiting times and clinic overtime costs. This study used information on scheduled outpatient appointments collected over a three-year period at a Veterans Affairs medical center. The call-in process for 400 clinic days was simulated and for each day two schedules were created: the traditional method that assigned one patient per appointment slot, and the proposed method that scheduled patients according to their no-show probability to balance patient waiting, overtime and revenue. Combining patient no-show models with advanced scheduling methods would allow more patients to be seen a day while improving clinic efficiency. Clinics should consider the benefits of implementing scheduling software that includes these methods relative to the cost of no-shows.     

Why 100 patients failed to keep an outpatient appointment-audit in a dermatology department.

Failure to keep outpatient appointments is common at all clinics and various explanations may be offered. One hundred attending patients who had failed to keep their previous dermatology clinic appointment were asked the reason for their non-attendance. Many and varied reasons were given but illness (28%), and problems related to appointments (33%) were prominent. They were also asked how they had obtained a further appointment. Stricter follow-up of non-attenders by the hospital including informing the GP, and subsequent GP action if necessary, may improve attendance figures.     

Surgical outpatient clinics: are we allowing enough time?

BACKGROUND: Performance management initiatives, such as the UK's Patient's Charter, are creating pressure for patients to be seen earlier at out patient clinics, thus increasing clinic workloads. There is, however, little information about whether this can be absorbed, either by utilizing spare capacity or by more efficient use of time, or whether it is likely to affect patient care adversely. METHODS: Nine surgical clinics, run by four general surgeons, in an English district general hospital were studied during a typical week. Clinic schedules and numbers invited to attend were extracted from clinic records. An observer recorded the actual time each patient spent with the surgeon to the nearest 5 seconds. Scheduled and actual times of commencement and completion of clinics were also recorded. RESULTS: The number of patients booked to attend each clinic varied from 11 to 82 (mean 37). The median consultation for new patients was 4.3 minutes and for follow-up patients it was 3 minutes. Consultants spent a median 2.7 minutes with patients whereas junior staff spent 4.2 minutes. These aggregate results conceal considerable variation between surgeons, even though the scheduled time available was similar. The median time spent with new patients by one consultant was 1.3 minutes and by another 13.1 minutes. Seven of the nine clinics overran their scheduled time (by up to 55 minutes). All doctors, with one exception, arrived late for the clinics (range 10 minutes early to 30 minutes late). The first patient was invariably seen after the scheduled starting time for the clinic (mean 17 minutes, range 5-50 minutes) and the median interval between a doctor arriving and seeing their first patient was 10.6 minutes. Overall, only 50% of the time spent by doctors at the clinics was with patients. IMPLICATIONS: The amount of time spent by patients with surgeons is already so short as to cause concern about both the appropriateness and value of consultations. It is unreasonable to increase workload further. There is a clear need for outpatient clinics to be managed, with regular examination of what is taking place and how long it takes. Only then will it be possible to tailor schedules to the actual requirements of the service.