OUT PATIENT DEPARTMENT

MINAKSHI GAUTAMAssistant Professor,IIHMR, DelhiOUT PATIENT DEPARTMENTContentsIntroductionDefinitionImportance of Outpatient ServicesTypes of OPDFunctions of OPDProjection of WorkloadPlanning and DesigningPolicies and ProceduresIssues and Challenges

INTRODUCTIONIn recent years the focus of healthcare delivery has been towards ambulatory care.An outpatient department provides primary as well as comprehensive healthcare for patients who come for diagnosis, treatment or follow up care.It is the point of first contact between a hospital and the patients.An OPD is therefore appropriately called the Shop Window of a hospital.

INTRODUCTIONWhen hospitals did not exist, outpatient services provided by an institution called Dispensary run by government, local bodies and other organizations, but lacked the backing of supportive diagnostic services.

The beginning of the current century saw the outpatient services progressively becoming an integral part of hospitals.

In many western countries, general care is given by private practitioners and all hospitals do not have outpatient departments.INTRODUCTION.In India concept of private practitioners as well as outpatient services in hospitals.

The focus in medical care has to considerable extent be shifted from entirely inpatient-oriented to the outpatient oriented service.DEFINITIONAmbulatory medical care provided to patients who are not confined to bed can be provided at a general practitioners clinic, a specialist clinic, a health centre or a hospital.

When such care is rendered at premises which are part of a hospital (outpatient department) such care is called outpatient care and the services originating from it are named outpatient services.DEFINITIONOutpatient department is defined as a part of the hospital with allotted physical facilities and medical and other staff in sufficient numbers, with regularly scheduled hours, to provide care for patients who are not registered as inpatients.OriginationOriginated in mid 17th century by Sir George Clark In hotel Dieu in Paris6 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

MAGNITUDE AND IMPORTANCE OF OUTPATIENT SERVICESExtent of outpatient services provided by hospitals in India The extent of services are gigantic, and the problems of organizing them are enormous.There are still large chunks of population who have no accessibility to medical care, even ambulatory care.According to currently available statistics:About 25 inpatients are given service per bed in a year.On the other hand, for each hospital bed, about 500 outpatients per year are given services.MAGNITUDE AND IMPORTANCE OF OUTPATIENT SERVICESOver 30 crore outpatients in a year are treated in the outpatient department of hospitals.

From 2 to 4 episodes of sickness varying from a mild to moderate to severe nature are suffered by each person in as year.

Considering that only two episodes out of these may require some kind of medical help, 200 crore episodes (for a population of 100 crore) of sickness would need attending to.

Only one-sixth to one-fifth of these persons manage to seek medical care in the outpatient departments of health centres and hospitals.

MAGNITUDE AND IMPORTANCE OF OUTPATIENT SERVICESOthers seek help from private practitioners, traditional healers, health workers and quacks.

The experience of the National Health Service of UK is similar.

Statistics show that every person goes on an outpatient visit in a hospital once a year whereas visits his or her GP four times a year on an average.

There has been tremendous increase in the outpatient service all over the world during the last two decades.

MAGNITUDE AND IMPORTANCE OF OUTPATIENT SERVICESIn USA outpatient visits increased by 180% in the 15 years between 1951 and 1971 and almost doubled in the next decade again.

As opposed there are examples of developing countries where almost 55% of population is seemingly timid to go to hospital medical clinics, because this segment of the people cannot afford to pay the medical expenses due to their deplorable socio-economic situation.

MAGNITUDE AND IMPORTANCE OF OUTPATIENT SERVICESMuch of investigative and diagnostic work that formerly necessitated admission to a hospital can now be carried out in a well-equipped outpatient department.

Thus saving of expenses and avoidance of the disruption of family life that hospitalization causes.

All patients get their first impression of the hospital from the outpatient department.

It has been described as the first point of contact between the hospital and community and

Can make or mar the reputation of the hospital.MAGNITUDE AND IMPORTANCE OF OUTPATIENT SERVICES The importance of the outpatient department lies in the following:An outpatient is the patients first point of contact with the hospital and entry point into the health care delivery system.It is an inseparable link in the hierarchical chain of health care facilities. It contributes to reduction in morbidity and mortality.It is stepping stone for health promotion and disease prevention.It helps reduce the number of admission to inpatient wards, thus, conserving scarce beds.It acts as a filter for inpatient admissions, ensuring that only those patients are admitted who are most likely to benefit from such care.

IMPORTANCEThe importance of the department is as follows:It contributes towards reducing the morbidity and therefore, provides a stepping stone to health promotion and disease prevention.By providing primary as well as comprehensive healthcare, an OPD can reduce the number of admissions for inpatient care.The cost of treatment in OPD being less than for inpatient services

SOME MORE DEFINITIONSOutpatient : A person given diagnostic, therapeutic or preventive service through the hospitals facilities.Outpatient can be grouped under following 3 broad categories;

Emergency OutpatientReferred OutpatientGeneral outpatientSOME MORE DEFINITIONSEmergency Outpatient

A person given emergency care as a result of sudden severe illness or accident.

The need of emergency care is determined clinically. However, there are conditions considered by the patient or his/her relatives as requiring emergency services.

The perception of emergency by patients or their relatives may be different from that of physicians.SOME MORE DEFINITIONSReferred OutpatientA person referred to the outpatient department by a private practitioner or other physicians from one clinical discipline to the other, for specific diagnostic or treatment procedures or opinion, and who will (or should) return to the referring physician for further care and disposal.

SOME MORE DEFINITIONSGeneral OutpatientA person not referred by other physician, given diagnostic and/or therapeutic services on an outpatient basis, for other than an emergency condition, his or her continuing care and disposal being undertaken by the outpatient department.

General outpatients, i.e. Those who come to the outpatient department on their own with a variety of ailments .

A sizeable proportion of them may come for minor ailments because for them the hospital represents the only available source of medical care.SOME MORE DEFINITIONSOutpatient VisitAn outpatient visit is the visit of a person at the outpatient department to receive service. The visit may be:

New Outpatient Visit outpatient visit by a person for the first time, orRepeat Outpatient Visit Outpatient visit by a person subsequent to initial outpatient visit.

Unit of Service Unit of service is a measurable part of the volume of service rendered in diagnostic or therapeutic facilities of the hospital, expressed in terms of time and quantity.TYPES OF OPD Basically can be classified in two types;

Centralized: In centralized type of system all the OPDs of clinical departments of the hospital are grouped together in the form of OPD Complex.

It will include all the diagnostic, therapeutic and utility areas concerning OPD.

The consultants from different departments come to this area for OPD work.

In some hospitals, there is organizational structure of the OPD.

TYPES OF OPD Basically can be classified in two types;

Decentralized: In decentralized system the outpatient care is provided in respective departments of the hospital.

Similarly the diagnostic and therapeutic services are also provided department wise.

The specialty Clinics are more suitable for this type of OPD like department of Opthalmology, ENT, etc.

FUNCTIONSAn OPD enables a hospital to deliver the following functions:Control disease by early diagnosis and timely treatment.Investigate and screen cases to confirm whether or not hospitalization is required.Facilitate screening and investigations for admission to hospital.Provide effective treatment on ambulatory basis.Provide follow-up care to discharged patients and their rehabilitation.Provide a facility for training of medical, para-medical and nursing staff.It may also provide avenue for epidemiological and social research.

Control and surveillance of communicable diseases to prevent an outbreak of epidemic. It may be used to conduct activities in the field of preventive medicine such as well-baby clinics, obstetric consultations, parenthood and health clinics for schools.

FUNCTIONS.Preventive Health ActivitiesWell baby clinics ANC, marriage counseling, Fammily PlanningSchool health clinic.Control of communicable diseasesEarly diagnosis & detection of chronic diseases likeCancer, TB, RHD etc.Health education & nutritional adviceRehabilitation & prevention of disabilities & handicaps

PLANNING OF OUTPATIENT SERVICESOutpatient department of a hospital has functional and administrative links with the hospital of which it is a part.It may also be linked with health centers, satellite clinics and dispensaries dependent on it. Expected demand will have to be determined based on the hospitals catchment area and the population to be served.As a matter of policy, preventive and promotive care should be provided with curative care.An assessment of the expected demand for outpatient care must be made in the very beginning.

PLANNING OF OUTPATIENT SERVICESA clear distinction needs to be made between expected demand for outpatient services in an area among a defined population and expected demand at a particular facility, which may be one of several such facilities in an area.

Demand for outpatient care varies widely and depends upon;Cost to the patient,Distance,Transportation,Degree of urbanization,Socio-economic status of community,Level of facilities and staff, andQuality of care providedPROJECTION OF OUTPATIENT LOAD FOR SELECTED TARGET AREAProjection of outpatient demand in a given area depends on:Unmet needs of population for general medical and surgical care,Potential of cases being referred by GPs (this will have a bearing on the demand on specialty clinics rather than on general medical and surgical clinics),Alternative services available in the area, and Reputation of the hospital.PROJECTION OF OUTPATIENT LOAD FOR SELECTED TARGET AREAPresent statistics indicate that per hospital bed, 1.5 to 3 patients attend the outpatient department of a hospital per day.A 300 bedded hospital should expect to cater for 450 to 900 outpatients a day.The attendance tends to rise towards the higher side of the scale as the bed strength of the hospital increases.Out of the cases seeking attention in a hospital, up to 65% are for minor ailments and only 35% are for major conditions.Of these 35%, 10% may be acute and 25% chronic, however this figure varies from hospital to hospital.SOURCES OF ORIGIN OF OUTPATIENTSPLANNING CONSIDERATIONSAfter the expected demand has been determined, the following considerations should be taken into account.Range of outpatient services to be provided and defining the functions of the outpatient department.Daily and hourly capacity required.Number of the staff required by category and the tasks required of staff.Possible service time per patient, both average and its distribution over various aspects of outpatient care.Flow of patients and workRequirement of furniture and equipmentLayout of the department considering all the above.

KEY PLANNING AND DESIGN PARAMETERSTo make it convenient for patients, the hospital staff and the community, an OPD should be a separate complex within a hospital.The location should be such that an OPD shares diagnostic services, such as medical imaging, laboratory, pharmacy, blood bank with other departments of a hospital.

KEY PLANNING AND DESIGN PARAMETERS.The following are the design consideration:An OPD should be readily accessible from the hospitals main entrance and people should not have to pass through the wards.OPD should be designed either as a centralized polyclinic or decentralized specialty clinic.May be planned as general OPD or specialty OPD.Patients have different degrees of physical and mental abilities. Patient accessibility should accordingly be designed.Effective, comprehensible, and standard signage should be planned.Peak hours should be estimated to cater effectively to peak load.

KEY PLANNING AND DESIGN PARAMETERS.Entrance should be near the reception to efficiently answer patient queries.Dignity and privacy of patients must be maintained.Design should cater for future expansion.Educational resource areas for patients education should be integrated in the lobby and waiting areas.Design of individual functional areas should not allow extraneous traffic to penetrate any work area. Preferably, design should be such that the flow of patients and visitors is unilateral.

KEY PLANNING AND DESIGN PARAMETERS.Waiting areas and public spaces should be large enough to accommodate patients and accompanying friends and family without causing congestion.Sub-waiting areas should be provided adjacent to various clinics.Space recommended is 0.8msq per patient for one third of the average daily number of the patients attending OPD in one session.Day care facilities may be planned as support services.Design should allow natural light and good ventilation. It is desirable to provide a good view of the outside.

PHYSICAL FACILITESThe main physical facilities to be planned are the following:Public AreasClinical AreasConsultation RoomsSpecial Examination RoomsAdministrative AreasCirculation AreasAncillary and Auxiliary Facilities

PHYSICAL FACILITES.the subsidiary/ ancillary facilities include:Injection RoomsTreatment and Dressing RoomsPharmacyMedical Records Room, exclusive for OPD or combined with the IPD records section.

PHYSICAL FACILITES.The additional/ auxiliary facilities include:

LaboratoryMedical Imaging ServicesHealth Education FacilityMedico-social servicesScreening Clinics

ADMINISTRATIVE AREASThe administrative area should include offices and counters for the hospital administrator, nursing superintendent and medico-social workers.This area may also include storage facilities.

FUCTIONAL ZONESThese include public zones, joint use zones and staff zones.Public Zone: This includes:Main EntranceFoyer, which further includes:Reception Sign BoardsLayout Plans and Touch Screens

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.

Procedure RoomFUNCTIONAL ZONES.Bays for trolleys and wheelchairsPublic telephone boothsPublic conveniencesValue added services such as vending machines for snacks and beverages and book storeRegistration Area which includes:Centralized counter for new, repeat patientsControl desk for monitoring sub-registration at the respective service areas.Cash counterHealth Education Facilities that include:PostersPamphletsAudio-Visuals AidsWaiting areas in the foyer as well as each tier of consultation and treatment rooms.

FUNCTIONAL ZONES.Joint Use Zone: These include areas jointly utilized by staff and the patients such as the consultation and examination rooms.It can be made as;Two consultation rooms with one examination cubicle.Combined consultation, examination cubicle.Rooms should be designed to accommodate multiple medical specialties.A room of about 12.5msq is adequate for a consultation as well as examination.This also includes the space for examination tables, a washbasin, instrument, instrument trolley, an X-ray viewing screen, desk and chair for consultant/ doctor as well as two chairs for patients/ visitors.If examination room is catered for separately, a space of 8 m sq is sufficient.Specialized examination rooms may be planned depending on facilities provided, such as:Refraction, perimetry, tonography and slit lamp.AudiometeryEEGDental ExaminationPlaster Room

CLINICAL LABORATORYThis should include a centralized sample collection area for urine, stool and blood.A wash room and toilets (separately for male and female) and a blood collection room should also be provided.In a large OPD, it would be advantageous to have a side room adjacent to the collection station for routine examination of blood, stool and urine.

It should be so located so as to serve both inpatients and OPD patients.They should have multiple dispensing windows, drug storage cabinets and shelves.

PHARMACYAncillary facilitiesInjection room :It should be with waiting area for 10-20 patients with 0.6-0.8 sq.meter/patient. Area may varyfrom 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

Health Education Facilities Min. area required is 15sq.meter.Medical Social Service Facilities should be located inOPD with suitable cubicle for each socialworker/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

SPECIALIZED OPDSpecialized OPD services may include the following;

Gastrointestinal endoscopy lab, sigmoidoscopy and colonoscopy.

Pulmonary Function Lab including spirometery

Cardiac OPD with ECG, Echocardiography, TMT and Holter Monitoring Lab.

STAFF ZONEThe following should be planned

Staff cloak rooms and toilets

Seminar Room

PARKING AND ENTRANCEThe following are recommended for the entrance and parking areas of an OPD:

Main entrance to the OPD should have gentle sloping ramps to facilitate movement of patients on wheelchairs and those carried on stretchers. The surface should be slip/skid free.Entrance should have a double door with a width of 1500 mm to facilitate passage of stretchers and wheelchairs.Wheelchairs should be readily available at the entrance. Storage area for wheelchairs and stretchers should be allocated, conveniently located and not obstruct the flow of traffic.Staff and patient entrance should be separate, with each entrance providing access to the respective zone.For convenience of patients especially those with disabilities parking should be as close to the entrance as possible.Barrier free movement for the disabled should be provided.

Entrance

ENQUIRY DESK, RECEPTION STATIONThe following are recommended:

The height of the counter should be adapted to the needs of wheelchair patients.

To ensure privacy of discussion between and reception staff, the reception should have counters.

Sufficient numbers of drawers and shelving space should also be provided.

Registration DeskWAITING AREAThe following parameters should be considered;

Waiting Area should be planned to accommodate more than the number of people expected during peak hours.Sub waiting area may be shared between the various consultation rooms. To facilitate movement of patients, a call system should be provided, which directs the patient to the appropriate consultation room.The distance from the waiting area to the consultation room should be short and clearly marked.Patients on wheelchairs require extra space for movement.Toilets should be close to the waiting area. Male and female toilets should be separate. A scale of 1-2 WCs for every 100 patients attending OPD and at least one urinal for every 50 patients are recommended.Toilets for the staff should also be separate from those for the patients.Circulation Area should be no less than 30% .

Waiting Area

POLICIES AND PROCEDURESIn view of the interdependence of the staff, facilities and services of the hospital with that of the outpatient department, it is imperative that policies and procedures for each aspect of its functioning should be laid down in writing.

Policies are guidelines for action in all situations in general.

Procedures aim at putting the policies into practice and in adapting the facilities to the operational needs, and are therefore standardized methods of work.

To run the outpatient department efficiently, these should cover both administrative and technical (professional) aspects of the outpatient services.

Clear policies and procedures should be understood by all concerned regarding the various aspects of OPD operations.

POLICIES AND PROCEDURES FOR SMOOTH FUNCTIONING OF OPDsClinicsOrganizationFunctionsStaffingEquipmentTechniquesReferralsConsultationsInter-RelationshipSupervisionRecordsEvaluation of careTimings DrugsSupplies

POLICIES AND PROCEDURES FOR SMOOTH FUNCTIONING OF OPDsTypes of PatientsGeneralPayingReferredEligibilityMedico legalExamination and TreatmentGeneralLaboratory investigationsRadiological investigationsInjectionsRecordsFollow up

POLICIES AND PROCEDURES FOR SMOOTH FUNCTIONING OF OPDsStaffOrganizationDutiesResponsibilitiesShiftsInter-relationshipEquipment and suppliesInventoryRequisitionPurchasingIndentingAccountingStorageMaintenanceStandardsSafetySterilization

POLICIES AND PROCEDURES FOR SMOOTH FUNCTIONING OF OPDsRecordsIdentificationFiling and retrievalRetention GeneralSafety and SecurityBudgetAccountingStatisticsHousekeepingMaintenanceCommunications to the pressPublic Relations

COMMON PROBLEMS IN OUTPATIENT SERVICESOperations Long Queues, Queue jumping, inadequate service time, patients queries not answered by medical staff, punctuality.

Resources Adequacy and competence of medical and other staff, availability of drugs and supplies.

Efficiency

Physical Facilities and layout

Quality of Care

Patient and Staff Satisfaction

Spicific ChallengesDelays and Wastage of TimeLaboratory Facilities Inadequate Lack of coordination among different facilitiesEither non-availability of medicines or inferior quality medicines are suppliedLack of faith amongst doctorsRestricted role of the doctorsAbsence of leadership qualities among hospital managersDull atmosphere outside OPDOvercrowdingSpicific ChallengesManagement of recordsLack of concern for patients and relativesLack of support for junior doctorsStaff not coming in time

Expected Role of DoctorsFunctionsActivitiesAs a Physician treatment of patientsPromotion of healthPrevention of diseasesrehabilitationAs an EducatorOneself, health staff, community, patientsAs a ManagerRelationship with referral services, communities, representatives of community, research activitesAs an agent of Socio-Economic DevelopmentParticipate in community development, committee meetings, advocacy, etcCONCLUSIONThe outpatient department has functional and administrative links with the hospital of which it is a part.

During planning a measure of adaptability has to be incorporated in the internal arrangements and a substantial capacity for expansion must be considered.

It is the first point of contact between the hospital and the community hence, substantial deliberation for the planning and designing of an OPD is a must.