How to Improve Patient Waiting Time: A Simple Question to a Complicated Problem at

The Lindi Regional Referral Hospital OPDY.A. Kassahun, advisor to Lindi RHMT and RRHM | M. M. Mohamed, RHMT/RQIFP, Lindi | C.A. Joyce, intern at GIZ, Georgetown University

Abstract: Based on simple observations and informal complaints from community members and patients, in November 2013, we, the Regional Hospital Management Team (RHMT)/ Regional Referral Hospital Management Team (RRHMT), set out to probe and understand the

challenges associated with dilated patient waiting time at the Lindi Regional Referral Hospital (RRH) Out Patient Department (OPD). To ascertain the precise bottlenecks in the system, we mapped out a visual representation of the OPD, specialized clinics and other services

associated with the OPD (Figure 1). Additionally, we constructed four tools: a) community impact assessment survey; b) time-tracking tool to capture real-time information as patients progress through stations; c) patient exit survey to gauge patients’ perception of waiting time

and quality of services received (Figure 2); and d) staff survey to understand the working conditions, attitude, and interaction with fellow staff and clients (Figure 4).

Study design: This cross-sectional study was carried out using mixed sampling methods: stratifi ed random and purposive selection. The fi rst (baseline) survey was conducted in October 2013 for a total of 14 days. In 2014, follow-up surveying was carried out over 5 days in

September. In the 2013 community survey, the sample size was calculated to be 225 (CI 95% and Ci 5) and was oversampled to hold a study population of n=333, sampled from 11 of 18 wards. For time-tracking, in the fi rst year, 412 patients returned time-track sheets and of these,

281 were incomplete; therefore, only 131 were accepted for analysis. The second year, 135 were used for analysis. The patient survey sample size was calculated to be 156 (Cl 95% and Ci 5). In 2013, 178 patients were interviewed and in 2014, 182 patients were interviewed. Staff

surveying was purposive, targeting staff at the OPD and specialized clinics, pharmacy and laboratory. The fi rst year, n=53 and the second year, n=39.

Results: According to the 2013 exit survey (n=178), 2:54 hrs. +/- 1:52 (15 min—11 hours) were spent in the hospital, compared to the time-tracking (n=142) 3:44 hours +/- 2:36 (9 min—14:20 hrs). In 2014, exit surveys report the perceived patient waiting time was (n=182) 3:01 hrs.

+/- 2:18 (13 min—10 hours), compared to time-tracking (n=135) 2:16 hours +/- 0:55 (10 min— 7:05 hrs) — the more precise measurement. Both years, the majority of waiting time was spent in the waiting area: 2:06 hours +/-1:37.

Discussion: Patient Satisfaction: Figure 2 refl ects a composite score of nine survey questions measuring patient satisfaction following OPD visits at Sokoine Hospital. All the questions pertain to patient-staff interactions and how these interactions were perceived by the patient.

Topics under investigation include friendliness and respect of staff members, communication with clients and etiquette/competency of the doctor, and the perceived quality of medical treatment received. In 2013, 49.9% (n=178) of patients were “very satisfi ed” with services received

and in 2014, 66.4% reported “very satisfi ed” — a 16.5% increase. However, those “not satisfi ed” decreased only 2.6%, from 3.8% in 2013 to 1.2% in 2014. Similarly, the combined percentage of patients who were “very satisfi ed” or “satisfi ed” increased 14.0% from 80.1% in 2013

to 94.1% in 2014. Those “somewhat satisfi ed” or “not satisfi ed” decreased 6.9% from 11.6% in 2013 to 4.7% in 2014. Lastly (Figure 3), the pattern of complaints seem to be spread out evenly, i.e. there were no glaring differences/discrimination between different groups: level of

education, payment method, sex and age. In general, more elderly and female patients were dissatisfi ed in 2013 compared to 2014. Moreover, the intensity of dissatisfaction declined noticeably from the fi rst year to the second, i.e. on the scale of 1-4, 1 being satisfi ed and 4 not

satisfi ed, 4 appeared seldom in 2014.

Lab Results: Patients were fi rst asked whether they received laboratory services during their hospital visit the same day and, if so, whether the results from their investigations were returned the same day. With the understanding that some lab test take days to process, we controlled

for those taking over 24 hours and only included those returned the same day. Of those who underwent lab testing in 2013, 76.7% (n=73) received their results. In 2014, that percentage increased 12.2% to 88.9% (n=63). Conversely 15.1% did not receive results the same day in

2013, while 11.1% did not in 2014 — a decline of 4.0%.

Sense of Belonging: Staff members were asked whether or not they participate in decision-making processes; whether they meet with their department head, colleagues, and other supervisors; and if they feel they are a member of the team. In 2013, on average, 81.8% (n=53)

answered affi rmatively and 17.6% answered negatively. By contrast, those who answered affi rmatively in 2014 rose 7.1% to an average of 88.9% (n=39), and those who answered negatively fell 6.5% to an average of 11.1%. This suggests that staff members generally felt an

increased sense of belonging and inclusiveness within the workplace as compared to last year.

Pharmacy medication: Lack of medication in health facility pharmacies is a frequent complaint of both doctors and patients nationwide; however, a comparison of 2013 and 2014 patient exit surveys reveal a 12.8% increase in availability of prescribed medications alongside a

10.7% decrease in unavailability from the previous year and a 2.8% decrease in those who were able to obtain “some.” The fi rst year, of those who received prescriptions, 71.1% (n=166) obtained their medication, 13.2% found none available and 15.1% received some. The following

year, 83.9% (n=155) obtained all, 2.5% found none, and 12.3% received some.

Health Education Sessions: Clinicians, nurses and other support staff (medical attendants) at the hospital have been encouraged to engage in health education and information sessions with patients. These can take the form of individual counseling sessions, group discussion,

and/ or distribution of health education materials and frequently involve discussions about nutrition, personal and environmental hygiene and family planning. Most importantly, health education sessions include informing patients what is being done to them during individual

examination, etc. In Figure 2, the index illustrating patient satisfaction, the highest level of dissatisfaction comes from doctors not explaining what was being done. Although there is a slight decrease in the proportion of patients somewhat or not satisfi ed, from 24.1% (n=178) in

2013 to 18.6% (n=182) in 2014, the complaint rate remains markedly higher than that of every other index question. Regarding health education sessions specifi cally, in 2013, 25.8% (n=47) of patients interviewed reported having had a health education session and in 2014, 32.4%

(n=59) received health education information — a mere 6.6% increase. Even more problematic is the fact that those who did not receive health education decreased only 0.6%, from 67.6% to 67.0%.

Administrative Mechanisms: Index 2 is a composite of nine staff interview questions gauging perception of administrative mechanisms and procedures at Sokoine Hospital. Staff members were asked about job descriptions, work plans, evaluations and evaluation feedback.

Follow-up questions for each of these helped better understand the effectiveness of such mechanisms. For example, those who reported having a job description were asked whether is it a written description and those who reported having a work plan were asked whether they

use said work plan. For all nine questions, a higher percentage of staff members answered affi rmatively in 2014 than in 2013. For all except one — “Would you like your work to be evaluated and get feedback regularly?” — a lower percentage of staff answer negatively in 2014: the

index average of 18.4% in 2013 was 9.2% in 2014. For the outlying question, a higher percentage of staff answer negatively in 2014: up 5.1% (n=39) from 0.0% (n=53) in 2013.

One of the most notable changes in the data was in regard to job descriptions. In 2013, 71.7% (n=53) of staff reported having a job description and in 2014, the result was 92.3% (n=39) — a 20.6% improvement. Staff who did not have job descriptions fell from 28.3% to just

7.7%. Additionally, only 58.5% of staff had written job descriptions in 2013, whereas 82.1% had them in 2014 — a 23.6% change. Those who did not have written descriptions fell from 34.0% to 10.3%. Another point worth noting is that in 2014, 100% of staff members who had

a work plan used it (n=30), and 100% of staff who received feedback from an evaluation found it useful (n=31). Both of these saw a increase from the year prior — 6.6% and 6.4% respectively. Correspondingly, the negative response fell from 3.3% (n=30) and 3.2% (n=31) in 2013

to 0.0% for both in 2014.

Overall, the index shows that an average of 76.8% of staff believed that the aforementioned administrative tools were in place and were used/useful in 2013, while 90.4% believed the same in 2014. Those who said they were either not present or not used/useful was 18.4% in 2013.

That number was halved by 2014.

Health Education Materials: Health education materials cover a variety of topics and are used by staff members in a variety of ways, including, but not limited to, discussion and demonstration during consultations, distribution to all patients, and placement on walls or tables.

Staff members were asked about their perception of health education materials — if the materials exist at the hospital and whether or not HEM are useful. Respondents who said that HEM was present were also asked if the supply was adequate and whether or not they use them.

Although more people said both the amount of material was suffi cient and that they did use what was available in 2014, fewer believed that HEM is useful – 83.0% (n=53) in 2013 and only 71.8% (n=39) in 2014. Conversely, those who believed there was no HEM and therefore

didn’t use it decreased between the fi rst and second years, while the percent of respondents with a negative perception of the usefulness of HEM increased – 31.8% in 2013 to 24.1% in 2014. Overall, there was an upward trend in the data and in 2014, 100% of staff members who

reported presence of HEM are also utilizing them with patients.

Equipment and Staff: Insuffi cient quantity and quality of equipment and the skilled staff continues to be a problem at the hospital. Responses to three questions about equipment, staff, and support for the community’s health needs were combined in order to ascertain the changes

between 2013 and 2014 (Figure 4). Slightly fewer staff members perceived that there were shortages in 2014 — 38.4% (n=39) compared to 39.3% (n=53) the year before (p-value not calculated). This suggests that, from the staff’s perspective, there has been little improvement in

the supply of human and material resources at the hospital which is also consistent with activities NOT CONDUCTED this past year, i.e. not much hiring or purchasing of new equipment had been carried out in the past hear 2013/2014 at the OPD.

Conclusion: All in all, we have seen a precipitous increase in client and staff satisfaction and decline in patient waiting time. Due to concerted efforts by the RMT, HMT and

QIT, as well as well as the hospital OPD staff and willing external partners, e.g. GIZ, EGPAF, Abbott Lab, etc. Having said this, there is still considerable room for improvement

quality of services, manage patient expectations, motivate staff and increase productivity. See recommendations below. We hope the OPD will serve as an example to the other

departments in the hospital and other hospitals in the nation — an example to be emulated.

Recommendations:

Possible reasons for improvement: The 2013 baseline survey was instrumental in identifying

gaps in many service areas, the majority of which have been ameliorated, as mentioned. These

improvements can be attributed to fi ve key measures. First, the quality improvement team (QIT),

in conjunction with the RHMT, conducted two ethical conduct trainings focused on public sector

ethical conduct. The trainings were tailored for healthcare providers and had the desire to impact

patient satisfaction, lab and pharmacy performance and provision of health education sessions

(Figure 2). Second, the OPD management structure was reorganized, including the appointment

of a new department in-charge, who uses basic management tools to increase accountability and

improve patient attendance (Figure 6). Third, the RHMT/RRHMT has assigned the task of screening

and proofi ng NHIF claim forms to a team of clinicians, registration staff and accountants. Since

then, the hospital’s income has shown a study increase (Figure 5.) Fourth, in late 2013 and early

2014, the RHMT and RRHMT conducted an employment review, which allowed for development

of human resources for health (HRH) terms of reference (ToR) and creation of a work plan for each

employee in the hospital as well as in the region (Figures 4 and 6). This likely contributed to the

improvement in staff effi ciency, i.e. each employee now knows what they should be doing. Finally,

in late 2013 and early 2014, the RHMT and RRHT, with the guidance of the HQIT, actualized some

structural rehabilitations in line with staff survey feedback. This undoubtedly made many of the

surveyed staff members feel heard (Figure 4).

Of particular note, patient education sessions and health education materials have increased but less dramatically than the other indexes (Figures 2 and 4). Overall improvement

is the direct result of the priority that patient education has been given in the QIT plan and discussions; however, although increasing health education the easiest task to achieve,

it is also the most expensive to implement. Thus, there remains signifi cant room for improvement.

Prompt return of laboratory results and availability of medicine at the pharmacies (Figure 2) can be further ascribed to two major changes. Following recommendations, the lab

sought out and received much-needed support and supervision from partners in early 2014, e.g. an external quality assurance consultant was brought in for three weeks of

on-the-job training focused on quality improvement. At the moment, the lab is a designated 2-stars in stepwise WHO designation, i.e. it now meets the international standard.

Likewise, the hospital has started a critical shortage and reporting scheme for the pharmacy, whereby the pharmacist-in-charge reports shortages to the RHMT/RRHMT before

depletion. Furthermore, the hospital has been granted the right to purchase medication from other venders than MSD if the medication in question is not available at the Zonal

MSD store. Improvement in communication between the pharmacy and clinicians, which also lends itself to an increased feeling of belonging among staff (Figure 4), is evidenced

by the fact that the critical shortage report is often presented at morning meetings, informing clinicians of the shortages and alternatives, etc.

a) improve triaging system to ameliorate patient congestion and

promptly identify emergency cases

b) adjust workfl ow and division of labour

c) improve use of waiting time (health education, messages, etc.)

d) computerize and integrate hospital data management, fi nancial

control, pharmacy and lab inventory

e) actualize non-fi nancial incentives and rewards

f) continue improving client-staff communication

g) utilize the complaint offi cer for further assessing client and staff

satisfaction

h) further improve NHIF claim report auditing and fi ling

Acknowledgement: Thank you to the COTC students — Sarati (team leader), Enok, Chritostom,

Wanaemku, Naema, Balthazar and Laticia — for their outstanding dedication and hard-work

during interview.

Thank you to the entire OPD staff for sharing your thoughts and valuable time with us. And

special thank you to dear colleagues for all your thoughtful and emotional support!!!

Our gratitude to the Lindi-RAS offi ce and the RMO (RHMT) for facilitating the survey.

Thank you GIZ/TGPSH for fully funding this study and the development of the poster and

accompanying report.

Thank You!!