Transcript out patient department

OUT PATIENT DEPARTMENT
MINAKSHI GAUTAM
Assistant Professor,
IIHMR, Delhi
Contents
 Introduction
 Definition
 Importance of Outpatient Services
 Types of OPD
 Functions of OPD
 Projection of Workload
 Planning and Designing
 Policies and Procedures
 Issues and Challenges
INTRODUCTION
 In 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.
INTRODUCTION
 When 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.
DEFINITION
 Ambulatory medical care provided to patients who are not
confined to bed can be provided at a general practitioner’s
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.
DEFINITION
 Outpatient 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.
Origination
 Originated in mid 17th century by Sir George Clark In
hotel Dieu in Paris
 6 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 SERVICES
Extent 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 SERVICES
 Over 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 SERVICES
 Others 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 SERVICES
 In 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 SERVICES
 Much 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 patient’s first point of contact with the hospital
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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.
IMPORTANCE
 The 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 DEFINITIONS
 Outpatient : A person given diagnostic, therapeutic or
preventive service through the hospital’s facilities
.
Outpatient can be grouped under following 3 broad
categories;
 Emergency Outpatient
 Referred Outpatient
 General outpatient
SOME MORE DEFINITIONS
Emergency 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 DEFINITIONS
 Referred Outpatient
A 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 DEFINITIONS
General Outpatient
 A 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 DEFINITIONS
 OutpatientVisit
An 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,
or
 Repeat 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.
FUNCTIONS
 An 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.
FUNCTIONS….
 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 wellbaby clinics, obstetric consultations, parenthood and health
clinics for schools.
Preventive Health Activities
 Well baby clinics
 ANC,
 marriage counseling,
 Fammily Planning
 School health clinic.
 Control of communicable diseases
 Early diagnosis & detection of chronic diseases likeCancer,
TB, RHD etc.
 Health education & nutritional advice
 Rehabilitation & prevention of disabilities & handicaps
PLANNING OF OUTPATIENT SERVICES
 Outpatient department of a hospital has functional and
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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
hospital’s 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 SERVICES
 A 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;
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Cost to the patient,
Distance,
Transportation,
Degree of urbanization,
Socio-economic status of community,
Level of facilities and staff, and
Quality of care provided
PROJECTION OF OUTPATIENT LOAD FOR
SELECTED TARGET AREA
 Projection 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 AREA
 Present statistics indicate that per hospital bed, 1.5 to 3 patients
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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 OUTPATIENTS
Unreferred Cases
Discharged Cases
from Hospital
(follow – up)
OPD
Emergency and
Accidents
Referred Cases from Private
Practitioners dispensaries and
peripheral hospitals
PLANNING CONSIDERATIONS
 After 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 work
 Requirement of furniture and equipment
 Layout of the department considering all the above.
KEY PLANNING AND DESIGN PARAMETERS
 To 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 hospital’s
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 FACILITES
 The main physical facilities to be planned are the
following:
 Public Areas
 Clinical Areas
 Consultation Rooms
 Special Examination Rooms
 Administrative Areas
 Circulation Areas
 Ancillary and Auxiliary Facilities
PHYSICAL FACILITES…….
 the subsidiary/ ancillary facilities include:
 Injection Rooms
 Treatment and Dressing Rooms
 Pharmacy
 Medical Records Room, exclusive for OPD or combined
with the IPD records section.
PHYSICAL FACILITES…….
 The additional/ auxiliary facilities include:
 Laboratory
 Medical Imaging Services
 Health Education Facility
 Medico-social services
 Screening Clinics
ADMINISTRATIVE AREAS
 The 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 ZONES
 These include public zones, joint use zones and staff zones.
 Public Zone: This includes:
 Main Entrance
 Foyer, which further includes:
 Reception
 Sign Boards
 Layout 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 Room
FUNCTIONAL ZONES…….
 Bays for trolleys and wheelchairs
 Public telephone booths
 Public conveniences
 Value added services such as vending machines for snacks and beverages and
book store
 Registration Area which includes:
 Centralized counter for new, repeat patients
 Control desk for monitoring sub-registration at the respective service areas.
 Cash counter
 Health Education Facilities that include:
 Posters
 Pamphlets
 Audio-Visuals Aids
 Waiting 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.
 Audiometery
 EEG
 Dental Examination
 Plaster Room
CLINICAL LABORATORY
 This 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.
PHARMACY
 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.
Ancillary facilities
 Injection room :
 It should be with waiting area for 10-20 patients with 0.6-0.8
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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 OPD
 Specialized 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 ZONE
 The following should be planned
 Staff cloak rooms and toilets
 Seminar Room
PARKING AND ENTRANCE
 The following are recommended for the entrance and parking areas of an OPD:
 Main entrance to the OPD should have gentle sloping ramps to facilitate
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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 STATION
 The 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 Desk
WAITING AREA
 The following parameters should be considered;
 Waiting Area should be planned to accommodate more than the number of people
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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 PROCEDURES
 In 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 OPDs
 Clinics
 Organization
 Functions
 Staffing
 Equipment
 Techniques
 Referrals
 Consultations
 Inter-Relationship
 Supervision
 Records
 Evaluation of care
 Timings
 Drugs
 Supplies
POLICIES AND PROCEDURES FOR SMOOTH
FUNCTIONING OF OPDs
 Types of Patients
 General
 Paying
 Referred
 Eligibility
 Medico legal
 Examination and Treatment
 General
 Laboratory investigations
 Radiological investigations
 Injections
 Records
 Follow up
POLICIES AND PROCEDURES FOR SMOOTH
FUNCTIONING OF OPDs
 Staff
 Organization
 Duties
 Responsibilities
 Shifts
 Inter-relationship
 Equipment and supplies
 Inventory
 Requisition
 Purchasing
 Indenting
 Accounting
 Storage
 Maintenance
 Standards
 Safety
 Sterilization
POLICIES AND PROCEDURES FOR SMOOTH
FUNCTIONING OF OPDs
 Records
 Identification
 Filing and retrieval
 Retention
 General
 Safety and Security
 Budget
 Accounting
 Statistics
 Housekeeping
 Maintenance
 Communications to the press
 Public Relations
COMMON PROBLEMS IN OUTPATIENT SERVICES
 Operations – 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 Challenges
 Delays and Wastage of Time
 Laboratory Facilities Inadequate
 Lack of coordination among different facilities
 Either non-availability of medicines or inferior quality
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medicines are supplied
Lack of faith amongst doctors
Restricted role of the doctors
Absence of leadership qualities among hospital managers
Dull atmosphere outside OPD
Overcrowding
Spicific Challenges
 Management of records
 Lack of concern for patients and relatives
 Lack of support for junior doctors
 Staff not coming in time
Expected Role of Doctors
Functions
Activities
As a Physician
• treatment of patients
•Promotion of health
•Prevention of diseases
•rehabilitation
As an Educator
•Oneself, health staff, community,
patients
As a Manager
•Relationship with referral services,
communities, representatives of
community, research activites
As an agent of Socio-Economic
Development
Participate
in
community
development, committee meetings,
advocacy, etc
CONCLUSION
 The 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.