Study on Process mapping, Waiting Time Based on Six Sigma Concepts in OPD
Dr Geetika Verma
Dr Geetika Verma, Management Trainee, Department of Patient Care Services, Fortis Memorial Research Institute, Gurgaon.
Abstract
This study focuses on to identify the various procedures at the outpatient clinic as well as to investigate the possible operational problems that may lead to excessive patients’ waiting time. A patients’ experience in waiting time will radically influence his / her perceptions on quality of the service. The study was carried out in Fortis Memorial Research Institute, Gurgaon (Haryana) for three months. The subjects were outpatients who came to the outpatient clinic in FMRI. Data was analysed using the six sigma approach.Significant reduction in waiting time was achieved in the outpatient services of department by using the six sigma approach. Doctors were on time in OPD to reduce the delay in the OPD. Patients were coordinated well to the doctors.
Keywords: ‘Lean Six Sigma’, ‘Waiting time’, ‘Process mapping’

Introduction

Patients’ waiting time has been defined as “the length of time from when the patient entered the outpatient clinic to the time the patient actually received his or her perception”.
Process mapping is a workflow diagram to bring forth a clearer understanding of a process or series of parallel processes. It views the system from the patient perspective following their journey across organisational boundaries. It helps staff understand how complex and confusing processes appear to the patient. It is organisation specific. It is diagnostic and used as a basis for redesign, actively involving frontline staff in the process. (Shows how things actually are).

Fig. 1: Patient Process

Aim Of the Study

The two main objectives of the study were:

To study the patients’ waiting time in the outpatient clinic, with a view to identify the factors that affect waiting time and recommend ways of minimising the delay
To use the six sigma technique to identify the delay and improve management capabilities.

Research Scope

This research was done at the outpatient clinic in FMRI. The research methods chosen were to:

Directly observe the patients.
Interview the patients.
Interview the people involved in managing the work process.

Literature Research

Defined as the total time from registration until consultation with a doctor.

Defined as waiting time from the moment patients submit a clinic card or referral letters at the counter until getting a call from the counter. During this time the payment process and record classification are made. Registration time is part of patient’s waiting time.

First introduced by Motorola in 1986, Six sigma is a method to measure the quality of a process to fulfil customers’ needs which approaches perfection. Data and statistical analysis were used to identify defects in processes and reduce variation. With Six sigma, defects in a process can be measured by identifying the best method to eliminate defects and approach ‘zero defect’.
Customers’ satisfaction is the main factor. A new and more effective method has to be adopted to ensure customers’ satisfaction.
Six Sigma specifies a very high standard of quality achievement. It utilizes a variety of existing project management, statistical and analytical tools. Several toolkits of the six sigma were applied during this study:

Statistical image shows characteristics of collected data. At this level, data will be presented using the best presentation tools such as histogram, pie charts or others.

Chart shows description and sequence of the process done.

Diagram shows the relationship of a cause that gives rise to a certain problem.

Methodology

MEASURABLES

1.Total waiting time for the consultation.
2.Time taken for Investigations.

SAMPLE SIZE

This study conducted at the outpatient clinic, FMRI, was an exploratory and evaluation study. Respondents of this study were selected patients, staffs and doctors at the outpatient clinic.
Table 1: Sample Size

RESPONDENTS

TOTAL

Patients

50 each day

Doctors

15

Nurses

5

Administrative staff

7

Retrospective data of 4500 patients was analysed for waiting time during the period August- October 2013.
Voice Of Patients was obtained from 150 patients.

TYPE OF DATA AND COLLECTION METHODS

Several variables monitored in this study were data on patients’ waiting time work process, number of doctors available and number of staffs at the registration counter.
Three major collection methods were used in the study:

The first method was observation. Data were collected through direct observation on the subjects involved in the various working processes in FMRI. Measurements of time spent from registration until consultation by a doctor were made using a stopwatch.
The second method is through interview. In carrying out this research, some of the management staff and doctors were interviewed to obtain information on the working process in the hospital.
Voice of patients (VOP) was obtained using standardized questionnaire.

DMAIC METHOD (DEFINE-MEASURE-ANALYSIS-IMPROVE-CONTROL)
The Six Sigma method which consists of the five steps of:

Define
Measure
Analysis
Improve
Control

(DMAIC) is the roadmap to achieve the objectives of this study.
 
 
DMAIC STEPS

Fig. 2: DMAIC Steps
PROCESS FLOW IN FMRI OPD:

Fig 3: Outpatient Flow
Study was carried out in the GENERAL OPD FMRI Outpatients of 50 per day.
Simple Random sampling was followed.
Period of Study – AUGUST 2013 TO NOVEMBER 2013.

STATISTICAL TOOLS

1. Process Map-Flow Chart that shows description and sequence of the process done.
2. Cause and Effect Diagram – Diagram that shows the relationship of a cause that gives rise to a certain problem.
3. Affinity Diagram- Business tool used to organize ideas and data.
4. Descriptive statistics- Analysis of data that helps describe, show or summarize data in a meaningful way.

Results And Conclusion

This is the first step that refers to defining the goals of the project. Process improvement goals may be aimed at increasing market share, the output of a particular department, bringing about improved employee satisfaction as well as customer satisfaction and so on.
The goal has to align the patient demands and the strategic goals of the organization. Data mining methods can be used to find prospective ideas for project implementation.
In other words, businesses are designing a road map for achieving the targets and goals of the organization.
Problem Statement:
Three months retrospective data from the department indicates that in August 2013 only 66.64% of patients were seen within 15 minutes by the physician. In September 2013 this decreased marginally to 59.68% and in October 2013 this was found to be 61.68%.
 
OPD WAITING TIME – PERCEPTION OF PATIENTS
For understanding perception of patients on OPD waiting time, VOC was collected from 150 patients in the OPD.
 
Questionnaire for OPD Patients:
1. Did you take an appointment for OPD visit?
a) Yesb) No
2. How did you get the appointment? Through telephone or direct?
3. Are you satisfied with the way your phone call was handled?
a)Yesb)No
4. What instruction was given by the counter staff at the time of appointment/arrival?
5. How did you feel at the reception?
a) Very good b)Goodc)Badd)Very bad
6. How much time it took at the reception, to attend you?
a)0-10 minsb)10-20 minsc)20-30 minsd)>30 mins
7. At what time you were asked to report at the counter and when did you reach the OPD reception?
8. Did any staff brief you regarding the workflow in OPD?
a)Yesb)No
9. How long you have been waiting in OPD?
a)0-10 minsb)10-20 minsc)20-30 minsd)>30 mins
10. Did any information regarding waiting time in OPD was given to you, at the time of appointment?
a)Yesb)No
11. How much time it took for you to interact with doctor after your arrival?
a)0-10 minsb)10-20 minsc)20-30 minsd)>30 mins
12. Are you aware of the existing appointment system in FMRI?
a)Yesb)No
13. What is your perception on waiting time in the hospital?
14. What would you suggest to reduce waiting time in OPD?
15. Any other suggestions?
How long have you been waiting in the OPD for Consultation (Observations):
 

It was observed that 20% patients take prior appointment to consult the doctor whereas 80% patients come Walk- in to consult the doctor.

Fig 4: Appointment for OPD Visit

67% patients who come to consult the doctor take prior appointment on the telephone whereas 33% comes directly to get the appointment.

Fig 5: Appointment System

It was found that 75% of the patients were satisfied with the telephonic call handled whereas 25% patients weren’t satisfied.

Fig 6: Satisfaction Level

As per as the behavior of the reception of the staff is concerned, it was found that out of 150 patients, 20 patients felt very good behavior; 90 patients felt good, 25 patients felt bad and 15 patients felt very bad behavior from the side of reception staff.

Fig 7: Reception Staff’s behavior

When process flow was observed to capture the waiting time, it was found that out of 150 patients, 50 patients were attended within 10 minutes; 70 patients were attended within 10-20 minutes; 25 patients were attended within 20-30 minutes and 5 patients were attended more than 30 minutes.

Fig. 8: Time taken to attend the patients

75% patients felt that they were briefed regarding workflow in OPD whereas 25% patients felt that they weren’t.

Fig.9: Briefing Regarding Workflow in OPD

Regarding waiting time it was that out of 150 patients, 60 patients had to wait up to 10 minutes; 5 patients had to wait within 10-20 minutes, 15 patients had to wait within 20-30 minutes and 30 patients had to wait more than 30 minutes.

Fig. 10: Waiting Time in OPD

93% patients felt that they were well informed regarding waiting time in OPD whereas 7% patients felt that they weren’t informed well.

Fig. 11: Information regarding Waiting Time

As per as interaction with doctor after arrival is concerned, out of 150 patients 98 patients interacted within 10 minutes, 12 patients interacted within 10-20 minutes, 26 patients interacted within 20-30 minutes and 14 patients interacted more than 30 minutes.

Fig. 12: Time taken for consultation to doctor

51% patients were found aware regarding existing appointment system in FMRI whereas 49% patients were found unaware.

Fig. 13: Awareness regarding appointment system in FMRI

This phase refers to the analysis of the existing system with various measurement techniques for the defects and levels of perfection that exist. In this step, accurate metrics have to be used to define a baseline for further improvements.
This helps in understanding whether any progress has been achieved when process improvements are implemented.
To identify High level process map the SIPOC has been done.
Table 2: SIPOC

SUPPLIER (S)

INPUTS
(I)

PROCESS
(P)

OUTPUT
(O)

CUSTOMER
(C)

Registration staff

Registration form

Patient registering

MRD No

Patient

Reception staff

MRD Card

Encountering

Token No. & Instructions for billing

Billing Clerk

Cash

Billing

Receipt

Nursing / Technician

Order

Preliminary Examinations/ investigations

Instructions to wait / have breakfast

Doctor

Consultation by Sr. Doctor

Advise

The various processes involved in the particular project have been described in detail in flow chart:
Fig.14: Process Flow Chart

NO

YES
Revisit
New Visit
Value Analysis: A value analysis was done based on the flow chart and the processes were categorized into Value added, Operational Value Added Activity and Non Value Added Activities.

Value Activity

No

Value Added Activity

35

Operational Value Added Activity

13

Non Value Added Activity

27

Table.3: Value Analysis

The analyze phase was undertaken to determine any disparity that may exist in the goals set and the current performance levels achieved. The understanding of the relationship between cause and effect is necessary to bring about any improvements, if needed. Brainstorming session was carried out and all the causes were listed in the affinity diagram. The Fish Bone Diagram was prepared.
The causes which got from the brain storming session have been segregated into non controllable causes, direct improvement causes and controllable and likely causes. Its fish bone diagram for controllable causes only.

Sl. No.

Nature of Cause

Numbers Identified

1.

Non Controllable Causes

32

2.

Direct Improvement Causes

11

3.

Controllable and Likely Causes

67

TOTAL

110

Table.4: Analysis Phase
 
 
 
 
CAUSE AND EFFECT DIAGRAM:

Fig.15: Cause and effect diagram
Causes were then ranked on the basis of severity and occurrence as per criteria given.

Occurrence

Rank

Severity

Rank

Once a Month

1

Mild

9

Once a Week

5

Moderate

5

Every Day

9

Severe

1

 
Table.5: Ranking of causes on the basis of severity and occurrence
A modified Failure Mode and Effects Analysis (FMEA) were carried out for Occurrence and Severity only. The top Risk Priority Number was considered for further analysis, using 5WHY.

Single Registration counter
Time taken to process blood test only
Time taken to process blood test and other Investigations.

As per analysis of data, following observations were made:
Month August-
As per observations,
Average Time = 13 minutes.
No. of patients seen >15 minutes = approx. 13
% of no. of patients seen > 15 minutes = 25.48%

Fig. 16: Observation in Month August
Month September-
It was observed,
Average Time = 17 minutes.
No. of patients seen >15 minutes = approx. 17
% of no. of patients seen > 15 minutes = 32.70%

Fig. 17: Observation in Month September
It was noticed that there was slight increase in the average time, no. of patients seen more than 15 minutes and %age of no. of patients seen more than 15 minutes. The main reasons behind it are:

Delay in Doctors’ in time( e.g. Doctor in OT/ On Rounds)
Delay in Investigations.
Long consultation time.

Month October-
It was observed,
Average Time = 15 minutes.
No. of patients seen >15 minutes = approx. 16
% of no. of patients seen > 15 minutes = 30.19%.

Fig. 18: Observation in Month October
In this month slight improvement was observed as the average time, no. of patients seen more than 15 minutes and its %age decreased slightly.
This was due to:

Doctors requested to be on time so that patients can’t feel inconvenient.
Complete consultation on time.

COMPARISON AMONG MONTHS AUGUST, SEPTEMBER & OCTOBER:

MONTH

AVG WAITING TIME (in minutes.)

MAX. TIME (in minutes)

MIN. TIME (in Minutes)

AUGUST

13

125

0

SEPTEMBER

17

116

0

OCTOBER

15

113

0

Table.5: Comparison among Months August, September & October
It was observed when compared the data of three months that:

Average waiting time was decreased followed by slight increase.
Maximum time for the consultation has decreased within three months.
Minimum time was approximately zero in these three months.

Fig. 19: Comparison among months August, September & October

Improvements in existing systems are necessary to bring the organization towards achievement of the organization goals. Creative development of processes and tools brings about a new lease on life for the organization’s processes and takes them nearer to organizational objectives. Various project management and planning tools can be used to implement these new techniques and processes. Appropriate usage of statistical tools is important to measure the data, which is necessary to understand improvements done and any shortcomings that may exist.
The solutions with their respective Causes are shown below:

Causes

Solutions

Registration form is lengthy & difficult to fill

Simplify Registration Form

Lack of proper communication

Provide adequate training

Time taken to barcode & process the samples in lab/ blood reports takes more time

Reducing TAT for investigations in labs.

Delay in Doctors in time.

Doctors to be on time so that OPD shouldn’t be delayed.

Delay due to entry in to EMR

Provide training to doctors.

 
 
 
 
 
 
Table.6: Causes & Solutions

Control phase is the last step in the DMAIC method. This phase is about sustaining the changes made in the Improve phase to guarantee lasting results. The best controls are MONITORING, appropriate CHECKS and balance the quality system for the long run.

Recommendations

Segregated OPD counters for billing.
Separated nursing station for the departments to reduce waiting time.
OPD schedule to be blocked for the time duration when the doctors are in procedure or on rounds.
Time slot for appointments to be increased from 10 to 20 minutes per doctor.

Conclusion: Significant reduction in waiting time was achieved in the outpatient services of the department. Doctors were on time in OPD to reduce the delay in the OPD. Patients were coordinated well to the doctors. Further data analysis will help to monitor and control the waiting time and process flow in the OPD.