Process improvement study to the increase efficiency of a Hospital

INTRODUCTION This project is done to improve the processes in a hospital unit of an integrated steel plant. The overall average number customers (OPD patients, IPD patients and Health check up patients) had increased to 27%. The average increase in customers is shown in Table -1: The rise in the number of patients has resulted in increase in workload of the employees (doctors, nurses, ward boys etc) working in the plant. An initial opinion would suggest increase in the capacity of Hospital by providing additional resources such as manpower would reduce the workload and ensure smooth functioning of the Hospital. However, the management has decided to assess the existing capacity of the hospital and improve the efficiency of existing facilities before providing additional resources. Secondly, the management is concerned about the increasing operational costs which in turn are increasing the service price to the customers. Increasing the efficiency and thereby lowering the costs would serve the purpose of reducing the operational costs DIMENSIONS OF EFFICIENCY/ PERFORMANCE OF HOSPITAL: Quality Cost Variety Time Cleanliness, sanitary, quality of doctors and medical equipments, consultation quality Cost of tests, consultation fees Types of facilities available in hospital, specialist doctors available Time taken to receive results, waiting time in registration, tests and consultation

Out of the several grievances faced by the customers (patients), the major areas of concern are the waiting times of the patients. The time dimension is the major area of concern of this project. Efforts are made to reduce the overall throughput time of the patients. Through put time is defined as the overall time required by a patient to receive hospital services from the time the customer arrives the hospital premises to the time he/she leaves the premises. Reduction in the overall Throughput time would, in addition to higher customer satisfaction, result in increasing the capacity of hospital, decrease in overall operating cost per customer and higher utilization of the existing facilities.

Customer segregation: Types of customers visiting the Hospital:

OPD

Incldes those customers who want to visit a specialist doctor Includes customers having no insurance and corporate certification. The payement is done through cash. These are the employees of certain corporates whose check-up is done annually as a part of their employee welfare schemes. These are patients who require constant monitoring by doctors/ nurses and require treatment and medications immediately. These include patients who attend the medical camps established throughout the year outside the hospital campus.

Health Check up

IPD patients

City Centre

The scope of this study includes finding out improvements in order to serve better the OPD, Executive health check up and IPD patients. The number of customers visiting the Hospital to receive health services is shown below. TABLE-I: NUMBER OF CUSTOMERS SERVED No. of patients Type of patient F.Y 2011-12 F.Y 2012-13 3,100 IPD 4,095 OPD 58,348 67,048 Health Check up 7,259 16,314 Total 68,707 87,457

% contribution 5% 77% 19% 100%

% increase 32% 15% 125% 27%

The above table shows that on an average 240 customers are served per day. Total number of IPD patients are 11 per day, OPD 184 per day and Health checkups are 45 per day. TABLE-2: FLOW RATE OF CUSTOMERS Average number of Type of patient customers per day IPD Volume OPD Health Check up Total 11 184 45 240

Working Hours/ day 24 8 8

Flow rate (cust/ Hr) 0.5 23.0 5.6 29

The flow rate of customers inside the hospital premises is about 29 customers per Hour.

DIRECT OBSERVATIONS FROM FRONTLINE

To get the customers perspective and to understand the existing problems in the hospital process, Time study is done of customers from start to the end i.e. from the moment the patient enters the hospital to the time he/she leaves the hospital after check-up. Time Study for all types of patients receiving hospital services is done. Primary inferences that are derived are: 1. Waiting lines in registrations vary throughout the day. 2. Different types of customers have different throughput time. 3. Delays have been observed in registration counters, doctor consultation and pharmacy 4. There are delays/ queues after almost every activity (after registration, after consultation, after tests) 5. Each customer for OPD had to stand in the line twice-first time for registration, second time for billing off the required tests 6. Secondary queues are formed before the wards of each specialist doctors The Process Flow Diagram of the customer flow in the Hospital is shown in Annexure-1. Pdf. The various delays occurring during the service is shown in the form of arrows and numbers.

COLLECTION OF PRIMARY DATA (based on observation)

OPD:
The Time taken for customers in OPD is shown below
GENERAL MEDICINE OPTHALMOLOGY GYNECOLOGICAL PHYSIOTHERAPY CARDIOLOGY DENTAL

ACTIVITY

waiting in queue for registration Registration Process Patients waiting in Queue Meeting of Patients with Doctor waiting in queue for billing for test in registration counter as suggested by doctor billing process goes for test Meeting of Patients with Doctor after test Patient Goes for medicine TOTAL TIME

1 2.2 1 8 1 2.3 5 6 4 30.5

2 2.2 2 25 2 2.3 30 5 70.5

TIME(IN MINS) 1 3 4 2.2 2.2 2.2 3 1 2 6 10 10 1 2.3 3.3 6 4 28.8 3 2.3 10 10 4 45.5 4 2.3 30 5 59.5

ENT

1 2.2 4 7 1 2.3 14 7 4 42.5

1 2.2 6 54.5 1 _ _ _ 4 68.7

HEALTH CHECK-UP:
The times taken for various Health Check up packages is shown below

TIME DURATION (Mins) FOR HEALTH CHECK UP

P h y sio t h e ra p y C o n su lta tio n G y n a e C h e c k -U p fo r F e m a le P a tie n t R e g istra t io n P a tie n t s g o t in str u c tio n slip (a s p e r c h e c k p la n a v a ile d ) P a th o lo g y D e n ta l C h e c k -U p R e p o rt g iv e n EC O /TM T G e n a ra l & P h y sic a l C h e c k Up C h e c k a s p e r p la n (w o rk e r h e a lth c h e c k u p ) P a tie n t s is e x a m in e d b y d o c to r w ith h is re p o rt T o ta l D u ra tio n (IN M IN ) ECG USG V is io n C h e c k -U p A u d io m e try P h y sic ia n c o n su lt a tio n W a itin g in Q u e u e S p iro m e try

Excutive health check up below 35 year 2.9 Excutive health check up Above 35 year 2.9 Worker health check up Pre employment health check up Worker Gate Pass Canteen worker health check up

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

4 25 81 4 25 86 4 25 71 4 25 81 4 _ 71 4 25 55 4 25 81 4 25 81 4 _ 71 4 _ 16 4 25 86 4 25 86 4 25 86 4 _ 26 4 _ 81 4 _ 81 4 _ 36 4 _ 16 4 _ 6

6.5 6.5 _ _ _ _ 6.5 _ _ _ 6.5 6.5 6.5 _ 6.5 6.5 _ 6.5 _

1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 _ 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 _ 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 _ 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 _ 3.3 _ 10 26 _ 1 90.3 5.7 14 _ _ 10 26 _ _ _

R e p o rt g iv e n

Type of Packeges

X -r a y C h e st P A V ie w

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4.7 4.7 4.7 4.7 4.7 _ 4.7 4.7 _ _ 4.7 4.7 4.7 _ _ _ _ _ _

282 287 251.5 275.5 226.5 230.8 282 275.5 215.2 170.9 287 287 287 164.5 252.3 252.3 186.8 221.2 51.9

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

287 292 257 281 232 236 287 281 220 176 292 292 292 170 257 257 192 226 57

2.9 2.9 2.9 2.9

Executive Heath Check-up for Visa Power 2.9 Employees (Female) Executive Heath Check-up for Visa Power 2.9 Employees (Male) Pre-Employment Health Check Up for 2.9 VISA Power Cardiac Health Checkup EHC For Indian Hume Pipe Executive Heath Check-up for L&T Employees(Female) Executive Heath Check-up for L&T Employees(Male) Pre-Employment Health Check Up for L&T DB Power EHC Above 45 Years Male

2.9 2.9 2.9 2.9 2.9 2.9

1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 _ _ 3.3 _ 10 26 _ _

1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 14 3.3 3.3 10 26 3.3 _ 1 90.3 5.7 _ 3.3 3.3 10 26 3.3 _

DB Power EHC Above 45 Years Female 2.9 Coal Mines Health Check Up INT. Woman Day Package Baisakhi Special Health Checkup

2.9 2.9 2.9

1 90.3 5.7 _ 3.3 _ 10 26 _ 54.5 _ _ 5.7 14 3.3 _ _ _ _ 15

IDENTIFICATION OF "WASTE" With reference to Flow process charts shown in Annexure-1, the various types of wastes observed for OPD and Health check-ups is shown below: MOTION (movement in billing) Patients have to go back once again to registration counter for billing before Tests in case of OPD patients Patients have to go back to registration counters once again to collect test results

Waiting Step 0,1,2 ,3,4,5 of OPD and Health check ups as mentioned in Annexure-1 in attached file

VARIABILITY:
VARIATIONS IN DEMAND

Flow rate: Cust/min (extrapolated for 30 mins)

25 20 15 10 5
9:00 - 9:30 - 10:00 - 10:30 - 11:00 - 11:30 - 12:00 - 12:30 - 1:00 - 1:30 - 2:00 - 2:30 - 3:00 - 3:30 - 4:00 - 4:30 - 8:30 - 9:00 5:00 -

Flow rate: Cust/min

Based on Process and delay analysis, several bottlenecks and delay reasons have been identified. Some corrective actions and improvement suggestions have been generated and its impact has been analyzed. The improvement suggestions are as follow

TABLE: SHOWING IMPROVEMENT SUGGESTIONS AT VARIOUS LOCATIONS (based on process analysis)

Location

Impact
(in Min)

Problem
Server down of the Computer system Change problem(Money) Long process of registration(Entering two to three times User password ) Enqiry or phone attended by registration operator Distribution of Lab report of health check up patient need to go registration counter once again for billing for test Time not mention in registration slip Intercom not works properly & they need to call doctors whenever required because other intercoms other than registration counter can call only on intercom nos. Form distribution for knowing the information of worker and receiving the fees after that entering the information in computer registration done in OPD registration desk Worker not coming on assigned time

Improvement Suggestions
Proper Maintenance of system Card payment using swipe machine Software Up gradation (having Once login of operator till his shift) Make separate Enquiry booth near the registration desk which give all information to the patients making a separate space for collection of lab report of all health check up billing for test can be done in test lab only for credit patient time should be mentioned in registration slip for maintain records properly

2 24 20

32

Registration Desk(OPD)

15

109.5

subjective

subjective

All intercom should have the facility to call on any nos. other than intercom nos.

ER Reception / Registration Desk(Worker health check up)

30

30

Sending the prior form of registration to concern department head Through mail who gives the worker registration form to fill up and they come with filled form at registration desk IT should be done the near the emergency department There should be provision for late fees if worker not come on assigned time

30

Location

Impact
(in Min)

Problem
takes time to fill the registration forms & distribution of forms uncertainty in no. of health check-up comes per day long queue outside test lab because all workers of a particular contractor follow same sequence for test Fee Submission by patients at registration desk For tests which is advised by doctor At some distance from the pathology lab long queue of patient waiting for their no.

Improvement Suggestions
form can be given 1 day before so that they can fill it before should be a fixed no. of health check-up per day different slips should me made and each slip having diff. sequence of order for test Registration and fees submission for test at assigned test department no movement of patients to registration desk Should be adjacent of the pathology lab or in the pathology lab

47 Health checkup subjective

60

Doctor Chamber Sample collection Outside Lab department

40

subjective

display system can be introduce

Outside the chamber of doctor Outside the chamber of doctor

subjective

long queue of patient outside doctors chamber waiting for their no. Long queue of patients due unavailability of doctor because doctor was in the round check up of admitted patients

display system can be introduce

60

Fix the timing for round check up of admitted patients I when doctor is Idle or use reserve capacity (Appointment system)

All these improvement suggestions have been discussed and further analyzed to assess its impact in the overall flow time of patients. Some of the above presented improvement suggestions are elaborated below.

1. REGISTRATON COUNTER: The operational practice is changed which has the potential of reducing significantly the registration processing times of workers arriving for Health check-ups Improved and existing process for registration is shown below:

2. OPD PROCESS: The existing and improved process is shown below:

DEPARTMENTS
OPTHALMOLOGY(EYE) GENERAL MEDICINE GENERAL MEDICINE GYNECOLOGICAL

DEPARTMENTS
OPTHALMOLOGY(EYE)

PHYSIOTHERAPY

CARDIOLOGY

CARDIOLOGY

EXISTING PROCESS

proposed process

ACTIVITY Registration Process Meeting of Patients with Doctor waiting in queue for billing for test in registration counter as suggested by doctor billing process goes for test Meeting of Patients with Doctor after test Patient Goes for medicine TOTAL TIME Time Reduction per patient 169 616 177

TIME(IN MINS) 50.6 72.6 24.2 68.2 575 198 110 310 112 357 117 22 545 23

ACTIVITY Registration Process (after implementing swipe m/c & help desk) Meeting of Patients with Doctor patient goes to respective test department as suggested by doctor for billing goes for test Meeting of Patients with Doctor after test Patient Goes for medicine TOTAL TIME

TIME(IN MINS) 116 616 77 34.5 49.5 16.5 46.5 76.5 575 23 198 33 110 11 310 31 357 51 15 545 _ _ 385 150 462 198 110 308 115 132 1964 898 719 7% 5% 8% 109 110 150 77 _ 40 600 5% 44 155 204 402 693 920 5% 8% 10% 154 _

52.9 75.9 25.3 71.3

385 150 462 308 115 2118 944

109 198 132 785

110 150 110 44 424

154 77

_ _

155 204 40 755 1022 630

PHYSIOTHERAPY

DENTAL

DENTAL

ENT

ENT

ENT

3. Improvement suggestion for Health check-up patients: Exsiting Process Activity Form distribution& Billing form fill up by patients & submitting to receptionist Waiting in Queue Entering the information in computer by receptionist Generated reg.slip and stamping on it Waiting in Queue(Total) First check up( Pathology ) Second check up (X-Ray) Third check up(Spirometry) Fourth check up (Dental) Fifth check up (ECG) Sixth check up (General examination) Seventh check up (Audiogram) Eighth checkup (ENT) Nieth check up (Eye vision) Total time Time Reduction per patient 2 1 20 5 3 3.3 25 6 5 3.3 3.3 3 86.9 29% 61.9 Time (MIN) 2 5 Proposed process Activity Patients come with Filled form and billing Entering the information in computer by receptionist Genrated reg.slip and stamping on it Given the reg slip with check up schedule First check up( Pathology ) Second check up (X-Ray) Third check up(Spirometry) Fourth check up (Dental) Fifth check up (ECG) Sixth check up (General examination) Seventh check up (Audiogram) Eighth checkup (ENT) Ninth check up (Eye vision) Time(MIN) 1 2 1 1 5 3 3.3 25 6 5 3.3 3.3 3

Assessing the impact of the suggestions has shown that the overall flow time of patients arriving for OPD and Health check-ups can be reduced significantly. This reduction will result in increasing the operational capacity of the Hospital and greater number of patients can be served.