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M.S. RAMAIAH

MEMORIALHOSPITAL
OUT PATIENT DEPARTMENT

By - Dr. Vinay Vatsayan

Dept. Of Hospital Administration
M.S. Ramaiah Medical College
Email- drvinayv@gmail.com
 OPD: Origins

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 V/s Domiciliary Care.
 OPD

Section of the hospital with allotted physical facilities

Regularly scheduled hours and personnel in adequate
numbers, assigned for established hours,
To provide care for patients who are not registered as in-
patients while receiving Health services.
 Importance of OPD
Services
ü First point of contact
ü It is the shop window of hospital
ü Makes or mars the hospital image
ü A good OPD service can reduce the load on in-patient services
ü It is a place for implementing preventive & promotive health activities.
ü Facilitates teaching
ü About twice the in-patients attend OPD every day
Functions of OPD

Early diagnosis, curative, preventive & rehabilitative care on

ambulatory basis
Effective treatment on ambulatory basis
Screening for admission to hospital
Follow up care & care after discharge
Promotion of health by health education
Rendering of preventive health care
Promotion of health through health education
Functions…

Training of medical / nursing students

Keeping upto date records for future treatment,
medical education, epidemiological & social
research
Preventive Health activities

Well baby clinics

ANC, marriage counseling, planned parenthood etc
School health clinic.
Control of communicable diseases
Early diagnosis & detection of chronic diseases like
Cancer, TB, RHD etc.
Health education & nutritional advice
Rehabilitation & prevention of disabilities & handicaps
 Types

OUT PATIENT
Any person given general or emergency diagnostic,
therapeutic or preventive health care and who at that time is
not registered as an in-patient in the hospital
Two types of OP Services
v Centralized Outpatient Services : All services are
provided in a compact area which includes all
diagnostic and therapeutics facilities being provided in
the same place.
v Decentralized Outpatient Services : Services are
provided in the respective departments.
 CONTD..
GENERAL OUT PATIENT
All the patients other than emergencies who report directly to
the OPD
EMERGENCY OUT PATIENT
A person given emergency medical care for condition which is
real or perceived emergency.
REFERRED OUT PATIENT
A person referred to an OPD by his attending medical/dental
practitioner for specific diagnostic/treatment procedure.
 Staffing

Staffing depends upon objectives of department and volume of work

load.
Ancillary staff in OPD e.g X-Ray, EEG & ECG technicians.
Clerical staff to carry out registration patient billing, cashiering etc.
In teaching hospital interns and residents assisting physicians.
Receptionist & other volunteer staff .
Availability of Administrator for planning, organizing, supervising,
evaluating, coordinating and improving out patient services.
 Planning Considerations

Location
ü Separate entrance
ü Easily accessible
ü Should have approach from main road
ü Adjacent to supportive facilities, x-ray & laboratory
ü Amenable for Expansion
ENTRANCE
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EXIT
EASY TO LOCATE
 Principles of Planning
Layout
Principles:
Patient flow should move in one direction to avoid undue back traffic.
Sharing with the IPD, All Diagnostic facilities, such as X-Ray &
pathology laboratory.
Should be amenable for expansion without serious dislocation of work.
Layout:
Double loaded single corridor with rooms on each side of the corridor.
Double corridor for entry from the opposite sides of the room.
Triple corridor which provides two rooms of examination treatment
rooms on each side of a staff corridor.
 Size Of OPD

Type & number of specialist clinics

Timings of OPD
Number of daily OPD patients
Number of attendants accompanying the patient
Availability of space
Plans for future expansion
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.
Physical Facilities

Physical facilities categorized into 4 groups:

Ø Public Areas(Entrance zone)
Ø Clinical Areas(Ambulatory zone and Diagnostic
zone)
Ø Administrative Areas
Ø Circulation Areas
 Public Areas (Entrance
Zone)
• Entrance : Should be Easily accessible, with wide door and have
ramps and steps
• Reception and Information : A desk or a counter located within
the public area.
• Registration and Records Area : Should be located near the
entrance. 100 cm high and with work surface 60 cm wide and with
file drawers. One desk for 20 patients/hours. 2 square meters per
bed for OP records.
• Waiting Area : Main waiting area should be adjacent to
registration area, sub-waiting area in each clinical department.
Area- 4 sq.meter with min. of 0.1 sq.meter/patient.
 Contd..

Public toilets & washrooms: One for each 200

patients & visitors separate for males & females.
Snack bar: Should be located near the main waiting
area.
Clinical areas

OPD include:
Ø Surgical , Dental , Opthalmic , ENT.
Ø Obstetric & gynecological
Ø Pediatric , Medical, Psychiatric
Ø Dermatology & Venerology
Ø Ortho & emergency department
SUPER SPECIALITY LIKE-
Neuro , Cardio , Urology.
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PATIENT’S WAITING AREA
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MINOR O.T AREA

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PATIENT’S WAITING
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LOUNGE
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PLAY AREA
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PROCEDURE ROOM
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DOCTOR’S CHAMBER &

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EXAMINATION ROOM
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RECEPTION AREA
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PATIENT’S WAITING
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AREA
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 General requirement

Sub-waiting area: Should be 1/3rd of total patients

visiting clinic /day
Consultation room: Space for doctor’s chair, patient’s
stool, follower seat ,wash basin, examination couch ,
equipment for examination. Area – 15-17 Sq.meter.& each
clinic should handle 100 cases /day.
Special examination room : Required for certain
departments.
 Ancillary facility

Injection room : It should be with waiting area for 10-

20 patients with 0.6-0.8 sq.meter/patient. Area may vary
from 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
 Auxiliary facilities

Laboratory – Should be able to serve IP&OP Patients

with 2 (male & female) washrooms & toilets – 15
sq.meter.
Bleeding room – 15-20 sq.meter with two or more
examining tables.
Radiology – Should serve both IP & OP PATIENTS.
Blood Bank
 Contd…

Health Education Facilities – Min. area required is 15

sq.meter.
Medical Social Service Facilities – should be located in
OPD with suitable cubicle for each social
worker/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
 Administrative Areas

Administrative Office : For 100 bed hospital -15 sq.meter

Business Office : Office for personnel section requisition, making reports
etc.
House keeping : Janitor’s closet, for house keeping and cleansing material
with size of 4 sq.meter
Storage Facility :
Ø General stores
Ø Drug stores
Ø Linen Stores : On each floor a closet with shelves, for storage of daily
supply linens with area of 2 sq.meter
Circulation areas

§ This includes corridors, stairs, lifts etc.

§ Occupies about 30% of total building area, easy
accessibility of elevator specially for obstetrics
and cardiac pt.
§ Corridor should be 1.8 meter wide.
§ Security check post at strategic location.
§ Availability of STD/ISD facility.
Equipment

Equipment related to specialty examination should

be available in concerned room.
Each consultation cum examination room should
have- Work table, physician’s desk, wall mounted
cabinets, X-ray view box, revolving stool, wash
basins, instrument trolley, chairs beside examination
couch.
All OPD should have equipment for resuscitation of
patients collapsing suddenly.
Work load.

The no.of patients visiting OPD depend on many

factors
1. Location of hospital
2. Community needs
3. Programme & resources
4. Season of the year
5. Transport & Communication
Out Patient visits

New out patient visit

Repeat out patient visit
Ratio between New : Repeat
= Varies between 1:1 TO 1:2
 CONTD….
DAILY OPD ATTENDANCE: Usually 4 per In-patient bed or 10 per daily admission.
THUMB RULE: 4 patients for every bed each day about 40% new & 60% old.
PROBLEMS IN OPD:
Patients overcrowding
Long waiting time
PROBABLE REASONS:
o Wrong planning of departments
o Restricted registration time
o Absence of appointment system
o Shortage of staff
 WORK FLOW
{Out Patient Flow Chart}
ENTRANCE

RECEPTION & ENQUIRY

REGISTRATION

RECORDS

SUB-REGISTRATION & WAITING

EXAMINATION & TREATMENT

INVESTIGATION PHARMACY

ADMISSION HOME
 Organization and Managerial
Considerations
Policy – The policy should be able to achieve continuity of high
quality patient care with modern techniques & methods.
Procedures
Managerial Considerations
Public Relations
OPD timing
Management structure
Waiting time (Queuing theory, Patient Scheduling)
Flow of patient should be smooth , easy & quick
 Monitoring and Evaluation

Volume :
Ø Clinic/department wise statistics of new and repeat visits on monthly and yearly
basis.
Ø Percentage change in new and repeat visit.
Ø Fluctuation in visit by day of week(month)-average, high and low.
Utilization and vital statistics : Average number of visit per person/year, vital statistics
of population(age & sex).
Visit Levels : (New & old visits)
Costs and revenues : Cost of each service should match with revenue
Gender wise calculation of patient
Calculation of PEDIATRIC & GERIATRIC visits.
 Hospital utilization statistics

The statistics pertaining to OPD services as follows:

Number of new cases.
Number of repeat cases.
Specialty wise break-up cases.
Unit wise break-up of cases.
Age & Sex distribution of cases.
Diagnostic statistics.
 CONTD…

Daily average out patient attendance:

Total no. of OPD attendance during the period
No. of OPD working days during the period
Average outpatient attendance per patient:
(average duration of the spell of sickness treated in OPD)
Total no. of OPD attendance
Total no. of New cases
 Queuing theory definitions

l (Bose) “The basic phenomenon of queuing arises whenever

a shared facility needs to be accessed for service by a large
number of jobs or customers.”
l (Wolff) “The primary tool for studying these problems [of
congestions] is known as queuing theory.”
l (Klein rock) “We study the phenomena of standing, waiting,
and serving, and we call this study Queuing Theory." "Any
system in which arrivals place demands upon a finite
capacity resource may be termed a queuing system.”
l (Math world) “The study of the waiting times, lengths, and
other properties of queues.”
 Little’s Law

System
Arrivals Departures

Little’s Law:
Mean number tasks in system = mean arrival rate x mean
response time
Observed before, Little was first to prove
Applies to any system in equilibrium, as long as nothing in black
box is creating or destroying tasks
 Characteristics of queuing systems

• Arrival Process
– The distribution that determines how the tasks arrives in
the system.
• Service Process
– The distribution that determines the task processing time
• Number of Servers
– Total number of servers available to process the tasks
 Queuing technique

Determination of waiting time, cost of waiting time & its reduction, identification of
bottlenecks.
This technique is used to analyze alternatives & arrive at solutions to many of all these
problems.
Data necessary to know – how often patients arrive? How long it take to serve them?
The order in which patients are served? With all these data queuing problem can be
solved.
A simple method of studying queue line is:
A multiserver queue in service area is represented by:
counter 1
Arrivals counter 2
counter 3
 The following observations are made at
intervals of selected unit time:
Time Unit Time Queue Length Number Served Number of
(Hrs/Min) (Person waiting) in Unit Time Counters Open
T Q N C
From these observations following can be calculated:
1. Individual service time (I.T) T X C (E.T.XC.)
N
2. Effective service time (E.T) T (Minutes)
N
3. Waiting time (W.T) Q X E.T
4. Capacity (C) 60 Min.
E.T
 Prevalent System in OPD
Consultation chamber no: 1 2 3 4 5
Patients 1-8 9-17 18-26 27-35 36-43

Modified System in OPD

n Consultation chamber no: 1 2 3 4 5
n Patients allotted as per arrival : 1 2 3 4 5
6 7 8 9 10
11 12 13 14 15..

The queuing technique can be applied in various Patient areas-

OPD ,Radio diagnosis ,Imaging ,Operations (surgery)etc…
Example application of queuing
theory

l In many retail stores and banks

l multiple line/multiple checkout system  a queuing
system where customers wait for the next available
cashier
l We can prove using queuing theory that : Output
improves when queues are used instead of separate lines
Example application of queuing
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