See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/318496777

To Study the Emergency Department Patient Process Flow in Hospital

Article  in  Indian Journal of Public Health Research and Development · July 2017

DOI: 10.5958/0976-5506.2017.00202.9

CITATION READS
1 115

2 authors, including:

Anil Pandit
Chellaram Diabetes Institute
35 PUBLICATIONS   26 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Hospital & Health care Management View project

All content following this page was uploaded by Anil Pandit on 25 December 2018.

The user has requested enhancement of the downloaded file.

 To Study the Emergency Department Patient
Process Flow in Hospital

Anil Pandit1, Meenal Kulkarni2

1
Professor, 2Asst Professor, Department of MBA (HHM) Symbiosis Institute of Health Sciences S B Road, Pune

ABSTRACT

Growing spectrum of disease and population has resulted in an increasing public demands and with the drive
towards effective service delivery, continuous performance and process improvements are essential to the
vitality of any Healthcare organization. ₁

Outpatient services have become an important component of health care. By hidebound thinking, the medical
profession emphasized that a physician’s time is more valuable than a patient’s time. This is no longer valid
in today’s consumer oriented society. Long waiting times for treatment in the outpatient department followed
by short consultations has long been a complaint. Nowadays, customers use waiting time as a decisive factor
in choosing a service provider. Therefore, idle time of both parties must be considered in designing a proper
OPD patient process flow although these two objectives are contradicted to each other.

Healthcare process mapping is a new and important form of clinical audit that examines how we manage the
patient journey, using the patient’s perspective to identify problems and suggest improvements. We outline
the steps involved in mapping the patient’s journey, as we believe that a basic understanding of this versatile
and simple technique, and when and how to use it, is valuable to clinicians who are developing clinical
services.₂

This research aims to provide a study of the major causes of OPD- Patient Flow Process for medical
treatment in tertiary hospital and also provide recommendation on the best strategy to improve OPD process
flow so that can maximize the effectiveness and efficiency of resource and capacity.

Aim: To Study the OPD- Patient flow process in Hospital and its Importance.

Objectives: 1. To know about the current work flow in Emergency department.

2. To understand the gaps if any, in the Emergency department.
3. To implement the interventions to eliminate/minimize the gaps.
4. To evaluate the benefits post implementation.
Limitation: Time is constraint: study was for 3 months (from 08May to 08 Aug)

Keywords: OPD, Emergency Department(ED) Process charts, performance measurement, healthcare

systems.

INTRODUCTION initiatives have been introduced to enhance customer

satisfaction. The healthcare industry providers globally
Customer satisfaction has become a serious concern
are experiencing increasing pressure to concurrently
in service sector. On Healthcare industry, a number of
reduce cost and improve the access and quality of care
Address for Correspondence: they deliver.
Dr (Brig) Anil Pandit. MD (HA) DNB (H& HA)
Any healthcare institutions are confronted with long
Professor, Symbiosis Institute Of Health Sciences
waiting times, delays, and queues of patients. Typical
S B Road, Pune- 411004,
questions challenging hospital managers include: How
E-mail: apandit70@hotmail.com, Mob.: 09423212709
 Indian Journal of Public Health Research & Development, July-September 2017, Vol. 8, No. 3
should they optimally allocate their limited resources?
How much exam rooms do they need? How much
physicians and supporting staff do they need? If they
increase or decrease the amount of exam rooms and/or
staff, how would this effect patient waiting time, the
length of a medical treatment and the total time spent in
clinic by patient?
To improve patient satisfaction, the performance
of key processes has to be improved ₃. There is no
doubt that healthcare institutions need to become high
performers. If they increase or decrease the amount of
exam rooms and/or staff, how would this effect patient
waiting time, the length of a medical treatment and the
total time spent in clinic by patient?. To improve patient
satisfaction, the performance of key processes has to be
improved ₃. There is no doubt that healthcare institutions
need to become high performers.
Practical issues such as the ease of use of the
appointment system, or implications on modifying
physicians‟ behavior need to be considered in order to
achieve the ultimate goal of improving “real systems”. It
may also be interesting to determine what are the most
commonly used patient flow process in practice. ₄
Effectively managing patient flow in an outpatient
unit is a key to achieving operational excellence as well
as ensuring clinical quality. It is especially so for an
outpatient department in a large hospital as it handles
very large volume of patients with a diverse case mix.
Medical care is a program of services that should
make available to the individual, and thereby to the
community, all facilities of medical and allied services
necessary to promote and maintain health of mind
and body. This program should take into account the
physical, social and family environment, with a view to
the prevention of disease, the restoration of health and
the alleviation of disability. ₅
Hospitals deal with the life and health of their
patients. Out Patient Department (OPD) Services is one
of the important aspects of Hospital Administration. It
is also called Ambulatory Care Services. It is a shop
window for patient. ₅
OPD is the mirror of the Hospital, which reflect
the functioning of the hospital being the first point of
contact between the patient and the hospital stuff.
287
Out Patient and Emergency Department:
Outpatient department is that section of the hospital
which is staffed and equipped and has scheduled working
hours to provide “Diagnostic, Therapeutic, Preventive
and Rehabilitative” care to those patients who are not
registered as in patients while receiving the service. ₆
Process mapping allows us to “see” and understand
the patient’s experience by separating the management
of a specific condition or treatment into a series of
consecutive events or steps (activities, interventions, or
staff interactions). The sequence of these steps between
two points (from entry of patient to exit of patient) can
be viewed as a patient pathway or process of care.
The process by which patients move through a
hospital or other health care setting—can be improved
the safety and quality of care.
LITERATURE REVIEW
A Hospital is an integral part of a social and medical
organization, the function of which is to provide for
the population complete healthcare, both curative and
preventive and whose outpatient services reach out to
the family and its home environment the hospital is also
a center for the training of health workers and bio-social
research. ₆
Outpatient services are the most important services
provided by all the hospital as it provides services to a
large number of patients at a low cost. Successful and
efficient management of OPD can lighten the burden on
the patient wards. ₇
The importance of the outpatient department lies in
the following:
1. An OPD is the first point of contact with the
hospital and the entry point into the healthcare delivery
system.
2. It is an inseparable link in the hierarchical chain
of healthcare facilities.
3. It contributes to the reduction in Morbidity and
Mortality.
4. It’s a stepping stone for health promotion and
disease prevention.
5. It help reduce the number of admission to
inpatient wards, thus, conserving scare beds.
288 Indian Journal of Public Health Research & Development, July-September 2017, Vol. 8, No. 3

6. It acts as a filter for inpatient admission,
ensuring that only those patients are admitted who are
most likely to benefit from such care.
7. It’s the “SHOP WINDOW” of the hospital.
In OPD, improving the patient pathway involves
the coordination of multidisciplinary practice, aiming to
maximize clinical efficacy and efficiency by eliminating
ineffective and unnecessary care. The data provided by
process mapping can be used to redesign the patient
pathway to improve the quality or efficiency of clinical
management and to alter the focus of care towards
activities most valued by the patient. ₈ Process mapping
has shown clinical benefit across a variety of specialties,
multidisciplinary teams, and healthcare systems.
Flow of Patients:
On outpatient visits, patients flow is in a predictable
manner usually from Enquiry to Registration to Waiting
to Examination room to Investigation facilities, although
there are many exceptions to this. Nevertheless, it
is beneficial to draw a flowchart of activities and
movements in the outpatient department to guide the
planning process for location of various facilities and
their relationship with one another.
OPD workflow in Emergency Department:
The ED is organized into three areas: Major
medical/trauma, Minor Medical/Trauma and ED Walk-
in. Each has a separate physical area (Figure 1-3) .Each
also serves a different set of patients.
When a patient enters the ED, he or she first sees a
triage nurse, who determines the severity of the patient’s
condition. Immediately afterwards, the Patient Flow
System ( PFS) assigns a Unique Health Identification
Number(UHIN) if the patient is new to the hospital.
With the help of the patient’s name, date of birth and
mother’s maiden name, PFS checks in the information
system for previous medical records. In some cases a
duplicate ID is created, but this is rare. Patients generally
have previously received an ID card, which shows their
UHIN and their financial situation regarding hospital
reimbursement.
be moved (“borders”). Also, processes are slowed in ED
due to limited accessibility of certain ancillary services.
Radiology, for example, is on a different floor and ED
patients must sometimes be moved up to that floor for
diagnostic services and then moved back down to the
ED.
After the patient’s condition has been stabilized,
each patient is assigned one PFS worker who asks
questions, enters data into the information system, takes
printouts and puts this info next to the patient’s bed for
the doctor to see them. If the patient needs to be admitted
into an inpatient bed, he/she is seen again by PFS. At the
end of the ED visit, or if additional service is needed,
such as admission to an inpatient bed, then the patient
receives “financial screening” from PFS.
METHODOLOGY
Study Design:
The research design used in this study is both
Descriptive and Exploratory.
Study Population:
All patients who came for ED visit at, tertiary clinic.
Sample Size: - 200 ED Patients.
Technique: - Convenient Sampling.
Observations & Analysis:
The study conducted in the ED showed the various
bottlenecks which cause to reduce the patient satisfaction
in hospital.
1. Crowd management was not proper because of
less manpower.
2. Long Patient waiting time.
3. Patient waiting area is insufficient.
4. Medical Record data of patients were not
properly maintained.
5. Proper signage were not there in the hospital.
6. Less availability of rooms.

The ED is extremely busy and crowded, and suffers Analysis:

long waits. This is due in part to waits for admission to
1. Understanding Patient arrival Patterns
inpatient beds. When inpatient beds are unavailable the
ED patients often must wait in ED beds until then can
 Indian Journal of Public Health Research & Development, July-September 2017, Vol. 8, No. 3
Patient arrival patterns drive systems for scheduling
staff and other resources. The patterns were somewhat
predictable. Hospital scheduling controlled most of the
other arrivals.
The following time of day graphs for the 12 noon
and 10.30 pm (Figures 1) show a strong peak early in
the day. The arrival pattern is somewhat different in
1350, with a peak in the evening hours, from about 5:
00 p.m. until 9:00 p.m., which may reflect the severity
and incidence of injuries resulting from accidents and
violence.
Figure 1: HOURLY ARRIVALS IN MAJOR MEDICAL/
TRAUMA
Figure 2: HOURLY ARRIVALS IN MINOR MEDICAL/
TRAUMA
ED arrival time has regular patterns over the typical
day and week. However, all of these measures may be
influenced by the ED being over busy (possibly on
diversion) and by long waiting time in the less acute area
of the OPD, discouraging additional patient arrivals.
Typically, during the course of a week, Monday and
Tuesday were busiest, and Sunday was the least busy, in
the total ED (Figure 2).
RECOMMENDATIONS
1. Improvement Process by creating motivated,
knowledge and empowered individuals to make needed
289
changes related to patient flow.
2. Hospital Portal - Patient appointments and
referrals are received by the hospital at a variety of
points. This complicates the scheduling process and
harms patient satisfaction through a lack of consistency
and control. A single centralized point of access and
a strengthened CSC would support a more efficient
hospital operation and improve customer service.
3. Patient Tracking System and ID - By
enforcing a system with a clear patient ID, costs can
be avoided. Many computerized patient tracking
systems, such as those the hospital is considering,
have capabilities in electronic tracking. Operational
data related to patient flow requires a clear, consistent
and efficient patient identification system. A variety of
alternatives are available, such as bar-codes and radio
frequency ID, which will save operating costs and offer
very useful data on patient flows.
4. Appointment/Scheduling Systems Using
Simulations Tools such as computer simulation and
an optimized scheduling system will support better
decisions. Scheduling requires complex tradeoffs
and such decisions should be based on forecasts and
determination of their likely impact before they occur.8
5. Including a step where nurse take all the
required readings like temperature and blood pressure,
this will substantially reduce the consultation time with
doctor.
6. Introduction of Doctor’s checklist to ensure
that Doctor’s come on time, as a result of which the time
wasted in patient waiting for Doctor to come would be
substantially reduced 9.
7. Performance measurement should be embedded
in continuing operation of the system, so that the key
decision are influenced and evaluated, according to the
established objectives.
CONCLUSION
• Clinicians and administrators can form
collaborative to reduce health care delays. Success
depends on an ability to understand health care as a
system, including the many interactions between patients,
clinicians, support services and other resources.
 290 Indian Journal of Public Health Research & Development, July-September 2017, Vol. 8, No. 3
• Success also depends on an ability to pinpoint
the bottlenecks and system failures, particularly with
respect to interactions among departments as patients
flow through the system10.
• Reviewing the patient journey is always
beneficial, and therefore a process mapping exercise
can be undertaken at any time. However, common
indications include a need to improve patients‟
satisfaction or quality or financial aspects of a particular
clinical service.
• The tools can be used, provided that hospital
management is committed to improvement, and that it
carries that message to its staff 11.
There is no Conflict of Interest. Not funded by any
organization.
The study was conducted as a part of Summer
Internship Program, for the students of MBA (Health &
Hospital Management), to study the managerial issues
in Emergency Department of a Tertiary Care Hospital.
There was no actual intervention in the patient care &
hence no Ethical issues were involved.
REFERENCES
1. Health Information of India—Min. of Health and
Family Welfare, Govt. of India, New Delhi, 1998.
2. Prasad Ram Nath. Managing the out- patient
department, EXPRESS HEALTH CARE
MANAGEMNET, Issue dated, 1st to 15th; 2003
Sept.pg.
3. Prasad Ram Nath. Managing the out- patient
department, EXPRESS HEALTH CARE
MANAGEMNET, Issue dated,1st to 15th ; 2003
Sept.pg2
View publication stats
4. Torres, J.E. and Guo, K.L. (2004) : Quality
improvement techniques to improve patient
satisfaction. International Journal of Health Care
Quality Assurance, 17 (6), 334-338.
5. Cayirli, Tugba & Emre Veral (2003) : Outpatient
Scheduling in Healthcare, Production and Operation
Management, vol 12(4)
6. BM Sakharkar - Principles of Hospital
Administration and Planning, Jaypee Brothers
Medical Publishers (P) LTD, New Delhi; 1999: Pg
4
7. BM Sakharkar - Principles of Hospital
Administration and Planning, Jaypee Brothers
Medical Publishers (P) LTD, New Delhi; 1999: Pg
5
8. Lawerance F. Wolper-healthcare administration;
// Hospital organization management by I. Donald
Snook,Jr: Pg.652.
9. Process Mapping - An Overview - NHS
Institute for Innovation and Improvement- http:
//www.institute.nhs.uk/quality_and_service_
improvement_tools/quality_and_service_impro
vement_tools/ process mapping.
10. The analysis of appointment system to reduce
outpatient waiting time with help of queuing theory./
Human Resource Management Research 2013,
3(1): 27-33 DOI: 10.5923/j.hrmr.20130301.06
11. Mapping out the patient’s journey: experiences
of developing pathways of care. Quality Health
Care1998; 7(suppl):S30-6.