Consultation wait time reduction

Project
Aim
To reduce the consultation wait time for fresh patients with
angiogram CDs by 50% in 1 month.

Measure
a) To decrease waiting time for Consultation
b) To decrease number of visits to hospital
c) To decrease number of doctors consulted for definitive diagnosis
d) To enhance patient satisfaction score
e) To decrease duration of next available appointment
Change –
1. No future appointments for CD patients at Q Complex
2. Effective screening in the screening block

Impact- Executive Head –Dr P.K.Dash

Process Owner – Cardiac OPD
People Process Leader – Dr Mahesh Agarwal

Service Team –
Sri Rajagopal (QC)
Sri Ramdas (Volunteer Leader)
Quality
Dr Hanumantha Rao (Screening Block)
Dr Amit Garg (Cardiology)
Cost Dr Reeta Varyani (Cardiology)
Sri Srikrishna S (Quality Control)
Growth Sri Subramanian and Sri Shiva Kumar (HMIS)
Sri Mahadevan (Admin)
Current State Analysis
Current State - Generic Routing Chart

Arrive at
Sevadal Desk

Q Complex
No
Appointment No
Age>60yrs Future Appointment Exit
present?

Yes Yes No

Ht/Wt Capture Counselling

Screening Priority Care?

Block
Yes

History and Vitals Capture Verification

Registration

No No
Refer to Further Echo
Exit Consultation
Cardiac OPD Consultant Tests?

Yes Yes
TMT/ECG
Consultation
Current State – Detailed process step listing

1. Patient arrives at sevadal desk

2. Patient asked if he has an appointment

Visit 1 3. Patient asked for old reports to ascertain age

4. Patient sent to room 7 in Screening block for counseling
5. Patient counseled by doctor in room 7
6. Patient returns to Q Complex to take future appointment
7. Patient exits hospital with future appointment

8. Patient returns with appointment 24. Patient waits for consultation

9. Patient issued registration slip 25. Consultation
10. Attendant issued attendant pass 26. Patient waits for diagnostics (TMT/ECG)

Visit 2 11. Patient routed to Screening block 27. TMT/ECG

12. Height/Weight Capture 28. Patient waits to show results to doctor
13. Patient waits outside doctors room 29. Consultation
14. History and Vitals Capture 30. Patient waits for Consultant
15. Patient waits at registration area 31. Consultant Consultation
16. Registration 32. Patient waits for counseling
17. Patient waits at verification desk 33. Counseling
18. Verification 34. Exit
19. Patient ferried to COPD ____________
20. Footwear deposit
Total Steps - 34
21. Patient arrives at OPD reception
22. Patient waits outside Echo room
23. Echo
Baseline Measures-

Study Duration 23.6.09 to 25.6.09 (3 days) – Fairly consistent data

Sample Size 9 CD patients
Study Method Shadowing patients during visit from start to finish
Study Limits Start – Patient arrives at Sevadal Desk in Q Complex
Stop – Patient obtains definitive diagnosis from Consultant

Outcome -
1. Average number of visits to hospital 2
2. Current next appointment date 20 days

2. Total Waiting Time for consultation (across 2 days) 2+6 hrs

3. Number of doctor consultations for definitive diagnosis 6
4. Patient Satisfaction Score – (Out of 5)
1 ( Poor), 2 (Satisfactory), 3(Good) 4(Very Good) 5 (Outstanding)

a) Waiting time for services 2

b) Doctor Interaction 3
c) Promptness of Staff 3
d) Clarity in routing communication 3
Future state proposal
Future State - Generic Routing Chart

Arrive at
Sevadal Desk

Q Complex

Batch CD patients
(With & Without Appt)
Exit

CD Screening by Can we offer No

Counsel and prescribe
Senior Doctor treatment here?
medication MM/LFU
Screening
Block Yes Register,
Record Diagnosis & Plan Print Screening Report
No prescribe medication WL & Waitlist
Online/On
Priority/Further
tests? Record Diagnosis, Plan & Register
Yes
Angio Report,order tests-
Refer to OPD

Review consultation in afternoon

Cardiac OPD Echo/TMT/ECG
by
Exit CD Screening doctor
 Future State – CD Screening Outcomes

Patient Doctor Office Outcome

category e-HIS Handoff Executive

Local Follow Up
MM Nil Advice on Nil Exit
prescription

Needs-LFU Nil Advice on Nil Exit

Prescription

CABG
Waitlist Diagnosis, Advice on Register, Exit
Treatment Prescription Waitlist, Print
Plan Screening
Report

CABG-Priority Diagnosis, History, Angio Register To COPD

(As per guidelines) Treatment Report Tests
Plan ordered

PTCA
PTCA Diagnosis, History, Angio Register To COPD
Treatment Report Tests
Plan ordered
Future State – Detailed process step listing

1. Patient arrives at sevadal desk

Visit 1 2. All patients with CD (with and without appointments) are organized into a batch by 9.30AM
3. Batch sent to room 9 in Screening Block
4. Height and Weight capture
5. Senior Doctor screens patient as per set guidelines (refer slide 6)
6. MM-LFU patients provided prescription and routed to exit
7. PTCA and CABG-Priority patients routed to registration
8. Patient waits at Registration area
9. Patient Registered
10. Patient waits at verification desk
11. Patient ferried on cart to OPD
12. Footwear deposit
13. Patient arrives at OPD reception
14. Patient waits for diagnostics
15. Echo/ECG/TMT performed
16. Patient waits at respective doctor’s room with reports
17. Consultation
18. Patient waits for counseling
19. Counselling
20. Exit
___________________

Total Steps - 20
Perceived Advantages –

Patient
1. Reduction in number of visits to hospital
2. Reduced waiting time for consultation
3. Prompt diagnosis and treatment plan – Enhanced Satisfaction
4. Single doctor follow up

Staff
• Interventional Fellows/JC gain Angio review experience
• Residents in OPD do not have to spend long time screening and reporting CDs.
• Faster patient through put in OPD
• Reduced work load for support staff, optimal resource utilization

Resources
1. Reduction in number of unnecessary diagnostics for CD patients
2. Reduction in number of PCs fitted with CD drives in OPD
Results
Brief –

Effective Screening was carried out in the Screening block for CD patients during the
month of July 2009. A Junior Consultant was deputed from the Cardiac OPD during this
period.

Summary Snapshot
30th June 09 31st July 09

Before After

1. Number of visits to hospital 2 1

2. Current next appointment date 20 days 0 Days

2. Total Waiting Time for consultation 8 hrs 4hrs

3. Number of doctors seen from start to finish 6 2
 Screening

CD Screening- July 09 Refer to OPD Exit

Patients Screened

20
15
10
5
0
1.7.09
2.7.09
3.7.09
6.7.09
8.7.09
9.7.09
10.7.09
13.7.09
14.7.09
15.7.09
16.7.09
17.7.09
20.7.09
21.7.09
22.7.09
23.7.09
24.7.09
27.7.09
28.7.09
Date

Result: Out of 321 patients, 187 ( 58% ) could be screened out at

the screening block
Concerns: Currently this data is recorded manually. Can we
employ eHIS data capture to faithfully record screening workload?
 Patients referred to OPD
Registration 133 (43%)
Patients registered
195 ( 60%)
Patients Registered July 2009

Why? Registered patients

include waitlisted patients
39% Registered (ROC), doubtful cases
referred to HOD, and those
that are asked to review
Registered
after a certain period.
61%

Concern: No significant
reduction in load for Office
Executives.
 Reduction in patient waiting
Average Number of Visits to Hospital for consultation

2.5
time
2 2
Number of Visits

1.5
Visits to Hospital - 50% Reduction
1 1 from 2 visits to 1 visit means patients
0.5 no longer make multiple visits to the
0 hospital for consultation
June 30th July 31st

Current Next Appointment Date

25

20 20 Next Available Appointment-100%

Number of days

15
Reduction from 20 days to 0 days
10
means that patients are not given
5
appointments, but seen on the same
0 0 day.
June 30th July 31st

Waiting time for Consultation

9
8 8
Waiting time for consultation 50%
Number of Hours

7
6 Reduction from 8hrs to 4 hrs means
that patients complete their
5
4 4
3 consultation in half the time during
their visit
2
1
0
June 30th July 31st
 Reduction in Diagnostics
Month-wise distribution of Treadmill Tests in COPD

450 Reduction in Treadmill tests

400
350
391
352
from 321 (average of last 6
339 335
months) to 175
327
300
Number

250
200
150
186 175 Male Echos – 1210 to 880
100
50 ( Not completely attributed to
screening, but definitely a
0
Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09
Month contributing factor)

Increase in PAP orders

Monthwise distribution of PAPs for PTCA

140 A slight increase in the

120 118
108 number of PAP orders for
PTCA has not translated
100
PAP count

80 79 78
to an increase in
77 71
60 57
40 waiting time for
20 admission.
0
Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09
Month
Phase 2- Dr Dash would like this project to be extended
to include Valvular heart disease patients.
Identified Criteria – 1. MVR
2. DVR
3.AVR over 60 years/with LV
Dysfunction

Requirements –
We need retrospective data on how much load this would
translate to in the screening block. This would help us
decide -
1. Do we need to depute an additional DNB student there?
2. In the absence of the portable echo, can we formulate
a screening echo protocol?

DISCUSSION – AUGUST 3rd - 4PM HMIS.

Please let me know if this is comfortable for
everyone.