# Observations ## Observer and methods One consultant from Lattice Innovations observed OPD workflow from December 3-5, 2014. Patient throughput time and stage-wise flow was measured on December 4, 2014, when the OPD had a load of 168 patients. Individual workstations were observed on December 3 and 5. Electronic records of all OPD visits from December 1 to 6, totaling 1,123, or 187 per day, were also analyzed. ### Current Workflow The complete OPD workflow (pathway) consists of twelve steps, as illustrated below.

Figure 1: OPD Workflow. Slow-track patients follow all steps; Fast-track patients follow those in yellow.

Patients follow two different pathways, or tracks, based on their healthcare needs. “Slow-track” patients follow all twelve steps, since their condition requires a full workup, with laboratory and/ or radiology investigations. “Fast-track” patients follow the six steps in yellow; they directly receive a prescription and collect medicines. Across the sample of 1,123 OPD visits from Dec 1 to 6, 46% of all visits were fast-track. ### Current Throughput Times An analysis of Electronic Records for December 4 shows the following:

Figure 2: Average throughput times across the day on Dec 4, split by fast and slow tracks

As evident above, average throughput times are particularly high in early hours. The registration desk opens at 8 am, and doctors report to the OPD at 9 am. Thus, patients arriving at or before 8 am wait for at least an hour. While the lowest throughput time for fast-track patient was 12 minutes, the average was 136 minutes. Their wait times were significantly increased by slow-track patients. On December 4, maximum throughput time for a slow-track patient was 346 minutes (5 hr 46 min), and that for a fast-track patient was 248 minutes (4 hr 8 min). ### Wait Time and Value-Added Time The figure below uses the "journey" of a slow-track patient on Dec 4, to illustrate the high proportion of wait time when compared with value-added time. Value-added time is the time when hospital staff performed activities directly related to diagnosis or treatment.

Figure 3: Patient journey - value-added sections in green, balance in red.

### Patient Load across the Day When we analyze patient registration of all 1,123 OPD visits from Dec 1 to 6, the variation in throughput time through the day is evident. 75% of all patients are registered by 11 am—the first 2 hours of OPD operation. The balance 25% patients are spread across the remaining 5 hours (11 am to 4 pm). This skewed load places strain on service delivery.

Figure 4: Patient load over time, in 15 minute increments, for 1,123 OPD visits

### Workstation-wise Load and Capacity To better understand OPD workflow, individual workstations were observed on Dec 3 and 5. Based on these observations, we calculated the time taken by each workstation counter to serve a patient. The data is reported in seconds.

S. No	Workstation	time per patient, s
1	Registration	120
2	Vital signs	58
3	Consultation	146
4	Investigation data entry	60
5	Investigation billing	90
6	Pathology lab	105
7	X-ray	519
8	USG	insufficient data
9	Prescription	146
10	Pharmacy data entry	60
11	Pharmacy billing	90
12	Pharmacy dispensing	224

Some workstations have more than one counter. For instance, the pharmacy has a total of 4 counters, at which tasks 4, 9, 10, 12 are carried out (incidentally, task 11, pharmacy billing, is *not* carried out at a pharmacy counter). In contrast, the X-ray workstation has a single counter.