Management in health

XVII/1/2013; pp. 31-37 QUALITY

REDUCING WAITING TIME IN OUTPATIENT

SERVICES OF LARGE UNIVERSITY TEACHING
HOSPITAL - A SIX SIGMA APPROACH
This papar presents the results of a project of improving the quality of services
Prof. Dinesh T.A1 , MHA, Ph.D provided in an outpatient department of an university hospital in India. The project
Prof. Dr. Sanjeev SINGH1 , DCH, M.Phil was conducted on the basis of the six sigma methodology and aimed to reduce
waiting times in outpatient cardiology office.
Prem NAIR1 , MBBS, MD
Significant reduction in waiting time was achieved in the outpatient services
Remya T R1 , MHA of the Cardiology department by using the six sigma approach. In addition to the
1
Amrita Institute of Medical Sciences and Research Centre, overall reduction in waiting time for cardiac medical consultation significant
reduction in waiting time for getting the lab results was also achieved.
Amrita Vishwa Vidyapeetham (Amrita University), Cochin,
As an off shoot of the study nine registration counters were started,
Kerala, India
registration forms were modified, usherers were appointed to guide patients,
additional staff were appointed to handle the telephones in the Cardiology OPD
and they were also taught basic telephone etiquette, dedicated biochemistry
analyser was provided for the cardiology department and an alert system was put in
place for patients waiting for more than one hour.

I NTRODUCTION
Patients’ waiting time has been defined as “the variance.
length of time from when the patient entered the
Further data collection through VOC will help to monitor and control any

outpatient clinic to the time the patient actually leaves Keywords: quality, health services, waiting time, India
the OPD”.
Whether it’s a time used for registration of patient, routine Six Sigma seeks to improve the quality of process outputs
doctor’s appointment, emergency room treatment, labora- by identifying and removing the causes of defects (errors)
tory/diagnostic test, procedures, receiving the results of vari- and minimizing variability in the work process [4].
ous tests, waiting happens to just about everyone seeking Data and statistical analysis are used to identify defects in
medical care. processes and reduce variation. DPMO (defects per million
It’s often one of the most frustrating parts about healthcare of oportunities) and sigma level are described in the Table 1.
delivery system.
Chart 1. Process capability.
Waiting times for elective care have been considered a seri-
ous problem in many health care systems since it acts as a
barriers to efficient patient flows.
OPDs is considered as the window to hospital services and a
patient's impression of the hospital begins at the OPD. This
impression often influences the patient's sensitivity to the
hospital and therefore it is essential to ensure that OPD ser-
vices provide an excellent experience for customers. It is also
well-established that 8-10 per cent of OPD patients need hos-
pitalization.

L ITERATURE REVIEW
Six Sigma is a business management strategy origi-
nally developed by Motorola, USA in 1986 [1,2] and was
Table 1. DPMO and sigma levels [5,6]
Sigma Percent Percentage
associated with statistical modeling of manufacturing proc- DPMO
level defective yield
esses. A six sigma process is one in which 99.99966% of the
products manufactured are statistically expected to be free of 1. 691.462 69% 31%
defects (3.4 defects per million). 2. 308.538 31% 69%
3. 66.807 6.7% 93.3%
The term "six sigma process" comes from the notion that if
one has six standard deviations between the process mean 4. 6.210 0.62% 99.38%
and the nearest specification limit, as shown in the chart 1, 5. 233 0.023% 99.977%
practically no items will fail to meet specifications [3]. This 6. 3.4 0.00034% 99.99966%
is based on the calculation method employed in process ca- 7. 0.019 0.0000019% 99.9999981%
pability studies (Chart 1).
31

QUALITY
M ETHODOLOGY
The DMAIC method under Six Sigma which consists of
the following five steps was used to achieve the objectives
of this study.
Step 1 - Define
Step 2 - Measure
Step 3 - Analysis
Step 4 - Improve
Step 5 - Control
Study was carried out in the department of Cardiology of a
large University Teaching Hospital with an average annual
Cardiac OP of 40000.
Period of Study – January 2012 to April 2012.
a. Measurables
1. Total waiting time for a cardiac consult.
2. Time taken for laboratory result.
3. Time taken for laboratory and ECG result.
b. Sample Size
Respondents of this study included selected patients, staffs
and doctors in the department of Cardiology at the Heart
Institute.
1. Retrospective data of 640 patients was analysed for
waiting time during the period Jan – Dec 2011.
2. Voice Of Customers was obtained from 320 patients
during the Define phase in April 2012.
3. Waiting time of 640 patients was obtained during the
Analyze phase in February 2012.
4. Waiting time of 640 patients was obtained during the
Control phase in March 2012.
Simple Random sampling was followed.
Data Collection
The following collection methods were used in this study.
1. Voice of Customers (VOC) was obtained using
standardized questionnaire.
2. Data was also collected through direct observation.
3. Management staff and doctors were interviewed to
obtain information on the working process in the
hospital.
Statistical Tools
1. Process Map—Flow Chart that shows description and
sequence of the process done.
2. Cause and Effect Diagram - Diagram that shows the
relationship of a cause that gives rise to a certain
problem.
3. Affinity Diagram.
4. Descriptive statistics.
5. SPSS analysis.
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Management in health
XVII/1/2013; pp. 31-37
R ESULTS AND DISCUSSION
D EFINE
This is the first step that refers to defining the goals of
the project. Process improvement goals may be aimed at
increasing market share, the output of a particular depart-
ment, bringing about improved employee satisfaction as well
as customer satisfaction and so on.
The goal has to align the customer demands and the strategic
goals of the organization. Data mining methods can be used
to find prospective ideas for project implementation.
In other words, businesses are designing a road map for
achieving the targets and goals of the organization.
Problem Statement:
Three months retrospective data from the department indi-
cates that in October 2011 only 49.27% of patients were
seen within 60 minutes by the physician. In November 2011
this increased marginally to 51.11% and in December this
was fond to be 53.31%.
OPD WAITING TIME - PERCEPTION OF CUSTOMERS
For understanding perception of customers on OPD waiting
time, VOC was collected from 320 patients in the cardiology
OP.
Questionnaire for OP Patients (Cardiology)
1. Did you take an appointment for OPD visit?
2. How did you get the appointment? Through telephone
or direct?
3. Are you satisfied with the way your phone call was
handled?
4. What instruction was given by the counter staff at the
time of appointment/arrival?
5. How do you feel is the reception staff?
6. How much time it took at the reception, to attend you?
7. At what time you were asked to report at the counter and
when did you reach the OPD reception?
8. Did any staff brief you regarding the workflow in OPD
9. How long you have been waiting in OPD?
10. Did any information regarding waiting time in OPD was
given to you, at the time of appointment?
11. How much time it took for you to interact with doctor
after your arrival?
12. Are you aware of the existing appointment system in
AIMS?
13. What is your perception on waiting time in the hospital?
14. What would you suggest to reduce waiting time in OPD
15. Any other suggestions?
How long have you been waiting in the OPD (Chart 2)
As is evident from the above diagram, 64% of the patients
had to wait for more than 3 hours for a Cardiac consultation
with 24% of patients waiting anywhere between 2 hours
to three hours.
 Management in health
XVII/1/2013; pp. 31-37
Only 6% of patients could have their consultation within
one hour. This clearly indicates that majority of patients
are not satisfied with the present waiting time.
VOC reflects customer expectation to see doctor within 60
minutes of Registration/Encounter.
It was found that routine lab test and ECG results are critical
information for a cardiac medical consultation. Patients were
waiting for either the lab test or both lab test and ECG.
To assess this measurable the time taken for the blood test
results and ECG results were collected separately in the
measure phase:
1. Time to complete the Blood Test.
2. Time to complete the Blood Test and ECG.
M EASURE
This phase refers to the analysis of the existing
system with various measurement techniques for the de-
fects and levels of perfection that exist. In this step, accu-
rate metrics have to be used to define a baseline for further
improvements.
This helps in understanding whether any progress has been
achieved when process improvements are implemented.
To identify High level process map the SIPOC (Table 2)
has been done.
The various processes involved in the particular project
has been described in detail in flow chart (Chart 3)
Value Analysis: A value analysis was done based on the
flow chart and the processes were categorized into Value
added, Operational Value Added Activity and Non Value
Added Activities as given in Table 3
A NALYZE
The analyze phase was undertaken to determine any
disparity that may exist in the goals set and the current
performance levels achieved. The understanding of the
relationship between cause and effect is necessary to bring
about any improvements, if needed.
Brainstorming session was carried out and all the causes
were listed in the affinity diagram. The Fish Bone Diagram
was prepared.
The causes which got from the brain storming session has
been segregated into non controllable causes, direct im-
provement causes and controllable and likely causes
(Table 4); its fish bone diagram for controllable causes
only is shown in the Chart 4.
Causes were then ranked on the basis of severity and oc-
currence as per criteria given Table 5
QUALITY
A modified Failure Mode and Effects Analysis (FMEA)
was carried out for Occurrence and Severity only. The top
Risk Priority Number were considered for further analysis,
using 5WHY.
• Single Registration counter
• Time taken to process blood test only
• Time taken to process blood test and ECG
DATA ANALYSIS
Null Hypothesis
Based on the data from the measure phase the following
Null hypotheses were formulated:
1. H0 = There is no reduction in waiting time before and
after starting new registration.
2. H0 = There is no reduction in waiting time for getting
lab result for the patients having Blood Test only.
3. H0 = There is no reduction in waiting time for getting
lab result in old & new data for the patients having
Blood Test + ECG.
1. H0 = There is no reduction in waiting time before
and after starting new registration counters
Analysis of waiting time after and before starting new reg-
istration counters Table 7.
It was suspected that there is no reduction in waiting time
before and after starting new registration counters. 2 t Test
was conducted to ascertain this.
Null hypothesis was rejected as the p-Value was found to
be below 0.05 at 95% confidence level.
It was suspected that there is no reduction in waiting time
for new patients as well as revisit patients in getting the
results of the Blood Tests before and after implementation
of six sigma. A t Test was conducted to ascertain this.
t-Test to analyse reduction in waiting time for patients
having Blood Test only Table 8.
Summary of Statistics Table 9.
Sigma Levels Table 10.
As is evident from the above table, there is significant reduc-
tion in waiting time with p-Value of <.05 at 95% confidence
level. The sigma levels have also shown a significant in-
crease from 2 before the study, 2.6 during the study and 3.4
during the control phase. Hence the hypothesis is rejected.
2. H0 = There is no reduction in waiting time for getting
lab result in old & new data for patients having Blood
Test and ECG
It was suspected that there is no reduction in waiting time
for patients in getting the results of the Blood Test and
ECG. A 2 t Test was conducted to ascertain this. It has
been described in Table 11, 12 and 13.
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 Management in health
QUALITY XVII/1/2013; pp. 31-37

Table 2 Chart 2 - Proportion of Patients Waiting - Before Study

SUPPLIER (S) INPUTS PROCESS OUTPUT CUSTOMER
(I) (P) (O) (C)
Registration Registration Patient MRD No Patient
staff form registering
Reception staff MRD Card Encountering Token No. &
Instructions for
billing
Billing Clerk Cash Billing Receipt
Nursing / Order Preliminary Instructions to
Technician Examinations/ wait / have
investigations breakfast
Jr. Doctor Work up by Advise / refer to
junior doctor senior physician

Jr. Doctor Order Additional Tests Advise

Doctor Consultation by Advise
Sr. Doctor

Table 3 Table 7
Value Activity Nos t-Test: Two-Sample Assuming Unequal Variances
Value Added Activity 35 April July
Operational Value Added Activity 13 Mean 23.2 17.7
Non Value Added Activity 27 Variance 127 96.5
Observations 382 331
Table 4 Hypothesized Mean Difference 0
Sl. Nature of Cause Numbers Identi- df 711
No. fied
t Stat 6.97
1. Non Controllable Causes 32
P(T<=t) one-tail 3.58
2. Direct Improvement Causes 11
t Critical one-tail 1.65
3. Controllable and Likely 67
P(T<=t) two-tail 7.16
Causes
t Critical two-tail 1.96
TOTAL 110

Table 5 Table 8
BT (Before) BT (Control)
Occurrence Rank Severity Rank Mean 89.82 70.63
Once a Month 1 Mild 1 Variance 230.07 9.99
Once a Week 5 Moderate 5 Observations 640 640
Every Day 9 Severe 9 Hypothesized
Mean Difference 5
Table 6 df 694
Causes Solutions t Stat 23.17
Single Registration Counter Start multiple Registration P(T<=t) one-tail 0.00
Counters t Critical one-tail 1.64
Registration form is lengthy & diffi- Simplify Registration P(T<=t) two-tail 0.00
cult to fill Form t Critical two-tail 1.96
Lack of proper communication Provide adequate training
Time taken to barcode & process the Provide a dedicated ma- Table 9
samples in lab/ blood reports takes chine for biochemistry test
BT
more time for Cardiology OPD
BT (Before) BT (Improve) (Control)
AHD asking patients to report at the Segregated appointment to
Mean 89.82 76.17 70.63
same time at OPD be given based on the fast-
ing blood sugar need and Median 88 77 71
the appointments available Standard
into forenoon and after- Deviation 15.16 6.43 3.16
noon Range 84 24 13
Delay in starting OPD To start work up for New Minimum 65 65 63
visit OPD at 8.30 am and Maximum 149 89 76
Sr doctor consultation at
10.00am every OP days Count 640 640 640
Delay due to entry in to EMR Provide training to doctors Confidence
Level (95.0%) 1.17 0.49 0.24
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 Management in health
XVII/1/2013; pp. 31-37 QUALITY

Table 10 Table 16
BT (Before) BT (After) BT (Control) t-Test: Two-Sample Assuming Unequal Variances
2 2.6 3.4 VOC Before VOC Control
Mean 164.85 71.61
Table 11 Variance 2710.56 2069.27
t-Test: Two-Sample Assuming Unequal Variances
Observations 320 639
BTE (Before) BTE (After)
Mean 91.67 77.55 P(T<=t) one-tail 0.00
Variance 197.71 37.14 t Critical one-tail 1.64
Observations 640 640 P(T<=t) two-tail 0.00
Hypothesized Mean Difference 5 t Critical two-tail 1.96
df 871
t Stat 15.04 Sigma Levels Table14. As is evident from the above tables,
P(T<=t) one-tail 0.00 there is significant reduction in waiting time with p-Value of
t Critical one-tail 1.64 <.05 at 95% confidence level. The sigma levels have also
P(T<=t) two-tail 0.00 shown a significant increase from 2 before the study, 2.9
t Critical two-tail 1.96 during the study and 3.3 during the control phase. Hence the
Table 12 hypothesis is rejected. Hence the hypothesis is rejected.
t-Test: Two-Sample Assuming Unequal Variances Number of patients waiting for cardiac consultation for less
BTE (Before) BTE (Control) than one hour has gone up from 6% before the study to 49%
Mean 91.67 70.75 during the study which further increased to 53% during the
Variance 197.71 10.64 control phase. Similarly patients waiting for more than two
Observations 640 640 hours has come down from 24% to 6% and 4% respectively.
Hypothesized Mean Similarly patients waiting for more than three hours has
Difference 5 come down significantly from 64%, 13% and 8% respec-
df 708 tively.
t Stat 27.90
P(T<=t) one-tail 0.00 3. H0 = There is no reduction in waiting time for getting
t Critical one-tail 1.64 lab result for patients having Blood Test only
P(T<=t) two-tail 0.00
t Critical two-tail 1.96

Table 13
BTE BTE BTE
I MPROVE
Improvements in existing systems are necessary to bring
the organization towards achievement of the organization
(Before) (After) (Control)
Mean 91.67 77.55 70.75 goals. Creative development of processes and tools brings
Median 88 78 71 about a new lease on life for the organization’s processes and
takes them nearer to organizational objectives.
Standard Deviation 14.06 6.09 3.26 Various project management and planning tools can be
Range 83 24 14
used to implement these new techniques and processes.
Minimum 66 66 63
Appropriate usage of statistical tools is important to meas-
Maximum 149 90 77
Count 640 640 640
ure the data, which is necessary to understand improve-
Confidence Level ments done and any shortcomings that may exist.
(95.0%) 1.09 0.47 0.25 The solutions with their respective Causes are listed in the
Table 6.
Table 14
BTE
BTE (Before)
2
BTE (After)
2.9
(Control)
3.3 C ONTROL
Control phase is the last step in the DMAIC method.
VOC was conducted to find out if there is any significant
Table 15 variation.
t-Test: Two-Sample Assuming Equal Variances
VOC Before VOC After Waiting Time for Consultation by using VOC (Table 15, 16)
Mean 164.85 79.54 Waiting Time for Consultation by using VOC
Variance 2710.56 3045.32
It was suspected that there is no reduction in waiting time for
Observations 320 320
P(T<=t) one-tail 0.00
consultation in VOC of old and new data. A t Test was con-
t Critical one-tail 1.64 ducted to ascertain this.
P(T<=t) two-tail 0.00
t Critical two-tail 1.96 35
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QUALITY XVII/1/2013; pp. 31-37

1-2 2-3

2-3
Chart 3 - Process Map

1-2

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 Management in health
XVII/1/2013; pp. 31-37 QUALITY

Chart 64 - Cause-effect
diagram

It was found that the p-Value was below 0.05 at 95% confi- handle the telephones in the Cardiology OPD and they were
dence level; the null hypothesis was rejected. also taught basic telephone etiquette, dedicated biochemistry
analyser was provided for the cardiology department and an
Conclusion: Significant reduction in waiting time was alert system was put in place for patients waiting for more
achieved in the outpatient services of the Cardiology than one hour.
department by using the six sigma approach. In addition to Further data collection through VOC will help to monitor
the overall reduction in waiting time for cardiac medical and control any variance.
consultation significant reduction in waiting time for getting
the lab results was also achieved.
Acknowledgement
As an off shoot of the study nine registration counters were Authors are grateful to Mata Amritanandamayi Math for providing the
started, registration forms were modified, usherers were ap- resources for carrying out the study and two anonymous referees for
pointed to guide patients, additional staff were appointed to their comments and suggestions.
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