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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 110-112

The dynamics of arrival and service delivery in a Nigerian public ophthalmic outpatient clinic


1 Department of Ophthalmology, Kubwa General Hospital, Abuja, Nigeria
2 Department of Office Technology and Management, Federal Polytechnic, Bida, Nigeria
3 Department of General and Liberal Studies, College of Administrative and Business Studies, Niger State Polytechnic, Bida Campus, Nigeria

Date of Web Publication18-Aug-2014

Correspondence Address:
Lasisi Akinola Muideen
Department of Ophthalmology, Kubwa General Hospital, Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9019.139069

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  Abstract 

Aim: To investigate the dynamics of patients' arrival and service uptake in order to propose a way of achieving the time target of the 'Service Delivery Charter' of the Federal Government of Nigeria. Materials and Methods: One hundred and seventy one presenting sample of patients between the 8 and 25 February, 2005 were monitored at the outpatient ophthalmic clinic of the Federal Medical Center, Bida-Nigeria. A trained principal confidential secretary using a digital watch timer and timed closed-circuit television (CCT) camera conducted a timed motion record - as developed by Frederick Taylor in 1911- of patients and service provider for the entire clinic period. These records included patients' order of arrival as well as the time for waiting, service call up, service times at different service stations as well as the time of exit from service for each patient. Data were entered and analyzed using the Statistical Package for Social Science computer software. Results: Only 3.6% of patients arrived before the commencement of clinic operations, but as much as 75% arrived before 9.00 am, a time that is 30 minutes before the attainment of peak clinical service operation. Only 6.4% will arrive spontaneously at an interval of time that is big enough to discharge the patient who arrived before them. With respect to the time for service uptake, 700% of time was spent in waiting for services, while clinic layout and logistic redesign offers a maximum time saving of 57% of service uptake time. Conclusion: A timed appointment system is therefore hypothesized to be a very important option to add to the booking systems for the attainment of time targets in public hospitals in Nigeria.

Keywords: Client satisfaction, clinical governance, community development, health service reform, hospital management, service delivery


How to cite this article:
Muideen LA, Folake LA, Philip O. The dynamics of arrival and service delivery in a Nigerian public ophthalmic outpatient clinic. Int J Health Syst Disaster Manage 2014;2:110-2

How to cite this URL:
Muideen LA, Folake LA, Philip O. The dynamics of arrival and service delivery in a Nigerian public ophthalmic outpatient clinic. Int J Health Syst Disaster Manage [serial online] 2014 [cited 2021 Feb 24];2:110-2. Available from: https://www.ijhsdm.org/text.asp?2014/2/2/110/139069


  Introduction Top


'Servicom' programme [1],[2] is a political and strategic solution devised by the government of the Federal Republic of Nigeria to redress the increasing failure of service delivery to its citizens. Like the citizen charter of many developed countries, [3],[4] it attempts to codify the expectations and target performances of various services inclusive of the civil service and health services. Based on the program regulation, various public hospitals are expected to produce a service charter through a process of stakeholders' agreement.

The codes of the hospital service charter among others, stipulate the maximum time limit of arrival that a patient is expected to have been examined at the various hospital clinics, wards, emergency and other service areas. The Federal Medical Centre Bida service charter's Codes stipulate a maximum of 30 minutes for patients in the outpatient clinics.

The Servicom program requires that the service charter be publicly displayed and communicated and encourage patients to complain and seek redress through established channels where they are not met. By this, service providers have been challenged to a new level of performance that at least allows a conflict-free relationship with clients, if not improved efficiency and productivity.

Though service charters have been able to improve efficiency in public service and improved work culture in many countries, it is believed that it has not been able to achieve its maximum impact in both developed and developing countries for many reasons. [4],[5] Issue of improved services would be better achieved by engagement beyond enactment of policy document alone, but also the inclusion of holistic parameters of accountability, social justice, democracy, market forces, consumer participation and providers' engagement and education. [1] A step-wise but steady improvement through pilot approach to creative solutions and the demonstration and scale-up of successful pilots would allow self re-assurance and economic use of funds, especially in low-resource economy like Nigeria.

Successful policies are to a large extent dependent on social research, which gives details of variables that are amenable for target achievement, hospital time target is not an exception. Though charters were made through stakeholders' deliberation and were heavily supported at the national level by international monetary and technical aids such as those offered by Department for International Development (DFID), United Kingdom, there is dearth of data about modifiable operational variables for target achievement. This data deficiency has to a large extent fuel the need for this research.


  Materials and Methods Top


A trained principal confidential secretary using a digital watch, timer and timed CCT camera did a timed Motion [6],[7] record, as developed by Frederick Taylor in 1911, for patients and service providers for the entire clinic period. These records included patients' order of arrival as well as the time for waiting, service call up, service times at different service stations as well as the time of exit from service for consecutive presenting sample of patients at the ophthalmic outpatient clinic of the Federal Hospital of Bida, Nigeria over 17 days in the month of February, 2005. Data were entered and analyzed using the SPSS computer software.


  Results Top


Clinic arrival time ranged from 7.20 am to 1.13 pm with a mean and modal arrival time at 9.00 am. Only 3.6% of patients arrived before the commencement of clinic operation but as much as 75% arrived before the attainment of equilibrium service delivery.

The average inter-arrival time between two consecutive patients is 7.8 minutes with 31% arriving simultaneously or within one minute of arrival of the other patient. Total of 87% of patients arrived within 15 minutes of one another, while only 6.4% will arrive spontaneously at an interval of time that is big enough to discharge the patient before them.

Traffic intensity continued to increase from onset of clinic to about 10.00 am, a time at which the discharge of patients just begins to exceed the new arrival.

The average time for clinical evaluation is 21.70 minutes, 13.55 minutes and 16.01 minutes for new, old and combined old and new patients, respectively. Additional time for non- clinical operational activities such as updating card records, counseling patients and prescription filling makes the total time spent within the consultation area to be an average of 31.6, 19.11 and 25.25 minutes, respectively. Follow-up cases offer a time saving of up to 42.4% (P = 0.003).

Though the average time spent with professionals in the consulting room was 25.25 minutes, it was possible to discharge a patient from service every 14 minutes. This is possible for reason of service overlap between two patients using two different points of the service layout.

The average waiting time on the queue before consultation is 113.75 minutes leading to a total of about 324 man-hour or 14 days loss to examine 171 patients for 46 man-hour or 2 days. Two-third of the patients were elderly or children needing company of one additional client in 32.9% and two accompanying clients in 5.7% with resultant additional man-hour loss. [Figure 1] shows the approximate time of call for consultation against the order of clients' arrival; this timing will reduce the before-consultation waiting time to zero.
Figure 1: Plot of consultation time versus order of arrival at the clinic

Click here to view


Queue discipline was fair in 80% of cases while 14% of patients disrupted queue for medico-social reasons. Others experienced uncommon queue situations like those at distracting emergency-call periods.


  Conclusion Top


This study has shown that the waiting and service delivery time of a public hospital in Nigeria is more than desired by the charter. Realizing that only 6.4% of patients will spontaneously receive service without waiting, it proposes the inclusion of time in appointment schedule as done by other developed nations of the world. Effort in service layout improvement could only achieve 8% impact of what is achievable with timed appointment in reducing waiting time, but would give a greater potential for increase in the total number of clients examined per clinic session.


  Discussion of Results Top


Our study uses a time-motion analysis by a non-participant observer, which introduces some level of objectivity [7] when compared with patient introspective techniques used by other workers, [8],[9] though with the limitation that the realization of being observed could probably make professionals more efficient than they would normally. This study demonstrated that not much has changed in half a decade of hospital waiting time in Nigeria given the similarity of waiting time between 2005, the year of this study and 2011. [8] Seventy-eight percent of Nigerian patients were satisfied with a time target of 30 minutes for clinic waiting [9] but the current waiting time of 113.75 minutes for consultation is much more than the target. It is important to note that this study has only looked at waiting time to see a specialist in the consulting clinic. It is known that the hospital health record documentation can take additional 50-100% [8],[9] longer waiting while pharmacy can take up to additional 100% [10] of time for receiving a consultation. Total hospital waiting time can therefore be expected to be three times more than in this study.

The ophthalmic clinic at the hospital has a team of one doctor, two nurses and a part time cleaner; it is probably the limit of what is found in many low-resources setting and equally a representation of a unit of the many teams in developed set-up. The clinic is equally the only tertiary facility in the Niger State of Nigeria. Our finding is therefore a representation of what is achievable with a maximally exploited team for care.

It is obvious that just 6.4% of patients will not wait to receive care if arrival is unregulated, and so this study advocates the inclusion of time in appointment schedule in Nigerian public hospital and we hope to pilot that in the near future. A regression analysis of order of arrival in the clinic against the approximate time of call up for consultation revealed that patients could be given appointment as two or three within each 30 minutes time bracket. This will help to reduce the frustration of no show and allow simultaneous entry into different points of the service layout.

Late commencement of clinic will be an issue to only 3.6% of our clients who arrived before 7.30 am, similar to low level of ascription of cause of long waiting to late commencement of clinics as was found by Umar and workers in Sokoto-Nigeria. [9]

Though logistics such as transportation and power supply failure may hamper an effective timed appointment in Nigeria, telecommunication and Information technology holds a very good promise in this regard.

 
  References Top

1.Thomson W. Delivering Service in Nigeria: A Roadmap, Office for Public Service Reform (OPSR), United Kingdom; unpublished report of DFID assisted rapid appraisal of service delivery in Nigeria. http://www.servenigeria.com/misc/wendyreport.pdf [Last accessed  on 2014 Mar 10].  Back to cited text no. 1
    
2.Federal Government of Nigeria, The Servicom: Service Compact with all Nigerian Servicom Office Abuja 2006 http://www.servenigeria.com/misc/servicombook.pdf [Last accessed  on 2014 Mar 10].  Back to cited text no. 2
    
3.Wilson J. Citizen Major? The rationale and impact of the citizen′s charter. Public Policy Adm 1996;11:45-62.  Back to cited text no. 3
    
4.James S, Murphy K, Reinhart M. The Citizen Charter: How Such Initiatives Might Be More Effective. Public Policy Adm 2005;20:1-18.  Back to cited text no. 4
    
5.Louis F, Ohemeng K. The new Charter System in Ghana: ′Holy grail′ of public service delivery? Int Rev Adm Sci 2010;76:115-36.  Back to cited text no. 5
    
6.Bratt JH, Foreit J, Chen PL, West C, Janowitz B, de Vargas T. A comparison of four approaches for measuring clinician time use. Health Policy Plan 1999;14:374-81.  Back to cited text no. 6
    
7.Weigl M, Müller A, Zupanc A, Angerer P. Participant observation of time allocation, direct patient contact and simultaneous activities in hospital physicians. BMC Health Serv Res 2009;9:110.  Back to cited text no. 7
    
8.Ogunfowokan O, Mora M. Time, expectation and satisfaction: Patients′ experience at National Hospital Abuja, Nigeria. Afr J Pharm Health Care Fam Med 2012;4:398  Back to cited text no. 8
    
9.Umar I, Oche MO, Umar AS. Patient waiting time in a tertiary health institution in Northern Nigeria. J Public Health Epidemiol 2011;3:78-82.  Back to cited text no. 9
    
10.Ndukwe HC, Fola T, Sariem NC. Factors influencing waiting time in outpatient pharmacy of Lagos University Teaching Hospital. Int Res J Pharm 2011;2:22-6.  Back to cited text no. 10
    


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