Orientation to Out-Patient Services

Patient reception

When a patient enters the hospital, a warm reception from the OA directly or indirectly conveys to the patient that he/she is important. The out-patient department work plan must have a holistic approach to patient care. This holistic approach includes greeting the patient with a smile, patiently replying to repeated enquiries of the patient, maintaining registrations, directing the patient to the appropriate departments, fixing appointments without confusion, admission and discharge procedures, assisting the patient to avail reimbursement facilities and directing the patient to optical dispensing units.

To execute these vital tasks, the hospital's management should train the OAs to approach the patient with a positive attitude, and to provide compassionate patient care. Efficient and caring out-patient service provides a favourable public image (Fig. 1.1).

A. Hospital entrance

The hospital is a strange place for patients. They may be frightened and need reassurance and guidance. An enquiry counter, near the entrance to the out-patient department is necessary so that the patient can obtain information about the location of various clinics and registration procedures. This should be prominently located at the entrance of the hospital and in close proximity to the admission, discharge and emergency services of the hospital. To isolate it from the noise of the busy departments, the enquiry counter can be enclosed in see-through cubicles with glass-paneled walls. This arrangement enables those at the enquiry counter to monitor the surrounding activity as well as be easily located by the patient. In the out-patient department of smaller hospitals, an open booth or counter will be sufficient (Fig.1.2).

B. Enquiry counter

During working hours, the enquiry counter in the out-patient department should be visibly designated and staffed with a competent and experienced person. A senior medical records staff or front-office manager is equally suitable for this job, provided the person has knowledge of the location of all facilities and activities of the out-patient and in-patient departments.

With the tremendous amount of activity taking place, tempers can easily be lost. Therefore the person at the enquiry counter should be well mannered and cool tempered, with infinite patience to listen to and answer the patient's many queries.

The entrance lobby should have public facilities, including a tea and snack bar, drinking water facilities and toilet facilities. The waiting area or entrance lobby should display information boards for the patients and public regarding names of doctors and nursing staff on duty during a clinic session.

For patients who cannot walk, adequate stretcher-trolleys or wheelchairs are required to carry them through the hospital. A place to park them should be provided at the very entrance to the out-patient department / Enquiry. The issue and replenishment of trolleys and wheelchairs can be organized under the overall control of the out-patient department coordinator.

The enquiry area should have all the information pertaining to the hospital and public services. This includes information regarding facilities, costs, names of the doctors and surgeons, and duration of hospital stay for all available treatments and problems. The medical records staff / Enquiry staff / should also be knowledgeable regarding all speciality clinic details available in the hospital. When the patient turnover is high, the hospital should be equipped with a computer system with information pertaining to out-patients and inpatients, thereby reducing the workload of the staff.

It is important that the medical record staff be informed about all meetings, seminars, and conferences that are conducted in the hospital. This will enable her to give a quick response about the availability of the doctors to the patients.

Since patients are likely to visit the hospital from different places, states, and countries, a travel desk is helpful for patients to reserve tickets and arrange travel and tours well in advance. It is advisable to have a list of air, bus, and train timings at the counter. The medical records staff can guide the patient to the travel desk. Having a map of the city may be helpful in assisting patients in visiting their places of interest.

C. Medical records

Maintaining the patients' case records is important to document the type of treatment given previously and for review. The medical records system must be well planned for the easy retrieval of case sheets (Fig 1.3). New patients must be managed in a separate queue and particulars like name, age, sex, address for communication, history of illness, and history of present illness must be made in their case record.

The Proper maintenance of medical records is very important because much time can be wasted looking for poorly stored records The records must be maintained manually, and, if possible, on the computer as well. The OA must learn and abide by the system planned out by the organisation, ensuring that all addenda are attached to the main file of the patient so that continuity of treatment is well documented. The medical records are to be arranged neatly in an order so that it could be traced easily.

Instruments, equipment and supplies

Supplies are expendable items or those articles which are used and must be replaced such as soaps, towels, stationery, sterile goods.

Equipment includes more permanent articles and may be classified as fixed or movable. Fixed equipment is not a part of the structure of the building but is attached to its walls or floors such as sterilisers and sinks. Movable equipment includes furniture, instruments, syringes etc. These are items which have to be replaced frequently.

Supplies and equipment are highly important factors in a smooth running unit. Maintenance and availability reflect directly on the quality of patient care.

If the supply of materials is inadequate, the care of the patient may be jeopardized. For instance, if there is not enough cotton and gauze, the preparation of materials used in dressing will be affected. Lack of proper materials will adversely affect the comfort of the patients and delay in treatment.

Equipment which is not maintained well or is not ready for use is often more troublesome than if it were not available. The ophthalmologist, the OA, and the patient may be ready for treatment, but if the slit lamp does not function correctly then the procedure will have to be delayed or aborted. Such situations are not just embarrassing they are an annoying waste of time to all concerned.

It is often necessary to lock up excess supplies to prevent loss or wastage. There should always be enough supplies available for use and a key to the locked cupboard should be accessible at all times to the OA in charge. A system should be developed to ensure that the supervisor does not forget to leave the key when they leave for lunch, for a conference, or for a day off. Time is wasted hunting for the individual who carries the key.

For convenience and prompt service, all necessary equipment and supplies for a particular treatment should be kept in one unit even though it may mean duplication of materials. For example, the emergency medicines and oxygen though available in the intensive care unit may be kept in the out-patient department and Wards also.

Thus, the OA must make sure there is an adequate supply of materials on hand and in good condition available for use; delegate the responsibility of handling supplies and equipment; be careful about wastage and misuse; educate colleagues and other personnel in the economical use of materials; keep shelves stocked and locked; and keep the treatment room in order.

Keeping an adequate supply of materials on hand

Standards are established to maintain quantities of materials required to meet the needs of each unit. For example if an out-patient department admits 100 patients everyday on average, the OA should have 110 needles autoclaved for checking lacrimal patency. If one or two are unsterile or do not function properly, the extra needles can be used. The number of needles should not exceed 110, as it is the standard for the out-patient load, unless the number of patients is constantly on the increase.

These standards are determined by the type of service, the cost and durability of the items, and the period of time between order and delivery. Additional factors include the patients' age, sex, and the type and degree of their illness.

Many hospitals maintain an exchange system for equipment to prevent overstocking or the lowering of equipment standards. In this system, a broken item is returned to storage before a new article is issued. This allows the administration to determine the amount of breakage that happens due to inferior quality items as well as due to careless handling.

An equipment inventory is a detailed list of articles in the out-patient department, their specification, and standard number or quantity. The specifications make it possible to identify the articles by size, number or description. The standard is the number of that particular item.

Taking inventory helps to determine whether standards are maintained. It allows the hospital to replace equipment immediately if it is lost or broken, and can act as a reminder to return an item borrowed from another unit. Taking an inventory also shows excess materials which are no longer in use so that we can dispose them off.

The frequency of such inventory depends on the type of equipment. For example the ophthalmoscope, torch, gonio lens, sphygmomanometer, and the tonometer may require daily counts. These items can disappear easily. Other items such as the slit lamp and furniture may be counted weekly or monthly. For some items a yearly inventory may be sufficient. However, regular inventory helps in tracing the articles. To make this happen, each individual can be assigned a certain group of items and will take responsibility for maintaining the same.

A requisition is a written order for supplies and equipment, or a request for their repair. One person should be responsible to put such a list together weekly or daily. The requisition should take into account the perishability of the items; storage facilities available; and the cost and convenience of the handling and transportation of the orders. A requisition form must be written clearly, with the exact number and description of the items needed; it should also include the OA's name and signature, as well as that of people in authority.

Some instruments required in the out-patient department include:

• Torch light
• Direct ophthalmoscope
• Indirect ophthalmoscope
• Gonio lens
• 90 D
• 20D
• Applanation tonometer
• Schiotz tonometer
• Slit lamp

Communication with patients

Effective communication is essential in all fields. In hospitals, communication with the patient plays a vital role. As they enter the portals of the hospital with a problem, patients are in a confused state of mind with hundreds of questions in their minds. The OA should be able to understand the mental state of the patient and clarify their doubts. Sometimes the patient may ask the same question several times and the OA should answer patiently. As the patient enters the department, greet them with a smile and enter the name in the register. Guide them to the appropriate cubicle or section for the doctor to examine them along with the case sheet. As per the doctor's instruction, take them for further tests. The doctor would have informed them about their eye problem and about further tests, yet the patient may still have questions. The OA should patiently explain the doctor's instruction without showing any irritation in their tone or facial expression. Clearly explain to the patient the procedure they are to undergo before actually performing the procedure.

Communication both verbal and non-verbal plays an important part in the out-patient department. The patient will also feel comfortable in their presence. The OA must be well versed with all the procedures. Since the OAs have been handling the instruments and equipment daily, they will not have fear either in handling them or in using them on the patients. The patient however may be afraid even to see them. So, the OA must have empathy, communicate with the patient effectively and encourage them to give their full co-operation.

The following examples illustrate the above mentioned point:

Instillation of eye drops: Inform the patient that drops will be administered to enlarge (dilate) the pupil for proper diagnosis, that the drops will have a burning sensation for a few seconds, and that there is nothing to fear. The patient will have blurred vision afterwards, so enquire about their mode of transport. If a patient came by vehicle alone, he may find it difficult to drive on his return. In some cases, the blurred vision may continue the next day and the patient may have an exam or an interview or some other important function and the blurred vision may cause inconvenience. If the OA clearly communicates the entire details, patients can plan their activities and accept the treatment.

Measuring intraocular pressure using a Shiotz tonometer. First, tell the patient why the test is being done and explain its significance. Tell the patient that drops will be applied in their eyes, and that they may cause a burning sensation, and that after one minute an instrument will touch their eye and it will not cause any pain. Step by step, give the patient instructions in their language and verify whether the patient has understood the instructions. Never assume that the patient knows about the procedure.

Telephone manners

The OA must be polite in responding to telephone calls. Though they may not be seen by the person at the other end of the line, their attitude can be sensed over the telephone and they must be clear in communicating relevant information to the patient. OA's method of handling calls must reassure the caller, and instill confidence in the hospital's service.

A good OA is / should be able to differentiate between important and casual calls. They must understand the urgency of the patient's condition and avoid unnecessary talk and comments. They must be sure about their replies, especially in granting appointments. The OA is expected to assist the doctor at any time, therefore, it is always thoughtful to maintain a separate message book to record all the messages received through phone or directly. OAs must also be very careful not to create unnecessary interruptions for the doctor.

Handling mail

Patients from far-off places may contact the OA to fix an appointment with the doctor for a check-up or surgery through post or email. The OA should bring those communications to the attention of the ophthalmologist. They must remind the doctor and ensure that a reply is sent to the patient.

Marking a review appointment

The OA is responsible for ensuring that the patient has undergone the complete treatment. If a follow-up check is recommended for the patient, fix an appointment for the patient after speaking to the doctor. The date given for each review patient must be noted in a separate book with date, time, and the name of the patient. The OA should remind the doctor about the list of appointments given to the patients every day. The OA must be very tactful in handling the patient if the doctor is late or called away for an emergency. In case the ophthalmologist happens to be out of station, the OA should immediately convey the message to the patients so that the patients can plan their visit for some other day or be seen by another doctor.

Relationship with other departments

The out-patient department should maintain cordial relationships with all the departments in the hospital to ensure smooth functioning.

For instance, the Out-patient department staff has to develop cordial relationship with the staff of the department of housekeeping and give instructions to clean the area depending on the volume of patients. When their work is not satisfactory, instead of shouting at them in the presence of the patients, have a one to one talk and make them realise the importance of maintaining cleanliness in the area.

The out-patient department and inpatient department work hand-in-hand because the patients in the ward occupy rooms as per the directions given by the ophthalmologist in the out-patient department. The OA in the out-patient department is responsible for handing over a record of all the procedures done in the out-patient department to the ward OA.

In larger hospitals there will be many departments that will be directly or indirectly connected to each other. Excellent patient care can be achieved by establishing a cordial relationship between the departments.

Department structure and functions

Chief medical officer (CMO): The chief medical officer is the chief of all the medical personnel. The doctors discharge their duties based on CMO's directions, and CMO passes suggestions and recommendations to the hospital's Board of Directors on behalf of the medical personnel. The nursing superintendent/head nurse will report to CMO about the patient and paramedical personnel and take advice in terms of manpower planning and patient satisfaction.

Medical officer: medical officers are the senior officers reporting to the chief medical officer. The medical officers are the doctors in charge of each of the speciality clinics. All the patients are discharged only after obtaining the final opinion from the medical officer. The OA of each speciality clinic take the instructions from these medical officers before instructing patients, fixing appointments, and in availing leave from regular duty.

Junior doctor: The junior doctors are those who work as post graduate students after completion of the MBBS degree. They work under the direction of the medical officer. The junior doctors handle basic science sessions for the OAs, check preliminary tests for the patient and assist the chief medical officer in surgeries. They are trained to become surgeons during their training period.

Nursing superintendent: The head OA (also called the nursing superintendent) is in charge of the entire paramedical personnel. They will be a role model for the entire paramedical department. They play a vital role in ensuring the smooth flow of the patients in the departments, the OA day-to-day activities, planning manpower, scheduling paramedical tasks, imparting training for the junior staff, and conducting continuing medical education programs for the senior staff. The nursing superintendent plans for the improvement of the OA department on the advice of the chief medical officers and medical officers.

Unit coordinators: Unit coordinators are responsible for the smooth functioning of their department. They are liaison officers between the patient, the department and the other departments. In the absence of staff, they are responsible for keeping the nursing superintendent informed, delegating duties to other OAs and ensuring that the work is completed. They supervise the junior nurses and guide them. They work with their department medical officer and the paramedics of their department to deliver the best service to the patient and towards the development of their unit.

Senior OA: Senior OAs know the rules and regulations of the organisation and will first of all be a role model for the juniors. They work under the instruction of the nursing superintendent. They handle classes for the junior OAs and demonstrate clinical functions in the training sessions. They also help the nursing superintendent in scheduling the tasks, and planning the appropriate manpower each month and year.

Junior OA: Junior OAs are trained by the senior OAs. The juniors must obey the senior OAs and respect them. They have to abide by the rules and regulations of the hospital and try to acquire the knowledge and skills required to become an efficient OA.

The OAs in the out-patient department should be efficient in fixing appointments for the patients and sorting the cases for the doctor. They should support the doctors by reminding them about the appointments for the day. OAs helps the doctors in scheduling and in the arrangement of smooth patient flow in the clinic or hospital.

Summary

In this unit the OA is given an orientation about the out-patient department. The OA plays a vital role in the patient care and patient satisfaction. Greeting the patient with a smile and communicating with them effectively creates a confidence in the patients. The OA is responsible for the adequate supply of necessary equipment and other materials in the department. OA has to check the availability of things and plan for the next day. Maintaining cordial relationships with all the departments is important for the smooth functioning of their department. To conclude it can be said the she has to be well versed not only with the clinical procedures but also in communication and maintenance of equipment and supplies.

Key points to remember

• Delegation of responsibility in handling supplies and equipment
• Keeping shelves stocked
• Keeping the treatment room in order
• Taking inventory
• Creating systems for routine procedures
• Reporting deficiencies
• Observation of waste and misuse
• Education of personnel on economic use of hospital property
• Handling all the instruments with care
• Taking faulty instruments to the service station
• Maintaining sterility of instruments
• Maintaining cordial relationship with all the departments

Student exercise

Answer the following

1. Write short notes on
   • The enquiry counter
   • Medical records
   • Maintenance of equipments and supplies
2. List the responsibilities of OA in maintaining adequate supplies.
3. What is meant by exchange system?
4. What are the different types of instruments required in the out-patient department?
5. How should telephone calls be handled?