Management Strategies in Out-patient Services

Office Efficiency and Public Relations

The OA not only assists the doctors in the cubicles and in the out-patient procedures and special procedures, but also performs secretarial tasks like staffing, scheduling and bookkeeping as part of their day-to-day duties. The OA helps to decrease the work of the ophthalmologists, so that they will be able to increase their volume of clinical diagnoses and treatment.

Scheduling review appointments

If a follow-up visit is recommended for the patient, schedule the appointment after speaking to the doctor. The date given for each patient's return must be logged in a separate book with date, time, and the name of the patient. The OA should remind the doctor every day about their list of appointments.

Handling the ophthalmologist's schedule

The OA should be efficient in fixing appointment of the patients and sorting the cases for the doctor. They should support the physician in reminding about the appointments of the day; help the doctors in scheduling and in the arrangement of smooth patient flow in the clinic or hospital. The OA should be very tactful and intelligent in handling the patient when the doctor happens to be late or otherwise engaged. To avoid overcrowding, the OA can also reschedule some of the appointments. If the ophthalmologist is going to be away, the OA needs to immediately convey that information to the patient so that the appointment can be rescheduled.

Maintenance of records

The maintenance of medical records in hospitals and clinics is very important because a lot of time can be wasted hunting for misplaced records. The records must be maintained manually, and, if possible, in the computer as well. It is the responsibility of the OA to adhere to the record-keeping system planned by the hospital or clinic. The OA should ensure that all addendum are attached to the main file of a patient so that continuity of treatment is easy.

Claim bills

Some of the patients may require bills and other certificates of fitness to claim leave in their office work. In such situations, the OA should know how to arrange for such bills and get them approved. It is important that the OA never issue false bills to patients.

Handling sales representatives

The sales representatives come to the hospital or clinic to introduce new products from their companies. Some of them frequently visit the clinic, and may even irritate/disturb the doctor. However busy the doctor may be, the medical representatives sometimes wait for hours to try to sell their products. The OA should be clever enough to systemise the patient flow and arrange for the doctor to meet with the sales representatives when necessary. The OA must also be able to explain the patient about the delay.

Staffing

The OA should also be aware of the speed of the patient flow. They must sense when more patients are expected, and when there will be fewer, and plan the staffing accordingly. They must ensure that their staffing planning reduces the patient's waiting time, and must be able to organize the roles of their subordinates so as to have the appropriate manpower required by their department.

Student exercise

• The patient is waiting for several hours with a young child, and the doctor is late due to a major surgery. How will you communicate this to the patient?
• The patient has red eye and asks for emergency appointment in the absence of the doctor. How will you react to the situation?

Out - patient services (OP)

Scope of OP services

• Preventive and promotive services (screening)
• Curative (consultation, investigations, therapeutic procedures, speciality services)
• Follow-up of discharged patient / review visits
• Rehabilitative (physiotherapy, occupational therapy, prosthetics etc.,)
• Counselling
• Health education
• Medical, nursing and paramedical education

The out-patient department is open during set, scheduled hours, and staffing will vary throughout the day depending on the patient load. To provide adequate service, the department should also have a set continuity of supervision to direct the patients to different departments and answer their questions. Competent staffing of the admission and records office will go a long way in establishing and operating a smoothly functioning out-patient department. A workable appointment system and a standardised medical records system must be followed.

Infrastructure in OPD

• The OPD must be easy for patients to navigate. So any symbols (including arrows and numbering) directing the patient to different OP stations must be kept clear and visible.
• Stations like the laboratory, radiology, and pharmacy services should be within the central part of the OPD so that they are easily accessible to the patient.
• While patients are waiting, they are a captive audience, so a waiting room's decor should be utilised to drive home facts about health, including posters, murals, pamphlets, and other display materials.
• The OPD of the various specialties within ophthalmology (like the glaucoma clinic, the cornea clinic, and the paediatric clinic) must be located in the same building. Problems in the OPD's functioning that must be rectified immediately. Prolonged waiting time of the patient because:
• Doctors arrive late or are absent from OPD for prolonged period of time
• Delays in registration
• Delays in the retrieval of medical records
• OP procedures are not streamlined properly
• There is insufficient manpower (especially during peak hours)
• The patient is directed to the wrong stations for consultation
• There is a shortage of critical equipment (slit lamp, ECG, etc.)

Dissatisfaction with amenities

• Insufficient / Unclean toilets.
• Lack of seating accommodation.
• Poor security, theft.
• Absence of female attendant when male doctor is examining lady.
• Poor transport facilities to hospital.

Strategy for ensuring the effective functioning of the OPD.

Reduce overcrowding and minimize patient waiting time by

• Screening and disposal of minor illness patients by general duty doctors, thus reducing load on speciality clinics.
• Appointment system to spread out the reporting time of patient: either 'individual' or 'block' appointments. The block appointment system calls for a certain number of patients to be present at a given time so as to provide a sufficient pool of patients; thus the physician will at no time find himself idle and it limits the pool to the capacity of the waiting room.
• Application of queuing theory modules of operations research whereby the waiting time can be estimated by noting the patient arrival rate per hour, service rate per hour and number of servers. By effective changes in these parameters and in the queue system it is possible to substantially reduce patient waiting time to acceptable levels.
• Synchronize functioning of ancillary facilities with OPD workload such that the laboratory, radiology and pharmacy are open and adequately staffed during peak hours when patients referred from the OPD arrive for these services. Also these departments are to remain open for a longer duration as compared to OPD.

Improve guidance of patients and facilitate easy understanding of hospital procedures and routine:

• Signage boards system, to direct the patient to different departments.
• Effective inquiry and reception services
• Hospital volunteers, guides
• Procedural instructions to be printed on reverse of investigation or requisition slips.

Claim bills

Billing and charges are chief sources of dissatisfaction, especially when:

• Patients are expected to handle the paperwork for their insurance
• Bills are sent before the patient's insurance coverage is determined

The OA should also be able to fill in the claim formats and get it approved by the concern doctors. It is very important that the OA be loyal to the hospital and not issue false bill when a patient will occasionally request them (sometimes patients have spent less money on treatment than they want to claim on their bills to the insurance company).

Student exercise

Answer the following

1. Explain the facilities that need to be available in the OPD
2. Describe the strategy for effective functioning of OPD

Patient Care and Patient Satisfaction

Hospitals play a vital role in restoring a patient's health, but the OA has to remember that the patient is the customer of the hospital. As such, the success of patient care and the reputation of the hospital depend to a large extent on the efficiency and compassion of the nursing staff. Therefore, ensuring a high standard of care by the nursing staff is vital to the hospital.

Patient care and satisfaction depend in large part on

• High quality nursing care
• High quality out-patient services
• In-patient hospital services
• Physician's services
• Emergency room procedures

Loyalty in hospital relationships

Positive interactions between the patient, the employee, the hospital administrators, and the doctors play a vital role in patient satisfaction.

In time of manpower shortage, high turnover and rising costs, it makes sense to consider how patient's attitudes affect employees. Evidence clearly suggests that health care organisations that enjoy higher level of patient satisfaction also enjoy higher level of employee satisfaction and overall morale.

Unhappy patients tend to become very demanding and critical, making their encounter with their caregivers negative for all parties involved. Conversely, highly satisfied patients who then praise employees orally or in writing contribute to overall employee satisfaction and to the quality of their life at work.

Patient Counselling

Patient counselling should be aimed at establishing a relationship, where in the counsellor is able to help the client to take the proper decision and act on it. The counsellor should aim to help the clients understand themselves better by informing their own needs and increasing their knowledge of the resources available to them.

What makes a good counsellor?

Personal qualities

• Respect for the rights and dignity of other people
• Honesty
• Empathy
• Emotional stability
• Active listening
• Able to keep confidentiality
• Able to express ideas clearly
• Institutional support
• Privacy
• Sufficient time for each session

Arrange for easy accessibility to counselling services

• Supply of needed resources
• Counselling skills and attitude
• Non-judgmental
• Listening skills
• Questioning skills
• Empathy (the ability understand how someone feels without imposing personal values)
• Psychological support (enabling someone to identify and explore their feelings, reactions and emotions; helping them to act on their own initiative)

What makes good counselling?

The six steps of counselling

G - Greet the patient with a smile

A - Ask about their general health condition

T - Tell them about the stage of their disease

H - Help them understand the problem in the right perspective

E - Explain the cause and nature of disease.

R - Reinforce the importance of returning to the hospital for follow-up

Good counselling consists of establishing a trusting and caring relationship with patients and giving relevant, accurate information to help patients to take appropriate decisions. When counsellors are concerned, empathetic, polite and understanding, the patients are satisfied with the health care they receive.

What are the interpersonal skills required for counselling?

Interpersonal skills are the verbal and silent ways that people interact with one another. Those who counsel patients should possess the following communication skills:

• Active Listening: Counsellors must listen to what patients say and mean. They also let patients know both verbally and non-verbally that they are listening. For example, rather than going through papers on their desks counsellors should sit facing patients and look at them while they speak.
• Attentive Behavior: Counsellors greet patients politely and make them feel comfortable. Facial expressions, eye contact, gestures and posture of counsellor would show patients that they are interested and paying attention.
• Questioning: Counsellors ask questions to encourage patients to talk about themselves. These should be questions that cannot be answered with a simple Yes or No.
• Summarizing and paraphrasing: By restating in their own words what patients say, counsellors show that they are listening and that they understand. This repetition may also help patients organize their thoughts.
• Reflecting feelings: By observing and listening, counsellors could discern how patients feel. Then they tell patients what they think their emotions are. For example, when a patient sounds and acts confused, the counsellor can point out that by saying "you seem confused". This serves three purposes:
• The patient thinks about how they feel and why
• The counsellor finds out whether the client is confused
• If there is confusion the patient and counsellor can clear it up through discussion
• Giving information: Counsellors instruct, explain and describe situations simply, clearly and accurately. They use words that patients under stand. They check the patients understanding by asking them to repeat information and instructi ons. If this feedback shows that patients do not understand or remember they explain again.
• Counselling and health education: Counselling is not the same as health education, but there are some similarities. Both aim to change behaviours in order to reduce risk; both use two-way interactions between provider and receiver; and both rely heavily on communication skills.

Yet, there are differences in the following respects

Types of counselling needed in an eye hospital

• Preoperative counselling
• Postoperative counselling
• Speciality counselling
• Group counselling (outreach programme)

Who is a good counsellor?

The counsellor should be a competent person with adequate training, experience and continued practice. They should not go beyond their levels of competence and abilities. There should be no hesitation in deciding to refer more difficult cases to those with more expertise in a particular area.

A counsellor should update their knowledge and skills continually. The counsellor's personal feelings, prejudices and biases should not interfere with their work; Cultural, ethnic, religious, linguistic, gender, class and other differences should not interfere with the relationship between the patient and the counsellor.

The spiritual strength of the helper helps a lot as well. Empathy is essential. The uniqueness and dignity of each person has to be appreciated.

In bigger hospitals they may have a separate counselling department. In hospitals where they do not have counsellors, the OA should take the role of a counsellor and counsel the patients. Listening plays very important role in patient care. So, in spite of the crowd in the department or any other reasons, the OA has to give attention to the enquiries of the patients.

Student exercise

Answer the following

1. What is counselling?
2. What are the skills needed for an effective counsellor?
3. What are the differences between counselling and health education?
4. Mention the different types of counselling needed in an eye hospital.
5. Who is a good counsellor?

Computer Applications in Ophthalmic Practice

The impact of computers in the field of ophthalmology is a reflection of many trends in office automation. Computers have control over many of the instruments in daily office use, such as the telephone, lensometer, kertometer, perimeter, ultrasound, and the copy machine.

Definition of a computer

A computer can be defined as a "device capable of accepting, restoring, retrieving and manipulating or processing information automatically at high speeds by applying a sequence of logical arithmetic or textual operations that follow instructions provided through a prearranged program".

Types of computers

• Digital Computers: Digital computers solve problems that use numbers or symbols by applying rules of logic to arithmetic operations. In hospitals, micro computers are used and are identified by their central processing unit, the amount of memory they have, the capacity of their disk drive, and their operating systems.
• Mainframe Computers: Mainframe computers are large, expensive machines that are able to store enormous amounts of information and to communicate with hundreds if not thousands of individuals simultaneously.

Components of a computer

The physical components of a computer are known as hardware. Computer hardware includes four major computer parts:

• Central processing unit: The central processing unit (CPU) is the heart of the computer. It performs logical and mathematic functions as addition and subtraction, as well as comparing numbers or names.
• Input devices: The most common computer input device is the keyboard. The mouse is probably the most popular. The mouse is used to manipulate data on the computer screen, move paragraphs around, delete words in word processing and graphics programs, and control the operation of windows programs. Some offices and hospitals use scanners, light pens, touch screens, and bar codes to enter data into the computer and control its operation. OAs can enter the output devices such as an automated lensometer, visual field machine, or corneal mapping devices directly into the computer by using sophisticated circuitry built into these devices.
• Output devices: The main output devices of a computer are video display terminals and printers.

Video display terminals

Video display terminals (VDTs), also called monitors, are the operators' main link to the computer. A good monitor with a high-resolution screen is essential to help avoid visual fatigue. If this is a problem, a glare filter can be installed directly over the front of the monitor to reduce glare significantly and thereby increase operator comfort. Colour monitors are the accepted standard for most ophthalmic offices. Although somewhat more expensive than monochrome (green or yellow) monitors, colour monitors can significantly increase operator efficiency by calling attention important details in a patient's record through the discriminating use of different colours.

• Printers: Printers are available in several varieties:
• Daisy wheel, such as that in most electric typewriters
• Dot-matrix, which uses a series of very small dots to form characters
• Ink-jet printers, which use a small ink cartridge to print with
• Laser printers, which use the same technology as a copy machine to produce an image on the paper. There are significant differences in speed, quality of output, and noise among the various types of printers.
• Storage devices: The last part of the computer is memory. Information entered into the computer needs to be stored for later use. Information in the random access memory (RAM) can be accessed by the CPU in a few microseconds. RAM has the significant disadvantage of being volatile; if the computer loses power for even an instant, the information could be lost. To store information permanently, it is written to a hard drive, which can hold information for later retrieval.

It is critical that hard drives are regularly backed up. This can be done using diskettes or cassette tapes. These tapes are capable of storing several gigabytes of information. They are crucial for restoring lost data if the computer crashes.

Use of computers in ophthalmology

1. Software applications

A computer can perform a variety of tasks in an ophthalmic office, including billing patients, scheduling appointments, keeping medical records etc. computers aid physicians in managing their finances, writing journal articles, or doing literature searches.

Billing: Accounts receivable software allows a hospital to easily prepare bills, convert codes for services into statements, and produce reminder letter for delinquent accounts and analyze accounts and referral sources.

Medical records: Most hospitals have their medical records computerized. The physician or a data entry professional types the patient's medical records directly into the computer as the patient is examined. Advantages of computerizing the medical record include better legibility, no lost records, less paper and clutter around the office, and usually better patient care. Computerized medical records also make it possible to automate clinical data research inasmuch as all records have been stored on the computer, to find and correlate disease entities, and even to critique the quality of care given. Once the patient record is entered into the computer, consultation letters can be automatically sent to referring ophthalmologists. In addition, research reports can be printed to inform pharmaceutical and contact lens companies about patients who are eligible for studies or research projects, and these companies can track the progress of the ongoing clinical research studies.

Management reports: The main reward of computerizing a medical office is that of more efficient use of the data collected daily in the hospitals, such as patient names, diagnosis, place, referring sources and procedures done. These computers make it possible for the office manager to easily determine where patients are coming from, whether a marketing program is successful, and how well office costs are being controlled.

Appointment scheduling: Larger practices with several hospitals and ophthalmologists find it necessary to utilize computers' ability to centralize appointment scheduling. The computer can be programmed to produce patient reminders; keep clinical records; keep track of drugs or contact lenses; notify office personnel of patients' reminders; keep clinical records; keep track of drugs or contact lenses; and notify office personnel of patients who repeatedly miss appointments. Computers also can call attention to patients who are receiving critically needed drugs and fail to return for routine follow-up visits.

2. Computer-controlled ophthalmologic equipment

Visual field testers : Automated visual field testers are now controlled by the use of computers. The order and size of stimuli presented, the timing, and even the monitoring of patient eye movement are controlled by a small computer present in the perimeter. Results of periodic testing are computer-analyzed, with small differences in the test results being quantified to identify disease progression. Perimetric test results are stored on disks for storage and analysis in both the humphrey and octopus perimeters.

Automated refractors: Small computers inside automated refractor control the placement of the infrared-sensing beam that maintains correct placement of the light source. The computers then carefully analyze the readings, and an accurate reading of the patient's refractive status is ready within a few seconds.

Automated keratometers: Keratometry is the measurement of the shape of the cornea. A number of instruments calculate this information automatically using microcomputers. In addition, corneal topographic measurements, as obtained by the photokeratoscope, can be analyzed and stored with the use of sophisticated computer programs.

Ultrasound: Microprocessor-controlled ultrasound equipment is used to determine the length of the eye for intraocular lens. It also can be used to measure reflectance echoes of intraocular tumors to determine type, size and location. The original A-scan equipment required the use of an oscilloscope, but today's computer-controlled equipment takes hundreds ofmeasurements, discard erroneous values and providing the ophthalmologist with an accurate measurement of globe length.

Automated lensometer: Lensometry, the measurement of eyeglasses, can now be done automatically. The Humphrey Lens Analyzer, for example, makes many measurements of the deviation of the light beam as it passes through a lens being measured. Multiple calculations are done by a small microprocessor in the lens analyzer to give the final accurate reading of sphere, cylinder, axis and prism of the lens.

Corneal topographic analyzer: The placido disk has been used to determine corneal shape for many years. It is used in automated keratometers to establish the shape of the cornea and the amount of corneal astigmatism.

Summary

In this unit, the emphasis is on how an OA can effectively play the role of an office assistant and help the doctor in scheduling his appointments and handling his mail and the patients. The OA has learned how to plan according to the flow of the patients, and to counsel patients about their disease. Computer skills help to store necessary data quickly and could use it for future reference.

Student exercise

I. Choose the correct answer

II. Fill in the blanks

1. The physical components of a computer are called _________.
2. Video display terminals also called _______ are the operator's main link to the computer.
3. The two main output devices of a computer are _________.
4. An instrument that automatically measures the corneal curvature and provides a printout of the dioptric power of the cornea is called a ________.

III. Write true or false

1. Ophthalmologic equipment may be run by a computer.
2. A printout of a result obtained from ophthalmologic equipment is a computerized act.
3. The most common output device is keyboard.
4. Automated visual field testers are now controlled by the use of computers.
5. Ink-jet printers use a series of very small dots to form characters

IV. Answer the following questions

1. What are the major advantages of computerizing in an ophthalmic hospital?
2. What are the major uses of computers in an ophthalmic practice?
3. List how computers can help the OA in an ophthalmic practice?
4. How does a computer work in an auto lensometer?
5. What types of printers are available for computers?