Servicom and Reform Unit

  • Patients Undergoing Triage at G.O.P.D


Introduction to Servicom

Public offices are the shopping floor for government business.
Regrettably, Nigerians have for too long been feeling short-changed
by the quality of public service… Nigerians deserve better!

In June 2003 President Olusegun Obasanjo declared to the National Assembly that:
“Public offices are the shopping floor for government business.

Regrettably, Nigerians have for too long been feeling short-changed by the quality of public service… Nigerians deserve better!”
Based on this, a study was commissioned to review service delivery in Nigeria which resulted in a special report which made clear recommendations – Delivering Service in Nigeria: A Roadmap.
A key recommendation of the report was for the Federal Government to initiate a far-reaching transformation of society through a service delivery
programme as a step in the process of moving towards a government that is responsive to the needs of the people.
Following the study, a Special Presidential Retreat on Service Delivery in Nigeria was held in March 2004. All Ministers and Permanent Secretaries signed a Service Compact with all Nigerians which became the basis for
the SERVICOM initiative.
In the words of the Federal Executive Council (FEC):
“We dedicate ourselves to providing the basic services to which each citizen is entitled in a timely, fair, honest, effective and transparent manner…” FEC also stated that “Public offices exist to fulfil the mandate of the government, which is to serve the people” and “All public servants/officers are under oath to deliver services to the people on behalf of the government.”


SERVICOM is also implementing a series of pilot service delivery improvement projects which aim to demonstrate how improved service can be achieved in a replaceable and sustainable way. To assist in the
replication of these pilots, a detailed tool-kit has been developed for each pilot which acts as a guide for those wishing to implement the lessons learned from the pilot.
The tool-kits are each intended to be a “how to” guide to implement the specific pilots and seek to provide advice on what to do – and what not to do –
in a user-friendly way which incorporates the materials, documents and training courses developed during the pilot.
This is the SERVICOM Tool-kit: General Outpatient Department Pilot Project.
This tool-kit has been developed by the SERVICOM Technical Team and derives from the experiences and lessons learned during the implementation of the SERVICOM General Outpatient Pilot Project at the
Keffi Federal Medical Centre and the Asokoro District Hospital over a period of two years between 2006 and 2008.

How can SERVICOM work for me?

As an ELECTED POLITICIAN, SERVICOM can help me deliver on political priorities and strategies to improve the quality of life for my constituents
• As a MANAGER, SERVICOM can help me coordinate and manage the use of resources to achieve the goals and targets set by the politicians
• As a PUBLIC OFFICIAL, SERVICOM can help me understand the work I have to do to make services more customer focused and accountable and how I can do this more effectively and efficiently. SERVICOM will provide me with opportunities to improve my skills and expertise in order to deliver a better service to my customers; and
• As a CUSTOMER, I now have a voice in determining the level and quality of services government provides, so that I can receive improved and more
appropriate services from public officials who are friendly and competent.


The Problem Addressed By This Toolkit

Long Patient Waiting Times

This tool-kit is for YOU if you have LONG PATIENT WAITING TIMES in your General Outpatient Department (GOPD) AND you want to improve
things but don’t know how.
If you have long patient waiting times in your GOPD, chances are that you also experience one or more of the 12 problems set out in the table below. This is because many of these problems are the very things that contribute to the problem of long patient waiting times.

  1. Early arrival and crowding of patients around GOPD registration point at start of the day
  2. Patients have to go through a long-winded process of visiting several windows to get registered, pay and receive their medical card
  3. Doctors are over-run with patients in clinic and they have no one to help them assess patients
  4. There is no system for identifying urgent and nonurgent patients
  5. Urgent cases sent to Accident and Emergency (A&E) from GOPD are sent back to GOPD
  6. Patients with only minor questions or issues still have
    to wait a long time to see the doctor
  7. Some patients wait to see the GOPD doctor but they’re in the wrong clinic
  8. Until seen by the doctor, patients remain anxious not knowing if they are in the system and will receive their rightful place in the queue
  9. Patients have no way of knowing how long they have to wait before they are seen
  10. Queue jumping is a perceived or real problem
  11. Doctors’ attendance and contribution to GOPD is uneven
  12. Doctors, nurses and staff of GOPD are stressed because of the chaos in GOPD and the anxiety of patients.

In this tool-kit, we will show you how you can address these problems and thereby make:
• drastic reductions in your patient waiting times; and
• dramatic improvements to your GOPD processes for the benefit of both staff and patients.
We will do this by showing you how to implement a relatively simple 3-part solution.
What’s more, you won’t need a lot of money or resources to implement this solution. What you need is a real desire to improve things and a willingness to put in some time and effort to drive things forward.

The solution offered here has been implemented and shown to really work in Nigeria.
Implementing this solution will enable you to achieve:
• A drastic reduction in patient waiting times (by as much as 80%)
• A more easy, relaxed and satisfying experience for patients attending GOPD
• A marked improvement in the quality of patient care in GOPD
• The freeing up of about 2 hours of each GOPD doctor’s time per clinic day

• A calmer, more ordered and organized GOPD; and
• Happier, more relaxed staff
This is what was achieved in Keffi Federal Medical Centre (FMC). Keffi FMC is one of several Nigerian hospitals where a SERVICOM pilot project aimed at improving service delivery to patients attending GOPD
was implemented, funded by UK Government’s Department for International Development (DFID).
And it is what you could also achieve in your GOPD. The table provides examples of what people said when they saw the results of this solution at Keffi FMC.

“I want what they’re having!” – This is what patients and clinicians were saying after seeing the dramatic improvements made in the General Outpatient Department (GOPD) of Keffi FMC.
Even patients in nearby hospitals were reported to be asking the authorities to “…..perform the same magic” in their hospital.
When a friend of the Keffi FMC SERVICOM officer visited the GOPD he commented: “I did not know this type of thing existed in Nigeria.”
Another visiting colleague from a state university had commented: “I did not know that Keffi had gone ‘international’”
When a staff member from Cross River State Government visited Keffi FMC they expressed surprise that: “This kind of thing worked in this country” and commented: “Before we came here, we thought this was
just talk. But now we have come, we see it with our own eyes. It is as if it’s not real. “
When a university lecturer from the Nasarawa State University attended Keffi so that his wife can be seen at GOPD he commented: “I don’t know what you did there, we attended Keffi at 2:00 pm, were given an
appointment for 2:20 pm, and by 2:22 pm we were seen. I’ve never seen anything like it. It was like magic”.
When the representative of the Emir of Keffi visited the Keffi FMC GOPD he commented: “Before 30 minutes everything was finished. Miniti biyar, miniti biyar (5 minutes, 5 minutes). Please continue”.


Solving the Problem of Patient Long Waiting Time


The biggest problem that plagues almost all GOPDs (as well as many antenatal and specialist clinics) is long patient waiting times. It is easy to
know the problems. They are clear for everyone to see. But to know what to do about them is more difficult. Here we offer a 3-part solution that has
been shown to work in Nigeria.
But before we talk about this solution, it is good to understand the main problem and its underlying causes.
Attending a GOPD clinic in Nigeria today is, for most people, an uncertain experience. Patients and relatives come into the GOPD not knowing how much of their day they have to spend in the hospital before they are
seen. Many expect to spend the good part of the day there – from early morning to late afternoon.
And while waiting, they are far too nervous to leave their place in the queue to attend to what they need, it to go to the washroom, get food or drink, stretch their legs or attend to their business outside the hospital.
What they do know with certainty is that there will be a long, often uncomfortable queue; a queue that starts gathering from early in the morning, around 6:30-7:00 am (well before the scheduled start of the clinic).

They also know that their day, as well as being long, is likely to be an anxious one. Not just because they are already worried and concerned about their health, but also because they know that they need to be on the
watch for other people’s attempts to get ahead of them in the queue.
But what causes the problem of long waiting times?
The problem of long and unpredictable waiting times is not caused by one single factor. It is caused by a number of factors which compound together to create this problem. Many of these problems are the very same problems we identified in section 2. So, by addressing these problems, we will not only reduce patient waiting times but also make dramatic improvements to the GOPD experience for patients and staff alike.
While each of these problems appears to need very different solutions, what we found is that all these problems stem from weaknesses in only three areas, and if we can strengthen these three areas, we can not
only address all these problems but also reduce patient waiting times.
These three areas form the backbone of our 3-part solution and are as follows:
• Changes to the REGISTRATION process
• Introduction of nurse TRIAGE prior to clinic; and
• Implementation of a patient APPOINTMENT system

How solutions relate to the underlying causes of long patient waiting times

In this section we will look a little more closely at each of these problems and see how our solution – and its 3 parts – helps to address our main problem of long waiting times.
In section 4 we will put it all together and in section 5 we will describe the steps you’ll need to take to implement this solution.

3.1 Registration:

Two of our problems stem from the current way in which many registration windows are run and can easily be improved through a few small changes here.
Changes to the registration process addresses problems 1 and 2

Problem 1: Early arrival and crowding of patients around GOPD registration point at start of the day

Often patients (perhaps as many as 60-70% of them) arrive at the GOPD at the very start of the clinic or several hours ahead of it.
Why do they do that?
In many hospitals the medical records registration window closes early; often much earlier than the close of clinic time. For example, some medical records registration points for GOPD close as early as 12:00
noon when the clinics continue to run until at least 4.30 pm.
Patients learn this over time. They realise that unless they get their registration completed by the closing time of the registration point, they cannot get to see the doctor that day.
Because they also know that there will be a long queue of people waiting to be registered, they figure that if they arrive early, they will secure for themselves an early place in the queue. These factors contribute to the early arrival and crowding of patients around the registration point. This
leads to huge congestion and stress around the registration point.
If you think it through, you would realize that there is no specific reason why registration has to close so much earlier than the close of clinic. This is just how things have always happened and no one had ever stopped to
think as to why. But continuing like this does not serve the patient well. What’s more, no practical system, however well organised, can process a large group of people at the same time. Inevitably a good number of
them will have to wait a while to be processed.

Problem 2: Patients have to go through a long-winded
process of visiting several windows to get registered, pay
and receive their medical card

In many GOPDs patients have to go through many steps to get registered and receive their medical card.
This means that patients have to go through a stressful and long-winded process of queuing from window to window before they can even start waiting to see the doctor.
This is what often happens:
First, when patients arrive at the hospital they go straight to the outpatients’ registration point. Here they all crowd anxiously around a small registration window, trying to muscle-in to ensure they get noticed by the
staff and receive some service. Once noticed, their registration details (name, age, sex, address etc) are written down in a book.
Second, they then need to pay for their card or for seeing the doctor. At this point patients have to go to another window often in a different part of the
hospital to pay for their card and collect a receipt as evidence of their payment. This involves another long and stressful queue. Third, having collected their receipt they then have to come back to the original
registration point, present their receipt as evidence of payment so that they can finally be issued with their card. This is yet another long and stressful queue.
The anxious queuing and crowding is repeated again and again at each service window. You can imagine how uncomfortable this is to go through but especially so when you may be feeling weak, unwell, or perhaps
even in pain.

3.2 Nurse Triage:

Many of our problems in GOPD can be eased through the introduction of nurse triage in GOPD. Triage is a process of prioritizing patients based on the severity of their condition. In other countries triage is most
commonly used in accident and emergency. Here, we use an adaptation of the process, suitable for Outpatient services in Nigeria. We recognise that many hospitals have already started some form of nurse
assessment prior to the patient being seen by the doctor. In many cases, this is in the form of a nurse taking the patients’ blood pressure. Here our concept of nurse triage is slightly wider than that and hence its
benefits greater.
Although the introduction or the extension of nurse triage means allocating nurses to this work, it also helps to free up the doctors’ time which is more
expensive and often less available. In this sense this change provides a true example of efficient use of available resources. It also brings organisation and protocol into the system which serves to assure both patients and staff alike.
Introducing nurse triage addresses problems 3, 4, 5, 6, 7, 8 and 9.

Problem 3: Doctors are overrun with patients in clinic and they have no one to help them assess patients

It may sound a little strange to say that doctors have no one to help them assess the patients. Who else should assess the patient apart from the doctor you might ask.
The reality is that a part of the doctor’s consultation –
especially for new patients – almost always involves the
taking of the patient’s vital signs. This means
measuring some or all of the following:
• blood pressure
• pulse
• weight
• height
• blood sugar (through a urine sample)
• waist measurements (recent studies suggest that the waist to height ratio is very strong indicator for heart disease) If it was left to the doctor to take all these measurements it would take the doctor an average of between 3-5 minutes per patient to complete the measurements for each patient. Assuming that each doctor sees an average of 30 patients in one day,
taking these measurements will take up a staggering 90-150 minutes of a doctor’s time per day. This is easily a third to almost half of a doctor’s time per day!
This is 90-150 minutes of potential consultation time per doctor per day spent on taking basic vital signs. If some one else could take on this task and provide the results to the doctor, then the consultation time can be
quicker and a full 90-150 minutes of the doctor’s time will be freed up for seeing more patients.
If a GOPD has 4 doctors, this amounts to a total of 360-600 minutes of a doctor’s time per day. This is a staggering and expensive 6-10 hrs of doctor’s time per day that is used on an activity that nurses could easily support.
Nurses are trained and qualified to do this and their time is more available and less expensive than that of a doctor’s. Using nurses in this way is a more efficient and effective way of using existing resources.
This is an example of how you can use what you have in a more effective and efficient way. It’s not always about having more of something. It’s often about how you use what you have. It is also a good example of
how team-work can bring benefits beyond the individual skills of the team.

Solution 3

Negotiate an agreement with the head of nursing to bring in a number of nurses to the GOPD to assess the patients’ vital signs.
When doing this both doctors and nurses need to be satisfied that the nurses are comfortable about taking the vital signs and can discharge this role effectively.
What is therefore needed is for GOPD doctors and the nurses assigned to support the triage process to sit down together to jointly:
• agree how to undertake the triage process
• define the triage protocol
• define any training needs
• agree how to address any training needs.
We will say more about how to introduce triage later in this tool-kit.
Problem 4: There is no system for identifying urgent and non-urgent patients
We have demonstrated how triage helps the doctor with assessing patients. But that’s not where the benefits of triage end. Triage offers the staff and
patients a host of other benefits too.
Triage also enables the nurses to quickly assess the urgency of the patient’s medical condition and to identify and fast-track urgent medical conditions to the doctor quickly. This is a key and important aspect of triage. Fast-tracking urgent cases can save lives.

Solution 4

Introduce triage.
And as part of the triage, build-in a process where urgent medical conditions are identified and fasttracked to the doctor.
This is a good example of how one solution can address more than one problem.
Problem 5: Urgent cases sent to Accident and Emergency (A&E) from GOPD are sent back to GOPD
This is one of the common problems experienced in GOPDS which is most easily resolved.
When a GOPD doctor sees a patient and realises that the patient needs urgent attention, the doctor naturally refers the patient to where the patient can receive the necessary care. Often times this is the Accident and
Emergency Department.
However, in some hospitals, when a patient is referred to from GOPD to A&E they are refused and sent back to GOPD. This is because, having first presented in GOPD, they are considered to be a non-emergency case.

There are examples where the patient is shuttled back and forth between these two departments, while all the while the patient’s condition is deteriorating. The GOPD doctor is unable to treat the patient and the patient will not be seen by A&E staff.

Impact of disagreement between A&E and GOPD One day, when SERVICOM was still evaluating the state of GOPD services at Keffi FMC we
noticed an elderly man pushing a very ill young woman in a wheel barrow.
The young woman was extremely pale and unwell and was discharging an offensive smelling discharge of blood and pus from between her legs. The elderly man was extremely distressed and frustrated at not being able to receive care for his daughter.
The elderly man was accompanied by another woman – the patient’s mother – who was following behind them. The woman had a piece
of cloth in her hand and was continually bending down to use the cloth to try to mop-up her daughter’s discharge of blood and pus which was spilling from her to the ground.
The patient was not able to receive treatment at GOPD and would not be seen by A&E and so the family was sent from one department to the
other in the hope of receiving care.
It became apparent later that the patient had suffered a miscarriage which had since become severely infected.

The infection had been present for several days and the condition
of the patient had severely deteriorated.
The extent of the infection was unclear. It was also unclear if there were any remains of a foetus that still needed to be evacuated.
What was clear was that the patient needed urgent care and was not getting it.
There are examples where the patient is shuttled back and forth between these two departments, while all the while the patient’s condition is deteriorating. The GOPD doctor is unable to treat the patient and the patient will not be seen by A&E staff.
The cause of this problem was the absence of an agreement between A&E and GOPD as to what cases could be referred from GOPD to A&E.
The problem was not new. What was new was the awareness that the situation needed to change and the doctors of GOPD and A&E were jointly responsible for changing it.

Solution 5
All that is needed here is for the Head of GOPD and A&E to sit together and agree a protocol that defines which patients can be referred to A&E
from GOPD.
The protocol defines the medical criteria that will qualify the patient for urgent referral to A&E. This protocol is part of the triage protocol.
After registration the patient is seen and assessed by the triage nurse. If the criteria for an urgent medical condition are met (these are referred to as
trigger points), the nurse fast-tracks the patient to the GOPD doctor.
The GOPD doctor then sees the patient and if the urgency of the patient’s condition is confirmed the patient is then referred by the GOPD doctor to the appropriate department.
Where this department is the A&E, because the patient’s condition meets the criteria for referral to A&E and the heads of both departments have an agreement set out in a protocol, the patient is accepted at A&E.
Problem 6: Patients with only minor questions or issues still have to wait a long time to see the doctor At the moment, there are a few patients in each
clinic who come to see the doctor to ask simple questions, or they have common problems that a qualified nurse can easily address. But these
patients have to wait along with other patients to see the doctor.
If their issues can be addressed quickly, then not only will it save the patient a lot of time, but it frees up the doctor’s time to see other patients and eases the pressure on the clinic.

How triage can help address minor patient problems
When SERVICOM was introducing an extended triage process in Calabar General Hospital, a GOPD doctor gave us an example of a new mother who had come to GOPD to see the doctor. This new mother had come with her small baby and she was complaining that her baby would not stop crying.
She had waited over 2 hours to see the doctor. Eventually she sees the doctor and the first thing the doctor asks her is about when she had last fed the baby. The answer she gives provides the solution. She had not fed the baby since early morning. She did not realise that the baby needs to be
fed every few hours. The doctor then asks her to go and feed her baby to see if the baby will stop crying. And when she does, the baby stops crying.
A triage nurse could easily have asked the same question, after first checking the baby’s vital signs. The nurse could have asked the
mother to try feeding her baby. The mother could have still been given an appointment to see the doctor, but if the crying had stopped
and the baby’s vital signs were normal then that appointment could easily have been given to another patient, thereby saving the mother’s time as well the time of the doctor and also of the other patients waiting to see the doctor.

This does not mean that if the patient still wants to see the doctor they cannot. But often if the patient’s question is answered by the nurse and their problem solved, the patient will decide that they no longer need
to wait to see the doctor. And if triage can help address even 5% of these minor problems, that is still 5% fewer patients waiting in the system.
Of course, doctors and nurses both need to be satisfied that the issues or questions that the nurse provides advice and information on is within the
capacities and qualifications of the nurses. But this is something that the doctors and nurses can develop and agree as part of the triage protocol. They can agree which conditions/situations the nurses can provide
advice on and which signs need to be present / not present for them to provide this advice. And with time, examples of issues that the nurses can easily address can be identified and added to the protocol.
If the conditions do not apply or nurses are in any doubt, or if the patient requests it, the nurses simply
continue to give an appointment to the patient.

Solution 6
Introduce triage and include treatment of minor conditions within the triage protocol.
The triage protocol sets out the conditions/ situations that the triage nurse can provide advice on. Doctors and nurses can agree this together, and develop this over time as examples of suitable conditions arise.
Problem 7: Some patients wait to see the GOPD doctor
but they’re in the wrong clinic
A certain percentage of patients arrive at GOPD, when in fact they are looking to attend a speciality clinic.
Some of these patients may be redirected to the right clinic before they join the GOPD queue, but some join the GOPD queue, wait to see the GOPD doctor and only then realise that they are in the wrong place. This
not only wastes the time of the patient but also that of the doctor.
The triage process would allow the triage nurses to identify these patients and direct them to the right clinic before they join the queue to see the doctor.
This saves the patients’ time and prevents this category of patients from unnecessarily filling up a GOPD doctor’s clinic.
Solution 7
Two solutions can be applied here. First – medical record staff at the registration point can enquire from the patient which clinic they have to
come to attend and re-direct any who are at GOPD by mistake.
Second – the triage nurses can ask the patient which clinic they have come to attend. It is best to ask this question prior to the taking of vital signs, so that vital signs are not taken unnecessarily.

Some patients may not be clear which clinic they have come to attend and may simply present their referral letter to the nurse. This would still enable the triage nurse to identify if the patient is attending the wrong clinic and redirect them appropriately

Problem 8: Until seen by the doctor, patients remain anxious not knowing if they are in the system and will receive their rightful place in
the queue Another benefit of triage is that it’s an activity that
takes place between patient registration and the doctor’s consultation. This serves to practically and psychologically break up the wait time for the
patient and thus reduce patient anxiety and stress about the wait.
It also helps the patient to feel that:
• they are in the system
• that “something is happening”; and
• they are being looked after and thoroughly assessed.
This helps to increase their confidence in the quality of their care. This is important because studies have shown that the confidence of the patient in the quality of their care is an important factor in their healing and
the clinical outcome of their condition.
Solution 8
Bringing organisation to the GOPD by introducing a triage and appointment system brings transparency and clarity to the system.
Patients know that they are in the system and their confidence in the system is increased.
3.3 Appointment System: Here we examine the problems that can be eased
through the introduction of a simple appointment system in GOPD. We recognize that many hospitals have introduced a numbering system. While the numbering system is a step in the right direction, the suggested appointment system enables the patients to have a specific time for their appointment, which brings clarity and ease to both staff and patients.
Implementing an appointments system addresses problems 9, 10, 11 and 12.
Problem 9: Patients have noway of knowing how long they have to wait before they are seen
In most Outpatient departments once patients are registered, they are directed to the waiting area to wait to be called to see the doctor.
And of course usually they wait and wait, sometimes for as long as 6 hours but on average for around 2 or 3 hours.
And often there is no clear relationship between the time the patient arrives and the time they are called to be seen by the doctor. The process seems ad-hoc, pot-luck. As one doctor in Keffi FMC described it “it is
like the survival of the fittest!”
There is no way for the patients to know if they would have to wait 6 hours, 3 hours or an hour before they are seen.
What the patients do know is that they better not leave the waiting area because they could be called in at any time, even if thirst, hunger or nature calls.

When patients don’t have any idea of the length of their wait, three things happen:
• First psychologically the waiting time feels longer
than it actually is
• Second, the patients’ frustration and anxiety is heightened because they don’t know if they are in the system and if other people are jumping ahead of them in the queue. This anxiety makes patients want to huddle as close to the consulting room door as possible, and be on the look-out for patients jumping ahead. This sometimes breaks into conflict between
patients and between patients and staff and generally creates stress for all concerned; and
• Third, the waiting time becomes unavailable to the patients. What this means is that the waiting time becomes wasted time; a time which the patients cannot use for anything else. This creates frustration.
If on the other hand, the patient is given a clear time when they will be seen, then:
• The waiting interval does not feel as long
• The patients know that they are in the system and they have been given a rightful time for their turn to see the doctor. This helps them relax and not be so frustrated or anxious about being left out of the system or about other patients jumping ahead of them in the queue; and
• The waiting time itself becomes available for the patient to use in whatever way they chose.
Solution 9
What is needed is a systematic way of allocating to patients, as they arrive, a specific time when they will be seen. This can be done through introducing an appointment system.
This was introduced with enormous success in FMC Keffi. When this was introduced not only was order and organisation brought to the GOPD but the waiting time was drastically reduced to:
• 15-20 minutes from the time of their appointment to the time seen by the doctor (i.e. the actual waiting time to see the doctor was reduced to 15-20 minutes)
• Just over an hour to 1 hr and 20 minutes from the time the patient arrives at registration to the time patient leaves the doctor (i.e. the total time the
patient needed to be processed was reduced to only 60-80 minutes).
We will say a lot more about this later.
Of the three parts of our solution, introducing an appointment system is the single most impactful part of our process to reduce patient waiting time.
And as you read through the rest of this tool-kit, you will realise that the benefits of an appointment system go far beyond simply reducing waiting time.
One of its many benefits is that an appointments system educates patients, over time, that they can arrive at any time in the day and right up to the close of the clinic and still be able to be registered and get an
appointment to see the doctor. This reinforces to the patients that they need not all arrive early in the morning thus preventing over-crowding early in the day. Thus it also helps to even-out the flow of patients
to the GOPD.
And this is exactly what Keffi FMC found when they introduced their appointment system. Patients quickly changed their arrival pattern to the GOPD and the early morning crowding that was so common-place
prior to the introduction of an appointment system was vastly eased.
We will explain later in this tool-kit what this appointment system looks like and how you can go
about introducing it in your GOPD. As with other parts of our solution, once you know how to introduce it, it becomes simple to introduce.
Problem 10: Queue jumping is a perceived or real problem
Where there is no transparent and clear system in GOPD, it becomes very easy for patients to jump the queue or to put the staff under pressure to give them priority.
Often times, patients believe there is queue jumping or favoritism when all that has happened is a minor mix up in the way the medical records department has stacked the patients’ records and sent them to the
doctor’s clinic. And because in most GOPDs doctors call the patients according to whichever medical record is highest on the pile, this may result in the doctor calling to see a patient ahead of another patient
who had arrived a little earlier.
The introduction of a triage and appointment system brings organization and importantly transparency to the system.

With this system, patients will be registered, triaged and seen by the doctor according to their arrival time.
The earlier they arrive the earlier they will be seen. And doctors will be calling the patients according to their appointment time – not according to whichever medical record is highest on their pile.

Thus, having a system reduces both the likelihood and the perception of queue jumping.
Solution 10
Once again the introduction of a triage and an appointment system would
considerably alleviate the likelihood and perception of the occurrence of this problem.
Problem 11: Doctors’ attendance and contribution
to GOPD is uneven.
Staff working in GOPDs will recognize that the uneven and sometimes unpredictable attendance of doctors at GOPD is a significant factor contributing to the long waiting times of patients.
Many hospitals find it difficult to address this issue with doctors. One reason for this is that doctors can easily dispute the frequency of their untimely arrival and departure times, and managers do not have any
data with which to support their case.
What the appointment system provides is:
• clear data on each doctor’s arrival and departure
time (through clinic start and close times for each doctor); and
• data as to the number of patients seen by each doctor on a daily basis.
When collected over a period of time, this data provides GOPD managers and staff with irrefutable and compelling data with which to address doctors’ attendance times in GOPD.

There are two approaches through which this data can be used to address the issue with doctors.
• The management approach: The Head of GOPD / Head of Medical Services / CMD / other responsible senior manager can meet with the relevant doctor/s (individually or with all GOPD doctors as a whole)
and use this data to discuss and agree an improvement in the doctor’s performance. Changes in the performance of the doctor can then also be
monitored using the same data which can be collected on an on-going basis; and
• The peer-review approach: Where managers do not wish to address the issue directly, an indirect approach can be used which has been proven to be a highly effective way of addressing the problem. This approach was used by Keffi FMC and is described here.
• What Keffi FMC realised was that by simply capturing and collating this data and presenting it to the GOPD medical team, the doctors themselves
started to challenge each other on a peer to peer level and thereby pressured each other to change their behaviour. It is said that the “the greatest factor affecting our behaviour is the expectation of
our peer group.”
• Where one doctor does not perform his or her share, that share has to be covered by the other doctors and it is the other GOPD doctors whose
load and pressure increases. Doctors are keen to maintain good relations with their peer group, sometimes even more so than with management
staff, so pressure from colleagues can be a highly effective way of changing doctors’ behaviour.
• At Keffi FMC this approach provided an effective yet indirect way of effecting sustainable change in the doctor’s behavior. Using this approach
management were able to take a back seat and observe the process self-regulate itself.
The approach you choose to use will depend on your local circumstances. However you can use the peer review approach first and only escalate it to the management approach if the peer-review approach is
not successful.
Regardless of the approach used, what is important is that GOPD – through an agreed mechanism – continues to collect and collate the data from the appointment system for on-going monitoring and evaluation.
Solution 11
Collect the data from the appointment system to examine the issue with the doctors.
Problem 12: Doctors, nurses and staff of GOPD are stressed because of the
chaos in GOPD and the anxiety of patients Doctors, nurses and staff of GOPD are themselves often stressed from the continuous crowding and poor organization of their GOPDs.
Every day the GOPD doctors and staff come into the clinic, see the long queue of patients and do not know how long they would have to stay behind before they finish seeing all the patients. And staff have to experience this on a daily basis, every working day. To deal with this on a daily basis is physically and emotionally draining. This may be part of the reason that some doctors try to minimise their time in GOPD by arriving late and leaving early.
When doctors come into clinic they have no idea how many patients they have to see, they don’t know how many of their colleagues will be in clinic taking a share of the workload and they don’t know how long they
have to stay behind to finish seeing all the patients.

Such a situation leads some doctors to hurry through the patient consultation session and speed through the diagnosis and discussion of treatment options.
At worse this may lead to misdiagnosis and at best may leave the patient dissatisfied that their problem has not been truly understood and addressed.
An appointment system can significantly change this situation. Such a system provides the doctor with a clear allocation of minutes per consultation time, enabling the doctor to know exactly how long s/he has
to consult with the patient and still be on track to see all his/her patients before the scheduled close of his/her clinic. When designing an appointment system doctors work out the average time they need to spend with a patient in order to carry out a satisfactory consultation. In Keffi
FMC they decided that on average they needed 7 minutes per patient. They recognised that they need more time for new patients and perhaps less time for follow-ups but on average this worked out at around 7 minutes per patient (or 3 appointments per 20 minutes). As this was accompanied with the introduction of triage, it meant that the doctors were not spending part of their consultation time taking the vital signs of patients.
The appointment system helped doctors realize that they can spend around 7 minutes or so consulting each patient and still have time to see all their patients by a per-agreed time. They realized that they need not hurry the consultation but can pace themselves and assess the patients properly. This, together with the order and organization brought by the system helped
create a calmer, more orderly environment and helped transform the atmosphere of the GOPD to one of calm confidence for all concerned.
A calm orderly atmosphere encourages the doctors and staff of GOPD to attend to their duties, be proud of their working place and be happier about working there.
Solution 12
Introduction of a triage and appointment system helps to bring order, calm and organization to the GOPD, thereby transforming its atmosphere into a calmer, easier more desirable environment to work in, thus encouraging staff to attend to their posts.
It also helps doctors realise how much time they can easily spend with each patient without delaying the clinic, thus preventing them from the need to rush through the consultation time. How hurried consultation can lead
to misdiagnosis and poor treatment
One day at Keffi FMC a lady arrives at GOPD feeling unwell. She was not from Keffi but had come to see her relatives who lived in Keffi.
She had not been seen by Keffi FMC before. She arrives at 8:00 am. At the time there was no appointment and triage system at Keffi
FMC, so the patient waits until 2:00 pm to be seen by the doctor. When she goes to see the doctor, the doctor
is stressed. He had had a long stressful day. There were queues of patients crowding around his clinic door and the doctor did not know how many more patients there were still left to be seen. So, he keeps the consultation short.
There was little privacy and so the doctor did not examine the patient.
What was noticeable was the fact that the patient was pregnant and she was complaining of pain. The doctor was in a hurry. He prescribes
vitamins, folic acid and an ultrasound scan and sends the patient to be scanned. When the patient exited the consultation room,
SERVICOM interviewed her. In the course of the interview it became apparent that she was in fact in the early stages of labour and
needed to head straight to the labour ward.
SERVICOM only spoke to the patient. They did not examine her.
She did not need expensive medicines or to pay for an unnecessary and time-wasting ultrasound scan. Such a situation could have been easily
prevented if the doctor had not hurried through the consultation and taken a little more time with the patient.


Putting it all together: model procedures


PART 1: Registration
• Patient arrives at the registration point
• The registration officer and the cashier now sit next to each other at one service window
• This service window now opens 20 minutes ahead of the start of the triage process and stays open until 40 minutes before close of the GOPD clinics
• Patient registers with the registration officer
• Patient pays the cashier – who is now sitting next to
the registration officer – for their medical records,
hand-card and consultation fee. The cashier gives
the patient a receipt for their payment
• The patient hands the receipt over to the registration
officer who then prepares the patient’s medical records and their hand-card
• The registration officer gives the patient their hand-card
• The registration officer also gives the patient a small card with a number on it. This card gives the patient their number for their turn in the triage queue. We will refer to this as the Triage Queue Number Card. (see
picture 1)

The registration officer also writes down this Triage Queue Number on the top corner of the patient’s medical records; and
• The patient is directed to the waiting area for triage and is advised to wait until their number is called.
[Note: You will note from the accompanying DVD to this tool-kit that at Keffi FMC they introduced another step prior to the registration process. This step provided the patients with a queue number for presenting at the registration window. This step was introduced as a way of increasing order in the way patients presented at the registration window.]
PART 2: Triage
• Medical records staff/attendants take a batch of the newly prepared patients’ medical records from registration over to the triage nurses
• There is 1 triage nurse for every 2 doctors. This ensures that triage itself does not become a bottle-neck
• Triage starts 20 minutes after opening of the patient registration window
• The triage nurses call the patients to be triaged using the Triage Queue Number (which is also written on the top corner of the patients’ medical records by the registration officer)
• Once the patient enters for triage, the triage nurse collects the patient’s Triage Queue Number Card.
These are returned to the registration point at the end of the day
• The triage nurse checks that the patient has come to the right clinic
• The triage nurse then asks the patient about the reason for their attendance and addresses any minor queries
• The triage nurse then assesses the patient using the agreed triage protocol (see picture 2)
• The patient’s triage results are recorded directly onto the patient’s medical records ready for the doctor to view; and
• Triage stays open until all patients registered for that day are triaged.
PART 3(a): Appointment given
• Having completed the triage process, the triage nurse proceeds to give the patient a specific time of appointment to see the doctor. Appointments are
given only for doctors who have arrived at clinic that day. This will be something that the triage nurses will check prior to the start of triage
• Each triage nurse is responsible for the appointment bookings of 2 doctors per clinic day. The triage nurse looks at the appointment sheet for the doctors s/he is responsible for and gives the patient the next available appointment for the day. On occasions the patient may ask for a different appointment time to the one offered. Using an appointment system
enables the triage nurse to offer the patient a later appointment slot in the day, as suits the patient.
Triage nurses should check with the patient that the appointment time offered is suitable for the patient and if not offer an alternative appointment time
• The triage nurse writes down the patient’s name on the appointment sheet against the patient’s appointment time
• The triage nurse then gives the patient a card with their appointment time written on the card. We will refer to this as the Appointment Time Card. (see picture 3).

• The triage nurse also writes the time of the patient’s appointment on the front corner of the patient’s medical records. This provides a cross reference to ensure that the correct medical records are used for
the right patient and according to the correct appointment sequence
• The triage nurse then directs the patient to wait in the doctor’s waiting area
• The patient is advised that if they have some business to attend to prior to their appointment they can go and do that, as long as they are back at least
20 minutes ahead of their appointment
• The triage nurse continues to give appointments until EITHER her appointment sheet is full OR as soon as the time gets close to the first appointment time on that sheet. At this point triage nurse signs and
dispatches that sheet together with the medical records relating to that sheet to the relevant doctor.
Once the sheet is dispatched, the triage nurse continues to give appointments on her continuing appointment sheets. Picture 3: Example of an Appointment Time Card Additional Information on the appointment process
• At the start of each clinic, the triage nurse checks with the doctors they are covering what time the doctor wishes to take their lunch break. This is agreed at start of every clinic. The triage nurse ensures that s/he
does not book any appointments for the doctor during the doctor’s agreed break times
• The triage nurses have a separate set of appointment sheets for each doctor. (see picture 4)
• New appointment sheets are used every day
• Each appointment sheet is divided into a number of appointment slots
• We recommend no more than 9 appointments per sheet
• Each sheet needs to be dispatched to the doctor as soon as it is full. If there are too many appointment slots on a page it would take too long for the slots to be filled and would delay dispatch to the doctor
• If the time for the first appointment on the sheet arrives before the appointment sheet is full, the sheet needs to be dispatched to
the doctor with some of the appointment slots unfilled
• When this happens another sheet needs to be used to give appointments for the remaining unfilled slots. Otherwise there will be a gap in the clinic
• The only occasion when slots can be left unfilled is if the clinic is running late. In which case the unfilled appointment times, if left unfilled, gives the clinic a chance to catch up
• Appointments start at the agreed clinic start time and end at the agreed clinic close time
• Each appointment slot is allocated a pre agreed estimate of minutes for consultation.
In Keffi FMC the doctors decided to give 3 appointments per 20 minutes. This worked well
• This meant that every 3 patients were given the same appointment slot. This provided the doctor with a degree of flexibility in the
consultation time; and
• The triage nurse continues to fill-up each 9 slot appointment sheet until all the slots are filled OR until the time reaches within a few
minutes of the first appointment on that sheet – which ever occurs sooner.

• If the triage nurse identifies an urgent case, s/he writes urgent on the corner of the patient’s medical records. S/he then writes the patient’s name in the next appointment slot but then writes “urgent- fasttracked to Dr” against it. (This is so that the clinic is able to recover any delays caused by the inclusion of the urgent patient in between other appointments)
• The patient’s records are then taken immediately to the doctor and the doctor is notified that this is an urgent case; and
• The doctor can then call this urgent patient to be seen next.
PART 3(b): Doctor’s consultation
• Clinics should be scheduled to start within 5-10 minutes of the start of triage
• Once the doctor receives the next appointment sheet and the medical records related to that sheet, they or their attendant call in the name of the patient with the next appointment time
• The patient presents their Appointment Time Card to the doctor, who collects them and returns them back to the triage nurses at the end of each day; and
• Before starting his/her consultation, the doctor or his/her attendant writes down the actual time of appointment against the patient’s allotted
appointment time. This is recorded on the same appointment sheet that was received from triage.
Picture 4: Example of an Appointment Sheet (surnames blurred to ensure confidentiality) Appointment sheet data can be used for monitoring and evaluation
• A comparison of actual and allocated appointment times provides details of patient waiting time and enables GOPD to monitor
impact of the appointments process on the patient waiting time
• The data on the appointment sheet also provides the number of patients seen by each doctor every day. This information can be collated to monthly numbers for comparison of doctors’ performance; and
• The appointment sheets also provide information as to start and end time of clinics by each doctor, which can also be used for improvement of doctor’s attendance times.


Implementing the Solution


So far we have discussed the problem, outlined the results you can achieve and how the 3-part solution works in practice.
In the following sections we explain how you can go about implementing this solution step by step.
Before we start, it is important to remember that in order to be successful in implementing this or any other solution, two things are needed:
• the technical elements of the solution need to be in place; and
• the people who are going to be affected by the solution have to understand the solution and be involved and willing in its implementation.
Research shows that regardless of how good your solution is, if the people are not brought along with you every step of the way, your solution will not be successful. There are no short-cuts to this.
This will of course be hard at times and there will be resistance. However it is important to remember that this is normal. And unless you involve staff,
listen to them and take them along with you, you will not succeed. You may of course implement the process – in the short term, but if staff are not brought into the process they will not keep it up in the long term.
You will need to involve all staff of GOPD. This means involving not only the department heads but as many of the medical, nursing, medical records and
attendants staff working in GOPD as possible.
Involving staff often means that the process of making changes will take longer, as time will be needed to talk to staff, to inspire them and to listen to their concerns and views. Time is also needed to allow staff to get used to the idea. Thus the process of change needs time. As they say “the dough needs time to rise”.
Once the ground of the hearts and minds of staff are prepared, it will be much easier to sow the seeds of change.
It is a natural process. It cannot be hurried any more than you can hurry the dough to rise to your timescale. So proceed with the changes. But keep in mind that it
is your staff that make the changes happen. Without them the change remains nothing but an idea.
Appendix 2 provides further information and guidance on how to manage staff resistance and nurture staff ownership of the changes.
To implement the solution we suggest you follow the
11 steps outlined in the following sections.
Step 1: Ask yourself this question
If you are still reading this guide, this means that you are very interested in implementing this solution. It shows you are committed to making a difference.
The question you now need to ask yourself is:
Are you the driver for the change? Every change programme (and this is one) needs a driver; someone who will push the change forward,
someone who will inspire the staff when they lose heart; someone who will keep their eye on the goal when staff lose direction; someone who will maintain the momentum for the change and not allow it to dissipate.
To be successful it is important that the driver for change for this programme is someone who:
• is seriously unhappy with the current situation in GOPD
• is hungry for a solution and wants to make it better
• is willing to put in the time and effort with the staff to
make it happen; and
• has the authority and more importantly the personal
credibility and influence with GOPD staff

We have talked here about the importance of personal credibility and influence of the change driver. This is because on occasions managers only have authority over staff by virtue of their position in the organisation.
However more important than this is the extent to which they have personal credibility and respect of their staff. Without this, the change driver’s efforts will not be effective. Having someone with the positional authority, the personal credibility and the desire and drive for change
is key to success.
If you are this person or you have this person in the organization, then you can proceed with the knowledge that your chance of success is great.
If you are the Nodal Officer or some other member of staff reading this, we applaud you and your interest in wanting to improve your GOPD. You can
be a champion for change. You can talk to staff and heads of GOPD to enthuse and inspire them.
Most importantly we suggest that you talk to the Medical Head of GOPD to see if s/he is interested in implementing this change programme.
If they are, you can be an important advocate and champion of this change and offer your support and assistance to the change programme.
In hospitals where the Nodal Officer is a senior member of the medical team, they themselves may choose to be– in collaboration with Medical Head of GOPD – the driver for change.
The role of the Nodal Officer If a SERVICOM Nodal Officer exists in your hospital, then their practical help and support will be a great
asset to the Medical Head of GOPD in implementing this solution.
Working together with the Medical Head of GOPD, the
Nodal Officer can assist practically with eg:
• arranging meetings
• securing meeting venues
• arranging resources
• rallying people around
• producing meeting materials
• producing appointment sheets, Triage Queue
Number Cards and Appointment Time Cards
They can also help with monitoring the process. This
can be done through collating the data from the
appointment sheets on:
• patient waiting times; and
• number of patients seen by each GOPD doctor.
They can keep a close eye on the change programme as it unfolds, visiting GOPD regularly to make sure that any practical problems are solved and the programme continues on.
They can also be a real champion for change and communicate the GOPD successes to other parts of the hospital, inspiring them to make changes too.1 In the case of this programme of change the best person in this role is the Medical Head of GOPD or other Senior Medical Staff provided
they meet the above criteria. 1 The principles of the appointment system, of triage and of colocating service windows are relevant and very easily applicable to many other parts of the hospital. For example, in hospitals such as Keffi FMC and Aminu Kano Teaching Hospital (AKTH) where
SERVICOM has implemented these changes in GOPD, the staff have
taken these principles and started to apply them to speciality and
ante-natal clinics


Prepare your minds

It is important to ensure that the Medical Head of GOPD, the Nodal Officer and the change driver have read and made themselves fully familiar
with the contents of this document and its accompanying DVD.
Step 3: Seek the support of the senior management team
The next step is to set up a meeting with the senior management team of the hospital.
By senior team, we mean any member of the senior management team who needs to know about your intention to implement such a programme and/or whose approval and support you need to implement this programme.
The purpose of the meeting would be to inform them of your plans and seek their approval and support.
Importantly such a meeting will also help inspire and excite them about that changes and will assist them to become champions of change both within their hospital and with their peer groups elsewhere. The
DVD that accompanies this guide can be shown to the senior management team to help with this process. The support of the senior management helps
you to secure the small level of resources you will need for the change programme. You will need a minimum budget of around 200,000 Naira for the purchase or production of such items as:
• appointment sheets and cards (Appointment Time
Cards and Triage Queue Number Cards)
• weighing scales for triage nurses
• digital BP monitors (to help speed up Triage); and
• refreshments to GOPD staff during their training
events (see step 6 below).
The support of the senior team can also help unblock any problems which you are unable to solve at your level. For example, they can use their authority to broker a meeting between Head of GOPD and Head of
A&E if required.
Having secured the support of the hospital management team, the next step is to secure the support and buy-in of the heads of the GOPD. The key
staff here are the Head of Nursing for GOPD and Head of Medical Records.
Step 4: Prepare the minds of the GOPD senior team We suggest that the Medical Head of GOPD and the Nodal Officer hold a meeting with these key staff to discuss and explain the idea and its benefits, provide further information (this tool-kit) and ask for their support and agreement.
If you encounter any resistance, do not be deterred. This is normal. Listen to their concerns and agree to work out any problems together. This is how resistance can be countered. Not by force but by gentle listening,
persuasion and involvement. (see Appendix 2 for more information on managing resistance.)
Step 5: Prepare the minds of GOPD staff
The next step is to hold a collective meeting with all the staff of GOPD:
• doctors
• nurses
• medical records staff
• cashiers and their managers; and
• attendants.
At this meeting, we suggest that the Heads of GOPD (Medical, Nursing and Medical records) communicate the purpose and benefits of the programme,
• what the initiative is
• why it is being done
• what the benefits are for patients as well as for staff; and
• what the next steps are.
It would be highly desirable if a member of the senior management team was also present at this meeting, as their presence would communicate to staff the support of the senior management team for the programme.
As before, you can show the DVD that accompanies this tool-kit to encourage and enthuse staff to become involved in this initiative.

Step 6: Arrange for GOPD staff trainings through SERVICOM
An important part of preparing the minds of staff is reorienting their thoughts towards the needs of patients and reminding them of how they can meet these needs.
SERVICOM has designed a specific training programme for GOPD staff to do just this. The training programme is a one day programme covering:
• Introduction: SERVICOM and the Nigerian Public Service
• Customer sensitivity for hospital staff
• Communicating with patients; and
• Improving GOPD: Case study – the story of FMC Keffi.
For this, we suggest that you contact the SERVICOM Institute and request their support in delivering this training to your GOPD staff. We suggest that all of your GOPD staff: doctors; nurses; medical records staff; pharmacists; lab staff; attendants and all of the hospital SERVICOM staff attend this training.
To enable as many of your GOPD staff to attend, the training can be arranged to run twice on two consecutive days. The training can be arranged to run on site at your hospital. A copy of the PowerPoint
slides for this training can be found in the CD that accompanies this tool-kit.

Step 7: Set up a Staff
Implementation Team
If you have actioned steps 1-6 you will so far have achieved:
• support from management
• a change driver
• a nodal officer to support the programme; and
• sensitised GOPD staff.
What you now need is a team of staff from GOPD to make it happen. What you need is a Staff
Implementation Team. (In our DVD this is referred to as a Quality Circle).
We suggest that you bring together a core team of your GOPD staff to form a Staff Implementation Team.
As minimum attendance, you will always need to have the attendance of:
• GOPD Head of Nursing
• Head of Medical records
• Medical Head of GOPD; and
• SERVICOM Nodal Officer.
But we also suggest that you invite and encourage the attendance of other GOPD doctors, nurses, medical records staff and attendants. The more involved staff feel in the process, the more likely they are to help
implement it.
It is however important that when these staff attend, their views are listened to, acknowledged and considered, so they feel encouraged to participate further. This is the case, even if you feel that at times
their contribution may be unhelpful, irrelevant or contribute to slowing down the meeting.
If, on the other hand, they feel discouraged and devalued, they will pull away from the process and will find ways to hinder it. This does not mean that you do everything that the staff might suggest. But it does mean that you listen attentively to what they have to say and respond to it appropriately and respectfully.
Step 8: Planning the implementation
The role of the Staff Implementation Team (or the Quality Circle) is to first plan and then to support the implementation of the agreed changes.
At the first meeting of the Staff Implementation Team, start with explaining the purpose of the meeting, making sure that everyone there understands what the meeting is about and what you are planning to do.
Explain that you want all staff to work together to implement this change.

The purpose of this first meeting is to brainstorm and identify all the actions that you as a team need to take to implement the changes. We suggest that you re-create the following simple table on a flip-chart
and fill it in as a team working together.

Using a flip-chart will enable all the staff to see what is being decided on and agreed. It increases participation and involvement and thus ownership. It also saves the team from having to write up separate meeting notes
as the same flip-chart paper can be brought back to the team’s subsequent meeting and used to check progress against the agreed actions.
The team need to work together and agree the actions they need to undertake in order to implement the 3 parts of the Solution, ie:
• Part 1: Co-locate registration and payment points AND extend the opening hours of GOPD patient registration
• Part 2: Introduce triage (or extend it)
• Part 3: Introduce the appointment system
Suggested actions to consider for each part of the solution are set out below, although you will need to adapt them to your local circumstances. You will likely need more than one meeting to agree all the necessary actions and take them through to implementation.
Actions to agree upon
Part 1: Co-locate registration and payment points.
This is a relatively straight forward part of the solution and can be implemented ahead of the other changes.
You will need to consider:
• Agreeing with the Head of Medical Records and
Head of Accounts about the need for co-location
• Identifying and agreeing on a suitable location for the co-location window

Communicating the changes to the staff affected; and
• Communicating the date from which the change will take effect.
Part 1(continued): Extend the opening hours of GOPD patient registration.
All that is needed here is to:
• Agree with Head of Medical Records and Head of
Accounts to extend the opening hours of the colocated registration and payment window. This may require some rescheduling of staff at the service windows by these two heads.
• Communicate the changes to the staff affected; and
• Communicate the date from which the change will take effect.

Part 2: Introduce triage (or extend it). Step 9: Base-lining
Implementation of this part of the solution is a little more involved and will require consideration of the following actions:
Triage Nurses
• Agreeing with Head of Nursing to release nurses for triage
• Note: we suggest 1 triage nurse per 2 GOPD doctors Triage Location
• Identifying and agreeing a location close to GOPD for triage
Triage Protocol
• Defining the triage protocol through joint discussion and agreement between GOPD doctors and nurses; and
• Defining the trigger points for referral from GOPD to A&E. Heads of GOPD and A&E need to agree this and communicate the agreement to other medical and nursing staff at both departments. Triage Nurse Training
• Identifying the training needs, if any, of the triage nurses. Training ensures that both doctors and nurses are comfortable with the activities to be
carried out by the nurse. One way to identify training needs would be for doctors to observe nurses while carrying out a triage practice run; and
• Addressing the training needs of the triage nurses. Doctors and nurses need to jointly agree how to do this.
Triage Equipment
• Identifying what equipment the triage nurses need for
speedy triage, e.g. digital BP monitors, weighing scales, thermometers etc
• Creating the Triage Queue Number Cards; and
• Deciding how to replenish any lost Triage Queue
Number Cards as a few cards will inevitably be lost every day. (See picture 1 for an example of the Triage
Queue Number Cards.)
Part 3: Introduce the appointment system.
This needs the creation of the appointment sheets
and cards.
Appointment Sheets and Cards
• Agreeing the start and end times of clinics with doctors
• Getting doctors to decide average time per
Consultation upon which an appointment system can be built. This, together with the start and finish time of clinics will determine number of
appointments per day.
• Creating the appointment sheets
• Creating the Appointment Time Cards
• Deciding how to have to hand a daily supply of appointment sheets; and
• Deciding how to replenish any lost Appointment Time
Cards (See picture 3 for an example of the
Appointment Time Cards.)
Running Appointment System
• Securing commitment of doctors to comply with their agreed times for the start and end of their clinics
• Training triage nurses on how to complete and use the appointment forms; and
• Training the doctors and their attendants on how to complete and use the appointment system.
Please refer back to section 4 of this tool-kit for details of how the 3 parts of the solution link and operate together and for details of the role of doctors and nurses in the process.
What the triage protocol describes The triage protocol defines the:
• questions the nurse needs to ask the patient to identify if they are in the right clinic
• procedure to be followed by the nurse when triaging
• areas where the nurses can provide initial advice and information to the patient on minor issues
• medical signs that if observed indicates to the nurse that the patient requires urgent
medical attention and needs to be fasttracked to the GOPD doctor. These are
referred to as “trigger points”; and
• actions to be taken by the nurse if they identify an urgent medical condition.
Picture 2 contains an example of a triage protocol.

It will take Staff Implementation Team some time to achieve the various actions agreed in the implementation planning process.
In the time being, an activity that will help GOPD staff determine the extent of improvements in patient waiting times is to base-line existing patient waiting times. Base-lining will allow the staff to both measure and demonstrate their progress in reducing patient waiting times. This can be done by capturing patient arrival and departure times at each service point
through a form such as the one presented in the table below:

The form can be given to the patient at the first registration point to hand to the next service points, until the patient is back at registration for their medical records. At this point the form can be attached to the
front of the patient’s records and completed by staff at the various service points, as the patient moves through the system.
The exercise if completed over a period of a week will provide enough information for the identification of:
• patient waiting times from arrival at the first service window to arrival at doctor’s consultation
• duration of consultation time by doctor; and
• weekly number of patients seen by each doctor.
This can provide information on average patient waiting times before the introduction of the changes. The process can then be repeated periodically after implementation of changes, thus providing information for comparison of before and after patient waiting times.
Once the appointment process is introduced, the appointment sheets will allow for the on-going collection of monitoring data such as:
• patient waiting times (from time of appointment given to time seen by the doctor)
• duration of consultation times per doctor
• number of patients seen by each doctor; and
• arrival and departure time of each doctor at their clinics.
Use of both approaches will allow for the regular monitoring and evaluation of patient waiting times and performance of GOPD doctors

The form can be given to the patient at the first registration point to hand to the next service points, until the patient is back at registration for their medical records. At this point the form can be attached to the front of the patient’s records and completed by staff at the various service points, as the patient moves through the system.
The exercise if completed over a period of a week will provide enough information for the identification of:
• patient waiting times from arrival at the first service window to arrival at doctor’s consultation
• duration of consultation time by doctor; and
• weekly number of patients seen by each doctor.
This can provide information on average patient waiting times before the introduction of the changes.
The process can then be repeated periodically after implementation of changes, thus providing information for comparison of before and after patient waiting times.
Once the appointment process is introduced, the Step 10: Trial implementation
Once a base-line has been, a trial practice of
the new process can be organized.
We suggest that you set a date for the trial implementation of the full process.
But before this is carried out with patients, we suggest that you run a practice simulation of the process at a specially organized Staff Implementation Team meeting with doctors, triage nurses, medical records
staff and attendants. Our experience of implementing this has taught us that the greatest confusion arises from the completion of
the appointment forms, the issue of the Appointment
Time Cards and understanding when the appointment sheets are dispatched to the doctor. This part of the process should therefore be given special attention at the practice run to ensure that all parties are clear
about their part in the process.

On the day of implementation, extra support from the Staff Implementation Team can be brought in to:
• observe how the process operates
• identify teething problems; and
• support implementation.
Even after a practice run, you are likely to experience a few teething problems on the day. We suggest that the Staff Implementation Team meet soon after the trial implementation day to discuss and address any
teething problems.
A second trial date should then be set soon and the process repeated. To maintain momentum we recommend that a second date is set within a few days of the first date.
Repeat the process until the teething problems are addressed and the process runs smoothly. It should then continue as part of the normal routine of the GOPD.
Step 11: Monitor data and address emerging issues
Once you have implemented the whole solution, you can collect post-implementation data as outlined in Step 9 above.
This will be key to your ability to monitor and maintain improvements in patient waiting times and address any uneven attendance or non-compliance by GOPD doctors.
Collecting and examining the appointment sheets will provide you with the information you need to address such issues.