J R Soc Med 2002;95:604-605
doi:10.1258/jrsm.95.12.604
© 2002 Royal Society of Medicine
Outpatient clinic: where is the delay?
H R H Patel PhD MRCS
C N Luxman
T S Bailey
J D M Brunning
D Zemmel
L K Morrell MSc RGN
M S Nathan MS FRCS(Urol)
R A Miller MS FRCS
Department of Urology and Minimal Access Surgery, Whittington Hospital
NHS Trust, Highgate Hill, London N19 5NF, UK
Correspondence to: Mr H R H Patel E-mail:
hrhpatel{at}hotmail.com
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SUMMARY
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In outpatient clinics, consultation times are often eroded by
extraneous
activities. We measured the components of each outpatient
episode in 167
patients attending a general urology follow-up
clinic. 41% of time in the
clinic was spent away from the patient—administration
17%, disturbances
15%, finding results 9%. The inefficiencies
had changed little since a study
in the same setting thirteen
years earlier. Since then, parallel
nurse-practitioner-run clinics
have been introduced in the hope of giving
consultants longer
with the patient; however, time with each patient is now
4.8
min compared with a previous 7.6 min. The most easily addressed
inefficiencies
are those relating to missing information, such as radiology
reports.
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INTRODUCTION
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The efficiency of the NHS is under intense scrutiny. The media
regularly
highlight the length of waiting times for outpatient
consultations. There is
continued pressure from the Government
to ensure certain patients are seen
within a particular time
period. Are the structure and resources of the
outpatient clinic
adequate to cope with these demands? The efficient working
of
the clinic depends upon a multiskilled team of support staff,
as well as
dependable means of transferring information between
healthcare
professionals.
We examined the time-efficiency of a general urology outpatient clinic
which had been studied thirteen years
earlier1.
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METHODS
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We examined the components of consultations in 167 men and women
with a
general case mix attending a urology outpatient clinic
for follow-up. Patients
were given the opportunity to refuse
observation before entering the
consulting room. Two consultant
urologists (MSN, RAM) saw all follow-up
patients over a period
of six weeks in 2001. The ten clinics were monitored by
independent
observers (CL, TB, JB, DZ) who recorded the time spent for each
consultation,
with a breakdown in seconds of where delays occurred. The
consultant,
supporting staff and patients were all blinded to these
measurements.
For every consultation, the assessors recorded times for:
discussion;
examination; reading notes (before, during or after consultation);
administration
(including form-filling, dictation, note-taking); finding
missing
results; disturbances. They also noted numbers of patients who
did not
keep their appointment, numbers for whom medical records
were incomplete or
missing and numbers for whom results of investigations
were missing
(specifying the department concerned). Data interpretation
was by reviewers
independent of the study (HRHP, LKM).
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RESULTS
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The mean time for each consultation was 8.2 min, of which 4.8
min was spent
with the patient.
Table 1 shows
how the remaining
3.4 min (41%) was occupied.
Regarding missing results, the main culprit was the radiology department,
accounting for 71% of this component; also commonly missing were records on
transrectal prostate imaging, urodynamic studies and flexible cystoscopy. An
item of some kind was missing in 25% of patients.
Disturbances (Figure 1) were
about equally attributable to the telephone, nurses, junior doctors, and
others (including students and fellow consultants).
Much of the administrative work consisted of requesting investigations and
writing up the notes. Over the ten clinics, 62 patients (27%) did not
attend.
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DISCUSSION
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Over 40% of outpatient time was lost in administration and inefficiency.
Some
of the administrative tasks might be eased by a computerized
information
system, with data input by well-trained staff; however,
the most conspicuous
waste of time is in hunting for missing
notes or results. In 1988, the
radiology department accounted
for only 13% of missing data, in 2001 71%. The
reason, apparently,
is that the department's workload has increased vastly
without
a corresponding increase in secretarial assistance; thus written
reports
fall into arrears. Whereas digital image acquisition is the
standard
for equipment used in ultrasonography and CT, MRI and
radionuclide scanning,
most radiological images are still recorded
on
film
2. Although
digital radiology allows immediate access
to images, it is not yet
trouble-free: a computer crash due
to overload can be hugely disruptive. Also,
of course, the information
still has to be processed.
The most disappointing finding in this survey was that time with the
patient decreased substantially, from 7.6 min to 4.8 min, between 1988 and
2001. This was despite efforts, in line with Royal College guidelines, to
increase the time spent consulting. The strategy in our clinic was to
introduce parallel one-stop clinics (e.g. for prostate symptoms, erectile
dysfunction) run by nurse-practitioners. However, the ‘nurse’
component in Figure 1 is
largely due to the need for consultant supervision and advice in certain
aspects of this work. So these clinics tend to dilute the consultant time
available in the main clinic. Telephone disturbances were mainly attributable
to general practitioners, who know that this is the only time when consultants
are readily accessible.
The main message of our study is that patients lost out on consultation
time between 1988 and 2001. If the inefficiencies in these clinics could be
cut by half, each patient could be given much more time or the throughput
could be increased by one-third. The best approach is probably to introduce an
electronic system for accessing and recording information on
patients3. This will
need to be backed by investment in staff and training to maintain the quality
of the system4.
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REFERENCES
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- Lee F, Patel HRH, Emberton ME. The ‘top ten’ urological
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SUMMARY
INTRODUCTION
juniors; 
telephone; [UNK] others