Telephone : 23092121 Integrated HQ of MOD (Army) Dte Gen of Med Services Adjutant General’s Branch ‘L’ Block, New Delhi – 11 B/75346/DGMS-3E/PC 15 Sep 2008 HQ Southern Command (Med) HQ Eastern Command (Med) HQ Western Command (Med) HQ Central Command (Med) HQ Northern Command (Med) HQ South Western Command (Med)

GUIDELINES ON STANDARDIZATION OF OUT PATIENT DEPARTMENT 1. Further to this Dte Gen letter No B/75346/DGMS-3E/PC dt 30 Apr 2008 and letter No B/75346/DGMS-3E/PC dt 01 Aug 2008, a presentation on standardization of OPD services of Service hosp was held at this Dte Gen and the following guidelines for OPD and Central MI Room run by fd med units have emerged which are as follows:- 2. Structural Standards.

(a) The structure of the OPD of service hospitals has been standardized vide Table-3A of “ Scales of Accn for Armed Forces Hospitals 2003” and Scale of accn Defence Services 1983, Table 7 III for MI Room, the scope of the structure is quite liberal and satisfactory. However, majority of service hospitals are still accommodated in old buildings and will have to dovetail the laid-down structure within available accn, probably with some addition/alterations. (b) Features of “Barrier-free Environment” – Essential features of “Barrier-free environment” that need to be incorporated in the OPD structure are as given below:-

(i) Separate car-parking with a min space of (3.5m x 3.5m) per car for wide opening of doors. (ii) Ramp at the entrance with a gradient of 1:20 with handrails at a height of 900 mm above ground. (iii) OPD doors, if present at the entrance must have a min width of 900 mm with door handles at 800-900 mm above ground and adequate maneuvering space infront. (iv) Waiting area seats must be 450 mm high with arm rests at 700 mm above ground. (v) One telephone cubicle of a size of (1.7 m x 1.7 m), with the telephone at a height of 900 mm and an empty space of 600 mm below the telephone.

2

(vi) One toilet of (1.7m x 1.7 m) with grab rails at 800 mm height, WC at 0.5m height and wash-basin at 0.7m height. (vii) One lift with a min area of (1.1 m x 1.4m), door width of 1m and floor indicators at eye level.

(c) Certain other generic standards : Structure

(i) Landscaping of the entire frontage to usher in the concept of “Holistic healing therapy”. (ii) A welcoming approach to the OPD building, clearly sign-posted. (iii) A comfortable ambience inside the OPD, with separate waiting spaces for different categories of patients provided with newspaper/magazine stands, drinking water facilities and sanitary blocks. (iv) Recreational facilities in the form of soothing music and wall-mounted flat screen TV sets. (v) Standards of accn – Though accn for the OPD has been standardized vide Table -3A of “Scale of Accn for Hospitals-2003”, min requirement of accn in hospital occupying old buildings needs to be laid down. Such a standardized template is shown below:-

(aa) Reception and registration -Separate for service pers/families/ESM.

(ab) Waiting area, separately for Offrs/PBORs/families of PBORs.

(ac) Consultation rooms, number of which will depend on availability of rooms and staff and average OPD load. (ad) Procedure room with at least two resuscitation beds. (ae) Diagnostic facility with structure for lab/radiological investigations. (af) Resusci tative facilities for providing life-saving resuscitative services. (ag) Dispensary. (ah) Patient/staff amenities incl separate sanitary blocks.

(d) Standards of staffing – Though service hospitals cannot substantially augment its OPD staff, the capability of available staff can be significantly upgraded to act as a force multiplier to the value chain being developed in the OPD. A template for essential staffing of this dept may be as given below:-

3 (i) Medical Officers - 02 (Trained in Critical Care by Anesthesiologist). (ii) Member of MNS - 01 (To function primarily as OPD Co-ordinator. (iii) Nurs/Assts - 03 (Trained in ACLS/ATLS by Anesthesiologist). (iv) Amb/Asst, MT Dvr - 01 each (Trained in BLS

Safaiwala protocols by MO I/C). (v) Ward Sahayika - 01

(e) Standardized sets of Eqpts – Generic standards for eqpts that will be necessary will be shown below:-

(i) Routine therapeutic/diagnostic eqpts (ME Scale). (ii) Diagnostic equipments - Semi-auto analyser/100

MA Mobile X-Ray machine. (iii) Resusci tative equipments - Procured from AAP from DGAFMS office/ACSFP (iv) Life-support equipments - Procured from

AAP/ACSFP. (v) Trauma Care Van - Modifying one 2.5 Ton

Amb veh with help of local EME Workshop.

(f) Misc facilities -These facilities will again depend upon the size and scope of operations of the OPD services. However, a min template is again being laid down as below :-

(i) STD/PCO (ii) Coffee/Tea dispensers (iii) Drinking water (iv) Snack counter (v) Newspaper / magazine racks (vi) Soft music (vii) Digital display system for waiting patients. (viii) Wall-mounted TV sets (preferably flat surface TVs)

4

3. Standardization of Imp processes.

(a) Automated flow of operations. The general functions of the OPD need to be automated for bringing in more efficiency in the service-chain. A sequence of the flow pattern may be as follows:-

(i) Capture of medical record data of the capture clientele by all hospitals, which will require some effort. This data will be available on the Registration computer.

(ii) Every node of the OPD services will be on LAN.

(iii) Registration of every patient will be automated on a standardized format and patient will only be given a registration number.

(iv) Waiting numbers will be displayed by a “Digital Display System”.

(v) Past medical record will be available to the clinicians from the data-bank, displayed on the computer screen.

(vi) Clinician will enter management plan in the patient record.

(vii) Subsequent interfaces namely procedure/diagnostic/ Dispensary will have access to the same information on their own computers and act accordingly.

(viii) The hardware necessary is now available in every hospital.

(ix) Electronic OPD formats, medical record data-bank and LAN facilities can be easily developed with the help of signal units of the station.

(x) This flow of operations will significantly reduce waiting time at each OPD inter face for the patients.

(b) Management of waiting time. One of the major problems plaguing the OPD service of service hospitals is long waiting time within the system for patients/visitors. This problem needs to be addressed by a series of steps, as described below :- (a) Provision of adequate comfortable waiting space. (b) Ensuring punctuality of OPD staff.

(c) Having a separate Filter Clinic/ separate time for chronic patients (ESM/dependent parents), many of whom come to collect their monthly quota of medicines. (d) Re-in forcing OPD staff to manage peak-hour workload. (e) Flexi time in OPD management, where a subset of patients, say offrs may be attended during evening hours.

5

(f) Staggering of OPD timing for sick report/attendance of families of different formations in the station. (g) Ensuring availability of all OPD staff throughout the duration of OPD by looking after their administrative requirements. (h) Starting appointment system for officers/officers’ families. (j) Deciding upon a ‘Quality Standard’ of waiting time in the system and continuously tracking random cases of OPD attendance against the standard for identifying variance.

(c) Standardized Protocols – Each hospital will have to decide upon and prepare a standardized set of protocols for superior patient-care and administrative efficiency. However, a sample set of protocols are given below:-

Clinical protocols Adm Protocols ∙ Cardiac arrest ∙ Sudden death/BID

∙ Acute MI ∙ Medico-legal case

∙ Acute CVA ∙ Case of Suicide/attempted suicide

∙ Acute Severe Asthma ∙ Case of rape victim

∙ Poisoning ∙ Failure of Essential services.

∙ Acute GI bleeding ∙ Vis of VIP

(d) Method Cards. Every protocol (both clinical and administrative) will be summarized into a single page format, which wil be prepared in easy-to-use cards, properly laminated. These set of cards will then be codified, with a ‘Master List’ of such cards being maintained in the OPD. These cards will be of tremendous help, as they give concise, sequential course of action against any emergency that may have to be managed at the OPD. (Sample method card attached as appx ‘A’).

(e) Equipment management - Every equipment in the OPD will have to be functional with “NIL down-time”. Moreover, every OPD staff must be capable of operating any equipment in the dept. Generic standards for operating and maintaining equipments will be :-

(i) All OPD staff fully trained to operate any and every equipment.

(ii) All equipments divided into categories depending on their criticality towards life-support, the criteria of criticality deciding the periodicity of Preventive Maintenance tasks for each equipment.

(iii) Each equipment to have individualized Preventive Maintenance task.

6 (iv) Each equipment to have a log-book, maintaining details of Preventive Maintenance task carried out. (v) Every equipment be checked every morning by the nominated staff for its functional status, before commencement of OPD.

(f) Real-time investigation reporting - Generic standards will be as follows

(i) All real-time investigative modality incl semi-automated analyzer, 100 MA mobile X-Ray, Ultrasound and ECG machine to be available.

(ii) Nurs/Assts working in the OPD to be multi-tasked in developing capabil ity in operating the investigative equipments.

(iii) Sample collection room to operate for the entire duration of OPD service.

(iv) Standard precautions to be practiced in the sample collection room.

(v) Availability of anti-anaphylaxis tray in the sample collection room.

(vI) Max efforts for investigation reporting on the same day, with particular focus on every investigation marked “Urgent”.

(vii) Quality standards on “Down-time Index” of OPD equipments.

(g) Drug formulary for the Dispensary - Every OPD will prepare a selected inventory of drugs that will be prescribed in the dept. This ‘Drug formulary’ will be prepared by preparing a VED/analysis, the formulary being open to review on a quarterly basis. This procedure will result in NIL wastage and zero stock out, if Re-order level is worked out at the same time.

(h) Quality Management - Quality standards will vary among various service hospitals, However, every OPD needs to decide upon achievable and realistic quality standards and then track its performance against these standards to evaluate its own quality of services as well as identity variances. Few common issues, where such standards might be set are given below :-

(i) Time for Registration

(ii) Total waiting time in the system

(iii) Inappropriate lab testing

(iv) Equipment Down-time index

(v) Medication Errors

(vi) Real-time lab reporting (Turn Around Time of lab reporting)

(vii) Availability of medicines at the dispensary

(viii) Consumer satisfaction index

(ix) Occurrence of ‘Sentinel Events’

(x) Complaint frequency and management

7 4. Standardized people initiatives

(a) Dissemination of vision and values. Every OPD staff must be fully aware of the vision of the CO about functioning of the dept as well as a set of value system that will be followed while providing OPD service. The vision and value system will be prominently displayed in the OPD for consumption of all OPD staff.

(b) Trg of OPD Staff. Already discussed under the heading “Staffing”. Quality standards need to be laid down for periodic testing of knowledge and skill of every OPD staff in BLS/ACLS/ATLS protocols and operation of every equipment available in the OPD.

(c) Empowerment of OPD staff in solving problems. OPD staff will be empowered to deal with and solve any and every problem arising during functioning of the dept without looking for his superior. Generic standards on this issue will be as follows:-

(i) Trg of all OPD staff in behavioral science, particularly communication, conflict resolution and problem solving methods.

(ii) Analysis of complaints/problems and their resolution.

(iii) Feedback to clientele and staff. 5. Outcome standards

(a) Satisfaction Survey Protocols. The modalities for exercising such instruments will be as follows:-

(i) The protocol will initially be pilot tested for assessing its validity/reliability.

(ii) The best method is to offer this instrument for anonymous feed-back by consumers after they return home.

(iii) The survey must be a combination of close-ended and open ended questions.

(iv) The survey results will be analyzed on a quarterly basis by a board of officers.

(v) Any negative feedback will be accepted as an opportunity for improvement and not as an issue to be defensive about.

8

(b) Reporting of ‘Sentinel Events’. Sentinel events are unexpected, undesirable incidents that may happen in the dept. Reporting of ‘Sentinel Events’ will require an org culture with following characteristics :-

(i) Culture of accepting occasional mistakes as proof of human frailty and taking lessons from mistakes.

(ii) Confidence among staff that reporting of mistakes will not result in witch-hunting.

(iii) Incidence of ‘Sentinel Events’ and its monitoring is a definite outcome standard of ‘Quality of service’ in the OPD.

(c) Quality Audit protocols.

(i) Deciding on Quality Standards for the OPD services, particularly for the hospital.

(ii) Continuous monitoring and record keeping of OPD performance against such standards.

(iii) Periodic assessment of performance against set standards, identify variances and undertake ‘Variance analysis’.

(iv) Audit report to be discussed with OPD staff to identify improvement opportunities.

(v) Open publication of the audit results for education of the external environment incl various system stake-holders.

6. Standardization of Service Ethos. All efforts towards standardization of OPD services towards improving efficiency in performance will come to a naught, unless the basic ethos of service is standardized first. The basic template of such service ethos is given below for internalization by every service hospital:- (a) S - Speed in appreciating the value of time of the waiting

patients.

(b) P - Personal interaction of every OPD staff incl MOs with the consumers to understand their grievances and

appreciations.

(c) E - Expectations of the consumers to be assessed by “Consumer Need Analysis” and aligning service facilities with the expectations identified.

(d) C - Courtesy while interacting with consumers in the OPD and

competence of every OPD staff to add value to the services being provided.

9 (e) I - Information to every consumer by effective communication at

every interface, particularly during consultation and at the dispensary.

(f) A - Attitude of “Can do” and “Can help” (g) L - Long term relationship to be developed with the captive

clientele of the OPD services. 7. Planning for Emergency unit in service hospitals. (a) Structure. The min structure that will be necessary is given below :-

(i) Reception - A separate reception may be necessary during duty hours.

(ii) Waiting areas - Available space in the OPD may not suffice

and separate waiting area may be necessary. (iii) Trolley/Stretcher bays - Available space in the OPD will suffice.

(iv) Resusci tation Cubicles - Though a treatment room has been

provided, separate resuscitation cubicles equipped with resuscitative equipments will have to be provided for.

(v) Surgical facilities - Space allotted for the surgical facilities may suffice for smaller hospitals, but for Zonal and Command hospitals,

a major OR will have to be catered for in place of Minor Surgery Room.

(vi) Facilities for diagnostic equipments - Available space will suffice, but a stat lab/CSR will be necessary for larger hospitals.

(vii) Staff amenities - Available space will suffice.

(b) Staffing. Staffing with necessary development of capability, as enunciated earlier will suffice.

(c) Equipment Planning. Min necessary availability of equipments that will be necessary in addition to available routine equipments will be as follows :-

(i) Monitor – defibrillator unit. (ii) Bag-mask unit (adult/child/neonatal size) (iii) Portable ventilator (iv) Endotracheal tubes and Laryngoscopes of all sizes. (v) Pulse oxymeters (vi) Infusion pumps.

10

(vii) Oxygen concentrators

(viii) Crash carts with consumables (ix) Semi auto analyser (x) 100 MA mobile X-ray machine and ultrasound (xi) Trauma Care Van for pre-hospitals care and cas evac. (d) Certain essentials to function within present constraints.

(i) Cross-trained team approach - with staff working in the dept suitably cross trained to attend to serious casualties as well as handle diagnostic equipments.

(ii) Devp of capability for pre-hospital care - with devp of “Trauma Care Vans” with appropriate internal environment and communication facilities.

(iii) Significant upgradation of staff competence - by continuous trg in critical care by the Anesthesiologist.

(iv) Availability of care protocols - for standardization of critical care practice.

(v) Training of the dependent community - for life saving first aid of a casualty on site and also during evacuation.

8. A line-plan of a proposed ‘Emergency unit in a service hospital and a conceptual diagram of Central MI Room is attached as Appx ‘B’ and ‘C’. 9. Conclusion. Guidelines have been issued to develop generic standards for OPD services of service hospitals incl Emergency Services to bring in procedural efficiency and increased patient satisfaction. The process of standardization in service hospitals will definitely vary to a greater or lesser degree, depending on the size and type of hospitals. However, generic standards can very well be laid down, which can be suitably applied by indl hospitals appropriate to their own needs and requirements. A dedicated effort towards standardization will definitely bring in substantial benefits in terms of superior efficiency to the value-chain of OPD services being provided by the service hospitals at present. 10. This has the approval of DGMS(Army).

11. Please ack. Sd/-x-x-x-x-x (SKM Rao) Col Dir MS (Hosp Proj) For DGMS (Army)

Encls : As above

Appx ‘A’

A PSYHIATRIC CASE

1. There are various types of psychiatric problems which can result from stress namely: Agitation, confusion and depression. 2. The following points should be considered to deal with the persons who are under Psychiatric mania:- ∙ Approach such patients in a calm, non threatening manner. ∙ Speak to him in short, concise sentences. ∙ Never compel such persons to talk about something if he doesn’t want to.

∙ Offer reassurance, speak softly and calmly and not in a loud condescending manner.

∙ Decrease sensory stimulation by caring for such persons in a quiet

environment. Limit the number of people coming in contact with them. If situation permits, soothing music may be tuned on.

∙ Provide a safe environment. Never leave a confused patient alone; He may

accidentally hurt himself. ∙ Try to orient the patient to reality. Tell the patient what is going to be done and

what is expected out of him. ∙ Never talk about condition of a psychiatric patient in his presence. ∙ Beware of a possible suicide attempt, while attending a severely depressed

patient. ∙ Provide 1: 3 guard round the clock to avoid threat to the patient as well as to

the care givers. ∙ Administer medications as advised by the physician. Be with the patient till the

medication is swallowed completely. ∙ Work and establish a rapport with a depressed patient.