It is beneficial to draw a flowchart of activities and movements in the department to determine relationships of various facilities to each other.
If the daily attendance as compared to total floor area of the OPD is low, a strict flow pattern is not warranted. However, the flow concept becomes important when the daily attendance crosses 400 to 500.
In comparison to the area occupied by other departments of the hospital, viz. wards, diagnostic and therapeutic services and administrative and service departments combined, the percentage of space occupied by the outpatient department of most existing public hospitals varies from 12 to 18 per cent.
As evident from overcrowding in outpatient departments in hospitals, this space seems to be grossly inadequate.
The area required for the outpatient department should be adequate to accommodate the reception and waiting hall, waiting rooms, registration and outpatient medical records, clinics, toilet facilities, and the injection and dressing room, pharmacy, minor OT and circulation routes.
Scales of space for outpatient department can hardly be standardised in view of the varied requirements and range of services provided.
For planning premises, half square foot for each expected annual outpatient visits is considered to provide adequate space in case of most general hospitals a hospital expecting 500 outpatients per day over 300 normal.
2. Reception and Enquiry:
A new outpatient is usually a frightened person who needs reassurance and guidance in what, for him, is a strange place.
A reception and enquiry counter in the outpatient department is necessary at the entrance lobby from where patients seek information about the location of various clinics, registration procedures and so on.
This is located at a prominent place at the entrance of the department and also in close proximity to the emergency and casualty department. The entrance lobby should connect with public facilities and with a tea and snack bar.
To isolate it from the noise that usually prevails in such a place, reception and enquiry can be enclosed in a see- through cubicle. A small room with glass paneled wall above a height of 1.10 metre and a swinging door or doors has been found to be very suitable.
This arrangement enables the patients to see the person manning the reception and enquiry from a distance as well as enabling this person to watch the activity all around. In the outpatient department of smaller hospitals, an open booth or counter will satisfactorily serve the purpose.
The reception and enquiry should be prominently signposted. Although seemingly of little importance compared to the other activities of outpatient department, reception and enquiry should be staffed during the working hours of outpatient department by an experienced and competent person.
Some hospitals favour a medical social worker to a reception clerk for this purpose, but a senior nurse as well as a lay administrator is equally suitable, provided the person has complete knowledge of the location of every single facility and activity of the outpatient department. With tremendous amount of hectic activity taking place all around, tempers are likely to be frayed easily in this situation.
Therefore, he or she should be well- mannered and cool-tempered with infinite patience to hear patients’ innumerable queries and answer them.
Reception and enquiry should have good communication through telephone and intercom sets with all clinics and other important areas in the OPD.
A well-illustrated, easily understandable guide map showing locations of all clinics and adjunct services units can be prominently displayed in this location.
3. Waiting Area:
There should be a main entrance hall where people first arrive and get registered. On entering an outpatient department the patient should find himself in the entrance hall faced by the reception and enquiry counter.
There are various scales suggested for the waiting areas by various authorities, from one square foot per outpatient attendance per day to 8 to 10 square feet per daily patient visit in Western countries.
In many countries, the large waiting hall where hundreds of patients waited for attention has become a thing of the past by introduction of the appointment system.
In our country and especially in large hospitals, it will perhaps take a long time to do away with centralised large waiting area where the hall also serves as a waiting place for the relatives or friends accompanying patients.
It should be remembered that in our country each outpatient is usually accompanied by one or two relatives or friends.
Apart from the main waiting area, subsidiary waiting areas for a small numbers of patients will be needed at each clinic and at the diagnostic and therapy rooms.
With the present volume and complexity of outpatient work in large hospitals, it becomes essential to provide subsidiary waiting areas for the clinics to expedite patient flow, to prevent corridors outside the clinics and consulting rooms from becoming overcrowded with waiting patients and impeding the circulation of traffic. Space provided in subsidiary waiting areas is 8 square feet per patient (0.75 m2) for one-third of the attendance at each department.
For a doctor session of up to 30 patients in hospitals in NHS hospitals in UK, waiting area for one-third of the patients is considered adequate. For paediatric clinic, the waiting space should be approximately for 14 patients with a clinic attendance of 25 to 30.
The size of the main waiting hall and subsidiary waiting areas determines the “holding capacity” of the outpatient department. This should be anticipated and planned in advance to avoid gross overcrowding at a future date.
Noise levels in the reception and registration area and in the main waiting hall has been found to be very high (up to 150 db) in public hospitals.
An acoustical ceiling is desirable in the main reception and waiting hall to absorb the high level of noise that prevails there.
With a large number of people continuously passing through it (3000 to 4000 outpatients per day in All India Institute of Medical Sciences and Safdarjung hospital, Delhi, and up to 2000 patients in many medical college hospitals) over a short period of about 4 to 5 hours, the main waiting hall should be well-ventilated and easy to clean.
In large public hospitals at least, the floor, preferably tiled, should be sloped towards an inset drain so that it is easy to sluice down with a hose. The halls should be furnished with comfortable benches or chairs.
If needed the waiting hall can be used for health education lectures and screening of health education films, thus utilising the patients waiting period for health education through diversionary audiovisual entertainment with television screens placed at appropriate places.
Adequate number of toilet facilities should be provided separately for males and females. Scales of 1 to 2 WCs for every 100 patients attending the OPD and at least one urinal for every 50 patients are recommended.
Arrangement for drinking water in the form of a water cooler and dispenser should be made, and space for one or more public telephone booth should be earmarked.
The waiting area or entrance lobby should display boards for information of the patients and public regarding names of doctors and nursing staff on duty during a clinic session.
4. Wheelchair and Trolley Bay:
For patients who cannot walk, stretcher-trolleys or wheelchairs will be required to carry them through the department. A place to park them should be provided at the very entrance to the outpatient department.
Adjoining to the reception and enquiry room would also be a good location. The issue and replenishment of trolleys and wheelchairs can be organised under the overall control of the outpatient department coordinator/administrator. Adequate space for the required number of stretcher-trolleys and wheelchairs should be catered for.
5. Registration counters and medical record room:
The registration counter and outpatient medical record room is conveniently located at one end of the main waiting hall.
All patients have to register at the outpatient registration counter. Each new patient is given a registration number in the form of a ticket, and an outpatient card is made for him/ her who is sent to the physician to whose clinic the patient is directed.
On subsequent visits, when the patient presents his ticket at registration counter, his folder is taken out from the record room and sent to the appropriate physician.
The folders is deposited back in the medical records room by the clinic staff at the end of the day and are restored to their appropriate place by the medical records clerk.
Considerable time can be wasted sorting unfiled papers and chasing missing reports. There should be a clear distinction between the work of medical records department and clinic staff.
A centralised registration and record system, wherein all outpatient visits are registered and record kept at one place has advantages of conserving manpower and space, as opposed to the decentralised registration and record system wherein each clinic like medical, surgical, paediatric, etc. has its own registration counter and records room, or the mixed system wherein the patient’s first visit is registered and outpatient card originated at the central registration, but subsequent visits are registered at the respective clinic where his or her medical record is then kept.
In the decentralised registration system, the patient goes directly to the appropriate clinic for registration on being directed at the reception and enquiry. In this case, there will be no registration counters and no records room in the main reception and waiting hall.
In the mixed system, only the new outpatients will use the main registration counters, as repeat visits will directly be registered at the respective clinics. The type of system that is practised has a bearing on the requirement of space and manpower.
The records are kept in filing racks with shelves. Depending upon the daily number of outpatient visits, appropriate number of racks must be provided. Up to 1000 outpatient records can be accommodated on each shelf of the rack. It is estimated that 1200 square feet (112 m~) space would be required for outpatient medical records room for a 500-bedded hospital.
6. Consulting and Examination Rooms:
Separate consulting rooms with attached examination rooms can be uneconomical in space. The number and arrangement of consulting and examination rooms will vary with the services offered and the outpatient load expected.
The essential point is that privacy of consultation should be assured and the flow of patients should be smooth. The organisation and operation of outpatient departments for efficiency is aided by carrying out actual studies to depict the number of patients which doctors in different specialties could be expected to deal with in a session with the proposed clinic organisation.
In a busy outpatient department, the arrangement of examination rooms should be such that doctors can see patients without waiting for patient to undress, lie down, etc. A two, three or four cubicle examination room for each doctor can achieve this.
In busy outpatient clinics, combined consulting-cum- examination rooms permit all activities associated with patient examination. It eliminates the use of dressing cubicles, with minimization of movement around the clinic. A series of intercommunicating consulting-cum-examination rooms offers an efficient as well as economical arrangement.
Each doctor uses two or more such rooms according to the nature of the work, his speed of operation and the number of assistants with him. While the patient is dressing, the doctor can write his notes, and then move on to the adjoining room to deal with the next patient who would be ready on the examination table.
With minor readjustments these types of consulting-cum- examination rooms can serve almost all specialties except otorhinolaryngology and ophthalmology.
There is very little wastage of the doctor’s time in this arrangement which ensures a great deal of flexibility of use and economy of construction
In large hospitals, providing examination rooms and other accommodation suitable only for a particular specialty has disadvantages.
If the volume of attendance in a speciality changes over time, accommodation intended for one may have to be used for others.
Some specialities require consulting and examination facilities only for part of the week, and others are required to share them. Standardisation of layout of examination rooms therefore facilitates the work of clinics as well as of the nursing and auxiliary staff who have to work in different clinics by rotation.