Introduction and Objectives

The Philippines, out of 234 countries, ranks at number 13 to be the most populous country in the world at almost 113 million people.  Even before the pandemic, Philippine health facilities were described to be urban-centric.  With this kind of distribution, social, economic, and geographic barriers become more pronounced, leading to health inequalities, with access and service delivery being most apparent.   COVID-19 exposed even more the vulnerabilities of the Philippine healthcare system.  For the early months of the pandemic, the entire island of Luzon and some provinces with the most cases of COVID-19 were placed under an Enhanced Community Quarantine (ECQ).  With restricted mobility, access to healthcare, and health service deliveries mostly for non-COVID conditions were limited to none.  Despite these restrictions, the healthcare system was still overwhelmed – tertiary hospitals could no longer accept patients regardless of condition and healthcare providers were overworked to exhaustion.   In April 2020, in the thick of the tightest lockdown, the Department of Health and the National Privacy Commission developed a framework for telemedicine services which allowed consultations over the phone, through chat or short messaging services and other audio and video conferencing platforms, to decongest hospitals and minimize risks posed by unnecessary patient traffic. 

The Quirino Memorial Medical Center (QMMC) is a Department of Health retained tertiary hospital which recorded 229, 097 patients seen in the outpatient department in 2019 (DOH HFDB, 2020).  Before the pandemic, the hospital had already seen its outpatient department overcrowded.  Hospital officials have been active in searching for ways to improve their operations and curb patient waiting time.  Due to the pandemic and the Department of Health memorandum they were expected to help unburden the health system by offering telemedicine services.  

Lean Six Sigma or LSS is a methodology which combines the Lean approach of waste reduction and Six Sigma approach of variation reduction in improving processes.  LSS employs the Define-Measure-Analyze-Improve-Control Framework (DMAIC), to improve processes and outputs through waste and process-variation reduction. Through utilization of LSS tools, wastes and variations in the process were identified and targeted for improvement. Thus, this study aimed to utilize the Lean Six Sigma (DMAIC method) in streamlining the Outpatient Department teleconsultation process in QMMC. The following were the specific objectives:

• Review the current processes and protocols in the outpatient department for teleconsultations
• Determine and evaluate the baseline average waiting time of Outpatient Department patients for teleconsultations
• Identify causes of long waiting times (i.e. bottlenecks, delays, inefficiencies) through the DMAIC method of LSS using Value-Stream Mapping and Root Cause Analysis, and differentiate between value-adding activities from non-value adding
• Measure the waiting time for Outpatient Department teleconsultations after implementation to determine whether intervention has improved the Outpatient Department teleconsultation process
• Recommend interventions that can minimize the waiting times and implement measures that will prevent delays

Methods

This was a single-institution study of a DOH Hospital with an Outpatient Department providing teleconsultation services, particularly that of Quirino Memorial Medical Center. Participant criteria included patients who availed of teleconsultations through the Outpatient Department of the partner institution. Due to the logistical constraints, only two departments were included in the study: the Family Medicine Department and the Internal Medicine Department, which conducted their teleconsultation through Zoom and Facebook Messenger as their platforms respectively. These departments were decided upon because most departments carried out teleconsultation via Facebook messenger as well, Internal Medicine having the most number of patients in the outpatient department.

Results and Discussion

A root cause analysis was done for the Internal Medicine department, revealing the following root causes in their telemedicine process: (1) no specified time for consultation, which resulted in erratic replies for both residents and patients, (2) only 1 resident in charge, which resulted in busy residents having to balance teleconsult duties and other administrative responsibilities, (3) Channels used beyond teleconsultation, which resulted in residents replying to non-teleconsultation related queries, and (4), no protocol for teleconsultation, which resulted in a non-standardized way of handling teleconsultations (varying per resident).

  For Family Medicine, the long zoom teleconsultation was caused by the queue for resident referral during calls. The team noted a discrepancy between the number of interns and the residents and consultants available at a given time.  As a teaching hospital, all patient encounters of the interns were expected to be relayed to the residents and consultants until management and final disposition.   Sometimes, further questions and/or clarifications were necessary, which created multiple back and forth correspondence between patient and resident/consultant, therefore prolonging the consultation time.

  Interventions were then recommended, with these being (1) improving information gateways (creating a Facebook page with clear instructions, automated messages, and FAQs), (2) Real-time patient logging via Google Forms, (3) Virtual Care Pathways for common concerns, and (4) a Teleconsult Process Guide.

Interventions

Conclusion

This study aimed to improve the teleconsultation process of the outpatient department with waiting time as its indicator. The two main outcomes computed were waiting time and consultation time.  In the pre-intervention or initial data collection phase it was observed that reply delays came from both the providers and patients.  Through utilization of LSS tools, wastes and variations in the process were identified and targeted for improvement. Significant improvements were seen post-intervention despite not all recommendations being carried out.  Therefore, in streamlining teleconsultation operations through LSS, effectiveness and efficiency can be improved by removing causes of delays by process variation and overall reducing waiting time.