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Afolabi & Erhun, 2003 Response to waiting time

Trop J Pharm Res, December 2003; 2 (2)207

Tropical Journal of Pharmaceutical Research, December 2003; 2 (2): 207-214

© Pharmacotherapy Group,Faculty of Pharmacy, University of Benin,

Benin City, Nigeria.

All rights reserved.

Available online at http://www.tjpr.freehosting.net

Research Article

Patients’ response to waiting time in an out-patientpharmacy in Nigeria

Margaret O Afolabi and Wilson O ErhunΦΦΦΦ Department of Clinical Pharmacy and Pharmacy Administration, Obafemi Awolowo University, Ile-Ife, Nigeria

Abstract

Purpose: To identify the dispensing procedure at a pharmacy, investigate the possible operational problems that may lead to excessive patient waiting times as prescriptions are filled and to examine patient disposition to perceived delays at the pharmacy.Methods: The study was carried out in a 574-bed university teaching hospital in Ile – Ife,Nigeria. The subjects were out-patients who gave their consent to participate in the study.Data were collected using the techniques of workflow analysis and time study in observing the dispensing process. A validated questionnaire was administered on the out-patients to measure their responses to waiting in the pharmacy as well as their level of satisfaction with pharmaceutical services rendered.Results: The workflow analysis revealed considerable delay in the dispensing procedure as a result of extended process components. The total waiting time for a dispensing process

averaged 17.09 min, and 89.5% of this was due to delay components. Specifically, the major delay components included patient queues for billing prescription sheets and subsequent payment to the cashier. Operational problems identified included patients’ indirect access to dispensing pharmacist and the tortuous procedure for prescription billing and payments.Generally, patients were not satisfied with undue delay caused by the dispensing procedure at the pharmacy.Conclusion: Most of the patient waiting time in the hospital studied can be accounted for by delay components of the dispensing procedure. Attempts should therefore be made to reduce the time on these components of the dispensing process so that more time could be devoted to counseling while reducing the total time spent by the patient in having their prescriptions sheets filled.

Key words: Dispensing process; hospital pharmacy; pharmaceutical service; waiting time

ΦΦΦΦTo whom correspondence should be addressed: E-mail: [email protected]




Trop J Pharm Res, June 2003; 2 (2)208

Introduction

Patient waiting time has been defined as ‘thelength of time from when the patient enteredthe pharmacy to the time the patient actuallyreceived his or her prescription and left thepharmacy’

1. A patient’s experience of waiting

can radically influence his/her perceptions ofservice quality. In a study carried out at theUniversity of Southern California, LosAngeles, USA, it was shown that the overallsatisfaction of patients with pharmaceuticalservices is closely related to their satisfaction

with waiting time2. Long waiting time hasbeen given as a reason why some patientsdo not have their prescriptions filled in aparticular pharmacy

3. This shows the

significance of waiting time on pharmacyservices and patronage.

Patients are attended to in various unitswithin the hospital system but almostinvariably a high percentage of out-patientpatrons visit the hospital pharmacy unit for

their drug needs. These patients leave thedoctors’ consulting clinics and any of theother units at various times thus constitutinga random arrival rate at the pharmacy, wherethe dispensing activities take placesequentially. Queues form when the rate ofpatient arrival at the pharmacy is greaterthan the service rate.

Excessive patient waiting time underminespharmacy efficiency. Such delay leads to

patient dissatisfaction and thus mayeventually result in loss of patronage in acompetitive health care system. It can alsolead to poor patient compliance withinstructions given at the pharmacy.Therefore, there is a need to carry out asystematic study on patient waiting time in apharmacy, with a view to identifying thefactors that affect waiting time andrecommend ways of minimizing the delay.

To this end, this study sought to find

answers to the following research questionsin the context of a Nigerian hospital:

i. What is the average patient waiting time

in the pharmacy?ii. Are patients favourably disposedtowards the prescription fillingprocedures i.e. the pharmacy dispensingprocedures?

iii. What time may be attributed to theprocess and delay components ofpharmacy dispensing operations?

iv. What are the possible operationalproblems that may lead to excessivepatient waiting times?

Methods

The study was carried out between April andMay 2002 at the out-patient pharmacydepartment in a university teaching hospitalsituated in Ile-Ife - an urban community inSouthwestern Nigeria.

Ile-Ife, known as the cradle of the Yorubas,is an ancient town with a rich culture andnotable historic sites. The town is one of the

main cities in Southwestern Nigeria andObafemi Awolowo University is strategicallylocated beside the hills within the city. Theuniversity teaching hospital known asObafemi Awolowo University TeachingHospitals (OAUTH) is a 574-bedgovernment-owned hospital providing healthcare services to Ile-Ife communities andother neighboring towns and villages. Also,by virtue of its location and the specialtyhealth care services it offers, the catchment

area of OAUTH is extremely large withreferral cases from about six adjourningstates thus bringing health care facilitiesclose to the communities.

The pharmacy department is a service armof the teaching hospital, which providespharmaceutical services to both the in-patients and out-patients at the hospital. It isopen to patients throughout the day but thepeak hours for out-patients transactions isfrom 10.00 am to 1.00 pm daily on

weekdays. At the time of this study, thenumber of pharmacists working in thehospital was 21, which consisted of 7 pupil





pharmacists, 2 National Youth Service Corps

Pharmacists and 12 registered pharmacists.The total number of pharmacists working inthe out-patient pharmacy was 9 and theywere assisted by 4 attendants. The averagenumber of prescriptions sheets dispensedper day at the out-patient pharmacy unit is185. Prescription sheets are written andduly signed sheets indicating the drug itemsprescribed for a particular patient. Out-patients take their prescription sheets to thepharmacist who vets the drug items beforedispensing. A prescription sheet may contain

one or more drug items.

Due permission was sought from relevantauthorities to carry out this study at theteaching hospital. Similarly, an initialinteraction was made with the out-patients toestablish rapport, introduce thequestionnaire, seek their consent to take partin the study before requesting those thatgave their consent to either complete orassist in the completion of the questionnaire

used in this study.

A total of 100 out-patients randomly selectedfrom the population of patients who normallypatronized the pharmacy agreed toparticipate in the study. Similarly dispensingoperations were observed and quantified forrandomly selected prescription sheets but forpatient samples different from those whocompleted the questionnaire.

Research Instruments

The data were collected by the use ofquestionnaire administered on the out-patient patrons at the pharmacy department.The questionnaire comprised of two sectionswith one of the sections on suchdemographic characteristics as sex, ageoccupation etc. The other section had 14items designed to evaluate the extent ofpatient views on waiting time and the level ofsatisfaction with the quality of

pharmaceutical services in the pharmacy.Examples of the items include ‘waiting timeat the pharmacy is too long’, ‘the

pharmacists are courteous to customers’ and

‘it takes an unnecessarily long time for theprescription sheets submitted at thepharmacy to be processed’. Thequestionnaire was subjected to pretest todetermine reliability, over a two-week period,resulting in a reliability coefficient of 0.81.Construct validity was ascertained by theprofessional judgment of hospitalpharmacists and a test developer. Inparticular, the items were ensured to sampleaspects of the service quality such aspharmacist attitude to patient waiting time

and frequency of pharmacists counseling ondispensed drugs.

Scoring of the items was done using talliesand summing up the frequency counts.

Measurement of Patients’ Waiting Time

Workflow analysis method and the stopwatch techniques were used to measurepatient waiting time

2. The dispensing

procedure in the pharmacy was first studiedand then divided into sub-components and astopwatch was used to determine the timespent for each sub-component. The workflowanalysis highlights the sequence of activitiesinvolved in the dispensing procedure. Theoperation starts with submission of theprescription sheet by the patient and itssubsequent flow through vetting by thepharmacist for appropriateness in drugcombination and dosage; billing of the

prescription items, payment to the cashier,dispensing and patient counseling. Varioussub-components of the dispensingprocedure were then grouped into two i.e.“process” and “delay”. A process componentinvolved a staff member actively working onthe prescription, while a “delay” componentinvolved the prescription sheet lying idle andwaiting for a staff member to work on it.

Analysis

Statistical analysis was done using theSPSS version 10.0 software program forfrequency distribution and cross tabulations.





Tests for statistical significance were done

by the chi-square test for categorical data.

Results

All respondents who agreed to participate inthe study actually did giving a 100%response rate. Most of the respondents(97.9%) came to the pharmacy to buy drugson prescription. The remaining 2.1% came torequest for drug information. Majority of therespondents visited the pharmacyoccasionally (92.7%) or always waited to

have their prescription filled at the pharmacy(91.7%). Too long waiting time was given asa reason for not always filling theirprescriptions at the pharmacy by 8.3% of therespondents.

The sub-components of the dispensingprocess and the time spent for each subcomponent are shown in Table 1. The timedistribution for the processing and delaycomponents showed that delay components

accounted for most of the patient waitingtime. Out of the average 17.09 min of patientwaiting time, 12.48 min were related to delaycomponents and 4.61 min were related toprocess components. The delay componentsaccounted for 73.02% of overall patientwaiting time. Significant delay occurred priorto payment for the billed prescription, i.e.“collection of money, issuing of receipts andrecording by the cashier” (8.68 min or50.79% of total patient waiting time).

Fifty-two percent (52.1%) of the respondentsdescribed the time they spent waiting in thepharmacy as adequate while the rest 47.9%of the patients that considered the waitingtime as either long or too long gave"shortage of pharmacists” and “too manyprocedures involved in dispensing process”as reasons for the long waiting time. Over20% of the patients were not satisfied withthe waiting time while 78.9% considered it aseither fairly satisfactory or very satisfactory.

All respondents with primary educationdescribed the waiting time as adequate

compared to 58.3% and 41.7% of those with

secondary and post secondary education,respectively (Table 2). More females(60.4%) than males (43.8%) considered thewaiting time as adequate. Respondentsbelow 20 yr of age and above 50 yr weremore satisfied with the waiting time thanothers. Eighty percent of respondents whowere traders found the waiting time to beadequate compared to 52% of students and43.3% of civil servants. Respondents livingoutside the town (60%) where the hospital islocated were less satisfied with the waiting

time than others.

On counselling, 28.1% of the respondentsclaimed that they were always counselled ondispensed drugs, 34.4% claimed they wereonly counselled occasionally while 36.5%claimed that they were never counselled ondispensed drugs. For those that werecounselled, the average counselling time bythe majority (80%) of them was less than 2min and this period was viewed as just

enough by the majority of the respondents.

Some of the respondents (12.5%) were notsatisfied with the pharmaceutical services atthe pharmacy while the extent of satisfactionranged from fairly satisfactory to verysatisfactory. The effect of demographicfactors on patients’ satisfaction withpharmaceutical services is shown in Table 3.

Discussion

The data in Table 1 presents the timedistribution in processing and delaycomponents of the dispensing procedure.Analysis of this data showed that the longestdelay occurred prior to “collection of money,issuing of receipt and recording”, whenpatients had to wait on queue for an averageof 8.68 min which was 50.79% of totalpatient waiting time. The source of this delayis likely to be the process step immediatelyafter it. On observation, the average time

taken by this process of payment/recording(1.42 min or 8.31% of total patient waitingtime) is quite minimal, indicating that the





process was not efficient. However therewas a time lag before this process wasinitiated and hence the long delay.

At the time of the study, there was only one“payment unit” at the pharmacy. Increase inthe number of “payment units” shouldsignificantly reduce this delay. The potential

for improvement is buttressed by the shortdelay observed prior to “filling of prescription

by pharmacist”. The processing time forfilling of prescription and payment/recordingare similar. This was probably because therewas more than one member of staff fillingprescriptions and the time lag (delay) beforeinitiation of the process which is significantlyshort.

Currently a significant number of theprocessing components involve movementfrom one area of the pharmacy to another.These processes included:-

Table 1: Observed time distribution between processing and delay components for each

component of the dispensing process

Time Spent (min)

Processing DelayComponents of Dispensing Procedure No ofsamples Mean ± SD % Mean ± SD %

Patient wait for attendant to collect prescription 24 0.76±0.05 4.45

Attendant takes prescription for billing 20 0.15± 0.00 0.88

Prescription placed on dispensing table forbilling

20 0.44±0.01 2.57

Pharmacist bill and review prescription 25 0.62±0.01 3.63

Billed prescription placed on dispensing tablefor attendant

25 0.60±0.02 3.51

Attendant takes prescription to patient 20 0.18±0.00 1.05

Patient takes prescription to cashier 25 0.14±0.00 0.82

Patient wait on queue for payment 8.68±0.98 50.79

Cashier collects money, issue receipt andrecord

25 1.42±0.37 8.31

Patient collect receipt and prescription; andtakes them to attendant

22 0.18±0.02 1.05

Patient wait for attendant to collect receipt andprescription

25 0.56± 3.28

Attendant takes prescription and receipt topharmacist

25 0.12±0.03 0.70

Prescription and receipt placed on dispensingtable for pharmacist to fill

20 0.58±0.01 3.39

Pharmacist fill prescription 25 1.38±0.38 8.07

Drugs placed on dispensing table for attendant 20 0.86±0.01 5.03

Attendant takes drug to patient, instruct anddispense

25 0.42±0.02 2.46

Total 4.61±1.24 26.97 12.48±2.04 73.02





Table 2: Cross Tabulation of Demographic factors against Patient Description of waiting time

Patient Description of Waiting Time (%)Demographic Factors

Adequate Long Too long Chi square

Level of EducationPrimarySecondaryPost Secondary

10058.344.6

033.332.4

08.323.0

12.33 p<0.025

SexMaleFemale

43.860.4

37.520.8

18.818.8

2.72 p>0.20

Age (Years)<20>20 – 30>30 – 40>40 – 50> 50

10043.831.650.0100

041.726.320.0

0

014.642.130.0

0

13.74 p>0.05

OccupationTradingSchoolingCivil ServantOthers

80.052.242.330.0

20.032.623.150.0

015.234.620.0

17.91 p>0.20

Area of ResidenceWithin town of hospital

Outside town of hospital

55.3

40.0

27.6

35.0

17.1

25.0

6.67 p<0.05

Table 3: Cross tabulation of demographic factors against level of patient satisfaction

Level of Patient Satisfaction with Pharmaceutical Services (%)DemographicFactors

Unsatis-factory

FairlySatisfactory

Satisfactory VerySatisfactory

Chi square

Level of EducationPrimarySecondaryPost Secondary

041.716.2

33.358.348.7

66.70

31.1

00

4.1

13.52 p<0.05

Sex

MaleFemale

16.78.3

58.337.5

25.047.9

06.2

5.99 p>0.10

Age (Years)<20>20 – 30>30 – 40>40 – 50> 50

012.526.3

00

100.056.331.640.030.8

010.431.650.069.2

00

10.510.0

0

21.07 p< 0.05

OccupationTradingSchoolingCivil ServantOthers

10.08.6

11.530.0

20.058.734.670.0

70.032.642.3

0

00

11.50

15.78 p>0.05

Area of ResidenceWithin town of hospitalOutside town of hospital

15.80

39.580.0

42.115.0

2.65.0

8.26 p<0.05





(a) Attendant taking prescription to

pharmacist for billing.(b) Attendant taking prescription to patient.(c) Patient taking prescription to cashier.(d) Patient collects receipt and prescription

and taking it to the attendant.(e) Attendant taking prescription and receipt

to pharmacist.(f) Attendant taking drug to patient,

instructing and dispensing.

All the above processes accounted for6.96% of the total waiting time or 25.81% of

the time spent on processing components.Restructuring of the pharmacy layoutappropriately to reduce movement will leadto a reduction in the total patient waitingtime.

A delay is more likely to come up at the endof a process component due to a break inthe workflow. Decrease in the number ofprocess components of the dispensingprocedure should lead to decrease in delay

and subsequent decrease in total waitingtime. For example, merging of the billingprocess and payment/recording will lead toelimination of about 9 out of the 16components of the dispensing procedure.The evolved process (merged billing andpayment/recording) could then becomputerised to make it efficient. Anotherway of reducing delay is by increasing thenumber of “payment units” or servers at thepharmacy to two, especially during the peak

hours. This has the potential of considerablydecreasing the time lag (delay) before theprocess of payment/recording is initiated.

In a study carried out at the out-patientpharmacy of the University Hospital Inc.Cincinnati, Ohio

2, workflow analysis was

used to document the detailed stepsinvolved in the existing system thatcumulated in a typical patient waiting time. Atthe end of the study, it was found that the“process” components accounted for 10.5%

of the waiting time while the ‘delay’components accounted for 89.5%. Thisshowed that time spent on “delay” was

greatly excessive and a significant reduction

in the time would have led to significantreduction in waiting time thus increasingefficiency of the out-patient pharmacy. In ourstudy, majority of the patients always waitedto fill their prescriptions at the pharmacy.Although only less than 10% did not alwaysfill their prescriptions at the pharmacy, thisgroup of patients should not be ignored aslong waiting time which was given as thereason for not filling prescriptions at thepharmacy is important. It is pertinent to pointout that patients who are told the expected

waiting time and are kept busy while waitinghave been found to have higher satisfactionperceptions

4. Overall, satisfaction has been

found to be more closely related tosatisfaction with waiting time and whetherthe pharmacy staff are helpful and caring

5. It

has been reported that patients are leastsatisfied when waiting times are longer thanexpected, relatively satisfied when waitingtimes are perceived as equal toexpectations, and highly satisfied when

waiting times are shorter than expected6

.

The average waiting time given by majorityof respondents is 10–30 min. Thiscorresponds to the average waiting timeobtained from the time study (17.09 min). Anumber of studies had shown that patientwaiting time could be managed effectively;thus improving the efficiency of the out-patient pharmacy. It has been found thatwaiting times, even if they cannot be

shortened, can be managed more effectivelyto improve patient satisfaction7. Drug

information/educational materials could beprovided at the waiting area as most patientsindicated that this was a desired servicewhile waiting.

Cross tabulation of some selected itemsshows that there is a relationship betweenpatient waiting time and patient satisfaction;most patients that described the waiting timeas adequate were satisfied with the

pharmaceutical services at the pharmacye.g. all the patients of primary educationlevel, while most patients that described the





waiting time as too long were not satisfied

with the pharmaceutical services e.g. 70.6%of patients with post-secondary educationwere not satisfied with the pharmaceuticalservices. In a study with physicians, theimportance of the level of education onperception of services was shown by the factthat patients who had higher educationassessed the work of physicians morecritically

8.

A considerable number of female out-patientrespondents (60.7%) considered the waiting

time as adequate (Table 2) and they werequite satisfied with the pharmaceuticalservices at the hospital (Table 3). Theseresults were not surprising as females aregenerally more likely to be patient and less inhaste than males. Patients of post-secondary education are not likely to beeasily impressed and are more likely to becritical and impatient than patient of lowereducational levels. Some similarities wereobtained between results obtained for

educational level, occupation and age. Thismay be due to the fact that in the groupstudied people of post-secondary educationlevel were more likely to be either studentsor civil servants and within the age range of20 and 40 yr. These groups of patients arelikely to be in haste due to their occupation(students and civil servants) because theymay have to get back to their various placesof work while most traders (because they areself employed) are less likely to be in a

hurry.

Patients may be less able to judge thetechnical quality of the care they receive, butthey do judge their social interaction with thepharmacist. Pharmacy professionals mustincrease patients' awareness of the value ofpharmaceutical care services and make itimportant to their judgment of satisfaction

9.

Conclusion

This study has shown that majority of thepatients were fairly satisfied with thepharmaceutical services at the pharmacy

and the major cause of dissatisfaction was

long waiting time although the level ofsatisfaction was found to vary amongdifferent groups of patients; with patients ofpost-secondary level of education, which aremainly students and civil servants being theleast satisfied. The conclusion is reachedthat most of the patient waiting time in thehospital studied can be accounted for bydelay components of the dispensingprocedure. Attempts should therefore bemade to reduce the time on thesecomponents of dispensing so that more time

could be devoted to counselling whilereducing the total time spent by the patient inhaving their prescriptions filled.

References

1. Worley MM, Schommer JC. Pharmacist PatientRelationship: Factors Influencing Quality andCommitment. J Soc Admin Pharm 1999; 16:158.

2. Alex C. et al. Identification of Factors Leading toExcessive Waiting Times in an AmbulatoryPharmacy. Hosp Pharm 1999; 34: 707-12.

3. Somani SM; Daniels CE, Jermstad RL Patientsatisfaction with Out-patient PharmaceuticalServices. Am J Hosp Pharm, 1982; 39: 1025-27.

4. Naumann S, Miles JA. Managing waiting patients'perceptions: the role of process control. JManag Med 2001; 15(4-5):376-86

5. Johnson KA, Parker JP, McCombs JS, Cody M.The Kaiser Permanente/USC PatientConsultation Study: Patient satisfaction withpharmaceutical services. University ofSouthern California. Am J Health Syst Pharm1998; 55:2621-9

6. Thompson DA, Yarnold PR. Relating patientsatisfaction to waiting time perceptions andexpectations: the disconfirmation paradigmAcad Emerg Med 1995; 2: 1057-62.

7. Dansky KH, Miles J. Patient satisfaction withambulatory healthcare services: waiting timeand filling time. Hosp Health Serv Adm 1997;42: 165-77.

8. Miseviciene I, Milasauskiene Z. Patient satisfactionwith the work of the hospital medical personnel.Medicina (Kaunas) 2002; 38:559-65.

9. Ried LD, Wang F, Young H, Awiphan R. Patients'satisfaction and their perception of thepharmacist. J Am Pharm Assoc. 1999; 39:835-42.

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