Case Report
Improving Outpatient Clinic Operations: A Case Study at Lady Ridgeway Childrens Hospital, Sri Lanka in 2019
GG Chamal Sanjeewa* and Lal Panapitiya
Corresponding Author: GG Chamal Sanjeewa, Registrar in Medical Administrator at Post Graduate Institute of Medicine, Consultant Medical Administrator-DDG (MS1), Colombo, Sri Lanka
Received: November 19, 2019; Revised: December 04, 2019; Accepted: June 26, 2020
Citation: Sanjeewa GGC & Panapitiya L. (2020) Improving Outpatient Clinic Operations: A Case Study at Lady Ridgeway Childrens Hospital, Sri Lanka in 2019. Int J Intern Med Geriatr, 2(1): 69-75.
Copyrights: ©2020 Sanjeewa GGC & Panapitiya L. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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This study focuses on improving outpatient clinic operations in an existing largest public free of charge pediatric hospital in the world, Lady Ridgeway Children's Hospital, Sri Lanka. According to our preliminary investigation, the outpatient clinic of this hospital is currently suffering from inefficient operations which lead to a significant patient’s waiting time to receive the doctor care and other services. This eventually leads to a decline in patient’s satisfaction in overall hospital services. The primary objective is to reduce the patient waiting time in each stage of operation. On-site data collection and exploratory study are carried out in order to fully understand the current operations and to identify the root causes of the problems. Process analysis is performed to identify the process bottleneck. Integrating areas of queuing theory, and facility layout, a set of improvement guidelines is proposed. Discrete-vent simulation results show that, with the proposed guidelines and operation settings, the overall patient’s waiting time can be significantly reduced.


Keywords: Inefficient operations, Patient’s satisfaction, Patient’s waiting time



Lady Ridgeway Hospital for Children is the largest public free of charge pediatric hospital in the world. It serves as the national referral center for pediatric care for Sri Lanka. It also serves as a local hospital for the population in and around Colombo city for minor ailments. This hospital has 1000 beds and it treats children below 14 years of age from all over the country. It has all supportive services required to provide quality patient care. The total number of staff is over 2000. The medical staff consists of nearly 70 consultants and nearly 300 medical officers. They are organized as medical teams headed by permanent senior consultants who have international experience in that particular specialty. Nursing staff consists of nearly 700 nursing officers and are organized as teams in line of the organization of doctors.

The outpatients department (OPD) and the accident services department of this hospital are open for 24 h a day, for 365 days. Out patients clinics conducted by the relevant consultants of inpatient units and visiting consultants of the OPD maintain a continuous link with patients discharged from their units. There is also an emergency treatment unit, diarrhea unit and immunization clinic which operate in the OPD to improve the quality of care.

This study explores current operations in an outpatient clinic department in Lady Ridgeway Hospital for Children, Sri Lanka. The participating hospital is the largest children's hospitals in Sri Lanka and one of the largest in Asia, which is currently facing patient’s long waiting time to receive the hospital services. Unlike any other major public hospitals, this hospital is subsidized by the government and totally free of charge to the patients. Therefore, public hospitals appear to be the only place affordable by the low income groups of patients. On the other hand, with high quality of professional and medical services, the hospital also serves middle to high income groups of patients as well. Besides the free of charge and the quality of health care, responding time to patients is another aspect of overall service quality that highly affects the patient’s satisfaction.

The outpatient clinic department of the participating hospital is currently facing patients’ dissatisfaction in unrealistically long waiting time to receive the medical care as well as other services within the outpatient clinic department. Based on preliminary evidence, patients are likely to experience significantly less waiting time to receive medical and other care in the private hospitals. This is why majority of patients could be willing to pay more in order to reduce queue time [1].

The primary objective of this exploratory study is therefore to investigate the current operations and to identify the causes of extensive waiting time in each stage of operations. The operations in the participating hospital are approached and investigated by defining resource and the effectiveness of the use of resource. A set of quantitative and qualitative studies are carried out. This study proposes the guidelines for improving the patient’s overall waiting time without affecting the quality of professional and medical quality. A set of recommendations is proposed after the case study.


To understand the overall processes and to identify the causes of problems, the study is initially carried out by observing the current operations and common procedures in outpatient clinic departments. The outpatient clinic department (OPD) of this hospital consists of seven clinics as follows: General Practice Clinic, Pathology Clinic, Pediatrics Clinic, Ear Nose Throat Clinic, Surgery-Orthopedics Clinic and Eye Clinic. Once one enters the hospital, patient has to report to the registration department (Figure 1). Then the registration department will retrieve the patient record and send it in a hard copy to the appropriate clinic. In the meantime, patient can go directly to one of seven outpatient clinics as appropriate or as suggested by the registration department staff. Patient that has appointment does not need to report at the registration department as his/her record is already transferred to the appointed clinic at the beginning of the day. Some patients may attend more than one clinic in one visit depending on the complication of their case. Once the treatment is completed, patient receives prescription and goes to the medicine/cashier department. As prescribed, medicine is received and transaction is completed, patient may exit the hospital (Figure 2).

Although each outpatient clinic has different number of doctors, nurses, and staff and different clinic detailed layout, it is found that all seven outpatient clinics have similar flow of operations as shown in Figure 3. As patient enters the clinic, he/she must first contact the front desk (counter 1). Nurses will check whether the patient’s medical record has arrived from registration department. Patient stays in queue waiting for their medical record and the availability of pre-diagnose nurses (counter 2). It is found that the waiting time at this stage is not significant. As pre-diagnosis are completed, patient transfers to a large queue waiting to be treated by one of the doctors. According to on-site data collection, it is found that patient spend a significant time in this queue. In some clinic during peak time, some patient may have to wait as long as three hours or more to receive the doctor care in this queue. After receiving medical treatment, patient contacts counter 4 to give the medical record to nurses and wait in queue. Nurses will print out the prescription and release to patient at counter 5. Patient exits the clinic with prescription and transfers to the medicine/cashier department. In this department, it is observed that each patient also spends significant time waiting to complete the procedure.

After observing the existing patients’ flow and common procedures in all outpatient clinics, the data collection sheet is designed and distributed. The primary elements required in data sheet are the average waiting time and service times in each stage of operation, the average time patient spends in the outpatient clinic department and the number of patients entering each outpatient clinic in each time period during the day. These information are then further analyzed to identify the process bottleneck and to calculate the patient inter arrival time, patient arrival rate and service rate in each operations which will be used in simulation models. The data was collected for 1 month period. It is found that patients spend more than 3 h on average in the patient clinics waiting for doctor cares and other hospital services. Although most internal operations in each clinic are similar, some clinics are suffering from extensive patient waiting time than the others (Tables 1 and 2 and Figures 4 and 5)

1.       Leung GM, Yeung RYT, Wong IOL, Castan-Cameo S, Johnston JM (2005) Time costs of waiting, doctor-shopping and private-public sector imbalance: Micro data evidence from Hong Kong. Health Policy 76: 1-12.

2.       Lady Ridgeway Hospital (2018) Annual Health Bulletin.