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Using appointment diaries and setting thresholds reduces overcrowding and client wait time

Dr. Kenneth Batsikana, Dr. Patrick Musinguzi
Thursday, July 24, 2014
Context: What was the issue or process affected? What was the root cause of the challenge?: 

Between June 2011-June 2012, Mubende Regional Referral Hospital’s ART clinic experienced uneven distribution of client load on various days, because scheduling patient appointments did not follow a clearly well thought-out method. Client numbers ranged from 80 up to 300 per day. As a result, overcrowding at the clinic led to an increase in client waiting time; on the heavy days, the last client often would not be seen until 7:00pm. Subsequently, retention of clients on treatment was negatively affected; the clinic recorded a retention rate of 65% between October-December 2011, which further dropped to 61% in January-March 2012.

What Happened: How was the challenge or gap addressed or improved?: 

In a weekly staff meeting, it was noted that clinicians were booking more clients on particular days and there was need to distribute client appointments evenly to avoid heavy clinic days. The team came up with two possible solutions:

1. Determining the clinic’s daily threshold according to the following formula:

Daily Clinic Threshold = Total number of active clients in the quarter + 20 clients (i.e.,
average # of
clients who attend
clinic days without an
Total number of clinic days in the quarter

2. Use of clinicians’ appointment diaries to track clinician thresholds:

Clinician Threshold = Daily Clinic Threshold
Total number of clinicians in the clinic

The clinic threshold was set at 100 clients per day.

Nugget: What is the lesson for others?: 
  • Setting a  daily threshold distributes clients evenly throughout a working week and avoids heavy clinic days
  • Determining each clinician’s threshold increases client-clinician interaction time and quality of services
Impact: What are the results of applying the nugget?: 
  • Overcrowding at the clinic decreased and the clinic no longer experiences “heavy” days. By 3:00pm each day, all clients have been seen by clinicians (compared to 7:00pm before the changes were introduced).
  • Client retention improved from 61% in March 2012 to above 84% in March 2014.
  • Mistakenly giving appointments on non-clinic days (e.g., weekends and public holidays) was controlled and eliminated altogether.
Implementation: What steps are needed to apply the lesson?: 
  • Determine the number of active clients in the clinic to arrive at the daily clinic threshold
  • Determine the average number of clients who come outside scheduled appointments dates per day
  • Determine the clinicians’ threshold, depending on the number of clinicians in the clinic.
  • Procure diaries for each clinician and teach them how to use the diaries according to the appointment system established.
  • Prepare weekly appointment summaries covering three months (from appointment books) to assist in updating the diaries. Appointments are given by clinicians and nurses using the dairies, while the weekly appointment summaries are made by a data volunteer who handles the appointment books.
Action: Who is this for? Where does this nugget to go next?: 

Clinicians, Nurses, Counselors and Data staff

Dr. Patrick Musinguzi, Clinical Care Coordinator ([email protected]); Diana Nkurunziza, Data Officer ([email protected]); Dr. Kenneth Batsikana, ART Clinic In-charge ([email protected])
Clinicians appointment diary
Weekly appointment summary