Facility Operational Hours
To ensure access to care, patients must be able to visit health facilities at times and days that are convenient to them and do not require substantial sacrifice in work or childcare. Because expanded days and hours of service may require more human resources, stakeholders must consider how they can reorganize the health system to accommodate these changes. The suggestions for reducing waiting times below may help facility managers rearrange service delivery to accommodate more hours of operation:
- Staggered shifts – Because increased hours may reduce the density of patients throughout the day, fewer providers may be scheduled on each shift in favor of extending the hours or days of operations. This may involve some pilot testing and observation of patient flow to optimize, and it is important to ensure that all services are staggered as well so patients still have access to comprehensive care.
- Integrated services – Often, clinics may have designated days for services such as antenatal care or antiretroviral therapy. Instead, clinics should ensure that patients can receive a comprehensive range of services at any time to optimize appointment time and minimize return visits.
- Increasing staff and/or expanding service delivery hours – Both of these considerations involve substantial financial inputs from the health system to direct funds to the compensation of additional staff or extended hours. Stakeholders should consider if they have the resources necessary to implement these changes. However, facility managers must ensure that staff receive adequate incentives and support to reduce provider burnout and maintain motivation. If staff are asked to work inconvenient hours, health systems may choose to consider additional incentives.
- On-call telephone systems – In areas where patients have access to phones or computer, clinics may choose to have providers available to provide remote consultations during non-clinic hours. Unless there is substantial telemedicine technology in place, these consultations may be limited to acute or emergency care.
Appointment systems can improve access to services at the point of care. These systems need not be complex but should be easy to use for both patients and providers, appropriately tailored to the internet connectivity and literacy in a given context, and adaptable to anticipate any changes in service delivery. These systems, if supported by a sufficient workforce, can improve waiting times and person-centeredness of service delivery. Appointment system options include:
- In-person or community-based appointment systems – In areas where some or all of the population does not have access to internet or phones, appointments should be able to be scheduled through in-person visits to the clinic. If the clinic is not conveniently located, appointment systems could be made available in the community. For instance, CHWs may make referrals or help schedule appointments during routine population outreach activities.
- Appointments made via SMS or telephone and linked with an appointment tracking system (paper or electronic) – In areas where patients have reliable access to telephones, appointments may be scheduled by calling or texting the facility. However, there must be an organized system for recording appointment availability for the clinic staff answering phones. Additionally, in low-literacy settings, texting cannot be the only system for requesting appointments.
- Electronic portals – Electronic portals may be an efficient option if patients have reliable access to computers or mobile devices and the internet. Additionally, systems must be in place to ensure that these portals remain up to date, and alternative means of scheduling should be available if any portion of the patient panel does not have access to the internet.
Even with efficient appointment systems, facility managers should ensure that patients can access care for urgent needs. This may be done by reserving specific days and/or times for walk-in visits or same-day appointments.
While reduced waiting times will improve patient experience and access, they can also contribute to clinic efficiency. Patients who miss their appointments often do so because of long waiting times or the need to select an appointment time that is inconvenient for them.11 Thus, improved systems may reduce no-shows and ensure that the provider time is maximized. It is also important for facilities to have systems for triaging patients once they arrive in facilities. For instance, patients may be triaged between emergency, chronic, and acute care. Assuming that facilities have sufficient human and material resources to address demand, some strategies to make appointments more efficient and reduce waiting times—along with questions stakeholders may use to assess the appropriateness of the strategy for their context—include:
- Group visits – Are there any patient types whose needs are fairly standardized (certain chronic care conditions, antenatal care, etc.) and could receive care in a group context? What sort of logistics would need to be in place to organize these visits? How will this change be effectively communicated to patients?
- Effective delegation to different providers – Are there any services that are currently being provided by doctors that can be effectively provided by nurses or CHWs who are in greater supply? What kind of training (if any) would these providers need to receive to be able to provide a wider range of services? Can any of these services be provided outside of the facility?
- Options for telemedicine appointments – Does the patient panel have access to mobile devices and appropriate connectivity? What form of communication would be most efficient for patients and providers (text message, video conference, email)? Which providers would be responsible for telemedicine and how would their workflow need to change to accommodate this responsibility?