JSS

Introduction

JSS is a non-profit healthcare organization based in Bilaspur, Chhattisgarh with a staff of approximately 140. The organization consists of a hospital situated on 7.6 acres in the village of Ganyari, about 20 km from Bilaspur, and three sub-centers located in remote areas in Bilaspur district. Each of the sub-centers is staffed six-days a week by trained health workers; one day a week a physician from the hospital in Ganayri visits.

Registration

NEW REGISTRATION

Mondays, Wednesday and Fridays are dedicated to outpatient consultations, while Tuesday, Thursdays and Saturdays are set aside for surgery and for visiting the three sub-centers. On an average out-patient day (M, W, F) the physicians at JSS see between 250 and 320 patients from 9:30am until 8pm.

Approximately 250 – 320 people are seen each OPD day (M, W, F). Overall, about 33% of the patients coming to the JSS OPD are new patients and about 66% of the patients are returning. There is one computer in this area, which is staffed by five employees. The computer is primarily used for registering new patients. On non-OPD days the registration area operates with only two employees.

Registration begins at 8 am with the opening of the window designated for newly registering patients. The process starts by dispensing numbered tokens and writing the names, registration numbers and queue numbers of each new patient in line. This process takes about an hour. After dispensing tokens to everyone in line, the employees at the new registration counter return to the top of the list (written in a ledger) and begin calling out patients, starting with number one, the person's name, number two, etc. It takes approximately 5-10 minutes for a new patient to get registered.

The process of registering a particular patient proceeds as follows: Three employees sit inside the new registration counter. Two take down patient details into new patient files while the third enters those details into the computer. The two employees who are registering a new patient copy the patient’s information into two locations: the patient’s file (stays at the hospital after the visit) and the patient registration card (goes with the patient). Sometimes only one person is registered at a time, but often it is two, side-by-side, while only one person sits at the computer.

Files and registration cards at JSS are color-coded. Males get white paper files, women get yellow paper files, children get blue colored files, and pink cards are for people coming from the three designated JSS sub-centers. Their registration cards, about a quarter the size of their files, are the same color. The patients are also given a thin plastic cover for their registration cards, for protection.

The information that is entered into the patient file, which is then transferred into the computer, includes the following: name, father / husbands name, form of work, caste, age, Tehsil (administrative area), panchayat (village), gram panchayat., chief complaint, mobile numbers (not entered into computer). There are a few other fields that can be filled into the computer registration system, such as education level attained, but these often go unfilled.

The computer format looks like this: Name (first), Last Name, CasteName, Fathers/Husband Name, Age, Date of Birth, Sex, Height, Weight, Family Card no., Remark (blank), District (drop down), Tahsil (drop down), Gram Panch (drop down), Village (drop down), Neighborhood (free text), then Education (drop down), Occupation (drop down), Class (drop down), T.B. Patient (free text).

Notably absent from the computerized file is phone number, although the patient's phone number is recorded on the patient's paper file. Registration area employees estimate that approximately 40% of patients have their own mobile phones but that perhaps twice that rate, at least, have access to one, in the the form of an immediate family member or neighbor.

One problem that has just recently arisen is that the Chhattisgarh state government has voted to carve out nine new districts out of the current 17. It's not clear how the drop-down menu in the system is going to be modified. Most likely it will not. People in the registration area feel that biometrics would not be necessary. Although the process of searching for the file of a returning patient can be time consuming.

After a patient’s new file and registration card are prepared each newly registered patient is weighed. JSS employees at the new registration desk also maintain a large ledger book with the following information: the number in which the patient appeared ('serial number'), the patient's registration number, patient's name, amount they paid (10 rupees for adult, 5 for child) and whether they are male or female.

One of the last things the new registration employees do is stamp the top left inside corner of the patient's new file with a stamp that has the day's date, under which will be written the patient's note.

If the computer is not functioning in the registration area then registrar who sits at the window for new patients walks over to the billing area, where there is a computer set up for processing people's bills and inputs the information in that computer. This process is time consuming.

There is a separate, parallel system for TB patients, diabetes, rheumatic heart disease HIV and cancer patients, which involve a ledger book, a card registration system and an excel database. Although these patients are also registered in the main registration system. All data can be exported into Excel spreadsheets.

SCHEDULEING AND QUEUING

Of the total number of patients seen each day in the OPD, only about 40 or 50 might have a prior appointment. JSS does not encourage the general public to make prior appointments because it favors those who have the means to do so (the relatively wealthy, those who live in close proximity to JSS) at the expense of those who do not. Given the limited number of physicians, and the time each physician would like to dedicate to each patient, there is a limited number of patients that can be seen each day.

For those patients schedule a prior appointment, it usually happens when the physician in the OPD recommends they return on a particular day. A diary is kept with the person at billing and the appointment is made and the person is given a slip. Another 50 patient are returning patient who had not registered, and 100 are new registrations. Patients may wait on the grounds of JSS (in the guesthouse area) for days to be seen.

Separate from these groups of patients, leprosy patients can get into a special leprosy queue. Also, patients who come from each of JSS's three community health sub-centers have a right of passage that allows them to be seen quickly, due to the fact that they come from forest villages and are amongst the poorest of the poor. On average there are fifteen of these patients per day, and about fifteen leprosy patients.

For cases that qualify as emergencies, the patient might go to the IPD and then later have their registration papers made. Or they could be admitted and receive a registration number the next day. At the same time, they could be refered elsewhere and never receive get a registration number. Another category of patients is maternity. Mothers who arrive with contractions go straight to the labor room. Currently between fifty and seventy-five percent of the women spend the night after delivering.

RETURNING PATIENTS

When returning patients arrive at JSS they stand in line to receive a numbered token, give their name and registration number. Employees estimate the 90-95% of returning patients return with their registration card. Using the registraiton number on the patient’s card, a JSS employee in the registration department searches for the returning patient's file and opens the registration window when he has located it. For the 5-10% of returning patients who do not bring their card, this employee will search for their information on the computer next to the window for newly registering patients using patient’s name, village and age. Employees report a very high rate of success of finding patients this way.

A large ledger is kept for recording returning registration visits, which includes the patient's queue number, registration number, name, sex, the amount they paid (usually it's either the requisite five rupees or nothing) and then the last date they visited.

When the patient’s token number is called they return to the desk (located in the doorway of the registration department) deposit their numbered token in a box, get weighed, and receive their file. Often an extra piece of paper has to be threaded or stapled to their file to make room for an extension of the patient note.

Otherwise, for returning patients there is no input of information into the computer. Their return to JSS is simply recorded into a large ledger book. Also, there is currently no printing facility in the registration office. 159,471 are registered in the system as of Aug 27.

Screener

A senior nurse, the screener, sees both returning and new patients at a small table set along the corridor between the registration area and the OPD. He keeps a blank piece of A4-sized white paper on the table, sub-divided into blocks, which represents the number of OPD rooms. On OPD days there may be seven active OPD rooms, but often two physicians sit in one room. For each patient directed to a particular room there are tick marks, so that the screener maintains a running count not of who was directed to each OPD room, but rather how many patients have been directed to each.

The screener can send the patient to one of five places: referred away; operating theatre; OPD; laboratory or other investigation (ECG or ultrasound); get medications filled. If being sent to the OPD, the screener records, in Hindi, the presenting chief complaint. This gets recorded on the patient record.

JSS physicians would like to have a senior person do comprehensive screening of patients at the registration level, but they don't have anyone with that skill set at the moment. So a senior nurse performs the task. Still, the patients must be more or less divided so one person doesn't do more than their fair share of work. Also so tht a disproportionate number of patients don't cluster in one particular area or another of the OPD.

The process begins with the screener looking to see which physician the patient saw on their previous visit (if they are returning patients). The physician's name is not written, but the knows who it was not because he recognizes the physician's handwriting. Then he sees what the last thing was that was written in the patient note. It may be a lab investigation, written at the end of the most cent patient note, which was requested of the patient to do at the beginning of the return visit. If that's the case, then the screener writes the investigation request underneath the stamp of the current date and sends the patient directly to the lab department for the proscribed investigation, after which they are directed to a particular OPD room.

(By noon on a Monday abut two hundred patients have passed through the registration and been directed to a particular OPD room by a screener.)

The screener also referes to an Operating Theatre diary, which will be discussed in the future update focusing on the OT.

For the most part the screener sends patients to the OPD, and after that sends patients to either the lab for investigation or pharmacy for medication. In the minority of cases does the screener refer the patients out of the hospital for a particular exam or simply away altogether.

On a very rare occasion, the person who functions as a screener, who is a senior nurse with advanced training, is able to prescribe medications. I wasn't aware of this until today, so apologies for not including it earlier in the workflow overview document.

OPD

The JSS Ganyari hospital has a total of six OPD exam rooms that are routinely used by physicians. In most of these rooms physicians double up. The order and arrangement of physicians in the OPD exam rooms is not fixed; although there are certain patterns, physicians do not claim ownership over a particular exam room. The number of physicians in the OPD can range from five to ten, including an ayerveidic physician and the two residents.

The six OPD exam rooms are arranged in a four + two fashion. Two OPD exam rooms are located along the same axis with a short corridor in between serving as a waiting area. These two OPD exam rooms are primarily (although not exclusively) dedicated to dealing with maternal and child health issues; the other four are arranged in a grid formation (diagram below) under a common roof in a building contiguous with the registration area. The first two OPD exam rooms are located in a building located a few steps away from the other four OPD exam rooms.

For the cluster of four OPD exam rooms there is a large ante-room, adjacent to which are two specially designated areas: one are for emergencies; the other area for for minor procedures and investigations. Each of these side areas usually accomodates two patients at a time.

All patients who are directed, by the screener, to one of the four exam rooms (in close to the registration department) must first wait outside the door to the ante-room to be called in by one of thre three or four nurses who staff the ante-room area. Waiting at the doorway to this room, the nurses take the patients’ files, then place those files in a stack in the order in which the patient presented. The nurses then begin calling in patients one-by-one.

When the patients enter this OPD ante-room room they always get their BP checked (less often other vital signs, such as respiratory rate and temperature are taken). The BP measurement is recorded in the patient’s paper file, usually in a place next to the patient’s weight. The nurse then tells the patient to wait outside the OPD exam room that they’ve been assigned to by the screener. The nurse then delivers the patient’s file to the desk of the physician in that exam room, in a stack on the physician’s desk, with the most recently arriving patient’s file at the bottom of the stack of files. The advantage of the nurse delivering the file to the desk of the physician is that the doctor can review the patient’s file before the patient enters the room.

(In the two separate OPD exam rooms, dedicated primarily to maternal and child health, the process is similar, except that there is not a dedicated ante-room for the nurses. Instead, the nurses wait at the entrance of the OPD exam room. These rooms are quite large and were orginally constructed to accomodate three physicians. Currently these two OPD exam rooms seat only one or two physicians, giving ample room for a nurses to sit and record a patient’s BP.)

In the ‘exam and minor procedure area’ located in the building that houses the four OPD exam rooms, there are certain minor procedures that the nurses can perform before the patients see physicians. Things include such things as getting sutures removed or dressing changed or injections given. These minor procedures will usually be given only if a physician has ordered it to be written in the file from a previous visit, ie that this minor procedure is meant to happen on the given day. From a senior physician, this includes, “removal of abdominal fluid; taking of sample; giving injection; putting bands on rectal bleeding.”

Even in these minor cases the patient will always be required to see the physician afterwards and only then proceed elsewhere (e.g. laboratory, billing, etc). Otherwise, the patients waiting in the OPD ante-room will see the physicians first and only later proceed to this ‘exam and minor procedure area’. This might commonly include a rectal or vaginal examination, a peritoneal tap, or a catheter change. Depending on the procedure or invesitgation, the patient might or might not see the physician again afterwards. Examples of procedures done in this area after the patient sees the physician includes: removal of suture, dressing, per vaginal exam, per scapulum exam, administering injections, taking CS fluid, pleural infusion, taking abdominal acetic fluid, giving chemotherapy, sending sample to the laboratory.

In the OPD exam rooms some physicians prefer to see new patients first, while other doctors prefer to see patients in the order in which they arrived, no matter whether they came from a JSS sub-center, are new or returning patients. The reason physicians like to see new patients first is that more often new patients require laboratory investigations and therefore the initial encunter with the physician can be relatively brief; the patient is sent for investigation, comes back and then the physician re-engages the patient with the laboratory results in the patient’s file. 

USE OF LABORATORY RESULSTS IN THE OPD

For the most part, the physicians at JSS will rely upon exams only from their the JSS laboratory. However, occasionally, if the patient comes with an ultrascan report showing a kidney lump malignancy, for example, then the phyisicians at JSS will rely upon this report without ordering an additional investigation. This appears in the extreme minority of cases.

Physicians might send a patient to the lab for investigations, only to then ask for more or or fresh investigations that might be done same day or next day.

FILES

In their notes physicians can include information about personal history, eg marriage, family, children, etc. Also what kind of work. And also social habits like smoking, drinking, etc. Also, physicians can fill out half of a patient note and then ask the patient to go see another doctor to finish the consultation.

If an OPD encounter results in a referral outside of JSS, then the patient’s file is kept with the physician and returns the next morning to the central registration area. Otherwise the patient holds onto their files and takes their files with them as they proceed to the next stage in the OPD process (e.g. laboratory, billing / payment / pharmacy)

OPD OUTCOMES

The physician in the OPD can order a procedure, to take place immediately, which does not involve the operating theatre or the in-patient ward. If that is the case then the patient goes to the ‘exam and minor procedure room’, which is located adjacent to the OPD. This treatment can take the form of draining of abcess, for example. This may be done by a physician or a nurse, who writes what they have done in the patient's file and then sends the patient to the billing / payment / pharmacy. 

OPD EMERGENCY AREA

Nurses make emergency notes on blank pieces of paper. They can create completely new files themselves but the registration information doesn't get inputted into the system at the registration office until the next morning when someone from the registration department assigns the patient a registration number and enters their details into the computer system. There is a phone on each desk in the OPD. This is part of the new 'intercom' system in the hospital, which connects a couple dozen locations on the JSS Ganyari hospital campus.

Laboratory 

The lab has approximately a dozen employees, divided into approximately five physical areas (NB: a new labratory building is under construction at JSS, which should open in the coming 2-3 months):

1. Collection of samples

2  Preparation of samples

3  Microscopy investigations

4. Biochemistry investigations (climate controlled)

5. Microbiology investigations (climate controlled)

(1) The area in which samples are collected has two employees. One receives the patient files and writes down the patient's number in which they presented in the queue, the patient's registration number, and also the investigation that is required; the other collects samples (draws blood, etc). After the samples are collected, (blood, urine, sputum, etc), all sample containers are labeled with adhesive paper labels and pen, indicating the patient's registration number and the test type (abbreviated) requested. Meanwhile patients congregate outside, waiting for their tests to be completed so that their files can be returned to them and that they can return to the OPD.

(2) Samples move to the sample preparation area, where a few tests are also conducted, namely those for pregnancy and blood sugar levels as well as certain TB tests. Aside from these tests a number of preparations happen here, like urine centrifuge and the drying of slides. [There is a dot matrix computer in the lab area, in addition to three functional desktop computers, none of which are used regularly.]

(3) Microscopy investigations. This is one of the busiest parts of the lab. Although only two people each man one microscope, the lab has six.  

(4) Biochemistry investigations has two biochemistry machines, an electrolyte counter and a cell counter.

(5) The microbiology room, where're Petrie dishes grow sample cultures.    

Currently every test result gets recorded at the end of the process in a large file and gets signed off on by the lab manager Currently every test is reviewed by the lab manager. The people who write the test results also write the test cost in a pre-stamped area that has threes rows: (1) for the cost of the test (2) for the discount amount given, if any (3) for the amount paid.

Samples also come from (1) the emergency room, located in the OPD, from (2) the ward (IPD), from (3) the OT, and from (4) the field, ie sub centers. Concerning the emergency room, ward and the operating theatre, the sample comes with a notice in the form of a phone call. The message to the lab is to come to fetch the sample.

There is a fast track process for these samples, as they are urgent, and are labeled as such. The reporting process is the same. Telephonic reports are also given and that would also be recorded in ledger looks located in the lab itself.

Samples can come from the pregnancy clinics in the sub centers, as can blood smears for malaria and sputum smears for TB, which get relayed from the health workers. The results are put into a dedicated ledger book for a field team and that book is then relayed physically back to and from the field. There is a rotation for someone from the lab to go back and forth running the samples, to and from the field.

The employees rotate the different parts of the lab on a monthly basis.

One other part of the lab that is not mentioned he is the blood bank. This will be discussed in detail in a later update.

There are five registration books that collect the results of various tests from five different parts of the labs. These ledgers are carried to the microscopy room and the information is then transferred from those books into the one large ledger book that collects all patient information, and from there into the patient file, which is then handed back to the patient.

The person in charge of this large file book first enters all  the requisite patient information and a list of the test(s) to be done, creating a sort of 'form' within the ledger book. Only later, when the various tests from the different parts of the lab have come together at this location, do they enter the results into the ledger, then the file, etc.

Currently, the lab takes money for the laboratory tests that have to be done outside (example: biopsies). Investigations that are conducted outside the premises of the JSS 'lab building' include x-ray and ECG, which are done by the same person in the same building, located closer to the where the operating theatre is situated. Ultrasounds are only done twice a month.

Almost all lab tests are done same day. Sometimes biochemistry tests take longer. Sometimes the physicians in the OPD walk over to the lab and sometimes they call, to tell them that a particular patients test is urgent. And sometimes the physician requests that a particular person in the lab do the test.

Billing 

Billing is a three-stage process. In the first stage patients take their files to a location behind the OPD where a JSS employee enters billing information into a computer, which is then saved in the system. The bill is simply prepared, totalling the costs from patient visit, medication orders, lab tests, procedures done, etc. No exchange of money is made.

The patient then proceeds to the payment counter, which is the second stage. In the room where the payment is made the process begins with the patient bringing their file to the window where an employee takes the file and reads the registration number, entering it into the computer. She then passes the patient file through a space in the wall between payment and pharmacy (located adjacent in the same building), where the pharmacist takes the file and proceeds to fill the order.

On the computer of the payment room the patient's bill appears after their registration number is entered and the amount due appears. The patient pays that amount, change is made if necessary, and receives an automatically generated receipt (via dot-matrix printer). At the same time, the payment employee copies down the patient's registration number, the bill number and the amount due into a large ledger.

The payment room also contains a separate computer dedicated to information about the RSBY program  (http://www.rsby.gov.in/  ) and inputting information from there is a bit of a complicated process that will be explained later.

Present computing capabilities 

SOFTWARE

The current recordkeeping system was developed approximately three years ago using Microsoft Access. The system stores past medication orders, lab orders (but not results) and demographic information for the registration department. There is no medical record kept as such, and the physicians themselves do not interact with this system frequently or regularly. The system is mainly for registration and billing purposes. The system is not currently used for querrying database metrics (trends, averages, etc).  

HARDWARE

The current recordkeeping system runs on desktop computers of varying age, of which there are approximately a dozen. Many are HP, Dell or Compaq computers. Only a couple printers are currently in place, one of which is in the office for public health outreach and another in the billing area, where patients receive receipts for their medication payments. Wifi nodes are currently in place throughout the hospital, although they are not used extensively. The work that goes on daily at the hospital does not, for the most part, require a dedicated internet connection.