Reducing waiting time among pregnant women attending antenatal care clinic at Alexandria University Hospital, Egypt: quality improvement project

ABSTRACT

Introduction

Antenatal Care (ANC) is crucial for preventing maternal morbidity and death. WHO guidelines published in 2016 recommended that women should attend eight ANC visits as a minimum throughout pregnancy. This research aims at boosting pregnant women satisfaction with the ANC in a public health care facility and thus their willingness to comply with treatment and care. Objectives of this study were to assess the current state of ANC visits system inside Alexandria Main University Hospital (AMUH) and to examine the outcome of appointment scheduling approach on waiting time and utilization of ANC.

Methods

A prospective survey with pre & post intervention (quasi-experimental study). The study took place between Jan 2023 and April 2023. All expectant mothers who showed up for their regularly scheduled antenatal appointment were advised and invited to take part in the study. The study enrolled pregnant females who were eligible and gave their verbal consent. Pregnant women seeking emergency medical attention and pregnant women who refused to participate in the study were among the exclusion criteria. A purposive sampling technique was used to enroll pregnant women. When they arrived at the clinic, pregnant women who were eligible for the study were recognized and given counseling regarding the study’s goals and the extent of their participation. Prior to enrollment in the study, oral informed permission was obtained from each participant.

Results

The findings of the study imply that patient experience is a crucial factor in and of itself, and that it may significantly influence utilization patterns.

Discussion

By practically applying QI tools a sound effective outcomes can be reached. However, patient engagement & effective communication with stakeholders are cornerstones for sustainability of any project and to ensure continuous commitment and leadership support.

KEYWORDS:

• Antenatal care
• quality improvement
• waiting time
• preganancy

1. Introduction

Antenatal Care (ANC) is crucial for preventing maternal morbidity and death. WHO guidelines published in 2016 recommended that women should attend eight ANC visits as a minimum throughout pregnancy [1].

The Institute of Medicine (IOM) has identified six fundamental objectives for delivering health care, including timeliness [2]. However, timeliness has received the least attention and study. Waiting times can lead to patient dissatisfaction and lost productivity. Patients may have to wait for the start of the ANC service and the physician’s appointment. Delayed examination start-up can cause patients to wait longer for medical attention and can also cause doctors to become overburdened with the patient load [3,4].

Studies have shown that patient satisfaction is important in determining how patients react to their care [5,6]. Patients who are unhappy with their care are less likely to follow treatment recommendations, more likely to put off seeking out further therapy, and less likely to understand and remember medical information. The amount of time patients wait and their pleasure are inversely correlated [7]. Long wait times in clinics are linked to dissatisfaction and may prevent women from receiving prenatal care or use it improperly. Patients expect to see the physician within 30 minutes and are more satisfied if the wait time is under 30 minutes [7].

Pregnant women are more willing to wait less in ANC, which will be reflected positively on the effectiveness of the received maternal health services [8,9]. On the other hand, waiting times can lead to undesirable patient experience, which may explain why fewer women utilize maternity services. The first step in solving the problem of lengthy wait times in clinics is to identify the points of delay in the service pathway. This will provide relevant information for making decisions and changing policy. A recent pilot study in Mozambique found that scheduling ANC appointments decreased waiting times and increased the percentage of ANC visits that were completed [10].

Public health facilities that provide ANC are the destination for many Egyptian women, principally those with poor socioeconomic position. Studies in Egypt show that pregnant women are dissatisfied with long wait times for ANC [11]. Pregnant women frequently take long time to see her health care provider. This could be attributed to the high patient volume and physician shortage. Additionally, no set appointment time is offered to women, so they must show up early to wait.

Alexandria University Hospital is the biggest governmental hospital in the city with a high load of patients together with highly qualified physicians. Due to the enormous burden of women visiting ANC clinics and the shortage of physicians, pregnant females tend to stay very long times to be seen by the doctor. This, in turn, adversely affect the compliance of the women to the ANC visits, become unsatisfied with the service as well as stressful working environment for HCPs. Obstetric physicians observed a lot of women coming for an emergency and high risk pregnancy the first or second time immediately before delivery which grasp their attention.

The type of visit (first or follow-up) and the arrival order of the patients (first come, first served) determine the sequence of consultations [12]. The way the facilities were set up varied; occasionally, first-time ANC patients were seen first, and other times, follow-up appointments took precedence. The method should be changed for a number of reasons, including less patient interactions, crowding, and the transmission of infectious diseases. It is critical to pinpoint the locations where service delivery is slow in order to address the problem of high wait times in clinics. This is in turn can inform judgments and adjust related policies.

This research aims at boosting pregnant women satisfaction with the ANC in a public health care facility and thus their willingness to comply with treatment and care. Objectives of this study include;

1. To assess the current state of ANC visits system inside Alexandria Main University Hospital (AMUH).

To examine the outcome of appointment scheduling approach on waiting time and utilization of ANC.

2. Methods

• (A) Identification and analysis of the current status for service provision inside the outpatient ANC clinic in AMUH. This was done by through three main activities:

  1. Literature review on the previous studies and research done in this area.

  2. Observation of both; the activities at the ANC clinic since the arrival of the client and the waiting time for a sample of pregnant women.

  3. Identify stakeholders who included; head of the obstetric department, resident physicians, nurses, pregnant women and registration officer & record keeper.

  4. Informal interviews were conducted interviewing women in the obstetrics outpatient ANC clinic to determine steps in process since their arrival till they receive the service.

  5. In-depth interviews with resident physicians and nurses to understand the current barriers for timely appointment.

• (B) Proposing the solution and set the study plan. A participatory approach was done to identify all proposed solutions through brainstorming with physicians, nurses and head of the department.

2.1. Study design

A prospective survey with pre & post intervention (quasi-experimental study). The study took place between Jan 2023 and April 2023. The study health facility was high-volume facility (ie, 100–150 ANC women per day) serving four nearby governorates. The pre intervention period was 2 month whereas applying post intervention took also 2 month.

2.2. Sampling and target population

All expectant mothers who showed up for their regularly scheduled antenatal appointment were advised and invited to take part in the study. The study enrolled pregnant females who were eligible and gave their verbal consent. Pregnant women seeking emergency medical attention and pregnant women who refused to participate in the study were among the exclusion criteria.

A purposive sampling technique was used to enroll pregnant women. When they arrived at the clinic, pregnant women who were eligible for the study were recognized and given counseling regarding the study’s goals and the extent of their participation. Prior to enrollment in the study, oral informed permission was obtained from each participant.

For the pre -intervention phase we took 15 pregnant women to measure the main outcome (waiting time) while five of them was being informally interviewed, where in the post- intervention phase, another 15 pregnant women were identified and the waiting time was measured. The sample size was calculated using Epi info software program based on power of the study 80% and confidence interval 0.05 , it was set 40 women , 20 preintervention and 20 post intervention . However due to the fact that unexpected construction inside the ANC unit , only 15 were feasible in the expected duration of the study.

Outcome measure: The difference in the waiting time before and after application of the intervention. Numerator: Time measured from coming to the ANC to being examined by the resident physician. Denominator: Number of pregnant females in the one shift.

Process measure: the proportion of pregnant females came on the exact appointment. Numerator: No of females coming appropriately on the exact informed scheduled time Denominator: All pregnant females came in the shift.

Secondary outcome measures included; patient satisfaction and total waiting time at each service pointed exit point (dropout rate pregnant females, that is, those who left without taking the necessary care).

• (C) Implementation of the proposed intervention Stakeholder engagement and communication plan; the intervention took place between March and April 2023. ANC-receiving pregnant women were prompted to choose a return time for the day of their subsequent appointment. Patients were advised that clinic staff would see them within an hour if they returned at the appointed date and time. On a scheduling card given to patients and in an appointment book kept in the clinic, nurses are instructed to note the appointment date and time. Nurses recorded the appointment date and time on a record file provided to patients. Grading of the urgency of the pregnancy was done by the resident physician and written on the card. Stakeholder engagement was done at this stage based on the mapping previously done through brainstorming sessions with physicians, nurses, and the head of the department to find the best approach to implement the appointment scheduling methodology.

• Implementation plan; it was agreed that the registration officer would keep proper documentation related to women. After the women were examined by the doctor, he would assess the urgency and the frequency of visits, this would be written on the medical file of the women coded by certain color and then the women would be given the exact time and date for the next appointment. The registration officer would prepare a daily list of those who should come on this date and starts tracking. At the end of every week, the house officer call those with appointments the next week and call the patients to confirm attendance on time. This system was displayed on a flow chart and communicated to all those concerned to start implementation.

• Stakeholders mapping exercise. This was done to determine the degree of power and interest of stakeholders, this was important to identify the most appropriate stakeholders to get what information from whom and also to establish communication channels according to the most convenient channel for everyone.

• Resources acquisition. The resources required were hardware and software to shift to electronic health information systems to enhance the process of record keeping as well as ensure effectiveness, trained personnel, and incentives were required for record keepers and nurses. Also, information communication materials like posters or brochures to inform and notify pregnant females of the correct process.

• Educational plan was set up clearly by the QI team and monitored regularly by the process owner.

3. Results

A. Identification and analysis of the current status of service provision:

1. Activities at the ANC clinic typically began with pregnant female check-in and presentation of the medical record appointment card (not presented most of the times) to the clinic’s medical records personnel for retrieval of the medical case record or opening of a new medical record. Medical histories of patients are kept in hard-copy files. The pregnant woman then continues to complete other tasks, such as a health education session, blood tests, urine analyses, blood pressure readings, and weight checks. The woman then go back to the waiting area to wait for the resident doctor’s consultation (Figure 1).

Figure 1. The actual flow chart for the current status inside the ANC clinic.

2. Also through observation, the waiting time for 15 women was observed and displayed in Figure 2 (X- chart to display the waiting time observed where the mean is 78.6 min ±11.8 min, the data is normally distributed).

Figure 2. Waiting time X chart.

3.1.

3. Informal interviews were conducted interviewing of at least five women in the obstetrics outpatient ANC clinic to reveal the steps in process of registration of women in the clinic.

4. In-depth interviews with two resident physicians and two nurses to understand the current barriers for timely appointment. Health care service providers (HCPs), all agreed that there is a very long waiting time for pregnant women to be checked by the resident. This impacts their technical capacity and the time the pregnant women consume with the resident. There are a large number of follow up visits despite the limited number of resident physicians and nurses. It has been noted from the same HCPs in the ANC that long waiting time for pregnant females lead to:

• Unsatisfaction patient outcome

• No compliance for ANC visits which will eventually impact patient safety

• Low utilization of services

• Stressful working environment.

HCPs also discussed causes of the delay; poor health information system, bad communication between HCPs, poor socioeconomic status and health illiteracy among pregnant women, and lack of monitoring and evaluation system within the organization. Figure 3 showed fish bone diagram with the different identified causes among healthcare service providers for long waiting time in the antenatal care clinic.

Figure 3. Fish bone diagram.

Among the most four identified root causes of the problem, a pareto chart was done to recognize the most priority causes accounting for 80% of the problem (20% of causes according to Pareto rule) Figure 4. It showed that the most impactful causes are poor health information system, poor socioeconomic status and health illiteracy among pregnant women in addition to lack of monitoring and evaluation system.

Figure 4. Pareto chart.

Based on discussions with HCPs and pregnant females, we displayed the aim, and the main drivers to reach the main goal through the key driver diagram in Figure 5. A specific aim was settled to reduce the waiting time of pregnant females in the ANC clinic in AMUH by 50% at the end of April 2023. This was to be achieved directly through building a robust health information system, engagement of pregnant females and establish strong policies and procedures.

Figure 5. Driver diagram.

B. Proposed solution & study plan

Based on the above identified root causes and deep understanding of the problem and through the adopted participatory approach during the brainstorming process with physicians, nurses and head of the department. The following interventions were suggested;

1. Appointment scheduling approach: This means to schedule an exact timing and date for every pregnant women for her follow up visit as well as organizing this process according the type of the visit whether initial visit or follow up visit.

2. Coloured cards according to urgency of the pregnancy: One of the physicians suggest to have a colored cards to be given to every pregnant female according to her trimester, for example, women in the first trimester shall be given red cards and come on Sunday only, and if on the second trimester she will be given yellow card and advised to come on Monday, and so on this might organize the process somewhat and reduce the burden on physicians.

3. Increase the number of physicians: This is a straight forward solution however may be less practical as Increasing the number of physicians and HCPs providing care to pregnant females is less feasible in a country with low resources. Table 1 Showed the impact/effort matrix as discussed and identified by stakeholders during brainstorming session to discuss possible interventions.

   Table 1. Impact/Effort assessment.

   Intervention	Impact	Effort
   Appointment scheduling approach	High	High
   Coloured cards according to urgency of the pregnancy	Low	Low
   Increase the number of physicians	Low	High

After doing the impact effort analysis (Figure 6), it was agreed to use the appointment scheduling methodology because this will be implemented with the least cost yielding high impact. Even though the intervention is high effort because it requires a lot of human working in term of establishing a robust medical record system, training personnel on registration and medical record keeping, setting policies and procedures (Standard operating procedures) in addition to developing a comprehensive educational plan for pregnant females to educate them about the importance of compliance to ANC visits as well as orient them about the signs of high risk pregnancy. Keeping in consideration the low resource setting. Also based on reviewing literature, it was evidence based that this approach yields best outcome results.

Figure 6. Impact/effort matrix.

Based on discussions and brainstorming, an intervention logic framework was developed to better describe the situation and visually display the system model in terms of input, process, output, outcome and long term impact while identifying our need Table 2

Table 2. Intervention logic framework.

Need/problem	Input	Output		Outcome	Long-term goals
Long waiting times for patients Stressful working environment for providers	Appointment scheduling system	Patient arrival more evenly distributed throughout the day	Decrease patient waiting time Decrease in provider stress	Primary outcome Waiting time	Increase satisfaction among pregnant females as well as healthcare service providers Enhance technical capacity of HCPs and hence quality of work
				Secondary Outcome Technical & non-technical quality

C. Implementation Results:

Due to unexpected construction events in the clinic, the intervention was applied on 15 women. However, this could serve as a basis or pilot to test the intervention and to educate persons involved.

1. Observing the process of application of the appointment scheduling approach; as described above, ANC-receiving pregnant women were prompted to choose a return time for the day of their subsequent appointment. Patients were advised that if they returned at the appointed date and time, clinic staff would see them within an hour. On a scheduling card given to patients and in an appointment book kept in the clinic, nurses are instructed to note the appointment date and time.

2. Observing other 15 pregnant women to determine and calculate the waiting time (figure 7) in the post intervention X- chart, displayed that the waiting time was shortened where the mean became 25.7 min ± 9.2 min. This was also found to be statistically significant difference (p value 0.001).

   Figure 7. X chart post intervention data.

   

• Interviewing of at least five women in the obstetrics outpatient clinic: to identify the impact of the intervention on the satisfaction of women, where they all felt very satisfied with the service provided and know the importance of the regular ANC visit.

• Interviewing physicians and nurses after application of the intervention also yielded a very positive results where they all felt very impressed by the results and feeling a bit relaxed than before while being able to increase the time given to every woman. One of the physicians said “We lost a lot of useless time before however the solution seemed to be very easy and just putting system”.

• To ensure sustainability of the project, an educational plan was set as mentioned previously as well as continuous monitoring from leadership side. This educational plan consisted of a continuous learning program for all stakeholders (monthly basis) on the process of appointment scheduling approach and other related matters (medical record and documentation issues, pregnant females education and engagement, set up policies).

4. Discussion

This study revealed that long waiting time for pregnant females during their ANC visits led to their un-satisfaction with the service thus less compliance to the follow up visits. Eventually, low utilization of ANC services in the studied setting. Pareto chart illustrated four priority causes that 80% of the problem is owed to them. Among them the poor health information system had the biggest share (29%).

Applying the intervention of appointment scheduling is revealed to be effective. ANC waiting times was shortened to be 25.7 min ± 9.2 min instead of 78.6 min ± 11.8 min before the implementing the intervention. This finding was consistent with the findings by other studies in Mozambique and Ethiopia [13,14]. The shortened waiting time was associated with elevated level of satisfaction among the pregnant women seeking ANC as well as the physicians and nurses the service providers. This in the long run may increase the percentage of pregnant women who receive the minimally required ANC visits during pregnancy.

However, setting policies and regulations are needed to enhance the technical and non-technical aspects of ANC visits. This is also important to ensure the sustainability of the project with appropriate application of an educational plan under continuous leadership monitoring and supervising. These efforts finally will result in improving the utilization of ANC services in the intended settings.

On the other hand, further research on larger scale in similar as well as different settings should be done to explore whether appointment scheduling can be supervised and maintained in effective way on long term and on large scales. More research is required to determine whether the intervention’s potential advantages diminish with time and whether this deterioration may be slowed down by better managing and supervising nurses to closely stick to schedules.

One limitation of the study is that medical records used to assess utilization were hard copies not computerized and not connected with other health facilities where it women could have visited during their pregnancy. Thus, record keeping and filing needs dramatic improvement as this is the cornerstone for applying the intervention.

Also, the sample size for the quality outcomes is quite small, and the quality outcomes are based on patient reports, which may be biased if patients fear that their answers will not be kept private [15].

It should be taken in consideration that, reorganizing the care process through interventions may have significant unintended implications, such allocating fewer resources to the non-targeted services. Also, scheduling may has un-avoided negative effects such as; the pregnant women may miss the group counseling that occurs before the start of ANC visit in some health facilities.

It is recommended for future research, to take in consideration the effect of scheduling on pregnant patients’ understanding of important health information. With the publication of the Lancet Global Health Commission’s Report on High-Quality Health Systems in 2018, the quality of healthcare has recently assumed a major role in the agenda for international health systems. ⁽¹⁷⁾ Patient flow management should be improved in future healthcare quality interventions since it may provide a low-cost, high-impact way to enhance patient experience.

5. Conclusion

The consumption of healthcare during pregnancy may increase as a result of very easy organizational changes that decrease waiting times. The findings of the study imply that patient experience is a crucial factor in and of itself, and that it may significantly influence utilization patterns. By practically applying QI tools a sound effective outcomes can be reached. However, patient engagement & effective communication with stakeholders are cornerstones for sustainability of any project and to ensure continuous commitment and leadership support.

Study limitations

Due to unexpected construction events in the clinic, the intervention was applied on 15 women. However, this could serve as a basis or pilot to test the intervention and to educate persons involved.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Nahla Gamaleldin

Nahla Gamaleldin, Associate professor of public health Alexandria Faculty of medicine. Doctor degree of public health informatics. Fellowship graduate for responsible conduct of research university of california. Master health care quality and safety Harvard University.

Eman Foda

Eman Foda, lecturer public health, community medicine department. Alexandria Faculty of medicine. Doctor degree of qualty managemnt in health care.

Tamer AbdelDayem

Tamer Abdeldayam, professor of gynecology and obstetrics, Alexandria Faculty of medicine specializies in critical labor.

Gihan Gewaifel

Gihan Gewaifel, associate professor of Public Health and Epidemiology at Alamein International University. She has been teaching public health and epidemiology since 1997 in Alexandria Faculty of Medicine, and Armed Forces College of Medicine. She holds a Ph.D degree in Public Health from Alexandria University (2006). She served, since September 2021, as advisor for president of Alamein International University (AIU) for internationalization and global engagement, and director of Public Health Program in AIU., she has been the assistant of Vice President of Alexandria University for education and students affairs, and the officer of Internationalization of Higher Education and Global Engagement for three year.