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ISSN: 2574 -1241
ISSN: 2574 -1241
Received: March 27, 2024; Published: April 12, 2024
DOI: 10.26717/BJSTR.2024.56.008792
This work reviews an already published work by adding more details in regard to the methodological design. The details on the undergone qualitative and quantitative study are further explained in this paper. This study attempts to measure the level of satisfaction among patients towards the old-fashioned Traditional Queuing Method (TQM) compared with the proposed Online Registration System (ORS), and to investigate the patients’ perceptions of ORS and the feasibility and acceptance of the Registration and Admission (R&A) staff. A mixed methods study was held at the Ministry of National Guard Health Affairs (MNGHA) hospital in Riyadh, Saudi Arabia. At first, a stratified random sampling technique was used to distribute 385 structured questionnaires among outpatients anonymously in the outpatient registration area to gather indicating information and perspectives. Then, eleven face-to-face semi-structured interviews with front line hospital workers in the R&A department was managed using a thematic content analysis approach to analyze the contents and produce results. In order for the researcher to have a direct understanding of the registration processes and activities and to gain a better understanding of the patients’ behaviors and attitudes toward them; a non- participant observation approach was conducted where observational encounter notes were taken and then analyzed using a thematic content analysis approach.
In general, this study found that most outpatient population (patients and registration staff) prefer ORS for a range of reasons including time consumption, cost benefit, patient comfort, data sensitivity, effortless, easiness, accuracy, and less errors. On the other hand, around 10% of them chose to go on with the TQM. Their reasons ranged from the unavailability of computer devices or internet connections to their educational backgrounds or physical disabilities. Computing devices and internet availability proved not to be an issue for the successful implementation of the ORS system, as most participants consented to having an internet connection or a device to enter ORS system (91%). Last, as more than the half of participated patients were unhappy with the TQM at registration desks (59.7%), this dissatisfaction should be addressed by an ORS implementation that would reduce waiting times, enhance the level of attention, and improve services from frontline staff toward patients’ care.
Keywords: Online Registration System; Patient Registration; Mixed Methods; Health Informatics; Qualitative Research
Abbreviations: TQM: Traditional Queuing Method; ORS: Online Registration System; R&A: Registration and Admission; MNGHA: Ministry of National Guard Health Affairs; DDE: Direct Data Entry; HIPAA: Health Insurance Portability and Accountability Act; KAIMRC: King Abdullah International Medical Research Center; ER: Emergency Room; ISID: Information Systems and Informatics Department
Background
Patients’ registration is defined as the process by which a patient is diagnosed at a member institution where information is entered into the institution’s records for a selected clinical trial and then, issued for a treatment assignment [1]. Herson [1] also defined the objectives of patient registration as to include initiation of data collection, randomization of patients, quality control (enforcing protocol adherence, reduction of bias, suggestion of needed protocol amendments, and evaluation of institutional performance), and planning future clinical trials (providing estimates of patient accrual and providing advice on registration matters). There are two accepted approaches to patient registration: either the TQM or through an ORS. The satisfaction of patients and the Registration and Admission staff with the patient's ORS has been discussed in the literature with the aim of proving the effectiveness and efficiency of this system inadvanced healthcare settings [2-9]. The motivation behind this study is to assure and enhance the quality of the patient’s registration processes to help maintain their outmost satisfaction toward the healthcare services provided by a huge medical city such as MNGHA hospital. In this research we are focusing on ORS as it is a technique that has been developed in order to improve the workflow and to lessen the waiting time required by outpatients [2]. At the end of this research, we would be able to answer the following questions: what is the level of perceived satisfaction among patients toward the current old fashion TQM compared to the suggested ORS? What are their perceptions on implementing an ORS System? And what is the acceptance level, constraints, and motivations of the R&A staff regarding this type of implementation?
Related Work
Challenges: Even though the ORS may appear to be a constructive move towards electronic healthcare transactions, many studies have shown certain challenges against its success that should be avoided and addressed in future implementation projects or research [3]. Such challenges include the lack of conducting internal and external marketing and advertising, educational programs, orientation posters, non-attendance occurrences, not having the capability to use the computer, lack of communication between the healthcare providers and the patients and engaging the end users. It is important to consider all of these issues for the sake of a successful system implementation and outcomes [4,5].
Solutions: A discussion about the solutions for ORS project success suggested accomplishing further studies on various interventions such as the promotion of online registration system, and the use of a reminder system [6]. In addition, a new technological solution was suggested such as the direct data entry (DDE) mechanism or the touch-screen computer kiosks in hospital waiting rooms [3]. These technological solutions answer and solve the problem that was raised by both Weiping, et al. [8], Coa, et al. [5], and Zhang, et al. [10] which is the lack of capability of using computers or patients who do not have access to the internet. Also, this research illustrated new benefits of using the ORS such as the eligibility inquiry and response using the Health Insurance Portability and Accountability Act (HIPAA) transaction standards that was indorsed by the Senate and House of Representatives of the Congress of the United States of America in 1996 [6]. The act’s main purpose is improving the portability and the steadiness of the coverage of health insurance in markets, fighting fraud and misuse in health care delivery, promoting how people use their accounts of medical savings, improving long-term care facilities access, simplifying health insurance administration, together with several other goals [6]. Another solution by Shortliffe [2] raises the importance of sharing the data between patients and frontline coordinators in case of vital information related to healthcare as discussed in Dent, et al. [7].
Therefore, the input from a patient through the portal could be seen from the healthcare providers’ side to be used as an input for other purposes serving the patients’ healthcare. This solution saves time of reentering the same data again and also saving money in recruiting extra clerks for this job. A study supporting this theorem is by Friedman, et al. [4] in their book of evaluation methods in biomedical informatics stating that registration data connections were necessary to simplify the importing of demographic data into the system and provide data about which patients are active in the clinic at a particular time [4]. Despite the intelligence of the previous study, it includes some limitations due to the inability to automate some of the paper-based processes because of its structural nature which caused loss of data details, inability to use data for multiple purposes, and limitations in the capacity to aggregate and query patient’s data. A cross sectional research by Wani and Sankaranarayanan [11] provides an advanced solution inthe mobile based appointment system [7]. This solution solved many issues in the ORS such as the ability to cancel, reschedule or the capability of reminding patients of their upcoming appointments and the hacking risk of patients’ appointments or medications as the online access is a vulnerable point threatening patient’s safety and privacy. Even though it has filled so many gaps and was a smart solution, it still has some issues such as the quality of service and security issues in the cloud used to store data while storing patients’ appointments and medical details.
Best Practices: Advice toward the ORS success encourages the consideration of user co-design and participation and take their needs requirements prior to the design or implementation to have a broad perspective of the system from the end user's point of view and also to grow the system ownership in the front-line staff who will hold the coordination processes later on whenever the patient gets lost in the system [8]. Furthermore, Dent, et al. [7] argue that for the sake of a successful technical system implementation such as the ORS which will be run in a complex and advanced organization setting, the new invented system needs to be treated as a process of organizational learning in which users are given the time and space to customize their practices and needs within the capabilities of the technology used which will enhance the adoption and ownership of the new system among them.
Objectives of the Study
The main objective of this research was to measure the level of perceived satisfaction among patients toward the current old fashion TQM compared to the suggested ORS. There are also some secondary specific objectives that this study aimed to prove such as investigating the patient perceptions on implementing an ORS System and investigating the feasibility and acceptance of the R&A staff regarding this implementation. In addition, some secondary objectives were under scope for analysis and examination such as enhancing scheduling processes in MNGHA using health informatics techniques, learning how we can manage the implementation of ORS in MNGHA, and studying what are the potential barriers and limitations of implementing ORS in MNGHA.
Quantitative Method
Questionnaire: For the quantitative method, questionnaires were used to explore outpatients’ perspectives and perceptions of the ORS (Appendix Figure 1), besides analyzing the potential reasons behind the success or failure of ORS implementation. Stratified random sampling technique was used to choose the participants. Consent forms were attached with every questionnaire form to be declared understood and signed by the patient (Appendix Figure 2). After the collection of the data, MS Excel sheet was utilized [9] to manage and analyze the data to get valid and accurate frequencies, percentages, and results.
Qualitative Method
Interview: Qualitative information was needed from the face-to-face semi-structured interviews with frontline hospital workers in the R&A Department using an interview guide (Appendix Figure 3) to help handling the interviews smoothly serving the collection of only needed data and prevent the deviation to side talks or unimportant subjects’ discussions. As per the R&A supervisor, there are 37 registration workers, 17 of them serving in the outpatient area. Since the number of the frontline staff is small, all 17 workers who satisfy the sampling inclusion criteria were interviewed. Interviews were supposed to be recorded after the permission of the interviewee and as per the signature of the consent form (Appendix Figure 4), but due to the refusal of the female participants to record their voices, the recording process was cancelled for both genders to have a steady and unified data collection and analysis method, and instead, notes of the relevant parts of the interviews that answers questions in the interview guide were written down by the researcher. Thematic content analysis approach was used to manage and analyze the contents and to produce valid and accurate results.
Non-Participant Observation: Spending 3 hours a day for 5 days which are a total of 15 hours of observational encounters in the hospital outpatient registration area, for the purpose of observing the patients’ experiences and behaviors and the whole atmosphere and workflow helped the researcher to understand and have a better perspective of the research topic being studied [11,12], in this case, the efficiency or limitations of the TQM compared with ORS. Notes were taken considering the above- mentioned points (Appendix Figure 5) and analyzed using thematic content analysis mechanism.
After having the approval of King Abdullah International Medical Research Center (KAIMRC), the researcher used a mixed method approach as front line staff were interviewed, and outpatients were questionnaired forming a cross-sectional study design, besides the general non- participant observation process. The researcher used a mixed method design because the results should be valid, accountable, and ready to be generalized. To accomplish the previous goal, the researcher used the quantitative method to extract themes from patients that were later used as predetermined themes for the qualitative study whether it is interviews or observations. In that regard, the researcher conducted the outpatients’ questionnaire first, then the observation. After that, interviews were conducted at last.
Quantitative Study Design
Questionnaire: Each Outpatient were given 30 minutes to complete the questionnaire using a stratified random sampling method, from which participants were randomly selected to fill up a questionnaire. As received from the MNGHA hospital database section regarding the total number of outpatients currently in the MNGHA hospital up to 24/12/2014 is 2,000,000 patients of them 1,087,326 outpatients. From the outpatients, 385 from 1,087,326 outpatients were randomly selected to be questionnaired according to the sampling calculation considering 95% level of confidence and 5%margin error. The questionnaire assessed satisfaction with the TQM and the time spent making appointments, further investigations about their opinion on the traditional window queuing to get a registration compared with their opinion about the new solution of the ORS were taken, and whether they thinkit’s an efficient method to get a registration done. The questionnaire, named "The Online Registration System Questionnaire", is a 12 items questionnaire focusing on feedback from patients on what they think is a better method to get scheduled to assess patients’ attitudes toward the new project and to measure their level of satisfaction with behavior of front-line staff. The outcome of those questionnaires was analyzed using MS Excel sheet calculation formulae.
Qualitative Study Design
Interviews: Regarding the front-line staff, and as stated by the R&A supervisor, they are 17 outpatient registration employees, all the employees having 1 year of experience or above were interviewed in their offices using a semi structured interview. The outcomes of those interviews were analyzed using a thematic content analysis mechanism. Interviews contents were transcribed by principal investigator and co-investigator, and results of themes were compared [10,13].
Non-participant Observation: General observations of the current workflow and the processes and procedures in the outpatient registration area were conducted by the researcher to have a better understanding of the current situation. Also, It is used to observe activities, interactions, and events to gain a direct considerate of the natural context. Outpatients were observed together with the front-line attitudes throughout the whole process. Notes were written down describing essential indicator schemes and situations. The results of the observations were analyzed using a thematic content analysis mechanism [12,11].
Project Design
The proposed solution using the ORS is resampled in patients who can select which consultant they prefer and which clinics they need to visit, or any services provided by the hospital through the hospital portal. What a patient is going to need for an ORS is the Medical Record Number (MRN), service date and time, type of service, Personal contact information, patient’s condition (Disable, senior citizen, pregnant, infant, or normal patient), gender, and date of birth. Then, they are given an appointment number. After submission of online registration form, the patient will receive a confirmation mobile message from the hospital. They will also be reminded to bring all the related materials with them on the day of their visit along with any items listed on their registration form. At the designated appointment time, patients arrive at the hospital and get the registration that is chosen to their appointment number and check-in with the registration staff to sign the required consent forms. These patients need not to queue at the registration window, but they need to bring their identification and medical cards at the time of service. A description of the two different approaches ORS and TQM were explained in Figure 1.
The study setting was the outpatient registration area in MNGHA hospital in Riyadh, Saudi Arabia where the workstation was put to administer the questionnaire distribution and collection to and from patients. In addition to the frontline staff offices in the R&A department where personal interviews were conducted. The researcher chose to conduct interviews in employees’ offices for the purpose of pure convenience, applicability, and comfortability for interviewees.
Study Subjects
The research study included outpatients attending in the outpatients’ registration area and the frontline staff in the R&A Department in MNGHA hospital.
Quantitative Study Subjects: The inpatients in the hospital were excluded because this research serves the outpatients ORS service. Furthermore, all kinds of patients must first register in the hospital through registration windows and thus inpatients were originally outpatients before they have been admitted as inpatients. Also, new patients who have no previous visits to the outpatient clinics were excluded as well; because the research aim to test the level of acceptance and satisfaction of the ORS compared with the TQM, and this requires the patient to be totally aware of the current situation to be able to compare between the two methods. In addition, all age groups including disabled patients were included; because the research should address all ORS potential users and the usability limitations whether it is computer usability, obstacles due to age, education, physical impairment, or simply lack of awareness.
Qualitative Study Subjects: Regarding the frontline staff in R&A department, all R&A workers with at least 1 year of experience or above in the same field were interviewed. Excluding all newly employed staff as the study needs the information to be valid and out of expert people in the MNGHA hospital. For the non-participant observation process, all patients and employees in the outpatient area were included in the qualitative study subjects for observation and analysis excluding people passing through the area.
Sample Size
Quantitative Sample Size: The total number of the patients in the MNGHA hospital according to the database administrator is2,000,000 patients. Of them, there are 1,087,326 outpatients. As the study is about outpatients’ visits, a patients’ sample size of 385 patients was considered based on the sampling calculation with level of confidence equals 95% and 5% margin error [14].
Qualitative Sample Size: Regarding R&A staff, the total number of registration employees in MNGHA hospital is 37 employees according to the R&A supervisor. Twenty of them in the emergency room (ER) department, and 17 employees in the outpatient area (11 males, 6 females). Figure 2 below show the hierarchical illustration of the qualitative sample size. Since the number of hospital frontline staff in the outpatient area is not so big, all staff with 1 year of experience or above were included in the interview process which means 4 females and 7 males were included in the study interviews, excluding all newly hired employees, excluding all newly hired employees.
Sampling Technique
Quantitative Technique
Questionnaire: Structured questionnaires were used to collect data from outpatients in the hospital of MNGHA after having the KAMCRC approval to personally administer the questionnaires distribution and collection to and from outpatients each for 30 minutes to complete the questionnaire using a stratified random sampling method, from which participants were randomly selected to complete the questionnaire. Data was analyzed to measure their satisfaction and views about the ORS or the TQM. All questionnaires were administered anonymously to discourage acquiescent or socially- desirable responses. Outpatients were also asked to sign a consent form of acceptance to participate in voluntary questionnaires prior to any questionnaire distribution.
Qualitative Technique
Interview: Using purposive sampling for the frontline staff, all 1 year of experience or above staff among the 17 outpatient registration employees were interviewed for a maximum of 1 hour each or until no significant new information is forthcoming.
Non-Participant Observation: For the non-participant observation process, all patients and employees in the outpatient area were included in the qualitative study subjects for observation and analysis excluding people passing through the area.
Ethical Considerations: IRB approval was received from the KAIMRC research center and was registered under Research Protocol SP15/074. The KAIMRC had approved the project idea, processes and methodology, and other data collection forms and procedures. An informed consent was clarified and signed by every participant whether to the interview or the questionnaire as the participation was optional and not compulsory. Also, participants were informed that their input will be used for the sake of the research study and analysis only and not for any other personal publications. In addition, participants’ names and personal contact numbers or any identification information were optional as well.
Quantitative Data
Questionnaire:
Goals of the Instrument: The aim of using patients’ questionnaires is to investigate the satisfaction level, perception, acceptance, and the likelihood of the feasibility of the ORS which is a new solution under studying from the perspective of the R&A staff and the patients themselves. Questionnaires were used especially because it allows the researcher to reach a big number of participants in a small amount of time. It also allows measuring quantitative variables that allow the researcher to have reliable data that help decide and conclude the final result of the study.
Overview of its content: Questionnaires were started by defining who are and what is the purpose of doing this questionnaire to encourage the participants on completing the survey. Then two guide statements were mentioned in order to instruct the patients to choose only one answer to multiple choice questions and write short answers on the dotted lines below each open question.
The variables that were measured using questionnaire tool are the percentage of patients’ satisfaction and dissatisfaction rates toward TQM and ORS, their level of education, age group, and their capability to access the internet or computer devices.
Qualitative Data
Interview: Frontline staff were interviewed in their offices using face-to-face semi-structured interviews. Interviews were supposed to be recorded after the permission of the interviewee, but due to the refusal of the female participants to record their voices, the recording was cancelled and instead notes of the relevant parts of the interviews were written down by the researcher. The results were analyzed using a thematic analysis mechanism.
Non-participant Observation: The goal of using this systematic data collection approach in the qualitative method is to have a general perspective of the atmosphere and the way outpatients’ appointments are handled and processed. This method helped the researcher to generalize the thoughts and the perspectives of the current TQM method by writing down noteworthy indicators to be analyzed later using a thematic content analysis mechanism. The variables that were measured by qualitative data collection methods are finding ideas and suggestions to enhance scheduling processes in MNGHA using health informatics approaches, their perspective of how the organization and its top managers can manage the implementation of ORS in MNGHA, and to discuss with them about potential barriers and limitations of implementing ORS in MNGHA to serve at the end the main objective of the interviews which are testing the acceptance and the feasibility of R&A staff towards ORS implementation.
Internal Validity
Quantitative: Beside the registration processes validity which has been emphasized by Hommel, et al [15] stating that the major importance in the patient’s registration processes is to be valid and complete [16], correct procedures were applied to assure research project internal validity as wellto be able to find reliable answers to the research questions as a pre-testing (piloting) of the survey on a small group of experts were conducted prior to applying it upon outpatient participants. Accepted scientific principles of analysis and methods were applied to produce reliable, valid, accurate and unbiased data and relevant to the research question. For this research study, quantitative results were analyzed using MS Excel calculation formulae for data that were collected from ambiguous and random participants to assure research validity. In addition, regarding internal validity, dependent variable (ORS satisfaction) was assured to be only caused by the independent variables rather than other external variables to make sure that results are valid, concise, and generalizable.
Qualitative: Predetermined themes, which were derived from the quantitative data collection method were used to conduct qualitative data collection. Qualitative data was transcribed by principal investigator and co-investigator using thematic content analysis. The 2 transcript themes were then compared to guarantee validity. The final result was decided by a unified agreement after using multiple methods to review and validate findings [17].
External Validity
To assure the external validity, participant’s selection bias was avoided and thus the research must include participants who are frequently under medical care and visiting hospitals regularly. Choosing all participants randomly eliminated the potentiality of a population selection bias and be representative of the population and therefore the results can be generalized to all patients in the National Guard Hospital and to the whole population of Saudi Arabia accordingly. The mixed method approach served the research validity in the way that qualitative themes were extracted from quantitative results which was dome first. In addition, the research idea consists of2 groups of participants, outpatients, and R&A staff. As patients sample size is 385 patients, it was feasible to use questionnaires to save time and effort. And because the R&A sample size is only 17, besides the need to analyze their perception about ORS, we used semi-structured interviews to collect as much important relevant information as possible. Doing mixed methods study would support the final result validity of the research paper in that both group of participants’ data and information were collected justifiably and thoroughly.
Quantitative Data
Questionnaire: Categorical variables (age group, level of education, level of satisfactory) were presented as frequencies and percentages (Appendix Table 1) using Microsoft Excel Sheet calculation formulas. Coding scheme of qualitative parts in questionnaires were conducted to convert qualitative results into quantitative frequencies. Percentages of a particular category under each measurable variable are calculated by subtracting all other categories frequencies from the total number of participants (385 patients). Percentages then are compared to analyze and examine which variables have the most effect on the success or failure of ORS system implementation and which variables are against or with TQM registration process. Results and discussion of the outputs from those calculations are presented in the results section.
Qualitative Data
Interview: Regarding the purposive interviews conducted to frontline staff in their offices using a semi- structured interview form, their outcome information was transcribed and translated whenever necessary, analyzed, and managed by the researcher using a thematic content analysis mechanism.
Non-participant Observation: For the 15 hours observational encounters management and analysis, a noteworthy and relevant observation notes were written down. In addition, general observations to the outpatient’s processes and workflow were noticed and summarized. Non-participant observation information outcome was analyzed and managed by the researcher using a thematic content analysis mechanism.
Quantitative Questionnaire Results
To investigate the outpatients’ perceptions on implementing an ORS System, and to measure the level of satisfaction among patients toward the current old fashion TQM compared to the suggested ORS, 385 structured questionnaires were used to collect data from outpatients anonymously to discourage an acquiescent or socially-desirable responses in the hospital of MNGHA after signing a consent form to assure the voluntarily participation using a stratified random sampling method. The collected data presented in Table 1 were analyzed to measure their satisfaction and views about the ORS or the TQM. After explaining to patients what ORS is before they are let alone to answer the questions, they were asked to choose between ORS or TQM for registration process, 89.1% surprisingly voted for ORS implementation. To further investigate their perception of ORS, they were asked to explain why they chose to go with ORS. Their answers ranged from Data sensitivity (2.4%), Time consumption (16.2%), Cost benefit (4.5%), Patient comfort (23.9%), Effortless (20.7%), Easiness (27.3%), Accuracy (1.8%), Errorless (3.2%). From those statistics, we understand that their biggest concern is the easiness of using the ORSsystem compared to the effort spent in coming to hospital, queuing for hours until they get screened or given the kind of service they are after.
To have a comfortable treatment environment and their ability to book for appointments or register from home in an effortless manner comes as a second goal as 79.2% of patients expressed their wishes of registering and booking appointments from their homes. It is also important to notice that most patients were unaware of the main goal of ORS implementation which is data sensitivity, accuracy, and its potentiality of being error-free.On the other hand, those who chose to continue with the TQM (10.9%) were also asked for theirmotives. Their reasons of choosing TQM were because of the unavailability of computer devices (32.4%) or internet connections (31.4%), besides other secondary reasons such as educational background (24.5%) and physical disabilities (11.7%). We can notice from those statistics that their refusal of the ORS system and their desire of maintaining the TQM is not mainly because of any defects or failings in ORS itself, but rather to other probable economical or educational issues. Computing devices and internet availability have proved to be not an issue for the successful implementation of the ORS system as most of participating patients have consented to have an internet connection and a device to enter ORS systems (91.5%, 91.7% respectively) whether it is atablet, smart phone, laptop, or a computer.
More than the half of participated patients were unhappy with the usual registration method at registration desk (around 59.7%). This percentage doesn’t indicate how much patients are indeed unsatisfied as quarter of them voted for neutral. The percentage of neutrals tells us that they were not able to judge possibly because they have not tried ORS yet in order to have a better understanding of what they are being asked about. Another possible reason for their dissatisfaction could be related to the amount of waiting time they have to tolerate per visit. Almost half of participants (50.1%) said they have to wait from 31 to 40 minutes, and 13.2% stated that they have to wait for more than 41 minutes. In addition, participating patients were asked whether they are satisfied with the level of attention and service they get from frontline staff, only 14% of them saidthey are satisfied. This is a big indication in that front line staffs are too overwhelmed with their daily routine duties instead of assuring patients’ comfort, guidance, and good care. Patients’ demographics could also be possible reasons of ORS systems failure or refusal as more than 12% of patients were above 51 years old and more than 21% held elementary certificates or lower.
Even though there are elderly patients who are highly educated (possibly 3.3%), but still this can be taken as a reasoning factor behind the inability to cooperate with ORS system. Finally, those statistical results conclude and justify the main objective of questionnairing outpatients which is to measure patients’ satisfaction or dissatisfaction toward the ORS implementation compared with current TQM. In addition, this study gave us a general perspective of the potential reasons behind patients’ perception and cooperation or the lack of regarding the use of ORS.
Qualitative Interview Results
To investigate the feasibility and acceptance of the R&A staff, predetermined themes were derived from the quantitative data collection method and used to conduct qualitative data collection presented as 11 purposive interviews with the outpatient registration staff in their offices. Semi- structured interviews were transcribed, translated, and analyzed using thematic content analysis mechanism. Only the relevant sections of the interviews were transcribed because participated female registration technicians refused to record their voices in tapes. The interviews highlighted nine themes of concern clarifying the predetermined themes derived from the questionnaires (Appendix Table 2). After that, interviews were summarized in a table to absorb and analyze only highly relevant statements (Appendix Table 3). To some extent, time factor, cost benefit, crowded environment, health related issues, patient’s educational background, hard\software availability, privacy and security concerns, higher management involvement, and age group had a direct impact on registration staff’s perspective and acceptance toward ORS system implementation. Weiping, et al. [8] explained how front-line hospital employees are often times-overwhelmed, besides the necessity of building a good relationship with the patients for more service satisfaction [7].
Through the non-participant observations, live as they happen, the researcher noticed an event acts as an indicator to the 15 stressful atmosphere for both frontline staff and patients resulted in an aggressive and unprofessional scene. “There is a male with his wife screaming and shouting with the registration staff at the window about how long they have been waiting and the reason behind the delay. She (the registration staff)became angry and responded aggressively that this is how things work and then she left the stationfor 15 minutes to calm down” (Day 3 (18/8/2015), 10:15 – 10:36) As the MNGHA hospital receives up to 500 patients a day and over 1 million patients including itsother 5 primary health care facilities, it would take almost all of the employee’s time and effort to control and guide those continuous streams of patients flow. “ORS will save a tremendous amount of time for the registration staff and allow them to focus more often in auditing files, improving the workflow, and guiding lost patients.” (MNGHA Reg. senior staff 1) “Automating the scheduling process where it can be provided online by the organizations' portal will allow the front-line employees to finally be more sophisticated around customer service, files auditing and checking, improving workflows and even financial planning.” (Reg. junior staff 7) Time has proved to be an important factor with a direct impact on the registration process quality and Improvement.
Front line staff reported to be fed up with daily registration routines as patients flow over the registration desk is uncontrollable and require long times to serve each one of them. Amatayakul [3] believe that long waiting times of registration to see a healthcare provider is problematic and in all kinds of public hospitals, reductions in waiting times for medical services could help promote patients’ satisfaction [15]. As been noticed during the non- participant observation encounters, several aggressive fights happen every now and then due to the problematic long waiting times. “There is a long loud and clearly unfriendly negotiation between a patient who just arrived wanting to see the doctor while the registration staff are trying to tell him there is no available slotfor him and the doctors are overwhelmed with many patients.” (Day 2 (17/8/2015), 11:00 – 11:11 a.m.) As a major goal, MNGHA aims to maintain patient’s satisfaction at all times in epidemiological conditions or healthy seasons. The use of tools such as ORS is believed to help reducing total waiting times, and substantially increase patients’ satisfaction with outpatient services. “Patient’s satisfaction is at risk because of the long waiting times that would reach up to 4 to 5 hours per visit.”
(Reg. junior staff 4) In addition, the process of automating scheduling processes and having patients information available online through the organizations' portal will give front-line employees to dedicate their time for more sophisticated duties that would improve the general workflow of registration process and provide a better patient service, auditing and checking patients’ files “I strongly agree upon the necessity to move forward and adopt the ORS because it wouldeliminate a huge amount of unnecessary daily routine works. I support ORS because the input from patient through the portal (e-services) could be seen by the registration staff side to be used as an input for other purposes serving the patients’ healthcare services and saving a lot of time that was used previously for data entry.” (Reg. junior staff 6) ORS is also believed to be a solution that saves time of re-entering the same data again and also saving money in recruiting extra clerks for this job which causes unnecessary extra expenditures. “And will also save money in recruiting extra clerks for this job. In addition, it would also be costbeneficial for patients.” (Reg. junior staff 9) Also, the waiting time in a very crowded waiting area makes the patients dissatisfied. In the MNGHA hospital case, there are a huge patients streams flowing to the registration windows has been observed by the researcher from the first day of observation until the last day.
“A crowd of above 40 patients both males and females are waiting in the outpatient’s waiting area, ground floor, gate 6.” (Day 1 (16/8/2015), 9:36 – 9:40 a.m.) Besides the dangerous potential hazards in case of any infectious diseases distribution among outpatients occupying the whole outpatient area leading to a general chaos especially with the existence of children or infants. Below are three observations supporting these statements. “There are 4 mothers with their children waiting in the area, among those children in the waiting area, there are 2 infants.” (Day 2 (17/8/2015), 9:18 – 9:30 a.m.) “I hear patients sneeze and cough continuously as per their arrival. Apparently, they have got influenza.” (Day 2 (17/8/2015), 10:26 – 10:35 a.m.) “Three children started to play around touching wall, trash baskets, leaflets, and other decorations.” (Day 2 (17/8/2015), 10:42 – 10:50 a.m.) Another angle of the crowd is saving money of building extra parking slots for those patients coming to hospital. “I believe that ORS would limit the danger of infection, solve crowd issues, and limited car parking area problems.” (Reg. senior staff 1) Shortliffe [2] raises the importance of sharing the data between patients and frontline coordinators in case of vital information related to healthcare as discussed in Dent & Eason's research [2]. Therefore, the input from the outpatient through the portal could be seen from the healthcare providers’ side to be used as an input for other purposes serving the patients’ healthcare.
“ORS would be extremely beneficial to impaired or very sick patients who cannot take the burden to come to hospital for booking an appointment or handling the long setting hours to finish their screening or treatment process.” (Reg. junior staff 4) Weiping, et al. [8] thinks that the major possible limitation against the success of ORS is the lack of conducting Internal and external marketing and advertising, educational programs, or orientation posters [7]. It is important to consider all of patient’s educational issues for the sake ofa successful system implementation and outcomes. “I would suggest ideas such as clear and simple brochures with big fonts describing ORS in few words for a beginning, and in the second stage, a more teaching concepts be adopted.” (Reg. junior staff 3) And as most of MNGH hospital patients are from a limited educational background according to the nature of the National Guard recruitment requirements and skills. It is believed that this factor would be fatal in the ORS implementation life cycle. “ A crowd of about 40 patients are setting in the waiting area. Among them, there are 5 patients inthe national guard unifom.” (Day 3 (19/8/2015), 9:10 – 9:21 a.m.) “We have distributed boxes of user manuals, 30% of patients actually used them only. That’s why idon’t believe posters and advertising or knowledge distribution campaigns will ever work.”
(Reg. junior staff 1) Furthermore, not having the capability to use the computer or internet availability would also be another requirement for the sake of a successful ORS implementation. Also, Zhang, et al. [10] considers the absence of internet connectivity or not having a computer device will lead to the lackof communication between the healthcare providers and the patients [18]. “I don’t believe the old traditional queuing method could be improved as most of MNGHA patients do not have the capability to use the computer or even can read sometimes. It would also require the availability of scanners to scan identity cards or other important documents besides the internet connectivity throughout the whole online registration process.” (Reg. junior staff 1) Wani, et al. [11] provides a solution of the mobile based appointment system to solve some of the ORS issues such as the hacking risk of patients’ appointments or medications as the online access is a vulnerable point threatening patient’s safety and privacy. Yet it still has some issues such as the quality of service and security issues in cloud which is used to store the data while storing patient appointment and medical details. Besides the harmful danger of violating patient’s privacy, paper loss and patient’s missing information plays a big role in withdrawing ORS one step backward [8].
“I am a bit anxious about the ORS idea because of the hacking risk of patients’ appointments or medications as the online access could be vulnerable which could threat patient’s safety and privacy.” (Reg. junior staff 4) Another ORS successful factor could be the level of the higher management involvement in the implementation of strict rules and regulations for the registration workflow. If a new registration process was put in place taking all the pre-requirements facilities of educating and teaching patients, patients will gradually obey the new movement in a slow and steady base as there will always be a first time for every invention and patients’ ignorance should not be taken as an excuse to stay still. “New strict rules to guide the electronic workflow of the registration process should be invented toteach lazy patients how to depend on themselves in their health service” (Reg. senior staff 1) The last possible factor that is believed to affect the smooth ORS success is the most common age group MNGHA outpatients belong to. Even though some patients are used to be served at the pointof visit, still age is not considered a crucial turning point in the ORS life cycle. “I think old, uneducated, and some educated type of patients prefer to be served rather than be initiative and self-dependent when coming to health services.”
(Reg. senior staff 1) At the end, those quotations prove and explain the reason behind the qualitative analysis in describing the main common factors affecting the acceptance level of R&A staff toward ORS system implementation and an illustration of the pros and cons of the ORS system from their point of view. In addition to that, it clarified how and through what possible mechanisms can ORS system implementation result in a positive outcome in a cultural and sociological manners in the environment of the MNGHA hospital. However, this research encountered some limitations suchas the inability to have a complete interview recording and transcription as some of the participants refused to record their voices on tapes, so we had to remove recording mechanism from the data collection method to have a unified data collection process for all participants.
Health informatics has become an important component in healthcare fields [19] as it aims to deliver the right information or service to the right person at the right time. It is growing swiftly and is involved in every health care delivery aspect [20]. The emergence of informatics in the healthcare field is causing rapid advances in the way healthcare is delivered technologically [21]. One essential area of health informatics that does not always receive enough attention is the scheduling process. It might look like a simple step with no remarkable impact on the organization’s workflow, but by analyzing current registration processes and utilizing health informatics solutions, the workflow will ease significantly according to Dent & Eason's research [6]. Front line hospital employees are often times-overwhelmed, besides the necessity of building a good relationship with the patients for more service satisfaction [7]. Additionally, and as the main focus of most hospitals is the front end of the revenue cycle, an informatics solution can be utilized by automating the scheduling process where it can be provided online through the organizations' portal. Not only to schedule a date and time, but the desired services as well with the payment of part or all of the fees to business center in order to allow the front-line employees to finally be more sophisticated around revenue cycle, customer service, and even financial planning.
Also, long waiting times for registration to see a healthcare provider has proved to be extremely problematic and in all kinds of public hospitals, reductions in waiting times for medical services could help promote patients’ satisfaction [3]. The use of tools such as ORS can help to reduce total waiting time, and substantially increase patients’ satisfaction with outpatient services. There are two accepted approaches for patients’ registration: either the TQM or through an ORS. In this study, we focused on ORS as it is a technique that aims to improve the workflow, lessen patient’s waiting time, and enhance patient’s care. In that regard, the current situation of registration workflow in the MNGHA hospital is the old traditional method of queueing and waiting for 2 to 3 hours to actually see the healthcare providers. The waiting time in a very crowded waiting area frustrates the patients leading to their dissatisfaction. Furthermore, as there isno ORS implemented in any way in the MNGHA website portal, the purpose of this study was to investigate the patient perceptions on implementing an ORS System and also to study the feasibility and acceptance of the R&A staff. The results of this study justify the main objectives in that it proved that more than the half of participated patients were unhappy with the TQM at registration desks (59.7%), this dissatisfaction should be addressed by ORS implementation that would reduce waiting time, enhance the level of attention and service from frontline staff toward patients’ care.
In addition, it helped to analyze the acceptance factors of ORS system among R&A staff. In the future, the results taken out of this study is advised to be used and presented to convince the ISID department and the higher management of the high necessity of such an essential technical project. It would allow the researchers to study the level of ORS success and patients’ satisfaction after 6 months of implementation and if it suits their outmost expectations of easy access to such an advanced hospital. Also, as an extra effort, the researcher would be able to document the ORS implementation management process in MNGHA hospital to have a prove of the incredible technical projects management experience. This paper complements a previously published paper [22] and adds more methodological details in terms of qualitative and quantitative details.
As the researcher who handled the interviews with R&A staff is from Information Systems and Informatics Department (ISID), interviewers were totally focused on the technical side of the problem whether as solutions, suggestions, limitations, or problems. This fact could have led the project to have technically-driven conclusions instead of social or other humanitarian impacts.
Below table shows some previously discovered facts and additional identified proves around the patient’s online registration system implementation feasibility and perceptions (Table 2).
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