Abstract
BACKGROUND: In a low-resource and high-volume setting, it is often felt that patient care cannot be improved within the limitations of existing infrastructure and resources. However, the use of a systematic problem-solving method can bring about significant improvement even in these settings. AIM: To decrease the mean waiting time from first visit to initiation of infertility treatment by 70% within 4 weeks (1-30 June 2019) for patients coming to the gynaecological outpatient department (OPD). METHODS: We constructed a multidisciplinary quality improvement team consisting of an academic consultant, a senior resident physician, a junior resident physician and a nurse to address the problem of long waiting times to initiation of fertility treatment. We collected baseline data from 10 consecutive women presenting to gynaecological OPD with complaints of infertility by calculating the time between their first visit to the facility and the day of performance of hysterosalpingography (HSG). The average waiting time was found to be 6 months and 25 days (mean=6.85 months; 3.5-10 months). The team used process flow diagrams and fishbone analysis to identify various causes of these long waiting times. The main reason for the delay in starting infertility treatment was that the date for HSG was given only after seeing the endometrial aspiration report (ie, after ruling out endometrial tuberculosis as there is a risk of dissemination of tuberculosis during HSG). Also, HSG was done only once a week during a short 2-hour slot in the fluoroscopy room. RESULTS: After the implementation of change ideas, there was significant reduction in the waiting period to starting treatment in patients with infertility. After the first change idea, the average waiting period seen in 10 consecutive patients with infertility reduced to 3.25 months, that is, by 51.8% from baseline within a 2-week interval, and there is shift in the run chart diagram. After the second change idea, the waiting time reduced to 2 months, that is, by 70%, seen in the next 10 consecutive patients with infertility within the next 2 weeks' time. The results were sustained to the average waiting time of 2 months for 6 months without any additional resources. CONCLUSION: With a well-organised and conducted quality improvement project and team efforts, the required changes can be brought about in an established conventional healthcare delivery system and improvements can be sustained over a long period of time.