CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Health care systems have been challenged in recent years to deliver high quality services with
limited resources (Hall, Bens et al 2001). Health care resources are becoming increasingly
limited and expensive thereby placing greater emphasis on the efficient utilization of the
resource and the corresponding level of services provided to patients. Consequently, one of
the most important operational issues in health care delivery involves capacity planning such
that the goals of efficient resource utilization and providing high quality services are met
(Pierskalla & Wilson, 1989; Smith-Daniels, 1988). In Nigeria, during the 2000’s some
teaching hospitals experienced restructuring and renovations to meet international standards.
In some regions of the country, the restructuring and renovation have produced serious
overcrowding effect such that patients wait for hours to see doctors or before attention,
particularly in emergency departments (ED) and intensive care units (ICU). There may be
growing recognition that mortality is increasing among patients to whom admission into
overcrowded intensive care units is refused (Nelson, et al 1998) principally due to the
rationalization programs of the EDs and ICUs. But there is an incomplete understanding
amongst health policy makers of the limits of the downsizing process and no concensus as to
the number of intensive care unit beds necessary to serve a given population (Meticafe, et al
1997). Nevertheless, emergency departments and intensive care units are among the most
complex and expensive of all medical resources, and hospital administrators are challenged to
meet the demand for intensive care services with an appropriate capacity (Green 2002).

The organizations that care for persons who are ill and injured vary widely in scope and
scale, from specialized outpatient clinics to large urban hospitals, Teaching hospitals, to
primary health care systems. Despite these differences, one can view the health care
processes that these organizations generate within the context of queuing systems in which
patient arrive, wait for service, obtain service, and then depart (Fomomundam & Herrmann,
2007). The healthcare processes also vary in complexity and scope, but they all consist of a
set of activities and procedures (both medical and non-medical) that the patient must undergo
in order to receive the needed treatment. The resources in these queuing systems are the
trained personnel and specialized equipment that these activities and procedures require.

1
Effectively managing patient flow in an outpatient unit is a key to achieving operational
excellence as well as ensuring clinical quality.

Queuing theory is a powerful operational research tool which assists managers to make vital
decisions capable of optimizing the performance of health system facility, minimize
operational costs and enhance the satisfaction of all interest group (Adeoye, 2021). Operation
research is an approach to the analysis of operations that to an extent adopts scientific method
as well as explicit formulation of complex relationships. The primary purpose of operational
research is obviously to identify the optimum way of operating. Since the attempt of Bailey
and Lindley to resolve outpatient clinic dissatisfaction, many operation research techniques
have been developed to understand the underlying problems better ( Bailey &Lindley,
19952). These techniques include the queuing theory, mathematical programming, modeling
and simulation (Cayirli & Veral, 2003). Queuing theory is an operational research tool
which has been applied in the assessment of prescription filling time, patient counseling time,
staffing levels, waiting and service costs, patient satisfaction among others.

With the knowledge of queuing theory, managers can make decisions that can optimize the
performance of the system, minimize operational costs and enhance the satisfaction of all
interest groups. A queue forms at any time when the demand for a service exceeds the
capacity of the service facility. Any group of people or objects awaiting their turn for service
constitutes a queue. One reason for studying queues is to enable the optimum service facility
to be selected so that the overall cost of a service is minimized. Wait times for health service
arise because capacity does not match demand or capacity or demand is not well managed
(Adeoye, et al 2021).

Excessive waiting times may be symptoms of inefficiencies in the health care system and
should be addressed as good management practice. The experience of waiting can be
extremely distressing itself. Some waiting periods have either saved the life of a client/patient
(e.g the case of spotting a medication error or an ADR signal) or aided to proper
diagnosis/counsel. The client/patient’s family life may be adversely affected by waiting.
Sometimes patient will have to wait a long time. If such a waiting situation is not addressed,
the client may leave and not come back. Patient would leave a practice if they feel that their
time has been disrespected,`` said Stephen Albrecht, a family physician and a medical

2
director of Olympia family medicine in Washington (Elliot, 2010). Experts emphasized that
waiting times do not have to be long to annoy patients and the way to solve a waiting time
problem will be different from every practice and settings (David H.M).

Most studies working on outpatient services focus on reducing or managing patient waiting
time, because waiting and treatment time are usually regarded as important determinant of
patient satisfaction and service quality. Reducing patient waiting time is not only valuable for
patient but also helpful to decrease the hospital workload (Gunal, Najmuddin et al 2010).

1.2 STATEMENT OF THE PROBLEM

The global human population officially reached seven billion in 2013. This is the fastest
billionth increase; the human population rose from six billion to seven billion in just 12 years
(Haub, 2011). The population boom, coupled with an increased life span, poses great
challenges to health care systems. The constant demand for cheaper service and yet improved
health care service quality has become more pressing in present day society (Cairrli & Veral,
2003). Funds provided for health care services become scarce, especially at times when the
economy performs poorly, exacting an ever increasing tool on health care services (Davis &
Robinson, 2010). Excessive patient waiting time at clinics leads to poor client satisfaction.
This is in fact becoming a global problem (Buckle & Stuart 1996)

In health care institutions the effects of queuing in respect to the time spent for patients to
access treatment is increasingly becoming a major source of concern to a modern society that
is currently exposed to great strides in technological advancement and speed (Stakutis &
Boyle, 2009). The danger of keeping customers waiting could become a cost to them
(Elegallam, 1978). The time wasted on queue would have been judiciously utilized elsewhere
(opportunity cost of time spent in queuing). The expectations on health care delivery are
increasing with enhanced medical care, improved diagnosis techniques and efficiency of
treatments. This evidently conveys a general increased demand for health care and tends to
raise health care costs. Nevertheless, it is a goal universally acknowledged that a health care
system should treat its patients – and especially those in need of critical care – in a timely
manner. However, this is often not achieved in practice, particularly in public health care
systems that suffer from high patient demand and limited resources (Au-Yeung et al, 2006;
Bruin et al, 2007).

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The way in which managers address the waiting line issue is critical to the long term success
of firms (Davis et al, 2003). Queuing has become a symbol of inefficiency of publicly funded
hospital in the world and Nigeria is not an exemption. Managing the length of line is one of
the challenges facing most hospitals. Consideration of cost takes an increasing amount of the
attention of managers in health care facilities and at local, state, and national levels of the
health services. This concern applies to both public and private sectors.

The above situation therefore necessitated the need to carry out this study and applying its
findings to estimate total health care cost.

1.3 OBJECTIVES OF THE STUDY

The general objective of this study is to apply queuing theory to estimate health care costs in
both public and private specialist health care settings.

The followings are the specific objective that guided this research. They include;

1. To assess patient waiting time, waiting and service cost.

2. To evaluate the effects of queues in the hospital on the cost of service provision.

1.4 RESEARCH QUESTIONS

This study seek to address the following research questions;

1. What are the factors causing patient delay in the hospital?

2. How does delay affect the cost of providing services?
3. What are the consequences of delay in provision of health care?
4. How does delay in service affect patients receiving service?

1.5 RESEARCH HYPOTHESES

The following hypotheses was tested in this research;

1. Ho; There is no significant difference in waiting in the system in both facility

Hi; there is a Significant difference in waiting in the system in both facility

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 2. Ho; there is no significant difference between facility type and level of satisfaction with
service delivery.

Hi; There is a significant difference between Facility type and level of satisfaction
with service delivery.

1.6 SCOPE OF THE STUDY

This research work on application of queuing theory in the determination of health care cost
was limited to staff of GOPD and patients that visit the GOPD of LUTH and St. Nicholas
hospital from the time of arrival to the time of exit. This study excluded patients that visit
other units/department of these hospitals.

1.7 SIGNIFICANCE OF THE STUDY

This study when completed will show what factors can be improved on in reducing patients
waiting time; it would bring new ideas and concepts to be implemented in health care
operations. It will also contribute to academic knowledge and hospital practice by providing
hospital management a powerful tool to evaluate the current capacity and to quantify the
impacts of resource reallocations.

1.8 DEFINITION OF TERMS

Queueing: queueing occurs when customers (patients) wait on a line to receive services. This
arises any time customer's demand for services and the service provider(s) are temporarily
busy.

Queueing System: This comprises the entire service provision mechanism. Queuing system
include waiting list, service facility (server) and departure.

Queueing Theory: queuing theory is usually used to define a set of analytic techniques in the
form of closed mathematical formulas to describe properties of the processes with a random
demand and supply (waiting lines or queues).

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 CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
According to Bergen mar. et. al, (2006), waiting time can be defined as an objective
evaluation of the quality of service received against the individuals expectations. In this
study, patient waiting time was expressed as an arithmetic sum of all sections waiting time.
Patients spend a considerable amount of time in hospitals waiting for services to be delivered
by physicians and other allied health professionals. Delayed access to health care is assumed
to negatively affect health outcomes due to delays in diagnosis and treatment plus unforeseen
cost implications on the patients and public health system (Mesfinet.al, 2010).
The current emphasis in improving quality outpatient service delivery especially in public
health facilities requires a detailed, fundamental understanding of how hospital outpatient
departments operate and mapping the process of care is an important step towards this goal
(Barach& Johnson, 2006). One index in healthcare delivery by which the quality of service
provided to patients can be evaluated is the uninterrupted movement of patients, known as
patient flow. According to Hall (2006), patient flow represents the ability of the healthcare
system to serve patients quickly and efficiently as they move through stages of care.
Blockage in the flow can increase waiting and through put time creating unnecessary delay at
the facility before the patient receives care, thus having an impact of health care outcomes
(Vos, 2007).
Reducing outpatient waiting times has been the focus of a large number of studies ( Nabbuye-
Sekandi et al., 2011) because waiting and treatment times are usually regarded as indicators
of service quality (Nabbuye-Sekandi et al., 2011). However, despite the declared importance
of ensuring timely access to care, little research has actually measured how long patients wait
and also examined any empirical associations with patient waiting time for outpatient care.
Waiting time is an important determinant of quality services as it is noted that in health care
provision, delays are expensive, not only in terms of direct costs incurred, but also in terms of
the potential costs of decreased patient satisfaction and adverse outcomes (Haussmann,
1970).
Waiting time studies have been done in settings such as specialized clinics like child health,
maternal health clinics and medical clinics for priority conditions such as Acquired Immune
Deficiency Syndrome, elective surgery clinics such as those dealing with organ transplant
and other cosmetic surgery clinics and general outpatients clinics. With the challenge to

6
deliver high quality services with limited resources (Hall et al., 2001) health care systems
have placed greater emphasis on the efficient utilization of the resources.
Therefore, one of the most important operational issues in health care delivery involves
increasing utilization and access by minimizing the delays in delivery. The literature review
on patients’ satisfaction with tertiary care indicates that key attributes of health care valued
by patient-centered including time spent with the physician, willingness or the physician to
listen to the patient and most primitive form of outpatient management is single block
scheduling (Mardiahet al., 2013).

There are two kinds of waiting times within health science. On the one hand there is the
waiting time for medical treatment, diagnostic procedure (like MRT), surgeries or
transplantation of organs and other tissues. On the other hand there are waiting times in
waiting rooms of doctors’ offices or hospitals. Although both issues are important and
currently topic of public discussions (&rzteZeitunget.al, 2014), only the latter will be part of
this research work.
Waiting times in outpatient clinics and at general practitioners occur temporarily and regional
differently and depend on the type of organization and its internal processes. For instance,
patients at the general practitioner often need acute care and don’t have the possibility to
arrange an appointment in advance. In contrast in most cases it is mandatory to arrange an
appointment before seeing a specialist. In hospitals acute cases are usually treated in the
emergency department, while the other departments use appointment systems.
Waiting times are not only an issue in the health care sector, but also a phenomenon
occurring in different areas of life: e.g. in the shopping area or any kind of governmental
course. Probably one of the most unpleasant areas where waiting times occur is the health
care sector. Therefore waiting times in hospitals and outpatient clinics have been topic of
interest for several scientific works in the last decades (Becker and Douglass 2008).
.
Many organizations, such as banks, airlines, telecommunications companies, and police
Departments, routinely use queuing models to help determine capacity levels needed to
respond to experienced demands in a timely fashion. Long waiting time in any hospital is
considered as an indicator of poor quality and needs improvement. Managing waiting lines
create a great dilemma for managers seeking to improve the return on investment of their
operations.
Customers also dislike waiting for long time. If the waiting time and service time is high

7
customers may leave the queue prematurely and this in turn results in customer
dissatisfaction.
This will reduce customer demand and eventually revenue and profit (Biju, M. K. et al,
2011). Though queuing analysis has been used in hospitals and other healthcare settings, its
use in this sector is not widespread. With rapid change and realignment of healthcare system,
new lines of services and facilities to render the same, severe financial pressure on the
healthcare organizations, and extensive use of expanded managerial skills in healthcare
setting, use of queuing models has become quite prevalent in it.
In an era of healthcare reform, improving quality and safety, and decreasing healthcare cost
have become even more important goals than before. With rapid change and realignment of
healthcare system, new lines of services and facilities to render the same, severe financial
pressure on the
healthcare organizations, and extensive use of expanded managerial skills in healthcare
setting, the use of queuing model has become a prevalent analytical tool (Singh,
2007).Scientific management of patient flow is at the heart of our ability to achieve these
goals. While on one hand we are faced with overcrowded facilities, on the other hand, the
industry's financial conditions do not allow us to add resources liberally. One key challenge
is our ability to match random patient demand to fixed capacity. Queuing theory is a
methodology that addresses this very challenge. Queuing theory was first used in
telecommunications and then was adopted by all major industries, like airlines, the Internet
and most service-delivery organizations. In the health care industry, however, queuing theory
has not been utilized until recently. When used appropriately, the results are often dramatic:
saving time, increasing revenue, and increasing staff and patient satisfaction.

2.2 THEORETICAL FRAMEWORK

According to Grossman (1972) theories of demand for health care, waiting time is a
component of the time input of the household production function in the production of both
market and non-market commodities. Thus, when waiting time increases it increases the time
input of demand for health care. This increases the opportunity cost of time for market
production due to wage effect. Depending on the wage elasticity, increases in waiting time
can influence individual to reduce demand for health care.

8
The Grossman model of demand for health care (1972) The Human Capital Model form the
basic framework of demand for health care that explains the difference between health as an
output and medical care as one of a number of inputs in the production of health. According
to the Grossman model, health is both an investment and a consumption good that individuals
invest to produce throughout their lifetime, and so individuals demand health care both for
consumption and for investment. The model views health as a durable capital stock that
yields an output of healthy time, and individuals inherit an initial amount of this stock that
depreciate with age and can be increased by investment. Health as a consumption commodity
enters directly in the consumer‘s preference or utility function, and as an investment
commodity it determines the total amount of time available for market and non-market
activities. The model employed the household production function of consumer behavior
analogous to the firms’ production function to explain the gap between health as an output
and medical care as one of the inputs into its production. Demand for medical care and other
inputs of health are said to be derived demand, derived from the basic demand for health.
According to the model, consumers produce gross investment in health in the non – market or
household sector together with a composite good for all other market goods (money earnings
and commodities) by combining medical care purchased in the market to contribute to gross
investment in health in the non- market sector and own time for producing both health and
the market commodities. Thus individual's own time is said to be constraint to producing
both market and non market commodities (production of market earnings), and all other
possible uses. This means there will be substitution in the time use among its uses according
to the value giving to each use. When wages increase in the market time required for
producing market earnings increases, which will require the individual to reduce time for
producing health. Thus if for example waiting time for purchasing medical care increases
consuming medical care will be at the expense of market earnings. It means when waiting
time increases individuals are more likely to reduce demand for medical care.

Also, according to Grossman, the price of medical care is zero in the presence of health
insurance. In effect the model therefore postulates that health care will be rationed by waiting
and travel times. In this case the opportunity cost of seeking health care will increase as
wages increases in the market. With respect to this study the absence of monetary price to
ration health care under an insurance system will mean possible long queues as a result of
free monetary cost, hence giving rise to long waiting time. In the existence of a parallel
alternative health care like a private health care system with a probable shorter waiting time,

9
individuals with high opportunity cost of time would be prepared to pay high prices to seek
care from such sources as the private hospitals. Otherwise individuals may have to substitute
health for market earnings by reducing health care demand.
Under the pure investment model of the Grossman model, time spent producing health can be
substituted for medical care as wage increases. This is because as wage increases, time spent
producing health falls so that demand for medical care increases due to substitution in
production between market and non-market activities. When wage increases, time spent to
produce health becomes costly so individuals reduce time spent to produce health and
increase demand for medical care. However, on the basis of this study consumption of
medical care can also become costly in time if waiting times associated with seeking care are
long. Which means individuals will have to seek care from alternative sources of care with
minimum waiting times. Alternative forms of health care such as over the counter
prescriptions or home self – medications could be used to avoid long waiting time. Or
individuals may use preventive measures such as protection with mosquito nets, and good
eating habits as ways of producing malaria care.

2.2.1 Queuing theory

The mathematical study of waiting in lines is a branch of operations research because the
results often are used when making business decisions about the resources needed to provide
service. At its most basic level, queuing theory involves arrivals at a facility (i.e., computer
store, pharmacy, and bank) and service requirements of that facility (i.e., technicians,
pharmacists, tellers). The number of arrivals generally fluctuates over the course of the hours
that the facility is available for business. The theory enables mathematical analysis of several
related processes, including arriving at the (back of the) queue, waiting in the queue
(essentially a storage process), and being served at the front of the queue. The theory permits
the derivation and calculation of several performance measures including the average waiting
time in the queue or the system, the expected number waiting or receiving service, and the
probability of encountering the system in certain states, such as empty, full, having an
available server or having to wait a certain time to be served (Wagner, H.M,1969).

A French mathematician S.D. Poisson (1781-1840) was credited with the pioneering work on
queuing theory. He created a distribution function to describe the probability of a prescribed
outcome after repeated iteration of independent trials. Nevertheless, it was first applied in
industrial setting By A.K. Erlang in 1909 in the context of telephone facilities. Thereafter, it

10
has been extensively practiced or utilized in industrial setting or retail sector– operations
management, and falls under the purview of decision sciences (Singh, 2007).

Kendall (1951,1953) was the pioneer who viewed and developed queuing theory from the
perspective of stochastic processes. The literature on queuing theory and the diverse area of
its application has grown tremendously (Medhi, (2003); prabhu (1987); Takagi
(1991);Dshalalow (1995,1997)). Infact, Takagi and Boguslavsky(1990) put up a bibliography
of books and survey papers on application of queuing in industrial settlings.

Queuing theory is usually used to define a set of analytical techniques in the form of closed
mathematical formulas to describe properties of the processes with a random demand and
supply (waiting lines or queues). Queuing formulas are usually applied to a limited number of
predetermined, simplified models of real processes for which analytical formulas can be
developed (Killer, 2009). Queuing system occurs anytime customers demand for services and
the server(s) are temporarily engaged. They are the obvious probabilistic models when
dealing with scenarios of congestions and blockages (Amero et al, 2004). Therefore, it seems
very logical to view the services or operations of emergency department and intensive care
unit as a queuing system: patients needing the services of the units wait in a queue to be
served and leave the system after service.

2.2.2 Basics of Queuing Theory

Basic structure of queuing model can be separated into input and output queuing system,
which include queue that must obey queuing rule and service mechanics (Hillier and
Lieberman, 2005). The simplest queuing model is called single- server single queue model as
illustrated in figure 2.1. Single–server model has a single server and a single line of
customers (Krasewski and Ritzman, 1998). It is a situation in which customers from a single
line are to be served by a single server, one after the other. For application of queuing model
to any situation we should first describe the input process and the output process (Singh,
2007).

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Figure 2.1: A High-Level View of a Basic Queuing Process

SERVED
CUSTOMER
INPUT SOURCE QUEUE SERVICE FACILITY
000000
DEPARTURE

QUEUING SYSTEM

2.2.3 Input and Output Process

Input process is known as the arrival process. Customers/patients are known as arrivals which
are generated one time by an input source randomly from a finite or infinite population.
These customers /patients enter the queuing system and join a queue to be served. In the
hospital setting, the group of individuals from which arrivals come is referred to as the call-in
population. Variation occur in this population size.

Total patient demand requiring services from time to time constitute the size of arrival
(Tutunci, 2009). At all times, a member of the patients on the queue is selected for service by
some rules known as the queue discipline. The required service is then performed for the
customer by the service mechanism, after which the customer leaves the queuing system
(Hillier and Lieberman, 2005).

The provision of services using certain rule and discharge of patients/customers is referred to
as output process. An example of both processes are shown below :

SETTINGS INPUT PROCESS OUTPUT PROCESS

Hospital Arrival of the patient at the Assessment, triage, provision

registration counter of services, discharge

Emergency department Ambulance arrival Assessment, triage to the

inpatient setting or discharge
Intensive care unit of treatment

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An important point to be noted is that the most sort of health services have the capacity to
serve more patients (on the average) than they are called to over the long term, so that
customer waiting line is a short term phenomenon and the employees (servers) who serve
customers may be frequently inactive while they wait for the customer to arrive (Ozcan,
2006). Another fact worth mentioning here is that the key word in queuing models is
"average". It takes the average of the random numbers of patients arriving, the service time,
arrival intervals. Etc. (Singh, 2007).

2.2.4 Queuing system characteristics

According to Adedayo et al (2006) and Medhi (2003), queuing phenomenon comprises of the
following basic characteristic: (1) arrival characteristics; (2) the queue or the physical line
itself; (3) the number of servers or service channels; (4) queue discipline; (5) service
mechanism; (6) the capacity of the system; (7) departure.

2..2.5 Arrival Characteristics

Arrival pattern describes the behavior of way customers' arrive. It is specified by the inter-
arrival time between any two consecutive arrivals (Medhi, 2003). The inter-arrival time may
be deterministic or stochastic in nature. Arrival can occur from unlimited population (infinite)
or limited (finite or restricted) population (Adedayo et al, 2006). There are four main
descriptors of arrivals as put forth by Davis et al, (2003) as shown in figure 2.2: the pattern of
arrivals (whether arrivals are controllable or uncontrollable); the size of arrival units (whether
the arrival occur one at a time or in batches /bulk); the distribution pattern (whether the time
between arrival is constant or follow statistical distribution such as Poisson, exponential etc);
and the degree of patience (whether the arrival stays in line or leaves).

A waiting line or queue occurs when customers wait before being served because the service
facility is currently/temporarily engaged. A queue is characterized by the maximum
permissible number of customers that it can contain. Queues are called infinite or finite,
according to whether this number is infinite or finite (Hillier and Lieberman, 2001). An
infinite queue is one in which for all practical purposes, an unlimited number of customers
can be held there. When the capacity is small enough that it needs to be taken into account,
then the queue is called a finite queue (Hillier& Hillier, 2003). Unless specified otherwise,
the adopted queuing network model in this study assumes that the queue is an infinite queue.

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Figure 2.2: Arrival characteristics in Queue

Controllable
Pattern

Uncontrollable

Single
Size of arrival

Batch/Bulk

Constant

Distribution Exponential or
Poisson

Erlang

Other

Patience (in line

Degree of and stay)
patience
Arrive, wait and
Inpatience
leave

Arrive, wait a while,

then leave

2..2.6 Queue Discipline

The queue discipline refers to the order in which members of the queue are selected for
service (Hillier and Lieberman, 2001). Winston and Albright (1997) posit that the usual queue

14
discipline Is first come, first served (FCFS or FIFO), where customers are served in order of
arrival. In this Study the case hospitals use FCFS queuing discipline. Although, sometimes
there are other Service disciplines: last come, first served (which happens sometime in case
of emergencies), or Service-in-random order and priority rule. Davis et al, (2003) assert that
reservations first,
Emergencies first, highest profit customer first, largest orders first, best customers first,
longest Waiting time in line, and soonest promised date are other examples of queue
discipline. Unless Otherwise stated, the queuing model adopted in this study assumes arrival
from infinite source with infinite queue and with first in first served (FCFS) queue discipline.
Obamiro, (2010)

Queuing management consists of three major components:

1. How customers arrive
2. How customers are serviced
3. The condition of the customer exiting the system

Arrivals: Arrivals are divided into two types:

1. Constant - exactly the same time period between successive arrivals (i.e., machine
controlled).
2. Variable - random arrival distributions, which is a much more common form of arrival. A
good rule of thumb to remember the two distributions is that time between arrivals is
exponentially distributed and the numbers of arrivals per unit of time is Poisson distributed.
The Servicing or Queuing System: The servicing or queuing system consists of the line(s)
and the available number of servers. Factors to consider include the line length, number of
lines and the queue discipline. Queue discipline is the priority rule, or rules, for determining
the order of service to customers in a waiting line. An important feature of the waiting
structure is the time the customer spends with the server once the service has started. This is
referred to as the service rate: the Capacity of the server in numbers of units per time period
(i.e., 15 orders per hour).
Exit: There are two possible outcomes after a customer is served. The customer is either
satisfied or not satisfied and requires re-service.

15
2.2.6 Service Mechanism: According to Mosek and Wilson (2001), service mechanism
describes how the customer is served. In a single server system each customer is served by
exactly one server, even though there may be multiple servers. In most cases, service times are
random and they may vary greatly. Sometimes the service time may be similar for each job or
constant. The service mechanism also describes the number of servers. A queuing system
may operate with a single server or a number of parallel servers. An arrival who finds more
than one free server may choose at random any one of them for receiving service. If he finds
all the servers busy, he joins a queue common to all servers. The first customer from the
common queue goes to the server who becomes free first (Medhi, 2003).

2.2.7 Capacity of the System: A system may have an infinite capacity-that is, the queue in
front of the server(s) may grow to any length. Furthermore, there may be limitation of space
and so when the space is filled to capacity, an arrival will not be able to join the system and
will be lost to the system. The system is called a delay system or a loss system, according to
whether the capacity is infinite or finite respectively (Medhi, 2003).

2.2.8 Departure: Once customers are served, they depart and may not likely re-enter the
system to queue again. It is usually assumed that departing customers do not return into the
system immediately (Adedayo, et al., 2006). Chase et al., (2004) is of the opinion that once a
customer is served, two exit fates are possible as shown in figure 2.3.
1. The customer may return to the source population and immediately become a competing
candidate for service again.
2. There may be a low probability of re-service. In hospitals, departure means home
discharge, admission or death (Smith and Mayhew, 2008).

Figure 2.3: Departure

Low probability of resources

Exit
Return to source population

Source: Davis et al., (2005)

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2.2.9 Types of Queuing System
There are four major types of queuing system and different combinations of the same can be
adopted for complex networks. Lapin (1981) broadly categorized queuing system structures
into the following
1. Single-server, Single-phase system:
Single-phase means only one stop for service.. This is a situation in which single queue of
customers are to be served by a single service facility (server) one after the other. An
example is flu vaccination camp where a nurse practitioner is the server who does all the
work (i.e. .paper work and vaccination (Singh, 2007). Diagrammatically it is depicted in figure
2.2.

Figure 2.4: Single-server, Single phase System.

0000
00000000 00000
0

Arrivals Queue Service facility Departures

Source: Obamiro, (2010)

2. Single-server, Multiple-phases System:

In this situation, there's still a single queue but customers/patients receive more than one kind
of service before departing the queuing system as shown in figure 2.3. For example, at
outpatient department, patient first arrive at the registration desk, get the registration done and
then wait in a queue to see a nurse for ancillary services before being seen by the consultant
(physician).
Patients have to join queue at each phase of the system.

Figure 2.5: Single-server, Multiple phases System

0000
00000 0 0 0 00000

Source: Obamiro, (2010)

17
3. Multiple-servers, Single-phase System:

This is a queuing system characterized by a situation whereby there is a more than one
service
facility (servers) providing identical service but drawn on a single waiting line (Obamiro,
2010).
An example is patient waiting to see consultants (physicians) at general outpatient department
of teaching hospitals as illustrated by figure 2.4.

Figure 2.6: Multiple-servers, Single phase System

0
0

000
0000
000000 0
000

000
Arrivals Queue
0

0 000

Server facilities Departures

Source: Obamiro, (2010)

4 Multiple servers, Multiple-phases System:

According to Singh (2007), this type of system has numerous queues and a complex network
of multiple phases of services involved as can be seen in figure 2.5. This is the type of
queuing system adopted in this study. This type of service is typically seen in a hospital
setting, multi- specialty outpatient clinics, patient first form the queue for registration, then
he/she is triage for assessment, then for diagnostics, review, treatment, intervention or
prescription and finally exits from the system or triage to different provider.

18
Figure 2.7: Multiple-servers, Multiple-phase System

0 000
0 0
0000
000000 0 0 0
000
arrivals Queue
0 0 0 000

Service facilities Departures

Source: Obamiro, (2010)

2.2.10 Queuing Model Analysis

Queuing models are used to achieve a balance or trade-off between capacity and service
delays.
Notation for describing the characteristics of a queuing model was first suggested by David
G. Kendall in 1953. Kendall's notation introduced an A/B/C queuing notation that can be
found in all standard modern works on queuing theory. Two simple single-server models
help answer meaningful questions and also address the curse of utilization and the curse of
variability. One model assumes variable service time while the other assumes constant service
time.

J. Jackson (1957, 1963) made notable contributions to the development of queuing network
models. A Jackson model is probably the most researched and widely applied network model
in various fields, including the healthcare field. Jackson's major contribution was to find a
product-form steady-state solution for in open and closed models with a tandem or a feed-
forward flow configuration. In a network model, various numbers of entities can exist at
multiple stations, and the state of the system is described by the joint probability
distribution for the number of entities at each station. Numerous theoretical works were
published which expanded the Jackson model, and many of those examined or modified the
Jackson properties (i) and (ii), in particular, in an open model. Among those, Disney (1981)
and Melamed (1979) are widely known. Disney (1981) examined the internal arrival rate
distribution with feedback flow as a generalization of Jackson model. His research showed

19
that when a system has any kind of feedback flow, the internal flows in the system do not
follow the Poisson distribution. Thus, the assumption of Poisson arrival is justified only
when the system under consideration has either a tandem or arbitrarily linked network
configuration with feed-forward flows. It is, however, known that the Jackson's product-form
solution holds regardless of whether or not internal flows are Poisson. Melamed (1979)
extended Burke's finding in an open Jackson system. He showed that departure rates from
internal stations to outside the system are mutually independent if arriving rates to all
internal stations follow the Poisson distribution. The finding, in turn, means that the sum of
all departure rates from the network must also be Poisson.

2.2.11. Summary of Queuing Model Assumptions

Hillier and Hillier (2003) summarize the assumption generally made by queuing models of a
basic queuing system. These assumptions should not be taken for granted unless model
explicitly State otherwise.

1. Inter-arrival times are independent and identically distributed according to a specified

probability distribution.

2. All arriving customers enter the queuing system and remain there until service has been
completed.

3. The queuing system has a single infinite queue, so that the queue will hold an unlimited
number of customers.

4. The queue system is first come first-served.

5. The queuing system has a specified number of servers.

6. Each customer is served individually by any one of the servers.

7. Services times are independent and identically distributed according to a specified

probability.

2.2.12Limitations of Queuing Theory

Queuing models have several limitations and are used in conjunction with the other decision
analysis tools such as Simulation, Regression, Markov Chains, etc (Singh, 2007). Some of the

20
limitations are the basic assumptions for the application of queuing models and according to
Singh, (2007) include the following :

 Takes average of all variables rather than the real number.

 Assumes steady state situation in most cases of queuing system
 Based on assumption that service time is known
 Service rate is greater than arrival rate
 Service times are described by the negative exponential probability distribution.

2.3 CONCEPTUAL FRAMEWORK

2.3.1 Concept of Waiting Time

Patients spend substantial amount of time in the clinics waiting for services to be delivered by
physicians and other allied health professionals. The degree to which health consumers are
satisfied with the care received is strongly related to the quality of the waiting experience.
Healthcare organizations that strive to deliver exceptional services must effectively manage
their clinic wait. Failure to incorporate consumer-driven features into the design of wait
experience could lead to patient and provider dissatisfaction (Ocheet al., 2013).

Waiting time refers to the time a patient waits in the clinic before being seen by one of the
clinic medical staff. Patient clinic waiting time is an important indicator of quality of services
offered by hospitals. The amount of time a patient waits to be seen is one factor which affects
utilization of healthcare services. Patients perceive long waiting times as a barrier to actually
obtaining services. Keeping patients waiting unnecessarily can be a cause of stress for both
patient and doctor. Waiting time is a tangible aspect of practice that patients will use to judge
health personnel, even more than their knowledge and skill (Ocheet al., 2013).

The Institute of Medicine (IOM) recommends that, at least 90% of patients should be seen
within 30 min of their scheduled appointment time (Ocheet al., 2013). This is, however, not
the case in most developing countries, as several studies have shown that patients spend 2-
4hours in the outpatient departments before seeing the doctor (Ocheet al., 2013). A source of
dissatisfaction with health care reported by patients has to wait a long period of time in the
clinic, and several studies have documented the negative association between increased
waiting time and patient satisfaction with primary care (Ocheet al., 2013). The duration of
waiting time varies from country to country, and even within country it varies from center to

21
center. Long waiting times have been reported in both developed and developing countries.
In the USA, an average waiting time of about 60 min was found in Atlanta, and an average of
188 min in Michigan (Ocheet al., 2013).

In Nigeria, an average waiting time of about 173 min was found in Benin, while in University
College Hospital Ibadan, a mean waiting time of 1 h 13 min was observed (Ocheet.al, 2013).
According to Blundell (2000), waiting time is a price that influences people to choose
alternative care from private hospitals or not seek care at all when the waiting time gets too
long. The model explains waiting time as a hassle cost to treatment that endogenously
determines demand for health care in equilibrium. It explains that, in equilibrium waiting
time cost will just be sufficient to reduced demand to equal supply of services. When demand
increases it will increase waiting time which in turn will cause demand to decrease. Thus the
waiting time essentially plays the role of a price, influencing people to look for alternative
care possibly private or no care at all. For this study waiting time is expected to reduce
demand for medical care (healthcare from hospital) for outpatient health care needs (Blundell
et.al., 2000).

2.3.2. Factors associated with waiting time in a health facility

1. Patient flow Patient flow represents the ability of the healthcare system to serve patients
quickly and efficiently as they move through stages of care. Blockage in the flow can
increase waiting and through put time creating a negative effect on the quality of service
delivery (Vos et al., 2007). When patient flow is handled well, it is represented by short wait
at registration, examination, diagnostic testing, pharmacy and discharge (Belson, 2010).
Thus, improving patient flow is one way of improving healthcare services.

2. Operational efficiency Once a health care facility has an understanding of its patient flow,
these flows can be used to improve the facility operation (Côté, 2000). Therefore, efficient
patient flow may be a key to achieve operational efficiency in the outpatient department
(Kunders, 2004). According to (Wanyenze et al., 2010) a number of factors can influence
efficiency and the emergence of bottleneck in health care operation during examining
operational efficiency with regard to patient flow. These factors include the volume of
patients seen on the daily basis, the types of patient seen in terms of stage of care, clinic
policies on frequency of patient visits, the type of provider who they should see, the size and
composition of the providers and the staffing model.

22
3. Physical design The physical environment greatly affects the quality, efficiency, and
efficacy of healthcare delivery in outpatient settings (A.I.A., 2004). To appreciate this
concept, it is important to understand the journeys that patients make through the department.
Patient environment can best be studied from the ordinary experience. Physical experience
can be affected by the way in which spaces are connected, the changes of direction imposed
by the circulation system, the creation of room sequences, the distribution of branching
points, the availability of alternative routes, and the relations of visibility between and across
spaces (Peponis and Zimring, 1996). Studies show that hospital design coupled with walking
distances and common journeys affects access to every department (Wanyenze et al., 2010),
with a direct impact on the movement of patients, staff, and supplies (HFM, 2011).
Therefore, controlling movement in terms of; the number of changes in direction needed to
access different service points from the main entrance, the distance and number pit stops
(treatment rooms), would ensure less use of time on walking to locate service points.
Therefore, physical accessibility is an important factor for optimizing patient flow; and to
achieve operational efficiency.

4. Emergence of bottlenecks in Outpatient departments

Patients are attended to in various units within the hospital system but almost invariably a
high percentage of out-patients visit the hospital pharmacy unit for their drug needs
(Margaret and Wilson, 2003). Most patients follow a single file from registration to
examination but as soon as they leave the doctors‟ consulting clinics or examination room,
they are either sent back and forth for further investigation to the laboratory or radiology
units at various times. This generates a random arrival rate at the pharmacy, where the
dispensing activities take place sequentially (Margaret and Wilson, 2003). Queues form when
the rate of patient arrival at the any service point is greater than the service rate. According to
Wanyenze et al. (2010) a number of factors can influence efficiency and the emergence of
bottlenecks in health care operations. These factors include the volume of patients seen on the
daily basis, the types of patient seen in terms of stage of care or illness, clinic policies on
frequency of patient visits, the type of provider who they should see, the size and
composition of the providers and the staffing model. Other factors identified by Marjorie,
(2008) include:

1. High Workload: If staffs are overworked, then patients have to wait longer as staffs have
too many patients to attend to. This can be solved by decreasing service times (if they are too

23
long); or by providing more staff if service times are appropriate or low; or by shifting staff
from facilities with a low workload.

2. Patients turn up in batches: If many patients arrive at the same time then most of these
patients would have to wait a long time as the staff member would be busy seeing the patients
who were first in the batch and the rest would be waiting. So if 20 Patients arrive at the same
time then the first patient would wait zero minutes if the health centre were empty and the
second patient would wait for the time it took the staff to see the first patient (let say 7
minutes), but the 20th patient would have to wait for the other nineteen to be seen, which
would be 19 times 7 minutes or a wait of 103 minutes. A Big Batch is defined as twice as
many patients arriving in a time-period than can be seen in that time-period.

3. Lack of efficiency: Patients may not effectively be attended to because much as staff
members are present at the service point they are busy with something else; such as
administrative work, preparation or teaching.

4. A logistical problem: Patients may be waiting to be seen and staff is available to see
patients but due to a lack of equipment, rooms or other logistical needs, staff is unable to
attend to the patients. .

5. Flow problems: Staff is available to see patients and patients are at the facility but they are
being delayed at some other service point. There was staff present but no patients, however,
patients are waiting long at a prior service point.

6. Queuing problems: This occurs when patients are attended to by staff in an illogical
order, i.e. the patients are not attended to in the order that they arrive at the service point. This
means that those who arrive first are not seen first, but are made to wait while others are seen
before them. Illogical queuing (jump queue) has a large effect on individual patient waiting
times.

2.3.3. Queuing System Terminologies and Notations

Queuing theory is a mathematical theory and its own standard terminologies and notations.
Few of the basic terminology and notations used in queuing model that are relevant in this
study are enumerated below;

λ= Average (mean) arrival rate i.e. the rate of arrivals of patients/customers at a system

24
µ= Average (mean) service rate i.e. the rate at which customers/patient could be served

= Expected inter arrival time

= Expected service time

= system utilization factor, where s is the number of servers. The formula is usually
denoted by e or rho. e or rho represents the fraction of the system’s service capacity
(sµ) that is being utilized in the average by arriving customers/patients (λ) (Hiller and
Lieberman, 2001).

Lq = Average number of customers waiting for service = =

Wq = Average number of customers in the system (those waiting and receiving service)
= or

Lq = Average time customers spent in the queue =

Ws = Average time customers spent in the system = or

Po = probability of zero customers in the system

Po = 1 – or 1 – p

Po = probability of exactly n units or customers in the system

P(x=n) = 1 - ()2 = (1 – p )pn

Probability of more than n units in the system = pn

Expected Service Cost E(Sc)= S.Cs

Where; S= Number of servers

Cs= service cost for each server

Expected Waiting Cost in the system E(Wc)

E(Wc) = (.Ws) Cw Where

=Number of arrivals

Ws= average time a client spends in the system

25
Cw= Opportunity cost of waiting by clients

Expected Total Cost, E(Tc) = E(Sc)+ E(Wc)

= S.Cs+ (.Ws) Cw

2.3.4 Cost Analysis As Management Tools

Operational research has also been employed in planning resource allocation. In general, the
demand for and cost for better healthcare increases at a faster rate than the allocation of
clinic resources such as healthcare staff and space. Healthcare services frequently find it
difficult to acquire more resources to cope with rising cost. For this reason, resource
allocation in healthcare planning is crucial to maintaining quality health services.
To plan resource allocation efficiently, the healthcare community has used simulation
modelling as an analytical tool (Jun et al,1999). Careful staff planning enables optimum
medical staff utilization for economic operation.
Simulation helps outpatient clinic management to make better decisions about resource
allocation. Better resource allocation improves financial efficiency as well as patients and
staffing satisfaction resulting in overall increase in outpatient clinic efficiency.
In both developed and developing countries, hospitals are seen as vital and necessary
community resources that should be managed for the benefit of the community (WHO 1996).
As such, hospital management has a responsibility to the community to provide health care
services that the community needs at an acceptable level of quality and at the list possible
cost.

Cost analysis is a technique for allocating direct and indirect costs. They are also means of
manipulating or rearranging the data of information in existing accounts in other to obtain the
cost of services rendered by the hospital. As financial management techniques, cost-finding
and cost analysis helps to furnish the necessary data for making more informed decisions on
operations and infrastructure investments. If structured accurately, cost data can provide
information on operational performance by cost centre. This information can be compared to
budgeted performance expectations in other to identify problem areas that requires immediate
attention. Moreover, knowledge of costs (both unit and total) can assist in planning of future
budgets and in establishing a schedule of charges for patient services. A hospital cannot set
rates and charges that are realistically related to costs unless the cost finding system
accurately allocates both direct and indirect costs to the appropriate cost centre.

26
There are two basic costs considered in the outpatient setting viz
1. Waiting cost –which includes loss of customers as some patients might not be willing to
wait for service and may decide to competing organization, cost due to delay in care or the
value of patient's time (opportunity cost) and decreased patients' satisfaction and quality of
care.
2. Service cost— Cost of providing services. This includes salaries paid to employees and
servers and cost of waiting space, facilities, equipment and supplies. When considering
improvements services the health care manager weighs the cost of providing a given level of
service against the potential cost of having patients waiting for service. The goal of queueing
system is therefore to minimize the total cost of the system (Kemte et al, 2012).

Economic analysis of these co-steward helps the management to make a trade off between the
increased costs of providing better service and the decreased waiting costs of customers
derived from providing that service.

2..4. EMPIRICAL STUDIES

Nonvigon (2010) studied treatment choices for fever in children under five years (5 years
below) in rural Ghana and found that longer waiting and treatment times encourage people to
use self-medication and over the counter providers compared to public and private holders.
Outpatient scheduling involves making patient’s appointments for an outpatient clinic or
general practitioner, and can be compared to scheduling an appointment with a hairdresser or
bank office (Nonvigonet al., 2010).

Blundell and Windmeijer (2000) used differences in average waiting times to identify
determinants of demand for health services in the United Kingdom. A framework of
equilibrium waiting time was developed which relaxed the full equilibrium assumptions by
selecting areas with shorter waiting times to estimate a semi – parametric selection model.
The essence of using areas with relatively shorter waiting times was to capture demand when
the time costs of waiting are low, since at longer waiting times, waiting time variable is likely
to interact in a complicated way with needs for care variable. Determinants of supply were
used as instruments for the endogeneity of waiting times. The results of the study showed that
long waiting times significantly influence demand, and cause demand to fall by acting as the
hassle cost constraining demand whist low waiting time do not influence demand (Blundell
and Windmeijer 2000).

27
Besley, Hall, and Preston (BHP) (1999) estimated a model of the demand for private health
care in Britain as a function of regional waiting time and found that, increases in waiting time
for public health care causes people to shift demand away from the public sector and
increased demand for private health care where waiting time was low. The results of the
study indicated that the demand for private health care increased by 2% as the waiting list
increases. This finding has been interpreted as indicating that the demand for private
treatment is responsive to the quality of public health care as the long term waiting list served
as an indirect measure of quality of care that provide the incentive to demand alternative care.

The results of BHP has been used to support arguments for subsidizing Private Health
Insurance (PHI) in order to shift the health care burden to the private sector and reduce public
hospital waiting times (Siciliani& Hurst, 2003, 2005). Between 1997 and 2000, the
Australian government embraced this strategy to reduce public hospitals‘ waiting times
(Willcox et al., 2007; Duckett 2005).

BHP‘s analysis was replicated in 2010 by the Centre for Health Economics Research and
Evaluation using Australian data and the result was found consistent with BHP‘s. Long
waiting time significantly increased private insurance demand as people reduced demand for
public health care associated with long waiting times (Martin & Smith, 1999).

King and Mossialos (2005) updated the BHP analysis using 1997–1999 NHI data in the UK.
They ensured long waiting time using the proportion of patients waiting over 6 months for an
inpatient stay. They found that long waiting time influences individually-purchased health
insurance decisions but not employer-financed insurance decisions. They found that a 1%
increase in waiting time was associated with a 4% increase in the odds-ratio of insurance
purchase for private health care.

Using data from the Medicare Current Beneficiary Survey and the Department of Veterans
(VA) Affairs in America, Pizer and Prentice (2010) estimated models to investigate the
impact of outpatient waiting times on insurance choice between VA (with low cost and high
waits) and Medicare (higher cost, low waits). The results show that higher VA waiting times
causes demand for Medicare-financed services to increase with an elasticity of 0.4.

28
 CHAPTER THREE

RESEARCH METHODOLOGY

3.0 Introduction

Research methodology is a way to systematically solve the research problem. It may be

understood as the science of studying how research is done. It refers to the various
procedures, methods and instrumentation, which data are sourced, specified, defined,
collected, processed and analyzed. It provides scaffolding for the validation, proper
interpretation and analysis of research data. It treats issues on the source of data, target
population, sampling in terms of research techniques, research population and sample.

This chapter will be discussing the study under the following headings: Research design,
population of the study, sample size and sampling technique, data collection instrument,
reliability and validity of instruments, data collection procedure, method of data analysis.

3.1. RESEARCH DESIGN

Research design is the process of identifying variables and their relationship to one another.
This study adopted descriptive survey design and observational study approach. The research
approach was purely quantitative with a questionnaire and observational survey method.

3.2. BACKGROUND OF STUDY AREA

The Lagos University Teaching Hospital (LUTH) and the medical school grew out of a
decision of the government of the Nigerian federation, April, 1961. LUTH was established
with a bed capacity of 330 at inception. Thereafter, the bed strength was increased to 761. It
was established with the objectives of excellent services of international standard in patient
care training and research. Admission of patients started in 1962. It was decided that the
teaching hospital and medical school should run on the principle of integrating as much as
possible pre-clinical and clinical teaching.

Despite numerous financial difficulties, aging equipment, irregular or non-continuity in

service due to regular national strike actions by various national health professionals, LUTH
is one of the best teaching /specialist hospital in the country with a high concentration of

29
skilled medical and paramedical staff in different areas of medicine. The hospital is
designated as a center of excellence in specialized areas of medicine such as; Neurosurgery,
Haemo-dialysis, cancer treatment, eye treatment, urology, pediatrics surgery, maternal health
etc.

St. Nicholas Hospital is a private hospital located in Lagos Island in Lagos, Nigeria. It was
founded in 1968 by Moses Majekodunmi. The hospital is in a building of the same name
located at 57 Campbell Street near Catholic Mission Street. It has other facilities at different
locations in Nigeria. Their other locations are: St. Nicholas Hospital, Maryland, St. Nicholas
Clinics, Lekki Free Trade Zone, St. Nicholas Clinics, 7b Etim Inyang Street, Victoria Island.

The population under study for this research will consist of the entire patients of Lagos
university teaching hospital and St. Nicholas hospital during the period of this study

St. Nicholas is a leading multi-specialty tertiary care providing hospital in Nigeria, providing
healthcare services to all the patients in its outpatient, inpatient and emergency care facilities.

The hospital offers impeccable clinical care in its state-of-the-art facility with contemporary
infrastructure and a team of highly trained medical professionals.

St. Nicholas Hospital being a forerunner healthcare centre is renowned for its achievements
like being the first private hospital to establish a dialysis and kidney transplant unit in Africa.
Also recognized for performing first pediatric kidney transplant in West Africa.

The hospital takes pride in proclaiming that the Transplant center has conducted 160
successful kidney transplant and dialysis for over 3724 patients.

3.3 POPULATION OF THE STUDY

The population under study for this research consist of the entire patients attending general
outpatient clinic of Lagos university teaching hospital and St. Nicholas hospital as well as
healthcare workers of GOPD in these healthcare institutions during the period of this study

30
3.4 SAMPLE SIZE DETERMINATION

The Cochran formula with a known population size and population proportion below was
used to calculate sample size of patients in both facilities.

n= p(1-p)
———————
d2 P(1-p)
— +
Z2 N

Where

n= sample size

N= population size

d= Acceptable sampling error (5%)

P= Assumed Population proportion of patient experiencing longer waiting time(90%)

Z= Z value at significance level/reliability level (95%,0.05), Z=1.96

SNH Sample size

n = 0.9 (1-0.9)
0.052 0.9 (1-0.9)
1.962 + 2000

n= 0.09
0.0006957705
n = 129

LUTH SAMPLE SIZE

= 0.9 (1-0.9)
0.052
1.962
+ 0.9 (1-0.9)
308

n= 0.09

0.0008174371667

n = 95

31
3.5 SAMPLE AND SAMPLING TECHNIQUE

In this type of research the entire population cannot be measured so a sample has to be drawn
that is, a small part has to be selected from the total population. A simple random probability
sampling method was used to select 129 respondents as sample size for SNH and 95
respondents for LUTH. While a quota non probability sampling method was used to select 20
staff from each of the study units

3.6 DATA COLLECTION INSTRUMENTS

The research instruments that was adopted in this research are; (a) a well-structured
questionnaire which was used to obtain primary information concerning overcrowding, its
effects and actions to be taken to manage such situation. The questionnaire contained
questions that relate to patients’ routings in outpatient department. (b) observation; the
researcher observed the patient routings and obtain the waiting time and service time of each
patient when they visit the outpatient department of the research areas, as well as patients’
movement within the nurses’ station , consulting room and pharmacy station was observed.

3.7 RELIABILITY AND VALIDITY OF INSTRUMENTS

The content validity of the instruments was ascertained by the researcher's supervisor in
school of health information management LUTH who ensured that questionnaire items are
structured in such a way that the variables in the study are well covered. All the corrections
were effected to make the items valid.
To ensure outright reliability of the instrument, the instrument was subjected to test and retest
reliability test so that the result can show a good internal consistency.

3.8 DATA COLLECTION PROCEDURE

The questionnaires were administered directly to the respondents by the researcher. The total
number of two hundred and twenty four(224) copies of questionnaires for both study area
were distributed to the respondents. Instructions was given on how to fill the questionnaire
and they were assured of confidentiality of their responses. Completed copies of
questionnaire was collected immediately after filling from the respondents for analysis.
Observations on patient's arrival time and length of stay was recorded into the patient-time
flow chart designed by the researcher.

32
3.9 METHODS OF DATA ANALYSIS
For the purpose of this study and to achieve accuracy in processing data collected, the use of
computer aided statistical package for social science (SPSS) was engaged. The data obtained
from the questionnaire were edited and subjected to Descriptive and inferential Statistical
Data Analysis. Statistical analytical techniques used in this research work include frequency
distribution table, simple percentage (%) coupled with write ups for proper interpretations.
Also, the patient-time flow chart was subjected to analysis using queuing network model.

3.10 LIMITATION(s) TO THE STUDY

33
 CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND INTERPRETATION

4.1 introduction

This chapter contains the findings obtained from the field survey as well as analysis of the

outpatient departments queueing model.

A total number of 95(100%) questionnaires(which was the sample size) were administered at

LUTH with all retrieved and subjected to analysis. Thus, 75(58%)questionnaires were

administered, retrieved and analyzed from a total sample size of 129 at SNH the total

percentage of response and retrieval was 76%. These analysis were carried out in order to

have insight information about sources of stress on hospital GOPD, GOPD staff and patient

perception about queue, possible causes, and the effects hospital services delay has on them,

how to improve on delay, how hospitals manage patient flow in GOPD, how hospital

coordinate care activities.

Descriptive analysis

Table 4.1 shows the general profile of respondents in the study sample.

Patients related variables for public and private health facility

VARIABLES L U T H S N H
G e n d e r

Male 37(39%) 35(47%)

Female 58(61%) 40(53%)
Age(years)
10-20 9(9%) —
21-30 30(32%) 23(31%)
31-40 35(37%) 32(43%)
40> 21(22%) 20(27%)

34
R e l i g i o n

Islam 27(28%) 24(32%)

Christian 68(72%) 52(69%)

Traditional — —

Others — 1(1%)
Occupation

student 25(26%) —

Civil servant 30(32%) 19(25%)

Self employed 20(21%) 13(17%)

Business/trader 10(11%) 25(33%)

Unemployed — —

Others 10(11%) 18(24%)

T r i b e

Igbo 38(40%) 16(21%)

Yoruba 45(47%) 29(39%)

Hausa — —

Others 12(13%) 30(40%)

Educational status

Non-formal 15(16%) —

Primary — —

Secondary 25(26%) 30(40%)

Tertiary 55(58%) 45(60%)

35
Hospital visitation frequency

daily — —

weekly 13(14%) 10(13%)

monthly 22(23%) 16(21%)

rarely 10(11%) 4(5%)

Only when sick 21(22%) 20(27%)

only on appointment 29(31%) 25(33%)

Can you afford to wait?

Yes 80(84%) 58(77%)

No 15(16%) 17(23%)
How do you queue?

Standing 10(11%) —

Sitting 80(84%) 75(100%)

Taking number 5(5%) 75(100%)

No queue at all — —

O pi ni on about queue

short 6(6%) 32(43%)

Long 30(32%) 10(13%)

too long 26(27%) 11(15%)

manageable 22(23%) 22(29%)

No queue 1(1%) —

Patients satisfaction

Not satisfied 20(21%) 12(16%)

Highly satisfied 30(32%) 43(57%)

Manageable 45(47%) 20(27%)

36
 Causes of delay

shortage of staff 50(53%) 52(69%)

poor staff attitude 32(34%) 7(9%)

too many patients 68(72%) 68(91%)

Lack of equipment and facilities 25(26%) 5(7%)

Poor planning 73(77%) 10(13%)

inadequate power supply 2(2%) —

Disorderliness on the part of patient 15(16%) —

Does coming to this hospital affect your business /income?

Yes 70(74%) 54(22%)

No 25(26%) 21(28%)
How does it affect your business /incom e

Better health to work 45(47%) 48(64%)

Loss of working hours 65(68%) 60(80%)

loss of business 25(26%) 8(11%)

More expenses 50(53%) 32(43%)

Delay in other activities scheduled 5(5%) 1(1%)

Income per day(#)

None 15(16%) —

500-3000 20(21%) 10(13%)

4000-7000 15(16%) 31(41%)

8000-15000 38(40%) 22(29%)

16000> 7(7%) 12(16%)

Effects of prolonged waiting time

Loss of life 20(21%) 3(4%)

source of dissatisfaction 50(53%) 52(69%)

37
Disappointment in keeping to appointments schedule 75(79%) 40(53%)

Worsening of ill-health condition 48(51%) 31(41%)

Stress for patients 80(84%) 70(93%)

How waiting time can be reduced

Increase staff strength 81(85%) 62(83%)

Introduce shift 15(16%) 4(5%)

Increase service points 75(79%) 34(45%)

I don't know 15(16%) 18(24%)

Transportation cost (to and fro)

#0.00 5(5%) 11(15%)

#100-1000 30(32%) 14(19%)

#1100-3000 42(44%) 27(36%)

#3100-5000 10(11%) 18(24%)

#5100-7000 5(5%) –

#7100-9000 3(3%) —

#9100> – —

REASONS PROFFERED BY RESPONDENTS FOR EITHER STAYING IN QUEUE

OR LEAVING QUEUE IN LUTH GOPD

 Because I need medical attention

 Because I desire the best treatment for my ailment

 Because LUTH services are thorough

 it depends on the severity of the sickness

 Because it is inconvenient and stressful

 Because I do not want to waste my transportation fee

38
REASONS PROFFERED BY RESPONDENTS FOR EITHER STAYING IN QUEUE

OR LEAVING IN QUEUE IN SNH GOPD

 I have to comply with admin processes

 Because I need medical attention.

 My job does not permit spending so much time outside my working hours

REASONS PROFFERED BY RESPONDENTS FOR EITHER BEING HIGHLY

SATISFIED, NOT SATISFIED OR MANAGEABLE IN LUTH GOPD

 They have the best hands and services

 Dedication of workers despite huge work load

 Highly organized

 Because there is no discrimination

 Because of the efficacy of prescribed drugs

 Sometimes stressful

 Too many patients to attend to

 It takes too long to see a doctor

 Need for improvement, every life matters

 Sometimes I come to the hospital without been attended to

 Mismanagement

 Because it's better than some hospital

 Been tossed around despite being sick

 more hands are needed

39
REASONS PROFFERED BY RESPONDENTS FOR EITHER BEING HIGHLY

SATISFIED, NOT SATISFIED OR MANAGEABLE IN SNH GOPD

 The hospital is very good when I come for urgency

 I have a good / quality medical attention experience

 Care givers are polite and give in their best to cope with number of patient.

 Though there's a queue, it's moving and better than what we have in government

hospitals

 Lack of servers especially doctors

 It's a private hospital, I think I should not queue for too long

 Satisfied but not greatly overwhelmed.

SUGGESTIONS BY RESPONDENTS ON HOW WAITING TIME CAN BE

REDUCED AT LUTH GOPD

 Adoption of EHR

 purchase of more equipments

 Improve staff efficiency

 Employment of young and agile staff

RESPONDENT OTHER REASON FOR CAUSES OF DELAY AT LUTH GOPD

 Payment system delay.

RESPONDENT OTHER REASON FOR CAUSES OF DELAY AT SNH GOPD

 HMO approval delay

 Doctors spends too much time with patients

40
RESPONDENT OTHER OPINION ON EFFECT OF PROLONGED WAITING TIME

AT LUTH GOPD

 change to other hospital.

Table 4.2
Both facilities staff bio demographic data and opinion about queue in their various facility.

Variables L U T H S N H

GENDER

Male 9(45%) 6(30%)

female 11(55%) 14(70%)

AGE

21-25 2(10%) 7(35%)

26-30 2(10%) 4(20%)

31-35 4(20%) 3(15%)

36-40 5(25%) 4(20%)

41-45 2(10%) —

46> 5(25%) 2(10%)

RELIGION

islam 5(25%) —

Christian 15(75%) 20(100%)

Traditional — —

Others — —

M A R I T A L S T A T U S

Single 4(20%) 9(45%)

41
Married 16(80%) 6(55%)

Widow/widower — —

Divorced — —

EDUCATIONAL QUALIFICATION

ND/TECH 1(5%) 1(5%)

HND 1(5%) 2(10%)

BSC/B.pharm 8(40%) 12(60%)

MBBS 9(45%) 4(20%)

M. Sc 1(5%) 1(5%)

PhD — –

P R O F E S S I O N

HIM 1(5%) 2(10%)

medicine 9(45%) 4(20%)

Pharmacy 4(20%) 4(20%)

Nurse 4(20%) 4(20%)

MLS — 2(10%)

Client Service — 2(10%)

Radiology — 2(10%)

Accountant 1(5%) —

YEARS SPENT IN SERVICE

1-5 4(20%) 15(75%)

6-10 4(20%) 3(15%)

11-15 3(15%) —

16-20 4(20%) 1(5%)

21> 5(25%) 1(5%)

Do you think there is queue in this hospital ?

Yes 18(90%) 19(95%)

No 2(10%) 1(5%)

42
Opinion about queue

short 2(10%) 7(35%)

Long 7(35%) 4(20%)

too long 3(15%) —

manageable 8(40%) 8(40%)

No queue — —

Causes of delay

shortage of staff 18(90%) 15(75%)

poor staff attitude 6(30%) 2(10%)

too many patients 12(60%) 6(30%)

Lack of equipment and facilities 17(85%) 1(5%)

Poor planning 8(40%) 2(10%)

inadequate power supply — —

Disorderliness on the part of patient 10(50%) 3(15%)

How waiting time can be reduced

Increase staff strength 18(90%) 14(70%)

Introduce shift 10(50%) 10(50%)

Increase service points 7(35%) –

I don't know _ —

Job satisfaction with working conditions

Not satisfied 9(45%) —

Moderately satisfied 7(35%) 9(45%)

Satisfied 4(20%) 10(50%)

Highly satisfied — 1(5%)

43
SUGGESTIONS BY RESPONDENTS ON HOW WAITING TIME CAN BE

REDUCED AT SNH GOPD

 establish and enforce guidelines for HMOs operation.

 Patients should comply with various service point rules and guidance

 Appointment based visit

 Create more effective servers to improve access to patient data.

RESPONDENT OTHER REASON FOR CAUSES OF DELAY AT SNH GOPD

 HMO approval delay

 Laboratory investigation result delay

 internet/server down time.

Table 4.1 shows a breakdown of patient's related variables while table 4.2 shows staff related

variables according to the chosen health facility (public and private). The table indicates that

the respondents in the study sample were heterogeneous on a variety of socio-demographic

and health related variables.

Queueing Analysis of the Case Hospitals

The patients' data obtained from the hospital out patient department were used to analyze

arrival pattern of patient's and average arrival per day. Also, patients' activities were used to

quantify patient flow in which the patients routings, length of stay and occupancy ratio of

GOPD were determined.

44
4.3 Arrivals

The queuing model adopted assumes that daily admission rates (average arrivals) follow a

Poisson distribution (coefficient of variation =1) in consonance with some studies which

have found out that the arrival rate of patients to out patient department follows a Poisson

distribution (McManus et al, 2004: Green, 2002: Arnoud, et al, 2007). Although the case

hospitals confirmed that they experience overcrowding most times depending on their clinic

days and patients in flow, in such situation some patients may leave the facility before being

served.

Available data shows that the total number of arrival for a month fluctuate around 450 and

800 for LUTH GOPD, this is so because of the incidence of COVID19 in 2020 being an

isolation and treatment center for COVID19 LUTH has to control the in flow of patients.

SNH GOPD number of arrival for a month fluctuate around 1000 and 2000.

The arrival data were considered over period of 8hours i.e 8am-4pm for both facilities.

4.4 Impact Of Fluctuation in Arrival and Variation in Length of Stay on Capacity

Management

This study adopts M/M/Φ in kendall's notation (Young, 1965) to analyze the impact of

fluctuations on arrivals. The queuing model assumed Poisson arrivals, exponential length of

stay. The aim of this model is to determine the resources required to accommodate all

arrivals. This is necessary because the main goal of the hospital management is to provide an

admission guarantee for all arriving patients. However, in reality, hospitals operates with

fixed number of resources (both human and material resources) and its effects are

overcrowding, bed blocking, patients turn away and/or denial of services.

45
The steady state analysis of GOPD of both case study using the M/M/Φ to model is presented

in Table 4.3—4.12, this model helps to determine the efficiency and effectiveness of the

selected units.

TABLE 4.3: TIME STUDY ANALYSIS OF PROCESSING AND DELAY

COMPONENTS FOR GOPD /FAMILY

Service location Mean processing Time + SEM(minutes) Mean delay time +SEM(minutes)

Nurse's station 17.83(31.36%) 39.03(68.64%)

Consulting roo m 74.51(41.2%) 106.27(58.8%)

Pharmacy station 15.37(33.13%) 31.02(66.87%)

Total 108.08 (37.48%) 180.27(62.52%)

TABLE 4.4 TIME STUDY ANALYSIS OF PROCESSING AND DELAY

COMPONENTS FOR GOPD SNH

Service location Mean processing Time + SEM(minutes) Mean delay time+SEM(minutes)

Nurse's station 11.60 30.03

(28%) (72%)

Consulting room 113.30 87.30

(56%) (44%)

Pharmacy station 11.92 82.00

(13%) (87%)

T o t a l 136.82 200.15
(41%) (59%)

Table 4.5 NURSE'S STATION

46
Performance measures LUTH SNH

µ 0.056/min 0.086mins

λ 0.054/min 0.071mins

e 0 . 9 6 4 0 . 8 2 6

26.78patient s 3.92patients
Lq

Wq 43.82mins 55.07mins

Ls 26.78patients 4.75patients

Ws 45.45mins 66.67mins

ST 18mins 11.6mins

1-e 0.036 0.174

Pr(r>_k) 0.042 0.37

Pr(r>k) 0.8636 0.47

Table 4.6 PHARMACY STATION

Performance measures L U T H S N H
µ 0.065min 0.084min
λ 0.054min 0.071min
e 0 . 8 3 1 0 . 8 4 5

Lq 4.086patients 4.61patients

Wq 75.55mins 65mins

Ls 4.92patients 5.45patients

Ws 90.91mins 76.92mins

ST 15.36mins 11.92mins

1—e 0.169 0.155

47
Pr(r≥4) 0.35 0.30

Pr(r≥4) 0.48 0.85

Table 4.7 Simulating a multi channel service (consultation rooms)

Performance measures L U T H S N H

U. F 0.156 0.877

Cp 1.872patients 7.893patients

Lq 0.00000013patients 7.31patients

Ls 1.87 15.20patients

Wq 0.000000066min 102.46mins

Ws 76.92mins 213.57mins

Table 4.8; cost of providing services

Salary(Service cost) per hour = monthly salary

————————
30.4375×24

Providers of care
Cost of service provision per hour

LUTH SNH

Nurses #994.69 #924.02

Doctors #22,439.53 #3,080.08

Pharmacists #1,263.15 #9,774.13

Total #24,697.37 #13,778.23

48
 Table 4.9 ; Cost Of Delay

To determine the hourly income of patients who are getting services from both facilities; the

waiting cost of a patient is calculated by using the per capital annual income of Nigerians.

This income is Converted into hourly income as a man works 23days a month and 8hours a

day.

GDP per Capital Income for Nigeria(Year 2021) = USD 2085.

= #890,149.05 per year

= #403.15 per hour

LUTH λ = 0.054/min = 3.21/hour

SNH λ = 0.071/min = 4.26/hour

Categories of patients cost at each point of care Cost of Delay per hour
LUTH SNH

Nurses' station #983.52 #1,906.34

Consulting room #1,659.05 #6,114.01

Pharmacists' station #1,960.79 #2,198.29

Total #4,603.36 #10,218.64

Table 4.10; Expected Total cost for LUTH

Service points Total hourly Service Cost E(SC) Arrival rate, λ Expected Waiting Time in System (Ws) in hour Total hourly Waiting Cost E(WC)= Total Expected Cost per hour E(TC)=
(per hour) CW(λWs) E(SC)+E(WC)

49
Nurses' #994.69 3.21 8.33 #983.52 #1,978.21
station

Consulting room #22,439.53 3.21 1.282 #1,659.05 #24,098.58

Pharmacists' station #1,263.15 3.21 1.51 1,960.79 #3,223.94

Table 4.11: Expected Total cost for SNH

Service points Total hourly Service Cost E(SC) Arrival rate, λ Expected Waiting Time in System (Ws) in hour Total hourly Waiting Cost E(WC)= Total Expected Cost per hour E(TC)=
(per hour) CW(λWs) E(SC)
+E(WC)

Nurses' station #924.02 4.26 1.1111 #1,906.34 #2,830.36

Consulting room #3,080.08 4.26 15.51 #6,114.01 #9,194.09

Pharmacists' station #9,774.13 4.26 1.28 #2,198.29 #11,972.42

Table 4.12; Total cost in the system for both facilities

TC= TC1+TC2+TC3

facilit y L U T H SNH

Costs in naira 1,978.21+24,098.58+3,223.94 2,830.36+9,194.09+11,972.42

Total #29,300.73 #23,996.87

4.3 HYPOTHESIS TESTING

Table 4.13; RELATIONSHIP BETWEEN FACILITY TYPE AND

50
WAITING IN THE SYSTEM

Ho; there is no significant difference between waiting in the system for

both facilities.

Hi; There is a significant difference between waiting in the system for

both facilities.

Waiting in the system

Facility type
Public Private Total

Nurses 45.45mi 66.67min 112.12

n min

Doctors 76.92 213.57min 290.49

Pharmacists 90.91 76.92min 167.83

T o t a l 213.28 357.16 570.44

Oij Eij Oij–Eij (oij—Eij) 2 (Oij—Eij) 2/Eij

45.45 41.92 3.53 12.46 0.30

66.67 70.20 -3.53 12.46 0.18

76.92 386.28 -31.69 1004.26 9 . 2 5

213.57 181.88 31.69 1004.26 5.52

90.91 62.75 28.16 792.99 12.64

76.92 105.08 -28.16 792.99 7.55

51
 35.44

At α=0.05, degree of freedom =2

X2 tab=5.991

Since X2cal >X2tab, Ho is rejected.

Thus Hi is accepted.

This implies that there is a significant relationship between waiting in the system in both

facilities.

Table 4.14; RELATIONSHIP BETWEEN FACILITY TYPE AND

LEVEL OF SATISFACTION WITH SERVICE DELIVERY .

Ho; There is no significant difference between facility type and level of satisfaction with

service delivery.

Hi; There is a significant difference between facility type and level of satisfaction with

service delivery.

Level of satisfaction
Facility type
P u b l i c Private Total
Highly satisfied
30 43 73
Manageable
45 20 65
Not satisfied
20 12 32

TOTAL 95 75 170

Oij Eij Oij—Eij (Oij—Eij)2 (Oij—Eij) 2/Eij

30 40.79 -10.79 116.42 2.85

52
43 32.21 10.79 116.42 3.61

45 36.32 8.68 75.34 2.07

20 28.68 -8.67 75.34 2.63

20 17.88 2.12 4.49 0.25

12 14.12 -2.12 4.49 0.32

11.73

At a=0.05, degree of freedom =2

X2tab=5.991.

Since X2cal>X2tab, Ho is rejected.

Thus Hi is accepted.

This implies that there is a significant relationship between waiting in the system for both

facilities.

4.4 DISCUSSION OF FINDINGS

The results of this study in table 4.3 and 4.4 shows a total waiting time of 288.35min with a

processing time of 108.08min and a delay component accounted for 180.27min in LUTH and

a total waiting time of 336.97min with a processing time of 136.82min and delay component

of 200.15min in SNH. Table 4.5 shows LUTH and SNH GOPD analysis of nurses' station

Where patient arrival rate (lambda) = 0.054 patients per min and 0.071min for LUTH and

SNH respectively, mean service rate of 0.056min in LUTH and 0.086min in SNH. The

system performance parameters for LUTH are as follow; e =0.964 which implies the

probability that the system is busy, Lq= 26.78patients which means there are approximately

27patients waiting in the queue, Wq= 43.82min which indicate that a patient spends

43.82min waiting in the queue, Ls=27 patients which means there are averagely 27 patients

at any point in time undergoing treatment, Ws= 45.45min this says that a patient spends

53
45.45min waiting in the system, ST= 18min which implies that 18 min is the service time for

each patient, 1-e= 0.036 this says that 0.036 is the probability of a patient not queuing on

arrival, Pr(r4) = 0.042 describing the probability that an arriving patient will meet four

patient in the system, Pr(r≥4)= 0.864 implies the probability that an arriving patient will meet

more than four patient in the system.

The system performance parameters for SNH are as follow; e =0.83 which implies the

probability that the system is busy, Lq= 3.91 patients which means there are approximately 4

patients waiting in the queue, Wq= 55.07 min which indicate that a patient spends 55.07min

waiting in the queue, Ls= 4.75 patients which means there are averagely 5 patients at any

point in time undergoing treatment, Ws= 66.67min this says that a patient spends 66.67min

waiting in the system, ST= 11.6min which implies that 11.6min is the service time for each

patient, 1-e= 0.174 this says that 0.174 is the probability of a patient not queuing on arrival,

Pr(r≥4) = 0.37 describing the probability that an arriving patient will meet four patient in the

system, Pr(r≥4)= 0.47 implies the probability that an arriving patient will meet more than

four patient in the system.

Table 4.6 shows the performance measures for pharmacy station in LUTH and SNH. For

LUTH; lambda(λ)= 0.054 and miu(u)=0.065, e =0.831 which implies the probability that the

system is busy, Lq=4.086 patients which means there are approximately 4 patients waiting in

the queue, Wq= 75.55min which indicate that a patient spends 75.55min waiting in the

queue, Ls= 4.92 patients which means there are averagely 5 patients at any point in time

undergoing treatment, Ws= 90.91min this says that a patient spends 90.91min waiting in the

system, ST= 15.36min which is the service time for each patient, 1-e= 0.169 this says that

0.169 is the probability of a patient not queuing on arrival, Pr(r≥4) = 0.53 describing the

probability that an arriving patient will meet four patient in the system, Pr(r≥4)= 0.48 implies

the probability that an arriving patient will meet more than four patient in the system.

54
The system performance parameters for SNH are as follow; lambda(λ)= 0.071 and miu(u)=

0.084, e =0.845 which implies the probability that the system is busy, Lq= 4.61 patients

which means there are approximately 4 patients waiting in the queue, Wq= 65min which

indicate that a patient spends 65min waiting in the queue, Ls= 5.45 patients which means

there are averagely 5 patients at any point in time undergoing treatment, Ws= 76.92min this

says that a patient spends 76.92min waiting in the system, ST= 11.92min which implies the

service time for each patient, 1-e= 0.155 this is the probability of a patient not queuing on

arrival, Pr(r≥4) = 0.30 describing the probability that an arriving patient will meet four

patient in the system, Pr(r≥4)= 0.85 implies the probability that an arriving patient will meet

more than four patient in the system.

Table 4.7 reveals the performance measures of Doctors in LUTH and SNH GOPD

For LUTH : lambda(λ)= 0.054 and miu(u)= 0.013, utilization factor (U.F)= 0.156 which

indicate the efficiency in the utilization of resources and that service is provided in a timely

manner, CP= 1.872 patients which is the average number of patient being served, Lq=

0.00000013 patient which are the number of patient waiting in the queue to be served, Ls=

1.87 patient which indicate the number of patient undergoing treatment at a point in time,

Wq= 0.000000066min which indicate the time a patient spends waiting in the queue,Ws=

76.92min which point to the time a patient spends waiting in the system, CP= 12 which is the

number of service points.

System performance for SNH are as follow: lambda(λ)= 0.071 and miu(u)= 0.009, utilization

factor (U.F)= 0.877 which shows the efficiency in the utilization of resources and that service

is provided in a timely manner , CP= 7.893 patients which is the average number of patient

being served, Lq= 7.31 patients which are the number of patient waiting in the queue to be

served, Ls= 15.20 patients which indicate the number of patient undergoing treatment at a

point in time, Wq= 102.46mins which indicate the time a patient spends waiting in the queue,

55
Ws= 213.57mins which point to the time a patient spends waiting in the system, CP= 9

which is the number of service points .Wq and Large for both facilities are like that due to

the fact that 12 and 9 servers were used respectively to analyze the activities at LUTH and

SNH GOPD.

It is important to say at this point that some incomplete information about the exact time of

patient arrival and departure in the consulting Room may affect the estimated patient arrival

rate and service duration

Table 4.8 shows the cost of service provision (providers cost) in LUTH and SNH . This was

derived by multiplying average labour cost per hour by number of server divided by days in a

month multiplied by hours in a day. It cost LUTH #994.69/hour to pay number of nurses at

GOPD, #1,263.15/hour to pay number of pharmacists, #22,439.53/hour to pay doctors.

Likewise in SNH, it cost the hospital #924.02/hour to pay number of nurses at GOPD,

#9,774.13/hour to pay number of pharmacists, #3,080.08/hour to pay number of doctors. An

hour delay of providing services to patients in both facilities lead to loss of service cost paid

to servers by the facilities, whether or not services is provided, the salaries of health care

providers will still be paid which implies that the hospital management suffer loss of

resources when services are not provided on timely basis. The total cost of service provision

is relatively low in SNH compared to LUTH as the result shows total cost of service

provision per hour as; #13,778.23 and #23,797.37 respectively. This is so because SNH is a

private owned establishment whose aim is to make profit as well as maintaining the loyalty

of their clients compared to LUTH a government establishment where bureaucracy and red

tapism are the order of the day.

Table 4.9 reveal the cost of delay(patient cost). This was derived by multiplying the GDP per

capita income of Nigeria converted to hours by arrival rate per hour and hours of waiting in

the system for each facility. Patient waiting cost at nurses station for LUTH and SNH =

56
#983.52 and #1,906.34 respectively, waiting cost per hour for drug dispensary =

1,960.79(LUTH) and #2,198.29(SNH), while waiting cost per hour for consultation =

#1659.05(LUTH) and #6,114.01(SNH). The waiting cost for dispensary and consultation in

SNH is higher than that of LUTH because, SNH utilization factor is higher than that of

LUTH, their service point is smaller than that of LUTH and also some patients decides to

wait for review of an investigation that takes a long time to generate result for some reasons

best known to them. All these add to their waiting time.

Table 4.10 and 4.11 shows the total cost for each faculties (LUTH and SNH) this shows the

total service cost and waiting cost of each unit (nurses, doctors and pharmacists) in both

facilities. While Table 4.12 reveal the overall cost for each facility which include providers

cost and patient cost. LUTH total cost = #29,300.73 while that of SNH = #23,996.87.

57
 CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 Introduction

This chapter is discussed under the following headings:

 Summary

 Conclusion

 Recommendation

5.2 Summary

This work examined the different chapters, with chapter one introducing the background to

the study, statement of problem, objective of the study, research questions, significance of the

study, scope of the study and definition of terms. Chapter two re-appraised past research

work relevant to this topic of discuss in the spectrum of knowledge. Chapter three revealed

methods through which data were gathered and unveiled. Questionnaires was designed in line

with research questions to obtain relevant information as well as a patient time flow chart to

monitor patient's movements . Chapter four unfold presentation and the analysis of the data

gathered through questionnaires and time flow charts. Questionnaires were analyzed by the

58
means of descriptive statistics such as frequency distribution table, and a queuing network

model to analyze patient time flow chart.

The result of findings shows that overcrowding, congestion and delay in service are caused

by too many patients and few medical officers to attend to them especially in LUTH GOPD

nurses and pharmacist unit. This supports the findings of WHO, 2006 statistics on doctor-

patient ratio in Nigeria which was 28 doctors per 100,000 patients. This has a serious

implication on patient flow. The work flow analysis and time study revealed a mean total

patient waiting time of 288.35min with the process component accounting for 108.08min and

delay component accounting for 180.27min in LUTH while we have mean total patient

waiting time of 336.97min with a process component of 136.82 min and 200.15 delay

component in SNH. Total cost of delay for LUTH and SNH are; #4,603.36 and #10,218.64

respectively.

Likewise analysis from patients questionnaires shows that; patients decided not to leave

queue in both facilities because they needed medical attention, majority of the respondent in

LUTH are of the opinion that the queue is long while majority of SNH patients are of the

opinion that the queue is short. According to respondents in LUTH poor planning is the major

caueses of delay while too many patients happens to be the major causes of delay in SNH,

coming to the hospital affects majority of the respondents in both facility in one way or the

order, majority of the respondents in both facility believed stress for patient is the major

effect of prolonged waiting time, patients waiting time can be reduced by increasing staff

strength majorly in both facilities according to respondents. Staff questionnaire analysis also

gave the following results; majority of the respondent in LUTH said the queue in the facility

is too long while most of the staff respondent in SNH believed the queue is manageable, both

facilities experience shortage of staff which happens to be the major cause of delay base in

respondents opinion and the solution proffered was increase in staff strength. Job satisfaction

59
level in LUTH states that majority of the staff are not satisfied while majority of SNH staff

are satisfied.

5.3 Conclusion

The researcher had carefully analyzed the outcomes of this research work"Application of

queuing theory in the determination of health care cost; a comparative study of

providers and patient cost in a public and private hospital" (A case study of Lagos

University teaching hospital and St. Nicholas hospital)

The following conclusions are hereby made;

Patient face delay in LUTH due to inflow of patient, shortage of nursing and pharmacy staff,

HMO approval delay, too long patient consultation, patient having to go outside family

medicine to make photocopies, undergo investigations which usually take a long time

because the patient may have to queue when they get to those points. Not too far from the

scenarios in LUTH, SNH patients experience delay majorly because of HMO approval delay,

inflow of patients, clinic days, server down time, prolong time of some investigation result

generation.

The total service cost for LUTH is greater than that of SNH with a difference of #10,019.14

while facility total cost (patient cost and providers cost) for LUTH as well is greater than that

of SNH with a difference of #5,303.86. Hypotheses testing shows that there is a significant

60
difference between facility type and level of satisfaction with service delivery and also that

there is a significant difference between waiting in the system in both facilities.

5.4 Recommendations

Having carefully conducted this research study, the researcher hereby proffers the following

recommendations:

1. Use of clinical and service performance standards (such as average arrival and length of

stay) to determine appropriate capacity /requirement in a timely fashion otherwise, it will be

impossible to to make any accurate determination of the optimal resource to serve a given

population which may lead to excessive delay for patient.

2. Payment points, investigation (laboratory , radiology) unit should be sited within family

medicine. This will stop the movement of patients outside the hospital department for

payment and examination.

3. Hospital management should conduct cost-benefit and trade-off analyses to identify

opportunities for increased efficiency and effectiveness for both hospitals.

4. Hospital management should liase with various HMOs on prompt approval of their clients

request for medical attention.

5. Upgrading medical equipment and technology to meet international standard.

6. Training of workforce in the context of increasing service quality and human relations.

7. Hospital management and health policy makers should address the issue of inadequate

manpower to improve service delivery. they should know that relationship between size and

quality of service is an important issue in capacity planning.

8. Server down time issue should be addressed.

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 ABSTRACT

This research work examines application of queuing theory in determination of health care
cost; a comparative study of providers' and patients' cost in public and private hospital
(Lagos University teaching hospital and St. Nicholas hospital) . Its objectives include: to
asses patient waiting time, waiting and service cost and to evaluate the effects of queues in
the hospital on the cost of service provision. The research adopted descriptive survey design
whereby research questions were generated and observational study approach in which
observations were made. A well structured questionnaire was established to test for the
variables under study as well as a patient time flow chart which monitored patients' arrival
and departure time at each service points (nurses station ,consulting room and pharmacists
station) .Data obtained from the flow chart was subjected to analysis using a queuing model
that follows a Poisson distribution. A sample size of ninety-five(95) was selected for LUTH
and one hundred and twenty-nine (129) for SNH using a simple random probability sampling
method. While a quota non probability sampling method was used to select twenty (20) staff
from each if the study units. Data generated from the questionnaires was subjected to
analysis via simple percentage. Its findings shows that there is a queue in both facility, poor
planning is the major caueses of delay in LUTH while too many patients happens to be the
major causes of delay in SNH, coming to the hospital affects majority of the respondents in
both facility in one way or the order, patients waiting time can be reduced by increasing staff
strength majorly in both facilities according to respondents The total service cost for LUTH
is greater than that of SNH with a difference of #10,019.14 while facility total cost (patient
cost and providers cost) for LUTH as well is greater than that of LUTH with a difference of
#5,303.86. Hypotheses testing shows that there is a significant difference between facility

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type and level of satisfaction with service delivery and also that there is a significant
difference between waiting in the system in both facilities.
Part of the recommendations given were; Use of clinical and service performance standards
(such as average arrival and length of stay) to determine appropriate capacity /requirement in
a timely fashion, Hospital management should conduct cost-benefit and trade-off analyses to
identify opportunities for increased efficiency and effectiveness for both hospitals, Hospital
management should liase with various HMOs on prompt approval of their clients request for
medical attention,Training of workforce in the context of increasing service quality and
human relations, hospital management and health policy makers should address the issue of
inadequate manpower to improve service delivery.

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