BOOKS OF RtfiDIfGS - PAHO/WHO

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spurred on by conflicting directives, lack of systematic. training
and enforcement, and a system which was difficult to master or
comprehend. Figure II depicts the dynamic feedback process
which led to the degradation of systems and procedures.
Productivity of the clerical staff, measured in terms of patient
visitslclerical position ratio, is shown in Figure III. The ratio
dropped sharply for the appointment-making personnel. In contrast,
the ratio for the other clerical staff categories remained
fairly constant. It is interesting to note that while thc "actual"
system effectiveness was dropping, the perceived effectiveness,
as seen by the physicians, had discontinued its downward trend
and appeared to be improving because of the ability of physicians
to exercise more control over clerical staff as the clinic'E
systems became more decentralized.
A study of the problem was made in early 1972 by a Subcommittee
on Registration and Routing which generated a report.
Another attempt to study the problem was made in late
1973, with the establishment of a Patient Flow Committee. In
January, 1974, this committee established the task force which
was led by the authors of this paper.
Method of study
The aim of this study was to report on the systein description
of the clinic and to provide a set of recommendations. It was
recognized that these were preliminary recommendations and
that more detailed investigation of the problem areas identified
by this study should be undertaken. Specifically, it was felt that
subsequent studies should repeat the activities of this study,
utilize mathematical models, and develop an implementation
scheme (Figure IV).
As shown in Figure IV, this study phase was devoted to learning,
describing and analyzing the clinic as a system. As part of
this phase, a graphical description was obtained by flow chartfng
the various patient flow related processes. Also, hard data were
collected to test various hypotheses which emerged from discussions
with members of the clinic's medical, administrative,
and clerical staffs on patient flow related operations. Future work