Are Your Patients Patiently Waiting?

Co-authors
Rhonda Blender and Cyndi Maxey

ABSTRACT
Patient wait times still exist, and elimination of office wait times still appears to be an important marketing tool. Patients feel increased demands on their time, and if the wait is too long, they may not come back. However, if it is reasonable and handled well, it accumulates with other positive perceptions of service, and patients return. In this article, the authors review the reality of wait times in medical practices today, what dissatisfies patients most, the treatment patients want while waiting, and a checklist of steps to take to reduce wait times in a medical practice.

Text Highlights

1. A study of patient satisfaction data collected at the University of Chicago Hospitals Center For Advanced Medicine concluded that patient rating of the promptness of physician service is directly related to the patient’s report of likelihood to return for follow-up services.
2. Patients seemed to associate long waits most closely with a physician overall negative attitude toward patients.
3. Avoiding contact with patients may only generate additional patient feelings of uncertainty and impatience.
4. An organization needs to look at specific systems/process issues that contribute to wait delays.
5. The top business issue mentioned was consistently long waits.
6. Most patients comment less on the length of the wait than how the wait is handled

An Important Tool
“We offered hot cocoa and we smiled a lot,” admitted the director of a busy clinic in Fort Worth, Texas “…but our sensitive staff was smiling at patients who were still sitting in the hallway waiting to be treated.” (1) Excessive patient wait times still exist, and elimination of office wait times still appears to be an important marketing tool in attracting new and return patients. Patients’ attitudes about waiting reflect the reality that exists for the general population: increased life demands with less time to get it all done has reduced their tolerance for delay. So, if the wait is too long, patients may not come back. However if it is reasonable and handled well, it accumulates with other positive perceptions of service, and patients return.

A study of patient satisfaction data collected at the University of Chicago Hospitals Center For Advanced Medicine concluded that patient rating of the promptness of physician service is directly related to the patient’s report of likelihood to return for follow-up services. The data revealed the following:

• When patients rated promptness of physician service as “excellent,” 98% of patients reported that they would definitely return for additional services, if needed.
• When patients rated promptness of physician service as “very good,” 90% of patients reported that they would definitely return for additional services, if needed.
• When patients rated promptness of physician service as “good,” 83% of patients reported that they would definitely return for additional services, if needed.
• When patients rated promptness of physician service as poor, 68% of patients reported that they would definitely return for additional services, if needed. (2)

The Reality of Wait Times
In the past, patient surveys revealed that many patients perceived waiting several hours in an office as an indicator of a good physician. (3) Today, however, in our time compressed society, patients are less tolerant of long waits. Often, constraints imposed by managed care make the problem worse. A recent one-year study of 2,374 adults by the Harvard School of Public Health showed that sick people who paid less for managed care health insurance waited longer to see their doctors than did fee-for-service patients. The average managed care patient waited an average of 38 minutes to be seen, whereas fee for service patients waited 27 minutes. Physicians who work with managed care systems find themselves facing greater scheduling demands than ever before.

Recent research reveals that long waits continue to be high on patients’ dissatisfaction lists. For example, a study by the American Hospital Association and The Picker Institute to better understand office and clinic patients’ points of view had some interesting results. Focus groups revealed that patients:

• Perceived an increasing trend toward care that was cold and impersonal
• Experienced problems with getting basic information
• Experienced long waits to see their physicians (4)

Patients continue to indicate that they like communication and attention. In another focus group study of patients’ assessment of medical care quality, a quality assurance director of a regional healthcare provider discovered that the most important factors used by patients for evaluating care revolved around the interactions with the physician in the exam room, and the primary issue was communication. Virtually all communication by the physician was appreciated.

Though business issues were of less importance than physician issues with respect to patient perception of quality, the top business issue mentioned was consistently long waits. Patients felt that these doctors were more interested in total billings than in patient care. Patients seemed to associate long waits most closely with a physician overall negative attitude toward patients. Frequently twenty minutes was given as the maximum acceptable time to wait in the waiting room, though some felt that was too long. (5)

Other studies show average acceptable waits to be in the 20-30 minute range. For example, in a recent Orange County, California, study of 49 physician groups, based on responses from over 25,000 patients, the “Physician Group Promptness Report Card” revealed that only 19% waited more than 30 minutes to see a doctor. (6)

What Patients Still Want
So, although some wait time is a reality, most patients comment less on the length of the wait than how the wait is handled, and if it is consistently long. Three important dimensions of care which relate to wait time experiences, from the point of view of patients, are:

• Access – Patients want access to care and are frustrated by voice mail, scheduling difficulties, and restrictions.
• Respect – Patients describe a strong need to be recognized and treated with dignity.
• Information, communication – Patients express fear that they are not being completely informed.

How to Build Service-based Communication Skills
The development of a service-based communication skills training program to address wait times with patients is one approach introduced at the University of Chicago Hospitals. They based the program on the premise that front-line staff may avoid communicating wait delays to patients since, understandably, patients are not thrilled to hear this information. However, avoiding contact with patients may only generate additional patient feelings of uncertainty and impatience. These feelings, accompanied by whatever apprehension the patient may bring to the visit regarding their medical condition, worsen the situation. Discussing the wait delay with patients, while not solving the problem, at least communicates to them that they are being taken care of and not ignored. To build staff confidence in approaching patients when delays develop, the University of Chicago Hospitals developed a three-hour training program for clinic personnel. The training program focused on the following objectives:

• Increasing staff awareness of the perceptions held by patients about wait times
• Understanding the theoretical foundation of the psychology of wait times
• Understanding the relationship between promptness and the likelihood of the patient to return and its potential impact on the financial health of the hospital
• Building skill based approaches for communicating with customers about wait times
• Developing action plans to address wait times in specific clinics
• Recognizing organizational commitment towards the issue of wait times
• Increasing awareness of what the organization was doing to respond to the issue

A variety of methods were used in the training to achieve the educational objectives. These included:

• A review of clinic specific patient satisfaction data, especially comments by patients about their wait experience
• Review of general patient flow in the clinic (present-future-ideal)
• Identification of factors contributing to wait delays
• Distinguishing those factors outside of the clinic’s sphere of control from those that can be controlled or influenced
• Role-play case studies to build situational problem solving skills and communication approaches

REDUCING WAIT DELAYS
Though important to patients’ perceptions of service, communication skills do not address systems or processes. An organization also needs to look at specific systems/process issues that contribute to wait delays. An example of a systematic approach to process improvement can be found at the University of Chicago Hospital’s Center for Advanced Medicine where a multi-disciplinary team has studied and continues to monitor physician appointment scheduling practices and the impact of those practices on the cardiac, thoracic, and vascular clinics of the Department of Surgery. The team’s assessment, based primarily on the clinic’s previous paper schedules, identified a number of scheduling issues, such as…”multiple appointments scheduled for the same time slot, inadequate time slots and shortened clinic sessions.” (7) The team then collaborated with individual physicians to develop computerized scheduling based on actual time spent with patients.

Based on the University of Chicago findings and those of other healthcare organizations, here some ideas for any medical practice that wants to take a closer look at whether its patients are waiting patiently, or impatiently, and why.

Consider Physician Scheduling Procedures
Look into redesigning your scheduling procedures. You may want to try scheduling patients in waves or pulses, by even times, by using only three of four quarter-hour slots to allow catch up time in the hour, or some combination that works in your environment. Pay attention to overbooking as well as the delay between patient booking and actual appointment date, and the effectiveness of your confirmation process. A telephone message can be followed up with a post card mailed three to five days in advance of the appointment. Also, common sense strategies such as allowing time for emergencies, for mid-day catch-up, and for very quick consecutive returns may alleviate unnecessary patient waits.

After reviewing the physician schedule, check for any additional obstacles that might interfere with the physician’s ability to move smoothly through the schedule. These obstacles may include:

• Unavailability of x-ray reports or laboratory results that are needed to confirm diagnostic impressions
• Lost or inaccessible patient medical records which provide the physician the documentation needed to chart the patient’s clinical course over time
• Insufficient patient transportation services which prevent the timely flow of patients from clinic to clinic or lab to clinic when multiple services are scheduled during one day
• Inadequate number of examination rooms

Use Synchronization and Huddles
Two other successful strategies used at the University of Chicago were “the huddle” and “synchronization”—two techniques suggested by authors Delio and Hein. (8) The huddle brings together clinic personnel for a brief period of time every morning to proactively identify and plan for any issues which may impact patient care or operations. Synchronization follows the huddle as “an agreed to set of tasks which should be completed prior to each clinic start time.” (9)

Collect Baseline Patient Satisfaction Data
Since physician promptness is related to return/don’t return decision making by patients, it is important to assess this dimension of the patient’s experience. Implement an ongoing patient satisfaction data collection process. The delivery of real time measurement and rapid feedback of results to clinic/practice personnel is essential.

Set Service Standards for Wait Times
Establish service standards for wait times around key points in the patient visit, for example, at the registration desk, in the waiting room, in the examination rooms, the consultation room, and at the check out station. Time and motion studies can determine current wait times throughout the length of the visit to set realistic targeted improvements.

Reduce Late Arrivals and No Shows
Provide directional aids to patients to assist them in finding the clinic or medical practice. Develop a system for routinely calling patients with appointment reminders.

Educate on Information Systems
Ensure that the staff responsible for scheduling appointments has been trained on related software systems.

Review Staffing
Review and modify staffing levels to adjust to peaks/valleys in patient volume. Wait times will be affected depending upon physician and nursing timeliness. (Some hospitals have instigated “quick care” sections within certain clinics staffed by a separate set of doctors and nurses.) (10)

Strengthen Communication
Among the Picker Institute’s survey questions to 37,000 patients in 120 clinics, offices, hospitals in 1996, those that correlated most strongly with patients’ overall ratings of care were those that related to communication and information. With respect to wait times, almost any staff person can offer information or communicate caring messages. (11)

Patients have reported appreciating when the receptionist keeps them informed about the wait in a friendly manner. Patients have also suggested that when a doctor falls behind early in the day, it is reasonable for coordinators to call patients to tell them to come later or to give them a chance to reschedule. If wait delays develop after the patient’s arrival, patients can be offered coupons for the cafeteria, free parking, etc.

Finally, physicians themselves should be proactive in communicating with their staff and patients about delays. Physicians who consistently inform their staff about anticipated lengths of appointments set themselves up for success. As for communicating with patients, the doctor who simply steps into the lobby to update patients on progress sends a clearly caring message. And, when in contact with the patient in the exam room, he or she should also personally apologize for any delay.

Conclusion—Cost Effectiveness
Collecting patient satisfaction data, setting service standards, reducing late arrivals, and attention to staffing, information systems training, patient communication, and physician scheduling can work together to keep patients satisfied. Though there are certainly costs involved with these strategies, the expense is minimal compared to that of marketing for new patients. Through persistence, research, and creativity, you can keep your patients patiently waiting.

References

1. Appleby, Chuck, “Time is on Their Side.” Volume 70, Hospitals and Health Networks, 10-20, 1996; pp. 49(2).
2. Blender, Rhonda. Interview with Allyson Hansen, Administrator, Center for Advanced Medicine, University of Chicago Hospitals, April 21, 1999.
3. Goiten, M. “Waiting Patiently.” New England Journal of Medicine 323(5):604-8, January 31, 1990.
4. Author not available. “Eye on patients: excerpts from a report on patient’s concerns and experiences about the health care system.” Vol. 23, Journal of Health Care Finance, 06-22-1997, pp. 2(10).
5. Ibid. “Eye on patients.”
6. “Promptness Report Card, Orange County,” www.healthscope.org.
7. Galluci, Armen, Frances Fullam, Doreen Hagerty, “Poster Session: Reducing Patient Waiting: Aligned Incentives and Focused Management Effort,” The 1999 Healthcare Information and Management Society Proceedings, Volume 3, 1999, pp. 285-296.
8. Delio and Hein, The Making of an Efficient Physician, Medical Group Management Association, 1995.
9. Op. Cit. “Poster Session: Reducing Patient Waiting,” p. 291.
10. Snell, Jackie, “Patients’ Assessment of Medical Care Quality.” Vol. 74, Hospital Topics, 04-01-1996 pp. 38.
11. Op. Cit. Appleby, Chuck, “Time is on Their Side,” pp. 49(2).