PRACTICE POINTERS

How to cut patient wait time

Patients who have to wait too long may start shopping for another doctor. See if these strategies for improving daily schedules will work for you.

By Gail Garfinkel Weiss
Senior Editor

You've probably heard the one about the patient who arrived for her appointment carrying a newly purchased copy of War and Peace—and was on the last chapter when her name was called.

The waiting room wait, long fodder for late-night television jokes and "I can top that" anecdotes around the water cooler, is as much a part of modern folklore as endless lines at the Bureau of Motor Vehicles and the airport.

"Long waits mean patient dissatisfaction and a reputation for poor service that's likely to affect referrals," says Judy Capko, a consultant in Thousand Oaks, CA. "And when staff has trouble dealing with the daily havoc of a physician 'running behind,' they're less productive and it takes more people to get the job done. Overtime occurs and morale plummets."

Another negative effect is a diminished perception of the quality of the care delivered. "The patient intuits that if you can't see him on time, you must be disorganized in other areas, too," says Jayne Oliva, a consultant with the Croes-Oliva Group in Burlington, MA.

This summer, waiting room waits turned into a legal threat as well when a fed-up patient took a doctor to court. (See "An impatient patient has his day in court—and wins".)

But many physicians have found ways to make waits in their office rare, or at least bearable. Consultants, too, have suggestions and strategies for improving scheduling and removing the word "inevitable" from discussions of medical office waits. Most of these scenarios involve planning and staff education, and pay off in fewer no-shows and increased profitability.

Scheduling patients: First, do the math

"Patients typically face two kinds of wait time: the delay before they get an appointment, and the time spent waiting to see the physician once they're in the office," says Jayne Oliva. To deal with the former problem, you have to take a realistic look at how many hours a day you're actually working.

"Often physicians tell us they're seeing patients 40 to 50 hours a week, when in reality they take time out for conferences, board meetings, dictation, reviewing test results, attending a child's soccer game," says Oliva. "They may be very busy, but patient time has been whittled away. It's important to determine when you're available to see patients and schedule accordingly."

A densely packed schedule is almost always doomed to run long. "Leave several slots open each day for work-ins," says Will Latham, a consultant in Charlotte, NC. "To determine how many, track the number of work-ins for a couple of weeks and use that as a guide." Latham also suggests scheduling long appointments first thing in the morning and right after lunch. "It's easier to catch up on one or two long appointments than it is on several short ones," he says. (See "Modified wave scheduling".)

When doing your patients-per-day and same-day-appointment calculations, be sure to take no-shows into account. "This is lost revenue and should be factored into the equation," says Judy Capko. "At the same time, examine the reasons for no-shows. Maybe patients who couldn't get same-day appointments went elsewhere, or those who were booked weeks down the road forgot—or their medical problems went away. Once same-day appointments are available, the no-show rate may drop."

Appropriate scheduling is often a matter of doing the math, says Jeff Denning, a consultant in La Jolla, CA. "Count the number of patients seen each day and divide by the hours spent seeing patients. Every physician has an average rate, but it's a good idea to time the morning and afternoon sessions separately. Some doctors start off fast and lose momentum later in the day; others need some time to 'warm up' to their peak rate. Either way, if you average four patients an hour and you've got five hours available to see patients that day, schedule 20 patients. If you schedule more, you'll get backups; if you schedule fewer, you'll miss out on billable encounters. This assumes a steady mix of long, short, and medium-length appointments."

It also assumes well-trained staffers who know how to estimate the urgency and likely length of an appointment—and assign slots accordingly, says Denning's colleague Judy Bee. They should tactfully defer schedule-breaking appointments for a week or two, if possible. For example, if a problem isn't urgent but requires a long visit, Bee suggests telling the patient, "It sounds like you really need some time with the doctor. Let's find a good slot for you rather than cram you in."

Keeping things moving as the day progresses

Be realistic about when you're ready to start your workday. "Many—actually most—physicians overestimate their ability to get to the office by a certain time, and they start out as much as a half-hour behind," says Will Latham. Track your arrival times for a couple of weeks, and schedule appointments based on that, Latham suggests. You'll have occasional delays, but you should aim to see your first appointment on schedule 90 percent of the time.

To smooth patient flow through the office:

Have the right staff in the right place at the right time. "Mondays and Fridays are usually busier than other weekdays. You might need to beef up the Monday and Friday workforce—by, say, adding a PA or an NP—and have fewer people on hand during slow days," Jayne Oliva says.

Appoint your own traffic cop. A patient-flow coordinator keeps things moving for FP Paul R. Ehrmann of Royal Oak, MI. "She acts like a floor general to make sure I see patients within 15 minutes of the time they sign in," Ehrmann says.

Don't let patients take advantage of you. If one of Baltimore FP Jeffrey Schultz's patients presents with four problems, Schultz has the patient pick the most urgent one—two, if the problems are minor—and tells him to make another appointment to deal with the other issues. "When a patient arrives late," Schultz says, "we usually ask him to reschedule. The same happens for patients with insurance problems we can't solve in five minutes. Patients who don't have proper insurance documentation are offered a choice: See us now and pay out of pocket, or work out the insurance problem and return then."

Don't try to do it all. "Physicians shouldn't be escorting patients, making referrals, or cleaning rooms," Jayne Oliva notes.

Set aside time for returning phone calls and doing administrative tasks. When Jeff Schultz gets a phone message that lacks important information, he asks a staff member to find the missing data, then he writes a response for the staffer to deliver. Patients with complex questions or abnormal lab results are asked to make an appointment to discuss these. "We schedule administrative time to review charts, fill out forms, and so forth," Schultz says. "This frees up patient time for the patients."

Standardize exam rooms. "Often in one room a particular instrument will be in a drawer on the left, in another it's in a drawer on the right, and in another it's in the cupboard," says Oliva. You'll save time if each exam room is set up the same way.

Allow for after-hours visits. "My office hours are 9 to 5, but we have a 'happy hour' from 5 to 6 or 6 to 7, when patients can come in without an appointment and wait as long as an hour—but with the knowledge that they will be seen," says pediatrician Wesley J. Sugai in Kailua-Kona, HI. "This gives patients access to me without causing unmanageable backups during the regular workday."

Make use of modern technology. Internist Mitchell Kahn, director of the Kathryn and Gilbert Miller Health Care Institute for Performing Artists in New York, wrote an electronic office management system for the practice. "When people check in at the front desk, we note the time in the computer," he explains. "I can monitor how long patients have been in the waiting room or exam room, and if someone is waiting more than 20 minutes I go and find out what the holdup is."

Likewise, urologist Dan Witt of Hoisington, KS, handles patient flow using a template his wife—who's also his office manager—obtained from their computer software company and customized to fit the practice's needs. "She built in an empty slot in the morning and in the afternoon for walk-in and emergency patients. That allows me to see patients within 15 minutes of their scheduled appointment over 90 percent of the time," he says. "It also allows patients to get into our office within one working day. We change it as needed."

What about the second half of the battle—the wait in the isolation of the exam room? "Exam rooms should be occupied for three reasons: so that patients can remove clothing, receive treatment, and get dressed," says Judy Capko. "Otherwise, keeping patients there is a waste of space and time. To free up exam rooms and speed up the simplest appointments, consider a quick-visit room where patients with minor problems can get in and out." Patients who come to see GP Liza Shiff of San Jose, CA, for blood pressure checks and immunizations are seen immediately and sent on their way, leaving exam room space free.

A blood draw station and patient education center can also help you improve productivity and maximize room utilization, Capko notes.

Keeping patients calm while they cool their heels

Even with the best of planning, things go awry. "I might discover during an annual exam that a female patient has a suspicious breast mass. Or a patient will admit to drug use and require more of my time than anticipated," says FP Steven Kamajian of Montrose, CA. Still, if anecdotal information is correct, it's not the wait that irks patients, it's the perceived indifference.

FP Paul Okosky of Saratoga Springs, NY, walks into the waiting room and apologizes when he's running late. "It never fails to bring smiles when I acknowledge that the patient's time is as important as mine," he says. Bala Cynwyd, PA, internist Eric E. Shore also apologizes for delays, estimates how long the wait will be, and offers patients an opportunity to reschedule. "Only a few people do," he says, "and there is rarely anger at waiting after that."

Wes Sugai agrees that the words "I'm sorry" have a magical effect. "My receptionist writes the time patients check in on the fee slip, so when I see them I can tell how long they've been waiting. If it's been longer than 15 or 20 minutes, I apologize. If I've been called out for an emergency and get backed up, I tell patients why I'm late—without mentioning names, of course. And as they're leaving, I'll pat their shoulder, apologize again, and thank them for their patience."

Patient satisfaction scores went up for FP Michael G. Charles of Virginia Beach, VA, after he had staffers post signs in the waiting room indicating that the physician was "on time," "15 minutes behind," "30 minutes behind," or "over 30 minutes behind." The signs don't make up for the wait, Charles acknowledges, "but I've always felt that not being properly informed about wait times bothers patients more than the wait itself."

If a patient has been waiting for a while, FP Meyer B. Hodes of East Rockaway, NY, spends a little extra time with that person in the exam room. FP Frederic F. Porcase of Jacksonville, FL, does what he can to explain why the delays occur. "Once patients realize that I'm taking care of people who need to be seen, not at my desk surfing the Net, they're okay. Some even end up apologizing to me," he says.

Urologist Stephen W. Leslie of Amherst, OH, gives patients a handout explaining why they sometimes have to wait and what they can do to speed things along. Two of the points he makes: "We're bombarded by calls from patients who lost their prescriptions or need us to call in a refill for them," and, "I can't rush an 80-year-old with a fistful of medications that need to be sorted out." He also stresses the importance of bringing all pertinent insurance and referral information to avoid delays at the front desk.

Let staff members get into the act. "As part of our training system, we ask our staff to keep patients apprised of our delays," says Boca Raton, FL, internist Steven Reznick. "If we're 15 minutes behind, the medical assistant apologizes for us and gives everyone in exam rooms the option of rescheduling. Our front desk staff offers patients in the waiting room the same option. We then call patients with later appointments and apprise them of the situation."

An early warning system does the trick in Mitchell Kahn's practice. "One of our specialists consistently keeps patients waiting too long," he says. "His new patients receive a letter stating: 'Please be advised that due to the nature of Dr. X's practice, appointment times are approximate, so plan accordingly. Every attempt will be made to contact you prior to your appointment if a longer–than-15-minute wait might be necessary, and you will be given the opportunity to reschedule.' "

Waiting room diversions, while no panacea, can also help make delays bearable. In our Nov. 7 issue, we'll explore ways to make the waiting room more comfortable and inviting in detail. Meanwhile, here are some ideas that go beyond the ubiquitous magazines and TVs:

• FP David E. Bright of Stuart, FL, has a patient education center with audios and videos to keep patients productively busy.

• At the Fort Wayne, IN, hospital where ED physician Mary Wilger works, patients who have been kept waiting receive gift certificates to local gas stations and eateries.

• Consultant Jeff Denning knows of an internist who has a shiatsu massage chair in his waiting room.

• Steven Reznick is toying with the idea of giving patients pagers, like some restaurants do. "Patients could travel to the cafeteria, library, or media room—or possibly local restaurants and shopping areas—and be called back when we're ready to see them," he says.

"Pediatricians, family physicians, allergists, and other doctors who see a lot of children can set up a separate area with a VCR that features kid-appropriate movies," says Will Latham. "Some practices have computers in their waiting rooms to allow patients to check e-mail and remain occupied." Have a staffer offer waiting patients a drink of water and ask if they can do anything else to make the wait more comfortable. Latham recommends providing small blankets to older patients who become easily chilled. FP Rosanne Hooks of Nichols, SC, has her staff assist patients in making necessary phone calls when she's running late.

"But books and fish tanks are not enough to pave over an attitude that suggests you don't care about patient service," Denning says. "Physicians have to be really special to get away with making no effort to run on time. Doctors wouldn't tolerate staff who arrive late two or three time a week—'unavoidable' or not."

Judy Capko agrees that the entertainment-in-the-waiting-room strategy is a mixed blessing. "Physicians need to quit putting Band-Aids on the problem and solve the wait," she says. "On that—hopefully rare—occasion when a wait occurs, the goal is to give the patients a choice and keep them informed." Meanwhile, Capko adds, watch your language. "The term 'waiting room' implies a wait, with all the attendant negative connotations, is inevitable. 'Reception area' sounds more inviting."

The bottom line, according to Jane Oliva, is that keeping patients waiting affects your bottom line. "Your wait time is your accounts receivable," she notes. "You just haven't earned it yet."

Modified wave scheduling

"This process schedules more patients at the beginning of the hour and fewer later on," says Will Latham, a consultant in Charlotte, NC. Determine how many patients you typically see in an hour, then schedule half that number at the top of the hour, a third at 20 minutes past, and the remainder at 40 minutes past. For example, if you see six patients an hour, you'd schedule as follows:

"With this method, you must also break appointments into three categories—comprehensive visits (e.g., complete physical), intermediate visits (e.g., pelvic exams), brief visits (e.g., blood pressure checks)," says Latham. "Comprehensive visits should be scheduled at the top of the hour, and only one each hour. The rest of the hour's mixture should consist of intermediate or brief visits. That way you can do a quick recheck on one person while another is getting undressed for a complete physical."

An example of modified wave scheduling, as well as a form for tracking your on-time performance, are available in "Office Productivity & Efficient Patient Scheduling," a booklet published by Practice Support Resources in Independence, MO (800-967-7790; www.practicesupport.com ).

An impatient patient has his day in court—and wins

In a scenario that brings the 1976 film Network to mind, an apparently "mad as hell" patient stomped out of his doctor's office and into small claims court, where he filed a $5,000 suit to—according to newspaper accounts—"teach the doctor a lesson." In July the court found in the patient's favor and ordered the physician, pain management specialist Ty Weller of Las Vegas, to pay $365 in damages and court fees.

"It reflects the litigious nature of our society that we feel the need to solve problems through the court," says Ed Kingsley, president of the Clark County Medical Society in Nevada. "The malpractice rate in Nevada has skyrocketed to the point that insurance companies are refusing to write policies. This new wrinkle—patients suing for long waits—will complicate doctors' lives further."

The patient, who was planning to leave on vacation the next day, had made a last-minute appointment to see Weller at a satellite office for an epidural to ease back pain.

Court records indicate that staffers at the satellite office placed an IV in the patient, but some four hours later, he still hadn't seen the doctor. Weller contends that he'd notified the staff that he would be unable to keep the appointment because he had been working on two cases that were more complicated than expected, but the patient and a witness testified that the staff neither passed along that information nor offered him an opportunity to reschedule.

"First he sent a $525 bill for lost wages, which of course the doctor ignored," Kingsley reports. "Then he went to small claims court."

In September, an appeals court upheld the lower court's decision.

 

Gail Weiss. Practice Pointers: How to cut patient wait time. Medical Economics Oct. 10, 2003;80:75.