The days of the patient patient are over.
Today's health care users want instant satisfaction, and they're scouring the Web looking for the hospital that will give it to them. With this growing consumer-mindedness, coupled with payments tied to the patient experience, hospital leaders are working overtime to address pesky wait times throughout the health care system.
Patients are comparing service they receive at hospitals to their experience at a restaurant or hotel, and leaders should be looking to those service industries for inspiration, says Gerard van Grinsven, a former Ritz-Carlton executive and president and past CEO of Henry Ford West Bloomfield (Mich.) Hospital. "It is crucial that all of us in health care make it an expectation that there is no wait," says van Grinsven, now CEO of Cancer Treatment Centers of America. "Wouldn't it be great if one day we could just do away with waiting rooms in emergency departments and hospitals?"
Press Ganey estimates that the average patient spends about 22 minutes waiting to see a doctor at a clinic, and more than four hours from entrance to discharge in the ED. As wait times balloon, the patient's experience worsens, and so does the risk of infection. One study by the firm found that those who waited five minutes or less expressed 95 percent satisfaction with their experience; that dropped to 80 percent when the wait swelled above 30 minutes. About 63 percent of patients believe the amount of time spent in a waiting room is "very" or "extremely" important, according to Harris Interactive.
The bottom line is at risk, too, and hospital executives who ignore wait times can expect a "dramatic reduction in reimbursement," says Christy Dempsey,. R.N., chief nursing officer for Press Ganey. The tie to payment will become more pronounced in the coming years, with the arrival of the Clinician and Group Consumer Assessment of Healthcare Providers and Systems — CGCAHPS — patient survey, which specifically asks how often a respondent has waited 15 minutes or more to see a doctor.
Framing the issue
• Everything from online rating sites, to transparent pricing and quality data are prompting patients to behave in a more consumerlike fashion, and shop around for the provider who offers the best experience.
• A key aspect of the patient's encounter at a hospital or clinic is how long he or she has to wait. Patients still wait about 22 minutes on average in doctors' offices, and more than four hours in emergency departments.
• As wait time increases, patient satisfaction drops. That fact becomes more significant because reimbursement is tied to HCAHPS surveys.
• Hospital leaders are placing downtimes squarely in their crosshairs to improve the patient experience by eliminating waiting rooms in clinics, reorganizing EDs and bolstering data to target bottlenecks.
Some hospitals are seeking ways to make downtime more useful and enjoyable through educational videos, comfy recliners or health coaches. But Dempsey believes eliminating avoidable wait times is the ultimate goal. "When you think about value from a patient's perspective, waiting is waste," she says. "The idea would be to get the patient to the care — whether it's the provider, the bed or the procedure — in the shortest amount of time possible. It's great to add value to the wait, but I would rather get rid of the wait."
Forward-thinking health systems are adopting that mindset to transform each patient's path through the health care system: building clinics free of reception desks, reinventing EDs to funnel visitors to the appropriate part of the hospital or installing kiosks for speedier check-in.
In focus group after focus group, Rob Klein of Klein & Partners Inc., Orland Park, Ill., keeps hearing the same demand from patients — "Physicians have to learn that my time is just as valuable as theirs." In days past, consumers may have been willing to sit in a waiting room for 22 minutes to see a trusted doctor, but now they're walking out. Hospitals need to see that behavior as a game changer, and take steps to keep the patient satisfied and loyal, says Klein, who does research and brand consulting in the health care field. Providing excellent clinical service isn't enough anymore to make a hospital stand out.
"In health care, for the most part, none of us are adapting. We still want to do things how we did 20, 30-plus years ago," Klein says. "Health care is never going to be the same. Clinical expertise is expected. It's not a brand differentiator. The differentiator is creating an experience that you can own."
Pinpointing the bottlenecks
Getting to that ideal state starts by figuring out what's causing the bottlenecks that lead to longer wait times. So, hospitals are mining data to pinpoint the root causes of downtime, utilizing such manufacturing methods of continuous improvement as the Japanese kaizen, and quizzing patients on ways to improve the health care experience.
The Mayo Clinic is working on a 217,000-square-foot, three-story expansion of the hospital on its Phoenix campus. As part of the project, the health system's Center for Innovation sent design researchers to study how patients interact with the system, and if there were ways to reduce wait times and better utilize staff.
Designers had assumptions going into the process — such as older patients would prefer face-to-face contact, while younger visitors might desire quick and easy electronic check-in — says researcher Allison Matthews. But demographics meant little; instead, preferences varied depending on the type of patient, reasons for visiting and the frequency of appearances. A patient who returns often might be OK with pressing a couple of buttons on a terminal to check in, while someone who rarely sets foot in a hospital would prefer a live body to help guide the process.
Rather than using a one-size-fits-all solution to reduce wait times, Mayo is looking to segment its space to cater to different visitors. Taking cues from the airline industry, patients could interact with three different modalities when they arrive. Those on chemo who return monthly or weekly, for example, could signal their arrival through an automated kiosk. Less-frequent guests, who need more guidance, could talk to the front desk receptionist. And when a waiting line backs up or a patient needs extra help filling out forms, a facilitator roving around with an iPad can assist.
"Waiting isn't necessarily bad. It can often be kind of a 'pause and get ready for your appointment' time, a time when people really are getting themselves mentally ready to go in and have this important conversation," Matthews says. "You shouldn't make assumptions about what people are going to want to do, like 'All people will want to engage in patient education while they wait because it's just a good time, and they need to do it.' Patients would like to determine their activities, so giving them the opportunity to engage with multiple things and self-define their experience is really important."
For nine-hospital PeaceHealth, in the Pacific Northwest, technology and data have been key to reinventing care pathways in its system. An employee hands badges to patients entering the ED to keep tabs on their movement and learn when their care stalls along the way. Clinicians are tracked with the same technology to make sure they are properly distributed throughout the area. It also tracks equipment to eliminate bottlenecks and to avoid, for example, technicians having to wait for an available X-ray machine.
A digital whiteboard shows patients each step along the way, and allows PeaceHealth to view where there's room for improvement, says Steven Willis, clinical applications system analyst for the health system. By adopting the new approach in its anesthesia clinic, for instance, they've started to room patients immediately, after previously keeping them waiting an hour on average. Collecting data is a critical first step in addressing wait times, he says.
"Once you put the system in place and you can start monitoring the data, it kind of rolls," Willis says. "There's some work that needs to be done on the front end, but the advice I would give is not to make too many assumptions. Once you start collecting data, you may find that maybe you're not as good as you thought. Data can show you a lot of good points and it can show you areas for improvement. So just be open to it."
Others, meanwhile, are using kaizen, the Japanese method of continuous improvement made famous by Toyota, to laser in on the cause of wait times. The approach is usually brief, and involves a facilitator who helps to guide the process of determining constraints in the system, implementing a better workflow, and measuring wait times and inpatient length of stay to gauge success.
"We are blind to the things that are actually happening. There's nothing groundbreaking as far as the ideas; it's just the ability to see where those opportunities lie in the first place," says Amichai Porges, a kaizen facilitator for Sheridan Healthcare.
Eliminating waiting rooms in clinics
Looking to compete better with convenient options offered by retailers like Walgreens and CVS in the primary care space, and make the best use of scarce doctor resources, some health networks are building clinics and other facilities without the typical front room, or repurposing that space in old buildings. Virginia Mason Medical Center in Seattle, itself a proponent of the kaizen method, has been ahead of the pack, working over the past decade to eradicate waste and the waits that come with it.
In its Kirkland Clinic and in another clinic opening in December, Virginia Mason spurned the traditional waiting room. Patients, instead, are either greeted by a medical assistant, or can travel straight to their rooms, says Michael Ondracek, vice president of clinic operations. In other older sites, Virginia Mason seeks ways to make the waiting experience more valuable by splitting reception areas into smaller spaces, and offering extra services, such as health education materials, at no extra cost.
It is also targeting other insidious ways in which the delivery system makes patients wait, such as time spent on the phone. Virginia Mason strives to make sure each call is answered in a timely fashion, and has increased the percentage of calls picked up within two rings from 64 to more than 80 percent. Email response times have been cut from an average of four hours to 90 minutes. The key is to measure constantly and make sure old habits don't return, says Ondracek. Data are reviewed every 30 days or so to ensure the changes stick.
"As we understand how health care is changing and the consumer is driving all those changes, they want care real-time, and a lot of the time it's through messaging or over the phone," he says.
Clinic waiting rooms are squarely in the crosshairs of two-hospital Mosaic Life Care, based in St. Joseph, Mo. The 2009 Malcolm Baldrige National Quality Award winner already has erected seven new facilities that don't have a front room built in a traditional mold. Instead, patients are greeted by a warm, earth-toned space with a water feature and recliners, meant for families accompanying a loved one or for patients idling before their ride returns, says Davin Turner, D.O., clinic physician administrator. Rather than a front desk, a "life coach" greets the patient and presents him or her with a tablet computer preloaded with music and magazines if there is any delay. Some even have chefs to teach about healthy eating habits.
Waiting vs. wasting time
Some, such as George Tingwald, M.D. and architect, are apprehensive about completely ridding the health care experience of waiting time and space. Certain patients like his elderly mother, who shows up an hour early for every appointment regardless of the circumstances, expect and even appreciate some sort of a wait. At Stanford University Medical Center, where he is director of medical planning, they're dividing wait areas into activity rooms that resemble a home. Features include a dining area with a café where patients can grab a bite to eat, or a space similar to a living room where they can watch TV.
Tingwald believes hospitals that state they're eliminating waiting rooms are just mincing words; a Starbucks with a bunch of recliners is still a waiting room, he says. And those who don't allow adequate space for downtime might end up displeasing patients in other ways, by having them sit in a chair in a hallway, or waiting in the exam room when they expected immediate care. He believes waiting times, especially in the ED, are a reality of the health care system that all sides should accept.
"We have patients coming from all over the world," he says of Stanford University Medical Center. "They rarely show up just on time. They are here well in advance and, frankly, they have nowhere else to go. So, we have to accommodate those people, and we have to deal with it. I think the key issue is that the term 'wait' is not equivalent to the term 'waste.' "
But, with wait times sometimes stretching beyond the eight-hour mark, according to Press Ganey, EDs are a frequent focus of patients' ire. Leaders at four-hospital Scripps Health based in San Diego are rethinking how they view the ED, meticulously managing the flow of patients, and sending them immediately to the appropriate care setting.
In the past, patients sometimes waited for hours to see a clinician, and then had to repeat the story of what brought them to the hospital several times to different nurses and doctors, says Valerie Norton, M.D., director of the ED at Scripps Mercy Hospital. Visitors were often frustrated and angry, sometimes storming off and never making it past the waiting room.
After going through a kaizen "event," the health system changed its approach to patient intake. New arrivals are greeted by a nurse who performs a quick screening and segregates them to a bed in the "blue" area for urgent patients, or a recliner in the "gold" area for those with lower-acuity problems. Each clinician has a specific role along the way; for example, the intake nurse sticks to her post, and is never pulled away to set up an IV, Norton says. The process also ensures that staff efforts aren't "diluted" by having skilled clinicians spending time on simple maladies when they should be mending broken bones.
The results have been remarkable thus far. On average, physicians see patients in 30 minutes or less. Scripps' rate of patients who "left without having been seen" has dropped from more than 7 percent at some sites to less than 2 percent. And it's gone from hundreds of hours on bypass to nearly zero at all of its sites.
Hospitals need to accept that patients will visit the ED, regardless of urgency, and tailor their approach to that range of visitors, Norton believes. "Our society has evolved to the point where people value that convenience, and they value having the resources of a large hospital available to them 24/7," she says.
Demand for care is only going to increase starting on Jan. 1 as patients enter the system from insurance exchanges; hospital leaders need to make sure they're eliminating all waste and using resources as efficiently as possible, says Cindy Hupke, director of the Institute for Healthcare Improvement. Hospitals need to make the most of the time patients have with providers. Getting leadership to make waiting times a priority, being transparent with patients about what's causing wait times, and engaging patients and their families are all key, she adds.
"The experience of waiting is something that is patient- and family-specific, frankly," Tingwald says. "I think the key issue is that in all the planning we do, we've got to put the patient and the family at the top of that pyramid. That's who we listen to most, and who gets the highest priority in our planning process."
Getting patients in and out faster
Discharge is another step along the patient's journey that can result in long wait times, possible harm from infection or even bed sores. Hospitals are developing strategies to release patients efficiently and effectively, without making them feel as if they are being rushed out the door.
Three-hospital Freeman Health System, in Joplin, Mo., was one of the first organizations to develop an admitting and discharge lounge to help address wait times in both the front and back end of the hospital stay. The room, located at Freeman Hospital West, is filled with recliners, TVs, blankets and a window for medication pick-up.
If Freeman staff know a patient is going to be admitted, clinicians can send him or her to the lounge to start an IV drip. The goal is to get all patients to a bed within 30 minutes, says Amber Kinder, director of nursing resources. On the other side, if patients have been discharged but a ride hasn't arrived to take them home, they can relax in comfy chairs, ask a nurse questions about their discharge instructions and coordinate any follow-up appointments. Freeman hasn't tracked numbers related to satisfaction, but the lounge has been heavily utilized, with almost 1,400 patients having used it in the last eight months.
"We strive for zero tolerance of wait times," Kinder says. "There are going to be times when that's not possible, depending on the patient volume, but we do everything we can to keep it at the forefront every day."
There's no shortage of innovative approaches to help expedite registration and discharge, says Peggy Crabtree, R.N., a vice president with the Camden Group consulting firm. Those vary from simpler methods, such as building a stronger relationship with post-acute providers, to complex bed-tracking systems that sound alerts as soon as a spot is available. Some organizations are creating new positions, such as dedicated "discharge nurses" or "bed czars," to monitor the process, she says, and tying turnaround times into their performance reviews.
"It builds accountability, heightens awareness and gets your staff engaged from the bottom to the top in trying to improve the patient experience," she says.
Three ingredients for better throughput
Peggy Crabtree, R.N., vice president of the Camden Group and a service-line expert, says throughput improvements can improve wait times and are top of mind among hospital leaders. Typically, there are three areas to target to make progress in throughput, all of which overlap in some fashion: processes, technology and staffing. "Throughput is making sure that you're keeping patients moving through the system, and keeping the processes in the hospital moving forward to avoid delays," Crabtree says.
1 Process: It involves deploying techniques such as Lean or Six Sigma to assess an organization's current condition and find opportunities for improvement. Strategies include beginning to plan discharge as soon as patients are admitted, avoiding duplicate labs, or utilizing a "war room," bringing key leaders together to talk about a particular situation.
2 Technology: IT encompasses bed-tracking systems, online patient registration and kiosks to speed up the intake of emergency department patients.
3 Staffing: On the staffing front, hospitals are adding new positions, such as admit-discharge nurses and bed czars to see immediately when a bed opens so that maintenance staff can rush in to prepare it for the next patient.
Patient experience experts at Press Ganey offer three keys to managing wait times across the delivery system. While cutting or eliminating them is ideal, there are also ways to make downtime more palatable for the patient.
1. Communicating about wait times
Research shows that patients are much more willing to wait for their care if they know the length or cause of the delay in advance. Some methods to communicate better include:
• Rounding the reception area: A staff member should enter reception every 15 minutes in clinics and 30 minutes in EDs to acknowledge patients, provide updates, ensure the patient's comfort and that the room is in order.
• Wait-time transparency: On check-in, staff should let patients know exactly how long it will be, or even post it digitally, to manage expectations and foster accountability among staff.
• Service recovery: When patients wait longer than expected, acknowledging and apologizing for the delay can help to diffuse the situation.
2. Improving perceptions of wait time
Providing some sort of valuable services to patients beyond magazines and talk shows can help to improve perceptions of wait times. Some examples:
• Refer to the waiting room as "reception area" or "lobby."
• Furnish the area with comfortable and clean seating.
• Adjust the room temperature.
• Create décor to make the room more homelike, including glare-free lighting, soft music, and snacks and beverages.
• Supply current magazines, family friendly TV, wireless Internet access and clean toys.
• Provide pen and paper for patients to take notes.
• Using pagers or cellphones, give patients the option to leave when wait times are extra long.
• Reschedule if the patient prefers not to wait.
3. Maximizing actual wait times
To truly improve the patient experience, it's necessary to actually reduce or eliminate wait times. A structured approach is critical.
- Identify and measure the actual wait times, from arrival to discharge in the ED, or check-in to the doctor's entrance in the clinic.
- Examine how patients perceive waiting times through surveys.
- Identify what systems and processes contribute to the delays.
- Select which of the problem processes to target.
- Implement solutions.
- Evaluate the effectiveness of those solutions.
- Modify the solutions as necessary.
- Repeat "listen" and "learn" to further refine your approach.
- Hardwire the improvements into daily operations through education, training and accountability