What are you waiting for? You can end patient delays

New methods help one practice improve by 50%

It’s flu season and your reception area is jammed with feverish, coughing patients. Everyone needs to see the doctor today, but the day isn’t long enough. Scheduled patients grow weary and angry from the delays.

You may think such waiting times are the inevitable byproduct of a busy practice. But you’re wrong. Those delays can be largely avoided by relatively simple changes in processes, says statistician Thomas W. Nolan, PhD, chairman of the Collaborative on Reducing Waste and Delays, a project of the Institute for Healthcare Improvement in Boston.

"Waiting times are a function of the structure of the system that’s put in place," says Nolan, who is also co-founder of Associates in Process Improvement, a consulting firm in Silver Spring, MD. "If you have long waiting times, you have a system that’s perfectly designed to produce those waiting times. We try to suggest to people different structures that will reduce the waiting times."

For example, physicians and practice administrators often cite medical emergencies as a reason for delayed appointments. Yet, Nolan notes, "Health care is not the only industry in which emergencies come up."

"No one would take the excuse that an emergency came up for the pilot, so there’s no one to fly this plane," he says. "Emergencies come up in every industry, and we don’t put up with delays in those situations."

In its collaborative — the Breakthrough Series — the Institute for Healthcare Improvement brings together quality improvement experts and medical professionals who have achieved breakthrough results. Three-person teams from various health care organizations attend sessions to learn how to restructure their own systems. (See editor’s note at end of article for more information on the Breakthrough Series.)

Dramatic results achieved

The Breakthrough Series on delays produced some startling results.

At the University of Texas M.D. Anderson Cancer Center in Houston, Charles Levenback, MD, discovered that change can be dramatic and quick — and at other times tedious.

"Within the space of a few weeks, we reduced the cycle time [of the entire medical visit] of my patients by 50%," says Levenback, medical director for quality improvement and associate professor of gynecologic oncology. Yet Levenback’s colleagues were not all equally impressed by the changes.

"Changing behavior can take time," says Levenback. "People are receptive to change at different levels. In my own group, this kind of change has been embraced rapidly by a proportion [of physicians]. There are those who need more time to be convinced that this is better."

Shortly after Levenback began the improvements to reduce waiting time, his patients started asking, "What’s wrong? You saw me on time today!" But now that is the norm.

"Before I did this project, one of the worst parts of my professional life was knowing there were patients in the waiting room waiting an hour, two hours, and knowing if I were them I would leave," he says. "I was constantly apologizing for being late."

Clearly, solutions to excessive delays vary according to the specifics of an individual medical practice. But based on their own experiences, Nolan and Levenback offer these suggestions for reducing patient waiting times:

1. Seek significant improvement.

Before Levenback began his quality improvement project, patients spent one hour and 46 minutes in the clinic, from the time they arrived until they left. That now has decreased to 54 minutes.

"The message here is that big change is possible, and that’s what you should look for," says Levenback. "If the average wait time of patients is 30 minutes, if you reduce it by 10% [or three minutes], have you really achieved something? From the patient’s perspective, probably not."

In keeping with the Institute for Healthcare Improvement model, Levenback designed an improvement project that involved minimal data collection but set high expectations. The changes he implemented were actually quite simple, he notes. "But if you put them together you can achieve a significant improvement."

2. Track delays.

This fast and simple process of quality improvement still requires a period of information gathering. Levenback began with a team that included the nursing leader of the gynecology center at M.D. Anderson, the nurse who works with Levenback’s patients, a nursing assistant, and a patient service coordinator who handles scheduling. "The people who are doing the work have to participate in the improvement," he says. "This isn’t about someone coming from the outside and imposing a solution."

Discovering the source of your delays doesn’t require an extensive or expensive time study. To determine what is causing interruptions of physicians, simply choose random times during the day and observe, says Nolan.

To get a sense for the severity of delays, pick two patients a day for each physician, he suggests. "Make it at 10:30 and 2:30, when you’ve had a chance to get backed up," he says. "Record the difference between when the appointment was scheduled and when the patient saw a physician."

Do that for a week or two and plot the delays on a graph. "It takes a minute a day to do that," he says.

3. Create a contingency plan for emergencies.

"Every practice, if they were serious about delays, would have a contingency plan," says Nolan.

The specifics of that contingency plan would depend on the needs and expectations of the physicians and patients, says Nolan.

For example, one practice might choose to call scheduled patients, tell them the doctor had been called away on an emergency, and ask them if they would like to reschedule. Another practice might designate a physician to have a lighter schedule on a certain day to be available to respond to emergencies.

4. Start on time.

It sounds basic, but if you start off the day running late, you will have a hard time catching up, says Nolan.

If the doctor is ready to see the first patient, the staff shouldn’t create a delay simply to handle administrative matters, he says. Those registration issues could be taken care of during or after the visit.

5. Set aside more same-day appointments.

Failing to set aside enough time in the schedule for same-day appointments is a common pitfall, says Nolan. "One of the changes people have made in our project is to study how many requests for same-day or emergency appointments they get in one day and reserve that many," he says. "If you don’t, you’re simply going to overbook and create delays."

In primary care, Nolan suggests leaving 30% to 50% of the schedule open for same-day appointments. Leaving only 5% to 10% vacant, as many practices do, generates long waits, he says.

6. Simplify appointment types.

It makes sense to distinguish between longer appointments for physicals and shorter ones for urgent care. But creating too many appointment types and slots can lead to unnecessary delays when patients call to schedule an office visit, says Nolan. "I might have a wait to get an appointment even though there are open [time] slots because there’s a line for the appointment type I want," he says.

Nolan uses an analogy of a supermarket. Suppose instead of express lanes and regular lanes, there was a separate lane for fruits and vegetables and for paper towels. "I have fruits and vegetables and I’m waiting for the cashier, but there’s no one in the paper towel line," he says.

7. Create a sense of teamwork.

Some communications problems and delays occur because of the detachment between physicians and office staff, says Levenback.

Levenback discovered that tests or future office visits often had to be rescheduled because he would fill out a form designating a day, but then the patient would realize he or she had a scheduling conflict.

"We moved one of the clerical people into the back right next to us," he says. "When I want to schedule something, I talk directly to the scheduler. I introduce the patient to the scheduler."

Levenback’s clerks now are receiving training in additional tasks such as taking a patient’s blood pressure. "If all the nurses are busy, the clerical person can take the person into a room and get the weight and blood pressure," he says.

8. Do tasks in parallel rather than in sequence.

This proved to be a major timesaver for Levenback. Previously, everyone in the clinic did their jobs in sequence. That is an assembly-line concept that doesn’t work for customer service, he says. It would be like going to a fast-food restaurant where the cook prepares the hamburger first — then the french fries.

Now, while the nurse weighs the patient, reviews medications, and gets a recent history, the physician is reviewing the chart and consultant reports, tracking down lab results, and looking at X-rays.

9. Reduce interruptions of physicians.

Staff may inadvertently interrupt physicians with tasks that could be handled by someone else or that could be reserved for administrative time at the end of the day, says Nolan.

Levenback realized that he was part of this problem. He would review articles he was writing or editing or return phone calls during his clinic time.

"The truth is, while I was doing those things, I was keeping my patients waiting," he says. "If I stopped interrupting myself, I would be done sooner. Instead of finishing clinic at 2 p.m., I finish at 1 p.m., so I have that hour to do everything else."

[Editor’s note: The Breakthrough Series Guide: Reducing Delays and Waiting Times Throughout the Healthcare System ($49.95 plus $5 shipping and handling), a book of case studies and improvement concepts, is available from the Institute for Healthcare Improvement, 135 Francis Street, Boston, MA 02215. Telephone: (617) 754-4800. Fax: (617) 754-4848.]