Reduce wait time by tracking patient queues

Research methods help in early re-engineering

You can’t manage what you can’t measure. Nowhere is this axiom more true than in ambulatory care redesign. For example, if you don’t conduct thorough research on pathway loading as part of the redesign plan, you may be sabotaging your own efforts.

"Understanding pathway loading — when and how many patients visit the area — is critical [in] eliminating bottlenecks and increasing patient satisfaction," says Jayne Talmage, president of Talmage & Company, an operations work redesign firm in Boston.

One of the fundamental problems in ambulatory care centers is that most patients arrive between 7 a.m. and 10 a.m. "You have to work fast and furiously until noon to deal with this peak," she says. "It’s a significant cause of system-wide wait times."

Monitoring these early morning queues should be a management priority, she stresses.

For example, if you know when patients arrive and how long they spend in each area — waiting room, registration, lab, same day surgery, recovery, etc. — you can expedite a better "entry, throughput, and exit," she says.

"This objective information also allows you to look at the system from the patient’s point of view," she adds. In addition, hard data makes the redesign an easier sell to administrators and physicians. "Everyone can give you anecdotal stories about how frustrating mornings are for both staff and patients, but having the numbers in black and white can help drive the point home." (See story on how to perform a qualitative audit, right.)

Often, managers who attempt such manual data collection in a high volume clinic create frustration instead of information.

For example, redesign staff at Cooper Green Hospital in Birmingham, AL, used Talmage’s Productivity Tracer while running their stop watches. Unfortunately, this proved too time consuming to monitor wait times of thousands of outpatients.

Even hundreds of patients can be too much to track manually, says Geoffrey Tryon, former executive director of ambulatory care services at Edward Hospital in Naperville, IL. When he wanted to identify the bottlenecks in the current preadmission testing system to design a one-stop process, he used the Productivity Tracer during the early phase of the operational research.

"A technological tool can help you find out the glitches in patient flow much faster," he explains.

At the core of the system is a portable data collection device consisting of bar code cards and a scanner.

Here’s how it worked:

When each patient arrived at outpatient registration, the receptionist scanned a credit card-sized bar coding device and gave it to the patient. To find out how long patients with or without an appointment had to wait, staff gave those with an appointment one numerical code, while walk-ins received another.

Patients carried the card throughout the testing process, presenting it to a receptionist at each stop. The subsequent receptionist then scanned the patient’s card to document the waiting time (about eight scanning stations were throughout the clinic).

The process continued as patients presented the cards at each stop during preadmission testing.

When the outpatient testing area closed at 6 p.m., the scanners were put into a downloader station. There, data were transferred to the department’s computers. The hospital then shipped the information on computer disk to the consulting firm for interpretation.

The data showed that patients were "walking and waiting all over the hospital," Tyron says.

Before using the Tracer, the redesign team assumed the registration process was the bottleneck, Tryon said.

"The time studies revealed patients started waiting after they registered. The average wait time was 31 minutes; about half the patients waited longer than that," he says.

Now, the entire testing procedure takes between 20 to 45 minutes. As part of the redesign, patients report to a central outpatient area, where phlebotomy and EKGs are completed. For chest and other X-rays, patients must walk about 20 feet to another area. X-ray, EKG technicians, and phlebotomists were cross-trained so patients don’t Shave to wait for the next one to become available.

Another change that reduced waiting time was improved scheduling. "We worked with central scheduling to remind them to spread the tests out over the entire day, rather than [in] the morning. By making better use of late afternoon time, you can take some of the burden off [of] morning staff," says Dan McGaffey, principal, who directed the study and subsequent reengineering.

McGaffey says that many hospitals need to be aware of these techniques to even the peak demand in their outpatient areas. In addition to the early morning peak, another occurs after lunch, lasting until about 3 p.m.


Talmage & Company, 145 Washington St., Suite 14, Nordwell, MA 02061. Telephone: (781) 878-3446. E-mail: