Scheduling and Tweeting: Reducing Wait Times | Orthopedics This Week
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Scheduling and Tweeting: Reducing Wait Times

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According to Dennis Kaldenberg, Ph.D., Chief Scientist at health care improvement firm Press Ganey Associates, wait times for orthopedic patients are, on average, longer than in other specialties. “Our data show that the median wait time in orthopedic practices is about two minutes longer than the wait time in practices for other medical specialties. This may reflect the growing demand for the services of orthopedic specialists in our aging population. If health care reform increases access to orthopedic services, this demand will be even greater.”

When an orthopedist is in an exam room with a patient, all of his or her focus should be on that person. However, say researchers, the people tapping their feet in the waiting room should figure into your thinking as well. Apart from the courtesy aspect of it, the fact is that someone who waits too long to see the doctor is less likely to refer him to other patients.

Dr. Jordan Greenbaum, now an attending surgeon at New England Orthopedic Surgeons in Springfield, Massachusetts, and Dr. Chris Chiodo, Chief of Foot and Ankle Surgery at the Brigham and Women’s Hospital, went looking for details. Dr. Greenbaum states, “In addition to wait times being a quality of care issue, I knew there was a burgeoning interest in patient centered outcomes such as patient satisfaction. While there is a substantial amount of literature on the impact of wait times on satisfaction in the emergency department and other subspecialties, I found that such information is really lacking in orthopedics.”  

So like all good researchers do when they see a gap in the literature, Drs. Chiodo and Greenbaum and their team dove into it. Dr. Greenbaum: “Our starting point was data from a research firm, Press Ganey, who surveyed 2.4 million patients in 2008; through them we learned that orthopedic patients have the lowest satisfaction among 15 subspecialties and perhaps not coincidentally, the longest wait times. Armed with this information, we took two weeks and studied wait times at an orthopedic practice affiliated with Brigham and Women’s Hospital. We measured how long patients spent in the waiting room and in the examination room, and how long the attending physician spent with the patient. After the patients emerged from the exam room they completed our survey on satisfaction with wait times and on the overall experience.”

While orthopedists attended medical school, not magician school, it may behoove them to understand the power of perception. Dr. Greenbaum:

In at least one of our analyses, how long people thought they spent in the waiting room was more important than how long they actually waited.

"Satisfied patients waited an average of 19.46 minutes; they thought they waited 20.41 minutes. The dissatisfied patients waited 40.21 minutes, but they thought they waited 48.26 minutes. In addition to patient estimated wait time, age and patient rated quality of the waiting room were also found on all analyses to be independent predictors of patient satisfaction. As far as age, older patients tend to be more satisfied than younger patients and perhaps less sensitive to a longer wait. Patients’ opinions of the waiting room also impacted their satisfaction. While there are no evidence-based guidelines on what makes a successful waiting room, we know from the literature that any effort to improve the quality of the waiting room likely needs to be multifactorial, and may include using a professional decorator, nice music, soft colors, etc. In one study from the emergency medicine literature, simply putting a television in an examination room did not improve satisfaction.”

Press Ganey Associates, Inc.
He adds, “Those patients rated as ‘satisfied’ also spent another 18.04 minutes in the exam room before the senior orthopedist came to see them. Interestingly, we determined that dissatisfied patients waited 17.97 minutes, meaning that time in the exam room may not be predictive of satisfaction. This finding may be confounded by the fact that patients were seen by a resident or fellow prior to being seen by the attending physician. Also notable was that in some of our analyses, patients who were new to a practice were more sensitive to wait times. My impression is that patients with whom you have a relationship and who already have a favorable opinion of you may be more likely to forgive a long wait time.”

Dr. Chiodo was senior author on this study. He notes, “Patient satisfaction has never been more important than it is now. We are seeing more patients whose expectations are higher…all the while we have less time to spend with them.”

Thus, says Dr. Chiodo, a bit of creativity is in order. “Many practices provide free internet service/Wi-Fi in the waiting room, accompanied by a pen and paper if people want to take notes on something. As for periodicals, we have found that magazines ‘grow legs.’ Every day I have my staff buy five newspapers, put a sticker with ‘office copy’ on them, and leave them floating around the waiting room. Also, you should offer patients coffee, tea, and water; you can also follow the restaurant example of giving people buzzers that activate when they are ready to be served. If you’re really running behind be prepared to give patients free parking and/or a gift card for coffee and a snack from the cafeteria or lobby kiosk.”

While none of the above suggestions usually require a staff meeting, Dr. Chiodo’s other idea may. “Strategic patient scheduling is critical when it comes to wait times. Patients are often scheduled/billed in 15 minute slots, and at times can be double or triple booked. In our practice we have found it helpful to realistically schedule patients so that an established patient needs less time than a new patient; a postop patients needs even less time. For example, instead of scheduling four people at 10:00, bring in two new patients at 10:15, one established patient at 10:30, and a postop patient at 10:30. You have a bit of leeway with the postop patient; you can have a physician assistant (PA) see them and then you can see them briefly afterwards. In the patient’s mind, seeing a PA counts as ‘face time.’”

Delving into the numbers, Press Ganey’s Dr. Kaldenberg explains,

In orthopedics, the median wait time in the waiting room is 14 minutes, with a range of six to 68 minutes; the median wait time in the exam room is 10 minutes, with a range of five to 32 minutes.

"This means the total waiting time in orthopedic practices is about 24 minutes. The place of the wait doesn’t matter; long waits in either the waiting room or the exam room will lead to dissatisfaction.”

The bottom line for those concerned with their bottom lines?

There is, ” says Dr. Kaldenberg, “a clear relationship between wait times and the willingness to recommend a practice (orthopedic or otherwise).

"Making a patient wait influences the perceptions of the treatment experiences that follow. A ‘way forward’ for physicians is to keep patients informed prior to bringing them into the exam room. We know that if they are waiting and they don’t know why, then they are more dissatisfied. If you have a backlog because of an emergency or some other event, let your patients know.”

So how to keep patients engaged instead of enraged? Follow the example of those who do it best, says Dr. Kaldenberg. “Look at Disney…they have figured out methods of keeping people involved and entertained, which has the effect of distracting them from how long they wait in line. Have a brainstorming session at your practice and discuss how you can adopt others’ methods and/or create new ones.”

Dr. Tom Grogan, an orthopedist in Santa Monica, California, is Tweeting his way to success in the wait time arena. He notes, “Because downtime in a practice produces no revenue, most practices like to have a full waiting room. The negative is that patients are vulnerable to a lot of factors that only increase waiting time. If one patient has a complex problem it backs everyone else up down the line. Add to that the issue of surgeons who operate in the morning and have their surgery run late.”

The biggest issue, states Dr. Grogan, is how to keep patients informed about the flow of your day. “Most practices do not even try. In ours, if I am delayed in surgery, a staff member will try to contact patients downstream in the schedule to let them know of the delay."

"My staff always advises patients to call before they come in to see how things are going. We also leave ‘holes’ in the schedule every hour to allow for some flexibility as well as the omnipresent same day emergency patient (6 or 7 a day). At present we are working on developing a new Twitter system to notify patients as well as an email alert.”

Use of new technology or not, the issue is only complicated by the issue of motivation, says Dr. Grogan. “Not only is the problem going to get worse as reimbursements shrink, but the trend towards physicians being hospital employees is also going to cause the problem to spiral out of control. Employed doctors have no reason to hustle and cut down on waiting times. Just think about the Post Office. Their job is to deliver the mail come rain or shine, nothing is said about customer service at the window. The job of an employed orthopedist is to do surgery. Keeping waiting times in the office in check is not their prime directive.”

In those situations, it may end up being in the bailiwick of hospital administration as they see their patients either rate them lower or move their business. As for private or academic practices, Tweet me.


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