The "waiting" room times: time is quality and quality time is satisfaction.

Outpatient clinics form the backbone of the US health system. It is estimated that there were 125.7 million patient visits yearly to various outpatient clinics and the visit volume is only expected to increase as the number of hospitalizations is in decline. Hence, waiting to get an appointment for an outpatient clinic and actually waiting to see a provider on the appointment day is a concern for an already burdened health care. The average patient spends 22 minutes waiting prior to seeing a doctor. Long waiting times with increased visit volumes is a challenge to quality of care and patient dissatisfaction is shown to be directly proportional to the time spent in the waiting room. There exist concerns with patient safety, risk of transmitting infections and patient privacy. In addition, reduced patient adherence rates, non-follow-up and possibility of reduction in reimbursement are important economic implications of waiting.

As an Early Career professional, delivery of quality health care is important to establish practice, along with patient satisfaction and safety. I was observing excessive wait times in our heart failure clinic and later my colleagues and I decided to pursue a quality improvement project to reduce the wait times in the waiting room. Using PDSA-rapid cycle improvement model from The Improvement Guide by Gerald Langley, system-wise learning about the 'no wait' culture in the outpatient department, and the provider 'team on time' practice has been already operationalized. As per Garabedian Model, above behavioral changes will be a structural intervention. The proposed 'process' intervention is a 'pre-clinical package' which involves a standardized nurse made telephone call on a day prior to the appointment. Data has previously shown that a staff made call rather than an automated call is more effective patient reminder system. The three components of this call include confirming and reminding about the appointment, discussion of review of systems and identification of the most important clinical problem to be addressed in the clinic, and reconciliation of medications, which is the most time-consuming part of the visit. We believe that the intervention will work manifolds as it will avoid no shows or late shows due to confirmation process, improve patient arrival on time and add value to the office visit by pre-packaging most time-consuming aspects (review of systems and medication reconciliation) of the face-to face visit. Thus, wait time (WT) in total office visit cycle time (OVCT) will reduce and total office visit cycle time will improve, enhancing productivity and patient satisfaction.

Logic Model

Using the above logic model, the evaluation questions at the 'structure' level would be as follows: 1. Availability of nurses and their time constraints? 2. Stakeholders commitment for such an initiation 3. Motivation and readiness of providers, support staff available for implementing such a program?

At the 'process' level: 1. What percentage of scheduled patients receive the nurse call? 2. What is the provider on time percentage? Evaluation questions at the outcomes level included 1. Are the patients arriving on time? 2. Is the wait time reduced? 3. Is the total office visit cycle time reduced? 4. Is there improved patient satisfaction?

The evaluation questions will lead to development of following indicators for the proposed quality intervention:

1. Percentage of nurse calls
2. Medication reconciliation index
3. Percent of patients and providers arriving on time
4. Percent of no shows
5. Decrease WT/OVCT
6. Decrease OVCT
7. Improvement in patient satisfaction (target 100 percent)

Routine outpatient data as well as time-flow data will be used for constructing the indicators.

We are hopeful that the waiting times in the heart failure clinics will be significantly reduced with these interventions. Ultimately, the goal would be to eliminate the waiting room and start rooming the patients right after they have checked in. In this era, where the doctor-patient relationship is also called a 'provider-consumer,' not having to wait to see a doctor will improve patient satisfaction and quality time spent with the patient to help patient health management. As for any provider, patient satisfaction and patient safety are key elements in delivering quality care. Positive patient satisfaction scores are surely a confidence booster early on for a young professional.

This article was authored by Sourbha Dani, MD, FACC, an Early Career cardiologist at Eastern Maine Medical Center in Bangor, ME.