Urgent message: Though patient waits are often unavoidable, understanding and addressing the causes can help mitigate negative impact on the patient and the practice.

Alan A. Ayers, MBA, MAcc, Experity

The term “urgent care” conveys immediate medical attention, so it’s no surprise that the greatest determinant of customer satisfaction for an urgent care center is how quickly patients are treated
and released. But how does a busy walk-in clinic which must be prepared to handle any condition while staffing at levels to remain profitable minimize the negative impact of long waits?

The answer is in identifying the causes of patient waits while working to improve the overall patient experience.

Patient Perceptions of Wait

Concentra Urgent Care recently studied patient attitudes toward wait times at its 324 medical centers in 40 states. The analysis included systems data of total, visit times (arrival to departure), wait time from arrival to being seen by a provider, and customer satisfaction scores pertaining to wait. [Disclosure: The author is assistant vice president of product development at Concentra, based in Dallas.]

Although one would expect patient attitudes to be more negative the longer they’ve waited, the Concentra study revealed that patients have negative attitudes towards any wait— even self-reported wait times of 15 minutes or less were frequently rated “too long.” In addition, the longer patients waited, the more likely they were to report a time longer than their actual wait.

Perceptions of wait are important because they influence patient attitudes toward every other element of the experience—including the quality of medical care delivered. The Concentra study demonstrated that the longer a patient waits to see a provider, generally the less satisfied they are with the amount of time the provider spends with them. Perhaps after an extended wait, patients feel a provider “owes” them more time.

Because some patient wait is unavoidable, a successful practice should understand what factors cause wait time to occur and then manage the patient experience to reduce the negative impact.

Determinants of Wait

Length of stay also known as throughput or turnaround—refers to the time that passes between a patient’s arrival and departure. Intervals spent waiting may be caused by processes including registration, triage, charting and billing; staffing levels, including the number of providers and technicians; the type, number, and acuity of visits; and the layout and capacity of the physical facility.

Knowing total throughput time is a starting place; process improvement involves understanding how patients move through an urgent care center, identifying the steps where waits occur, evaluating the reasons for each wait, eliminating non-value-added activities, and finally, becoming responsive to patient needs.

Identifying Areas for Improvement

The current process is defined using a flowchart that illustrates all the steps a patient passes through.

For example, a patient signs in at the front desk and completes a patient information form; the front desk verifies insurance, enters data into the billing system, and assembles a chart; a medical assistant calls the patient back to the clinical area, records symptoms and takes vitals; and so on.

Once the process is documented, it’s possible to identify the steps where patient waits are occurring. Table 1 provides a sample template that can be attached to the cover of each chart to track the patient’s time at various steps. The sample period should be at least one week. In addition to providing an in-depth understanding of the patient experience from arrival to departure, the flow charting and time- tracking activity should reveal causes of delays, including task dependencies, duplication of effort, unnecessary steps, and bottlenecks.

Addressing the Causes of Wait Time

Value-added activities are process steps that are necessary to treat the patient and assure that the center gets paid collecting demographic information, verifying insurance, collecting copays, taking vitals, conducting a history and physical, and documenting findings in a chart cannot be avoided. It is possible, however, to make these activities more efficient.

While process enhancements may improve the overall patient experience, only improvements that target the cause of wait time intervals will reduce length of stay.

For example, the first impulse of many urgent care operators is to  tackle  wait  time  by  applying  technology  to  highly visible processes. Installing a self-registration kiosk may reduce the amount of time required for the front desk staff to register a patient, but if patients typically wait 30 minutes to be put in an exam room, reducing registration time from 10 minutes to five minutes may not necessarily reduce total wait times. Most likely, the provider isn’t sitting in the back waiting for patients to be registered; rather, it’s the patients who are waiting for their turn with the doctor.

The most significant bottleneck in urgent care tends to be the medical provider. Thus, activities that focus on improving the efficiency of the provider are likely to have the greatest impact on total wait times.

A time study of the provider’s activities should re- veal how the provider prioritizes and moves between patients and time spent on charting and documentation, as well as tasks that could be performed by ancillary staff. Although a growing center may not have the resources or infrastructure to add a second provider during busy times, it may be able to utilize a nurse or mid-level provider to better triage patients and manage workflow during busy periods.

When Wait Time is Inevitable

When wait time cannot be eliminated, the urgent care operator should focus on improving patient perceptions by making the wait as pleasant as possible. Table  2 provides some practical suggestions.

Generally, the longest wait in an urgent care center occurs after completing registration and before being placed in an exam room. Some urgent care operators rightly seek to minimize this wait by rooming patients quickly, following the logic that patients in the waiting room are anxious to move to the back and that a crowded waiting room may turn off prospective patients walking in to the center.

However, compared with the isolation of an exam room, a comfortable and well-equipped waiting room is actually the best place for patients to wait. Instead of “disappearing into to the abyss,” patients can gauge wait times by seeing other patients being called to the back and then leaving the center. Having patients assembled in the waiting room also allows the staff to better monitor and communicate wait times.

Patients in the waiting room are waiting for the next step in a process to move to the clinical area for treatment. Thus, they are less likely to attribute the cause of their wait to the provider than to factors they can see, such as heavy volume or complicated cases. By comparison, patients waiting in exam rooms are focused on the arrival of one person the provider who they hold responsible for their wait. In an isolated exam room, a patient cannot see other activities that may be the cause of his or her wait.

Regardless, there will still be some wait in the exam room. To reduce feelings of anxiety, many centers have added television with remote control, magazine racks, and windows with blinds that can be opened to the outside. For many visits particularly involving children it may also be appropriate to let a family member accompany the patient to the exam room if the patient so desires. The visitor will keep the patient company and when a spouse or parent hears a treatment plan, generally compliance (and thus, medical outcomes)  is  improved.  An  extra  chair  should be available in the exam room for visitors.

Understanding that a provider’s capacity will determine initial wait time, some urgent care operators have found ways to shift inevitable waits outside of their centers. For example, Internet preregistration and call ahead scheduling add patients to the workflow when they would normally sign in. The front desk calls within 15 minutes of when the provider will be ready to see them. The wait time isn’t eliminated, but patient perceptions of the wait significantly improve.

One patient who was summoned to the clinic two hours after registering online raved about a “five minute wait” upon arrival. The actual two-hour, five- minute wait was perceived as minimal because the patient spent that time at home.

Avoid Setting False Expectations

Some urgent care centers advertise “visits in under an hour” or “see a doctor within 15 minutes.” While such promotions may draw attention to a start-up center that is building volume, they also set an expectation for turnaround that, if not met, will disappoint and dissatisfy patients.

Even if turnaround times are not advertised as a guarantee, their presence in an ad will be interpreted as a guarantee by consumers. It is advisable to avoid marketing specific turnaround times; instead, emphasize the core benefits of urgent care: extended hours, walk-in service, no appointments necessary, and faster turnaround than the emergency room.
If patients ask about wait times, be honest even if it means some patients will balk. Telling a patient who calls ahead there is a “short wait” will lead to disappointment if that patient waits 60 minutes upon arrival. The better solution is to let the patient know if there is an extended wait, then provide options, including returning at an off-peak time or taking the patient’s cell phone number and calling when the provider is ready to see them.

Conclusion
Although urgent care centers seek to provide immediate attention to all patients, there are times when it’s necessary for patients to wait. Taking a process approach, an urgent care operator can identify the causes of patient wait and seek solutions to improve operational efficiency. When patient waits simply cannot be reduced, the urgent care operator should strive to make the wait as pleas- ant as possible in order to reduce negative perceptions that may carry over to other elements of the patient experience.

Managing Wait Times for Greater Customer Satisfaction

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine
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