7 Common Patient Waits & How to Fix Them

After supper, a friend told me healthcare gave terrible service.

As a senior management consultant for a well-known multi-national corporation, he spends his time helping companies run well. In his opinion, healthcare runs poorly.

While full of wonderful, caring people, healthcare is inconvenient and inefficient.

7 Waits and How to Fix Them

1. Waiting for appointments with Family Practice – All family docs could offer same day visits. Some physicians have been doing it for decades. Their patients love it, and their practices remain profitable. Some patients want appointments booked days in advance and that should continue. Other patients want to be seen the same day and could be accommodated with on-site urgent-care clinics or advanced access booking.

Patients should never have to wait to see their family doc (or a physician in the practice group).

2. Waiting in the waiting room for your physician – This should be very rare. When it happens every visit, it represents terrible practice management. Physicians run 2-3 exam rooms to prevent patient waiting. If physicians are double-booking because of patient no-shows, then they should collect no-show fines or consider firing patients from their practice who continue to not attend for booked appointments. If physicians are booking too many patients to see them promptly, they need to stop booking so heavily and spread out appointments. They should stop fooling themselves and book a longer day at the office. They are staying late anyways; they might as well do the courtesy of allowing their patients to arrive later instead of making them sit in the waiting room for hours.

Either way, it’s up to physicians to keep their own waiting rooms empty.

3. Waiting for blood-tests and X-Rays – Lab tests can be processed in minutes to hours, but we make patients book separate visits to get blood-work and imagining, then we make them book another visit to discuss the results! Basic blood-work and x-rays should be available same day for all patients. This can be done by allowing advanced access at labs and imaging suites. Digital images can be read off-site.

Patients could receive basic tests and results in the community just as they do in the ED without extra cost to labs and with great savings for patients.

4. Waiting to see specialists. Ostensibly, wait times to see specialists are long because there aren’t enough specialists. However, there’s a glut of unemployed specialists in many fields (e.g., orthopedic surgery, cardiac surgery, etc). Most of the specialists are ‘unemployed’ because they can’t get operating room time. If there really are too few specialists, why don’t they leverage family docs (or unemployed surgeons) in their clinics to screen through their consults and follow-ups?

I worked for a few years as an associate with our local vascular surgeon to churn through his office visits and minor procedures so he could focus on patients needing surgery.

5. Waiting in an ED waiting room – We discuss how to close your waiting room in other posts. It’s the right thing to do – get patients inside, get them seen, get them treated.

6. Waiting for an inpatient bed inside the hospital – There is no reason to warehouse patients in emergency departments. Unless hospitals make a conscious decision to get patients up to the wards, nurses and physicians will not change their behaviour and get patients upstairs. Dozens of papers show that quality and patient satisfaction improve when patients wait in the halls on inpatient wards instead of waiting in the ED. Furthermore, hospitals that send admitted patients up to the wards, when there are ‘no beds available’ on the ward, somehow find a way to put patients into rooms. Staff find a way to discharge other patients to open up space.

Admitted patients should never be left in the ED to wait for an inpatient bed.

7. Waiting for surgery – Patients wait because OR time is limited by OR closures or cancellation of surgery. ORs need to be kept open – after hours if necessary – to treat patients. Surgery must not be canceled because surgical beds are full of medical patients.

Let surgeons manage surgical beds; do not let medical flow issues shut down surgical flow.

Rebuttals

1. If we remove waits, won’t demand go up? Won’t utilization increase? Anxious patients who demand ‘unnecessary’ investigations receive those investigations in the current system. Most average patients don’t want to give blood or get X-Rays and then wait around for results unless they really have to. Average patients would continue to pursue investigations only on advice from their physicians.

2. Wouldn’t MDs start ordering too many tests if they knew they could get same-day results? Sure, more family docs might order blood-work and X-Rays for patients that they presently send to the ED preventing a few ED visits. Same day service would still require hours of waiting for patients; hardly a convenience all patients would want. The current technology for blood-work and x-rays still dissuades frivolous testing because of the time and effort required. Until investigations become as quick and convenient as a medical scan on Star Trek, we won’t see a giant spike in investigations.

Canadians wait politely, and they should not. There’s no need for most of it.

We need to challenge the old way of doing things: waiting for appointments, waiting in waiting rooms, waiting for labs, waiting for x-rays, waiting to discuss results, etc, etc…

We need to adopt a ‘get it done now’ approach all across healthcare.

If you agree, feel free to leave a comment by clicking on leave a reply or # of replies.

112 Patient Flow Solutions for Emergency Departments

This list should get us started… Please add your ideas in the comment section at the end!

Close your waiting room – bring patients straight inside to chairs if no beds open
Use triage to enhance flow: triage = sorting and nothing else
Limit the number of nurses at triage – 1 nurse can SORT 200 patients per day easily
Have patients self triage
Use on-line triage
Use Bedside registration
“Quick Reg” – limited registration; just enough to create a chart
Have patients use self registration
Offer pre-registration on line
Post live wait times on-line to smooth patient volumes
Use patient passports – patient education hand-outs at front door
Educate the community to arrive in ‘slow’ hours (e.g., before 11am Tues – Fri)
Educate community to avoid the surges on Sunday evening/all day Monday
Limit 1 visitor per patient
Encourage patients to bring med lists with them
Encourage community MDs to send in referral notes
Have on-call MDs
Have flexible start and stop times for MDs
Get MDs to take responsibility for flow in real time
Have on call RNs
Shorten nursing documentation (1-2 pages max)
Use combined triage & nursing secondary assessment form
Use physician scribes/navigators
De-zone – move staff to where need is greatest; don’t leave a zone overstaffed
Use advanced directives
Use pre printed orders
Measure and reward MD performance
Measure consultant response times
Insist on in-house consultant coverage for internal medicine, anesthesia, pediatrics…
De-unionize – flow will improve
Have nurses only do nursing tasks (carry out orders, give medications), not clerical work
Track RN break times – insist on accountability
Reward RN extra effort (staying late, skipping breaks, going the extra mile)
Match RN staffing to patient volumes by hour
Match MD staffing to patient volumes by hour
Never allow MDs to go home if waits are long
Staff extra MD and RN shifts on known high volume days (Mondays, holidays)
Encourage MDs/RNs to work in teams and hand over readily
Stagger RN shift changes
Have dedicated ED X-Ray
Have U/S (and tech) in the ED
Use techs for lab draws and ECGs
Stat labs
Prioritize ED lab and DI
Don’t batch
Dedicated porters (RN/tech should porter if porters overwhelmed)
Track DI and lab turn-around times
Get a great EDIS (ED information system)
Create meaningful alerts on EDIS to identify LOS, reassessments, etc
Have a modern EMR linked to the EDIS
Retire outdated EMRs – an old, slow EMR might be worse than none at all
Consider a real time locating system (e.g., RFID)
Consider EMR on tablets for each MD
Computer terminal in each room
Link ED EMRs with community EHRs
Have forms available on-line
Bypass ED for STEMI identified by EMS (straight to PCI)
Eliminate phone calls for CT, etc
Extend CT hours of operation
Encourage the hospital to work on a 24-7 service model (at least a 7 day service model!)
Do not schedule big surgical cases on Monday
Track admits and discharges by time of day and day of week
Eliminate day-day variations of admits/discharges
Perform nurse handover on the ward; not by phone from the ED
Get admitted patients straight up to the ward before a bed becomes available
Use a visual bed management system for inpatient flow admitted patients leave promptly
Use patient flow navigators
Create robust medicine clinic follow-up clinics (next day)
Do not allow consultants to ‘send patients to the ED’ and see them there
Teach residents about quality and efficiency as paramount in their education
Use PO instead of IM, and IM instead of IV treatments if possible
Position EMS off-load in-front of the main nursing station – not hidden away where patients can languish
Form psychiatric patients promptly as needed
Do not perform an internal medicine ‘ward’ work-up in the ED
Order all tests and treatments on the first touch
Plan on disposition from the first encounter
Have Multi-use rooms (eliminate bottle-necks)
Establish procedures to sedate patients in any room
Partner with volunteers – they can help a ton!
Establish CDUs on in-patient wards – do consultations there
Give every MD, RT and Consultants a phone to carry
Do not scale down services over holidays when demand always goes up!
Encourage same day, out-patient cardiac diagnostics and consultation
Establish direct referrals to cardiology (not internal med, NP, cardiology, etc)
Have everything needed for work in every area (don’t make staff walk to the ‘tube system’)
Use pre-printed prescriptions
Have the chief call in 2-3 times per day to monitor flow
Create an internal, real-time ED surge plan
Create a hospital wide surge plan and link it to the ED surge plan
Give admin on call authority to move admitted patients out the ED
Have back on-call to support internal medicine consults
Do not allow surgeons to be on-call to the ED on their OR day
Teach all nurses to apply splints and/or casts
Use ‘just in time’ approach to patient movement – don’t stock-pile patients by loading rooms
Avoid batching
Assign patients to areas; not rooms
Use overhead paging liberally – don’t walk around looking for patients
Improve patient signage
Use patient instruction sheets
Use a re-assessment check-list so MDs aren’t called to reassess prematurely
Build a minor treatment area (aka fast track)
Get rid of as many stretchers as possible (limits holding admitted patients)
Use exam tables where-ever possible
Use some chairs instead of stretchers in the acute area for telemetry patients
Get rid of walls – use curtains to divide most rooms
Eliminate sequential processing
Insist on parallel processing
Look for bottlenecks – theory of constraints
Learn queuing theory and how it applies to your department
Learn and love LEAN
Employ an unlimited capacity mindset – don’t limit flow for lack of ‘rooms’
Adopt a ‘get it done NOW‘ attitude across the organization!

More ideas? Questions? Feedback? Click on leave a reply or # replies below:

Physician Scheduling Extreme – Interview with Dr. Marko Duic

Imagine a schedule where you could work any day you wanted, see as many (or few) patients as you wanted, and take as many holidays as you wanted.

Sound unbelievable?

Dr. Marko Duic has honed a physician scheduling system that delivers MD choice, MD control and a perfect fit between physician speed and patient volumes. He shares how he does it:

Welcome, Marko. You’ve figured out a way to give physicians choice, control and as many holidays as they want. Is that true?

For individual physicians, it’s true. The only restriction is that a few physicians need to stick around to keep the emerg going–so not everyone can take off at the same time. This might be an issue if everyone in the department wants to go to the same conference. But if an individual physician wants to go off for 3-6 months, to, say, cycle from Cairo to Capetown, it’s not a problem.

How long have you been doing this for?

Since 2001

How do the physicians like it?

They state that it’s a major reason why they’d never go to another ED to work.

How do patients like it – what results do you achieve?

The most important patient satisfaction correlate is their time to see the doctor (Physician Initial Assessment time). Well, the two hospitals in Ontario that use this system are often number 1 and number 2 in PIA times, and one of them is definitely a leader in satisfaction among peers.

What do the nurses think of this system?

At first, not that pleased that we could muster up ANY number of physicians ANY time, and they would get stuck with a pile of orders. They had to see that a pile of orders is better than a pile of unseen patients. At least with the patients having been seen by MDs, nurses could be asked to do the most urgent orders first. What the nurses like about his system is that there are always enough doctors to see the patients, so they never have to get abused by impatient patients. There’s never a day when three slow physicians work back to back and the place explodes.

Could this system work anywhere; do you think you could teach others to do it?

Of course it could work anywhere. It’s how patients would schedule doctors, if patients were allowed to schedule us.

Most emergency departments schedule a fixed number of shifts every single day, but you don’t. Why?

Each physician has a number of patients per shift that the physician is most comfortable seeing. It could be 15, could be 30, could be 45, could be 60. And each emergency department has a number of patients that they see any given day. So for example, in one of our departments, we see 300 on Sundays and Mondays and 270 the other five days. So I have to schedule enough physicians that their combined capacity to see patients adds up to the number of patients I’m expecting. So if all the fast docs go on a conference together, the slow remaining ones have to be scheduled in larger numbers–maybe 9 or 10 of them in a given day to see that many patients. If the slow guys go on a conference, I might only need five or six of the remaining fast docs to see the patients. If everyone’s in town, and I alternate fast and slow docs, I might need 7 or 8 physicians. If the physicians are different speeds, how can you expect to have the same number of them per day?

So, how do you determine exactly how fast each MD works?

I have stats, but they don’t really work that well. So I do it by trial & error repetition and intuition.

But what if more patients arrive on a particular day?

Shifts start when patient waits get up to a certain level. Physicians call each other to figure out when the next one needs to show up. If the day’s busier, it becomes evident in the conversations. Physicians come in early, and stay late, and if needed, call an extra physician.

And what if you need another physician to help?

We use our on-call funds to pay one of them to show up. We call in turn, alphabetically, and change the order by one physician each time, so everyone gets a chance.

Who decides if more MDs are needed on any given day?

The physicians who are working in the department at the time. If they risk running over the target patient waiting time, they call extra help in.

What if the physicians working that day do NOT call for extra help?

Then the times go over, this is a disaster, and they need to explain why they don’t.

What are your thoughts on the provincial Hospital On-Call funding system?

It’s good to have money to pay physicians to come in to serve patients. Especially in the ED, where volumes and acuities are unpredictable, and where timely access to care is what’s held out to the public in the name EMERGENCY DEPARTMENT that’s posted on the door.

Are there times when you have scheduled too many MDs on one day? What happens then?

They either shorten all the shifts, or cancel one of them, or both. They come to an agreement that suits them all.

Okay, let’s focus on the mechanics of schedule creation. How do physicians ‘pick their shifts’?

They submit a selection form that shows me when they want to work, when they can work, when they would prefer not to work, and when they can’t work. I use all the physicians’ forms to give everyone a schedule that’s almost entirely made up of shifts they want or can do.

Is it completely different every month?

Basically, yes. Some patterns repeat–some people like nights; other people like Wednesday mornings; some people can never work Friday evenings. But overall, it’s different every month.

What happens if there are too many shifts requested by the group?

Everyone gets a bit less than they asked for.

What happens if you can’t provide enough coverage to meet the expected volumes on a day?

Short term, everyone works a bit more than they would like. Long term, hire more people. But if it’s one day, and no one wants to work then, then there’s a lottery.

Can MDs take holidays?

Yes, any time, for any length of time. We’ve had people take full-year sabbaticals or 4 to 6 months LOAs and come back to a full shift roster. This system is totally flexible. 20 doctors can cover the absence of 1-2 docs with minimal disruption for a long time.

What if everyone wants to take holidays at the same time?

Then we close the department. No, seriously, there’s a max of about 1/3 of the department that can be on holidays for a longer period, or 1/2 the department for a few days, or 2/3 for a day or two, and it can still have full staffing.

What about Christmas, New Years and summer vacation – how do you handle those holiday requests?

In whatever way EPs want, but overall, some people always want to work them, and if there are not enough, then there’s always the record of who did it last year and the year before–those people get first dibs on taking them off this year.

Wow – this seems too good to be true, but it looks like the results prove it works. Do you have any final comments?

Try it, you’ll like it. More importantly, the physicians will love it and insist on always doing it this way. Patients will love it too.