Wait Times and Satisfaction

I SENSED THE TENSION as I came through the front door of our office and strode past the two people sitting in the waiting room. While I was on a hospital call, an elderly patient had been referred to our office without an appointment. Rather than schedule an appointment for another time, he and his daughter had chosen to wait until I returned. Their body language and the glance I exchanged with the office administrator communicated clearly that the wait had not been pleasant for either party. In a brief hallway discussion, she informed me of the reason for the referral, and I escorted the patient into an exam room and began the encounter within a few minutes of my arrival. The daughter chose to remain in the waiting room (I assumed it was out of an abundance of frustration) while my encounter with the patient proceeded pleasantly and without incident. At the conclusion of the visit, I led the patient back to the waiting room, and then moved to the adjacent office to finish documentation, pleased with myself for having quickly and graciously accommodated the patient and referral source. My self-congratulatory thoughts were interrupted when I overheard the patient's daughter complaining belligerently to the office administrator about the initial wait time. In the interest of defending my coworker, I stepped out of the office and explained that we did our best to see her father as quickly as possible without an appointment. The daughter's anger was not appeased. Frustrated with our responses, she asked, "What ever happened to ‘the customer is always right'?" My answer was both accurate and insightful but did nothing to improve the situation. After leaving our facility, the daughter filed a complaint with our corporate office. Waiting is a normal part of the human experience and seems to be inextricably connected with receiving medical care. None of us like to wait, and we've all experienced the constellation of negative emotions that accompany any prolonged delay. Some of our most frequent and severe criticisms of service provision relate to how long we waited before or while it was performed. Negative feelings about wait times can affect not only our satisfaction with service, but our perception of its quality. This article discusses the relationship between wait times and patient satisfaction with medical care. While O&P care differs in many ways from other medical encounters, there is value in identifying distinct time periods involved in different aspects of providing care. Figure 1 describes some of the ways wait time has been defined and investigated in clinical research, modified to fit the context of O&P care. 1 UNDERSTANDING THE PSYCHOLOGY OF WAITING In "The Psychology of Waiting in Lines," David Maister, PhD, points out the importance of paying attention "not only to the readily measurable, objective, reality of waiting times, but also how those waits are experienced…. We must learn to influence how the customer feels about a given length of waiting time." 2 In 2008, Donald Norman updated Maister's work by describing eight design principles for waiting in lines (Figure 2). Noting that many studies on waiting take an objective, mathematical approach that focuses on efficiency, Norman says that "fairness, equity, and the experience of the people are ignored." "Experience," states Norman, "is more important than efficiency." 3 Recent research on waiting can help us better understand our patients' experiences with waiting and work to improve it by focusing on what is important to them. RE SEARCH ON WAITING Nottingham, et al. investigated how time spent in the waiting room affected perceptions of the quality of care "in rural settings and across multiple clinic types," as well as "the effect of gender on…waiting time satisfaction." 1 (See Figure 3 for insights included in the background of their paper.) The researchers collected data from more than 4,000 patients at a variety of specialty clinics in the Upper Peninsula of Michigan (e.g., family practice, orthopedics, pediatrics, sports medicine, surgery, internal medicine, and rheumatology). They found that "male patients tended to be more satisfied if kept abreast of delays. Female patients were more tolerant of delays but receiving delay information did not link to satisfaction." 1 Longer wait times decrease patient satisfaction even with information about delays, indicating that there may be diminishing returns to keeping patients updated on wait times. (At some point, patients want the services they came in for, not more explanations about why it is delayed.) Increased satisfaction with "time-related variables" is connected with increased satisfaction with the quality of care, and an increased likelihood that "the patient will recommend the care provider and the practice." 1 Overall patient satisfaction was significantly impacted by how much time the patient spent with the provider. The researchers report that "patients who wait 15 minutes or less are likely to be ‘very satisfied' with their waiting time…whereas those who wait 30 minutes or more are only ‘satisfied'…. For information about delays, the rating turns from ‘very satisfied' to ‘satisfied' at 45 minutes of waiting." 1 While there is a connection between wait time and satisfaction "overall patient satisfaction is fairly insensitive to wait time. Only when wait time is 45 minutes or greater does there begin to be an effect (down from very good to good) on patient satisfaction." 1 Research on wait times in O&P practice may demonstrate different patient priorities, but the authors' conclusion about time thresholds is valid for our profession: "Finding these threshold values…and noting their effect on overall patient satisfaction, can help healthcare providers allocate resources effectively and monitor performance." 1 Knowing specifically which delays impact satisfaction the most allows us to tailor our care delivery processes to maximize each patient's positive experience. For example, I have found that in most cases meeting or exceeding the expectations set for the time from impression to delivery is more important than expedited delivery. SPECIAL CONSIDERATIONS IN O&P Patients have different expectations about O&P care that may impact their perceptions of wait time. First, our facilities may be perceived anywhere along a continuum from retail outlets to specialized medical practices, and our services from inconvenient to life-transforming. How our patients view us affects their experience of waiting. According to Maister, "the more valuable the service, the longer the customer will wait." 2 Second, many medical practices have various levels of assistants who facilitate the movement of patients between locations and procedures during an appointment. All but the largest O&P facilities lack the economy of scale that justifies employing multiple levels of assistants to improve practitioner efficiency. (Although, I suspect that re-thinking this assumption would result in significant improvements in care delivery.) O&P practitioners perform many tasks that would be delegated to support staff in other medical practices, which decreases time available for direct patient care and may increase wait time. Third, the time required to complete O&P procedures can vary greatly from case to case. It is difficult to predict the time required for repairs and adjustments, for example, and an appointment scheduled to address a "simple" problem may take hours of practitioner time while patients wait. Fourth, many O&P practices regularly see patients on a walk-in basis. Walk-in volume falls outside of normal scheduling protocols and can never be predicted with certainty. Since we depend on referrals from other providers (most of whom never accept walk-ins), we do what we can to accommodate these patients by working them into a schedule and potentially increasing wait times for all patients. The way O&P care is delivered also provides some advantages when compared with other medical professions. We work closely with patients and caretakers over extended periods of time, allowing a high trust level to develop. Long wait times may be more tolerable when patients are convinced, based on extensive past experience, that we have their best interests at heart. O&P clinicians' greater involvement with scheduling and other administrative and technical tasks also allows them to adjust the schedule and procedures to accommodate unique or challenging situations. CONCLUSION The regional manager who contacted me about the above-mentioned complaint was understanding. This was the first such complaint about our office, and he figured there was a reasonable explanation. I agreed but wrote the daughter a card saying that I felt bad that the encounter had not met our high standards or her expectations. I've spent some time reflecting on that interaction with the patient and his daughter. The wait time after I arrived at the office (only a few minutes) was clearly not an issue, the patient himself never expressed any dissatisfaction with any aspect of the visit, and the daughter's dissatisfaction was related to the wait, not the orthotic services. Without accepting responsibility for the daughter's emotions or choices on that day, I've wondered what else contributed to her anxiety and what more we could have done to minimize it. In addition to providing transportation, the daughter was likely responsible for providing other care for her elderly father. The daughter had let us know that their visit to our office came after a long day including other medical appointments. It is quite likely that they had spent hours in other waiting rooms before entering ours. She may have been confused by the disconnect between the confidence of the physician's staff that we were available to see walk-in patients and the delay after arriving at our office. These and other factors probably worked together to push her past the limit of what she believed acceptable. How patients and caretakers feel about a visit is important, and a robust assessment of care quality should consider more than their perceptions. Patient satisfaction is not the ultimate measure of quality. However, we need to be aware of how different aspects of an encounter, including wait times, impact the patient experience, and work to improve the aspects of the care that we can control. This includes maximizing efficiency in all aspects of our practice, managing patient expectations, and developing skills for resolving conflicts when they inevitably arise. We will never be able to ensure that everyone leaves our practice completely satisfied, but reflecting honestly on patient dissatisfaction can help us identify areas for improvement. Over time I've come to see this encounter as less about inappropriate expectations and difficult behavior, and more about a missed opportunity to positively affect a caretaker's experience and memory of an unpleasant wait. If the encounter had ended more positively, the patient's daughter may well have recalled the wait as only a minor inconvenience. Instead, the tense discussion at the end of the appointment probably guaranteed that the daughter remembered the whole experience more negatively for a much longer period of time. It is worth remembering that empathy is more effective than rational argument in most cases of interpersonal conflict and dissatisfaction. As Norman put it when describing his design principles: "Emotions dominate: This is the most important and critical of the principles. Not only do emotions dominate over all else, but all the other rules are essential to ensure a positive emotional reaction. Emotions color the experience and, more importantly, how the experience will be remembered…. The memory of an event is more important than the experience itself." John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center (NUPOC). He has over 30 years of experience in patient care and education. References Nottingham, Q. J., D. M. Johnson, and R. S. Russell. 2018. The effect of waiting time on patient perceptions of care quality. Quality Management Journal 25(1): 32-45. Maister, D. H. The psychology of waiting lines. Boston, MA: Harvard Business School, 1984. https://davidmaister.com/articles/the-psychology-of-waiting-lines. Norman, D. A. 2008. The psychology of waiting lines. https://jnd.org/the_psychology_of_waiting_lines.

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