May 23, 2018

Managing Waits for Hospitalized Patients

Unlike the waiting room of a primary care physician’s office, hospitalized patients are not checking the clock at regular intervals waiting for their turn for their doctor to see them. The unknown waiting time while waiting in a hospital bed often leads to the misleading perception that patients who are admitted to the hospital are available for rounding at any time during the day that is convenient for the provider. The assumption that patients don’t need to know when to expect their doctor’s rounding visit is flawed. In fact, the delay in rounding can create more uncertainty and anxiety for patients and their families. Unlike a routine physician office visit, where there is a receptionist available for patients to ask for information about when they will see the provider, they are left to guess when they’ll receive a visit when they are admitted to the hospital. I have known hospitalists who don’t get around to rounding on some of their patients until way past dinner time, but the patients didn’t know that this was their routine, as many physicians do rounds very early in the morning. An unpredictable rounding time can have a negative impact on the patient experience and affect outcomes due to delay in instituting the plan of care and the availability of the support staff. Outside of healthcare, there is a science around managing waiting times in the consumer world. Successfully managing wait times is often a sophisticated and deliberate endeavor. For example, Disney World has implemented activities and entertainment to reduce unfilled time as people wait in lines to get on a ride. In restaurants, meal creators allow the customers watch as the staff is making their sandwich or burrito to order. When waits are inevitable, the goal is to optimize the consumer experience as much as possible to enhance their overall satisfaction. The hospital is far from a pleasurable experience and patients are usually very sick, and families are stressed. In the hospital environment, we are limited in what we can do to keep the patient informed or entertained. However, principles of ‘design thinking’ can be used to make waiting less painful for our patients and their families when they are admitted to the hospital.

Reduce the wait

Most hospitalists round on their intermediate care and ICU patients early in the day.  Conventional thinking dictates these patients are the sickest and need the provider’s attention first. Often, the sickest patients are intubated, confused or too sick and aren’t focused on ‘waiting’ for the physician to visit them (although their families will be). The one situation in which rounding on these units earlier would be of benefit is when patients could be transferred to the medical floors to improve patient flow. Following these insights, one potential way to organize your rounding and improve the patient experience of care is to try the following, in this order:

  1. Conduct your chart reviews upon arrival to the hospital and plan discharges
  2. Round on potential discharges
  3. Round on potential ICU and intermediate care transfers
  4. Round on remaining medical floor patients
  5. Round on remaining ICU and intermediate care patients

Minimize uncertainty, increase predictability

Patients rely on the hospitalist to explain the plan for the day of discharge but have no way of knowing when they will make it to the patient’s hospital room. It would be helpful for the provider to give the patient a general time-frame, so they know when to expect rounds to occur during their hospitalization. For example, if you cannot see a patient during the promised time frame, provide an honest explanation for the delay (e.g., “I am sorry I could not make it during the time-frame I promised. I had to take care of a patient who suddenly deteriorated.”)

Make the wait less prominent

When a patient has tests or procedures already planned for the day, it draws attention away from the passage of time. Such patients can be prioritized to be visited later in the day as a plan of care is already in place. If the test results are available at the later time, it can also make the visit more informative. On the flip side, an attempt should be made to visit patients earlier who have nothing planned for the day except the hospitalist’s visit. This will make the wait less prominent.

Ensure a positive discharge

Last but not least, the discharge process is an opportunity to end the patient experience on a high note. Daniel Kahneman, the Nobel Prize-winning behavioral economist once said, “When people evaluate an experience, the end is not only more important than the beginning, but it can also lead people to ignore its duration.” By implementing small changes in your rounding and discharge practices, it is possible to improve the patient experience and improve the quality of care overall.   References:

  1. Bitran G, Ferrer JC, Oliveira PR: Don’t Manage Waits, Manage Experiences. Expert Insight, 2009
  2. Norman DA: Designing Waits That Work. MIT Sloan Management Review. 2009

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