Using Educational Material to Improve Patients’ Perception of Wait Time
Michelle Lane
University of San Francisco
Background
Same day surgery was once compared to a production line with “the sick person as the raw material and the healed person as the product” (Fox, 1999, p. 1308). However, today many patients favor same day surgery because, much like other western culture expectations, it is efficient and speedy (Mottram, 2011). Patient satisfaction has become increasingly important in the assessment of healthcare quality (Umar, Oche & Umar, 2011) and wait time is often a primary determinant of satisfaction. A study by Medway, deRiese, deRiese & Cordero (2016) concluded that patients view their wait time as the time they arrive to the clinic rather than the actual time of the appointment, and those with shorter wait times were more satisfied with their visit. To the patient, wait time directly correlates with perception of the quality of care received (Medway et al., 2016). According to Parasuraman, Zeithaml & Berry (1985), in service sectors, tangible evidence of quality is usually limited to the provider’s facility, equipment and personnel, making it difficult to determine how a consumer will perceive services and quality. A Press Ganey survey revealed that waiting times significantly impact all measured aspects of ambulatory care experiences, including diminishing a patient’s confidence in their physician (Bleustein et.al, 2014). With increased access to healthcare information, patients now have higher expectations of their healthcare service (Farber, 2010). Patient centered care is the new mantra of healthcare and it equates to quality of care. It means the patient (and the family) are “listened to, informed, respected, and involved in their care” (Epstein & Street, 2011, p. 100).
Patients consider waiting as inactive, wasted or lost opportunity time, therefore healthcare organizations should accommodate patients so that they don’t perceive that their time waiting has no purpose (Yeddula, 2012). Emotional responses to waiting may manifest in annoyance, irritability, stress and anger (Becker & Douglas, 2008).
At Channel Islands Surgery Center (CISC), the performance analysis scores for 2016 revealed that the primary patient complaint was wait time. CISC utilizes Symphony Performance Health to analyze patient satisfaction surveys. Favorable percentage scores for patient wait time were 92.3%. Any score less than 95% equates to over one in twenty patients providing an unfavorable response (Symphony Performance Health, 2016). Wait time has topped the complaint list of this facility for several years, but due to the volume of patients serviced and the variety of procedures performed, it would be nearly impossible to know where the delay lies outside of a long-term flow study. Therefore, short-term, it would be beneficial for the facility to accommodate patients and their families in a way that would increase their overall perception of the care received, by minimizing the negative effect of prolonged wait times. Research on queuing shows that occupied time feels shorter than unoccupied time. People will tend to look back positively when the wait ends with a happy emotion, even if they are miserable most of the time. If one is feeling negative toward the end of the wait, they may be cynical even if the wait was painless (Stone, 2012). A study by Yeddula (2012), revealed that occupied patients in a waiting room revealed significantly higher levels of satisfaction than unoccupied patients.
By implementing educational television and educational reading material in the CISC waiting room, patient and families will be occupied and distracted, resulting in increased patient satisfaction scores related to wait time. Scores will be expected to improve by twenty percent within three months of implementing the changes. These changes will address the six domains for health care quality launched by the Institute of Medicine (2001).
System Setting
Channel Islands Surgicenter (CISC), located in Camarillo, California is a multi-specialty, for-profit ambulatory surgery center (ASC) serving a diverse population including pediatrics. CISC comprises four operating rooms, three procedure rooms, a six-bay preoperative area, a two room GI pre-procedure area and an eight-bay post anesthesia care unit. The center averages 30-70 procedures daily, Monday through Friday, and varies anywhere from epidural steroid injections to orthopedic surgery. In addition to clinical areas, the front office houses eight to ten support staff in varying roles (Channel Islands Surgicenter, 2017). The overall culture of the nursing units, although giving excellent nursing care, remains one of apathy toward the center itself. There does not appear to be a desire to change the status quo. CISC continues to adopt a hierarchical system of leadership.
Healthcare systems are complex, adaptive systems and the “actions of individuals are interconnected so that the actions of one changes the context for all the others (Barach & Johnson, 2006, p. i10).” This is experienced at CISC by both the Pre-Op unit and the PACU as multiple phone calls are received daily from the front office regarding patient inquiry into estimated wait times. The elements of the microsystem include the patients and their families, the clinicians and support staff who directly interact with the patients, and the care processes. The key stakeholders are the clinicians, support staff and patients. A desire to increase patient satisfaction will not be enough to facilitate change, it will require motivated leadership. Studies show that 60-80% of change initiatives fail (Pexton, nd). According to Chreim, Williams, Janz & Dastmalchian (2010), there is much research relaying the importance of leadership to successful change, but the traditional hierarchy of leadership must change, and distributed leadership leads to change visioning and implementation (p.188). Finkelman (2016) refers to this type of leader as a “champion for change (p.74).” Change champions are those who are creative, innovative and flexible and who understand how behavior affects an organization’s response to change (p.74). For change to be implemented, there needs to be people who support it. Usually, the pattern of teams adopting change is represented by an S-shaped curve (see appendix A for example), where support starts with a few followers, gradually picks up more followers, and then flattens off, with some people only coming on board at the end of the process (Hall & Hord, 2011).
Resistance to change is inevitable and it is important to identify the reasons behind resistance (Finkelman, 2016). Incorporating the proposed changes at CISC will primarily affect the workload of the front office staff and the administrative budget. Possible obstacles to the proposed change are front office staff unwillingness to participate due to increased workload (overseeing the publications and/or educational videos) and administrative denial of funds to cover the cost of the materials. Having a clear aim will allow those involved in change to understand the rationale and how it will be achieved. Identifying objectives will influence the success of change as it helps to clarify what is expected. The empirical rational approach assumes that people will participate in a process if they understand the reasons and benefits (Hewitt-Taylor, 2013). Because change often means a disruption in established routines, it is important to assure that adequate resources are available to those involved (Hewitt-Taylor, 2013). Administration will likely be more willing to supply funding if a special purpose budget and financial analysis are presented. If the costs are minimal compared to the outcome of improving quality and regulatory compliance, it will be evident that the problem being addressed is important and that the plan is feasible (Penner, 2017).
CNL Role
More and more, as healthcare becomes value-based, healthcare organizations (HCO) look to become centers of excellence. There are increasingly positive outcomes related to quality of care and cost benefit from HCO’s which are utilizing Clinical Nurse Leaders (CNL). Because the CNL examines care delivery from the perspective of a patient or microsystem population, they are positioned to guide teams in ways necessary to sustain a culture of safety by continuous quality improvement that is based on evidence (Harris & Roussel, 2010).
The CNL uses evidence-based practice to ensure that patients benefit from the latest innovations in care delivery. This change proposal includes several of the fundamental aspects of CNL practice including:
Participation in identification and collection of care outcomes, design and implementation of evidence-based practice, team leadership, management and collaboration with other health professional team members, information management or the use of information systems and technologies to improve healthcare outcomes, stewardship and leveraging of human, environmental, and material resources, and, advocacy for patients, communities, and the health professional team (AACN, 2013, p.4-5).
Change Theory
Sales, Smith, Curran & Kochevar (2006) suggest that a developed theory will address the question: why do organizational entities behave as they do? Given the way they behave, what would motivate them to change behavior? Change theory should provide hypotheses and guidance to action at the microsystem, and at higher levels (p. 44). Process theory refers to implementation of change by determining how change activities will be planned and organized, and how the target group will be influenced (Grol, Bosch, Hulscher, Eccles & Wensing, 2007, p.98).
Rogers’ diffusion of innovation theory submits that once a person or organization has gained the necessary knowledge about an idea, they will then adopt or reject it based on the degree of social reinforcement from others (Sahin, 2006). Therefore, as the idea spreads and more people come on board, the idea becomes diffused until a saturation point is achieved. Rogers theory further postulates that when the idea is compatible with current values, is easy to fulfill, is observable and easily tested, it is more quickly adopted (McDonald, Graham & Grimshaw, 2004, p.30). The goal of Rogers’ theory is to streamline intervention to meet the needs of all five categories but not to necessarily move people into another category.
Rogers describes five categories of adopters as:
- Innovators: risk takers, change agents
- Early Adopters: opinion leaders, role models
- Early Majority: want proven applications, risk avoidant
- Late Majority: respond to peer pressure, skeptical, require proof
- Laggards: isolated from opinion leaders, maintain status quo
(as cited in Kaminski, 2011, p.1).
Action Plan
Keeping Rogers’ theory in mind, and knowing that resistance to change is inevitable, it will be critical to express a clear statement of purpose. Neal (2008) advises clear and consistent communication from change agents to encourage employees to embrace the desired change.
According to Finkelman (2016), lack of staff input and participation is the most common reason for resistance (p.75).
The action plan will model the AHRQ template (2015) and focuses on four areas:
- Goal- Patient satisfaction scores will improve by twenty percent within three months of implementing changes.
- Planning Initiative- An important first step is to engage in proactive leadership to dialogue with stakeholders about the need for change (Finkelman, 2016), then, a business plan can be developed to present to administrators to persuade resources to support the goal (Penner, 2017). A SWOT analysis will provide an understanding of the situation by assessing the strengths, weaknesses, opportunities and threats to the plan (see appendix B). Following the initial discussion, three to five innovators/early adopters will be identified in the facility to create a team of change agents who will champion the cause by providing knowledge to others, and creating energy. Change agents will include administrative personnel, nurses and office staff. Further, a vendor will be chosen to provide educational media, television and reading material. Expectations/education will be provided to business office staff regarding their role in change project.
- Timeline- (see Appendix C)
- Communicating Plan- Identified change agents will provide ongoing communication with all stakeholders to enhance momentum, bringing all adopters on board and ensuring sustainability of the plan.
Evaluation
Performance indicators will be used to inform the team whether the proposed change is leading to improvement (Institute for Healthcare Improvement, 2017). The expected outcome of this plan is that patient satisfaction will improve. The indicator of this is that survey scores will reflect increased satisfaction with wait time. To measure scores, a survey card will be given to 50 random patients one week a month for three months (see appendix D). The patient will be asked to fill it out and drop it in a box at discharge for tallying. The results will be plotted using a run chart (see appendix E), and a Plan-Do-Study-Act (PDSA) worksheet will be used with each survey completed to test for changes (see appendix F). Results will be communicated with all stakeholders and, learning from the results, the plan may be adjusted and re-tested.
Conclusion
Wait time weighs heavily in patient satisfaction scores and is directly correlated with the patient perception of care. To improve wait times overall would require a long-term flow study of the center, however patients’ perception of wait time may improve if the patients are distracted with educational media. It is expected that patient satisfaction scores will improve by 20% within three months of implementing a program of educational television and reading material in the waiting room. Rogers’ diffusion of innovation theory will guide the implementation of this process and change champions will lead it to success.
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Appendix A
S curve adoption model. (2014). Retrieved from http://thecomputerboys.com/?p=676
Appendix B
SWOT Analysis
Demplates. (2016). Pie based template. Retrieved from http://demplates.com/free-swot-analysis-template-in-word/
Appendix C
| Estimated Time Frame |
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Process | Immediate | 2 weeks | 1st month | 2nd month | 3rd month | 4th month | 5th month | 6th month |
Leadership discussion |
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Develop business plan |
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Develop SWOT analysis |
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Identify change agents |
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Procure media co. |
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Educate staff |
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Begin Survey cards |
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Identify outcome measures |
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Begin PDSA cycles |
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Communicate with stakeholders |
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Appendix D
Survey Card
TODAY’S OFFICE VISIT Survey Card
- Did you see the clinician, or team member, that you wanted to see today? o Yes o No o Did not matter who I saw today
- How would you rate the length of time you waited to get this appointment?
- o Excellent o Very Good o Good o Fair o Poor
- How would you rate length of time waiting during today’s visit?
- o Excellent o Very Good o Good o Fair o Poor
- How would rate a recent experience getting through to this office by phone?
- o Excellent o Very Good o Good o Fair o Poor
Institute of Healthcare Improvement. (2017). Today’s office visit survey card. Retrieved from http://www.ihi.org/resources/Pages/Tools/TodaysOfficeVisitSurveyCard.aspx
Appendix E
Sample Run Chart
Appendix F
PDSA Worksheet
Institute for Healthcare Improvement. (2017). PDSA worksheet for testing change. Retrieved from http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx