Clifford Bleustein, MD, MBA; David B. Rothschild, BS; Andrew Valen, MHA; Eduardas Valaitis, PhD; Laura Schweitzer, MS; and Raleigh Jones, MD
With the paradigm of healthcare solutions becoming increasingly consumer-driven, and with an age of personalized and customized treatments on the horizon, the need to provide not just quality care but overall patient satisfaction is becoming more important by the day.1
The changing tides of the healthcare landscape have been well researched, and the Institute of Medicine’s report “Crossing the Quality Chasm” outlines a framework of guiding principles to staying ahead in a more competitive healthcare economy. One of these 6 principles is the ability to provide timely care that reduces harmful delays.2
Wait times can manifest in a variety of ways, including delays in scheduling either for testing, procedures, or physicians themselves, as well as wait times in the office or emergency department (ED). Of these, time spent waiting for a scheduled appointment is the largest source of patient dissatisfaction.
Time spent in a care provider’s office can be divided into a number of distinct segments. First, the patient spends time in a “waiting room.” Second, they are placed in a queue to be brought back to the “exam room,” where, after some initial screening, the patient awaits the arrival of the primary healthcare provider, usually a physician. The third segment is the examination and consultation. From the patient’s perspective, the first 2 segments should be minimized, and the final segment—time spent with the physician—maximized.
Various instruments have been used to measure patient satisfaction, but patients’ perspectives on hospital care are currently measured by a national standardized survey instrument called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).3
The survey used in this study was administered by Press Ganey, an independent firm that offers the nation’s largest comparative customer feedback databases, and is an approved HCAHPS survey vendor. The survey focused on the patient perspective on care received in a physician’s office, as measured by 46 different metrics.4
It is easy to intuit that a review of patient satisfaction scores would reveal a negative correlation between wait time and general patient satisfaction. A literature review of patient satisfaction reports in emergency departments EDs found that satisfaction was associated with 3 key aspects, namely provider-patient interaction, patient-specific characteristics, and perceived waiting times.5
Furthermore, a recent study performed in 2 family practice clinics found that the majority of patients who waited less than 10 minutes gave an excellent or good rating, while only a minority gave this rating after waiting longer than 20 minutes.6
The negative relationship between time spent waiting and overall patient satisfaction has been well documented, and case studies of specific procedural strategies to decrease wait times have been shown to abate low satisfaction scores.7-10
This analysis, however, reveals a new wrinkle we find both interesting and pertinent to care providers and clinic management.
In this study, we assess the relationships between reported wait times and various measures of satisfaction across the ambulatory centers of a large academic medical center in the Midwestern United States, as surveyed independently by Press Ganey. With a particular interest in both the likelihood of the patient to refer the facility, and in the perceived quality of care, we analyzed and assessed the impact of wait times on patient satisfaction scores, looking to compare scores on general satisfaction with the appointment experience to metrics specific to physician performance and confidence in the care provider. While it is intuitive that a patient would be less satisfied with the office visit upon an extended wait, we examined if the perception of the provider’s competence would also be affected.METHODS
The academic medical center used the Press Ganey4 HCAHPS survey tool to collect data on the satisfaction with the care received by ambulatory patients at all of the 44 disparate clinics within the medical center system during the period from January 1, 2008, to December 31, 2008. All patients were sent a survey in the mail following an outpatient visit. The survey contained 46 questions regarding demographic information, time spent waiting before receiving care, and satisfaction with the visit. Satisfaction questions were related to the quality of the care and of the care provider, as well as the experience from an operational standpoint. The respondents evaluated their satisfaction using a Likert scale, with following designations: 1–very poor; 2–poor; 3–fair; 4–good; and 5–very good. The overall response rate to the questionnaire was 23.06%, totalling 11,352 respondents. Of those, there were 9945 unique patients and 1407 patients with multiple responses. Multiple responses from the same patient were tallied; which while not significant on its own, this could have potentially contributed to positive skew.
Of the 46 survey questions measuring the satisfaction with the visit, we chose to assess responses to 13 questions on clinical care received and on the clinical staff. Table 1
provides the question text and question identification used throughout the paper when discussing study results.
Statistical analysis began after the surveys were collected. We employed univariate and multivariate association tests and statistical modeling techniques to identify individual factors associated with significantly lower or higher evaluations of the clinical care received, while evaluating the joint effects of these factors on patient satisfaction. Specifically, we began our analyses by using the χ² test on the assumption that there was no association between the satisfaction scores given for each of the 13 questions and the following set of potential explanatory variables:
Time in the waiting room, categorized into 5 groups: 0 to 5 minutes, 6 to 10 minutes, 11 to 15 minutes, 16 to 30 minutes, and more than 30 minutes; • Time in the exam room, categorized into the same 5 groups;
Combined time, with the cut points doubled from those used for the 2 individual times;
Age, grouped into 5 categories: 18 years and younger, 19-29 years, 30-39 years, 40-49 years, and 50 years and older;
A binary variable denoting first visits;
A binary variable for self-filling.
To further study the effects of the waiting times and other explanatory factors on the ordinal satisfaction scores, and to assess the relationships using a model specification which allowed the slope vector to vary for each of the categories considered, we fitted 4 separate equations with a binary response variable. For discussion purposes, however, we report the results of the univariate logistic regression for 1 equation only—the probability that the satisfaction score given equals 5. Since the score of 5 was the median for each study question, we can more easily assess quality of care by treating the satisfaction score as a binary variable with scores of 5 mapped into a value of 1, and the lesser satisfaction scores treated as zeroes.
We expanded our univariate study of the relationships by considering multiple explanatory variables in the logistic regression setting. When choosing adequately fitting models, we included either the combined waiting time or both the exam and waiting room times. However, when including the combined time only in the set of explanatory factors, we did not want to lose the relevant information contained in the distinction between waiting and exam room portions. Hence, we added a new explanatory variable that measured the percentage of time the patient spent waiting in the waiting room. Finally, we also considered interactions between waiting times, age, whether it was the first visit, and self-filling indicators. We used a backwards elimination approach in our stepwise multiple regression models to select the final regression models.RESULTS
Summary Statistics and Graphical Assessment
The summary statistics in Table 2
provide insight into the distribution of the waiting time variables and selected demographic characteristics. The waiting times exhibit extreme positive skew. For example, 1 respondent reported a wait of 1415 minutes (23.6 hours) in the waiting room and exam room before being seen—clearly a statistical outlier that exemplifies the positive direction of the skew. Hence, when analyzing the effects of waiting times on satisfaction scores, we truncated the waiting room times at 120 minutes and exam room waiting times at 60 minutes. On average, respondents waited about 23 minutes in the waiting room and 15 minutes in the exam room.
Before performing quantitative analyses, we examined the relationships between the satisfaction scores and explanatory variables graphically. Figure 1
helps assess the sensitivity—the size of the decrease in satisfaction scores associated with an increase in the waiting time—of satisfaction scores to waiting times for all questions jointly: we found that satisfaction scores are more sensitive to exam room waiting times than they are to waiting room wait times.
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