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Emergency Medicine News:
Quality Matters

The Science of Waiting

Welch, Shari J. MD

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Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, faculty at the Institute for Healthcare Improvement and the Urgent Matters Project for the Robert Woods Johnson Foundation, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.

Waiting is a part of life in the modern world, and increasingly researchers are bringing their insights to this realm of subjective experience. Armed with data and new understanding about the psychology of waiting, some organizations are managing the waits involved at their facilities quite deftly. (Disney and the Ritz Carlton come to mind.)

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It is an area that ought to be addressed by emergency physicians and ED managers because it greatly affects the experience of patients in our emergency departments.

Bursch et al has shown that perceived waiting time is the most important variable contributing to patient satisfaction, and this finding has been replicated by others. (Ann Emerg Med 1993:22[3]:586; Emerg Med 1996;28[6]:657.) In fact, several large multifactorial reviews of the literature consistently show wait times to correlate with patient satisfaction. (J Emerg Med 2004;26[1]:13; Acad Emerg Med 2002;9[12]:1379; Acad Emerg Med 2004;11[2]:162.) Wouldn't this suggest then that some attention ought to be paid to the experience of waiting in our nation's emergency departments?

Before looking at the psychology of ED waiting, there are two laws of service worth noting. First, if the service provided exceeds the customer's expectations, the customer will be satisfied. The converse is also true; if service does not meet expectations, the customer will likely be unsatisfied. Secondly, it is difficult to catch up, so if the service encounter begins with unmet expectations, it is difficult to improve on the patient's perceptions later on. (“The Psychology of Waiting Lines.” http://davidmaister.com/articles/15/52/. Accessed June 27, 2006.)

These principles are routinely employed in the restaurant industry when guests are deliberately promised a wait time in excess of the true expected time, and customers are pleased to be seated earlier than expected and have a more positive feeling as they begin their meals.

There are several other principles inherent in the psychology of waiting that can be addressed and even exploited for the benefit of patients and their families waiting for emergency health care. (See table.)

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The Principles of Waiting

The logic behind the idea that occupied time feels shorter than unoccupied time is what puts televisions in the ED along with magazines, phones, and laptop portals. Other facilities are experimenting with game carts, snack carts, and beepers that allow the mildly ill to leave the ED area and be paged back for results. Any opportunity to keep patients and their families occupied during the wait should be utilized.

A second principle, that preprocessed waits feel longer than processed waits, allows a patient to feel that his service has begun. The shorter the upfront wait to get started, the less likely the patient will walk away. In particular, the shorter the time to see a physician, the better overall waits will be tolerated. Any processes which facilitate and expedite the physician-patient encounter will be rewarded in patient satisfaction and fewer walkaways. Some facilities with overcapacity problems are employing teams with physicians (Am J Emerg Med 2002;20[4]:267), and this improves patient satisfaction. In general, waits under 30 minutes seems to be the best tolerated before seeing a physician. (Ann Emerg Med 1993;22[3]:586; Health Care Manager 2002;21[1]:46.) By sharing these data with practitioners, time intervals can be reduced. (Ann Emerg Med 2001;38[5]:533.)

Waiting for any service can cause anxiety, but none as marked as that in health care. Staff should try to convey that there is no threat to the patient; constant reassurance goes a long way in reducing a patient's anxiety. This also can create the elusive sense of empathy and caring that correlates with patient satisfaction. (Ann Emerg Med 1991;20:1014; Ann Emerg Med 1987;16:857.)

Uncertain waits feel longer than known, finite waits. A profound source of anxiety in waiting is how long the wait will be. Unfortunately, this can be difficult to remedy in the ED. Many institutions, however, are beginning to schedule certain diagnostics. For instance, MRI scans and some nuclear medicine scans can be scheduled, allowing the patient to leave and return for the test. Frequent updates on status and delays correlate with patient satisfaction and satisfactory length of stay. (Am J Emerg Med 2002;20[6]:506; J Emerg Nurs 2004;30[4]:336.)

Unexplained waits also feel longer than explained waits. Consumers are more patient waiting in situations when they understand the causes of delay. Airline pilots are very good at announcing the reasons for a flight's delayed departure. Some institutions also attempt to reach a service quality goal of updating patients about their wait every 20 minutes. Others use a status board that allows patients and their families to follow their progress through the ED.

Although privacy issues are at the forefront in the emergency department because of HIPAA laws, it is still a worthwhile exercise to explain and inform patients about delays, particularly due to a severe trauma case or critically ill patient. Most patients are generous under these circumstances, provided they are informed. I like to say if a patient has to wait for a prolonged time in the ED, he ought to at least leave with a good story to tell his family and friends!

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Perceived Longer Waits

Another principle influencing patient satisfaction is that unfair waits feel longer than equitable waits. Patients presenting to the ED frequently overestimate the urgency of their need for health care, and they typically do not understand the triage system. They often interpret patient flow in the department as somehow being unfair. (Soc Sci Med 1988;27:935.) Posters, brochures, informational videos, and closed-circuit television are being used to educate patients and correct any perceptions of unfair access.

Patients also will wait longer if they believe the service is valuable. This has huge implications for the emergency department on subspecialty consultations. Recently when a family was growing disgruntled about waiting for a neurology consultation in our department, we informed them that most neurologists in our area were booked for more than six weeks in advance. The entire complexion of the ED visit and the wait changed.

A person waiting alone also feels that his wait is longer than a patient waiting in a group. Although visitors are often viewed warily by staff in the emergency department, family members and friends need to be with loved ones in the ED for their comfort and satisfaction. A liberal visitation policy with highly visible security is the new order of the day.

Actual waiting times and perceived waiting times can be managed in the emergency department. By understanding these eight principles of the psychology of waiting, the waits can be altered to an extent to improve a patient's subjective experience. By giving patients the sense that their ED journey has started in a timely fashion, the stage is set for a positive experience. By constantly setting expectations and exceeding them when possible, the quality of the ED experience is altered. By keeping patients occupied and informed and by addressing the unknown and seemingly unfair, we can shape the ED patient's perceptions of the waiting experience and enhance their overall ED visit.

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The Psychology of Waiting

* Occupied time feels shorter than unoccupied time.

* People want to get started.

* Anxiety makes waits seem longer.

* Uncertain waits are longer than known, finite waits.

* Unexplained waits are longer than explained waits.

* Unfair waits are longer than equitable waits.

* The more valuable the service, the longer the customer will wait.

* Solo waits feel longer than group waits.

Source: “The Psychology of Waiting Lines.” http://davidmaister.com/articles/15/52/. Accessed June 27, 2006.

© 2006 Lippincott Williams & Wilkins, Inc.

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