Exclusive Online Content - ACEP Scientific Assembly: Oct. 8, 2009
Patience, n. A minor form of despair, disguised as a virtue.
The Devil's Dictionary, Ambrose Bierce
Waits in the ED seem inevitable, sometimes tortuous. While many EDs are actively experimenting with workflow processes to curb crowding and minimize wait times, EDs can also try to manage the quality of the wait.
The relationship between patient satisfaction and time spent in the ED is unequivocal: The longer a patient is in the ED, the less satisfied they are, said Kirk B. Jensen, MD, MBA, who taught “The Psychology of Waiting” course at a Wednesday session of ACEP's Scientific Assembly. Dr. Jensen is the chief medical officer of BestPractices, Inc., and a faculty member of the Institute for Healthcare Improvement.
“We know there are choices and tradeoffs to be made,” Dr. Jensen said of emergency care. But that doesn't mean EPs are completely helpless in trying to make the waiting experience for patients a little easier to bear. To the contrary, with a few guiding principles and some practical applications, EPs can mitigate the pain of waiting.
It's a Service
It's useful for EPs to remember that their care is a service, not a product, Dr. Jensen said, and two laws of service are worth noting. One, if the service provided exceeds the consumer's expectations, the consumer will be satisfied. The converse is true, too. Two, it is difficult to play “catch-up ball,” meaning if the service begins poorly, it is difficult to improve the patient's perception later.
Naturally, certain companies of the hospitality and entertainment industry, an industry that requires good service to survive, serve as prime examples in satisfying these laws. Disney, the Ritz-Carlton, and Starbucks “manage the waits at their facilities quite deftly,” Dr. Jensen said.
Eight Principles of Waiting
Dr. Jensen borrowed eight principles of waiting from David Maister, a former business professor at Harvard University and now a business consultant, who wrote “The Psychology of Waiting Lines” in 1989.
- ▪ Unoccupied time feels longer than occupied time. Disney, for example, entertains customers waiting in line with strategically placed videos or characters in costume. EDs can adapt this by placing televisions and reading materials in the waiting room, or have patients complete necessary forms while they wait.
- ▪ Pre-process waits feel longer than in-process waits. Well-run EDs will move patients along sequentially. “There is no need to keep the patient waiting until everything is ready,” Dr. Jensen said. He suggested having a triage nurse meet the patient, gather information, and move him into a room: If patients feel they are moving through the system, the wait seems more tolerable.
- ▪ Anxiety makes waits seem longer. Dr. Jensen used the common scenario of a long flight with a layover but a delay on the first leg of the trip to explain how anxiety makes a wait seem interminably long. “You spend the entire time and flight waiting, watching, wondering if you'll make the connection,” he said. In terms of the ED, patients are often anxious, he noted, but by regularly communicating with patients and their family about why they have to wait — for tests? for a specialist? — can reduce this stress.
- ▪ Uncertain waits are longer than known, finite waits. Qualitative answers to the patient question of “how much longer?” are not comforting. Dr. Jensen recommended giving a finite amount of time, rather than simply “soon” or “very soon.” He cautioned, however, not to set unrealistic expectations for the patient as this will only incite more agitation.
- ▪ Unexplained waits are longer than explained waits. Again, the rule should be to keep patients informed. If there is a code or a major trauma that is interrupting the expected workflow, tell the patient; patients often understand the delay in their care.
- ▪ Unfair waits are longer than equitable waits. “First come, first served is something that people intuitively believe,” Dr. Jensen said. Unfortunately, that's just not how emergency medicine works. Reframing the scenario — literally — can convey the message to patients that they have not been given a “lesser” priority. Separate waiting areas for more acute and less acute patients would be beneficial because everyone in a particular waiting area is moving at the same relative rate.
- ▪ The more valuable the service, the longer the patient will wait. It's easy to see why concertgoers, for example, will wait hours and more hours to watch their favorite band perform. Though emergency care isn't nearly as pleasant as a concert, the same truth applies. A way to manage waits even before patients step foot in the door is to build the reputation of the ED or institution, Dr. Jensen said. “Make your facility the place where patients want to go.”
- ▪ Solo waits feel longer than group waits. If misery loves company, then the ED is the place to be. And in the face of an emergency, good company especially is useful. EDs can make room for family and friends so patients have someone to help them pass the time.