MANY RURAL communities lack options when it comes to healthcare and urgent care, and patients living in these areas sometimes experience health disparities due to their geographic location.1 Adams County, Ohio, which has a high rate of unemployment and poverty, is one such rural community where healthcare options can be limited. Because access to public transportation is also limited, families in the area may have difficulty obtaining healthcare without personal transportation.2
An urgent care clinic opened in the county 2 years ago, the only facility like it in a 50-mile radius. Unfortunately, patients often experience long wait times before being seen by a healthcare provider. This article details a change project initiated to improve patient satisfaction at the clinic.
The practice problem
The urgent care clinic, which operates within a family health center, was experiencing problems with diminished patient satisfaction. Extensive data collection took place to determine the cause, and patient surveys revealed that dissatisfaction was largely due to prolonged wait times to see a provider. According to the CDC, 69% of urgent care facilities have patient wait times of 20 minutes, which is considered less than convenient.3 Additionally, 28% have a wait time of 21 to 40 minutes, and 3% have more than a 40-minute wait.3 At the Adams County urgent care clinic, many patients waited an hour or longer before their assessment, which led to decreased patient satisfaction.
When patients are dissatisfied, they may discontinue care at a facility. Because healthcare options in rural communities are limited, these patients are likely to refrain from seeking care altogether rather than inconveniencing themselves with an extended wait time. Patients who do not receive proper preventive, urgent, or follow-up care risk the prospect of further deteriorating health and preventable complications.4
If patient satisfaction did not improve, patients would likely discontinue care at the facility. Without sustainable revenue, the urgent care clinic would be forced to close, the staff would lose their jobs, and the local community would have lost a valuable healthcare option.
To address this, the facility initiated a change project by posing a question based on a PICOT (patient/problem, intervention, comparison, outcome, time) approach that would serve as the basis for the implemented communication changes.5 The PICOT research question was: For patients experiencing long wait times (P), how will the implementation of an evidence-based practice (EBP) communication protocol (I) compared to not using the communication protocol (C) affect patient satisfaction (O) over an 8-week period (T)?
Following the AIDET communication protocol
The mission statement for the 8-week change project was to sustain a quality healthcare option for the community by improving patient satisfaction and patient-centered care. A communication protocol known as AIDET (acknowledge, introduce, duration, explanation, thank you) was introduced to support this mission.6 The nursing staff supported and directed unlicensed assistive personnel (UAP) and assisted with communication and coordination. Using the AIDET protocol, staff follow this sequence of events:
- Acknowledge: Patients are greeted by name and with a smile.
- Introduce: UAP and nurses introduce themselves and ask for verbal consent to participate.
- Duration: Patients are given an estimated wait time based on their level of urgency and place in line. A white board hanging in the waiting room is updated with the current wait time every 15 minutes.
- Explanation: Patients are given a written information sheet explaining the change project at check-in.
- Thank you: At check-out, the UAP thanks each patient for choosing the facility for their urgent care needs. A follow-up survey is emailed to patients to document their experience.
Before the AIDET protocol was implemented, patients had checked in and waited to be seen without being informed of their estimated wait time. As they waited, no efforts were made to keep patients informed of when they would be seen.
Researchers collaborated with the staff to ensure the success of the change project.7 One week of training was scheduled to discuss the project with any staff involved in the change. The nursing staff and UAP were educated on the AIDET communication protocol, with an explanation that improving patient satisfaction was important for the sustainability and profitability of the urgent care clinic. After all responsibilities were reviewed, a trial implementation was conducted over a second week to ensure that all nurses and UAP were adherent, during which time no surveys were sent to patients.
After the trial period, the AIDET protocol was implemented. Researchers continued to discuss the AIDET communication protocol with the staff during weekly meetings. Any issues and/or concerns that arose were addressed and discussed to identify strategies to make the change process less stressful.
Outcome and results
As measured by pre- and postintervention surveys, the goal of the project was to increase patient satisfaction by 10% during long wait times, which were defined and specified by the CDC.3 If patients feel respected and valued, they will be more satisfied with the care they receive, despite any extended wait periods before seeing a provider.8 The researchers hypothesized that the communication protocol and improved information flow would leave patients more satisfied during extended wait times.
To evaluate response to the project, each patient was emailed a survey following his or her urgent care visit. The validated survey used for this project was taken from a 2011 EBP study, and it was used for both pre- and postintervention data collection.9 Surveys were anonymous, so no identifiable patient information was obtained. The questions yielded information on how many times patients had visited the clinic in the past 3 months, the urgency of the most recent visit, the time of day, the waiting period, and their satisfaction with the experience. The data were exported for analysis, and ordinal data were produced according to the results.
Data were collected over the course of 8 weeks, with the communication protocol in use for approximately 840 urgent care patients during implementation. Typically, a 10% to 30% response rate is expected on customer satisfaction surveys.10 After discarding incomplete surveys, the sample response rate was slightly lower than average at 9%, with 58 preintervention surveys and 54 postintervention surveys. Although all participants were emailed surveys, distribution of physical surveys at check-out may have yielded better results. The data revealed that satisfaction increased following the implementation of the AIDET communication protocol.
Notably, although most patients had rated their satisfaction positively, the number of patients who rated their satisfaction level poorly was drastically higher in preimplementation than in postimplementation. Each survey question was scored between 1 (extremely dissatisfied) and 5 (extremely satisfied), and overall patient satisfaction was rated between 7 and 35:
- Extremely dissatisfied: from 7 to 10
- Dissatisfied: from 11 to 17
- Neutral: from 18 to 24
- Satisfied: from 25 to 31
- Extremely satisfied: from 32 to 35.
The preimplementation surveys reflected an average satisfaction score of 23.26, with a standard deviation of 10.8. The postimplementation surveys demonstrated an average satisfaction score of 31.52, with a standard deviation of 4.68. From the given dataset, there is 95% confidence that the overall satisfaction rating of preimplementation patients was between 20.4 and 26.1 on average. Postimplementation scores ranged from 30.24 to 32.8, with an overall satisfaction rating between 9.84 and 6.7 points higher than their preimplementation counterparts on average.
Wait times were measured in 15-minute increments. Postimplementation patients consistently rated their satisfaction level higher than preimplementation patients across each interval. The patient who experienced the longest wait time (90 minutes, postimplementation) still gave a high satisfaction rating. These results demonstrated increased patient satisfaction as a result of the communication protocol.
Discussion and analysis
Previous studies on the AIDET communication protocol demonstrated benefits within hospital settings, but few had been conducted in a rural urgent care setting.6 Data analysis showed that patient satisfaction increased by approximately 24% in this setting following the protocol's implementation. Specifically, researchers conducted a SWOT (strengths, weaknesses, opportunities, threats) analysis, analyzed the project results, and arrived at the conclusion that the project's benefits outweighed its limitations.
By initiating a relatively simple, inexpensive change in facility protocol, the project demonstrated many benefits, including the retention of current patients and the potential to attract new ones. A major limitation was the project's small sample size. Additionally, staff satisfaction with the implementation of the communication protocol was not evaluated, but it may be beneficial in future change projects.
In today's healthcare environment, patient satisfaction drives not only service reimbursement, but also patient referrals and brand recognition within a community. EBP communication tools such as the AIDET protocol can be used in both the ED and in rural urgent care settings, where long wait times can negatively impact patients' experience and outcomes.
Based on these results, the researchers recommend repeating the change project to evaluate staff responses. Allowing patients to complete the surveys onsite after their visit may also help to increase the number of completed survey responses, but there are pros and cons to this approach. Although the visit may be fresh in patients' minds at check-out, their perception may change over time. Additional research into interventions to decrease wait time is also recommended, evaluating satisfaction scores and wait time with any subsequent processes.
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