The waiting game: Dispatches from urgent care

After spending years as a practicing physician and later working with others to improve processes in health-care delivery, it’s still refreshing to spend some time on the other side of the exam table.

urgent careI recently lacerated my toe when a blender jar fell from the counter top and, bleeding profusely, went with my partner to a nearby urgent care, my toe tightly wrapped in a bandage. We entered a large waiting room with 20 chairs and only one other patient only to spend 10 minutes waiting for a medical technician to enter my information into a computer. This is after I spent five minutes completing the form on paper. This made me very, very pessimistic about how long I might have to wait to see a physician. The television playing a History Channel documentary showing bridges falling and the destruction of surrounding areas didn’t help.

The registration process triggered my lean thinking: Many hospitals are spending a lot of money installing kiosks for self-registering patients. The idea is great but the cost ultimately isn’t justified. Filling out the forms, I thought of how efficient it would be if the registrar had turned her own computer screen to me and asked me to enter the information directly on the computer. With a quick confirmation of some key information, that would save 10 minutes. Small change, big benefit.

Patient intake is only one challenge, though. Patient variation is an entirely different issue.

While in the waiting room, I saw a female patient in her late 60s arrive with her daughter. At least another 15 minutes passed as the new arrivals scrambled to find an insurance card and driver’s license and another patient in the waiting room was called back. Eventually, we were called back to sit in an exam room, where my mind was still lingering, thinking about the fate of the older patient and her daughter.

What transpired in the waiting room over a half-hour is nothing but patient variation: I was signed in within 15 minutes, while another lady waited for more than 30. So how do you apply lean/six sigma to the business of health care with so much variation? The answer: With empathy! Some experts in the field tend to downplay the very existence of patient variation, which only evokes defensiveness from health-care professionals who treat patients day in and day out. Ultimately, it’s important to examine data on the number of times events deviate from the normal and develop an improvement plan that incorporates that variation.

On our way to the exam room, my partner asked if I’ll need an X-ray. The answer: “I can take your X-ray if you want.” I was shocked. When I practiced medicine, patients weren’t entertained this way. I’d always have a reason for any labs or X-rays. In turn, I responded that I didn’t want an x-ray unless there was a reason for one. She shrugged her shoulders and said: “If you don’t want the X-ray, we won’t do it. It’s up to you.”

Once in the exam room, my vitals were taken and I asked to unwrap my bandage but was told “Not yet.” It’s essential to take vitals, but I was getting desperate for the provider to open my bandage, examine the wound and treat me.

We waited some more. I flipped through a WebMD magazine labeled “complementary waiting room copy.” This made me realize how much we’ve built waiting into providing care.

A half-hour later, my toe was finally examined but I waited another five minutes for the doctor, who went directly to the wound and got down to the suturing business. He explained what he was going to do, but didn’t say whether I should continue to sit or lie down. Four painful stitches later, he took off his gloves and left the room with the instruction to take painkillers on and off and change the bandage every day. But I realized that he hadn’t put any bandage on my toe. After waiting for about 10 minutes, my partner went out to get someone to bandage my toe. Five minutes later, someone arrived, put on a fresh pair of gloves and dressed my wound.

The doctor came after 15 minutes and handed me a two-page document, asking me to come back in a week to 10 days to get the stitches removed.

There are a multitude of problems here. The doctor didn’t put a bandage on my wound, but he had gloves on and it only would have taken a few more minutes. He preferred to leave me without a bandage and type out a two-page document, which, frankly, I still haven’t read. A physician’s assistant in scrubs had to waste a pair of gloves to do the dressing. Here, we’re providing more assistants and nurses so doctors can focus on clinical work – but a patient really doesn’t really care how or how much a physician writes notes. A hospital doesn’t benefit from wasting supplies, and a doctor isn’t doing clinical work when he or she is documenting.

The solution here is to help physicians by slashing the amount of documentation and keeping only value-added information. When I practiced, I used to take the vitals and history. I sutured and dressed the wound myself. There were almost no handoffs. I also documented with the patient sitting with me in my clinic. I could finish a regular visit in fewer than 15 minutes.

We’re asking providers to document a bit too much. And even though we are providing them additional resources to “save” them time, that savings isn’t benefitting who it truly should: Patients. This is never more apparent than when you’re the one on the exam table.

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