# The Effect of Patient Arrival Time on Overall Wait Time and Utilization of Physician and Examination Room Resources in the Outpatient Urology Clinic

Authors: Onisuru T. Okotie; Neel Patel; Chris M. Gonzalez
Journal: Advances in Urology
 (2008)

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## Abstract

Introduction and objective. We examined patient waiting times, physician utilization, and exam room utilization in order to identify process improvements that may improve patient satisfaction. Methods. Time patient arrived to clinic, time patient was placed in the exam room, time the physician arrived in the exam room, and time physician discharged the patient from the exam room were prospectively recorded for 226 outpatient visits. Results. Overall, 63.2% of patients were on time for their scheduled appointment with 14.8% patient “no-shows.” On-time patients were found to have a longer wait time once in the exam room for the physician than those that were late (14.8±9.2 minutes versus 11.0±8.4 minutes, P=.005); however, those patients spent a significantly longer time with the physician (10.7±6.0 minutes versus 8.9±5.8 minutes, P=.041). Exam room utilization was lower for late patients (28.9% versus 44.7%, P=.03) with physician utilization lower in clinics with 3 or more late patients when compared to clinics with 2 or fewer (59.7% versus 68.7%,
P=.004).
Conclusions. Late patients had significantly less time with the physician than on-time patients.  Late patients also decreased the overall efficiency of the clinic; therefore, measures to reduce late patients are vital to improve clinic efficiency.


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## Body

## 1. Introduction

In 1999, the Institute of Medicine's (IOM) article “To err is human” reported that
approximately 98000 people die annually in the US because of preventable
medical mistakes [1]. This report raised public awareness of
medical errors and sparked new solutions to increase health care quality. In 2001, the IOM's subsequent report “Crossing the quality chasm”
recommended aligning reimbursement policies with quality improvement,
increasing awareness of pay-for-performance (P4P). P4P is based on rewarding physicians for the
quality of provided care with financial or other incentives [2]. Traditionally, physician
reimbursement has reflected the type and quantity of care without any
measurement of health care quality or patient satisfaction [3].One important component of measured health care quality is
patient satisfaction. The goal of this study was to define and analyze the
impact that patient arrival time to the clinic had on overall patient flow
through the office during the course of an ambulatory visit. Focus was placed
on such parameters as patient waiting time, time spent with the physician, and
time spent in the examination room.


## 2. Materials and Methods

A systematic analysis of the Northwestern urology outpatient
clinic process was prospectively observed over the course of three months. Parameters
including patient clinic arrival time, time the patient was placed in the exam
room, time the physician arrived in the exam room, and time the physician
discharged the patient from the exam room. All data were recorded for 226 outpatient visits over a total of 306 scheduled appointments for one urologist (CMG) (Table1). A patient was considered “late” if he/she
arrived to the office check in counter after the scheduled appointment time. A
patient was classified as a “no show” if he/she did not arrive for their
appointment and did not call to reschedule. Exam room utilization was
calculated as the ratio of total MD time in the exam room to the total patient
time in the exam room. Physician utilization per clinic session was calculated
as the ratio of total time the physician was in the exam room with a patient to
the total time of the clinic session. An independent t-test was used to
compare exam room and physician utilization per clinic stratified by on-time,
late, new, and return patients. Patients undergoing procedure-related visits
were not included in this analysis. An independent t-test was used to
compare exam room and physician utilization per clinic stratified by on-time,
late, new, and return patient status.Table 1
Demographic characteristic of outpatient urology clinic patient population.
Total outpatient appointments306Total outpatient nonprocedure patients226Number of clinics19Mean no. of patients per clinic15.9±5.0Mean no. of new patients clinic4.1±1.7Mean no. of return patients per clinic7.7±3.3Mean time in clinic per patient (minute)34.1±16.2Mean time with MD per patient (minute)9.0±6.0


## 3. Results

Patient flow through the outpatient urology clinic is illustrated. There were a total of 306 schedule patients included in the study
analysis. Of these, 45 patients were no show
patients and 35 patients were patients who underwent an office procedure. Of the 306 total scheduled patients included
in the study, 63.2% were on-time or arrived before their scheduled appointment, 15.1% were <15 minutes late, and 6.8% were >15 minutes late. “No show”
patients were 14.8% of the appointments (Table2). On-time patients were found
to have a statistically longer wait time once in the exam room for the
physician than those who were late (14.8±9.2 minutes versus 11.0±8.4 minutes, P=.005); however
on-time patients spent a significantly longer time with the physician in the
exam room (10.7±6.0 minutes versus 8.9±5.8 minutes, P=.041)
(Table 3).Table 2
Patients stratified by arrival time compared to scheduled appointment time.
Percentage of no show patients14.8Percentage of on time patients63.2Percentage of patients <15 minute late15.1Percentage of patients 15–30 minutes late4.9Percentage of patients 30–60 minutes late1.6Percentage of patients >60 minutes late0.3Table 3
Patient wait times  by on time versus late arrival patients.
On-timeLateP-value**Total patients (%)*63.222.0—Mean time in exam room waiting for MD (minute)14.8±9.211.0±8.4.005Mean time in room with MD (minute)10.7±6.08.9±5.8.04*No show patients were 14.8%.**P-values determined by independent t-test.The overall exam room utilization ratio was 32.5% and did not
significantly differ between on-time and late patients (P=.067) or new
and return patients (P=.35) (Table 4). When new patients were
stratified as late or on-time, exam room utilization was significantly lower
for late patients (28.9% versus 44.7%, P=.03). Furthermore, physician utilization was
significantly lower in clinics with greater than 2 late patients when compared
to clinics with 2 or fewer late patients (59.7% versus 68.7%, P=0.004)
(Table 5).Table 4
Exam room utilization (P-values determined by independent
t-test).
NTotalOn timeLateP-value*All patients3060.330.310.37.07New patients790.310.290.45.03Return patients1470.330.320.35.52*P-values represent difference between on-time
and late groups.Table 5
Physician utilization stratified by number of late patients per clinic.
NPhysicianP-value*utilization≤2 late patients90.69.023 late patients50.58≥4 late patients50.61*P-value determined by ANOVA.


## 4. Discussion

With the implementation of quality reporting, there is an increased
emphasis on efficiency and patient satisfaction. We attempted to evaluate one
phase of the ambulatory patient flow process, patient arrival, and analyze its
impact on physician and examination room utilization. In our study, we have
shown that patients who were late for their clinic appointment can be a key
problem to the efficiency of the outpatient urology clinic. As the number of
late patients in a clinic increases, the utilization of the physician's time
significantly decreases. Furthermore,
late patients were found to have spent less time with the physician, thus
putting more pressure on the physician to compact the visit in a shorter amount
of time in order to stay on time and maximize patient satisfaction.Another measure of process efficiency that we analyzed was
exam room utilization, defined as the
ratio of the total time the physician was in the exam room to the total time
the patient was in the exam room. Overall exam room utilization for all
patients was poor with a mean of 32.5% use of existing capacity. Our clinic
process analysis indicates that this is likely secondary to such reasons as poor
communication between the office support staff and the physician as to when the
patient arrives in the room and also the fact that appointments are scheduled
for inappropriate amounts of time, either too long or short, where multiple
patients are “overbooked” at the same time creating a scheduling bottleneck. The visit durations allowed in
our electronic medical record (EMR) are 15 and 30 minutes. With the variety of patients visits categorized simply as
either new or return, this inflexibility in scheduling does not capture the
true amount of time needed for each visit. Many times, return postoperative patients require only 5-minute visit,
whereas patients who require cancer treatment counseling may require upwards of
one hour. The ability to project estimated visit times prior to the clinic
session and schedule the number of patients appropriately would more closely
match the demand and supply of outpatient visits and improve patient flow. Finally,
we found that the need to automate patient arrival would be very helpful as
many times patients arrived on time and were not properly logged into the EMR
as a result of human error. In response to these data, we now ask new
ambulatory clinic patients to arrive 20 minutes early and return patients 10
minutes early. Those who
arrive late without warning are offered the options of waiting for the next
available appointment time that day or rescheduling for another day. Data are forthcoming on the success of these
strategies.Another relevant process flaw that we have derived from these
data includes the
lack of stored or “prework” prior to the patient visit. New patients in our
system are asked to fill out an intake questionnaire that provides basic
medical information as well as insurance information. This form is typically sent to the patients
before their visit as it can take up to 20 minutes to complete. Despite sending
it prior to the visit, we found that only 50% of patients completed this
information prior to the visit which, although they were technically on time,
made them late arrivals within the confines of the process as they completed
the form in the registration area. If these patients were counted as being late,
the aforementioned utilization problems of this study would augmented further. Measures to improve previsit compliance with
this process are needed.Limitations of this study include the lack of postvisit
patient satisfaction questionnaires which could be stratified according to the
arrival time of the patient. These data would corroborate if spending more time
with the physician did indeed lead to improved patients satisfaction. The use
of only one physician in one office location in order to define this process
may have led to specific biases commensurate with the practice patterns of that
individual or institution. Multiple sites with several physicians would
eliminate many of these biases. Nonetheless, these data attempt to demonstrate
the complexity of patient flow processes and the ramifications of one variable,
patient arrival time, within an ambulatory setting.


## 5. Conclusion

Late patients spent significantly
less time with their physician in the exam room as compared to those who arrive early or on time.
On-time or early patients spent more time with the physician, but spent longer
times waiting idle in the exam room.  Physician utilization per clinic session was
significantly decreased in clinics with 3 or more late patients. Future
improvement in the clinic process and methods to reduce the number of late arriving
patients may improve the efficiency of the ambulatory patient flow process in
the urology clinic.



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