UO > Feature > Staying on Schedule

February 25, 2003 is a day Dr. Ty Weller would just as soon forget. One of his patients, Aristotelis Belavilas, was scheduled for a 2 pm appointment. Weller, a pain management specialist in Las Vegas, was supposed to give Belavilas a steroid injection in his spine to help fight pain before his patient left on vacation to Greece.

Belavilas came early, but Weller didn’t arrive until 5:15 that afternoon. Belavilas received no apology or explanation for the long delay, and believed the doctor was rude to him. He stormed out of the doctor’s office without any treatment and later sued Weller in small claims court. Weller’s crime: having Belavilas wait more than three hours for medical care.

Belavilas won the suit and was awarded a $250 judgment, but he didn’t care about the money. All he wanted was a little respect. Although the physician appealed the decision, the pair ended up settling. Weller wrote a letter of apology to Belavilas and offered to donate $360 to the Nevada Childhood Cancer Foundation while Belavilas agreed never to talk about the case to the media.

While the case set off debates across the country as to whether Belavilas was justified in suing the doctor, it also shed light on an important problem that still challenges many physicians today: staying on time with patient appointments.

It sounds simple, but it’s among the most difficult goals for any practice to achieve. Blame it on emergencies, chatty patients, or double-booked appointments. Regardless of the reason, the fallout can be hazardous to a physician’s reputation and bottom line. Still, some practices manage to run like clockwork, keeping patients waiting no longer than 15 minutes. How do they do it? They apply a variety of techniques that keep them on task, in focus, and on time.

Consider asking this question to each person employed at your practice: If a patient has an 8 am appointment, what does that mean? Does the doctor see him at 8 am? Is he brought back to the exam room at 8 am? Does the nurse record his chief complaint or take his blood pressure at 8 am? Or, is the patient supposed to check in at the front desk at 8 am?

Don’t be surprised if everyone has a different interpretation. Most do, says Debi Croes, a principal at The Croes Oliva Group, a national health-care consulting firm based in Burlington, Massachusetts.

“It all starts with the definition of where [the day] begins,” she says. “You can’t have a correct operation unless everybody has the same definition. This is a really big point.”

To test the waters, sometimes she schedules business appointments with physicians when their practice opens in the morning but arrives 30 minute early. More often than not, she’s waiting in the parking lot or outside the practice’s front door with other patients who are confused about what their 9 am appointment time means, especially when staff doesn’t arrive until 8: 55 am.

She says this is a very common mistake among practices, but it is easy to fix. Yet, the opposite can be equally as problematic. She tells the story of one physician who began seeing patients when they arrived, sometimes one-half hour earlier than their scheduled appointments. They quickly learned to come early since the doctor observed a first-come, first-seen schedule. Soon patients began coming anytime they pleased and complained when they weren’t seen within 15 minutes of their arrival time. The lesson, says Croes, is for physicians to create their own rules and be consistent.

Another tip is assigning someone to be in charge of office flow. It could be a medical assistant or office manager who would monitor patient appointments on a daily basis and identify potential problems that could cause delays.

Other times, a big waiting room could be the culprit. She remembers one obstetrician with time management issues, partly because he didn’t have enough patient exam rooms. So he shrunk the size of his waiting room and expanded the number of exam rooms in his office, all within the same square footage.

“He told me, ‘You fixed my operations. This enormous waiting room was a sign of my dysfunction,’” says Croes. “He built two extra exam rooms. That translated to close to (an extra) $250,000 a year.”

Dr. Neil Baum believes the problem mainly boils down to office flow. A urologist in New Orleans, he averaged 30 patients each day, mostly within 15 minutes of their designated appointments.

On a typical visit, he briefly greets the patient in the exam room. Shortly after, his nurse enters the room to record the patient’s history on a tablet PC. At this time, Baum leaves the room to examine another patient. After each exam, he shares diagnostic and treatment information with the nurse, who then enters the data into a computer system and prints out a report for the patient that summarizes the visit and includes details like when to take prescribed medications.

While the report is being prepared, a patient can watch a five- to seven-minute video about his specific condition. Each video features Baum explaining a common ailment and treatment options. Afterward,


	Dr. Neil Baum, a New Orleans urologist, organizes his appointments carefully and keeps patients involved at every step. This keeps him efficient and helps patients feel they have his undivided attention. © 2006 mary lou uttermohlen

Baum returns to the exam room, summarizes the information once more and answers any questions. Then the patient is handed the summary report, which also reiterates highlights of the video.

“Patients only retain 5 to 10 percent of what they hear,” says Baum, who is slowly rebuilding his practice post-hurricane Katrina. “Once you give them written material that summarizes what you said, you can enhance the likelihood of patient compliance many fold.”

But there are other advantages. He says patients rarely call the practice with follow-up questions, which can consume valuable time from staff and cause delays in delivery of care. Sometimes, it even makes patients feel like Baum is devoting more time to them than the standard five minutes per visit. Part of the reason is they’re occupied—either with him, a nurse, or a video—instead of being left alone in an exam room.

Still, there’s one cardinal rule that should never be broken: Don’t interrupt physicians during patient visits unless there’s an emergency.

This was a valuable lesson one patient taught him years ago. While examining the patient, Baum was interrupted by a phone call. He stepped out of the room and returned within a few minutes. During the same exam, he was interrupted two more times, each time stepping out of the room to accept the call. When he returned to the same exam room the third time, the patient informed him that he would seek care elsewhere. Baum was devastated.

Now patients believe they have his timely, undivided attention. “One patient said, ‘I can see you’re thinking out of the box,’” Baum says. “My attitude is there is no box. I’m not even seeing a box.”

Dr. Ari Brown, a pediatrician in Austin, Texas, also relies on what she calls the Disney World approach. When parents check in at the front desk, they’re usually handed a developmental assessment for the child and lead or cholesterol screening forms to complete while they wait 15 minutes to see her.

“If you give them something to do, they don’t feel like they’re twiddling their thumbs waiting for you,” says Brown, explaining that Disney World keeps patrons occupied while waiting in long lines for rides. “And you just saved yourself time because you don’t have to ask those questions.”

Patient education also ranks high on her to-do list. Her staff informs patients about why the practice may be running behind and provides guidance to avoid it. Parents are consistently told to call if they’re running late, to come early if their health insurance has changed and if they’re bringing a second child along who has suddenly developed a bad cough, to book a new appointment. She has even co-authored a book, which many of her patients have read, called Baby 411: Clear Answers and Smart Advice for Your Baby’s First Year, (Windsor Peak Press, 2003). Among her favorite chapters is “Behind the Scenes: Why Is My Doctor So Late?”

“Educate the patient—-that’s the first step,” Brown says. “It’s not rude to say, ‘We don’t want you waiting in the waiting room for an hour. Here are some things you can do.’”