1. Ian Brewer 1
Health Services Operations Management
Final Project
Finding the Time: Why, Why, and How
Written by Ian Brewer
2. Ian Brewer 2
Table of Contents
I. Executive Summary p.3
II. Introduction p.4
a. Describing the Problem p.4
i. Face Time
ii. Health Promotion
iii. Prevention
III. Why You Should Find the Time Medically p.7
a. An Ounce of Prevention p.7
IV. Why You Should Find the Time Financially p.8
a. Assuming We Are Villains for a Moment p.8
b. Community as a Ship p.9
V. How You Should Find the Time Operationally p.9
a. Scheduling Plans p.9
b. Doctor-Patient Relations p.13
VI. Conclusion p.13
VII. Works Cited p.15
VIII. Appendix p.16
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Executive Summary
I find wide-ranging support for expanded appointment windows as a means to achieve
better and more cost-effective health outcomes for patients. Patients value the time their doctors
spend with them. When that time is shortened or punctuated with distractions and interruptions,
the patients’ health and satisfaction can be adversely affected. Patients should be given the time
to state their needs at each visit and doctors must be taught the proper listening and solicitation
strategies. Important medical information can be left out or forgotten when communication
between doctor and patient is curtailed. A communicative doctor-patient relationship creates the
proper foundation for the provision of preventive advice, screening, and directives.
Preventive medicine makes sense both medically and financially. Averting the need for
acute intervention in the future is frequently cost-effective. The sacrifices and lifestyle changes
required to live a healthy life now are easier to undertake than drastic efforts to save a life
threatened by years of poor health decisions. Simple interventions are also cost-effective. Advice
and assistance can go a long way toward ending damaging dietary behaviors or smoking habits,
for instance.
Pursuant to instituting these changes, I provide a number of recommendations for
scheduling and no-show reduction strategies. My research also includes a scheduling tool which
will be useful to practices which take data collection and utilization seriously.
A deeper relationship between doctor and patient supports better health outcomes and can
be supported by the proper tools, strategies, and employee commitment.
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Introduction
Describing the Problem
In our country, short doctors’ appointments have become a common complaint. This
problem is certainly not systemic in the United States. As Shaw, Davis, Fleischer, and Feldman
found in their 2014 study, appointment lengths have increased by an average of about two
minutes from 1993 to 2010 (p. 822). Many patients, however, feel that their needs are not being
met by the appointments they receive from their doctors. They describe three and four minute
consultations like the one described by Joan Eisenstodt in USA Today’s article detailing the
inadequacies patients are reporting in their care (Rabin, 2014). No matter how common these
sorts of practices are, your institution cannot afford to be among them.
Shaw et al. write, “According to a National Research Corporation Survey, patients listed
‘willingness to explain things’ as the most important factor in selecting a physician” (Shaw,
Davis, Fleischer Jr., & Feldman, 2014, p. 825). Practices could be in danger of losing patients to
competitors who are prepared to spend more time educating their patients. Shaw et al. point out
that patients are self-informed about medical matters to a higher degree than ever before due to
the availability of information online. This means that patients are more likely to be equipped to
have deeper discussions of their health with their doctors and are likely to be disappointed if a
doctor is unwilling to engage them.
Spending more explanatory time with patients is also a great avenue for presenting
educational material and preventive consultations to patients. One study found that extension of
appointments by only one minute produced a significant increase in prevention-focused activities
and educational discussions. They write, “Recording of blood pressure, smoking, alcohol
consumption, and advice about immunization was significantly more frequent in [longer
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appointments] (Wilson, McDonald, Hayes, & Cooney, 1992, p. 227). The time spent on these
activities made an impression on patients in this case as well. Wilson et al. write, “Patients more
often reported discussion of smoking and alcohol consumption and coverage of previous health
problems in the [longer sessions] (Wilson, McDonald, Hayes, & Cooney, 1992, p. 227).
Another study focusing on one practice showed similar results. Wilson writes, “There
was a suggestion that lifestyle factors (smoking, alcohol and diet/weight) were discussed more
frequently and that screening activity increased after the change” (Wilson A. , 1989, p. 24). We
can see that longer appointments lead doctors to allocate more time to educational discussions
with their patients. Wilson also points out that other facets of the relationship do not appear to
suffer. Prescribing, investigation, and referral rates were stable in both conditions (Wilson A. ,
1989, p. 25).
Another related communication problem among doctors is their listening skills. A
University of South Carolina study showed that doctors have an interruption problem. The
authors write, “Patients spoke, uninterrupted, an average of 12 seconds after the resident entered
the room. One fourth of the time, residents interrupted patients before they finished speaking.
Residents averaged interrupting patients twice during a visit” (Rhoades, McFarland, Finch, &
Johnson, 2001, p. 528). They also point out to doctors that verbal interruptions are not the only
means by which a conversation with a patient can be disturbed. They write, “Computer use
during the office visit now accounts for more interruptions than beepers. Verbal interruptions, a
knock on the door, beeper interruptions, and computer use all interfere with communication”
(Rhoades, McFarland, Finch, & Johnson, 2001, p. 531).
Marvel, Epstein, Flowers, and Beckman studied the rate at which doctors solicited the
full agenda a patient wanted to discuss in a visit. They found a pathetic trend. They write,
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“Physicians solicited patient concerns in 199 interviews (75.4%). Patients’ initial statements of
concerns were completed in in 74 interviews (28.0%) (1999, p. 283). This measure only analyzed
how often that initial statement went uninterrupted. In addition, when doctors redirect patient
agendas, as they frequently do, a patient’s full agenda is almost never completed. As they write
in the study, “Once the discussion became focused on a specific concern, the likelihood of
returning to complete the agenda was very low (8%) (Marvel, Epstein, Flowers, & Beckman,
1999, p. 286). The data in this study support a strategy of setting a full agenda at the outset of a
patient interview. After the conversation has been derailed by an interruption or focused on a
single issue, there is a very small likelihood that late-arising concerns will be brought up or that
important information will be shared by the patient. This disjointed communication creates a
“superior to inferior” relationship between the doctor and patient rather than a “service-provider
to customer” relationship as is normative in other industries (Marvel, Epstein, Flowers, &
Beckman, 1999).
Your practice can avoid these impediments to a positive relationship. With nationally
increasing consultation times, you do not want to fall behind the competition. At the same time,
other practices may not be aware of the other factors in the doctor-patient relationship that are
having an effect on the health of their patient population and their bottom line. Astute doctors
and managers will see the benefits to implementing improved processes to gain a strategic
advantage over other practices.
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Why You Should Find the Time Medically
An Ounce of Prevention
Amidst all this talk of spending more and higher quality time with patients, it is
reasonable to ask whether we can expect to see a return on our investment in terms of the health
of the patient population. The CDC has this to say concerning prevention: “Chronic diseases,
such as heart disease, cancer, and diabetes, are responsible for 7 of every 10 deaths among
Americans each year…. These chronic diseases can be largely preventable through close
partnership with your healthcare team, or can be detected through appropriate screenings, when
treatment works best” (Centers for Disease Control and Prevention, 2013). When doctors take
the time to promote vaccinations, screenings, and healthy behaviors with their patients, they are
improving the health of those patients and averting the need for more difficult remedies to acute
illnesses in the future. For example, screenings could identify pre-diabetic patients who could
then be counselled on diet and exercise regimens rather than developing a chronic condition.
When patients are redirected and not able to communicate their full list of concerns to
their doctor, their doctors are more likely to miss key information. Even if the patient is unaware
of developing health concerns, doctors who take extra time to discuss screenings with their
patients are more likely to convince them to undertake them. This increase in screening activity
and the promotion of healthy habits will support a healthy population. Doctors can take the time
to counsel their patients to take advantage of their insurance companies’ prevention programs.
As the World Research Foundation writes, “These companies are happy to cover preventive
medical expenses because they have the statistics that proves how much it saves them down the
road” (WRF Staff, 2014). Patients with a doctor’s prompting and financial backing are going to
be more likely to get involved in efforts to manage their health proactively.
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Why You Should Find the Time Financially
Assuming We Are Villains for a Moment
Why should we care if our patients are healthy or not? Perhaps it is more profitable to run
a practice addressing chronic illness after it develops rather than devoting resources to less
invasive, less labor intensive prevention programs. Cycling through patients as quickly as
possible could be a viable way to keep the money flowing and the illnesses treated (however
temporarily that treatment may last). Imagine that we throw the triple bottom line out the
window and operate our business only according to what makes the most money. Let us also
assume that no one would ever notice what a horrible thing we were doing and would let us get
away with treating them cost-effectively instead of effectively. Would we be able to make as
much money as a similar practice which employs preventive measures?
According to the data compiled by Maciosek, Coffield, Flottemesch, Edwards, and
Solberg, no. Exhibit 1 from their paper summarizes the life-years saved, the medical costs,
savings, and net costs of employing preventive measures (see the Appendix for Exhibit 1).
Several preventive measures jump out as medical savings. They write, “Clinical preventive
services that produce net medical savings . . . include the childhood immunization series,
pneumococcal immunization for adults, discussion of daily aspirin use, smoking cessation advice
and assistance, vision screening in older adults, alcohol screening and brief advice, and obesity
screening” (Greater Use Of Preventive Services In U.S. Health Care Could Save Lives At Little
Or No Cost, 2010, p. 1658).
Even if we turn out to be terrible people, we are still well-served to undertake many
preventive services for our own benefit as providers. We can see impressive savings from some
activities as easy as “discussing” daily aspirin use and “advice” regarding smoking.
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The Community as a Ship
Thankfully, most of us are not bad people. We take the triple bottom line into account
when planning our services. Social, environmental, and financial integrity create a future for a
business. Preventive services are like regular maintenance on a ship. Palliative medicine is like
patching the holes in our hull as they appear. The community a health care institution serves is
like a ship. When we employ regular maintenance to the hull and its other systems, the ship runs
smoothly. Situations inevitably arise in which the only good option is to patch the hull. These
blows to our integrity can more easily be handled by a ship that undergoes regular maintenance.
When many flaws are allowed to build up, the cascade effect is more likely to take over the
system at any given time. Eventually, the straw will fall and break the camel’s back. A very well-
designed process of hull patching will only keep the ship sailing for so long. When the hull
buckles, the patchers will go down with the rest of the ship.
Just like this, spending a little extra time performing regular maintenance upon our
community keeps the community viable for a longer time than episodic treatment alone. Since
the human race is capable of self-perpetuation, a community can flourish indefinitely under the
right circumstances. Community health is an indispensable element of those right circumstances.
In your community, a proper practice should employ maintenance and patching methods both.
How You Should Find the Time Operationally
Scheduling Plans
Cayirli, Veral, and Rosen found a few factors that have a significant effect on keeping to
an appointment schedule. They write, “No-shows, walk-ins, clinic size and patient punctuality,
emerged as the major factors affecting the performance and the ultimate selection of an
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appointment system” (Designing appointment scheduling systems for ambulatory care services,
2006, p. 57). How can we reduce the effect these factors have on the doctors’ and patients’ time
and put that time to the best use with the fewest delays? First, we must find an appropriate
appointment rule. An appointment rule is a model of patient intervals designed to keep doctors
and patients interacting at an optimal rate. Exhibit 2 in the Appendix details several appointment
rules studied by Cayirli et al.
They found three rules that perform with high efficiency among the seven rules they
studied. They write, “2BEG, MBFI and IBFI dominated the efficient frontiers as best
performers” (Cayirli, Veral, & Rosen, Designing appointment scheduling systems for
ambulatory care services, 2006, p. 57). Importantly for our purposes, they go on to make
recommendations based on the type of practice applying an appointment rule saying,
“Individual-block rules are mostly suited to specialties with short consultation times. In fact,
these rules should be avoided in clinics with long consultation times” (Cayirli, Veral, & Rosen,
Designing appointment scheduling systems for ambulatory care services, 2006, p. 57). Therefore,
if a practice is seeking to expand its consultation time, as I recommend, the best appointment rule
would be MBFI, a rule which calls patients two-at-a-time with intervals set at twice the mean
length of service in that practice. This will require data collection on the part of the practice
seeking to implement an efficient rule. Since the rule relies on an average of service time, I
recommend that its implementation be undertaken after efforts to increase the length and quality
of appointments are completed. I also recommend that this metric be frequently updated with
new average service times being applied to dates beyond the horizon of scheduled appointments.
The authors of this study also looked at strategies for scheduling new patients. They
write, “Placing new patients in the beginning of the session is preferred when doctor’s idle time
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is assumed to be highly valuable compared to patients’ time” (Cayirli, Veral, & Rosen,
Designing appointment scheduling systems for ambulatory care services, 2006, p. 57). The
opposite structure was best when the opposite dynamic between doctors’ and patients’ time was
present. In cases where a parity of value between their times was the norm, an alternating rule
worked best. The combination of this rule and the appointment rule produced sixteen cases the
authors studied for optimal efficiency. They write, “Rules that utilize multiple-blocks, 2BEG and
MBFI, appear among the best performers in all the sixteen environments investigated” (Cayirli,
Veral, & Rosen, Designing appointment scheduling systems for ambulatory care services, 2006).
When seeking to increase efforts to educate patients and more frequently provide screenings and
other preventive care, this model should serve well.
Another study addressed the issue of no-shows and walk-ins. These rates will vary
depending on the practice, but they must be accounted for so that your efforts in scheduling
patients are not brought to ruin by the variations inherent in this type of service delivery. A
practice must begin by measuring the prevalence of walk-ins and no-shows in their practice.
With longer-running data, a practice could make tailored predictions every day as retailers do for
sales. This is demand planning. With the proper numbers, your practice can find the right number
of appointments to schedule per a given time period in order to reliably fill the time efficiently.
In order to facilitate this, the authors provide an open source online tool for scheduling at
http://www.appointmentschedulingtool.com/. The authors describe their process saying, “The
procedure adjusts the mean and standard deviation of service times based on the expected
probabilities of no-shows and walk-ins for a given target number of patients to be served, and it
is thus relevant for any appointment rule that uses the mean and standard deviation of service
times to construct an appointment schedule” (Cayirli, Yang, & Quek, 2012, p. 682). Data
12. Ian Brewer 12
collection should thus become a priority at your practice. An operations officer should be tasked
with collecting this information so that it can be put to the proper use as soon as possible.
Dealing with no-shows is just a form of institutionalized fire-fighting, though. In some
practices, this reality will never be eliminated. The practice can, however, be curtailed if the
proper interventions are undertaken. One study showed that multiple methods could be employed
to create a dramatic reduction in the no-show rate. The authors describe the various methods
used in the study writing, “The group designed a multi-method intervention to decrease the
clinic’s no-show rate: (1) an educational program focused on the NS cohort that discussed the
effects of no-shows, (2) a modified method of double-booking patients in providers’ schedules,
and (3) a modified advanced access scheduling system to replace the traditional scheduling
model of the clinic” (DuMontier, Rindfleisch, Pruszynski, & Frey III, 2013, p. 636). The NS
cohort was made up of the worst offenders of the no-show patients. These patients missed more
than six appointments in an 18-month period. As the authors say, “The NS cohort, although 2%
of the total practice population, accounted for almost one sixth of all no-shows in the pre-
intervention time period” (DuMontier, Rindfleisch, Pruszynski, & Frey III, 2013, pp. 636-637).
Exhibit 3 shows the results of their interventions. They saw an almost 13% reduction in
no-shows from the NS cohort and a 3% reduction in no-shows in the total population
(DuMontier, Rindfleisch, Pruszynski, & Frey III, 2013, p. 638). These improvements persisted
over the next four years of observation. This persistence in the change is likely due to the
commitment of the staff to the new system of education and scheduling. I recommend this study
highly for the purposes of educating your workforce so that they may be invested in the
implementation of these interventions.
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Doctor-Patient Relations
The USC study cited earlier shows that doctors need not be concerned that a full
solicitation of the patient’s agenda will put them in a time crunch. They write, “Patients allowed
to complete their statement of concerns used only 6 seconds more on average than those who
were redirected before completion of concerns” (Marvel, Epstein, Flowers, & Beckman, 1999, p.
283). They point out that fellowship-trained physicians were more likely to solicit a full agenda
from their patients. Training all the doctors in your practice to employ the methods described in
this paper would be beneficial. It could be hurtful to a patient’s health to employ practices which
frequently leave important medical information unsaid. The authors describe the habits of these
fellowship-trained physicians saying, “The opening solicitation of patient concerns often was
characterized by an open-ended question followed by nondirective facilitating utterances (e.g.
‘Uh-huh’ or ‘What else?’) (Marvel, Epstein, Flowers, & Beckman, 1999, p. 286)
Doctors must also be aware that sensitive and emotional topics are likely to take
somewhat longer to come out in an interview and thus a few extra seconds can potentially lead to
the most important subject the patient wishes to address. The authors also recommend the use of
focused questions regarding the patient’s most recent complaint followed by open-ended
questions inviting the patient to air out any other concerns before moving on ( (Marvel, Epstein,
Flowers, & Beckman, 1999, p. 286).
Conclusion
A good practice supports a healthy community. This support can be provided responsibly,
not only with regard to social and environmental responsibility, but also to your financial well-
being. Patients value a doctor who addresses their needs by listening to them and clearly
14. Ian Brewer 14
explaining their treatments and recommendations. When those doctors take a little time to listen
to and educate their patients, many practices will see a net benefit.
Research has provided strategies and tools to accomplish the schedule you aim for in
your practice. According to your needs and the needs of your patients, you can use the tools they
provide to optimize your practice. One must remember, though, that these tools do not work on
their own. You must begin collecting data from your doctors and patients and the circumstances
of their meetings to determine what the best solution is for you.
Leaving no-shows and walk-ins at their natural levels is not beneficial to your practice.
Undertake educational efforts to fireproof your home instead of constantly putting fires out.
In short, implement policies that support preventive medicine. The strategies and tools
needed to successfully do so are at your disposal. Your practice can support a healthy population
by working with its patients educationally and cooperatively.
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Works Cited
Cayirli, T., Veral, E., & Rosen, H. (2006). Designing appointment scheduling systems for
ambulatory care services. Health Care Manage Sci, 45-58.
Cayirli, T., Yang, K. K., & Quek, S. A. (2012). A Universal Appointment Rule in the Presence
of No-Shows and Walk-Ins. Production and Operations Management, 682-697.
Centers for Disease Control and Prevention. (2013, June 12). Preventive Health Care. Retrieved
from Centers for Disease Control and Prevention:
http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/preventive
health.html
DuMontier, C., Rindfleisch, K., Pruszynski, J., & Frey III, J. J. (2013). A Multi-Method
Intervention to Reduce No-Shows in an Urban Residency Clinic. Family Medicine, 634-
641.
Maciosek, M. V., Coffield, A. B., Flottemesch, T. J., Edwards, N. M., & Solberg, L. I. (2010).
Greater Use Of Preventive Services In U.S. Health Care Could Save Lives At Little Or
No Cost. Health Affairs, 1655-1660.
Marvel, M. K., Epstein, R. M., Flowers, K., & Beckman, H. B. (1999). Soliciting the Patient's
Agenda: Have We Improved. JAMA, 283-287.
Rabin, R. C. (2014, April 20). USA Today. Retrieved from You're on the clock: Doctors rush
patients out the door: http://www.usatoday.com/story/news/nation/2014/04/20/doctor-
visits-time-crunch-health-care/7822161/
Rhoades, D. R., McFarland, K. F., Finch, W. H., & Johnson, A. O. (2001). Speaking and
Interruptions During Primary Care Office Visits. Family Medicine, 528-532.
Shaw, M. K., Davis, S. A., Fleischer Jr., A. B., & Feldman, S. R. (2014). The Duration of Office
Visits in the United States, 1993 to 2010. Am J Manag Care, 820-826.
Wilson, A. (1989). Extending appointment length -- the effect in one practice. Journal of the
Royal College of General Practitioners, 24-25.
Wilson, A., McDonald, P., Hayes, L., & Cooney, J. (1992). Health promotion in general practice
consultation: a minute makes a difference. BMJ, 227-230.
WRF Staff. (2014, January 12). Preventive Health Care Helps Everyone. Retrieved from World
Research Foundation: http://www.wrf.org/preventive-healthcare/preventive-
healthcare.php
