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Improving satisfaction among established patients in a midwestern pain clinic
Applied Nursing Research 33 (2016) 54–60
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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Improving satisfaction among established patients in a midwestern pain clinic Kathy A. Baule a,c,⁎, Linda D. Scott a,b, Kelly D. Rosenberger a,d, W. Stephen Minore d,e a
University of Illinois at Chicago College of Nursing, 845 S. Damen, Chicago, IL 60612, United States University of Wisconsin-Madison School of Nursing, 701 Highland Ave, Madison, WI 53705, United States c Indiana University Ball Memorial Hospital, 2401 W. University Ave, Muncie, IN 47303, United States d Rockford Anesthesiologists Associated, 2202 Harlem Ave, Loves Park, IL 61111, United States e University of Illinois at Chicago College of Medicine, 845 S. Damen, Chicago, IL 60612, United States b
a r t i c l e
i n f o
Article history: Received 4 August 2016 Revised 24 September 2016 Accepted 15 October 2016 Available online xxxx
a b s t r a c t Background: A problem in many health care practices is deciding the appropriate appointment length for new and established patients. Patients become frustrated when there is inadequate time to have their needs met, yet when a patient's clinic time is spontaneously lengthened, the provider gets behind in schedule, causing delays and greater frustration for others. Aim: The aims of this evidence based project were to determine whether implementation of a flexible appointment system would improve the current scheduling process in a pain clinic by allowing complex patients the opportunity to schedule a longer clinic appointment and would improve patient satisfaction. Design: This evidence-based practice innovation followed a program evaluation process using a descriptive, existing survey completed by clinic staff and patients. Setting: A Midwestern pain clinic caring for patients with acute and chronic pain diagnoses. Participants: A convenience sample of 120 patients were surveyed before and after the process change. Thirteen staff members completed the survey on SurveyMonkey pre and post procedural change at the same intervals the patients were surveyed. Results: Patients were more satisfied with the time that they spent in the exam room and the waiting room. The process change improved communication with staff and patients and provided an opportunity to discuss their concerns and health changes prior to their scheduled appointment. Conclusion: Allowing an option for flexible scheduling in appointment lengths provided an opportunity to meet patient needs, offer improved service, and improve patient-provider communication. © 2016 Elsevier Inc. All rights reserved.
1. Improving satisfaction among established patients in a Midwestern pain clinic An essential element to any provider practice is patient satisfaction. It is a consumer's market and a healthcare consumer can choose which provider best fits their needs. Patient expectations are higher as they seek to find the provider to meet their requirements (Al Ali & Elzubair, 2016; Tuli et al., 2010). The difficulty with such an expectation is many clinics schedule patients according to grids and mathematical equations rather than the individual needs of the patient (Tuli et al., 2010). Providers are being rated on social media when consumers utilize Google + (http://plus.google.com) and HealthGrades (http:// www.healthgrades.com) to express their levels of satisfaction with their provider and their overall healthcare experience. Social media is used by 25% of Americans aged 18–39 years to communicate the level ⁎ Corresponding author at: Indiana University Ball Memorial Hospital, 2401 W. University Avenue, Muncie, IN 47303, United States. E-mail address: [email protected] (K.A. Baule).
http://dx.doi.org/10.1016/j.apnr.2016.10.009 0897-1897/© 2016 Elsevier Inc. All rights reserved.
of satisfaction with their healthcare provider (Greensweig, 2014). The frequency of social media use for persons ages 50–64 years old between April 2009 and May 2010 grew by 88% and the individuals 65 years and older grew by 100% (Madden, 2010). It is a challenge to meet the expectations of consumers and provide adequate revenue for a given practice. The Affordable Care Act is focused on patient experience and is often played out in social media (Grbavac & Seidman, 2013). A national standardized instrument that allows for a comparison of hospitals is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Centers for Medicare & Medicaid [CMS.gov], 2014). Focusing on patient satisfaction is an area that can attract patients to certain healthcare clinics and distract from others. The Centers for Medicare and Medicaid Services (CMS), clinics, hospitals and insurance companies have identified that patient satisfaction is a key performance indicator for reimbursement (Morris et al., 2013). Many factors that contribute to patient satisfaction include communication, kindness, patient wait time, and trust. Patients are frustrated when there is not adequate time at their scheduled appointments (Bleustein et al., 2014). The patients may translate the lack of time at their
K.A. Baule et al. / Applied Nursing Research 33 (2016) 54–60
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scheduled appointment as a lack of kindness. According to a survey completed by Dignity Health, one of the largest health systems in the United States, 90% of Americans would leave their current healthcare provider if the individual felt that the provider was unkind at the time of service (Greensweig, 2014). An appointment length that meets the needs of both the healthcare provider and the patient is an outcome that can improve provider and patient satisfaction (Moore, Hamilton, Krusel, Moore & Pierre-Louis, 2016; Sepulveda & Berroeta, 2012).
scheduling results in decreased costs due to fewer no-shows, etc. (Feldman et al., 2014; Robinson & Chen, 2010; Tuli et al., 2010). Medicare allows for higher reimbursement rates for longer appointments as well (Jensen, 2005).
2. Background
3.1.1. Program development A meeting involving key stakeholders (physicians, nurse manager, compliance officer, nurses, medical assistants and clerical staff) took place in an effort to discuss the current scheduling process. An outcome of the discussion was the development of an algorithm to incorporate an option for flexible appointment. For this process change, the reminder call to the patients provided the patients with the option of extending their appointments if their health status had changed from their previous appointment. In addition to the phone message that was sent to the patients, a statement was also added to the discharge forms that reminded the patients about the opportunity to extend their appointments. The statement was reinforced to the patient by the nurse or medical assistant and the schedulers upon patients' discharge from their previous appointments. If the patient recognized that there is a need to extend their appointment, the patient was instructed to call the office and discuss the new health issue with the triage nurse. The triage nurse would determine if the patient met the criteria for a longer appointment by comparing the patient's clinical condition to the algorithm. The patient would then be transferred to the scheduler if a longer appointment was warranted.
Effective nurse-patient communication is an essential tool to delivering effective patient care. Vowles and Thompson (2012) articulate positive nurse-patient relationships have positive impact on patient satisfaction. Ross, Goldberg, Scanlan, Edwards and Jamison (2013) describe how customer service initiatives can impact patient satisfaction. Effective nurse-patient communication continues to be a struggle for many. This struggle is exemplified in patients who suffer from an underlying pain condition and are then upset about the process of communication with the clinic staff (Vowles & Thompson, 2012). The challenge is to improve the communication process between the clinic staff and the patient when scheduling a clinic appointment, discharging a patient from the clinic, or scheduling a return appointment to the pain clinic. The environment for this practice innovation was a Midwestern pain clinic caring for patients with acute and chronic pain diagnoses resulting from cancer, or neck, back and trauma issues. The clinic staff is comprised of receptionists, schedulers, medical assistants, nurses, an advance practice nurse and two physicians. A significant issue that the clinic faces is not scheduling enough time for the patient appointments. The patients are scheduled for follow up appointments based upon their previous visit, yet the patient's medical conditions may have changed from the previous appointment. There is not a current communication vehicle in place for the patient to alert the staff to changes or concerns. Consequently, when patients come for their appointment, there is not enough time allotted in the scheduled clinic visit to discuss both their new and chronic pain issues. As a result, the patients arrive for an appointment with multiple complaints without enough time to discuss all of their issues with their physician or their advanced practice nurse. The patient becomes upset, frequently leading to difficult communication between the clinic staff and the patient. If a patient's clinic time is spontaneously lengthened, the provider gets behind schedule in seeing the rest of the patients on their schedule. The dissatisfaction perceived by patients often transforms into a harsh tone and negative atmosphere for the patient and staff. The challenge is to improve the process of communication between the clinic staff and the patients when scheduling the patient appointments. Increasing the length of appointments does improve patient satisfaction (Geraghty, Franks & Kravitz, 2007; Lin et al. 2001). Patients' satisfaction improves when communication between patients and healthcare providers improve and the patients' needs have been met (Health Foundation, 2013; Trentman et al., 2012). In addition, improving communication between patients, providers and clinic staff in an organization will make the clinic run more effectively and efficiently specifically with patient scheduling. It is a particular interest for this outpatient clinic as it is an environment where there is a large chronic pain population and patient attitude and tone are challenges for effective communication. Patient satisfaction is a challenge, as 10–60% of the chronic pain population exhibit negative and difficult behaviors with unrealistic expectations of their healthcare providers (Hahn, 2001). Chronic pain management is challenging and often complicated by associated medical needs (Ross et al., 2013; Wasan et al., 2005). If patients have a positive clinic experience there is a tendency to have an improved outcome; whereas, if there is a negative clinical experience there tends to be adverse clinic outcomes (Trentman et al., 2012). Studies show more flexible
3. Method 3.1. Structure
3.1.2. Organizational characteristics The Midwestern pain clinic was founded in 1992 by a group of anesthesiologists. The pain service was comprised of two anesthesia pain physicians and one advanced practice nurse. The pain providers from this group serve four area hospitals, a stand-alone pain clinic and an ambulatory surgical center. It was the stand-alone pain clinic that served as the setting for this evidence based process improvement project. The patients were seen for numerous pain treatments including medication management, spinal cord stimulators, kyphoplasties, injections and management of intrathecal drug delivery systems. 3.1.3. Targeted population The study used a non-cross sectional convenience sample. The targeted population to participate in this evidence-based practice project was the present-day pain patients at the Midwestern pain clinic. The patients were considered established if they had visited the stand-alone clinic at least one time; and were over the age of 21; could read and write English and had an acute or chronic pain diagnosis which was currently being treated. The patients were not asked to participate if they had not met the criteria listed and were unable to fill out the survey without assistance. 3.1.4. Design This evidence-based practice project followed a program evaluation process using a descriptive survey completed by a convenience sample from clinic staff and established patients from a Midwestern pain clinic. Surveys were distributed to patients before starting the practice innovation of flexible scheduling and again at three months following the initiation of the new scheduling option. The implementation of the project took place August 2015 to December 2015 and surveys were collected. A nurse distributed the survey to the patients at the end of their visits, and asked them to complete it prior to leaving the Midwestern pain clinic. Participation in this project was voluntary. The information the patient provided was kept confidential. The staff satisfaction tool was completed by staff members prior to the flexible scheduling process was initiated in the Midwest pain clinic
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and three months following the initiation of the flexible scheduling options. The staff surveys were conducted via SurveyMonkey, an online survey engine, and were conducted anonymously. Consent was obtained from staff that chose to complete the survey via an online consent page. 3.1.5. Program assessment tools The patient satisfaction tool selected for this project was an established instrument developed with funds from the Bureau of Primary Health Care, an agency of the US Department of Health and Human Services. In addition to brief demographic information, the tool contained 24 questions with a 5-point Likert response scale. The questions were divided into seven categories: ease of getting care (four questions), waiting (four questions), staff (seven questions) payment (three questions), facilities (four questions), confidentiality (one question) and the likelihood of referring friends and relatives to the facility (one question). There were also three open ended questions which ask: what the individual likes best and least about the clinic and asks for suggestions for improvement. This tool had established reliability and validity, and has been used in other settings including primary care and rural health settings (Midwest Clinicians' Network, 2014). Therefore no pilot study was necessary prior to utilizing the survey instrument. The staff satisfaction tool was developed from a question bank retrieved from SurveyMonkey (www.surveymonkey.com/). The questions address satisfaction with their job, coworkers and customers/ patients using a 5-point Likert scale. The survey was taken by nurses, medical assistants, schedulers and receptionists. All of their responses to the survey were kept confidential and anonymous. 3.2. Process 3.2.1. Procedure The process improvement protocol included three prompts that provided the patients the opportunity to lengthen their appointments: 1) the opportunity to extend their clinic appointment was added to the patient discharge form and was reviewed with the patient by the nurse or the medical assistant upon discharge from the office appointment; 2) it was further reviewed by the scheduler as the patient planned their future appointment; and 3) an automated reminder call offered the patient the opportunity to lengthen their appointment if they had a change in healthcare status. The patient's 15 min appointment would be lengthened to a 30-minute appointment if the individual's health status had changed necessitating a longer appointment. The schedulers extended the patient appointment and monitored the number of patients requesting a longer appointment. 3.2.2. Outcomes 3.2.2.1. Data analysis. The Likert items on the patient surveys were used to evaluate differences in satisfaction ratings before and after the implementation of the scheduling change process using a MannWhitney U test. The level of significance was set at p b 0.05 for all tests. The results were further analyzed to see if there were significant differences in scores based upon demographics including age, gender and race/ethnicity. The data of patients who had an option to lengthen their appointment were compared to those patients with current uniform patient appointments. The open ended responses were reviewed using qualitative content analytic coding procedures using NVivo to identify trends in the data. Similar analytic procedures were used for the staff surveys to determine if there were significant differences in rating following the implementation of a new scheduling process. 3.2.2.2. Ethical considerations. Approval from the Midwestern pain clinic's President/CEO was obtained as well as permission from the
University of Illinois at Chicago's Institutional Review Board (IRB) to implement this process improvement. The process change did not require any changes in the manner in which patients were treated. A Health Information Patient Accountability Act (HIPAA) waiver for the Midwestern clinic was used in this project and was signed as part of the routine education practice. 3.3. Patient response to extended appointment times Of the clinic's 526 established patients, 30 patients (6%) took advantage of the extended appointment opportunity during the course of the program. This created the potential for an improved dialog with the schedulers to inquire if there was a change in their overall health, recent hospitalization or a new pain issue. Therefore, it was also possible for the scheduler to obtain the health records prior to the patients' scheduled appointment and discuss their new pain issues with the schedulers, who in turn were able to alert the providers. Additionally, the schedulers assigned another 61 patients (12%) extended appointment times due to other factors without consulting the patients ahead of time. The schedulers primary reasons that caused them to extend patient appointments included: a new provider seeing the established patient, but did not meet the requirements for a new consultation or it was a patient who frequently went beyond the scheduled appointment because of complex issues. The schedulers made the decision to extend the appointment without patient input. Of the three schedulers, N 80% of the extended appointments came from one of the schedulers. It appeared that the schedulers did not approach the intervention in the same manner. Scheduler A was responsible for 17% of the extended appointments while Scheduler B was responsible for making 83% of the extended appointments. Scheduler C did not schedule any of the extended appointments. In follow up with Scheduler B, she asked each established patient if he/she had been recently hospitalized, was experiencing a new pain issue or had new test results that needed review with the provider. Scheduler A ensured patients were aware of the opportunity to schedule a longer appointment but did not proactively query patients in the same way that Scheduler B did. Scheduler C did not mention the opportunity and relied on the automated phone system to remind patients of the option to extend an appointment. 3.4. Patient demographics While there were a total of 526 patients that had the opportunity to be involved in this process change, only 120 (22.8%) completed surveys at each data collection period. The 120 patients in the pre-process change ranged in age from 27 to 94 years old (mean = 60.13; SD = 13.06). The mean age of the post-process group was 56.50 (SD = 13.16). The majority of the pre-process respondents identified themselves as females (n = 70) while the remaining respondents were male. In the post-process change group, 66 respondents identified themselves as female and 52 as male. A breakdown of the respondents are available in Table 1. The racial breakdown of the pre-process change respondents included 114 Caucasians, three African American, one Native American, and Table 1 Age distribution of respondents. Age range
25–34 35–44 45–54 55–64 65–74 75–84 85 and over
Pre-process change patients
Post-process patients
Male
Female
Unknown
Male
Female
Unknown
3 9 15 13 9 2 1
3 10 10 19 18 3 2
0 0 0 1 0 0 0
0 3 12 14 6 8 0
3 7 17 18 14 10 1
0 0 0 1 3 2 0
K.A. Baule et al. / Applied Nursing Research 33 (2016) 54–60
two of mixed race/ethnicity. In comparison, the racial breakdown of the post-process respondents included 106 Caucasians, nine African American, two Native Americans, and one Asian. 3.5. Patient satisfaction Based on the results, there was little difference between responses for most of the satisfaction items. Of the 24 satisfaction items, only one was significantly different post-process change compared to the pre-process survey results. Respondents were significantly more satisfied (Z = −2.48; p = 0.01) with the amount of time spent in the exam room (mean rating = 4.46) compared to the mean rating of pre-process respondents (mean rating = 4.08). These results provide positive support for implementing the scheduling process change. However, there was not a significant difference in respondents' satisfaction related to the amount of time it took to be able to see their provider or the amount of time spent with them. The results of the between group comparison are present in Table 2. The satisfaction items were also compared between the pre- and post-process change by gender. Similar to the overall group comparison, no significant changes in satisfaction were found. 3.6. Qualitative responses Patients were allowed to provide open ended commentary at the end of each the pre-process change and post-process change surveys to three questions: 1. What do you like best about our center? 2. What do you like least about our center? 3. Suggestions for improvement? In total, 85 pre-process change surveys included narrative responses. Similarly, 81 of the post-process change surveys included comments (Table 3). Categorizing the opened ended responses to each question, there were several broad themes that the responses could be placed: 1) standard of care; 2) personal relationships and interaction with staff; 3) logistical issues and 4) other, which was a general category to handle responses not falling into one of the three primary categories.
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3.6.1. Standard of care Thirty-three of the positive comments and five of the negative comments addressed the standard of care received. The positive comments can be characterized by statements such as: “help you have provided regarding my situation” and “attention to detail & listening to the patient's concerns.” Negative comments tended to relate to nursing or office staff. Three of the suggestions for improvement related to the standard of care included comments such as “more time to talk with the Doctor” and …maybe showing a little empathy.” 3.6.2. Personal relationships and interactions with staff Personal relationships with empathetic and friendly providers and staff were mentioned 18 times as positive while, seven were categorized as negative issues. One suggestion for improvement was to have both the physician and the APN at the same patient appointment. Another patient further identified that the addition of an APN to the office provided a valuable member to the clinic. Another patient indicated having male nurses and medical assistants was beneficial. 3.6.3. Logistical issues Thirteen positive comments and 32 negative comments were received within the logistical category on the pre-process change survey. A number of patients commented positively on such issues as hours, location, parking and price. However, none of the positive comments were related to wait times or scheduling issues. Instead, there were 19 comments shared that described what the patients' liked least about the amount of wait time and eight comments concerned specific issues. Twelve of the suggestions for improvement were logistical in nature with suggestions such as: have a person answer the phone and not the machine, provide extended hours of service and improve the furniture in the waiting room. 3.6.4. General category Six responses were in this category. Two replied “everything” when asked, “What do you like best about the center?” When asked, “What they like least about the center?” two responded “nothing”. The two responses for the question. “What suggestions do you have for improvement?” were “keep doing what you are doing” and “Can you clone the staff?”
Table 2 Comparison of satisfaction ratings between groups. Items
Pre-process change mean rating
Post-process change mean rating
Z
p
1. Ability to be seen 2. Hours office is open 3. Convenience of office location 4. Prompt return calls 5. Time in waiting room 6. Time in exam room 7. Waiting for tests to be performed 8.Waiting for test results 9. Providers listen to you 10. Providers take enough time with you 11. Providers explain to me what I need to know 12. Nurses &MAs friendly and helpful 13. Nurses & MAs answer your questions 14. Other Staff friendly and helpful 15. Other Staff answers your questions 16. What you pay 17. Explanation of charges 18. Collection of payment/money 19. Neat and clean building 20. Ease of finding where to go 21. Comfort and safety while waiting 22. Privacy 23. Keeping my personal information private 24. The likelihood of referring your friends and relatives to us:
4.33 4.64 4.58 4.29 4.43 4.08 4.36 4.41 4.81 4.80 4.84 4.79 4.80 4.78 4.76 4.27 4.45 4.52 4.85 4.84 4.81 4.85 4.79 4.81
4.37 4.47 4.42 4.19 4.58 4.46 4.41 4.47 4.78 4.77 4.78 4.80 4.77 4.74 4.76 4.24 4.36 4.35 4.84 4.84 4.86 4.86 4.87 4.80
0.104 1.21 1.36 −0.39 1.45 −2.48 0.80 −0.34 0.05 0.07 0.46 −0.02 0.13 0.30 −0.15 0.02 −0.36 0.75 0.03 0.11 −0.24 −0.05 −0.74 −0.08
0.92 0.23 0.17 0.69 0.15 0.01 0.44 0.73 0.96 0.94 0.65 0.98 0.89 0.95 0.88 0.98 0.72 0.45 0.98 0.91 0.81 0.96 0.45 0.93
Level of significance = 0.05.
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Table 3 Frequency of open-ended responses. Question
What do you like the best about our center? What do you like the least about our center? Suggestions for improvement
Pre-process responses
Post-process responses
Total responses
Responses of N/A, none, etc.
Total responses
Responses of N/A, none, etc.
85 66 42
1 18 17
81 50 49
1 17 20
The post-process change survey comments provided different insight. While approximately the same number of respondents provided some positive comments, nearly a third fewer participants described any areas of concern. 3.6.5. Standard of care Thirty-five responses addressed the standard of care. Thirty responded positively with such comments as, “able to address multiple pain issues,” “willingness to listen to me,” and provides attention “to my entire medical condition.” Three negative comments focused on failure to return patient phone calls and two other responses described problems with staff communication with the patients. 3.6.6. Personal relationships and interaction with staff Forty patients responded in this category. Thirty-seven responded positively indicating that they, “liked the APN, doctor or staff members” and the “attention, trust and respect that was received.” There were three negative responses, one concerning the front desk, one regarding a specific nurse and one regarding the wait time for doctor. 3.6.7. Logistical issues Forty-three total comments were included in this section on the post-process change: 34 positive and 9 negative. The negative comments were related to hours of operations, location and parking. There was only one comment regarding scheduling and time in the exam room. This decreased from 17 responses regarding scheduling in the pre-process survey. A number of patients commented positively on such issues as hours, location, parking and price. Thirteen positive comments and 32 negative comments were received within the logistical category on the preprocess survey. None of the positive statements comments were related to wait time or scheduling issues. Instead 19 responses to the question about what the patients' liked leased involved wait time and eight identified scheduling issues. Twelve of the suggestions for improvement were logistical such as offering more appointment options later in the day, sending reminder emails and improving the comfort of the furniture in the waiting room. 3.6.8. General category Thirty-eight responses were all positive. There were no negative responses in this area. They replied that they had “no complaints.” They “would not change anything.” The response rate in this category rose from six responses pre-process change to 38 responses postprocess change, with all of the post-process change responses being positive. 3.7. Staff satisfaction Thirteen staff members completed the survey on SurveyMonkey pre and post procedural change. There were eight questions utilizing a 5-Likert scale are summarized in two categories: 1) patient interaction and 2) staff stress, workload and workplace satisfaction. 3.7.1. Patient interaction The first question for staff was: Do you interact with the patients too much, too little or about the right amount? The pre-process change responses indicated that 92.3% of the staff perceived it was the
“right amount” and 7.69% responded that there “slightly too much.” In contrast, 100% of the post-process change respondents thought it was the “right amount.” Overall, the staff conveyed that the interactions with patients took the right amount of time and did not perceive that they were rushed or stressed when surveyed post-procedurally. The second question was: How often do you feel patients are rushed during their appointment? Overall, the staff did not perceive that patients were rushed before or after the process change. When responding to this question, six of 13 (pre-process change) and eight of 13 (post-process change) felt that patients were “rarely” or “very rarely” rushed. In response to the third question (How often do rushed patients become negative?), 11 of 13 staff responded “almost always,” “often” or “sometimes” in the pre-process survey while 10 of 13 responded similarly in the post-process survey. Although staff do not think that patients are rushed, they still perceive that patients are negative. 3.7.2. Staff stress, workload and workplace satisfaction The first question in this section asked, “In a typical week, how often do you feel stressed at work?” The options for response were: “always”, “most of the time”, “about half of the time”, “once in a while” and “never”. One staff member responded “often” in the pre-process staff survey. However, to the post-process survey, there were no staff members that responded “often” to this question. The pre-process staff survey revealed that seven answered “rarely” or “very rarely”. Again, in contrast to the post-process staff survey, nine staff responded “responded “rarely” or “very rarely”. The post-process staff survey had a positive response to their perception of their place of employment. This is a slight improvement to the pre-process survey where one staff member responded negatively to this question. When the staff where asked, “Overall, how much did you like working here?” The options for responses where: “a great deal”, “a lot”, “a moderate amount” and “not at all”. In the pre-process staff survey, four staff responded “a great deal” while in the post-process staff survey six staff responded “a great deal”. The last question queried, “How likely is it that you would recommend this company to a friend or colleague?” The responses ranged from 0 (not at all likely) to 10 (extremely likely). The staff responded more favorably to this question post-process survey compared to pre-process survey. This was evident by the percentage of improvement to this question increasing from 31% pre-process staff survey to 46% post-staff survey being likely to recommend the clinic to friend or colleague. 4. Discussion While the result of this practice innovation showed significant statistical improvement in patient satisfaction regarding the amount of time they spent with providers in the exam room after the scheduling process was changed, patients did identify some common themes which were echoed in the literature. For example, patients found that this scheduling process offered more time with their healthcare provider and an opportunity to improve service, a finding similar to Brown et al.'s (2002) and Moore et al.'s (2016) outcomes. In addition, the extended appointments provided a mechanism to meet patients' needs which reinforces the findings identified by other colleague (Bleustein et al., 2014; Morris et al., 2013; Wasan et al., 2005). By extending patients' appointments, the patients responded more positively than with the standard scheduling practice and were more
K.A. Baule et al. / Applied Nursing Research 33 (2016) 54–60
satisfied with their appointments which confirmed the findings of Geraaghty et al. (2007) and Robinson & Chen (2010). The narrative responses to the patients' survey post-process change showed only four negative comments in comparison to 17 negative comments on the pre-process change survey. A scheduler also identified that inquiring about patients' health condition and appointment length prior to their scheduled appointments provided an avenue to increase productivity with the availability of complete medical records. Prakash (2010), Press Ganey (2010), and Whear, et al. (2013) acknowledged that early identification of patient satisfaction problems within a practice can help to improve services. Likewise, Ross et al. (2013) recognized that if the staff is more involved in patient care, the patients will have an improved perception of their care. This was noticeable when patients were more satisfied with the time that they spent in the exam room and the waiting room. However, it is unclear if the satisfaction level was influenced by the staff who may have appeared less rushed since the number of appointments may have been reduced because of the increases in patient appointments. The findings of Tuli, et al., (2010) and Geraghty, et al., (2007) both support the findings of this study in that more flexible and accessible scheduling will increase patient satisfaction. The staff satisfaction improved slightly with the implementation of the scheduling process change. While Moore, Hamilton, Krusel, Moore and Pierre-Louis (2016), Prakash (2010), Vowles and Thompson (2012) and Warner (2011) all suggest that patients' relationships and provider-patient communication have a positive outcome, it could be a result of having more opportunity for the staff to feel less rushed and able to spend more time with the patients. 4.1. Strengths and limitations One of strengths of this evidence-based practice innovation was the generous support of the entire staff, leadership and stakeholders. Individuals working at the Midwestern clinic identified that there was an overall benefit to improving dialog with patients by offering the opportunity to schedule longer clinic appointments. Another strength of the project was it provided an opportunity for the patients to discuss new, as well as chronic pain issues at the same office visit. The translation of current evidence allowed the pain clinic to view scheduling as an individual patient issue and not a standard process. Considering the patient's individual needs and preferences when scheduling appointments is a key to improving patient and staff satisfaction. It is also recognized that there were limitations associated with this evidencebased practice change. A major limitation was that the pre-and postchange surveys did not include an evaluation of satisfaction between the same respondents. Therefore, identifying specific changes in satisfaction over time was hindered. The patient population was homogenous; there was not much racial/ethnic diversity in either the pre-or post-process change groups. The patients did not always know the length of their scheduled appointment. It is unclear if the patients' level of pain at the time of the survey reflected their level of satisfaction with the Midwestern pain clinic. Another limitation to this finding is the reaction from the schedulers. There were 526 patients that had the opportunity to request an extended appointment however the three schedulers only extended a total of 30 patient appointments. Nevertheless, they also extended an additional 61 patients without the patients' knowledge. The schedulers must have identified a benefit from having an option of a longer patient appointment, but did not follow the provided protocol. If all of the schedulers asked established patients the same questions when scheduling their appointment, perhaps the number of patients requesting an extended appointment would have been larger. It is also unclear if more patients would have requested a longer appointment if the reminders calls were made by the scheduler and not a prerecorded message. It is also recognized that there was a limited number of individuals who could complete the staff survey. Another possible limitation was
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within the survey tool itself. For example, the question “How likely is it that you would recommend this company to a friend or colleague?” could be interpreted a number of ways. Several of the staff initially answered that they would not stating that the Midwestern clinic is a smaller clinic of a bigger organization. Some other staff members responded they would not recommend the clinic to friends due to its size but also stated that they did not want to work in such close proximity to relatives or non-work friends. None of these statements were meant as a negative reflection on the work environment itself. 4.2. Program recommendations In the future, it may be beneficial to assess the level of patient satisfaction with those patients who chose to extended their appointments and compare the level of satisfaction with those patients who did not lengthen their appointment. It would also be helpful to evaluate the amount of “no-show” appointments with those extended their appointment. While it may be beneficial to have a live person confirm the patients' appointment, it might present one more opportunity to have a conversation between the scheduler and the patients which may add another avenue to influence patient satisfaction. Likewise, implementing a standardized script for the schedulers may help with appropriate patient appointment lengths and decrease the number of patients' appointments that were lengthened without the patients' knowledge. Replicating this project in a larger more diverse pain clinic setting or utilizing the same patients in the pre-process change as the post-process change would be ways to improve on this project. 4.3. Application to nursing practice Overall, patients and staff were more satisfied after offering patients a flexible appointment option. A key element is that patients continue to stay with clinics and providers they feel trusted with their health care concerns (Tuli et al., 2010). The staff exhibit the element of security when they are less stressed in their job. By offering the patients the option to extend their scheduled appointment, the staff was less stressed and more supported by the leadership in their work environment. Additionally, the patients were more pleased with their service. Staff tend not to leave their place of employment if they feel supported and have a manageable workload. Staff retention translates into cost savings for employers as the average cost to train a new staff nurse is minimally $10,000 (Lafer, 2003). Patient retention adds to staff satisfaction as there is continuity with their care delivery. 5. Conclusions Patient satisfaction is an important facet of modern clinical practice. This evidence-based practice innovation found that allowing the option for flexibility in appointment lengths helps to increase patient satisfaction. There are three areas of consideration for further exploration. The first area would be to consider the incorporation of a more detailed question heuristic to be used by the schedulers to ensure the appropriate appointment length for each patient and have the necessary patient records at the time of the appointment. The second area is to evaluate the impact of modifying the clinic's hours of operation to be more favorable to working patients on overall patient satisfaction. Replicating the process of more flexible appointment lengths in a larger clinic setting would be beneficial. By increasing the scope of this practice change to a larger setting, there may be further evidence to support the translation of this practice innovation in other pain clinics and chronic care center. References Al Ali, A. A., & Elzubair, A. G. (2016, January). Establishing rapport: Physicians' practice and attendees's satisfaction at a primary health care center, Damman, Saudi Arabia, 2013. Journal of Family and Community Medicine, 23(1), 12–17.
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Bleustein, C., Rothschild, D. B., Valen, A., Valaitis, E., Schweitzer, L., & Jones, R. (2014). Wait times, patient satisfaction scores, and the perception of care. The American Journal of Managed Care, 20(5), 393–400. Brown, L., Payne, S., & Royle, G. (2002). Patient initiated follow up of breast cancer. Psycho-oncology, 346–355. http://dx.doi.org/10.1002/pon.576. Centers for Medicare & Medicaid (2014, September 25). HCAHPS: Patients' perspectives of care survey - Centers for Medicare & Medicaid Services. Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalHCAHPS.html Feldman, J., Liu, N., Topaloglu, H., & Ziya, S. (2014). Appointment scheduling under patient preference and no-show behavior. Operations Research, 62(4), 794–811 Retrieved from http://dx.doi.org/10.1287/opre.2014.1286 Geraghty, E. M., Franks, P., & Kravitz, R. L. (2007). Primary care visit length, quality, and satisfaction for standardized patients with depression. Journal of General Internal Medicine, 22(12), 1641–1647. http://dx.doi.org/10.1007/s11606-007-0371-5. Grbavac, R., & Seidman, W. (2013, March 3). Creating a culture of patient satisfaction. Retrieved from http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/ templatedata/HF_Common/NewsArticle/data/HHN/Daily/2013/Mar/seidman0307133110007162 Greensweig, G. (2014). Recognizing the value of kindness in healthcare. Retrieved from http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/ templatedata/HF_Common/NewsArticle/data/HHN/Daily/2014/Mar/011314Greensweig-Kindness-Patient-Care Hahn, S. (2001). Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Annals of Internal Medicine, 134(9), 897–904. Health Foundation (2013). Improving patient flow. How two trusted focused on flow to improve the quality of care and use available capacity effectively. Retrieved from http://www.health.org.uk/public/cms/75/76/313/4196/Improving%20patient% 20flow.pdf?realName=TxPs1T.pdf Jensen, P. R. (2005, September). Coding “routine” office visits: 99213 or 99214?: Before choosing 99213 for routine visits, consider whether you22222r work qualifies for a 99214. Retrieved from http://www.aafp.org/fpm/2005/0900/p52.html Lafer, G. (2003). Solving the nursing shortage, AFSCME health care. Retrieved from http:// www.afscme.org/news/publications/health-care/solving-the-nursing-shortage Lin, C., albertson, G. A., Schilling, L. M., Cyran, E. M., Anderson, S. N., Ware, L., & Anderson, J. (2001). Is patients'perception of time spent with physician a determinant of ambulatory patient satisfaction? Archivesof Internal Medicine, 161, 1437–1442. http://dx.doi. org/10.1001/archinte, 161.11.1437. Madden, M. (2010, August 7). Older adults and social media | Pew Research Center's internet & American Life Project. Retrieved from http://www.pewinternet.org/ 2010/08/27/older-adults-and-social-media/
Midwestern Clinicians' Network (2014). Patient satisfaction surveys. Retrieved from http://www.midwesterclinicians.org/products Moore, A. D., Hamilton, J. B., Krusel, J. L., Moore, L. G., & Pierre-Louis, B. J. (2016, April). Patient provide recommendations for improving patient satisfaction. Military Medicine, 181(4), 356–363. Morris, B. J., Jahangir, A. A., & Sethi, M. K. (2013, June). Patient satisfaction: An emerging health policy issue what orthopedic surgeon needs to know. Retrieved from http://www6.aaos.org/news/PDFopen/PDFopen.cfm?page_url=http://www. aaos.org/news/aaosnow/jun13/advocacy5.asp Prakash, B. (2010). Patient satisfaction. Journal of Cutaneous and Aesthetic Surgery, 3(3), 151–155. http://dx.doi.org/10.4103/0974–2077.74491. Press Ganey (2010). The importance of patient satisfaction survey | Why patient satisfaction? | Press Ganey. Retrieved February 2, 2015, from http://medpractice.pressganey. com/why-patient-satisfaction–pages-141.php Robinson, L. W., & Chen, R. R. (2010). A comparison of traditional and open-access policies for appointment scheduling. M&som-manufacturing & Service Operations Management, 12(2), 330–346. http://dx.doi.org/10.1287/msom.1090.0270. Ross, E. L., Goldberg, I., Scanlan, E., Edwards, R. R., & Jamison, R. N. (2013). Dealing with difficult patients: Do customer service initiatives improve patient satisfaction at an interdisciplinary pain center? Journal of Applied Behavioral Research, 18, 123–133. Sepulveda, J. P., & Berroeta, C. (2012). Reglas de decision para la seleccion de sistemas de citas basadas en caracteristicas del paciente y de la institucion de salud. Revista Médica de Chile, 140, 867–872. Trentman, T. L., Cornidez, E. G., Wilshusen, L. L., Chang, Y. H., Seamans, D. P., Rosenfeld, D. M., ... Chien, J. J. (2012). Patient satisfaction in an academic chronic pain clinic. Pain Practice, 13(5), 372–379. http://dx.doi.org/10.1111/papr.12004. Tuli, S. Y., Thompson, L. A., Ryan, K. A., Srinivas, G. L., Fillipps, D. J., Young, C. M., & Tuli, S. S. (2010). Improving quality and patient satisfaction in a pediatric resident continuity clinic through advanced access scheduling. Journal of Graduate medical Education, 215–221. http://dx.doi.org/10.4300/JGME-D-09-00087.1. Vowles, K. E., & Thompson, M. (2012). The patient-provider relationship in chronic pain. Current Pain Headache Reports, 16, 133–138. Warner, D. (2011). Effectively communicating patient reminders: Improving patient care. Journal of Health Care Compliance, 13(5), 55–56 (67-68). Wasan, A. D., Wootton, J., Div, M., & Jamison, R. (2005). Dealing with difficult patients in your pain practice. Regional Anesthesia and Pain Management, 30(2), 184–192. Whear, R., Abdul-Raham, A., Thompson-Coon, J., Boddy, K., Perry, M. G., & Stein, K. (2013). Patient initiated clinics for patients with chronic or recurrent conditions managed in secondary care: A systematic review of patient reported outcomes and patient reported outcomes and patient and clinician satisfaction. BMC Health Services Research, 13(1). http://dx.doi.org/10.1186/1472-6963-13-501.
Contents lists available at ScienceDirect
Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Improving satisfaction among established patients in a midwestern pain clinic Kathy A. Baule a,c,⁎, Linda D. Scott a,b, Kelly D. Rosenberger a,d, W. Stephen Minore d,e a
University of Illinois at Chicago College of Nursing, 845 S. Damen, Chicago, IL 60612, United States University of Wisconsin-Madison School of Nursing, 701 Highland Ave, Madison, WI 53705, United States c Indiana University Ball Memorial Hospital, 2401 W. University Ave, Muncie, IN 47303, United States d Rockford Anesthesiologists Associated, 2202 Harlem Ave, Loves Park, IL 61111, United States e University of Illinois at Chicago College of Medicine, 845 S. Damen, Chicago, IL 60612, United States b
a r t i c l e
i n f o
Article history: Received 4 August 2016 Revised 24 September 2016 Accepted 15 October 2016 Available online xxxx
a b s t r a c t Background: A problem in many health care practices is deciding the appropriate appointment length for new and established patients. Patients become frustrated when there is inadequate time to have their needs met, yet when a patient's clinic time is spontaneously lengthened, the provider gets behind in schedule, causing delays and greater frustration for others. Aim: The aims of this evidence based project were to determine whether implementation of a flexible appointment system would improve the current scheduling process in a pain clinic by allowing complex patients the opportunity to schedule a longer clinic appointment and would improve patient satisfaction. Design: This evidence-based practice innovation followed a program evaluation process using a descriptive, existing survey completed by clinic staff and patients. Setting: A Midwestern pain clinic caring for patients with acute and chronic pain diagnoses. Participants: A convenience sample of 120 patients were surveyed before and after the process change. Thirteen staff members completed the survey on SurveyMonkey pre and post procedural change at the same intervals the patients were surveyed. Results: Patients were more satisfied with the time that they spent in the exam room and the waiting room. The process change improved communication with staff and patients and provided an opportunity to discuss their concerns and health changes prior to their scheduled appointment. Conclusion: Allowing an option for flexible scheduling in appointment lengths provided an opportunity to meet patient needs, offer improved service, and improve patient-provider communication. © 2016 Elsevier Inc. All rights reserved.
1. Improving satisfaction among established patients in a Midwestern pain clinic An essential element to any provider practice is patient satisfaction. It is a consumer's market and a healthcare consumer can choose which provider best fits their needs. Patient expectations are higher as they seek to find the provider to meet their requirements (Al Ali & Elzubair, 2016; Tuli et al., 2010). The difficulty with such an expectation is many clinics schedule patients according to grids and mathematical equations rather than the individual needs of the patient (Tuli et al., 2010). Providers are being rated on social media when consumers utilize Google + (http://plus.google.com) and HealthGrades (http:// www.healthgrades.com) to express their levels of satisfaction with their provider and their overall healthcare experience. Social media is used by 25% of Americans aged 18–39 years to communicate the level ⁎ Corresponding author at: Indiana University Ball Memorial Hospital, 2401 W. University Avenue, Muncie, IN 47303, United States. E-mail address: [email protected] (K.A. Baule).
http://dx.doi.org/10.1016/j.apnr.2016.10.009 0897-1897/© 2016 Elsevier Inc. All rights reserved.
of satisfaction with their healthcare provider (Greensweig, 2014). The frequency of social media use for persons ages 50–64 years old between April 2009 and May 2010 grew by 88% and the individuals 65 years and older grew by 100% (Madden, 2010). It is a challenge to meet the expectations of consumers and provide adequate revenue for a given practice. The Affordable Care Act is focused on patient experience and is often played out in social media (Grbavac & Seidman, 2013). A national standardized instrument that allows for a comparison of hospitals is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Centers for Medicare & Medicaid [CMS.gov], 2014). Focusing on patient satisfaction is an area that can attract patients to certain healthcare clinics and distract from others. The Centers for Medicare and Medicaid Services (CMS), clinics, hospitals and insurance companies have identified that patient satisfaction is a key performance indicator for reimbursement (Morris et al., 2013). Many factors that contribute to patient satisfaction include communication, kindness, patient wait time, and trust. Patients are frustrated when there is not adequate time at their scheduled appointments (Bleustein et al., 2014). The patients may translate the lack of time at their
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scheduled appointment as a lack of kindness. According to a survey completed by Dignity Health, one of the largest health systems in the United States, 90% of Americans would leave their current healthcare provider if the individual felt that the provider was unkind at the time of service (Greensweig, 2014). An appointment length that meets the needs of both the healthcare provider and the patient is an outcome that can improve provider and patient satisfaction (Moore, Hamilton, Krusel, Moore & Pierre-Louis, 2016; Sepulveda & Berroeta, 2012).
scheduling results in decreased costs due to fewer no-shows, etc. (Feldman et al., 2014; Robinson & Chen, 2010; Tuli et al., 2010). Medicare allows for higher reimbursement rates for longer appointments as well (Jensen, 2005).
2. Background
3.1.1. Program development A meeting involving key stakeholders (physicians, nurse manager, compliance officer, nurses, medical assistants and clerical staff) took place in an effort to discuss the current scheduling process. An outcome of the discussion was the development of an algorithm to incorporate an option for flexible appointment. For this process change, the reminder call to the patients provided the patients with the option of extending their appointments if their health status had changed from their previous appointment. In addition to the phone message that was sent to the patients, a statement was also added to the discharge forms that reminded the patients about the opportunity to extend their appointments. The statement was reinforced to the patient by the nurse or medical assistant and the schedulers upon patients' discharge from their previous appointments. If the patient recognized that there is a need to extend their appointment, the patient was instructed to call the office and discuss the new health issue with the triage nurse. The triage nurse would determine if the patient met the criteria for a longer appointment by comparing the patient's clinical condition to the algorithm. The patient would then be transferred to the scheduler if a longer appointment was warranted.
Effective nurse-patient communication is an essential tool to delivering effective patient care. Vowles and Thompson (2012) articulate positive nurse-patient relationships have positive impact on patient satisfaction. Ross, Goldberg, Scanlan, Edwards and Jamison (2013) describe how customer service initiatives can impact patient satisfaction. Effective nurse-patient communication continues to be a struggle for many. This struggle is exemplified in patients who suffer from an underlying pain condition and are then upset about the process of communication with the clinic staff (Vowles & Thompson, 2012). The challenge is to improve the communication process between the clinic staff and the patient when scheduling a clinic appointment, discharging a patient from the clinic, or scheduling a return appointment to the pain clinic. The environment for this practice innovation was a Midwestern pain clinic caring for patients with acute and chronic pain diagnoses resulting from cancer, or neck, back and trauma issues. The clinic staff is comprised of receptionists, schedulers, medical assistants, nurses, an advance practice nurse and two physicians. A significant issue that the clinic faces is not scheduling enough time for the patient appointments. The patients are scheduled for follow up appointments based upon their previous visit, yet the patient's medical conditions may have changed from the previous appointment. There is not a current communication vehicle in place for the patient to alert the staff to changes or concerns. Consequently, when patients come for their appointment, there is not enough time allotted in the scheduled clinic visit to discuss both their new and chronic pain issues. As a result, the patients arrive for an appointment with multiple complaints without enough time to discuss all of their issues with their physician or their advanced practice nurse. The patient becomes upset, frequently leading to difficult communication between the clinic staff and the patient. If a patient's clinic time is spontaneously lengthened, the provider gets behind schedule in seeing the rest of the patients on their schedule. The dissatisfaction perceived by patients often transforms into a harsh tone and negative atmosphere for the patient and staff. The challenge is to improve the process of communication between the clinic staff and the patients when scheduling the patient appointments. Increasing the length of appointments does improve patient satisfaction (Geraghty, Franks & Kravitz, 2007; Lin et al. 2001). Patients' satisfaction improves when communication between patients and healthcare providers improve and the patients' needs have been met (Health Foundation, 2013; Trentman et al., 2012). In addition, improving communication between patients, providers and clinic staff in an organization will make the clinic run more effectively and efficiently specifically with patient scheduling. It is a particular interest for this outpatient clinic as it is an environment where there is a large chronic pain population and patient attitude and tone are challenges for effective communication. Patient satisfaction is a challenge, as 10–60% of the chronic pain population exhibit negative and difficult behaviors with unrealistic expectations of their healthcare providers (Hahn, 2001). Chronic pain management is challenging and often complicated by associated medical needs (Ross et al., 2013; Wasan et al., 2005). If patients have a positive clinic experience there is a tendency to have an improved outcome; whereas, if there is a negative clinical experience there tends to be adverse clinic outcomes (Trentman et al., 2012). Studies show more flexible
3. Method 3.1. Structure
3.1.2. Organizational characteristics The Midwestern pain clinic was founded in 1992 by a group of anesthesiologists. The pain service was comprised of two anesthesia pain physicians and one advanced practice nurse. The pain providers from this group serve four area hospitals, a stand-alone pain clinic and an ambulatory surgical center. It was the stand-alone pain clinic that served as the setting for this evidence based process improvement project. The patients were seen for numerous pain treatments including medication management, spinal cord stimulators, kyphoplasties, injections and management of intrathecal drug delivery systems. 3.1.3. Targeted population The study used a non-cross sectional convenience sample. The targeted population to participate in this evidence-based practice project was the present-day pain patients at the Midwestern pain clinic. The patients were considered established if they had visited the stand-alone clinic at least one time; and were over the age of 21; could read and write English and had an acute or chronic pain diagnosis which was currently being treated. The patients were not asked to participate if they had not met the criteria listed and were unable to fill out the survey without assistance. 3.1.4. Design This evidence-based practice project followed a program evaluation process using a descriptive survey completed by a convenience sample from clinic staff and established patients from a Midwestern pain clinic. Surveys were distributed to patients before starting the practice innovation of flexible scheduling and again at three months following the initiation of the new scheduling option. The implementation of the project took place August 2015 to December 2015 and surveys were collected. A nurse distributed the survey to the patients at the end of their visits, and asked them to complete it prior to leaving the Midwestern pain clinic. Participation in this project was voluntary. The information the patient provided was kept confidential. The staff satisfaction tool was completed by staff members prior to the flexible scheduling process was initiated in the Midwest pain clinic
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and three months following the initiation of the flexible scheduling options. The staff surveys were conducted via SurveyMonkey, an online survey engine, and were conducted anonymously. Consent was obtained from staff that chose to complete the survey via an online consent page. 3.1.5. Program assessment tools The patient satisfaction tool selected for this project was an established instrument developed with funds from the Bureau of Primary Health Care, an agency of the US Department of Health and Human Services. In addition to brief demographic information, the tool contained 24 questions with a 5-point Likert response scale. The questions were divided into seven categories: ease of getting care (four questions), waiting (four questions), staff (seven questions) payment (three questions), facilities (four questions), confidentiality (one question) and the likelihood of referring friends and relatives to the facility (one question). There were also three open ended questions which ask: what the individual likes best and least about the clinic and asks for suggestions for improvement. This tool had established reliability and validity, and has been used in other settings including primary care and rural health settings (Midwest Clinicians' Network, 2014). Therefore no pilot study was necessary prior to utilizing the survey instrument. The staff satisfaction tool was developed from a question bank retrieved from SurveyMonkey (www.surveymonkey.com/). The questions address satisfaction with their job, coworkers and customers/ patients using a 5-point Likert scale. The survey was taken by nurses, medical assistants, schedulers and receptionists. All of their responses to the survey were kept confidential and anonymous. 3.2. Process 3.2.1. Procedure The process improvement protocol included three prompts that provided the patients the opportunity to lengthen their appointments: 1) the opportunity to extend their clinic appointment was added to the patient discharge form and was reviewed with the patient by the nurse or the medical assistant upon discharge from the office appointment; 2) it was further reviewed by the scheduler as the patient planned their future appointment; and 3) an automated reminder call offered the patient the opportunity to lengthen their appointment if they had a change in healthcare status. The patient's 15 min appointment would be lengthened to a 30-minute appointment if the individual's health status had changed necessitating a longer appointment. The schedulers extended the patient appointment and monitored the number of patients requesting a longer appointment. 3.2.2. Outcomes 3.2.2.1. Data analysis. The Likert items on the patient surveys were used to evaluate differences in satisfaction ratings before and after the implementation of the scheduling change process using a MannWhitney U test. The level of significance was set at p b 0.05 for all tests. The results were further analyzed to see if there were significant differences in scores based upon demographics including age, gender and race/ethnicity. The data of patients who had an option to lengthen their appointment were compared to those patients with current uniform patient appointments. The open ended responses were reviewed using qualitative content analytic coding procedures using NVivo to identify trends in the data. Similar analytic procedures were used for the staff surveys to determine if there were significant differences in rating following the implementation of a new scheduling process. 3.2.2.2. Ethical considerations. Approval from the Midwestern pain clinic's President/CEO was obtained as well as permission from the
University of Illinois at Chicago's Institutional Review Board (IRB) to implement this process improvement. The process change did not require any changes in the manner in which patients were treated. A Health Information Patient Accountability Act (HIPAA) waiver for the Midwestern clinic was used in this project and was signed as part of the routine education practice. 3.3. Patient response to extended appointment times Of the clinic's 526 established patients, 30 patients (6%) took advantage of the extended appointment opportunity during the course of the program. This created the potential for an improved dialog with the schedulers to inquire if there was a change in their overall health, recent hospitalization or a new pain issue. Therefore, it was also possible for the scheduler to obtain the health records prior to the patients' scheduled appointment and discuss their new pain issues with the schedulers, who in turn were able to alert the providers. Additionally, the schedulers assigned another 61 patients (12%) extended appointment times due to other factors without consulting the patients ahead of time. The schedulers primary reasons that caused them to extend patient appointments included: a new provider seeing the established patient, but did not meet the requirements for a new consultation or it was a patient who frequently went beyond the scheduled appointment because of complex issues. The schedulers made the decision to extend the appointment without patient input. Of the three schedulers, N 80% of the extended appointments came from one of the schedulers. It appeared that the schedulers did not approach the intervention in the same manner. Scheduler A was responsible for 17% of the extended appointments while Scheduler B was responsible for making 83% of the extended appointments. Scheduler C did not schedule any of the extended appointments. In follow up with Scheduler B, she asked each established patient if he/she had been recently hospitalized, was experiencing a new pain issue or had new test results that needed review with the provider. Scheduler A ensured patients were aware of the opportunity to schedule a longer appointment but did not proactively query patients in the same way that Scheduler B did. Scheduler C did not mention the opportunity and relied on the automated phone system to remind patients of the option to extend an appointment. 3.4. Patient demographics While there were a total of 526 patients that had the opportunity to be involved in this process change, only 120 (22.8%) completed surveys at each data collection period. The 120 patients in the pre-process change ranged in age from 27 to 94 years old (mean = 60.13; SD = 13.06). The mean age of the post-process group was 56.50 (SD = 13.16). The majority of the pre-process respondents identified themselves as females (n = 70) while the remaining respondents were male. In the post-process change group, 66 respondents identified themselves as female and 52 as male. A breakdown of the respondents are available in Table 1. The racial breakdown of the pre-process change respondents included 114 Caucasians, three African American, one Native American, and Table 1 Age distribution of respondents. Age range
25–34 35–44 45–54 55–64 65–74 75–84 85 and over
Pre-process change patients
Post-process patients
Male
Female
Unknown
Male
Female
Unknown
3 9 15 13 9 2 1
3 10 10 19 18 3 2
0 0 0 1 0 0 0
0 3 12 14 6 8 0
3 7 17 18 14 10 1
0 0 0 1 3 2 0
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two of mixed race/ethnicity. In comparison, the racial breakdown of the post-process respondents included 106 Caucasians, nine African American, two Native Americans, and one Asian. 3.5. Patient satisfaction Based on the results, there was little difference between responses for most of the satisfaction items. Of the 24 satisfaction items, only one was significantly different post-process change compared to the pre-process survey results. Respondents were significantly more satisfied (Z = −2.48; p = 0.01) with the amount of time spent in the exam room (mean rating = 4.46) compared to the mean rating of pre-process respondents (mean rating = 4.08). These results provide positive support for implementing the scheduling process change. However, there was not a significant difference in respondents' satisfaction related to the amount of time it took to be able to see their provider or the amount of time spent with them. The results of the between group comparison are present in Table 2. The satisfaction items were also compared between the pre- and post-process change by gender. Similar to the overall group comparison, no significant changes in satisfaction were found. 3.6. Qualitative responses Patients were allowed to provide open ended commentary at the end of each the pre-process change and post-process change surveys to three questions: 1. What do you like best about our center? 2. What do you like least about our center? 3. Suggestions for improvement? In total, 85 pre-process change surveys included narrative responses. Similarly, 81 of the post-process change surveys included comments (Table 3). Categorizing the opened ended responses to each question, there were several broad themes that the responses could be placed: 1) standard of care; 2) personal relationships and interaction with staff; 3) logistical issues and 4) other, which was a general category to handle responses not falling into one of the three primary categories.
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3.6.1. Standard of care Thirty-three of the positive comments and five of the negative comments addressed the standard of care received. The positive comments can be characterized by statements such as: “help you have provided regarding my situation” and “attention to detail & listening to the patient's concerns.” Negative comments tended to relate to nursing or office staff. Three of the suggestions for improvement related to the standard of care included comments such as “more time to talk with the Doctor” and …maybe showing a little empathy.” 3.6.2. Personal relationships and interactions with staff Personal relationships with empathetic and friendly providers and staff were mentioned 18 times as positive while, seven were categorized as negative issues. One suggestion for improvement was to have both the physician and the APN at the same patient appointment. Another patient further identified that the addition of an APN to the office provided a valuable member to the clinic. Another patient indicated having male nurses and medical assistants was beneficial. 3.6.3. Logistical issues Thirteen positive comments and 32 negative comments were received within the logistical category on the pre-process change survey. A number of patients commented positively on such issues as hours, location, parking and price. However, none of the positive comments were related to wait times or scheduling issues. Instead, there were 19 comments shared that described what the patients' liked least about the amount of wait time and eight comments concerned specific issues. Twelve of the suggestions for improvement were logistical in nature with suggestions such as: have a person answer the phone and not the machine, provide extended hours of service and improve the furniture in the waiting room. 3.6.4. General category Six responses were in this category. Two replied “everything” when asked, “What do you like best about the center?” When asked, “What they like least about the center?” two responded “nothing”. The two responses for the question. “What suggestions do you have for improvement?” were “keep doing what you are doing” and “Can you clone the staff?”
Table 2 Comparison of satisfaction ratings between groups. Items
Pre-process change mean rating
Post-process change mean rating
Z
p
1. Ability to be seen 2. Hours office is open 3. Convenience of office location 4. Prompt return calls 5. Time in waiting room 6. Time in exam room 7. Waiting for tests to be performed 8.Waiting for test results 9. Providers listen to you 10. Providers take enough time with you 11. Providers explain to me what I need to know 12. Nurses &MAs friendly and helpful 13. Nurses & MAs answer your questions 14. Other Staff friendly and helpful 15. Other Staff answers your questions 16. What you pay 17. Explanation of charges 18. Collection of payment/money 19. Neat and clean building 20. Ease of finding where to go 21. Comfort and safety while waiting 22. Privacy 23. Keeping my personal information private 24. The likelihood of referring your friends and relatives to us:
4.33 4.64 4.58 4.29 4.43 4.08 4.36 4.41 4.81 4.80 4.84 4.79 4.80 4.78 4.76 4.27 4.45 4.52 4.85 4.84 4.81 4.85 4.79 4.81
4.37 4.47 4.42 4.19 4.58 4.46 4.41 4.47 4.78 4.77 4.78 4.80 4.77 4.74 4.76 4.24 4.36 4.35 4.84 4.84 4.86 4.86 4.87 4.80
0.104 1.21 1.36 −0.39 1.45 −2.48 0.80 −0.34 0.05 0.07 0.46 −0.02 0.13 0.30 −0.15 0.02 −0.36 0.75 0.03 0.11 −0.24 −0.05 −0.74 −0.08
0.92 0.23 0.17 0.69 0.15 0.01 0.44 0.73 0.96 0.94 0.65 0.98 0.89 0.95 0.88 0.98 0.72 0.45 0.98 0.91 0.81 0.96 0.45 0.93
Level of significance = 0.05.
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Table 3 Frequency of open-ended responses. Question
What do you like the best about our center? What do you like the least about our center? Suggestions for improvement
Pre-process responses
Post-process responses
Total responses
Responses of N/A, none, etc.
Total responses
Responses of N/A, none, etc.
85 66 42
1 18 17
81 50 49
1 17 20
The post-process change survey comments provided different insight. While approximately the same number of respondents provided some positive comments, nearly a third fewer participants described any areas of concern. 3.6.5. Standard of care Thirty-five responses addressed the standard of care. Thirty responded positively with such comments as, “able to address multiple pain issues,” “willingness to listen to me,” and provides attention “to my entire medical condition.” Three negative comments focused on failure to return patient phone calls and two other responses described problems with staff communication with the patients. 3.6.6. Personal relationships and interaction with staff Forty patients responded in this category. Thirty-seven responded positively indicating that they, “liked the APN, doctor or staff members” and the “attention, trust and respect that was received.” There were three negative responses, one concerning the front desk, one regarding a specific nurse and one regarding the wait time for doctor. 3.6.7. Logistical issues Forty-three total comments were included in this section on the post-process change: 34 positive and 9 negative. The negative comments were related to hours of operations, location and parking. There was only one comment regarding scheduling and time in the exam room. This decreased from 17 responses regarding scheduling in the pre-process survey. A number of patients commented positively on such issues as hours, location, parking and price. Thirteen positive comments and 32 negative comments were received within the logistical category on the preprocess survey. None of the positive statements comments were related to wait time or scheduling issues. Instead 19 responses to the question about what the patients' liked leased involved wait time and eight identified scheduling issues. Twelve of the suggestions for improvement were logistical such as offering more appointment options later in the day, sending reminder emails and improving the comfort of the furniture in the waiting room. 3.6.8. General category Thirty-eight responses were all positive. There were no negative responses in this area. They replied that they had “no complaints.” They “would not change anything.” The response rate in this category rose from six responses pre-process change to 38 responses postprocess change, with all of the post-process change responses being positive. 3.7. Staff satisfaction Thirteen staff members completed the survey on SurveyMonkey pre and post procedural change. There were eight questions utilizing a 5-Likert scale are summarized in two categories: 1) patient interaction and 2) staff stress, workload and workplace satisfaction. 3.7.1. Patient interaction The first question for staff was: Do you interact with the patients too much, too little or about the right amount? The pre-process change responses indicated that 92.3% of the staff perceived it was the
“right amount” and 7.69% responded that there “slightly too much.” In contrast, 100% of the post-process change respondents thought it was the “right amount.” Overall, the staff conveyed that the interactions with patients took the right amount of time and did not perceive that they were rushed or stressed when surveyed post-procedurally. The second question was: How often do you feel patients are rushed during their appointment? Overall, the staff did not perceive that patients were rushed before or after the process change. When responding to this question, six of 13 (pre-process change) and eight of 13 (post-process change) felt that patients were “rarely” or “very rarely” rushed. In response to the third question (How often do rushed patients become negative?), 11 of 13 staff responded “almost always,” “often” or “sometimes” in the pre-process survey while 10 of 13 responded similarly in the post-process survey. Although staff do not think that patients are rushed, they still perceive that patients are negative. 3.7.2. Staff stress, workload and workplace satisfaction The first question in this section asked, “In a typical week, how often do you feel stressed at work?” The options for response were: “always”, “most of the time”, “about half of the time”, “once in a while” and “never”. One staff member responded “often” in the pre-process staff survey. However, to the post-process survey, there were no staff members that responded “often” to this question. The pre-process staff survey revealed that seven answered “rarely” or “very rarely”. Again, in contrast to the post-process staff survey, nine staff responded “responded “rarely” or “very rarely”. The post-process staff survey had a positive response to their perception of their place of employment. This is a slight improvement to the pre-process survey where one staff member responded negatively to this question. When the staff where asked, “Overall, how much did you like working here?” The options for responses where: “a great deal”, “a lot”, “a moderate amount” and “not at all”. In the pre-process staff survey, four staff responded “a great deal” while in the post-process staff survey six staff responded “a great deal”. The last question queried, “How likely is it that you would recommend this company to a friend or colleague?” The responses ranged from 0 (not at all likely) to 10 (extremely likely). The staff responded more favorably to this question post-process survey compared to pre-process survey. This was evident by the percentage of improvement to this question increasing from 31% pre-process staff survey to 46% post-staff survey being likely to recommend the clinic to friend or colleague. 4. Discussion While the result of this practice innovation showed significant statistical improvement in patient satisfaction regarding the amount of time they spent with providers in the exam room after the scheduling process was changed, patients did identify some common themes which were echoed in the literature. For example, patients found that this scheduling process offered more time with their healthcare provider and an opportunity to improve service, a finding similar to Brown et al.'s (2002) and Moore et al.'s (2016) outcomes. In addition, the extended appointments provided a mechanism to meet patients' needs which reinforces the findings identified by other colleague (Bleustein et al., 2014; Morris et al., 2013; Wasan et al., 2005). By extending patients' appointments, the patients responded more positively than with the standard scheduling practice and were more
K.A. Baule et al. / Applied Nursing Research 33 (2016) 54–60
satisfied with their appointments which confirmed the findings of Geraaghty et al. (2007) and Robinson & Chen (2010). The narrative responses to the patients' survey post-process change showed only four negative comments in comparison to 17 negative comments on the pre-process change survey. A scheduler also identified that inquiring about patients' health condition and appointment length prior to their scheduled appointments provided an avenue to increase productivity with the availability of complete medical records. Prakash (2010), Press Ganey (2010), and Whear, et al. (2013) acknowledged that early identification of patient satisfaction problems within a practice can help to improve services. Likewise, Ross et al. (2013) recognized that if the staff is more involved in patient care, the patients will have an improved perception of their care. This was noticeable when patients were more satisfied with the time that they spent in the exam room and the waiting room. However, it is unclear if the satisfaction level was influenced by the staff who may have appeared less rushed since the number of appointments may have been reduced because of the increases in patient appointments. The findings of Tuli, et al., (2010) and Geraghty, et al., (2007) both support the findings of this study in that more flexible and accessible scheduling will increase patient satisfaction. The staff satisfaction improved slightly with the implementation of the scheduling process change. While Moore, Hamilton, Krusel, Moore and Pierre-Louis (2016), Prakash (2010), Vowles and Thompson (2012) and Warner (2011) all suggest that patients' relationships and provider-patient communication have a positive outcome, it could be a result of having more opportunity for the staff to feel less rushed and able to spend more time with the patients. 4.1. Strengths and limitations One of strengths of this evidence-based practice innovation was the generous support of the entire staff, leadership and stakeholders. Individuals working at the Midwestern clinic identified that there was an overall benefit to improving dialog with patients by offering the opportunity to schedule longer clinic appointments. Another strength of the project was it provided an opportunity for the patients to discuss new, as well as chronic pain issues at the same office visit. The translation of current evidence allowed the pain clinic to view scheduling as an individual patient issue and not a standard process. Considering the patient's individual needs and preferences when scheduling appointments is a key to improving patient and staff satisfaction. It is also recognized that there were limitations associated with this evidencebased practice change. A major limitation was that the pre-and postchange surveys did not include an evaluation of satisfaction between the same respondents. Therefore, identifying specific changes in satisfaction over time was hindered. The patient population was homogenous; there was not much racial/ethnic diversity in either the pre-or post-process change groups. The patients did not always know the length of their scheduled appointment. It is unclear if the patients' level of pain at the time of the survey reflected their level of satisfaction with the Midwestern pain clinic. Another limitation to this finding is the reaction from the schedulers. There were 526 patients that had the opportunity to request an extended appointment however the three schedulers only extended a total of 30 patient appointments. Nevertheless, they also extended an additional 61 patients without the patients' knowledge. The schedulers must have identified a benefit from having an option of a longer patient appointment, but did not follow the provided protocol. If all of the schedulers asked established patients the same questions when scheduling their appointment, perhaps the number of patients requesting an extended appointment would have been larger. It is also unclear if more patients would have requested a longer appointment if the reminders calls were made by the scheduler and not a prerecorded message. It is also recognized that there was a limited number of individuals who could complete the staff survey. Another possible limitation was
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within the survey tool itself. For example, the question “How likely is it that you would recommend this company to a friend or colleague?” could be interpreted a number of ways. Several of the staff initially answered that they would not stating that the Midwestern clinic is a smaller clinic of a bigger organization. Some other staff members responded they would not recommend the clinic to friends due to its size but also stated that they did not want to work in such close proximity to relatives or non-work friends. None of these statements were meant as a negative reflection on the work environment itself. 4.2. Program recommendations In the future, it may be beneficial to assess the level of patient satisfaction with those patients who chose to extended their appointments and compare the level of satisfaction with those patients who did not lengthen their appointment. It would also be helpful to evaluate the amount of “no-show” appointments with those extended their appointment. While it may be beneficial to have a live person confirm the patients' appointment, it might present one more opportunity to have a conversation between the scheduler and the patients which may add another avenue to influence patient satisfaction. Likewise, implementing a standardized script for the schedulers may help with appropriate patient appointment lengths and decrease the number of patients' appointments that were lengthened without the patients' knowledge. Replicating this project in a larger more diverse pain clinic setting or utilizing the same patients in the pre-process change as the post-process change would be ways to improve on this project. 4.3. Application to nursing practice Overall, patients and staff were more satisfied after offering patients a flexible appointment option. A key element is that patients continue to stay with clinics and providers they feel trusted with their health care concerns (Tuli et al., 2010). The staff exhibit the element of security when they are less stressed in their job. By offering the patients the option to extend their scheduled appointment, the staff was less stressed and more supported by the leadership in their work environment. Additionally, the patients were more pleased with their service. Staff tend not to leave their place of employment if they feel supported and have a manageable workload. Staff retention translates into cost savings for employers as the average cost to train a new staff nurse is minimally $10,000 (Lafer, 2003). Patient retention adds to staff satisfaction as there is continuity with their care delivery. 5. Conclusions Patient satisfaction is an important facet of modern clinical practice. This evidence-based practice innovation found that allowing the option for flexibility in appointment lengths helps to increase patient satisfaction. There are three areas of consideration for further exploration. The first area would be to consider the incorporation of a more detailed question heuristic to be used by the schedulers to ensure the appropriate appointment length for each patient and have the necessary patient records at the time of the appointment. The second area is to evaluate the impact of modifying the clinic's hours of operation to be more favorable to working patients on overall patient satisfaction. Replicating the process of more flexible appointment lengths in a larger clinic setting would be beneficial. By increasing the scope of this practice change to a larger setting, there may be further evidence to support the translation of this practice innovation in other pain clinics and chronic care center. References Al Ali, A. A., & Elzubair, A. G. (2016, January). Establishing rapport: Physicians' practice and attendees's satisfaction at a primary health care center, Damman, Saudi Arabia, 2013. Journal of Family and Community Medicine, 23(1), 12–17.
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