kEEP PATIENTS WAITING ? NOT IN MY OFFICE
Good doctor-patient relations begin with both
parties being punctual for appointments. This is particularly important in my
specialty-pediatrics. Mothers whose children have only minor problems don't
like them to sit in the waiting room with really sick ones, and the sick kids
become fussy if they have to wait long.
But lateness-no matter who's responsible for
it-can cause problems in any practice. Once you've fallen more than slightly
behind, it may be impossible to catch up that day. And although it's unfair to
keep someone waiting who may have other appointments, the average office
patient cools his heels for almost 20 minutes, according to one recent survey.
Patients may tolerate this, but they don't like it.
I don't tolerate that in my office, and I don't
believe you have to in yours. I see patients exactly at the appointed hour more
than 99 times out of 100. So there are many GPs (grateful patients) in my busy
solo practice. Parents often remark to me, "We really appreciate your
being on time. Why can't other doctors do that too?" My answer is "I
don't know, but I'm willing to tell them how I do it."
BOOKING APPOINTMENTS REALISTICALLY
The key to successful scheduling is to allot the
proper amount of time for each visit, depending on the services required, and
then stick to it. This means that the physician must pace himself carefully,
receptionists must be corrected if they stray from the plan, and patients must
be taught to respect their appointment times.
By actually timing a number of patient visits, I
found that they break down into several categories. We allow half an hour for
any new patient, 15 minutes for a well-baby checkup or an important illness,
and either 5 or 10 minutes for a recheck on an illness or injury, an
immunization, or a minor problem like warts. You can, of course, work out your
own time allocations, geared to the way you practice.
When appointments are made, every patient is given
a specific time, such as 10:30 or 2:40. It's an absolute no-no for anyone in my
office to say to a patient, "Come in 10 minutes" or "Come in a
halfhour." People often interpret such instructions differently, and
nobody knows just when they'll arrive.
There are three examining rooms that I use
routinely, a fourth that I reserve for teenagers, and a fifth for emergencies.
With that many rooms, I don't waste time waiting for patients, and they rarely
have to sit in the reception area. In fact, some of the younger children
complain that they don't get time to play with the toys and puzzles in the
waiting room before being examined, and their mothers have to let them play
awhile on the way out.
On a light day I see 20 to 30 patients between 9
A.M. and 5 P.M. But our appointment system is flexible enough to let me see 40
to 50 patients in the same number of hours if I have to. Here's how we tighten
My two assistants (three on the busiest days) have
standing orders to keep a number of slots open throughout each day for patients
with acute illnesses. We try to reserve more such openings in the winter months
and on the days following weekends and holidays, when we're busier than usual.
Initial visits, for which we allow 30 minutes, are
always scheduled on the hour or the half-hour. If I finish such a visit sooner
than planned, we may be able to squeeze in a patient who needs to be seen
immediately. And, if necessary, we can book two or three visits in 15 minutes
between well checks. With these cushions to fall back on, I'm free to spend an
extra 10 minutes or so on a serious case, knowing that the lost time can be
made up quickly.
Parents of new patients are asked to arrive in the
office a few minutes before they're scheduled in order to get the preliminary
paperwork done. At that time the receptionist informs them, "The doctor
always keeps an accurate appointment schedule." Some already know this and
have chosen me for that very reason. Others, however, don't even know that
there are doctors who honor appointment times, so we feel that it's best to warn
them on the first visit.
FITTING IN EMERGENCIES
Emergencies are the excuse doctors most often give
for failing to stick to their appointment schedules. Well, when a child comes
in with a broken arm or the hospital calls with an emergency Caesarean section,
naturally I drop everything else. If the interruption is brief, I may just
scramble to catch up. If it's likely to be longer, the next few patients are
given the choice of waiting or making new appointments. Occasionally my
assistants have to reschedule all appointments for the next hour or two. Most
such interruptions, though, take no more than 10 to 20 minutes, and the
patients usually choose to wait. I then try to fit them into the spaces we've
reserved for acute cases that require last-minute appointments.
The important thing is that emergencies are never
allowed to spoil my schedule for the whole day. Once a delay has been adjusted
for, I'm on time for all later appointments. The only situation I can imagine
that would really wreck my schedule is simultaneous emergencies in the office
and at the hospital-but that has never occurred. When I return to the patient
I've left, I say, "Sorry to have kept you waiting, I had an emergency-a
bad cut" (or whatever). A typical reply from the parent: "No problem,
Doctor. In all the years I've been coming here, you've never made me wait
before.And I'd surely want you to leave the room if my kid were hurt."
Emergencies aside, I get few walk-ins, because
it's generally known in the community that I see patients only by appointment
except in urgent circumstances. Anonemergency walk-in is handled as a phone
call would be. The receptionist asks whether the visitor wants advice or an
appointment. If the latter, he or she is offered the earliest time available
for nonacute cases.
TAMING THE TELEPHONE
Phone calls from patients can sabotage an
appointment schedule if you let them. I don't. Unlike some pediatricians, I
don't have a regular telephone hour, but my assistants will handle calls from
parents at any time during office hours. If the question is a simple one, such
as "How much aspirin do you give a one-year-old?" the assistant will
answer it. If the question requires an answer from me, the assistant writes it
in the patient's chart and brings it to me while I'm seeing another child. I
write the answer in-or she enters it in the chart. Then she relays it to the
What if the caller insists on talking with me
directly? The standard reply is "The doctor will talk with you personally
if it won't take more than one minute. Otherwise you'll have to make an
appointment and come in." I'm rarely called to the phone in such cases,
but if the mother is very upset, I prefer to talk with her. I don't always
limit her to one minute; I may let the conversation run two or three. But the
caller knows I've left a patient to talk with her, so she tends to keep it
DEALING WITH LATECOMERS
Some people are habitually late; others have
legitimate reasons for occasional tardiness, such as a flat tire or "He
threw up on me." Either way, I'm hard-nosed enough not to see them
immediately if they arrive at my office more than 10 minutes behind schedule,
because to do so would delay patients who arrived on time. Anyone who is less
than 10 minutes late is seen right away, but is reminded of what the appointment
When it's exactly 10 minutes past the time
reserved for a patient and he hasn't appeared at the office, a receptionist
phones his home to arrange a later appointment. If there's no answer and the
patient arrives at the office a few minutes later, the receptionist says
pleasantly, "Hey, we were looking for you. The doctor's had to go ahead
with his other appointments, but we'll squeeze you in as soon as we can."
A note is then made in the patient's chart showing the date, how late he was, and
whether he was seen that day or given another appointment. This helps us
identify the rare chronic offender and take stronger measures if necessary.
Most people appear not to mind waiting if they
know they themselves have caused the delay.And I'd rather incur the anger of
the rare person who does mind than risk the ill will of the many patients whom
would otherwise have to wait after coming in on schedule. Although I'm prepared
to be firm with parents, this is rarely necessary. My office in no way resembles
an army camp. On the contrary,most people are happy with the way we run it, and
tell us so frequently.
COPING WITH NO-SHOWS
What about the patient who has an appointment,
doesn't turn up at all, and can't be reached by telephone? Those facts, too,
are noted in the chart. Usually there's a simple explanation, such as being out
of town and forgetting about the appointment. If it happens a second time, we
follow the same procedure. A third-time offender, though, receives a letter
reminding him that time was set aside for him and he failed to keep three
appointments. In the future, he's told, he'll be billed for such wasted time.
That's about as tough as we ever get with the few
people who foul up our scheduling. I've never dropped a patient for doing so. In
fact, I can't recall actually billing a no-show; the letter threatening to do
so seems to cure them. And when they come back-as nearly all of them do-they
enjoy the same respect and convenience as my other patients.
1. What features of the appointment scheduling
system were crucial in capturing "many grateful patients"?
2.What procedures were followed to keep the appointment system
flexible enough to accommodate the emergency cases, and yet be able to keep up
with the other patients' appointments?
3. How were the special cases such as latecomers and no-shows
44. Prepare a schedule
starting at 9 a.m. for the following patients of Dr. Schafer:
Johnny Appleseed, a
splinter on his left thumb.
Mark Borino, a new
Amar Gavhane, 102.5
degree (Fahrenheit) fever.
Sarah Goodsmith, an
JJ Lopez, a new patient.
Angel Ramirez, well-baby
Bobby Toolright, recheck
on a sprained ankle.
Rebecca White, new
Doctor Schafer starts
work promptly at 9 a.m. and enjoys taking a 15-minute coffee break around 10:15
or 10:30 a.m. Apply the priority rule that maximizes scheduling efficiency.
Indicate whether or not you see an exception to this priority rule that might
arise. Round up any times listed in the case study (e.g., if the case study
stipulates 5 or 10 minutes, then assume 10 minutes for the safe of this