Care Redesign

Nobody Wants a Waiting Room

Article · February 6, 2019

With his nose buried in a binder full of specifications for standardized outpatient clinics, the architect asked, “Where do you want your waiting rooms?”

 

“I don’t think anyone wants a waiting room,” came the earnest reply.

 

Chuckling, the architect persisted, “Yeah, you’re probably right, but let’s figure out where they’re going to go in this building.”

 

“Actually, we’re not going to have waiting rooms. Nobody wants a waiting room.”

 

The room grew quiet, and a few people shifted uncomfortably. The architect, sensing no jest in the exchange, looked up and gently closed his binder. “But everyone has waiting rooms . . .”

If it’s true that nobody wants a waiting room, then why does everyone still seem to have one? This initial conversation would be the spark for a series of struggles over the next 2 years as we attempted to establish a new model of care, with a service blueprint and an environment to enable it.

In the summer of 2015, as the new Dell Medical School at The University of Texas at Austin began planning for the launch of its specialty clinics, the school’s embedded Design Institute for Health was asked to assist in the design of both the service model and the physical layout of the clinic.

The school had been established only a few years earlier, funded in part by a property tax increase that was passed by the local county taxpayers as an investment in a future model of care to better serve their needs and priorities. The school’s commitment to challenging existing norms began with disavowing the fee-for-service model in favor of a value-based1 model of care. This model was a centerpiece for the fledgling medical school — a clean-sheet opportunity to adopt a payment structure better aligned with society’s needs, to improve the patient experience, and to focus on deploying Integrated Practice Units (IPUs). IPUs are a structure for delivering care through highly coordinated multidisciplinary teams, organized around a specific medical condition (or set of conditions). They are responsible for the full cycle of care for that condition, including education, engagement, and follow-up, and incorporate inpatient, outpatient, rehabilitative, and support services (e.g., nutrition and social work). Teams are co-located, measure processes and outcomes as a team (instead of individually), and most importantly, accept joint accountability for outcomes and costs.2

The possibility of eliminating waiting rooms represented one opportunity to transform the patient experience. For patients and family, the feeling of wasted time, alongside others who were ill, was a source of frustration and anxiety, and reinforced the prioritization of the system’s needs over the patient’s. We felt it was impossible to address these drawbacks, no matter how many amenities were included, and waiting rooms wasted valuable floor space that could be better utilized for other purposes. In agreement with the dean of the medical school, we decided to make the elimination of waiting rooms an anchor tenet of the new clinics.

We started with an empty shell. The building had been designed before most of the leadership of the medical school had arrived, and certainly before we had committed to a value-based model of care. The existing plan reflected a more traditional fee-for-service model with rows of small exam rooms meant to shuttle patients through at maximum efficiency: an interior layout that reflected current “best practices.” Fortunately, we took over before any of the interior had been finalized and took the opportunity to revise the plan for our new care and service models.

The architects were initially reluctant to depart from known practices. If our experiment were to go awry, the plans we were developing would require a complete renovation in order to revert to a more traditional layout, at a cost we couldn’t afford. The architects even offered to do a computer simulation of staff and patient flow to show the advantages of having a waiting room, but we found there was no preexisting data that could be used for a meaningful simulation.

Instead, we built small-scale prototypes, then full-scale prototypes in which we did mock operational run-throughs to assess the feasibility of our proposed model. Could we assign patients one room for the duration of their stay and get providers to circulate effectively between them? Could patients self-navigate to their rooms? Could we standardize room layouts across specialties? Each prototype provided valuable feedback about how the launch model would behave and allayed our concerns.

Dell Medical School No Waiting Room - full-scale prototypes allowed us to explore concepts and test assumptions about behavior of providers and patients

Figure 1. Click To Enlarge.

Despite their initial reservations, the architects eventually became our allies, recognizing that traditional layouts wouldn’t serve our new care model and that this project was an opportunity to explore concepts that they didn’t have permission to try in other venues. The eventual buildout included movable walls and reconfigurable furnishings to produce a flexible, evolvable space that accommodated not only our launch model, but also the inevitable changes that would happen as we made new discoveries in the clinics we call our “learning lab.”

“But I need a waiting room. Where else will I get my patients from?”

A clinical leader at the medical school, when told that we wouldn’t be building waiting rooms, insisted quite sincerely that the clinic wouldn’t be able to operate efficiently without a ready supply of patients at hand. The concern reflected a “factory” metaphor that is almost universal in traditional clinics paid on a fee-for-service basis.

The waiting room is nothing more than a temporary stock room, or intermediate warehouse for patients with billable conditions that feed exam rooms every 10–15 minutes, ensuring the unbroken stream of billable encounters demanded by RVU targets or other measures of productivity. No health care provider I know actually views patients as a packaged revenue opportunity, but the fee-for-service system has incentivized this warehousing behavior.

Dell Medical School No Waiting Room - patients in waiting room are akin to materials in a factory but integrated practice unit returns focus back to patient

Figure 2. Click To Enlarge.

In a value-based model, the pressure to push patients quickly through appointments is not the primary driver, since each encounter doesn’t represent a distinct billing event. Instead, getting to productive outcomes is more important, so we incorporate as much as we can into a single visit, including interactions with multiple providers, imaging and diagnostics, nutrition counseling, physical therapy, social services and care coordination, and other associated services. Because single appointments can last 1.5 hours, a small gap in the provider’s schedule is less consequential. Importantly, patients can get through several stages of their care journey in a single visit. One long appointment may mean a half-day of missed work, but three short visits effectively meant three missed half-days of work anyway, when accounting for travel time. Especially for patients who struggle with transportation access, this was a welcome improvement.

Even so, providers still wanted to minimize their downtime in the clinic. To address this, we shifted “ownership” of the exam rooms from the provider to the patients. Rather than delivering patients serially to one exam room after another, each owned by a different provider, we made the patients the owner of their own rooms, and instead, circulated the providers to the patients. In our model, patients and family are shown directly to their rooms when they arrive (now renamed “care rooms”) and reside there for the duration of their visit. Providers then walk to patient care rooms as soon as they want to see the next patient. We no longer need to deliver patients from a waiting room to provider exam rooms with perfect efficiency. Our model does require more operational coordination, but the care teams are tightly integrated to help facilitate this. When one care team member exits, they can let the next team member know. There are still small gaps of time, but the patients are told about them, and they stay in their care room instead of being shuttled off to an interstitial waiting area. Care rooms are also arranged around the central provider team space to minimize traverse times.

In the old model where the providers “owned” the care rooms, they knew exactly where all their supplies were; in the new model, we have standardized supplies and placement so that providers are comfortable no matter which room they are in.

Dell Medical School No Waiting Room - integrated practice unit layout blueprint identical regardless of specialty with front-of-house zones for patient flow and back-of-house zones for care teams

Figure 3. Click To Enlarge.

Dell Medical School No Waiting Room - back of house designed to encourage care team members to intersect and overlap - everyone sharing same workspace leads to better communication coordination

Figure 4. Click To Enlarge.

“Are we really going to give patients control over their experience?”

We launched this project with in-depth design research to understand what each of the stakeholders wanted out of the new model and environment. For both the patients and providers, we established design principles that would guide our work throughout the project.

Dell Medical School No Waiting Room Design Thinking - design principles based on what patients and providers want to guide the project

Figure 5. Click To Enlarge.

Most of our clinical colleagues embraced the ideas as worthy aspirations, but one provider in every audience would eventually inquire whether we were really committing to “grant the patient control over some aspect of their journey?”

Providers didn’t question whether a patient deserved to have some control over their situation, but some perceived the patient-provider relationship as a zero-sum game — if the patient gained control, then there was the risk that the provider might lost some.

We sought to give patients control over their experience and environment without diminishing the provider’s influence, and eliminating the waiting room was part of that effort. Anxiety is a known issue for patients in medical contexts. Granting control to an individual, even if it’s incomplete control, helps to mitigate that anxiety, which improves patient engagement and decision-making. Our model also asks patients to engage meaningfully in their own care, whether through goal-setting, patient-reported outcomes3, or shared decision-making. In our model, these are introduced prior to the first visit, revised at the clinic appointment, and revisited in follow-up care.

Unallocated Time

Depending on the shift, if a patient and family arrive within 10–15 minutes of their appointment, they can reasonably expect their care room to be available. However, if they show up an hour early, we are likely to still be utilizing that room during high-capacity shifts. Likewise, if they show up an hour or more late, we will have shuffled the room schedule to accommodate other appointments, and they may have to wait for a room to be available or be rescheduled.

Traditional clinics stick those patients in a waiting room, to watch TV or the fish in the tank or their fellow patients. In our clinics, the patients can choose how to spend their unallocated time — in the atrium, the café, or the learning library where they can get educated on their condition or therapy. Our concourses have alcoves designed to accommodate different types of activity (quieter secluded seating for one, chairs facing each other for couples, larger lounges with couches for families, or workspaces for those who want to be productive). Wi-Fi is free and pervasive, and plug-ins for electronics are everywhere. The shift in intent is subtle, but the effect is powerful. Patients note how the experience feels completely different from any clinic they’ve been to before, how much less stressful it is, and how much happier they are for it.

Dell Medical School No Waiting Room - concourse is the first thing patients see for patients and family only and is designed to be quiet and calming

Figure 6. Click To Enlarge.

Dell Medical School No Waiting Room - end of patient concourse has large windows and additional spaces for focused work or larger families

Figure 7. Click To Enlarge.

In the care rooms themselves, we incorporated vital sign devices into each room so that there’s no need to create inefficiencies or bottlenecks by pausing at another station beforehand. The care room doors can be closed and locked by the patient (the providers have a separate entrance). We encourage the patients to adjust the lighting to suit their needs. Available furniture accommodates companions, and there’s even a closet for the patient to store their belongings.

Dell Medical School No Waiting Room - care rooms designed to be owned by patients for duration of stay and to equalize power balance between care team and patients

Figure 8. Click To Enlarge.

After walking providers through prototypes of the experience, we returned to their original concerns.  Did they think the control we gave to the patient would be meaningful? Would it threaten a provider’s influence on the course of care? They answered, “Yes, and no.”

“My clinic operates differently from the others.”

At some point across the span of the project, the clinical lead of every specialty clinic expressed the same sentiment, in roughly the same words. This claim to exceptionalism wasn’t an issue of arrogance — it was really a testament to the siloed nature of specialty care. Because specialty practices typically run as their own business unit, they function based on circumstance and individual preference of the managing providers.

In our clinics, we needed to institute a level of standardization across the different specialty clinics in order for a no-waiting-room model to work consistently across the entire building. Furthermore, many of the conditions we’d treat would require collaboration between multiple specialties as part of a combined IPU. Developing a common core approach to the service model was as important for the experience of the patients as it was for the outcomes of the clinics.

It took 6 months to define the new practice model, reconcile differences between specialties, and build a universal service blueprint that would serve as a foundation for every specialty. By normalizing what we believed would work best, we could elevate the baseline for everyone. We still accommodated any necessary variation justified by a specific specialty’s needs, but the vast majority of the blueprint remained the same between specialties.

In the end, we found much more commonality than difference between the specialties and preserved our ability to deploy common services to support the elimination of waiting rooms. Figure 9 shows the 21 stages of the care process that are common to virtually all the specialties. (The only optional component is diagnostic imaging, because not every specialty requires it.) There were some minor variations in the rooms themselves, primarily around specific supplies that were required, the positioning and selection of furniture, and how the treatment room was utilized. Depending on the clinic, the treatment room could be used for outpatient procedures (many of which were previously done in a hospital) or in other specialties, like psychiatry, as group therapy rooms. Otherwise, the clinics remained the same. Each of our floors (at about 45,000 square feet) accommodates four and a half clinics, and each clinic accommodates 10 patient rooms.

Dell Medical School No Waiting Room - 21 stages of care process common to all specialties

Figure 9. Click To Enlarge.

“What if we lose the patient?”

We had always planned to greet patients as soon as they arrived in the building (at the garage or pedestrian entrance), do a lightweight check-in (name and appointment), and then immediately assign them to a room. Not unlike in a hotel or other hospitality experience, we expected they would have no issue taking the elevator to the right floor, and then finding their way to their room.

As we developed the check-in protocol, members of the operations staff raised a concern: What if patients got lost on the way to their room? We couldn’t track them in between check-in and arrival, so there was a chance they might fall off our radar. Wouldn’t a waiting room model work better, because we’d always know where they were?

We believed that the options under consideration represented a false choice between “enforce sequestration” or “leave them to unguided autonomy.” A third option, guided autonomy, could get them where they needed to go through the use of thoughtful design.

The building was set up for real-time location services using RFID technology. Eventually, we planned to give each patient a tag to track their progress through the building, but we had to delay the deployment of that capability in order to focus on other priorities more critical to the clinic launch.

In the interim, we developed a paper-based protocol, with human backup. We had already developed a straightforward wayfinding scheme: Floors were labeled with numbers, hallways with letters, and then rooms with a second number. At arrival, each patient was given a “boarding pass” with their room assignment.

Dell Medical School No Waiting Room - care rooms are labeled with hallway letter and room number

Figure 10. Click To Enlarge.

Dell Medical School No Waiting Room - patients are provided with boarding pass upon arrival with simple directions and light orientation and a tear-off for accompanying family

Figure 11. Click To Enlarge.

We stationed a concierge on each floor in front of the elevator to direct patients to the correct hallway if needed. Once they arrived at their room, we developed a number of prototypes to allow patients to indicate to care team staff that they had arrived and were ready to be seen.

Dell Medical School No Waiting Room - two of several approaches were developed to signal the care team that patient had arrived and ready to be seen

Figure 12. Click To Enlarge.

Mock operational run-throughs suggested that this approach would work with some tweaking, but learnings at launch showed that these were ultimately unnecessary. To further reduce risk, we moved check-in to each individual floor, just to take the elevator ride out of the equation, with a plan to move back to the original model later to ensure scalability.

“You have to have a waiting room for the EHR to work.”

While setting up the electronic health record (EHR) for the clinic, members of the operation staff had discovered that the software was organized around “stages” of a standardized clinic journey. In the first stage (called “Check-in”), there were a significant number of patient information fields that had to be completed before the software would allow us to assign a room to the patient. Our staff, in configuring the software, realized that a number of those information fields wouldn’t be completed until the patient was already in the care room. Our model clearly required room assignment much earlier in the process.

To avoid having to institute a waiting room solely to accommodate our EHR, we found a way to manipulate the software by leaving the first-stage information fields incomplete, overriding the default rules in order to assign the room, and then coming back to complete the fields later. This process taught the operational staff the important lesson that the model could, and should, dictate how the tools are used, rather than allowing the limitations of the tools to dictate the model.

These efforts, and the challenges we faced, weren’t about just eliminating waiting rooms. Many clinics don’t have waiting rooms, especially in models like concierge medicine that don’t emphasize high throughput. Also, some of the best traditional clinics have waiting rooms that are usually empty.

For us, eliminating the waiting room catalyzed a broader effort to challenge norms and change perspectives. The obvious benefits included improved patient experience and control, better integrated provider teams, and streamlined operations. Less obviously, the change reminded our staff that we could do things differently and that a focus on the patient didn’t have to come at the expense of the staff’s priorities. Alongside team-based care, patient-reported outcomes, and a focus on comprehensive care, the elimination of waiting rooms served as a visible signal to our community that we were committed to honoring their investment by doing things differently.

None of the practical solutions were groundbreakingly difficult to achieve. We had to disentangle people from long-held beliefs, help them understand the system’s true needs, equip them with a process to discover new solutions and evidence, develop the institutional courage to persevere to a solution, and understand the role that technology, the environment, and the human players all have in standing up a new model of care.

Lessons Learned

We had thought that a design of an environment that empowered and enabled patients would be quickly appreciated and intuitively adopted. But just like providers, patients had been trained into behaving in certain ways in medical environments, and we would discover them perched on the edge of the exam chair, afraid to touch anything. To address this issue, we began utilizing “rooming” concierges who, under the guise of helping patients find the way to their rooms, explained how this model was different along the way, showed them the room, and encouraged them to get comfortable, before making a warm handoff to care team staff. These scripted encounters eliminated the need for the patient to signal to the care team that they had arrived. We also utilized vinyl lettering on the walls to allow the room to explain itself to its occupants, revealing the intent of the room’s design and giving the room its own voice and personality.

Dell Medical School No Waiting Room - the care room speaks directly to the patient, signaling a different experience

Figure 13. Click To Enlarge.

As part of the room buildout, we specified large monitors, with a video camera that could be deployed to conduct a video checkout directly in the room (instead of a separate checkout desk). It allowed for patients, providers, and the phone center staff to collaboratively set follow-up appointments as part of a video call. The available technology still isn’t seamless enough, so instead the medical assistants check the patients out directly from the room, setting follow-up appointments as necessary, which removed the need to coordinate with the third-party phone center staff. For most patients, this method has helped us preserve the goal of eliminating another stopover on the way out of the clinic. However, for complex follow-ups that require highly coordinated or stacked visits, an additional conversation with a dedicated scheduler still is necessary and will require further work to streamline. We are continuing to pursue technology solutions, but only when they improve the patient experience and remove staff burden.

The large monitor is also intended to mirror the EHR record in which the provider is working. The goal is to provide transparency to the patient about what is being recorded and to allow the patient to correct any immediate errors, in case the provider mishears or mischaracterizes something the patient said. It is not consistently used, as some providers find it very uncomfortable for patients to be watching what they type into the record, or because they don’t typically document in the room at all. This issue will also need further work.

We launched with three clinics in October of 2017: Musculoskeletal (Orthopedics), Women’s Health (Complex Gynecology), and WorkLife (Urgent Care). Since then, we have opened clinics for Multiple Sclerosis, Cognitive Impairment, Bipolar Disorder, Pain Management, Worker’s Comp, Primary Care, Bipolar Disorders, Psychiatry, Cancer, Rheumatology, and Heartburn and Esophageal Disorders. Interestingly, in a model that anchors on longer duration visits (up to 1.5 hours), we manage six room turns a day at capacity, better than the industry average of three to five room turns per 8-hour shift for fee-for-service specialty clinics. Our team of multiple physicians, advanced care practitioners, and other providers makes efficient turnover possible, because the rooms don’t have to wait for the attention of a single physician.

Whether this model can scale at full capacity across other venues is still to be proven. Whether it can work in an environment where most appointments aren’t prescheduled is also not yet known. What role technology will play in the evolving model is yet to be resolved. We fully expect that changes in disease patterns, new developments in diagnosis and treatment, and evolving payment mechanisms will require us to continuously modify the model over time.

In hindsight, one thing is certain, though — I would have revised my reply to the architect’s initial query. It’s not true that “Nobody wants a waiting room.” Patients certainly don’t, but plenty of other stakeholders think they do. I should have said that in this model, nobody actually needs a waiting room.


References

1. Porter M, Teisberg E. Redefining health care: creating value-based competition based on results. Boston, MA: Harvard Business Review Press, 2006.

2. Porter, M, Lee TH. The strategy that will fix health care. Harvard Business Review October 2013; 91, no. 10: 50–70.
3. Weldring T, Smith SM. Patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs). Health Serv Insights. 2013;6:61–8.

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