Monday, April 23, 2007

When you mess up, just admit it

A letter of complaint, and the reply from our SVP for Ambulatory Services. Fully justifiable complaint, and the right kind of answer: Not defensive, respectful of the patient and her niece, and with a promise of appropriate follow-up. With 500,000 ambulatory visits per year, we cannot necessarily expect perfection each time, but we keep trying. This kind of letter is really helpful to us in finding holes in our service. It supplements our mystery shopper program and patient satisfaction surveys.

Dear Mr. Levy,
I have an 84 year old aunt with a slow moving lymphoma and have been bringing her from New Jersey, where she lives, to an oncologist at BIDMC, who she likes very much. This past Wednesday we had an appointment at 11 a.m. We had not even been called to an examining room by 1:00, at which point I had to insist to a somewhat annoyed person in the reception area that we page the nurse. As a result, by 12:40, the nurse had examined my aunt.

Still we waited for the doctor, who we had seen in the halls of the clinic a number of times since we'd arrived. At 1:40 I finally had to leave my aunt in the examining room, because I had to get to a 2:15 appointment at work. I arranged for my husband to pick her up when she called to say she was ready. Later I found out that the doctor had not seen my aunt until after 2:30.

The reason I accompany my aunt to her appointments is that she does not remember things well and this time she didn't either, including when she should make her next appointment and when to stop her current medicine. She did say the doctor told her something about patients who were late that morning which accounted for the wait. This might have made the event somewhat palatable except for the fact that we have always waited at least two hours and sometimes three for this doctor, whom we have seen about five times.

This time, booking six weeks ahead, I tried to get an early appointment but they were all booked for the week. I am not surprised. I'm sure you'd agree that something is wrong with this picture, and I wanted you to know.

Thanks for reading.

Dear **,

On behalf of the Oncology Clinic, I apologize for your Aunt's delay in this visit and all her other visits. I also am sorry it impacted your schedule, too. As you are aware, we are very busy, but it is no excuse for this type of delay with this physician nor the clinic.

It seems from your email that this happens as a regular process for this doctor. I will follow up with my directors, and they will get in touch with you to get any additional information and share with you our current plans to improve the flow and physician's time/efficiency in the clinic.

As well, the next time you and your Aunt are here, I would like to pick up your parking and lunch if I may. I will work that out also via my directors.

Again, my sincere apologies, and I look forward to hearing your next visit is a quick and ON TIME one!

Warm regards,
Jayne Sheehan


Anonymous said...

This is a difficult problem - its not like the oncologist she was waiting to see was playing poker in the back while the patients were waiting. It is probably a combination of patients' slight lateness early in the day and an overly-optimistic schedule. If you change the schedule, she will have to wait 12 weeks for the next appointment, which is not acceptable either. If you force the oncologist to spend less time with each patient, that isn't fair to the patients either. Perhaps having more PA's or NP's could speed things up a little, but I am sure everyone wants as much time with their oncologist as possible.

- bidmc medical resident

Anonymous said...

I have also had this experience on numerous occasions. What I find infuriating is what I perceive as arrogance and total disregard for the value of the patient's time and that of any family member who accompanies the patient. I know that emergencies occur, and other unforseen circumstances can cause delays. However, I don't think it would be hard for the receptionist to inform the patient that we are running, say, an hour or two hours behind, so if you would like to go get something to eat or just go out for a walk and come back later, that would be fine. Also, many doctors are notorious for booking more patients than they can handle, so they just let them wait. If the last appointment of the day is for 4:00 PM, the doctor really expects to be done by 6:00, and it's OK with him or her to let patients wait for up to two hours. It's NOT OK with me, and I'm sure many other patients feel the same way.

Anonymous said...

Healthcare needs to follow the airline industry in terms of constructively using (rather than punishing, which leads to ass-covering) each mistake to improve overall system performance.

Perhaps there is a need for regulatory bodies to help provide some cover from over-anxious litigation so that healthcare professionals can be more open about mistakes.

Anonymous said...

It's hard to define when wait times become too long. Is one hour reasonable? Two hours?

I don't mind a one-hour wait because I do know how unpredictable a physician's day can be. What's frustrating is to sit there as the hours crawl by and to not even be acknowledged. You don't know whether you should run down to the coffee shop and take a quick break, whether you should simply reschedule the appointment or whether your visit with the physician is imminent within the next 10 minutes.

I think a little proactivity on the part of the reception desk could go a long way. Come over and tell me the doctor is running 90 minutes late, so I know what to expect. Give me the option of getting some coffee or an up-to-date magazine to read. Offer to reschedule (although for people who must take a day off work, place their kids with a babysitter or drive long distances, this isn't always an option).

I've been a cancer patient so I know you can't rush patients through their appointment with the oncologist. I think it's important to account for this when appointments are being scheduled. If you kept track for a week of how long the patient actually spent with the onc, you might have a metric for the length of the average appointment and could book patients accordingly. Flexibility also is important. Some of the most time-consuming discussions tend to take place either when a cancer dx is first made or when the patient has run out of treatment options. It would be nice if this could be planned for, rather than giving every patient a standard 10- or 15-minute appointment.

As someone who is punctual, I admit to being irritated when I am forced to wait because other people show up late. It's not fair to me, and I have sometimes ended up being rushed through an appointment because I was there for something relatively uncomplicated and the physician was trying to make up for lost time. Maybe there is some way of applying sanctions to people who are more than, say, 15 or 20 minutes late? Make 'em wait longer. My dentist actually has a 15-minute rule; if you're more than 15 minutes late, your appointment is canceled and you have to reschedule. IME when there is some kind of penalty attached to lateness, people tend to try harder to be on time.

I appreciate that you respond to patient complaints and are sincerely interested in trying to resolve them. It is a huge change from the majority of my experiences with the health care system. I hope you can keep it up!

Anonymous said...

Hi Paul,

Good post. I think the real value is the distance b/w Comment #1 and Comment #2. The issue is sometimes misconstrued by doctors as an unreasonable expectation by patients that they be seen on time. Instead, I think most patients are like #2...what they want is simply an UPDATE on the schedule.

How hard would it be for a BIDMC pilot program where the receptionist gives an updated reading of the appointments on the half hour?

Or, since there might be 4 or 5 patients waiting at any given time, just circulate like a teacher in the classroom, spending 30 seconds with each, saying "Dr. X is at least one hour behind because of a complicated lung cancer case. Would you like to go out and get lunch downstairs or across the street? If you leave me your cell number, and things clear up, I'll call you."

Anonymous said...

As a current cancer patient at Dana Farber that shows up regularly very early for appointments, I enjoy the fact that the check in desk has beepers available for patients. If the wait time for an infusion chair is rather long, or if I want to step outside for a change of scenery, the beeper will let me know a seat is ready for me. Why don't more check-in desks offer this is service if it makes so much sense?

Anonymous said...

I second Rebecca's comment and was planning to suggest it myself. As a patient, it's much more comforting when the experience of seeking medical care doesn't add to or enhance the feeling of things being out of your control. With one of those beepers, at least I could choose where I want to spend my waiting time (in the coffee shop or cafeteria, outside in the fresh air, etc.). The receptionist could then beep patients when the waiting time might only be 5 minutes, to ensure enough time for the patient to return to the waiting room so that the doctor wouldn't have to wait either.

Lyss said...

I had a terrible experince at BUMC in March. If I hadn't accidentally been a half-hour early, the Central Reg process would've put me 20 minutes behind schedule. I also was the only person in that doc's office not on the verge of rioting b/c the schedule (same morning) was so off.

I ended up having to miss half a day of work. For a 9:15am appointment.

Something's wrong with the system. Not just one hospital.

Anonymous said...

I am a self-employed attorney. If I am running more than 15 minutes late for an appointment for ANY reason (and I definitely DO have emergencies!), I call my assistant and ask her to contact the other party, let them know my ETA, and offer to reschedule. This shows both basic courtesy and the fact that I respect someone else's time.

Why is it so hard for doctors to do the same thing? Or do basic rules of courtesy just not apply in DoctorLand?

I had an appointment with a specialist scheduled for 4:30 on a Friday. I showed up on time. The doctor did not. The secretary did not seem to be interested in informing me or the other two people in the waiting room when we might expect him. I did not get into the exam room until 5:45. If someone had taking two minutes to call me with an ETA, I could have elected to either work later or to reschedule. Since I was not given that information, I lost a meaningful amount of billable time.

I am sorely tempted to send the doctor a bill for my lost time.

Carl Meyer said...

I am a general pediatrician with a schedule that is packed with same day appointments. All of us have 24 hours in each day and deserve to be treated with respect and courtesy when we interact, whether in professional or personal matters. This is not difficult. Naturally, in our profession we have emergencies and I have only a few patients become upset when our mutual schedules are altered by a sick baby that demands my time. Most people appreciate the fact that I will care for their baby in a similar manner when the situation merits and will reschedule. This all depends on communication and respect for people. It is not that hard to do.

Anonymous said...

Yes! Communication and respect are the keys to making delays acceptable. A small minority of medical offices give patients a realistic estimate of how long it will be until they are seen. Even fewer volunteer that information, and I don't know of any that proactively contact their patients in advance.

Transparency is one helpful approach. Delta posts their standby list on a screen at the gate so you can see where you are on it. Bus stops in London show you how many minutes until the next buses will arrive. Deli counters figured out long ago that ticket numbers give customers a sense of how far back in line they are.

Give patients some freedom so they aren't tethered unnecessarily to the waiting room. Use beepers, or just tell patients they have X minutes or hours before they will be next in line. If you know they won't be seen for an hour, tell them. If you know that it might be 1-3 hours, tell them that, and tell them to check back in at 1 hour for an update. We know that you're probably not able to tell us to the minute, but you can give us an estimate and you can update it down the road.

And please call patients when a schedule has seriously slipped, so they can know in advance that they should come in 2 hours later than they planned. Airlines offer flight delay notifications, which both reduces the frustration level and shows customers that their time is respected. (Those are connected.)

Doctors often apologize for running late, but the patient is rarely upset with the doctor for running late. Far more common is that the patient is upset with the person at the desk for not providing the available information.