Practices try dropping waiting rooms

Why did the patient cross the road? To get to the office with no waiting room.

That's the situation at Boys & Girls Pediatrics in Knoxville, Tenn. Parents are declining appointments at its location with a waiting room in favor of appointments across the street at the location without one -- even if they have to wait longer to get an appointment. The office has 18 exam rooms, each with an outside door that opens directly to a parking space.

"We have patients who come specifically for that very reason," said Jim Kimball, MD, a pediatrician and senior partner with Boys & Girls Pediatrics. "When parents come for the first time, we tell them it may seem a little strange at first, but you get used to it quickly. You can't come in a wrong door."

There's been a lot of attention devoted making the waiting-room experience more pleasant for patients, but a few practices like Boys & Girls Pediatrics have decided the best approach is to not have a waiting room at all, or, at the least, minimize its use by ushering patients back to exam rooms as soon as they check in.

The idea has clinical roots, especially in pediatrics, where sick and well children are often separated in the office. But practices have found business advantages from not using waiting rooms as well, like better office efficiency and happier patients.

Do patients actually spend less time waiting in these practices? Probably not, physicians and administrators say, though it may feel like it because patients sense they are a step closer to seeing the doctor.

Waiting rooms can foster a "feeling of not knowing when you're going to be seen, especially when the doctor's running late," said Bruce Bosquet, a principal with Medical-Dental Consultants Inc. in Cranston, R.I.

Peachtree Park Pediatrics in Atlanta, which has a small, mostly unused waiting room, avoids that dilemma by ushering patients back to exam rooms as soon as they arrive in the office. It accomplishes this strategy through effective scheduling and because on any given day, it averages five or six exam rooms per physician, more than the typical practice.

The practice used to have exam rooms that opened directly to the street, but it outgrew its space a few years ago and couldn't duplicate the model in its new location. The doctors kept the same operations strategies alive at their new office, though.

Staff is given the flexibility to prioritize patients and alter the routine to keep the physician moving, said pediatrician Robert Wiskind, MD, a partner with the four-doctor group.

"The doctor can enter the visit at any point," he said. "We can have kids get their immunizations before the doctor comes in to see them. If the patient is in the room and I have availability, I can go see them. It helps the efficiency."

Boys & Girls Pediatrics, which opened its waiting room-less office in the 1960s and expanded it more than 10 years ago, has to operate with flexibility as well, simply because the patients dictate the work flow with their arrivals. Instead of sitting at a desk, a front office staff member works the hallway, going from room to room to collect co-payments and verify insurance information. The system not only gives patients a sense of privacy, but it offers built-in protection against many changes to HIPAA security rules.

"One disadvantage is we need an extra half [full-time-equivalent staff member], but we have the staffing to work on three patients as they walk in the door at once," Dr. Kimball said.

The building features overhangs that allow families to enter the exam rooms shielded from the weather. The exam room doors have locks, and the rooms have a switch that activates lights in the hallway, to let staff know a patient has arrived, and outside, to let other patients know the room is occupied. The office is usually staffed with three or four physicians and nurse practitioners at a time.

Trade-off for no waiting rooms

As Boys & Girls Pediatrics shows, the idea of eliminating the waiting room has been around for a while. Consultants aren't sure why more practices haven't warmed to the idea, but it appears one reason is a lack of demand. "People have become accustomed to waiting," Bosquet said.

But also, getting rid of the waiting room also represents a major -- and perhaps expensive -- change in how an office conducts its business. Going without a waiting room requires either an excess of exam rooms or fewer appointments, said Charles Kilo, MD, MPH, an internist and president of GreenField Health in Portland, Ore. Dr. Kilo's clinic -- which has some elements of a retainer practice, including a $350 annual fee -- cuts down its patient visits by handling many issues with established patients over the telephone and through e-mail.

Using exam rooms for lengthy waiting times can easily get costly, and only the more efficient physicians can make the idea work, said Dick Haines, president of Medical Design International, a medical space designer for an Atlanta-area company. The cost to renovate an existing office to reduce the size of the waiting room could be prohibitive as well, though a practice may later be able to incorporate the idea into any new designs.

Peachtree Park Pediatrics' costs per full-time physician are higher than Medical Group Management Assn. benchmarks, but the office makes up for the cost in volume, said Donna Scowden, the group's administrator. This past year, for example, the practice went through about 3,000 doses of flu vaccine, and the extra exam rooms kept patients coming through at a swift pace, Dr. Wiskind said.