Rebecca Bastoli - Transparency and Waiting. Design for Health. Semester 1, 2020

Visiting the GP: Transparency and Waiting

Rebecca Bastoli s3814809 1

Author Biography Bec Bastoli is a second year Industrial Design student at RMIT university and completed a Diploma of Product Design at Enmore Design College in 2013. She returned to university at 25 with a renewed passion for learning about and contributing to the field of sustainable design. After completing her Diploma, she interned with Amigo and Amigo, an interactive lighting and design studio in Sydney. Bec also has experience working in customer service for more than 9 years with T2 Tea giving her a unique insight into the consumer mentality and empathising with the customer journey.

Figure 1. Author profile, Credit Author

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Table of Contents Part One: Research

Introduction ..............................................

Negative Impacts of Waiting ...................

Site Visit ....................................................

Loading and Early Computers .................

Operational Transparency .......................

Initial Design Proposition ..........................

Part Two: Design Intervention

Refined Design Proposition ......................

New Patient Journey .................................

Contribution to the Design Field and My Own Practice ..............................

Conclusion ...............................................

Table of Figures ........................................

Bibliography .............................................

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32 34 39 40 41 42

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Part One: Research

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Introduction One area of our health system that is often neglected is the waiting room; a transition space between our everyday lives and the GP’s office that can often be the cause of stress and frustration (Sherwin et al., 2013). In his book ‘Delayed Response: The Art of Waiting from the Ancient to the Instant World’ Farman (2018) even describes waiting as “moments of endurance and pain… [that] tends to hide the reason it exists”. This report will look at the stressors associated with delays and waiting at the GP and the benefits of incorporating operational transparency and salutogenic thinking. Operational transparency and clear communication not only minimises the negative impacts of waiting, but if communicated thoughtfully and with good design, can increase one’s sense of coherence, an integral part of the salutogenic model of health.

Right by ravensong7 . Retrieved from https://pixabay.com/photos/ chairs-row-office-waiting-room-325709/

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The Beginning: An Anecdote I began this journey through my own, very negative, experience in a clinic waiting room. I arrived at the clinic at 11:10 for an 11:20 appointment and after waiting for an

hour I still hadn’t been seen. I asked how much longer I would be waiting and the receptionists couldn’t give me an estimate and had to checking with the nurses. There were still three people ahead of me in the queue, and they explained that as some appointments just take longer than planned.

Even with 3 doctors on at the clinic it could be anywhere from 5 minutes too much, much longer. They also explained that my time 11:20 was in fact the last booked appointment for the day. I was quite frustrated as I this meant that they had expected huge delays and built that into the booking system. But some information was better than nothing.

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At 1:30 I still hadn’t been called up, but instead 2 doctors came out and let me know that the clinic was now closed (an end time was news to me) and I would have to make

another appointment, and at a clinic that ran only once a week. Kindly one of the doctors offered to come in early to see me before the clinic started next week as the next couple of weeks were already booked out. The stress and uncertainty of this whole experience resulted in a very emotional reaction.

Waiting without clear expectations and then an end that was completely unexpected was very stressful.

This experience helped me to understand two things. That often clinics cannot accurately estimate how long a wait will be, and it allowed me to empathise with the stress of waiting without a clear expectation for an end time. There must be a better way!

The Negative Impacts of Waiting

Figure 3. Patient Wait Times. From “How to Treat Patient Wait-Time Woes” by McCormack, M, 2013, (https://www.softwareadvice.com/resources/how-to-treat-patient-wait-time-woes/)

The frustration of waiting at GP clinics is well documented, and largely expected as a normal part of going to an appointment.

McCormack (2013) finds in her article “How To Treat Patient Wait-Time Woes” that 97% of patients surveyed feel frustrated by waits, even though 45% of their waits

were for less the 15 minutes. This tells us that patients become frustrated by waits of any length, even in a space where wait times are usually expected. Lessening the wait time will not necessarily reduce frustration, so it is therefore important to look at that waiting experience itself.

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In several different health agencies and research articles, wait time is so common and expected that it is a key measure of quality used in research (Agency for

a bigger impact on a person’s health, especially when looked at through the lens of salutogenics. The theory of salutogenesis, begun by Aaron Antonovsky in 1996,

Beyond simple frustration and perception of service of care, waiting can also have

Antonovsky defines a sense of coherence as a ‘dynamic feeling of confidence that one’s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected’ (Antonovsky, 1979, p. 123). When a person has a feeling of control over their world and circumstances this reinforces their Sense of Coherence, and is reinforces further

Healthcare Research and Quality, 2019) ( National Health Service, 2019)(Caggiano et al, 2015)(Camacho et al, 2006)(Teunis et al, 2015). However, Chu et al. (2019) finds that there is not necessarily a correlation in the research literature between patient’s wait time and overall care experience. They found through their own study that a patients willingness to wait, and a reduction of the frustration associated with waiting can be improved by three factors: “1) proactively informing patients of delays, 2) explicitly apologizing for delays, and 3) providing opportunities for diversion”.

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asked the question, ‘what are the origins of health?” and discusses that health is more than just a lack of illness, but a spectrum along the ease/dis-ease continuum. A key ingredient in Salutogenic health is a person’s sense of coherence.

Figure 4. Impact on patient frustrations. From “How to Treat Patient Wait-Time Woes” by McCormack, M, 2013, Retreived from (https://www.softwareadvice.com/resources/how-to-treatpatient-wait-time-woes/)

when additional resources to draw upon in times of stress. Simply put, it better enables someone to comprehend and cope with the stress and difficulties of everyday life.

Similarly, when expectations are not met, and there is a feeling of lack of control over one’s situation; one’s sense of coherence can be damaged, impacting their health.

This lack of control is familiar to anyone who has had to wait for an unknown amount of time with no idea as to why. This idea of control, or lack thereof, supports the findings by Chu et al. (2019) that promptly informing patients of delays can reduce stress and frustration.

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Site Visit To get a better understanding of the experience of being in a waiting room and the processes behind getting there I conducted a covert auto-ethnographic study and (very brief ) interview.

As the staff were so busy and as we were social distancing, I was only able to squeeze in one question with the receptionist. Though for a one question interview it was quite insightful perspective one what causes delays.

Q: What in your experience causes the most delays and increases wait times.

A: When a patient comes in and they haven’t communicated that there are multiple reasons they need to see the doctor, so they do not know to allocate a longer appointment time.

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Figure 6. Booking Process. Credit Author Left Figure 5. GP Waiting Room. Credit Author

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Auto-ethnographic Study

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Raw Data (objective)

Interpretations (subjective)

I was able to discuss best times with the receptionist and went with a new to the practice female doctor who I not yet available for booking on the website.

I found it annoying that I was directed to a different website when trying to book online - I was also unsure as to whether I would need a shorter or longer appointment time so I called.

When calling the call was answered very quickly and I was immediately asked if there was an emergency or if I could hold. I was happy to be on hold.

From this initial introduction I was immediately given the impression that they were very busy which made me happier to be patient and wait. It was great to have the call answered very quickly though.

I was able to discuss best times with the receptionist and went with a new to the practice female doctor who I not yet available for booking on the website.

It was very comforting to be able to talk to someone and discuss what options would be right for me. It felt very lucky to have been able to get a great time for me and with a doctor not available on the online.

Received a reminder text the day before reminding me of the appointment and requiring a confirmation. the text included a link to the booking website hotdoc.com and the date and time of my appointment.

I was appreciative of the text as it was a good reminder for my appointment the next day.

The General Practice building was a single story brick building on the corner of a cul de sac and supermarket car park. At the door there was a sign that stated; Due to COVID19 precautions, please ring the doorbell and one of the receptionists will let you in.

The sign and doorbell was a new, slight scary and completely understandable precaution.

Raw Data (objective)

Interpretations (subjective)

The waiting room itself was down a long thin hallway with some consulting rooms off to the right. As you enter the main space the receptionist desk is to the left and the main waiting area is to the right.

The floor was wooden, and the walls were white and grey and the space is decorated by some plants, a TV and many information brochures, as well as a water fountain. Grey benches wrapped around the edge of the waiting room with marking tape used to indicate appropriate spacing.

To me the space felt quite clinical, mostly because of the grey unattractive couches and the number of brochures. The fact that it was a re-purposed house gave the waiting room a homely feeling which was comforting.

I approached the receptionist desk and after giving my name I was told to take a seat. There was one other patient in the waiting room. The phones were ringing off the hook and the receptionists were extremely busy managing appointments for a flu clinic as well.

I did not expect there to be much of a wait as there was only one other patient in the waiting room.

I was seen at 9:35 and had a 9:15 appointment and was not informed at any point that there was a delay.

I cannot be 100% sure that it was standard practice to not be informed of delays as the receptionists were so busy, but on previous appointments I have never been notified when there were delays.

I felt restless during the wait, it was a lot longer than I had expected. During the appointment I felt guilty about the time I was taking up as I had no idea how long my slot was.

After my appointment I was able to book in the next one straight away on my way out.

I was frustrated after the appointment as I had forgotten some of the things I wanted to ask the doctor. Besides that I felt like I was given great care by the doctor who never made me feel rushed. I am fairly sure we sent over time though.

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Loading and Early Computers

Figure 7. Loading Icons. From “Wait Wait…Tell Me!”, by 99%invisible, Retrieved from https://99percentinvisible.org/episode/wait-wait-tell-me/

In wanting to understand the design language of communicating wait times and how we got to where we are now, I went back to the first graphic representations of waiting; the loading bars on computers.

Good (or bad) design can have a huge impact on perceived wait time and satisfaction while waiting, especially in a setting like computers were a 3 second wait while a page loads can feel like an eternity.

As Roman Mars says in the 99% invisible podcast ‘Wait Wait…Tell Me!’ “it turns out that design can completely change whether a five-minute wait feels reasonable or completely unbearable.” While a lot has been done to try and reduce wait times in this area, a lot of progression has also been made in improving the waiting experience itself.

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In the early days of the Xerox star and early Macintoshes the loading icons were a static hourglass or wristwatch icons. And even though these were the fastest computers to date, the general perception was that these computers were frustratingly slow. Later on they animated the icons, but even when the

loading icon moved and was more pleasing to look at, like a watch with spinning hand, and a hourglass with dropping sand, it didn’t change the feeling of powerlessness, that you had no idea how long the wait would be, and had not control over that time. It could be minutes or hours, and the user felt trapped.

(Farman, 2018) The designs that worked well are the ones that not only gave the user an idea of how long they would be waiting for, but the transparency to see what the computer was doing while you waited. This allow the user

to see the work that was being done and therefore the time was more valued. There is a clear difference between the feeling of waiting as the spinning beach ball of doom seemingly spins forever without any hope of progress and seeing a progress bar fill up as a program installs. The transparency here is that the user can see that the computer is

Figure 8. Loading Bar. From “Wait Wait…Tell Me!”, by xmodulo.com, Retrieved from https://99percentinvisible.org/episode/wait-wait-tell-me/ (CC BY 2.0),

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Figure 9. Spinning ball of death. From “Wait Wait…Tell Me!”, by 99% Invisible, Retrieved from https://99percentinvisible.org/episode/wait-wait-tell-me/

doing something, even if it not clear what is being done. There is also the setting up of expectation. As soon as the user sees how long the first 10% takes to load, there is an indication of how long the rest will take. The user is then given back a sense of control over what they can do in that time.

Some examples of progress in this direction were various progress bars, some showing percentages and others flash though files as program installs. The biggest issue with this type of loading icon is when it sets up a false expectation if the first 10% loads really fast

and the rest is slow – we feel let down.

What this highlights is that expectations are just as important as seeing the progress.

This realisation lead designers in the 2000’s to design the “front-loaded loading” bars, that loaded artificially slow at the beginning and fast at the end, tricking the user into a feeling of satisfaction that the process loaded faster than expected. This version of the loading bar, and all previous versions, really shows how much a designer is able manipulate the users experience.

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Operational Transparency

Figure 10. Operational Transparency. From Operational Transparency. By Stephen Lewis (2019) Retrieved from (https://hbr.org/2019/03/operational-transparency)

A method researched by Ryan W. Buell and used by designers to improve the waiting experience is operational transparency.

Operational transparency is a simple theory that a user can value what they can see and what they are aware of, or from another perspective, they cannot value what they cannot see. It draws on the ideas around 20

the psychology of waiting to manage frustration of the user and when successful can even make the service more valued and appreciated (Buell, 2019). As services in this modern world become increasingly automated, human contact between companies and their customers decreases to improve efficiency. Therefore, increasingly

the challenge for companies and all services is to find the balance between delivering an efficient service with less customer facing contact, often resulting in lower customer

satisfaction, and increased customer contact, which is often more expensive and less efficient (Buell, 2019). One example of how increased automation can result in lower customer satisfaction is the bank ATM. While they are more convenient for customers in almost every way, customer satisfaction with their bank decreased with the implementation of ATM’s (Buell, 2019).

Buell suggests that “when consumers can’t see the work that’s being done to serve them, their perception is that less effort went into delivering the service, so they don’t appreciate or value it as much”.

In one study Buell along with London Business School’s Kamalini Ramdas and Nazli Sonmez worked with doctors at Aravind Eye Hospital, in Pondicherry, India to study the effects of transparency at a glaucoma clinic by having some shared appointments with three or four other patients. At this new style of appointments patients could see what the doctor saw when

examining others and hear other patients’ questions. This had the great result; patients were more likely to follow through with advice and prescriptions and come back for follow up appointments than those who had the normal one on one appointments.

In another test Buell set up cameras in a Harvard dining hall so students could see the cooks while they waited, and cooks could see the people they were making the food for. They found that satisfaction with the food went up 22% and chefs also felt better about the expertise with one stating “When [the customers] can see us [make their food], they appreciate it, and I appreciate that. It makes me want to improve.”

Buell (2019) also explores several risks associated with operational transparency and how some companies can get it wrong.

Too much transparency, that is not sensitive to the context, can expose an ineffective process, powerless employee, lack of progress or an inferior product/service. At worst this “can repel customers and undermine employees” (Buell, 2019). As a result, it is extremely important to be careful with what information is made transparent and why.

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Food Delivery Progress Trackers Food delivery progress trackers like Uber Eats and Deliveroo use the theories of operational transparency by giving the customer as much insight into the progress of their order as possible. The user is notified when the restaurant accepts the order, cooks ‘making’ the order, and even tracks the driver as they travel (Fast Company, 2019). Various apps and services do this slightly differently, Dominos with its pizza tracker, Uber eats where you can track the delivery driver, and Deliveroo’s progress

bar to name a few. Not only are these companies giving you updates on where your food is at, but they are subtly reminding you of all the people that are involved in preparing the order, from the cooks in the restaurant to the delivery driver. As a result, the customer can see and appreciate all the hands that went into getting the food to them.

What each version has in common is clean, clear, colourful and simple graphic representations of what is going on.

Figure 11. Domino’s Tracker. From Pizza party! Domino’s is on IFTTT. by IFTTT. (2017) https://ifttt.com/discover/pizza-party-dominos-is-on-ifttt

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Figure 12. Uber Eats Progress Tracker. From “Uber Eats is going to stop gaslighting you with confusing design�, by Fast Company, 2019, (https://www.fastcompany.com/90331468/uber-eatsis-going-to-stop-gaslighting-you-with-confusing-design)

Yes, they are choosing to be more transparent about the process, but they are also making very active decisions about what not to show. And there are definite lessons to be learned from that. They are not showing the actual kitchen or your actual dish being cooked, just graphic representations. Even though users are only seeing graphic representations

of the process, which for all they know could have no correlation to what is actually going on, seeing this process allows the person ordering see each step that is involved in getting their food to them, which manages expectations, and when deliver on time (or earlier), builds confidence and trust in the service.

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The TESSEI cleaners of the Shinkansen

Figure 13. TESSEI workers. From Japan Today. (2014). Retrieved from (https://japantoday.com/ category/features/lifestyle/shinkansen-cleaning-crew-have-just-7-minutes-to-get-train-ready)

One great example of the power of transparency to the waiting experience is the TESSEI cleaning team of the Shinkansen, the Japanese bullet train system. In between the trains many trips a day it waits at the station for just 12 mins, and once previous passengers departs, that leaves just 7 mins for the TESSEI team to clean and prep an 24

incredible 1000 seats for the next trip. For the next passengers waiting on the platform 7 mins can seem like a long time, especially if you don’t know why you’re waiting there.

Initially the workers felt pressured and the passengers waiting on the platform felt impatient and frustrated that they couldn’t get on the train that was waiting right in

front of them. They didn’t know why they were waiting.

The trains started to get cleaned on time, passengers started cleaning up after In 2005 a new leader of TESSEI Teruo Yabe themselves a lot more, and people even introduced a policy of transparency between started catching the Shinkansen so they could watch the cleaners do this amazing the passengers and the cleaning staff, and amount of work in only 7 mins. This ‘show’ one part this new policy was to change the has even been given a name, the 7min colour of the cleaners clothing from a pale miracle or Shinkansen Theatre that finished blue that blended into the train, essentially with a bow from the TESSEI staff. This is making them invisible, to a vibrant red. a great example of what can change when The waiting passengers could now clearly the people waiting can see why they are see why they were waiting and began to appreciate the service so much more. He also waiting. They begin to value the work going on behind the screens, and value the service let the cleaners speak with the passengers even more. that wasn’t allowed before.

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Left Figure 14. TESSEI Summer uniforms. From Asia News Network. (2018) Retreived from http:// www.asianews.eu/content/admired-shinkansen-cleaning-crews-add-touch-summer-76869

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Initial Design Proposition With the above research in mind, an improved communication system between GP clinics and their patients is proposed. This system will utilise the theories of operational transparency to proactively communicate delays and waiting times with patients through text messages (when necessary) and through a wait time board in the waiting room.

It will incorporate the visual design language of health system in Australia

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to be instantly relatable and appropriate to the context of a GP clinic. S Henning, a graphic designer at the SLHD (Sydney Local Health District) describes three key aspects of the health districts design language: 1) Simple vector drawings 2) warm colours, and 3) direct personal language, using ‘you’ in descriptions and recommendations.

Features and Functions Below are a list of proposed functions and features of the communication system: • Text messages to confirm appointment once made including doctors name, appointment date and time • Test message the day before as reminder to reduce DNA’s • If the clinic is heavily delayed, (30-45+mis) a text message 1 hour before will be sent to the patient • A waiting room screen that shows each doctor and their rough delay time • Delay brackets rather that exact minutes with an associated colour. 5-15 mins is green, 15-30 is yellow, 30-45 is orange, 45+ red • Clear graphic communication – health styling • Slightly overestimated delays to beat expectations • Shows the number of patients helped already that day • Integrates with current booking system What not to show: • Patient details and name • Exact time estimates • Inside the appointment rooms

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Part Two: Design Intervention

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Refined Design Proposition

Current Patient Journey 1.

3.

2.

OR

Current Patient Touch Points 1. Make an appointment via Call or Online 2. Confirm Attendence 3. Appointment

1.

Figure 15: Current Patient Journey. Credit Author

The current patient journey consists of three patient touch points. The first is making an appointment online, if the clinic provides that service, or over the phone. After the appointment is booked, a day before the appointment a text is sent to confirm attendance, requiring a yes or no reply.

This is a great way to remind the patient of their appoints and reduces the amount 32

of DNA’s (do not attends). It also provides the patient with the options to cancel the appointment if the time no longer suits.

The next communication touch point is the appointment itself, which leaves are large gap of possible communication, especially in the case of large delays. From the patients perspective they do not know what to expect when they get to the clinic.

Propositon We know from the above research that it is best to be as transparent as possible with proactively communicating delays, when they happen. So, to increase transparency with the patients and increase communication of the potential delays, three new patient touch points are proposed: 1) A confirmation text 2) Delay Warning Text and 3) A waiting room delay screen. The confirmation text will provide the patient with readily accessible details of their appointment which they can view any time without the need to download an app or even have access to the internet. This feature is especially useful when an appointment is booked over the phone and the patient does not have the means to write the details down at that time, whether that be due to disability or if they are on the move. The delay warning text is a case by case feature

that will notify the patient of a delay large enough that I may impact their travel arrangements. It also set up the expectations of the delay as early as possible which give the patient as much control over their time as possible. The third touch point is in the waiting room itself, a delay board or screen which shows an estimation of delays sorted by doctor. It also states when the board was last updated and how many patients have already been helped that week (or day).

These new touch points will work with existing touch points that are already part of the patient’s journey and will increase the transparency and resources the patient has before their appointment. By working with systems that are already integrated into clinics booking system, these new touch points will be relatively easy and cheap to implement.

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New Patient Journey

New Patient Touch Po Confrimation Tex

- Confirms booking - Includes date, time, clinic and doctors name

1.

2.

OR

1.

New Patient Touch Point Delay Warning

- Notifies patient of large delay long before appointmen

Figure 16. New Patient Journey. Credit Author

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New Patient touch point 3: Waiting room Delay Board - Shows delay time for each doctor - Time last updated - Show patients helped this week

oint 1: xt

c name

6.

3.

t 2:

nt.

5.

4.

User Touch Points

1. Make an appointment via call or online 2. (New) Confirmation text 3. Confirm attendence 4. (New) Delay warning text 5. (New) Waiting Room Screen 6. Appointment

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New Touch Point 1: Confirmation Text * Please note this is not the final graphics, just a wireframe.

Hi (Patient’s first name), Thanks for making an appointment at (Clinic Name)! Your appointment is on (DD/MM/YYYY) with Dr. (doctors name).

- (Clinic Name) Figure 17. Confirmation Text. Credit Author

The confirmation text includes all the details of the patient’s appointment, including the time, date, location, and doctors name.

This enables the patient to have all the information regarding their appointment

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on hand without the need for an Internet connection or an app. This will be sent once a patient makes their appointment either online or over the phone.

New Touch Point 2: Delay Warning * Please note this is not the final graphics, just a wireframe.

Hi (Patient’s first name), We wanted to give you a heads up that, unfortunately, (the Clinic) is delayed by approx 30-45mins. We sincerely appologies for any inconvenience. Thank you for your patience and see you soon!

- (Clinic Name) Figure 18. Delay Warning Text. Credit Author

This text message will include the estimated amount of delay on the patient’s appointment, an apology for any inconvenience and thanks the patient for their patience. This text will only be sent if

there is a large delay, and gives the patient as much heads up as possible and gives then increase ownership of their time before they get to the waiting room.

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New Touch Point 3: Waiting Room Screen * Please note this is not the final graphics, just a wireframe.

Estimated delay time, thank you for waiting!

Dr. WY 5-15mins Dr. JP 15-30 mins Dr. WY

On Time

Dr. HB 30-45mins Dr. LG 45+ mins Last Updated: 5 mins ago

People helped this week!

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Figure 19. Waiting Room Delay Screen. Credit Author

The waiting room board will include the estimated delay times of each doctor, the last time updated, and number of patients helped this week (or day if the clinic chooses) as shown in the above wire frame. This feature is conceived to be as minimally invasive as possible to the clinic’s doctors and staff through the use of a pop up or desktop app on the doctors computers. Doctors simply click when each appointment starts and ends, and the waiting room screen will 38

work out the rest, feeding into appointment information the clinic already has. The ‘last time updated’ feature gives patients in the waiting room assurance that the information they are seeing is up to date and relevant to them. The ‘patients helped this week (or day)’ adds another small window of transparency into the amount of work that goes on behind the scenes with information that clinics will already have, and there easy to implement.

Contribution to the Design Field and my Own Practice This project contributes to the design work around health and waiting by applying the theories of Operational transparency and Salutogenesis to the patients waiting experience at the GP. Most of the interventions in the field have previously focused around reducing wait times, but this design proposition instead takes the approach of improving the waiting experience by proactively communicating delays.

This project was also a great introduction to the theories of Salutogenesis and Operational Transparency which I will be able to apply to many projects in the future.

Reading about Salutogenesis in particular, changed the way I think about the potential

that design can have in the systems humans have created and will create, and the objects that we surround ourselves with. Design has huge effect on our lives and health that are not always anticipated or immediately obvious. Therefore, I believe it is hugely important to be thoughtful and considerate about the design decisions I make, and theories of Salutogenesis are now another tool I have to do this in my own practice.

Similarly, learning about operational transparency will greatly inform my design practice especially in any future UX design projects.

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Conclusion In conclusion, waiting for a GP appointment can have numerous negative impacts, increasing stress, frustration and negatively impacting one’s health. In this report it was found that a wait, no matter how small, is frustrating to the vast majority of people, so it is therefore important to focus on the waiting experience itself and how waiting times are communicated. This aligns with the theories of Salutogenesis that tell us a person’s sense of coherence is affected when they feel a lack of control and agency over their time. In this report three new communication touch points are proposed between a GP and their patients before their appointment as a way to proactively communicate wait times.

With this proactive communication of delays and wait times, and increased operational transparency, the stress and frustration of waiting can be reduced, and a person’s sense of coherence is reinforced.

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Table of Figures Figure 1.

Author profile Pg. 2 Figure 2.

Chairs Pg. 7 Figure 3.

Patient Wait Times Pg. 9 Figure 4.

Impact on patient frustrations

Pg. 11

Figure 5.

GP Waiting Room Pg. 13 Figure 6.

Booking Process Pg. 13 Figure 7.

Loading Icons Pg. 17 Figure 8.

Loading Bar Pg. 18 Figure 9.

Spinning Ball of Death

Pg. 19

Figure 10.

Operational Transparency Pg. 20 Figure 11.

Domino’s Tracker Pg. 22 Figure 12.

Uber Eats Progress Tracker

Pg. 23

Figure 13.

TESSEI workers Pg. 24 Figure 14.

TESSEI Summer Uniforms

Pg. 26

Figure 15.

Current Patient Journey

Pg. 32

Figure 16.

New Patient Journey

Pg. 34

Figure 17.

Confirmation Text Pg. 36 Figure 18.

Delay Warning Text Pg. 37 Figure 19.

Waiting Room Delay Screen

Pg. 38

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Bibliography 99% Invisible (2019) Wait Wait…Tell Me! https://99percentinvisible.org/episode/wait wait-tell-me Asia News Network. (2018) Admired Shinkansen cleaning crews add touch of summer. http://www.asianews. eu/content/admired-shinkansen-cleaning-crews-add-touchsummer-76869 Agency for Healthcare Research and Quality. (2019). CAHPS Clinician & Group Survey. https://www.ahrq.gov/cahps/surveys-guidance/cg/index.html Antonovsky, A. (1979). Health, stress, and coping.

Buell, R. (2019) Operational Transparency. Harvard Business Review, March–April 2019

102–113. https://hbr. org/2019/03/operational-transparency Building Better Healthcare. (2011). CASE STUDY: Waiting for a solution: How a new management solution has helped GP practices in north Yorkshire. https://www. buildingbetterhealthcare.com/news/article_page/CASE_STUDY_Waiting_for_a_ solution_How_a_new_management_solution_has_helped_ GP_practices_in_north_ Yorkshire/72317 Caggiano, N. M., Fegley, M. W., & Matullo, K. S. (2015). Patients’ preferences regarding the

delivery of health care in a hand surgical practice. Hand, 10(4), 785-788.

Camacho, F., Anderson, R., Safrit, A., Jones, A. S., & Hoffmann, P. (2006). The relationship between patient’s perceived waiting time and office-based practice satisfaction. NC Med J, 67(6), 409- 413.

Chu, H., Westbrook, R. A., Njue-Marendes, S., Giordano, T. P., & Dang, B. N. (2019).

The psychology of the wait time experience–what clinics can do to manage the waiting experience for patients: a longitudi nal, qualitative study. BMC health services research, 19(1), 459.

This research report investigates the relationship between patients waiting experience and how this impacts the overall patient care experience. This study finds through their own research and in general literature that there is not a clear correlation between the length of the wait time and the patients experience of care as one might expect. Instead, the biggest 42

influencer on the patients experience and willingness to wait is clear communication regarding delays and wait times.

While this article adds another useful study to the body of literature already on this topic, it is a narrow sample size of two HIV primary care clinics in Houston, Texas. It would have been great to see comparisons of similar tests done in other countries or at the very least different states.

The clear and concise listing of the key steps that a HIV clinic or provider can make to improve a patient waiting experience is a great first step in my own research regarding the waiting experience for patients in GP. Similarly to my area of study, there is a general understating in the patience community that there will be delays, but the way in which these are communicated and acknowledged by the clinics can be easily applied to a GP setting.

Clapton, G. (2016). The GP waiting room under examination. The British Journal of

General Practice, 66(646), 260.

This very short article from the British Journal of General Practice discusses, through photos of ‘unloved waiting rooms. how the physical appearance of a waiting room can either increase a patients anxiety or prepare the patient for an appointment by calming them.

After writing a list of what makes the spaces ‘unloved’ it explores waiting rooms to pay more attention to the spaces patents enter.

Even though this article is in a reputable medical journal, it is very short and does not back up any of its findings with references to studies or research, and most of the comments are subjective or intuitive to the writer.

This article is relevant to my research because it suggests the impact the waiting room environment can have on a patient’s mental clarity and ability to have a productive exchange with their GP. The reduced stress levels enable a patient to bring up everything they need to, and remember to ask all of the questions they may have. And by extension, any kind of stress reductions in the waiting room experience would have a similar outcome I would just 43

need to dig a bit deeper to find some research to back up the claims made.

Farman, J. (2018). Delayed response: The art of waiting from the ancient to the instant

world. Yale University Press.

Fast Company. (2019) Uber Eats is going to stop gaslighting you with confusing design. https://www.fastcom pany.com/90331468/uber-eats-is-going-to-stop-gaslightingyou-with- confusing-design IFTTT. (2017) Pizza party! Domino’s is on IFTTT. https://ifttt.com/discover/pizza-party dominos-is-on-ifttt Japan Today. (2014). Shinkansen cleaning crew have just 7 minutes to get train ready. https://japantoday.com/ category/features/lifestyle/shinkansen-cleaning-crew-havejust-7-minutes-to-get-train-ready Knight, A. W., Padgett, J., George, B., & Datoo, M. R. (2005). Reduced waiting times for the GP: two examples of “advanced access” in Australia. Medical Journal of Australia, 183(2), 101-103.

This article looks at how the principles of advanced access work in two general practices case studies to assess the feasibility of in Australia. “Advanced access” is a set of change principles for improved scheduling in office-based health care, widely applied in the United States and in the United Kingdom. They found that in the two cases studied that advanced access improved workplaces conditions, timely patient access to appointments and the increased manageability for staff. It also lowered the amount of DNA’s (did not attends) and as a result increased the practices income.

There is a clearly small sample size with only 2 general practices studies, but as the findings in these two cases are aligned with case reports carried out overseas. The report itself does highlight the lack of rigorous evaluation of advances accesses. Even in these two case studies the only objective data are DNA’s and estimates of the practices income, all other markers for success are through subjective reports.

This is a great example of a systems design that improves the functionality of the booking system which lowers the stress levels for both the staff and patients. It also provides are more in depth understanding of the booking systems and some of the things that can go wrong.

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McCormack, M. (2013). How to Treat Patient Wait-Time Woes Industry View. https://

www.softwareadvice. com/resources/how-to-treat-patient-wait-time-woes/ This article makes suggestions for ways in which medical practices can use to minimised patient frustrations regarding wait times based on a survey of 5003 patients in the US. Their survey shows that while it is clear that wait times make the majority of patients frustrated, 97% in fact, 80% would have this frustration minimised if they had some idea of what the wait time would be in advance. What this article also finds is that even though they found that 45% of patients interviewed wait less than 15 minutes, they are still frustrated by this relatively short waiting time.

While it is useful to get a patients opinion of what they would think or do in a particular situation it may not be entirely consistent with how the patient actually reacts when faced with the experiences first hand.

This report is extremely useful for my area of enquiry as it directly asks questions about ways in which the waiting experience could be improved such as having a T2 in the waiting room or being told the wait time in advance.

Mittelmark, M. B., Sagy, S., Eriksson, M., Bauer, G. F., Pelikan, J. M., Lindström, B., &

Espnes, G. A. (2017). The handbook of salutogenesis.

National Health Service. (2018). GP Patient Survey. https://gp- patient.co.uk/Files/ Questionnaire2018.pdf Sherwin, H. N., McKeown, M., Evans, M. F., & Bhattacharyya, O. K. (2013). The waiting room “wait”: From annoyance to opportunity. Canadian Family Physician, 59(5), 479-481.

This article tries to shifts the waiting room from an often neglected space to a space for intervention and opportunity. It explains that patients feeling towards their physician are directly related to the impression of their time in the waiting room, and that lower patient satisfaction is linked to longer with longer wait times; but if they are occupied in that time their impressions improve. The article then goes onto to recommend 5 interventions that general practices can use to improve the patients waiting room experience. (1) Validated questionnaires, (2) Question prompt sheet or coaching, (3) Patient education material, (4) 45

Decision aids, (5) waiting room manager.

All the intervention suggestions that are made are largely information based but very little discussion on the best way to present the information without overwhelming the patient, especially if all the recommended interventions are implemented. The only suggested is to employ a waiting room manager, and in many smaller practices this may not be a financial option.

This article presents some great and well researched suggestions for how to improve the

waiting room experience which is exactly my field of enquiry. Some great studies are also referenced which would be useful for further reading and research.

Teunis, T., Thornton, E. R., Jayakumar, P., & Ring, D. (2015). Time seeing a hand surgeon is not associated with patient satisfaction. Clinical Orthopaedics and Related ResearchÂŽ, 473(7), 2362-2368.

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