Friday, January 9, 2009

I Love Lines

I love standing in line.

Or, more accurately, I love what I learn from standing in line. Being stuck in traffic, waiting at the grocery store checkout – they're all golden learning experiences if you're a student of queues. But nothing beats air travel...

Over the holidays, I enjoyed a tremendous learning opportunity courtesy of a leading national airline. So many of the problems I observed at Toronto airport were analogous to the situation in physicians' offices. Because so many people have experienced the frustration of waiting in line at the airport, perhaps this could be an effective model to explain Advanced Access/Clinical Practice Redesign to novices.

Before we even arrived at the airport, we had been primed to expect a long wait. Airlines establish cultural norms with the advisory printed on every ticket: Be at the airport at least 60 (or 90, or 120) minutes before your flight departure. So we shrug our shoulders and drag our suitcases to the end of the line, because... that's the way it's always been!

Sound familiar?  It takes forever to get in to see my doctor. You'll wait a long time to see a specialist. Health care sets the same norms. Earlier this week, I heard a presentation about a new project in the Saskatoon Health Region, aimed at reducing patient wait times when they come for assessment and education at the Pre-operative Clinic. The project coordinator showed a sign currently posted at the entrance of the clinic. It showed a drawing of a man resigned to his fate (shrugging his shoulders in a C'est la vie kind of way) and said: Your visit to the pre-operative clinic may take 4-5 hours. Those are the expectations we establish for our patients. That's the promise of service we give as our patients come through our door.

Most major airlines feature self-serve check-in – either online before you come to the airport, or via self-serve kiosks at the airport. My oldest son was traveling on a separate ticket, so he checked himself in, and received both his boarding pass and baggage tag. He tagged his bag, stood in the (very short) self-serve baggage line, put his bag on the conveyor belt and was ready to go.

The rest of us checked in at the self-serve kiosk and received our boarding passes, but no baggage tags. The kiosk screen told us to take our bags to the check-in counter. I asked one of the airline clerks why we hadn't received baggage tags and now had to stand in line again. He gave a C'est la vie shrug and said something about the kiosks being finicky. We joined the snaking line of finicky-kiosk victims.

I've written a few times about our office's attempts to coordinate certain preparation and lab testing before the patient arrives for consultation with us. Because most testing for common conditions (like microhematuria) can be done by other-than-specialist, we can streamline the process when the patient finally reaches the specialist. This is what the airline is trying to do with their self-serve check-in. You don't need the counter agent to do all the mundane work of entering your name, number of bags to be checked, etc. – a computer can do that and save the counter agent's time for more complex tasks. But, if there is no reliable system for completing the pre-work, then customers take up more of the counter agent/specialist's time, and the lines get longer.

While waiting in this line, I reflected on what we learned early in our Advanced Access project about predicting demand. We found that the average number of new consultations we receive daily is steady at about 30. That's the capacity we need to provide. Shouldn't airlines be able to predict demand even more accurately? After all, they know almost exactly how many passengers are traveling, when the flights leave and when the passengers will arrive at the airport. I suspect there are industry figures on the average time needed to process each passenger. Do the math, guys! Is it unreasonable (or naïve) to conclude that, given the management expertise present in such a large business and well-established industrial principles for efficient work flow, the presence of long lines must reflect a conscious choice by that business to allow their customers to have a bad experience? Bluntly put, airlines are saying: Yeah, we know how to fix it, but it's not a priority for us.

At what stage of introducing Advanced Access/Clinical Practice Redesign in health care will we start to characterize wait lists not as inevitable, but as the consequences of conscious choices we practitioners make? Once there is a sufficient number of practices that have successfully managed wait times via AA/CPR, our patients could reasonably conclude that remaining practices continuing to offer long wait times a) are aware of AA/CPR, and b) couldn't be bothered to fix the problem.

As we shuffled toward the front of the line, another airline clerk paced back and forth calling our flight times and numbers. She was picking people out of line if their flights were leaving soon. These people were more "urgent" that the rest of us. Great example of the cost of managing a wait list! The airline had to pay a person just to triage urgent cases of people who needed to be moved up in line.

The same thing goes on in physicians' offices. My staff fields calls from patients and physicians who feel that a particular patient needs to be moved to the front of the line. I have to triage all referrals that come in to ensure that urgent cases are seen promptly. Those costs (my time, staff salary) would disappear with shorter wait times.

Finally, I felt the anxiety level of the queue. As time passed, more people asked the triage clerk what flights she was calling and if they could move up in line. Some passengers accepted their fate while others quietly grumbled. For me, it was a bad service experience, but a great learning experience.

C'est la vie!


  1. Originally posted by Larry Flynn 01/09/09 1:45 PM

    I read with interest your comments on standing in lines and learnings there-from. Reminded me of a poem I wrote (many, many years ago) when first attending university and going through what were significant lines to register for classes. I don't know why, but back then, one queued for everything from getting book lists to having your picture taken to entering an address for the telephone book. My poem essentially said "Figure out what you can do while in line, because you are going to be in many of them".

    Within a few years, the University managed to change their systems to do many of the things you advocate in your blog, including individual completion of many documents rather than depending on the "specialist" to do so, grouping and bunching processes to permit scale economies and using data bases for common information. My children tell me that internet registration has created further streamlining, however has removed much of the human contact with "specialists", thereby making it a voyage of self-discovery with fewer guides. (As an aside, it is probably this latter process which is enables universities to still get students to register for 8:30 classes, a more frequent occurrence for first year students than later ones.)

    However, an impressive learning experience for me occurred a few years later when I took my family to Disney World. Tremendous crowds, resulting in lengthy delays for most if not all attractions, and yet managed so well, that frequently, they organized the wait so they would be value added to we, the waitees. In particular, I recall their use of "packeting" to take a subset of the waiting line, and move us from display to display, provide us with specific information in a timely and incremental fashion, and ensure there were alternatives available when they ran out of other screening or information packages. And of course, a requirement of working for Disney Corporation is that staff are trained to make the experience a pleasant one for the consumers, so they would tell their families and neighbours and come back themselves.

    I haven't thought in detail about what that could mean for waiting times within a single office, but I am willing to wager significant money there are applications throughout the system.

  2. Originally posted by Peter McClung (BC Medical Association) 01/09/09 2:05 PM

    I loved your article on the airport line. I was in one of those lines this winter and was talking with my girlfriend about why it existed. You mentioned that the airlines "Choose" the long line, which I believe is correct but not because it isn't a priority from a passenger-care perspective. I was confused as to why all departing flights are at the same time, and all arriving flights are at the same (but different) time. The explanation I was given is the 'product' in an airport (namely people and baggage) flows one way. Either the airport is "Departing" or it is "Arriving." The staff involved are the same, and the machinery is the same, but the function switches - the conveyor belt only goes one way. This explains the congestion of numerous flights at the same time, resulting in uneven peak demand cycles. So why the "shortage" of supply resources? If the Airline quadrupled its staff at peak times, they could process the people far more quickly. But then what would those staff do while the bags were travelling on the conveyor belts, the planes were being cleaned and restocked, and passengers arriving were making space for passengers leaving? From a labour perspective, you can hire one person to work 4 hours a day far more easily than four people to work 1 hour. It is much easier to tell the passenger to expect to wait two hours.

  3. Originally posted by Marlene Smadu (Health Quality Council Chair, University of Saskatchewan and University of Calgary, January-June, 2009) 01/12/09 8:35 AM

    Kishore, as always your blog is fascinating and important. However, it has particular resonance with me today as my husband and I have just arrived in Doha, Qatar to spend 6 months working with the University of Calgary-Qatar Nursing program here. Part of the process for acquiring work visas is being blood typed, having a chest x-ray, and having blood tested for HIV/AIDS. We went to two different facilities, including the National Medical Commission, and were amazed at the waiting rooms full of people, as well as the long queues. We had a "facilitator" help us through the process, which meant back door access and jumping the queue, but learned that many of the hundreds of people waiting for these tests had been there for 8-9 hours. For the majority of workers, who are labourers, that likely meant lost wages for the day. I agree with you that when we make fixing these kinds of waiting lines and times a priority, it will be done.