Primary Care Patients’ and Staff’s Perceptions of Self-Rooming as Alternative to Waiting Rooms

INTRODUCTION

Self-rooming is a relatively new process where patients direct themselves to an assigned exam room immediately after checking in, bypassing the traditional experience in which a staff member would escort them from a waiting room to their exam room. Self-rooming decreases waiting time for patients and decreases staff time and cost, while increasing patient satisfaction, as we previously reported.¹ However, leaders of traditionally designed clinics are often reluctant to redesign the rooming experience, believing their buildings need specific features like hallways with few intersections, and dual-access rooms.² Previous studies have demonstrated that self-rooming can increase efficiency, cost effectiveness, and patient satisfaction, but emphasize the need for modified or additional technology³ and specially designed buildings.^1,4,5 Health systems did not routinely consider potential benefits and missed opportunities of widespread self-rooming practices until the presence of patients in a traditional waiting room became an intolerable risk due to the COVID-19 pandemic.

Health systems responded to the threat of COVID-19 spread by rapidly implementing self-rooming with existing clinic layouts to promote physical distancing and avoid viral exposure in waiting rooms. Our health system, UW Health, is a public academic institution in Madison, Wisconsin. We successfully piloted self-rooming in 2 clinics in 2008-2009, which informed the design of 4 clinics in 2015-2016 specifically designed and built to improve team-based care and patient flow.^1,4,5 Faced with the need to limit COVID-19 spread, our health system quickly overcame concerns about uninviting or confusing building infrastructure, patients getting lost, or unescorted patients compromising privacy. The rooming process was rapidly redesigned to implement self-rooming in the majority of our primary care clinics without the need for investments in technology or building construction.

The objective of this study was to determine whether self-rooming is an acceptable alternative to escorted rooming based on the perceptions of patients and staff in 25 primary care clinics that implemented self-rooming. We surveyed patients and staff rooming process preferences and perceptions. Based on our initial experience and survey results, concerns that self-rooming would be unworkable in most primary care clinic settings were unfounded. Ultimately our health system decided that self-rooming will be a permanent feature and it has been implemented across the remaining primary care clinics in the health system.

METHODS

Intervention and Implementation

Figure 1 shows our self-rooming workflow. Patient scheduling representatives (PSRs) give patients laminated cards with directions to their exam room and patients go directly there. Exceptions include patients waiting when no rooms are available or being escorted by PSRs if unable to find their room. Patient scheduling representatives inform MAs electronically through the schedule or secure messaging. Medical assistants complete usual processes directly in exam rooms, clean rooms after clinician visits, and take laminated cards back to reception. This self-rooming plan was implemented in all family medicine clinics and all but 2 general internal medicine clinics by May 30, 2020. It has now been implemented across all primary care clinics including pediatrics and will be a permanent change for our institution. Our detailed workflow (both check-in and check-out) and supplemental materials including surveys are available on HIPxChange (www.hipxchange.org/SelfRooming).

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Figure 1.

Process map of the self-rooming workflow.

Jabber = electronic messaging software used to facilitate communication among team members; MA = medical assistant; Pt = patient; receptionist = patient scheduling representative; RM = room

RESULTS

Patient response rates across clinics (median = 79%, interquartile range = 38% to 100%) did not vary systematically with patient demographics. Patient respondents (n = 1,561) were mostly female, average age 52.4 (Table 1). Of the respondents, 1,336 patients self-roomed, 80 were escorted, and 99 described elements of self-rooming (eg, told which room to go to but not given a card).

On the preferred rooming process question, 86.4% of patients selected self-rooming (Table 2), 7.2% escorted rooming, and 6.4% “other,” describing in comments elements of self-rooming or no preference. Preferring self-rooming was significantly higher among patients aged <65 years and in family medicine clinics. Few patients reported feeling less welcomed (10.6%), less cared about (6.8%), more isolated (15.6%), more lost/confused (7.6%), or more frustrated (3.2%) with self-rooming. Early adopter clinics that implemented self-rooming ≤2016 had even lower rates of patients feeling more isolated, lost/confused, or frustrated with self-rooming.

Staff surveys were completed by most staff (n = 241; 180 clinical, 161 nonclinical), who are mostly clinical staff with ≥5 years of experience (Table 1). Table 3 shows over one-half of staff preferred self-rooming (59.3%) and reported most patients like self-rooming (65.8%). These proportions were significantly higher among clinical staff and in early adopter clinics (≤2016). Clinical staff respondents were additionally asked about waiting times, crowding, and patient confusion. Few reported longer waiting times for patients (12.4%), MAs (15.9%), and clinicians (16.4%) or more crowding in waiting areas (1.7%) and hallways (10.1%). However, in contrast with patient-reported perceptions, most staff thought self-rooming led to more patient confusion (63.8%) though this was significantly lower (44.4%) in early adopter clinics.

Most open-ended survey responses reported positive perceptions of self-rooming. Some comments described remaining concerns and respondents provided suggestions for self-rooming implementation to mitigate these concerns (Table 4).

DISCUSSION

Our institution successfully implemented self-rooming across primary care during the COVID-19 pandemic with no capital investments in new technological or building infrastructure. This large post-implementation survey of patients (n = 1,561) and staff (n = 241) in 27 clinics showed that most patients and a smaller majority of staff selected self-rooming as their preferred process. Furthermore, only few respondents thought self-rooming was worse than escorted rooming in terms of patient friendliness, waiting times, and crowding. Self-rooming was perceived even better in pre-pandemic early adopter clinics (≤2016) and among patients aged <65 years and clinical staff. One notable exception was that most staff believed that patient confusion would be worse with self-rooming than with escorted rooming, a belief that was not consistent with actual patient-reported perceptions.

This study demonstrated that implementing self-rooming does not require new infrastructure and significant capital investment as previously believed. Redesigning workflows within existing infrastructure achieved accelerated and low-cost implementation of self-rooming across all primary care clinics during the pandemic. Building on our previous pilot estimating clinic cost-savings of 6 staff hours monthly translating to $1,500 annually,¹ our self-rooming implementation in 25 clinics yields estimated cost savings of 150 staff hours monthly translating to $37,500 annually. With the ongoing staff turnover and retention challenges in health care, self-rooming could be part of a solution. The benefits of self-rooming reported by patients and staff in this study are consistent with benefits shown by previous studies focused on implementing self-rooming through mobile technology³ or in clinics with intuitive layouts.^1,3 Specifically designed infrastructure for self-rooming was previously seen as a requirement and its absence as an impediment. With the pandemic, those concerns were set aside and our study shows them to be unfounded. This study demonstrated that even without investments in mobile communication technology or building redesigns, self-rooming is acceptable to patients and staff. In line with human factors engineering models of work systems design,^8-11 this finding suggests that our redesigned workflow is well aligned with the user needs of patient and staff, with task and organizational features adequately balancing out the absences of dedicated technology and building infrastructure.

Most patients selected self-rooming as their preferred rooming process and few felt it was less patient friendly than escorted rooming. We found that patients often feel at least as welcome and cared about when able to immediately go to their own exam room rather than waiting in a designated waiting area. The time alone in the exam room also appears to provide patients the opportunity to mentally prepare for the visit without distractions. This is consistent with research suggesting that the emotions and behaviors of other patients in the waiting room may increase a patient’s stress before the visit.^12,13 Our findings suggest that with some exceptions to be investigated in future work as described below, most patients are able and willing to find their own exam room and that this may honor their sense of autonomy. Our study therefore demonstrates that there may have previously been missed opportunities for widespread adoption of self-rooming, beyond the obvious safety advantages of not grouping patients in the same space to avoid contagion during and beyond a pandemic.¹⁴

Our study shows that staff concern about patient confusion with self-rooming was unfounded. Most staff believed it would be more confusing for patients to be asked to room themselves; in contrast, few patients actually felt more confused with self-rooming. This kind of misalignment between staff perception of patient experience and the reported experience of patients has been found in previous studies^15-17 and adds more specific details to our previous report about patient satisfaction with self-rooming.¹ Possible explanations for the disconnect include the general uncertainty associated with the pandemic, a natural resistance to change, the inertia of a longstanding process, and staff’s overestimation of their role in patient experience and underestimation of patients’ abilities. It is reassuring that the misalignment of perception between staff and patients about the patient experience appears to diminish over time. In fact, in clinics that had implemented self-rooming ≤2016, staff perceptions that self-rooming leads to more patient confusion than escorted rooming are significantly higher than in clinics that implemented it recently. The same trend is observed with staff perceptions that most patients like self-rooming, which mirror patient perceptions in clinics that have had self-rooming for a few years. The low proportion of patient confusion was also not significantly different for patients aged >65 years, who, despite being somewhat less likely to prefer self-rooming (82% vs 88%), were not significantly more likely to feel confused, lost, isolated, or frustrated with self-rooming. This suggests that self-rooming is acceptable even for some patients whom staff may perceive as more vulnerable. Some comments from patients and staff did suggest that certain patients with a physical or cognitive impairment may prefer escorted rooming. Suggested approaches for managing negative staff expectations include education and awareness about positive patient preferences and perceptions, future reassessment of self-rooming after a period of adjustment, and engaging staff and patients in informing future refinements to the self-rooming process. Refinements may include reviewing how patient-reported information may be collected from patients if they are no longer in a waiting room, such as via patient portals or telephone calls.

CONCLUSIONS

The pandemic forced us to explore innovative ways to address concerns about the feasibility of implementing self-rooming as a process redesign, without technology or building investments. Waiting rooms have become an unsafe way of serving our patients during this pandemic and beyond. Self-rooming is patient friendly and acceptable within staff workflows. Our organization and patients benefitted during the pandemic from this work to conclude that self-rooming is not only efficient, economical, and safer than the waiting room, but that it is also preferable to patients and staff, with minimal concerns compared with escorted rooming.