Parental perception of waiting time and its influence on parental satisfaction in an urban pediatric emergency department: are parents accurate in determining waiting time?

Objective: The objective of this study was to determine whether parental perception of waiting time in an urban pediatric emergency department (ED) is accurate and whether the actual waiting times or their perception of waiting times impact on parental satisfaction.

Methods: A prospective convenience sample study in which the on-duty emergency physicians randomly administered a questionnaire at the time of the ED visit was used. During a 3-week period from December 15, 1999, through January 7, 2000, 500 parents or legal guardians of children who visited our ED were questioned about their perceived waiting time, and the responses were compared with the actual waiting time. The parents or guardians were also asked if they were satisfied with the waiting time.

Results: The majority (84%) of parents overestimated waiting time in the ED (median difference, 26 min; interquartile range, 9-50 rain). Parents with perceived or actual waiting times that exceeded 2 hours were significantly more likely to be dissatisfied than parents with actual or perceived waiting times that were 1 hour or less (P < 0.001). Satisfaction was not related to the age (P = 0.35), sex (P = 0.30), race/ethnicity (P = 0.90), or mode of arrival (P = 0.28).

Conclusion: Parents lend to overestimate waiting time. Both perceived and actual waiting times that exceed 2 hours were associated with parental dissatisfaction. ED administrators may need to keep this in mind when arranging ED staffing patterns to match peak patient hours to achieve optimal parental satisfaction.

The emergency department (ED) is the gateway that a majority of patients use to access care within hospitals. The public perception of the quality of service provided by an institution may be solely based on the care provided in its ED. ED efficiency is usually judged in terms of waiting time. Waiting time in a pediatric ED may be particularly important because anxious parents and caregivers may become unduly stressed and intolerant of what may seem an excessive wait.

Patient satisfaction has become increasingly important in the current health-care environment. Waiting time is considered an important determinant of patient satisfaction, (1, 2) Lengthy waiting times tend to cause dissatisfaction with the ED care and may lead to poor compliance with the medical recommendations. (2, 3) In addition, patient satisfaction in the ED can have an impact on the patient's decision to continue with the follow-up care within the same hospital. (4)

Waiting time has two dimensions: actual (measured) waiting time (AWT) and perceived (subjective) waiting time (PWT). PWT is an important determinant of parents' satisfaction with a pediatric ED visit. Understanding the relationship between AWT and PWT is important because if the perceptions of parents are inaccurate and they overestimate the passage of time, unwarranted dissatisfaction may result. By knowing the relationship between the AWT and PWT, ED staff will be able to respond appropriately to parents' complaints of lengthy waits and to potentially implement changes to modify parental perceptions. Most existing studies are retrospective and have concentrated on obtaining telephone interviews weeks alter the ED visit. (5-8) One study examined the correlation between AWT and PWT, but received significantly fewer responses from patients who waited longer times, potentially affecting the comparison between this group and the group with shorter waiting times. (9)

The primary objectives of this study were to determine the accuracy of parental perception of waiting time and to evaluate the effect of AWT and PWT on parental satisfaction in the ED. The secondary objective was to determine whether parents or guardians tended to overestimate waiting times.

Materials and Methods

This study was conducted in a freestanding pediatric ED that is a Level 1 trauma center and provides emergent and urgent care to an inner city population. The ED receives approximately 55,000 pediatric visits each year. A computerized database is maintained for all visits. Every child is triaged by a trained pediatric emergency nurse. The triage nurse classifies the patients into three primary categories: emergent, urgent, and not urgent. Study investigators collected multiple elements of data for each child's visit: arrival time, time seen by a physician, PWT, and satisfaction about the wait. AWT is the time between the patient arrival and first examination by an emergency physician, and PWT is the parent's estimation of how long it had taken for their child to be seen by the doctor. We defined "overperceivers" as parents or guardians whose estimated waiting time (PWT) exceeded the AWT (PWT - AWT > 0).

Exclusion criteria were emergent patients, urgent cases who were brought in immediately to the treatment area for rapid evaluation, patients who were not accompanied by parents or legal caretakers, infants less than 1 month of age, and children with psychiatric illnesses.

A convenience sample of 500 parents or guardians who visited our pediatric ED from December 15, 1999, through January 7, 2000, was used. The principal investigator collected most data (approximately 70%) during his work shifts. Each parent or guardian was interviewed by the physician at the beginning of the physician encounter and informed that study results would be used to improve the ED services. They were asked about their perceptions of waiting time and satisfaction. The question regarding the length of wait was phrased to measure the magnitude. "How long have you been waiting to see the doctor?" and "Are you satisfied with the waiting time?" The responses of the second question were recorded as whether they were satisfied or not. Institutional review board exempted this study from full review.

Statistical analyses were performed using Stata 6.0 software (Stata Corp., College Station, TX). Data were presented as proportions or medians (with interquartile range [IQR]). Potential differences between the satisfied group of parents and the dissatisfied group of parents were tested using [chi square] and Fisher's exact test. All P values were two-sided, with P < 0.05 considered statistically significant. Ninety-five percent confidence intervals (95% CI) were used when appropriate. In addition, the influence of race, triage category, and mode of arrival were assessed with regard to parental satisfaction (Table 1). The characteristics of overperceivers were also determined.

Results

During the study period from December 15, 1999, through January 7, 2000, 500 parents or legal guardians were interviewed. Median AWT among all patients was 111 minutes (IQR, 74-149 minutes). Median PWT was 135 minutes (IQR, 90-180 minutes). Among patients in the satisfied group, mean AWT was 58 minutes (IQR, 36-75 minutes), whereas in the unsatisfied group it was 129 minutes (IQR, 95-159 minutes). Four hundred twenty (84%) parents overestimated waiting time. The median overestimation of waiting time among the overperceivers was 31 minutes. Of these, 10% perceived their waiting time to be more than 76 minutes in excess of the AWT, and 5% perceived the wait to be more than 99 minutes in excess of the AWT. Seventy-nine parents or guardians (16%) underestimated the AWT. The median underestimation of waiting time among those who underestimated the AWT was 10 minutes less than the AWT (IQR, -4 to -22 minutes).

There were no statistically significant differences in mode of arrival, sex, age, or race/ethnicity of the child between parents or guardians who either overestimated or underestimated waiting times. Forty-five percent (45%) of Hispanic parents and 42% of black parents perceived waiting time to be longer than the actual wait (not significant). Of the parents who overestimated waiting time, approximately 51.5% of their children were triaged as not urgent and 48.4% as urgent (not significant; Table 2).

Characteristics of the overperceiver group are summarized in Table 3. They tended to be parents or guardians of children between 2 and 11 years of age. Those with infants or teenagers were less likely to be overperceivers. Sex, race, and mode of arrival were not associated with overestimation of the AWT.

Discussion

When it comes to improving patient satisfaction, an ounce of prevention doesn't necessarily equal a pound of cure. Parental satisfaction is a valid and worthwhile goal for an ED, (10) and there are ample reasons for implementing a plan to achieve it. As our data show, there is a very strong association between waiting time and patient satisfaction. Satisfaction results from meeting or exceeding parental expectations. (11-13) The correlation between actual and perceived waiting times has not been extensively studied. There are relatively few studies on the relationship between waiting time and patient's satisfaction. How accurate are parents' waiting time perceptions? Is it the perceived or the actual elapsed waiting time that affects parents' satisfaction? Earlier studies were retrospective telephone interviews conducted a few weeks after the ED visit. Thompson et [al.sup.6] concluded that perceptions regarding waiting time rather than AWT have a greater influence on patient satisfaction. By contrast, our study was designed to see how accurate parents or guardians were in estimating the time they waited to see a physician in real time. Thompson et [al.sup.7] defined the time that a patient waits to see a physician as the "preprocess" waiting, the time period a customer waits to obtain a service. If the parent or guardian fails to see the triage and registration process as part of the service, then there may be a greater propensity to overestimate the time from triage to physician contact.

There are several factors that may offer an opportunity to understand ED satisfaction. First, the relation between AWT and PWT needs to be appreciated. The analysis of waiting time in our study suggests that parents are not very accurate in their perception of waiting time in our ED. Most parents (84%) overestimated waiting time (PWT). The explanation for the inability of parents to accurately estimate waiting time is not clear, and our study was not designed to obtain those data. Our study suggests that the difference between PWT and AWT was not related to triage category, race, or mode of arrival.

Second, how long were parents willing to wait when they said they wanted urgent attention? Our data showed parents started overestimating waiting time when the waiting time exceeded approximately 2 hours. We do not know to what extent health-care providers can manage waiting time perceptions and thus positively impact overall parent satisfaction.

Finally, what factors were common among overperceivers? In our study most overperceivers tended to be caregivers of children between 2 and l 1 years of age. Parents of infants and teens were less likely to overperceive the AWT. This may be owing to children between 2 and 11 years of age being more disruptive to the parent, making time appear to drag. Parents with infants may tend to be more focused on holding and feeding their babies, whereas parents with teens may be able to engage in quality conversation time something that may otherwise be hard to find in the course of a busy day.

Our study suggests that parental estimation of waiting time in the ED differs widely from AWT. Limiting waiting times to less than 2 hours may significantly improve parent satisfaction in the ED. If waiting times cannot be decreased through increased staffing or decreased throughput times, then interventions that affect the perception of time are warranted. Awareness of these results may help to improve the understanding of health-care providers and administrators and thus enable them to better respond to parents' complaints of prolonged waiting time.

There are limitations to our study that may have influenced our results. This was a convenience sample study; therefore, our results may not be representative of true perception. Other determinants of parent satisfaction were not investigated in this study including prior expectations, sense of security and safety, availability of parking, crowded conditions in the waiting room, and courteousness of staff: The site was an urban Level 1 trauma center, so the expectations of our customers may differ from those in suburban community hospitals. Finally, our study may suffer from a bias toward greater satisfaction, as the parent or guardian may be less likely to express dissatisfaction directly to the physician about to care for their child.

Further research on patient satisfaction in a pediatric population may focus on several areas. First, novel interventions that might keep children between 2 and 11 years of age occupied so that the parents may focus on an activity--such as reading or watching television--may allow time to pass more quickly. Second, the use of researchers who are not directly involved with patient care may allow parents or guardians to express more candid answers to questions related to satisfaction with waiting time. Other factors affecting parents' satisfaction should be addressed in future studies.

Conclusion

Parents tend to overestimate waiting time. Both PWT and AWT that exceed 2 hours were associated with parental dissatisfaction. PWT is an important determinant of patient satisfaction with an ED visit. ED personnel should reduce the perception of long waiting times.

Key Points

* Perceived waiting time is an important determinant of patient satisfaction with an emergency department visit.

* Lengthy waiting times are the greatest source of patient dissatisfaction with an emergency department visit.

* Parents are not very accurate in their perceptions of elapsed waiting time.

* Waiting time that exceeded 2 hours was associated with parental dissatisfaction.

Table 1. Patient characteristics (a)

                       No. of
Characteristic      patients (%)

Age group
  <24 mo             208 (42%)
  24 mo-11 yr        241 (48%)
  >12 yr              51 (10%)
Sex
  Male               283 (57%)
  Female             217 (43%)
Race
  White                0 (0%)
  Black               59 (12%)
  Latino             436 (87%)
  Asian                5 (1%)
  Other                0 (0%)
Arrived by EMS
  Yes                 28 (6%)
  No                 472 (94%)
Triage Class (b)
  Urgent             244 (49%)
  Non-urgent         256 (51%)

(a) EMS, emergency medical services.

(b) Emergent patients not included as they were seen immediately upon
arrival.

Table 2. Differences between parents/guardians who
were and were not satisfied (a)

                                      Satisfied     Not satisfied
Characteristic                        (n = 112)       (n = 388)

Age group, %
  <24 mo                                 46%             41%
  24 mo-11 yr                            43%             49%
  [greater than or equal to] 12 yr       11%             10%
Female sex (%)                           47%             42%
Race
  Black                                   11             12
  Latino                                  88             87
  Asian                                    1              1
Arrived by EMS                             4              6
Actual time waited, min               60 (36-75)    126 (95-159)
   (median [+ or -] IQR)
Perceived time waited, min            60 (30-60)    180 (180-240)
   (median [+ or -] IQR)
Overperceivers (b)                        57             92

                                        P
Characteristic                        value

Age group, %                           0.46
  <24 mo
  24 mo-11 yr
  [greater than or equal to] 12 yr
Female sex (%)                         0.30
Race                                   0.91
  Black
  Latino
  Asian
Arrived by EMS                         0.28
Actual time waited, min               <0.001
   (median [+ or -] IQR)
Perceived time waited, min            <0.001
   (median [+ or -] IQR)
Overperceivers (b)                    <0.001

(a) EMS, emergency medical services; IQR, interquartile range.

(b) Overperceivers were those whose perceived waiting time was greater
than the actual waiting time.

Table 3. Differences between overperceivers and nonoverperceivers (a)

                                                          Non-
                                   Overperceivers    overperceivers
Characteristic                       (n = 420)          (N = 80)

Age group, %
    <24 mo                              41%               48%
    24 mo-11 yr                         51%               36%
    [greater hthan or equal to]
      12 yr                              9%               16%
Female sex                              44                43
Race, (%)
  Black                                 12                10
  Latino                                87                90
  Asian                                  1                 0
Arrived via EMS                          6                 5
Actual time waited, min (median
  [+ or -] IQR)                     115 (78-150)      74 (47-135)

Characteristic                      P value

Age group, %                          0.05
    <24 mo
    24 mo-11 yr
    [greater hthan or equal to]
      12 yr
Female sex                            0.86
Race, (%)                             0.52
  Black
  Latino
  Asian
Arrived via EMS                       0.80
Actual time waited, min (median
  [+ or -] IQR)                      <0.001

(a) EMS, emergency medical services; IQR, interquartile range.
Overperceivers were those perceived waiting time was greater than the
actual waiting time.

References

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From the Department of Emergency Medicine, Lincoln Medical & Mental Health Center, Bronx, NY.

Reprint requests to Muhammad Waseem, MD, Department of Emergency Medicine. Lincoln Medical & Mental Health Center, 234 E. 149th Street, Bronx, NY 10451. Email: [e-mail]

Accepted September 18, 2002.