Hospital Pharmacy Volume 36, Number 3, pp 275279 2001 Facts and Comparisons

PEER-REVIEWED ARTICLE

Queuing Theory and Customer Satisfaction: A Review of Terminology, Trends, and Applications to Pharmacy Practice
Ronald Anthony Nosek, Jr., MS* and James P. Wilson, PharmD, PhD

Abstract Queuing theory is the formal study of waiting in line and is an entire discipline in operations management. This article will give the reader a general background into queuing theory, its associated terminology, and it relationship to customer satisfaction. Queuing theory has been used in the past to assess such things as staff schedules, working environment, productivity, customer waiting time, and customer waiting environment. In pharmacy, queuing theory can be used to assess a multitude of factors such as prescription filltime, patient waiting time, patient counseling-time, and staffing levels. The application of queuing theory may be of particular benefit in pharmacies with high-volume outpatient workloads and/or those that provide multiple points of service. By better understanding queuing theory, service managers can make decisions that increase the satisfaction of all relevant groups customers, employees, and management. Key Words customer satisfaction; queuing Hosp Pharm 2001;36:275279

aiting in lines or queues seems to be an American pastime. Think about the many times you had to wait in line in the last

month or year and the time and frustration that was associated with those waits. Whether we are in line at the grocery store checkout, the barbershop, the stoplight, or in the pharmacy, waiting

*Pharmacy Department, The National Naval Medical Center, Bethesda, Maryland, 20889; ranosek@bethesda.med.navy.mil (Ronald A. Nosek, Jr., LCDR, MSC, USN is an active duty pharmacist in the United States Navy. At the time of writing this article he was attending the University of Texas as a full time student in Navys Duty Under Instruction program); Assistant Professor, Pharmacy Practice and Administration Division, The University of Texas College of Pharmacy, Austin, TX; wilsonj@mail.utexas.edu. Address correspondence to Dr. James P. Wilson, Pharmacy Practice and Administration Division, PHR 2.212 Mail Code A1930, Austin, TX 78712; wilsonj@mail.utexas.edu. The opinions or assertions herein are the private views of the authors and are not to be construed as official or reflecting the views of the U.S. Department of the Navy or the Department of Defense.

our turn is part of our everyday life. Queuing theory is the formal study of waiting in line and is an entire discipline within the field of operations management. The purpose of this article is to give the reader a general background into queuing theory and queuing systems, its associated terminology, and how queuing theory relates to customer satisfaction. Also, past and present applications of queuing technology and what pharmacies can do to manage patient or customer queues more effectively will be discussed. Finally, automated queuing technology will be described. Queuing theory utilizes mathematical models and performance measures to assess and hopefully improve the flow of customers through a queuing system.13 Queuing theory has many applications and has been used extensively by the service industries. Queuing theory has been used in the past to assess such things as staff schedules, working environment, productivity, customer waiting time, and customer waiting environment. In pharmacy, queuing theory can be applied to assess a multitude of factors such as prescription fill-time, patient waiting time, patient counseling time, and pharmacist and technician staffing levels. The application of queuing theory may be of particular benefit in pharmacies with high-volume outpatient workloads and/or those that provide multiple points of service, such as those in the
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Department of Veterans Affairs (VA), Department of Defense (DoD), university health systems, and managed care organizations. Problematic queuing systems (ie, long lines) can lead to the customers perceptions of excessive, unfair, or unexplained waiting time resulting in significant detrimental effects on the customers overall satisfaction with the service transaction.4
QUEUING SYSTEMS AND TERMINOLOGY

payment made by the customer and the various operating costs of the system. Other elements that impact the queue structure and performance include the number of service stations and the number and speed of servers.2,5
THE IMPORTANCE OF QUEUING MANAGEMENT

my name is called! I pay the cashier and my pharmacy encounter is complete. However, I dont feel good about it. Why did I have to wait so long? Did others get special priority over me? Maybe another pharmacy will service my needs better? Am I a satisfied customer? QUEUING APPLICATIONS IN SERVICE INDUSTRIES

On the surface it may seem like queuing is just simply waiting in a line. To most customers, the waiting experience is all that matters. However, waiting in line is just a part of the overall queuing system. A queuing system (also known as a processing system) can be characterized by four main elements: the arrival, the queue discipline, the service mechanism, and the cost structure. The arrival is the way in which a customer arrives and enters the system for service. Whenever customers arrive at a rate that exceeds the processing system rate, a line or queue will form. Arrivals may come in singly or in batches; they may come in consistently spaced or in a completely random manner. A potential customer can also leave if, on arrival, he or she finds the line too longthis is called balking. The queue discipline is the rule for determining the formation of the line or queue and the order in which jobs are processed. There may only be one line and jobs are processed First-In, FirstOut or FIFO. Others may have more than one line to give certain customers priority such as express lanes in grocery stores. The service mechanism describes how the customer is served. It includes the number of servers and the duration of the service timeboth of which may vary greatly and in a random fashion. The service time may be similar for each job or it could vary greatly. The cost structure specifies the

Pharmacy, like other service-oriented industries, functions in an increasingly competitive environment. Speed of service has been shown to provide businesses a competitive advantage in the marketplace.4 In addition, the literature reveals several studies documenting customer dissatisfaction with long waiting times and indicates that this is a pervasive problem in pharmacy practice and a common source of anxiety and dissatisfaction among customers and, in many cases, pharmacists.6 Speed of delivery is being emphasized increasingly and can be partly attributed to increased competition and the value a customer places on his or her time. We live in a society who has come to expect film development and eyeglasses to be ready in an hour or less. A brief story told from the customers perspective will help to further illustrate this point:
I just arrived at my local pharmacy to get a new prescription filled and to pick up a few other things. There is a line of four people at the register and another six people sitting in the waiting area. By the time I get to the counter to hand the cashier/technician my prescription, 5 minutes have passed. I ask how long the wait will be and I am told 30 to 40 minutes. I go about my shopping and return to the pharmacy 35 minutes later. Again, there are people in line at the register and it takes me another 5 minutes to find out that my prescription is not ready. Feeling weary and somewhat frustrated, I have a seat in the waiting area. As I sit there, I watch people come and go and wonder, Wasnt I here before that guy? At last

Queuing management has been applied very successfully in many service-oriented industries. L. L. Bean, a large telemarketer and mail-order catalog house for high-quality sporting goods and apparel, used queuing theory to optimize staffing levels resulting in an estimated $500,000 per year savings.7 The Department of Motor Vehicles in Virginia and Arizona used queuing technology to virtually eliminate long lines and greatly improve customer satisfaction. In addition, they were able to significantly improve employee morale and reduce operating costs.810 Queuing models have also been used to plan staffing levels in an outpatient hospital laboratory department and a centralized appointment department in Lourdes Hospital in Binghamton, New York. Queuing models were used to identify an optimal configuration of capacity and staffing levels for both departments. The lengthy delays in answering telephone calls in the centralized appointments department were completely eliminated by rearranging work shifts of current employees.11,12 The Virginia Mason Medical Center in Seattle, Washington used queuing theory and other classic quality management principles to drastically reduce patient waiting time for appointments (42 days to 13), emergency room triage time (45 minutes to 15), and increased staff morale.13 Queuing theory has been used extensively in the banking industry to increase business by careful placement of merchandising materials while at the

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same time alleviating both the actual and perceived amount of time a customer spends waiting in line.14 Finally, queuing theory has been applied to computer simulation models to help with business decisions and problems.15,16
CUSTOMER SATISFACTION AND CONSUMER BEHAVIOR

repeat business and will be more than willing to share his or her bad experience with whoever will listen. This will have an obvious negative impact on profits and revenues.14
CUSTOMER SATISFACTION AND WAITING TIME

In general, customer satisfaction is multifactorial and is considered a part of overall consumer behavior model. Consumer behavior evolves over time and is influenced by many factors. Several key factors that greatly influence satisfaction include consumers expectations, attitudes, and intention about the service provided. Expectations are the consumers anticipated beliefs about a product or service prior to the interaction. Attitudes consist of the consumers evaluations, emotional feelings, and action tendencies toward a product or service that has developed over time. Intentions are the decisions the consumer makes about future actions toward the firm producing the product or service. Together, these factors influence the future behavior or the actual future action taken by the customer. For the most part, these factors are intangible so it is the perceived performance rather than the actual performance that is more critical to customer satisfaction. The main goal of queuing management is to maximize the level of customer satisfaction with the service provided. Therefore, the primary issue in queuing management and customer satisfaction is not the actual amount of time a customer waits for service, but the customers perception about that wait and the associated level of satisfaction. A highly satisfied customer will be very likely to provide repeat business and spread the positive experience by word of mouth (advertising), resulting in increased revenues and profitability. Conversely, a dissatisfied customer will most likely not provide

Customer satisfaction has been defined as the difference between the customers perceptions of the experience and his or her expectations, which is many times based on past experience. Although it is possible to manage and decrease actual waiting time and to some extent to manage customer expectations about customer satisfaction, managing the customers perception of the queuing experience can be the vital element in satisfaction with the service interaction.4 The measurement of customer satisfaction as it relates to waiting time is highly qualitative and subjective, and the relationship is generally inverse in nature (ie, in general, as waiting time decreases, satisfaction increases). This relationship was further expanded by Maister who, in 1985, postulated that satisfaction is dependent on customer perception and customer expectation.4 Numerous scientific studies, journal articles, and text books have been published describing the relationship between customer satisfaction, waiting time, and consumer behavior.125 For example, one study examined customer attitudes toward waiting times in the hotel and restaurant industry and found that over 70% of all respondents were clearly concerned about waiting times. In fact, those most concerned about waiting times were generally more willing to pay more to avoid waiting in line and believed that quality is worth waiting for. The results of this survey indicate that queues do affect the satisfaction level of customers and their willingness to spend. In addition, this study also suggests that there is a point where a lengthy wait begins to affect the customers perception of quality.17

Another study examined patient satisfaction with outpatient pharmaceutical services at a large university hospital. This study reported that of the patients who received prescriptions from university physicians and did not fill them at the university pharmacy, 21% went elsewhere to have their prescription filled because of the long waiting time, even though prescription prices were less expensive through the university system.18 Similarly, another study conducted in a large Veterans Affairs hospital reported that pharmacy redesign improved patient satisfaction because of a 50% decrease in patient waiting time.6 Finally, another article describes the relationship between waiting time and satisfaction in the context of social justice or injustice, as the case may be.19
QUEUING THEORY IN PHARMACY

Queuing theory and its application has gotten very little attention from pharmacy operations management; however, pharmacy practice could benefit by understanding and applying some of the concepts of queuing theory. A publication, Operations Management for Pharmacists, briefly discusses queuing theory and customer wait-time management. The authors appropriately acknowledged that the advanced mathematical models used in queuing theory were beyond the scope of the book. Unfortunately, the only suggestion offered by the authors for managing perceived waiting time is to distract the customer by providing entertainment, refreshments, or comfortable conditions, such as television and coffee in the waiting area.20 A literature search revealed few published articles in the area of pharmacy practice and queuing theory. Donehew and colleagues used queuing theory to address prescription queues and work measurement assessment of prescription fill times.21 Similarly, Boyce and colleagues sought to deter-

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mine the impact of a computerized waiting time program on order turnaround time in a hospital pharmacy.22 Perhaps the most common and useful application of queuing theory in pharmacy operations is to reduce patient waiting time and maximize staff effectiveness. Lin and colleagues used workflow analysis and times study to identify factors leading to excessive waiting times in an ambulatory pharmacy at the University Hospital Inc. (TUH), Cincinnati, Ohio.23 In another study, also by Lin, work measurement and computer simulation were used to assess the re-engineering of community pharmacies to facilitate patient counseling.24 Although queuing theory was never mentioned in these articles, the authors used many concepts similar to queuing theorys and their results could be instrumental in designing queuing applications for reducing patient waiting time and improving staff utilization. In a study by Moss, queuing theory was used to assess the relationships among the number of pharmacy staff members, prescription dispensing process, and outpatient waiting times. He used a mathematical queuing model to estimate the probability of waiting time exceeding a given value, when prescription arrival and service rates and number of servers are known. The study revealed that the major factors determining outpatient waiting time were the arrival pattern of prescriptions at the pharmacy, sequencing of work, and percentage of staff at work.25 Finally, Vemuri used computer simulation with a queuing model to assess patient waiting time in the outpatient pharmacy at the Medical College of Virginia. This study concluded that the most significant factor contributing to patient waiting times was the interaction between pharmacy service providers, specifically the typist and the technician.26 Many different mathematical equations can be used to describe queue

formation and behavior; however, the decision to choose one over the other is beyond the scope of this article. Although Moss25 provided the mathematical formula used in his research, most queuing research applications are now completed through some form of computerization due to the complexity of the models and the accessibility of off-the-shelf software and personal computers.
WHO MIGHT BENEFIT FROM QUEUING APPLICATIONS?

QUEUING TECHNOLOGY IN PHARMACY

It is true that many pharmacies do not experience problems with queues. However, there are many pharmacies that do experience difficulties with queue formation. For example, pharmacies that experience high-volume prescription workload frequently have difficulty in managing workflow and waiting times. This could also be true in pharmacies that offer their customers multiple points of service (ie, bank teller design). Pharmacies such as those in large managed care organizations, university health systems, and those in the VA and DoD typically fit this description. It is safe to say that the traditional methods employed by pharmacies to distract customers (eg, comfortable waiting area, coffee, and television) would be of limited benefit in pharmacies that fill in excess of 1,000 prescriptions per day and have patient waiting times that commonly exceed 1 to 2 hours. Recently, however, automated queuing technology has been successfully developed and applied in areas of pharmacy practice that specifically address customer waiting times. Prior to this innovation, the most advanced queuing applications to manage customer waiting times in pharmacies was a consecutive number ticketing system commonly found in barber shops and grocery stores.

Automated queuing technology (AQT) is primarily utilized in the federal sector and includes numerous pharmacies in the DoD and the VA. However, several prominent nonfederal pharmacy organizations utilize AQT, including the University of North Carolina, Medical College of Virginia, Jewish Hospital in Cincinnati, and Parkland Hospital in Dallas, just to name a few.27 Both the DoD and the VA operate very busy outpatient pharmacy departments, some filling in excess of 2,500 outpatient prescriptions and servicing over 1,000 patients daily. Automated queuing systems are typically PC based systems that can track a multitude of useful information that was previously very difficult to quantify for pharmacy managers. Pharmacies utilizing AQT can easily track variables such as customer arrival and departure time, patterns of arrival, prescription fill time, waiting time, and individual staff member productivity. In addition, AQT can track numerous points of service and different service categories (ie, certain patients may get priority service or can be used to track patient counseling) if desired. Finally, AQT can also provide pharmacy customers with information that can directly improve their queuing experience, such as with a ticket with a unique number and the estimated wait time. This makes for a less confusing, more relaxed, and much more positive waiting environment for the patient. At the time this article was submitted for publication, only one company, the QMatic Corporation, that distributes automated queuing technology systems could be identified. Their website address is http://us.q-matic.com.27
CONCLUSION

Queuing theory is a powerful management tool that often gets overlooked, especially in pharmacy operations management. Proper application

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of this effective management tool can yield impressive results. There are volumes of additional material on queuing theory and in fact this paper has only touched the surface. The goal of this paper was to give the reader a general understanding of concepts, current technology, and applications of queuing theory as it relates to customer satisfaction and waiting time. Undoubtedly, there are numerous factorsphysical, psychological, and emotional, to name a fewthat affect a customers perception of the waiting experience. By better understanding queuing theory and the various measures associated with customer waiting time, service managers can make decisions that have a beneficial impact on the satisfaction of all relevant participants: customers, employees and management. There are several tools such as computer simulation, modeling , and automated queuing technology that can assist in this process improvement endeavor. Waiting in line will always be prevalent in our society and in our pharmacies. As the health care industry continues to evolve, pharmacists are under continued and growing pressure to do more and more. Wouldnt it be nice to practice pharmacy in a setting where the worry and burden of wait time management was eased, even eliminated keeping customers happy and decreasing the anxiety of those behind the counter trying to provide the best pharmacy service?

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2. Prabhu NU. Foundations of Queueing Theory. Ithaca, NY: Kluwer Academic Publishers; 1997. 3. Gorney L. Queueing Theory: A Problems Solving Approach. New York: Petrocelli Books, Inc.; 1981. 4. Davis MM, Heineke J. Understanding the role of the customer and the operation for better queue management. Int J of Operations Production Manage. 1994;14: 2134. 5. Bierman H, Fouraker LE, Jaedicke RK. Quantitative Analysis for Management. 9th ed. Chicago: Irwin; 1997, 540. 6. Pierce II RA, Rogers EM, Sharp MH, et al. Outpatient pharmacy redesign to improve workflow, waiting time, and patient satisfaction. Am J Hosp Pharm. 1990;47:3516. 7. Andrews B, Parsons H. Establishing telephone-agent staffing levels through economic optimization. Interfaces. 1993;23: 1420. 8. Anonymous. Profiles and projects: Customers enjoy visiting Virginia, Arizona service centers. Move. 1997;Spring:323. 9. Rosenfeld M. Arlington DMVs speedy service: New system eliminates long lines. The Washington Post. 1997;Aug 8:A1, A17. 10. Squires PC. Commissioners goal: efficiency. Commissioner tries to make DMV customer friendly. The Richmond Times-Dispatch. 1997;Jun 10:C1, C7. 11. Khan MR, Callahan BB. Planning laboratory staffing with a queueing model. Eur J of Operational Res. 1993;67:32131. 12. Agnihothri SR, Taylor PF. Staffing a centralized appointment scheduling department in Lourdes Hospital. Interface. 1991;21:111. 13. Nordhaus-Bike AM. No room for waiting. Hosp and Health Netw. 1997; 71:64. 14. Wayne CB, DiSotto K. Bank design from the bankers point of view. Bank Marketing. 1994;26:3942.

15. Proctor RA. Queues and the power of simulation: helping with business decisions and problems. Manage Decisions. 1994;32:505. 16. Proctor RA. Simulation in management services. Manage Services. 1994; 38:1821. 17. Jones P, Dent M. Improving service: Managing response time in hospitality operations. Int J of Oper Production Manage. 1994;14:528. 18. Somani SM, Daniels CE, Jermstad RL. Patient satisfaction with outpatient pharmacy services. Am J Hosp Pharm. 1982; 39:10257. 19. Larson RC. Perspectives on queues: social justice and the psychology of queuing. Oper Res. 1987;35:895905. 20. Mantel SJ, Evans JR. Product planning and capacity. In: DeSalovo RJ, Woebkenberg, T, eds., Operations Management for Pharmacists: Strategy and Tactics. Cincinnati, OH: The Institute for Community Pharmacy Management; 1992, 556. 21. Donehew GR, Hammerness FC. How to measure time that is involved in filling Rxs. Pharm Times. 1978;44:549. 22. Boyce T, OHare S. Effect of a computerized prescription log on prescription turnaround time in a hospital pharmacy. Pharm Manage. 1998;14(2):1720. 23. Lin AC, Jang R, Lobas N, et al. Identification of factors leading to excessive waiting times in an ambulatory pharmacy. Hosp Pharm. 1999;34:70712. 24. Lin AC, Jang R, Sedani D, et al. Re-engineering a pharmacy work system and layout to facilitate patient counseling. Am J Health Syst Pharm. 1996;53:155864. 25. Moss G. Hospital pharmacy staffing levels and outpatient waiting times. The Pharm J. 1987;239(Jul 18):6970. 26. Vemuri S. Simulated analysis of patient waiting time in an outpatient pharmacy. Am J Hosp Pharm. 1984;41:112730. 27. Q-Matic System company brochure. Ashville, NC: The Q-Matic Corporation; 1998. !

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