Friday, December 28, 2007

Not So Happy Holidays

November and December have been lean months from the point of view of getting rid of our backlog. As we noted during the summer months, when several physicians are away, it’s difficult to find extra office capacity for the remaining physicians.

As holidays are a recurring reason for reduced clinic capacity, we need to consider if we can manage them more effectively.

The first thing I’d like to implement is a more effective way of requesting and tracking holiday requests. Our traditional method is to write the request on a scrap of paper and attach it to the paper “master calendar”. I then mark my initials on the days I want off. If there are already x number of urologists away at that time, I’m not supposed to request that time off. Special circumstances may be negotiated individually.

I need to see the actual calendar in order to check available dates. It usually lives in the holiday coordinator’s office, but it may occasionally go missing for a few days. It’s usually our office manager or the call-scheduler who have it, but it’s still a nuisance when I want to book holidays and can’t find the calendar.

Friday, December 14, 2007

The Emperor's New Clothes

I recently received this comment on my “Adventures in Improving Access” blog:

I am currently on the wait list for a vasectomy. I'm scheduled with Dr. Jana. My G.P. referred my case to Urology September 13, 2007. I didn't receive a letter from Urology after a few weeks so I followed up with the Kenderdine Clinic to see if the referral had been sent to Urology. The Kenderdine clinic said it had been faxed over. I phoned Urology but my name was not on the wait list. The reception at Urology told me that as soon as faxes come in that the name was added to the list, so they probably hadn't faxed the referral yet. I then phoned back to Kenderdine Clinic and they re-faxed the referral. I did receive a letter from Urology after those conversations. My Urological Surgeon consult appointment was booked for December 5th, 2007, I received that appointment letter on October 17th, 2007. Consult wait time was pretty much 2 months if the first request from Kenderdine would have been successful. My feeling is that I was 99% sure I was going to go for a vasectomy so I would have preferred just to have my surgery scheduled directly from the first request. Maybe even a quick phone conversation to brief me on the procedure and ensure that I wanted it. Dr. Jana did examine me to ensure he could perform the procedure on me but how many times does it happen that it's not possible to do the surgery?

I would suggest that I could have had a shorter wait time if I had been scheduled for the procedure right away.

Dr. Jana told me the likely wait time for my vasectomy would be 3 to 4 months from the December 5th consult date.

It's my opinion that waiting 2.5 months for a consult appointment is excessive then waiting another 3 to 4 months for the surgery is excessive.

Who does this guy think he is, telling me how to run my practice? Does he have any medical training? Does he know anything about assessing men before vasectomies? What experience does he have in booking surgical procedures?

Big fat zip on all counts, I’ll bet.

Yet, oddly enough, he nailed it. Right on the button. Nothin’ but net.

Without any “pertinent” experience, he’s suggested changes to our system that could not only improve service, but also eliminate unnecessary office visits.

Friday, November 30, 2007

Total Recall

At last week's team meeting, we discovered a weakness in how we measure our internal demand.

In the same way that we measure new referrals from family physicians (external demand), we've also been tracking the number of recall appointments requested by our urologists (internal demand). These recall appointments are generated when we want to follow a patient with a chronic or ongoing condition, such as cancer. We receive an average of 150 new referrals, and request about 44 recalls each week.

We can reduce recalls by returning follow-up to the patient's referring physician. This is the true role of a "consultant," that is, provide the service that requires specialty care and then, with appropriate instructions, return care to the primary physician.

Even though all the urologists have agreed that we should try to "repatriate" patients to their referring physicians (where appropriate), we haven't seen a drop in the total number of recall requests. Our project team interpreted this as inadequate implementation of this change by the doctors. However, we now think the lack of change may be an artifact of our data collection.

Friday, November 16, 2007

Uphill Both Ways

Wow! A month away from this blog. It's hard to get back to putting pixels on paper. We're making slow progress with the project, but have had some challenges over the last month. Here's an overview:

Working down the backlog is still our main goal. We've realized that we won't see the end of the backlog by November 30. This month, four out of nine urologists are on holidays. The rest of us are doing our regular work as well as looking after lab results and returning patient phone calls for our vacationing partners. There's not a lot of free time (or much appetite) for adding extra office visits. Even so, Amanda continues to recruit (successfully!) for working evening office hours (5-6 pm, once a week for each doctor). Also, our part-time partners continue to come back to work on their "month off" to work extra days.

December is also going to be a difficult month in which to mobilize extra effort toward the backlog. Hospital holiday slowdown at the end of the month should free up some of us to do extra work at the office. On the other hand, when the hospitals slowdown, we plan for half of us to take holidays over Christmas week and the other half are off New Years week. We'll try to work through as much backlog as possible over the holidays. I'm hopeful that our efforts in January and February will set us up to wipe out the backlog by the end of February.

Friday, October 19, 2007

Blog Break

Kishore’s entries will resume in early November.

Until then, regularly visit his other blogging project: Plain Brown Wrapper.

Friday, October 5, 2007

Accounting for Demand

"Insanity: doing the same thing over and over again and expecting different results." Albert Einstein

Most of our efforts so far have been directed toward reducing backlog. We've had some success in other areas, particularly when we asked family physicians to consider referring to "Urology Associates" rather than a specific urologist. This let us distribute referrals to the urologist with the shortest wait list. As our backlog shrinks (wishful thinking?), we need to think about making changes to our office workflow. Otherwise, the backlog may creep back up.

"Managing demand" is the jargon for many system changes that improve workflow. We've been reducing our internal demand (patients who we recall for follow-up appointments) by carefully considering which patients truly need to be followed by a specialist and which ones should be followed by their family physician. Managing external demand (patients newly referred by family physicians) is more difficult.

Occasionally, I may receive a consultation request that can be managed without needing the patient to visit me. In those cases (especially when the patient may have to make a long trip in to see me), I'll write a letter to the family doctor giving advice on further management. Most situations, however, will require an appointment with me. How can I reduce that demand? After all, that's how I make a living!

Maybe we need to change the way we perceive external demand. At present, we consider each consultation request as being one "unit" of demand on the physician's time. What if we looked at demand units in the same way a lawyer would look at "billable hours"? Lawyers charge for each time they handle your file. This may include making phone calls to you or on your behalf, or even just picking up your dossier and thinking about the contents.

Friday, September 21, 2007

Swing Shift

Extending office hours from 5 to 6 pm required some negotiation. Our receptionists have agreed to try a couple of late shifts. This brought up some unanticipated issues. As it starts to get dark by 6 pm, our staff won't be comfortable walking home from work, so we'll need to provide transportation. Also, we need to check that our office building will still be unlocked at that hour.

The real test of the plan is getting physician bodies behind desks. Amanda made a sign-up sheet for two evenings next week and circulated it to the urologists. She did a nice sales job. Four doctors signed up for one evening and two for the other. Six doctors at four patients per hour means an extra 24 appointments off the backlog that week. I hope this is a small change we can sustain.

P.S. Turns out that blogging is mildly addictive. There’s a spin-off from the Advanced Access project that I’m pursuing at Come on over and check out “Plain Brown Wrapper”!

Friday, September 7, 2007

Summertime Blues, Part 2

Our last team meeting was a little glum. As noted previously, summer slowed our efforts to work down our backlog.

Now we're trying to come up with a plan that will address our new target (almost 100 extra patients per week) in order to work down the backlog by the end of November. We thought about adjusting our target date: if we push it back by another few months, that would ease the work. It would also prolong this initial phase of eliminating the backlog. Already, I'm feeling enthusiasm is dampening in the office. As the project proceeds (drags on?), it's harder to keep the energy up. Moving back the target date will be like dying the death of a thousand cuts. We need a new plan. Something bold.

We already thought about asking the "half-timers" to work a few extra days seeing backlog patients. Donna mentioned that, many years ago, the urologists in our office had come to work on Saturday mornings to see patients. Amanda wondered whether working one evening a week would be more acceptable than working a weekend. Either one would be a tough sell, given the hours we're already working. Maybe we just need to see what happens during September and October, now that we're back up to full steam again.

Friday, August 24, 2007

I Love Crappy Service

I recently had the chance to observe operations at a local fast-food outlet. I stood unacknowledged at the counter while three clerks went about their business. One fellow was working hard, putting together four sundaes for a drive-through order. A girl stood at the sink, haphazardly rinsing off the milkshake equipment. The other young woman wandered back and forth behind the counter sipping on a soft drink, studiously looking away when we came close to making eye contact. When the first girl finally finished at the sink, she stepped over to the counter and stood silently at the cash register. I finally asked her if she was ready to take my order. It was atrocious customer service.

I loved every minute of it.

I used to (and occasionally still do) get upset at bad customer service. Now, I relish it by playing a little mental game similar to Switch! I spot the poor performance and try to relate it to ways I could improve my own work. I was annoyed when the restaurant staff didn't acknowledge me at the counter. Is every patient coming to my office greeted as soon as they arrive? The clerk was cleaning equipment while customers were waiting.  Am I putting patients first by not keeping them waiting while I finish paperwork or review lab tests?

When I saw the girl carelessly cleaning the milkshake equipment, I thought "What else is being done sloppily around here? Are the cooks washing their hands properly?"  One bad impression was enough to give me a pervasive negative feeling about the place. If I habitually keep people waiting, does this affect their overall impression of my ability to practice medicine in an organized and reliable way?

Embrace crappy service for the lessons it teaches us.

Friday, August 10, 2007

Summertime Blues

Summertime is giving us some insight into a source of our waiting list backlog. When we started this project in the spring, our capacity appeared to exceed demand. The problem, we thought, must be a mismatch between the two, and that it should be straightforward to fix once we get rid of our backlog. We were making good progress with our backlog until summer came along. As you would expect, having half the doctors away for most of the summer reduces our capacity. Our ability to work down the backlog is reduced further because those of us who are working are often fully booked at the hospital taking advantage of the OR time that those on holidays have left unused. Not only have efforts to work down the backlog stalled, I wonder if the backlog might be creeping up over the summer.

This Advanced Access project is like a fitness program. You set a target weight (appointment wait time) and then match your intake of calories (demand) to the amount of exercise (capacity). Of course, it takes some extra effort (reduce calories and/or increase exercise) to get rid of the flab (backlog), but once it’s gone, balancing calories and exercise should maintain your target weight. If you're like me, though, a week at the lake can throw off the whole program. Lounging at the beach plus marshmallow roasts pack on the flab and it can take weeks to get back on track again. It’s looking like the same thing has been happening every summer at our office, i.e. we shed the flab during the rest of the year when we're all working full-tilt, only to pack on the backlog during summer holidays.

We may need to reconsider how many physicians can take holidays at a time, or reconfigure our office hours to make sure our backlog doesn't creep up every summer.  Otherwise, we'll be starting from scratch every fall. It would be nice if the number of new referrals fell off over the summer, but that's not the case:

Also, in January, one of our urologists started working half-time, and as of July, two other partners are working half-time. We have a new partner joining in mid-August, but our capacity will still be down 0.5 FTE. Our most recent calculations show we have to see 97 extra patients a week just to work down our backlog by the end of November.  Considering the number of doctor-days in the clinic, each urologist will need to see between 4 and 5 extra new referrals each day they are in the clinic to work down the backlog in a 12 week time frame. That's a lot of work! Perhaps we can convince the "half-timers" to help us out by working a few days extra. If they came to work for 2 days during their month off, they could see up to 60 new patients each. That would really add up.

Friday, July 27, 2007

Keep those cards & letters coming!

In his book In Search of Excellence, Tom Peters describes project champions with phrases like "fired-up," "fanatic," and "zealot." I can relate to that. (He also uses "irrational" and "obnoxious." Ditto.) But even though I am still fired-up about Advanced Access, it's tough to keep up the enthusiasm when the project seems stuck in the summer doldrums. That's why it's such a great boost to read all the encouraging comments that you've sent.

But don't just send your comments to pep me up. Perhaps you'll read some feedback from someone in your own community. Get in touch with them! Build your own quality improvement network. You don't need to bite off a big project like this one; try something small. And then let us all know about it.

I’m most grateful, however, for the people who've given us license to make mistakes. Cathy Fooks wrote: "Not to say you must always deliver it." Sheri M wrote: "...we don't expect ourselves to be perfect!" Imagine how much we would achieve if we built a culture where well-intentioned failure is valued more than ineffective inertia. Thanks again.

Friday, July 13, 2007


“Change the way you look at things and the things you look at change.” Wayne Dyer

I'm veering off the access topic this week because my last two posts have me thinking more about the broader idea of patient-centred care/patient experience…

You guys like improv comedy? You know, where performers make up impromptu scenes, often based on suggestions from the audience. Here's an idea on using an improv game to help focus on patient-centred care.

In the "Switch" game, two performers are creating a scene when the moderator calls "Switch." The last speaker then repeats his line, with a word changed, or gives a completely new line. This changes the context of the scene and may take it in a completely different direction. Hopefully a funny direction. (Go to YouTube and search "Improv game switch" to check out some samples.)

Improv performers want to make their audience laugh; we want our patients to have a Great! experience. Here's how I've been playing with this game at work:

Friday, July 6, 2007

Crossed Lines

An elderly lady was in to see me two weeks ago.  She was given a backlog appointment, so I had seen her within 10 days of receiving the referral.

"How did you like our appointment system?"  I admit that I was (partly) fishing for a compliment.

"I didn't like it very much at all!"  Uh-oh. Snagged line.  "Your secretary phoned me with the appointment.  Why couldn't you just send a letter?"

Friday, June 29, 2007

Gimme 5!

Our project goal: Reduce appointment wait times. Why? Well, because that would be good, right? Good for our office efficiency, the flexibility of our appointment system, and our financial bottom line. But ultimately, we want to improve the service we provide to our patients. Who gets to decide if we've succeeded? We could use our 3rd next available appointment time to show what a great job we're doing. But what waiting time will our patients be happy with? Two weeks? One week? Same-day service? I guess we'll have to ask them.

Patient surveys are completely new for us, as I suspect is the case for most physicians. After all, we're not really a business. Not like a car dealership. Wow, those guys are nuts for customer surveys. Every time I take my car in for servicing, they give me a card with an online link to complete a survey. If I don't do the survey, I get a reminder phone call. It's not good enough for them to know I'm getting my oil changed regularly, they want to know how I feel about it! Geez, you'd think they wanted satisfied customers or something.

When we started the Advanced Access project, we began giving out satisfaction surveys to patients checking in for their appointments. They're "experience" surveys because they don't just ask one all-inclusive question like "Were you satisfied?" Our survey breaks down various aspects of the patient's visit with us:

Friday, June 22, 2007

My Bad / My Learn

"You live, you learrrrrrrrnnnnnn." Alanis Morissette

I love this Quality Improvement stuff! No "mistakes", just "learning opportunities"! And I had a big one 2 weeks ago. Yup, learned something up real good.  

While Karen was out of town, I thought I'd try some number crunching on my own. Turns out that stuffing the wrong data into Excel and hitting the Chart button doesn't make you Nobel material. Who knew? Also, you're apparently supposed to "analyze" the data with "statistical techniques" rather than just eyeballing it and then going ballistic. In your blog. That anyone in the world can read.

In "Throw me a bone," I groused about our time to 3rd next available appointment starting to rise again, according to this graph:

Friday, June 15, 2007

Talking Dirty

“I don't wake up for less than $10,000 a day.”  Linda Evangelista

Warning: The following may not be suitable for people who think their doctor goes to work out of the goodness of his heart.

It’s time to address the 800 lb gorilla in the room: Money.

Universal government health insurance has, for some, divorced the delivery of medical care from payment for that care. For virtually all services I provide, patients are never aware that I get paid by submitting a bill under their name to the Saskatchewan government. It's a very sanitized process. I'm so used to it that I’m sometimes uncomfortable discussing payment for uninsured services with patients.   

Some physicians receive a salary, but many are fee-for-service, i.e., we get paid a fixed amount for each office visit or surgical procedure. We need to discuss this aspect of medical practice openly as it will be on physicians' minds as they consider adopting Advanced Access. Will their practice revenue rise or drop? Will there be any other non-monetary effects?

If we just consider Advanced Access as a way to balance demand and capacity, then it should be revenue-neutral. (Working down the backlog will increase fee-for-service revenue temporarily as more services are being provided.)  But AA has some benefits that aren’t immediately obvious.

Friday, June 8, 2007

Throw Me a Bone

“Are we there yet?” - Every kid since the dawn of time

Look at this crazy graph!

It looked like our 3rd next available appointment (3NAA) time was dropping, then, BOOM! it's back up again! What's going on? We're working hard on the backlog:

So why don't we see the 3rd NAA time dropping?

Friday, June 1, 2007

Preaching to the Choir

Sing. Sing a song. Sing out loud. Sing out strong. - The Muppets

This is a graph of reckless exhibitionism:

It is the weekly tally of hits this blog gets. It makes me break out in a cold sweat. People are finding out about this project. If we fail, we fail very publicly. "Specialists' waiting lists down to 2 weeks? Hah! I knew they couldn't do it..."

When we started, my first instinct was to keep things quiet. Let's be sure this is going to work before we spread the word. Then I mouthed off at a committee meeting. And got invited to present our project to another committee. And another. Then HQC asked me to write this blog. WWW = cat out of the bag.

Now that the word's out, I want to take advantage of it. I don't want to get carried away, but I have big expectations for this project. Way beyond improved access for the patients of one urology practice in one city. We're just the guinea pigs. If we can do it, why can't all specialists do it? And family physicians? All over the province! (Even WW! Read, wide world) Spread the word!

Who do we need to tell? Everyone reading this blog? Well, it's a start, but I suspect I'm preaching to the choir. (I wanted to say "QI-er" but a pun that bad is a sign of the Apocalypse.) Many people who follow this blog are already part of the Quality Improvement community. So, who else needs to know about this? How can we leverage publicity into action? Psst. Lean in close to the screen and I'll tell you: Grassroots. Forget top down. Let's go bottom up. Get the word out to the public, the people who are waiting for doctors’ appointments. Let everyone know that access can improve, and that it's already being done.

Friday, May 25, 2007

The "I" in Team

How many surgeons does it take to change a lightbulb? One – to hold up the bulb and let the world revolve around him.

Think I've been doing this on my own? No way; I'm just the glory hound. Let's meet the team:

Office staff

Amanda, Delores, and Donna have expanded my definition of muda. (Ladies, this is not personal - read on!) A few weeks ago, I wrote about muda as waste in our appointment booking system (rebooking appointments, no-shows, etc.). Now I think there's an even more important source of waste: untapped potential.

Our Advanced Access project has been new ground for most of the team. We're learning as we go. No one is the expert. That fosters a different interaction between physician and office staff. Usually, I'm "the boss" and ideas flow only one way because... the boss is always right. (It's hard to be right all the time, especially when you're wrong.) As there's no boss at our team meetings, I see a new level of interaction and sharing of ideas. Our staff representatives have some great improvement ideas that wouldn't occur to me. Imagine if we could uncork that creative energy in all our staff.

Friday, May 18, 2007

Gaining Momentum

How do you eat an elephant? One bite at a time.

We're starting to see some changes! But, first...

Epilogue to last week

Thanks to everyone who sent best wishes for my father. He's back home, doing well. I received a note from someone wondering how much of my father's "exceptional service" could be attributed to the fact that we are a "medical family" (Dad's a retired surgeon).  This person (a notorious and flagrant straight-shooter) suggested that medical types might get preferential treatment from other medical types.

No argument from me. I've been guilty of this myself. However, at Calgary Foothills ICU, I saw ample evidence that the terrific, patient-centred care provided to my father was given to all patients. Maybe this idea – that health care workers sometimes get "perks" from the system – should be part of the definition of exceptional service. That is, treat all our patients as we expect to be treated. Golden Rule, anyone?

Back to our story

Feel the burn! Over the last 4 weeks of working down our backlog, we've seen 207 extra patients.  For the urologists, this meant seeing patients during snippets of time usually reserved for phone calls and paperwork. For the staff, it meant 207 extra appointments to book, 207 additional charts to create, 207 more letters to type... Great work, everyone! 

I've been introduced to the concept of good backlog. I thought all backlog, or waiting, was bad but there are circumstances where that isn't necessarily so. If someone chooses to have their appointment scheduled in 6 weeks rather than 2 weeks, perhaps to accommodate holiday plans or harvest time, their wait is considered good backlog.

Friday, May 11, 2007


"Every little thing she does is magic..." The Police

Dear Reader: Forgive me for wandering off topic in this post.

Saskatoon Health Region's vision is "Healthiest people, healthiest communities, exceptional service." Exceptional service. What does that mean in health care? As a member of the region's patient- and family-centred care steering group, answering that question was my homework last week.

I decided on the literal interpretation of exceptional, that is, "beyond what is expected." A friend of mine who’s a businessman describes exceptional customer service (somewhat cynically) as: "Underpromise, overdeliver."

It shouldn't be hard to "overdeliver" in health care. Let's face it: we've set the bar pretty low. Expectations are so dismal that they're clich├ęs:
  • Check your dignity at the hospital door.
  • It'll be cold.
  • It's going to hurt.
  • Wait to see the busy specialist.
  • You're the doctor.

Friday, May 4, 2007


“No battle plan survives contact with the enemy” Helmuth von Moltke

Project team assembled. Goals set. Baseline data gathered. So far, this Advanced Access stuff has been a breeze. Fun, even. It seems a shame to ruin it by actually getting down to work, but it's time. Charge!

Where to start? Our plan took shape after we read a great AA success story from Fargo, North Dakota. By a urologist! Dr. Duffy started AA by working down his backlog of waiting patients. He doesn't sugar-coat it - this is hard work.

Our team calculated the backlog and how many extra patients we would need to see every week in order to eliminate the backlog over 6 months. I emailed the figures out to the urologists. This was one reply:

“As you know I am personally scared about this program. I thought I was seeing enough patients per month and 30 more seems a lot. I wish I could be more optimistic about things being a whole lot better after the backlog is eliminated. Seeing more patients potentially generates even more review visits although I understand we are to be hardnosed about getting them back into the care of primary care physicians. I am not sure what constitutes good backlog and what constitutes bad backlog.

I see more work (dictating letters, reviewing investigations, and catching up to consults) having to be done after hours of our already long days or on holidays. However I also do not have any other constructive solution so I will try to be cooperative but I am concerned if I have the energy to cope with more work and stress.”

Uh oh.

Friday, April 27, 2007

We Need a New Hole

"You cannot dig a hole in a different place by digging the same hole deeper" - Edward de Bono

For the 15 years I've been in this group (currently eight urologists), the wait to see one of us has been three to four months. We squeeze in urgent cases - cancer, kidney stones - but for most urology referrals, you'll wait quite a while. Over the last four years, our group averaged about 13,000 patient visits annually. Hospital rounds start at 7 am. Every day is jam-packed with surgery, outpatient clinics, office visits, emergencies, phone calls and paperwork. Leaving the office by 5 pm is cause for celebration. We'd love to get our wait time down, but how can we possibly see more patients? We're digging this hole as fast as we can.

It's a testament to our desperation that we were willing to try something as crazy as Advanced Access (AA). I mean, who's heard of seeing a specialist within seven days of referral? I'd wonder if there was something wrong with him if his waiting list were that short! Some of the urologists were skeptical (more about that in future posts), but everyone was willing to at least try something different.

Friday, April 20, 2007


December, 2006. Orlando, Florida.  What excitement!  This place is incredible!  Disney World?  No, I'm attending the annual conference of the Institute for Healthcare Improvement (IHI). Over 5,000 people are at this international clearinghouse of ideas and techniques for - you guessed it! - Improving Healthcare. Everyone seems so thrilled to be here, it gives the conference centre a theme park atmosphere.

I've been to some great sessions, but have pretty limited expectations for the next one: "Improving Access to Primary Care". My urology group has a long wait for consultations - about 3 or 4 months. We'd like to see patients sooner, but we're all working full out as it is. The brochure says the presenter, Mark Murray, has successfully improved access to primary care in many American centres. That's great, but specialty practice is very different. Well, maybe I can pick up a few tidbits.

"Are there any specialists in the room?"

What?!  Is he going to kick us out? Family physicians only? A few hands go up - mine too.

He points at me.