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.

AA applies supply and demand principles from industry to improve access to health care. First, we needed to understand the demand for our services. We counted how many referrals we received from family doctors (technical jargon: external demand): 710 in the first 5 weeks. It's interesting to look at the weekly breakdown of that number. AA theory suggests that demand is predictable over time, given a stable population. Our weekly external demand looks pretty steady, allowing for some variation from week to week (see chart). Followup office visits requested by the urologist (internal demand) totalled 117. Other demand included patient requests for visits, family doctor urgent requests ("Fam Dr S-in" = squeeze in), urologist urgent appointment ("Spec S-in") and off-hours call back (urologist sees patient outside of regular office hours).  Total demand for the first 5 weeks was 889 office visits.

Next step, measure our capacity (supply). Could we handle about 180 visits a week? Think of our office as a bathtub. Water running in from the tap is demand. Water draining out is capacity. Water standing in the tub represents patients waiting for appointments. If the water drains out as fast or faster than it comes out of the tap, the bathtub won't fill and patients don't wait. If inflow exceeds outflow, our plan turns into a big soggy mess. Actually, if that's our situation, don't think bathtub, think toilet.

The good (and surprising!) news: our weekly office capacity is 275 visits. Even allowing for appointments cancelled to fit in urgent surgery, holidays, and meetings, it looked like there should be plenty of capacity in our current system. So why the waiting list?

Most AA projects find that their clinic’s capacity exceeds demand. The waiting list grows because of a mismatch between capacity and demand. If capacity isn't available when the demand is there (several doctors are on holiday, for example), the demand accumulates in a waiting list (technical jargon: backlog; homey metaphor: water sitting in the bathtub). The million dollar question is how you match the capacity and demand - more on that as our project develops.

If you're a patient waiting for an appointment, the demand and capacity don't mean much to you. You're interested in the actual wait for your appointment. We measure that time using the "3rd next available appointment" (NAA). Once weekly, we look at each physician's appointment book and count the number of days (including weekend days) until the 3rd next opening. For the initial measurement period, the office average 3rd NAA was about 60 days, ranging from 40 to 120 days among the physicians.  Third NAA will be the key measure to let us know how we're succeeding.

So far, the signs look promising. Capacity exceeds demand. The docs are motivated.

What could possibly go wrong?

Real-time Spoiler Alert!

Last post, I told you how satisfying it was to hear patients' pleasant surprise at having such a short wait to see me. This week, one of my partners was pleased to relate the same experience with several of his patients.

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