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.

It's not this response that worries me. My partner has a valid point: eliminating our backlog will be hard work and we are crossing into unfamiliar territory. But at least he's voiced his concern and is willing to give the plan a try. I'm more concerned about silent skeptics. Maybe others have misgivings about the project, but aren't admitting it. What if they decide not to start working down the backlog? I can't force a partner to make the extra effort.

The family physician on our improvement team had some good advice. "It's easy," she said, "you surgeons are super-competitive, so just start posting everyone's wait times and how many extra patients they're seeing. If anyone's not pulling their weight, peer pressure will do the rest!"

Are surgeons really that transparent?

I’m learning plenty of jargon to go with Advanced Access. My favorite word so far is muda, a Japanese term for anything that is wasteful and adds no value. Eliminating muda is a key concept in industrial quality improvement. From the patient's point of view, waiting for an appointment is (usually, but not always) a waste. But, until I started to think about our appointment booking process, I didn't realize how much waste we were experiencing on our end of the process.

When a referral request comes in, my staff reviews the information provided by the family doctor, and assigns a tentative appointment. Some consultations (suspected cancers) are given urgent attention, while others (vasectomy requests) are less urgent. (Effort to triage problems = muda)  I then review each referral letter, decide whether the appointment date is appropriate (more muda) and return the chart to my secretary who contacts the patient. If I judge that a situation requires an earlier appointment, she’ll look for another appointment time (again with the muda). This process would be unnecessary if everyone could be seen within the time we currently see “urgent” cases.

But the waste keeps coming. It's common for patients to call back and ask for an earlier appointment. My secretary searches the appointment schedule for a cancellation (muda). If she can't offer one, she’ll spend time on the phone giving what she can – sympathy and understanding (well-intentioned muda). It’s stressful and unsatisfying for my secretary to say “no” all the time.

And there's more. “No-shows” waste 10-15% of our available appointments (muda, muda, muda). While there are various reasons for missing a scheduled visit, “I forgot” ranks pretty high. An appointment made 3 months ago is easy to forget. If we drastically reduce that wait time, it should cut down on no-shows. While trying to remedy our current booking system, our practice management consultant suggested we phone and remind all our patients a few days prior to their appointment. We could do that, but would need more office staff just to make those calls. Actually, if AA works out, I guess we will be calling our patients a few days prior to their appointment - but just once, rather than an initial call and then a reminder. (Take that, muda!)

Here's the tally. Less referral triage by urologists = go home earlier. Less stress for staff = happier office. Fewer no-shows = office time used more productively = better financial bottom line.  That should motivate even the most hardened skeptic.
Real-time Spoiler Alert!
This week, my secretary told me the new system has already made her job easier. Every Monday, I'm looking 2 weeks ahead to identify any times when I can see more patients. This has opened up anywhere from 4 to 12 appointments per week. Previously, my secretary would need to search through my schedule 2 or 3 months in the future to find openings for new referrals. Now, she can find and fill those openings much more quickly as she only needs to look a few weeks ahead. Of course, once AA is up and running, I won't be doing extra appointments, but there will be easy-to-find appointments available within 7-14 days. Out, damned muda!

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