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.


Another example of good backlog is the wait associated with coordinating multiple visits or investigations. Patients often travel 3 or 4 hours to visit us, so if they need a CT scan or cystoscopy we try to coordinate the office visit on the same day as the other test. Even if our practice's wait time is only 2 weeks, the wait time for a CT scan may be longer. Patients may prefer to delay their office visit to coincide with the CT scan in order to save a trip to Saskatoon.

I think we're mangling the definition of "good" here. Sure, postponing the office appointment saves the patient a trip, but it's really the X-ray department's bad backlog that makes it necessary. (Note to self: If the X-ray department measured how many CT scans our office requests [demand] in a week, it could give us "blocks" of CT time [capacity].  We could then schedule those CT times to fit our own scheduling.)  (Note to self:  How about finishing one project at a time?)  Any backlog that the patient himself doesn't choose is bad backlog.

Measuring the external demand for appointments (a.k.a referrals) has shown some interesting results. The daily number of "named" (i.e., directed specifically to one urologist) referrals we receive varies from an average of 2 to an average of 6 among our group. However, if one urologist has a very long wait time, our staff will contact the family physician's (FP) office to ask if we can reassign the consultation to another urologist with a shorter wait. The response is almost always "I don't care which urologist she sees - just get her in as soon as possible."

Some referrals are directed to "Urology group" and are given the earliest appointment available with any urologist. The more "pooled" referrals we get, the easier it is to schedule early appointments. We set up a mini-project with the goal of maximizing the number of pooled referrals we receive. A letter was sent to all family doctors in our referral area. Its main points:

• We're trying to improve access for your patients; you can help.
• If you send referrals to "Urology Group", we'll give your patient the earliest appointment we have.
• You can still specify the urologist you want your patient to see if they have seen one of us before (continuity of care is important!), or you or your patient have a preference about who he sees.
• We will review referrals to determine if they would be best directed to a urologist with a sub-specialty interest

A couple of interesting things happened after this letter went out. First, we saw a spike in pooled referrals (chart below). Someone actually read our letter! Behavior changed!

The second result of the letter was unexpected. One of my partners attended the recent Saskatchewan Medical Association meeting and reported this:  At an open forum session, a FP stepped up to the microphone, brandishing a copy of our letter and asked, "Why can't all specialist groups do this?"  Not only did he want improved access for his patients, he also wanted his patients seen by the appropriate specialist. His point was that it's very difficult for referring physicians to keep track of those sub-specialty interests. He wanted a central registry of that information so he can make appropriate referrals.

In our group (the only urology practice in Saskatoon), we look after directing patients with certain conditions to the urologist(s) most able to manage that problem. It didn't occur to me that FPs would have trouble determining which general surgeon specializes in hemorrhoids or which neurologist concentrates on headaches.

Maybe specialists should be asking FPs about other areas where we can improve service. We're going to start by sending a brief survey asking how satisfied FPs are with the wait time for urology appointments. In a future survey, I’d like to find out how useful my consultation reports are. Do FPs want more information? Less? Formatted differently? More timely? 

Hey, if we’re not careful, this might lead to communication and possibly even teamwork.