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.

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.


  1. Originally posted by Sheri McMann (Five Hills Health Region) 5/19/2007 8:05 AM

    WOW! I am so impressed with Kishore's blog entries from his journey in "improving access" for patients. And I would be remiss if I didn't acknowledge the hard work of his "team" at their Urology Practice as well. Way to go you guyz!!! Yes, it is very hard to introduce behavioral/communication change into any big system - but especially health care delivery.

    Build it and they will come...

    Please keep up the good work. You are raising the collective consciousness of those in the health care system that can lead change. And in this case, change is good. It is the right thing to do at the right time.

    Please let me share one of my bazillion favourite quotes with you:

    "We should not let our fears hold us back from pursuing our hopes." John Fitzgerald Kennedy

  2. Originally posted by Maura Davies (Saskatoon Health Region) 5/21/2007 3:11 PM

    Keep up the great work! I am very impressed.

  3. Originally posted by Tim Archer (Saskatoon Health Region) 5/22/2007 1:33 PM

    Kishore, thanks so much, not only for taking the risk of trying Advanced Access (AA) but for publicly sharing your trials and tribulations along the way. You have accurately illustrated that while this is hard work for you, your colleagues and your staff, the benefits to patients are already showing themselves and that is encouraging and morale-boosting for you and your 'team'!

    And yes, it can be done here in Saskatchewan and within any specialty if we set our minds to the task. Well done.

  4. Originally posted by Sandy Murray (Director for IHI's Improvement Advisor Professional Development Program) 5/22/2007 2:51 PM

    Hi Kishore: I work with Karen in the IHI Improvement Advisor Program. I want to thank you for sharing your work and your thoughts. I was so touched by your experiences with your father's care! I also really enjoyed reading about your recent test very much, including the unanticipated—and delightful—consequence. Wishing and hoping are lovely, but nothing gets better until we have the courage to test a change to the process. Your team seems to have the courage! My best to you and to each of them. I'm looking forward to hearing more!

  5. Originally posted by Debby Criddle (President & CEO, Nightingale Nursing Group Inc) 5/22/2007 3:09 PM

    Your blog is one of the best things I've seen for encouraging people to take another look at how to improve the delivery of health care in Saskatchewan. It's really one person at a time, encouraging others to participate and so on and so on. The results you are seeing in your practice could be achieved in so many more offices and wings and floors of our system. Sometimes we just have to know that it can be done before we have the courage to try it ourselves.

    The graph you showed us in your last blog was amazing! That one picture tells a reader exactly why you are making this effort and shows the way for the rest of us.

    Thank you for showing us the way!

  6. Originally posted by Dennis Kendel (College of Physicians & Surgeons of Saskatchewan) 5/23/2007 9:53 AM

    Thank you for taking the time to maintain this blog. So often we hear messages about health care professionals being demoralized and very critical about "the system" in which they work. It is so refreshing and encouraging to hear about your effort and that of your colleages & staff to improve the patient experience in our system. I also appreciated your sharing your perceptions of the excellent care your dad received in Calgary. I'm glad to hear he's home and doing well. Please pass along to him my best regards.

  7. Originally posted by Doug Calder (Saskatchewan Health, Director Specialized Services) 5/24/2007 1:01 PM

    This is great stuff. Keep up the good work. We need to be sharing this approach with others. I know Mark O’Grady in Regina is also doing patient surveys and making changes to his office practice on surgery points mentioned to him by his patients. I think it is great that you have the "pooled office practice approach," as it is certainly more patient focused than waiting for a specific specialist. I like and support the ideas of dialoguing more with family physicians and their needs. Keep up the good work. We need to figure out how we can communicate this and other efforts to a larger audience?? Cheers for now.