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.

Project facilitator

Karen is like an Advanced Access Play-Doh machine: Squish in raw data, unformed plans, and 9 people's disparate schedules. Out come nifty charts, a project charter, and weekly team meetings (with manageable agendas!). But without that weird Play-Doh smell.

Family Physician

Carla led the implementation of Advanced Access at the Saskatoon Community Clinic (see their Summer 2006 and Fall 2004 newsletters). Now, she's helping to spread AA through the Health Quality Council Chronic Disease Management Collaborative. She loves this stuff. On our team, Carla does double duty as family physician representative and battle-tested technical advisor. Triple duty, if you include cheerleader.

Patient Representative

I balked at first. The idea of having a patient representative (Stephen prefers "patient" over "client" or "customer") on the team made me uneasy. It's just seems so foreign to involve a patient in decisions about medical care. I realize that looks ridiculous when you put it in writing, but you know what I mean, right? I'm not talking about decisions regarding personal treatment. I'm all for that. I mean that it's unusual to have patients involved in decisions about the medical system that profoundly affects their individual care. Uh...still not looking good in writing. Karen gently insisted that involving a patient representative was important for the team. In the absence of a rational objection, I relented.

Once I'd crossed that mental hurdle, Stephen sprang immediately to mind. He'd been in for a check-up a few weeks before we started the project. He had to cancel his original appointment and was told it would be several months before the next opening. After some negotiation, he was able to reschedule his visit with me. At that visit, he suggested (very graciously) that there must be a better way to do things. That sounded like a volunteer to me.

Stephen was the "outsider" on a 9-person team. Would he be comfortable? Would he feel able to make a contribution? Would the project engage him? Yes, yes, and yes. But Stephen's role goes beyond his overt contribution. I recently surveyed my partners to see how they wanted to handle patient recalls under Advanced Access. Should we continue to keep track of regular review appointments or should we have patients take responsibility for remembering? I presented the results at our team meeting: "It looks like the urologists are in favour of..." I looked up at Stephen. "... Um, I guess we should survey some patients to see how they feel..." Just having an end-user (aren't we all end-users?) in the room reminds us that our focus is patient satisfaction, not making changes that suit the workers.


Although Peter B, Peter L, and I were the original sponsors of this project, it's developed a life of its own. Now, our job is to make sure no one decides to improve patient satisfaction by having us make house calls.

This project is shaking up my concept of teamwork. Strange, because surgeons, more than any other physicians, regularly work in a team. Performing major surgery requires at least 5 people: Surgeon, assistant, anaesthetist, scrub nurse, and circulating nurse. But the dynamics of an operating room team are very different than this project team. In the OR, the surgeon is in charge. Numero uno. (Occasionally, you run into an uppity anaesthetist, but not often.) Sometimes, during surgery, authoritative leadership (read: dictatorship) is critical. But when is a collaborative model more useful? Recent experience with our AA team members makes me wonder how much potential we're wasting in the OR (or hospital wards). How can we tap that team's potential? Level that hierarchy? Increase job satisfaction? Improve patient safety and care? They don't teach you that in surgery school.


  1. Originally posted by Leigh-Ann Kreager, Chilliwack, BC (maiden name: Cassels) 5/25/2007 10:25 AM

    My brother, Alan, is a Drug Policy Researcher out of the University of Victoria. He sent me your info and what your office is doing to reduce patient wait times. Wonderful work.

    On a personal note, your Dad was our family doctor in Estevan, Saskatchewan, where we were raised. Nice to see you have followed in his footsteps. Keep up the good work.

  2. Originally posted by Keith Ogle (Academic Family Medicine) 5/25/2007 10:28 AM

    ".....surgeons, more than any other physicians, regularly work in a team."

    Kishore! Puleeeeze! Family Physicians? Primary Care teams? At West Winds, we work with a nurse practitioner, a social-worker/counselor, a clinical health psychologist, a clinical pharmacist, several nurses, public health, diabetes nurse educators, etc., etc.

    No argument with your point, though.

  3. Originally posted by Jill Christensen (Yellowknife Health and Social Services Authority) 5/30/2007 9:03 AM

    Here we are in the far north providing services to a very diverse population who are spread out over a huge geographic area. Travel to Yellowknife and then perhaps on to Edmonton is a reality for many of our patients. Tele-health is being used in some areas with success. My question - the patient who participated on your group - did this prove to you and him to be a valuable experience? Do you have links, resources etc that you can suggest to us regarding Advanced Access? I know that wait times can be beaten!

  4. Originally posted by Bonnie Brossart (Health Quality Council) 5/30/2007 9:43 AM

    I just wanted to say a BIG thank you for attending the Chronic Disease Management Collaborative’s Learning Workshop last Friday and sharing your still-unfolding “Adventures in Improved Access” story with participating practices and improvement teams.

    Although we are already seeing some really impressive results across many of the practices for various key measures for diabetes and coronary artery disease, progress on the access front has been less encouraging. We’ve heard directly from practices that “we don’t need to measure access - it’s not a problem in our practice” or more commonly “we’re busy enough as it is, we don’t have time to measure access.” I hope that hearing about your commitment to leave the status quo (that is, the harried, perpetual hamster wheel existence of a busy practice), and about your desire to improve both access to your practice and the quality of your and your colleagues’ work lives, will inspire Collaborative participants to kickstart efforts to improve access in their own work environments.

    Thanks again for the urologist’s perspective on flow – office flow, that is. As you’ve already heard from many of your blog readers, it’s fantastic to have Saskatchewan stories to learn from – stories like yours, Carla Eisenhauer’s and the Saskatoon Community Clinic, and Mark Ogrady’s. It is one thing to hear someone from another country or another province talk about what’s possible, but quite another when that person is someone you know who has achieved success, from right around the corner.

    You MUST come to our last Learning Workshop in October and provide an update on what Improved Access looks like at your practice at that time. I’m hoping that you’ll be sharing the stage with family physician from the Collaborative who are sharing their own success stories about improving access.

    Keep up the great work!