Cup Holder Conundrum

Over the last few days, many of you watched, as I did, the Pan-Canadian Broadcast of IHI's National Forum. The keynote speeches weren't very cheery.

Don Berwick looked downright ticked off. Change isn't progressing fast enough for his liking. I suspect that most people involved in quality improvement share his frustration. Dr. Berwick imagined 2 letters that he would write, for his daughter to open 20 years from now. One letter presumes that the quality agenda will flourish over the next 2 decades. The second letter is an apology: Sorry we let the nay-sayers beat us down. Sorry we couldn't budge the inertia of groups with a vested interest in the status quo. Sorry that you're paying the price 20 years from now.

John Kitzhaber – ER physician and former Oregon governor – made a passionate appeal for reforming the US healthcare system before it becomes financially unsustainable. His perspective is purely American, but in the current economic situation, Canadians should take notice as well.

Gloomy!

It made me think of automobile cup-holders.

North American automakers have been pilloried as they plead (and make not-so-veiled threats) for a financial bailout. GM has made an astonishing mea culpa: We acknowledge we have disappointed you. Whether or not you think they are sincere (GM gets savaged in some of the comments below the article), some of their admissions could just as easily come from the healthcare industry.

Silver Platter

There's a great article – The Ergonomics of Innovation – linked at the IHI website. It's a case study of IHI's 100,000 Lives campaign, and how they succeeded by making innovation easier rather than harder.

Easier is better than harder? Well, duh!

It seems obvious, but complicated solutions are appealing. Don't we feel smart when we cobble together a multi-stage change initiative that comes with a thick instruction manual?

The authors spotlight IHI's ventilator-associated pneumonia bundle that included elevating the head of the patient's bed to 45 degrees. Some hospitals drew a line on the wall behind the patient's bed and encouraged anyone – families, janitors, other patients – to notify medical staff if the head of the bed was below the line. Simply brilliant – brilliantly simple!

Ergonomics of Innovation made me think of some recent changes we made at the office.  They seem ridiculously simple and obvious (so much so that I debated even mentioning them in the blog) but have been very effective. I've described them in a previous post.

Making Lemonade

I've had a sour taste in my mouth for the last couple of weeks.

Whenever I have the opportunity to share our Advanced Access results, I love to show this chart as the presentation's punchline:

It's our 3rd NAA (next available appointment) from the start of our work in March 2007 (61 days), and from February 2008 (39 days). Nice!

But recently, I've had to follow that slide with this slide:

Our 3rd NAA in September 2008 was up to 60 days. And it looks like I'll need to start showing this chart (with data up to mid-October) in the near future:

Business as Usual

All models are wrong, but some are useful. – George Box

Earlier this year, I was running late in my cystoscopy clinic. As I greeted my next patient, I apologized for keeping him waiting.

“That’s OK, I understand.” he said. “I’m in the service industry too.”

What?!

I felt vaguely insulted.

I’m not in the service industry; I’m a doctor!

But, what would happen if I pretended to be in the service industry? I mean, could I use the service industry model to improve my quality of care? Obviously, there are significant differences between business and medicine. The doctor-patient relationship is special, and doesn’t happen in the service industry. But, models are just tools to achieve an end, and we don’t need to buy into them all the way.

For example, my 2 little boys groan when I take them grocery shopping with me. But, if we pretend we’re soldiers attacking Safeway, then they hit the ground running. The “assault team” model/game works from several aspects: following the commander’s (Dad’s) orders, carrying out risky missions (Rescue a can of tomato soup from aisle 3!) and getting the team in and out on the double. (Also, commandos don’t ask for a packet of Smarties while waiting in the checkout line.)

Here’s how a service industry model could be useful:

Suggestion Box

Last week's staff meeting reminded me of one of the world's most famous companies. Or at least, a book I'm reading about that company.

It was a great meeting. We welcomed some new staff and oriented them to our Advanced Access project. Over lunch, we discussed staff suggestions for Clinical Practice Redesign.

A few weeks ago, we set up a suggestion box in the staff area. It sounds like a corny idea, but we wanted to see if it would encourage people to share thoughts on how we can improve our office processes. It really paid off. While none of the ideas are earth shattering, I think they'll have an immediate effect for office workflow, and they illustrate principles of quality improvement.

Which brings me to "How Toyota Became #1 – Leadership Lessons from the World's Greatest Car Company" by David Magee. He tells the story of the development and practice of the Toyota Production System, Toyota's approach to management and quality improvement. Several of our staff's ideas reminded of the principles Magee writes about. Here are some of the ideas we'll be implementing.

Just Tell Me What You Want

This week's Canadian Medical Association Journal was a goldmine.

MD Lounge's topic is "Referrals". Improving our referral system is part of our office's Clinical Practice Redesign effort, but it looks like we're reinventing the wheel! The College of Family Physicians of Canada and The Royal College of Physicians and Surgeons of Canada looked at the referral/consultation process in a 1993 task force report.

In a 2006 review, they suggested 3 features to enhance the process:

• A defined single access point within local referral/consultation systems.

We're the single access point for urology in Saskatoon, and my family physician colleagues say that's very handy for them. Imagine a single website listing all Saskatchewan specialists with their particular area of clinical interest. This would be very valuable in Saskatchewan, where there are regularly new physicians, who aren't familiar with local specialist resources.

A single access point could be leveraged by also providing wait time information (for surgery, in the following examples) for individual specialists (like Alberta), or by region or hospital (like Ontario). Of course, you would make this information public so that patients are better able to choose the specialist they wish to see. This requires a significant investment in infrastructure to measure the wait times and update the website regularly. It doesn't require any change in physician behavior, making it easier to sell to physicians.

Summer Wrap-Up

Last week, at our team meeting, we cleaned up the aftermath of the summer. Doctors' holidays make it challenging to keep up with our backlog. Last summer, we saw our 3rd NAA times creep up. In the early part of this summer, the numbers were looking good, and we thought we'd changed the system enough that the wait wouldn't grow, despite reduced capacity.

No such luck. Our latest 3rd NAA is up to 60 days. Here's hoping that the end of summer holidays signals an improvement here.

There is some brighter news. Last post, I looked at our patient-recall patterns. We've got data from May to August now, and there's still a striking variation among urologists in the rate at which we recall our patients for review. Here are the average recall rates:

Here's the promising part:

Isn't That Special?

In "Bang for your Buck," I reported our urologists' recall rates. The variation among urologists was striking. Some rarely recall anyone, while others recall nearly a quarter of their patients. Here are the rates (thanks, Amanda) for May to July:

Two of the docs have zero monthly recall stats because they were away for those months. But another doc, who was working during this period, also had no recalls. I asked both of the low-recall docs why they are so different from the rest of the group. One didn't know why there was such a discrepancy, but commented that maybe he wasn't recalling often enough!

In the previous post, I made the same observation. I meant it slightly tongue-in-cheek, but there is a kernel of truth in that comment. We want to reduce unnecessary recalls (internal demand), but not at the expense of compromising patient care.

All-Access Pass

Since my last post, I've continued my trial of mydoctor.ca's secure messaging system. I've signed up 27 patients and receive 1-2 messages per day. Several patients have written that they think this is a great way to communicate. My impression is that all the questions I've received would have warranted phone calls or office visits if electronic messaging was not available.

I like the option for asynchronous, or time-shifted, communication. If I have calls to return, I either make the call before I leave the office, or it waits until the next day. With electronic communication, I can leave the office on time to see my son's soccer game, and then deal with emails later in the evening.

I currently have a patient who had to travel very soon after having a biopsy done. I'm planning to use electronic messaging to let him know about his results. Playing phone tag with someone on a different continent would be very frustrating.

It's also easy to cut-and-paste the messages from mydoctor.ca into our electronic chart, so I don't have to make additional notes, like I would for a phone call.

There are some negative aspects to electronic messaging. There's no way to pick up on the sometimes-subtle emotional cues you get over the phone.  I wouldn't want to break bad news this way.

Some of the exchanges I've had could have been dealt with better on the phone. The mydoctor.ca site already has a notice telling patients to call their doctor for emergencies. Also, some complicated discussions about multiple treatment options are more appropriately handled with a live conversation.

There are plenty of people who don't have internet access, or who are just not comfortable with communicating this way. I wouldn't force this option on them.

Tech Talk

In this age of Google and iPhones, a colleague of mine is ostentatiously low-tech. He scrawls his to-do list on a pocket-sized notebook.  And takes a lot of ribbing for it.

I fancy myself at the other end of the tech spectrum.  I'm always watching for the latest device or application that will help me run my practice more effectively.  So whenever I see him squinting at the tiny writing in his notebook, I think:

Good for you!

He's got a system that works.  He reviews and updates his list regularly.  It's with him all day.  It's accessible, versatile and user-friendly.   It's not bloated with esoteric "features". 

I have other colleagues who say, "I have the latest PDA."  Which they leave at home because it's a hassle to carry it around. 

Contrast the $2 practice management tool with the $250 paperweight.  Information technology has huge potential to increase our practices' efficiency and improve the service we provide.  We each need to pick the tool that fits our style and needs.

And then use it!

The most significant technological Clinical Practice Redesign (CPR) change we've made in our practice was implementing an electronic medical record (EMR).  I've sung the praises of EMR before. We started computerizing the office over 20 years ago, but initially just used the system for appointments and billing. The physicians didn't have computers in their offices.  About 3 years ago, we decided to adopt an EMR.  It's been a slow process.

Bang for Your Buck

A new MRI machine was installed in St. Paul's Hospital this month. While this latest-generation scanner will add new diagnostic capabilities, its main task is to add diagnostic capacity. That is, it may have some new tricks, but mainly it's going to be doing much more of the same old tricks. Not that that's a bad thing.

Or is it?

A paper in the latest Canadian Association of Radiologists Journal reviewed CT/MRI scan use in Ontario. The authors looked at the stated indications for the examination, and correlated it with the final report (normal/indeterminate/abnormal). Any conclusions are limited by the retrospective, chart-abstraction design of the study, and the authors are careful to point this out. However, some findings should lead to further study.

"Less than 2% of CT scans of the brain for headache found abnormalities that could explain the headache." That's a lot of normal CT scans (which, aside from utilization issues, are not completely risk-free). The authors point out that a negative CT scan may still be valuable to reassure the patient, but also wonder whether the same reassurance may come from a frank discussion between physician and patient about the (un)likelihood that the CT scan will show any significant abnormality.

Headache was the stated indication for 26.8% of outpatient brain CTs, so reducing this demand for service could have a significant impact on access to scans.

It sometimes seems more expedient to use the "brute force" approach of adding capacity (more MRI/CT scanners) to manage queues, rather than looking at managing demand (are the tests being ordered appropriately?). I've griped about this before in a different context, namely the CMA's "Help Wanted" campaign to expand the physician pool.

Which brings me to our latest attempts to manage demand in our office. We started thinking about the frequency of internal demand (urologists recalling a patient for review) last fall. I posted some initial data in April. When I circulated the early results on how frequently each urologist was asking for patients to be recalled, my partners told me that the data was confusing and it wasn't clear what it indicated. So, we've continued to collect the data, and tried to show it in a more useful format.

Wow! That's a lot of variation. Some docs hardly recall any patients at all. Some recall a lot of patients on an annual basis (yellow bars) and some are recalling patients every 3 months (blue bars).

But, this first chart we generated is somewhat misleading. It's showing the number of patients recalled and doesn't account for the total number of patients seen by each urologist. We need to look at the recall rate (number of recalls/total number of patients). This will also level the playing field between part-time (lower volume) and full-time practitioners.

Healthy Skepticism

Canadian Medicine/National Review of Medicine recently featured an Annals of Internal Medicine paper that reported an attempt to implement Advanced Access in several American primary care practices. The Canadian Medicine post summarizes the study's findings (you can read the abstract here); essentially that it was difficult to maintain improved wait times in the study groups. Also, the study didn't find any improvement in other parameters like no-show rates, and patient and staff satisfaction.

As noted by commentators on both the Canadian Medicine and Annals sites, the lack of change in these measurements is not surprising, as the practices didn't successfully implement Advanced Access, and therefore couldn't be expected to reap its benefits. Advanced Access-expert Mark Murray pointedly diagnoses the problems with this study.

It may be that there was a lack of buy-in among the clinic staff in the practices studied. Even though the investigators who wrote the paper and supported the implementation efforts may have been highly committed, if the "troops on the ground" weren’t engaged, the initiative would fall apart.

This report raises the issue of the tension between evidence-based medicine’s rigid approach to assessment and the Quality Improvement movement’s "just do something" mantra. IHI’s Don Berwick commented on this in a March 2008 JAMA editorial. He advocates embracing methods of statistical proof other than randomized clinical trials (RCT). RCTs are notoriously difficult to conduct, and are resistant to mid-course modification should unexpected findings arise. However, other commentators stand by RCTs’ proven value in eliminating unforeseen biases when new treatments, technologies, and techniques are studied.

Calling All Patients

It had been a month since our last team meeting, so I was happy – and a little relieved – to meet again last week. Now that we’ve distilled our project team down to just members of our office staff and physicians, there’s a temptation to let regular meetings slide.

I had a proposal for our next mini-project: reducing our no-show rate. Our no-show rate usually runs between 10-15%. That’s unused capacity that could help get rid of our backlog, reduce wait times and, as a bonus, increase revenues.

Great idea, right?

Amanda had already thought of it. And, as part of her Clinical Practice Redesign (CPR) School work, had carried out a test of change. And she showed us the results.

Since the week of May 12, a staff member has been confirming appointments by calling all patients a week in advance.

Since implementing that change, our no-show rates have all been below the median (10.88%).

But, that's a lot of phone calls. Maybe we can target people at "high-risk" of not keeping appointments. Perhaps we only need to remind new referrals, or people from out-of-town. We'll take a look at some of the characteristics of our no-shows to see if we can cut down the number of calls needed.

If that doesn't work, and we decide that routine reminder calls are valuable, Amanda has heard (through her CPR classmates) of online automated telephone messaging services we may want to explore.

While the no-show rate is one of our project's benchmarks, a lower no-show rate doesn't necessarily translate to reduced wait times. Our no-show rate is the number of no-shows divided by the total number of patients scheduled. It doesn't include empty appointment slots. So, if we've phoned our patients and identified those who aren't planning to attend their appointment, we'll reduce our no-show rate, but may be left with unfilled slots. If the staff responsible for booking appointments aren't notified about those newly-opened slots, the time remains unused. That's wasted capacity.

Perhaps "wasted" is the wrong word. One of my partners took me to task for describing unfilled appointment slots as wasted time. He pointed out that no-shows give him the chance to return phone calls and catch up on paperwork. I've heard similar comments from other physicians during Advanced Access discussions. That is, they're not really upset about no-shows because there's always plenty of other work to fill in those time slots.

Booster Shot

Sometimes I wonder: Is there anyone else out there?

When I go for a stretch without connecting with anyone who's engaged in quality improvement work, I feel a little isolated.

But I’ve had a great couple of weeks, with plenty of chances to connect with people who are truly excited about the quality improvement opportunities they’re pursuing.

I started out at HQC’s Clinical Practice Redesign (CPR) school. Participants from clinics and health regions are learning to apply QI techniques in their clinical work.

And they ask some tough questions, like “What would you do differently, if you could do Advanced Access over again?”  Ummmm…2 things.

First, I would ask for more time set aside for this project. When I took on the Urology Division head position, I asked for a half-day every month to pursue administrative activities. I usually split that into two 2-hour chunks. At the time, I thought that was a lot to ask, given that our practice is fee-for-service and administrative work doesn’t pay the bills.

Ha! What a rube! I got owned… big time.

Spice of Life

Last week’s post brought some interesting responses. I had suggested that a large hotel’s elevator system was a good model for managing health care queues. A couple of people commented that, in principle, it might be advantageous to have a system that automatically assigns patients to the shortest wait list. However, they wanted to have a choice of which physician they saw.

They point out that personalities and skills vary among physicians, and some people will choose to wait longer so they can see someone they have confidence in.

I agree that it’s important to let patients choose their physician – recognizing that their choice may result in a longer wait. Our recently implemented "default" referral system recognizes this. As of May, all new referrals to our practice are considered "pooled" and go to the urologist with the shortest wait time. If the patient requires subspecialty attention, we set up the appointment with the appropriate urologist. However, the patient or referring physician can request ("No substitute") a specific urologist, with the understanding that there may be a longer wait.

Returning to the elevator analogy, some people may prefer the "services" of a specific elevator. Most of the elevators were glass-walled and faced out over a 40-storey atrium. Anyone with a fear of heights would be very uncomfortable with that ride and would prefer to wait for one of the enclosed elevators.

So, choice is important. But, it's not the only solution to this problem. And perhaps not the most desirable one, either.

Going Up

My wife and I spent last week in New York City. And I couldn't stop thinking about Advanced Access!

Our hotel had 49 floors and 16 elevators. I was intrigued by the elevator triage system. Rather than pressing the button and waiting for an elevator to show up, you punched in your floor number and the display directed you to the next elevator that was going to that floor. The lobby was so busy that the traditional system (pick an elevator, stand in front of the doors and elbow your way in when it shows up) would have been chaotic and inefficient. Some people would have long waits, both in the lobby and in the elevator, as it made a milk run to the 49th floor.

The hotel's automated (dare I say "expert"?) system grouped people according to their destinations, for example, batching all those going to floors 30-39 together, so the lower floors could be bypassed.

Part of my fascination with the elevators was pure yokel, i.e., in Saskatoon, we ain't got no real tall buildings. But I was also interested in the similarities between waiting for an elevator and waiting to see a specialist. In the traditional system, customers line up for an elevator/specialist without any idea of how busy that elevator/specialist is or how long they will wait. Some users, such as hotel staff/health care workers, may have inside information that helps them choose the shortest queue.

Users shouldn't need expert knowledge of the system in order to gain rapid access. There's an inherent inequity in a system that rewards expert/inside knowledge. The system should provide the expertise needed to get the user to their destination efficiently.

Cutting the Cord

When I decided that this would be my final Adventures in Improved Access blog post, I was struck with the parallels between our Advanced Access project and some changes in my personal life.

Last month, my eldest son moved away from home. He’s only a 5-minute drive away, and I see him frequently, but I wasn’t prepared for the mixed feelings I’ve had about his departure. I’m looking forward to a new relationship with an independent young man, yet I’m missing (somewhat) his regular presence around the house. On reflection, I think I’m unsettled by the fact that this change in his life signals a major change in my life.

With three children still at home, my wife and I are at least a decade away from being empty-nesters. Still, having our eldest move out heralds a new phase. Raising children brings new experiences almost daily, and the excitement of watching them grow and discover the world. Parents revel in our children’s success and wince at their failures (necessary though they may be). Our goal, as parents, is to raise happy, successful, and independent people, and then let them find their own way in life.

We’ve been having similar growth and change with our Advanced Access project. Karen has been our project advisor since its inception over a year ago. She has other duties to pursue and has let us know, over the last several weeks, that she’ll be withdrawing from the project’s ongoing management. We’ll collect and analyze all our data in-house, and continue with regular meetings with me, Donna, and Amanda, to keep the effort going.

Stephen, our patient representative, has indicated that he would also step down from the working group. His membership in the working group has changed our culture to the point that we ask the question (if he is ever absent from a meeting), “What would Stephen say about this new initiative/change?”

Likewise, Carla, our family physician colleague, will step back from regular involvement. All three of them have contributed enormously to the success of Advanced Access so far, and have graciously offered to consult if we need their advice.

We've also reached a significant milestone with the achievement of a new, stable system of reduced wait times.

Culture Change

As usual, the big news comes last. No reading ahead!

Last month, I mentioned that we were going to send another letter to referring physicians regarding sending us "pooled referrals". We've found this practice has been very helpful in distributing demand and reducing wait times. Our first letter increased the pooled referral rate from 11% to 34%. We'd like to boost that rate further.

I presented our latest Advanced Access results to my partners and reported our plans to send out the second request. One of the docs trumped that.

"Why not make pooled referrals the default condition?" he asked.

Any new referral, regardless of which urologist it's addressed to, could be considered a pooled referral. Patients and their family doctors can still choose to see a specific urologist by indicating "No Substitutes" (or words to that effect) on the referral letter. As before, we will look after directing patients with specific problems to whichever urologist has a specialty interest in that area. Also, continuity of care is important, so we'll try to have continuing care provided by the same urologist. If patients do choose to see a particular urologist, we'll indicate that they may have to wait longer than if they choose the earliest available appointment.

Reformation

I've had this clipping on the fridge for over a month...

Followup MD visits need more thought
Marilyn Pachal, Special to the StarPhoenix
Published Friday, February 15, 2008
Following is the viewpoint of the writer, a senior from Yorkton

My husband had a recent appointment with a medical specialist in Regina. Although we were grateful to see the specialist for advice on my husband's condition, the trip involved winter driving that we dread because a storm can come up anytime on the prairies.

We were also concerned that a prolonged wait in the doctor's office – a common occurrence – would mean returning home in the dark. Both of us are older than 75 and aren't safe on the road when our vision is compromised.

However, the 3 p.m. appointment not only was on time, but lasted all of one minute. My husband was told to go to the lab for urinalysis and blood work – both of which I believe could have been done in Yorkton – with the results returned to the doctor. We were also told to return in a month.

I've come to learn this is a common experience for many rural residents, who must travel long distances to see a specialist. I had a similar experience following a medical treatment. On the return visit I was told that I am fine and require no further treatment. It's good news that I would have preferred to learn by phone or mail.

Taxpayers pay for all these visits out of a stretched health-care budget. Patients personally pay for transportation, food, wear and tear on our vehicles and our emotions. There is also the wear and tear on the environment and the highways from all this travel.

I understand specialists are now charging a fee to patients who don't cancel or keep appointments. I agree such patients are inconsiderate, especially when there is a waiting list to see these doctors. But the list would not be as long if unnecessary appointments aren't made. There's little consideration for those who must travel long distances for short, no-hands-on visit.

There's endless talk about making the health system more efficient and cost-effective. The initiative should come from the medical establishment itself, but the current practice is financially beneficial, so I guess it's hard to give up.

The shortage of qualified physicians in Saskatchewan and fear of losing them makes us hesitant to criticize their actions. But surely there is ample work for them all and they don't need to add this unnecessary strain and expense on the health-care system.

I’ve been holding onto this letter because it’s hard to know where to start dissecting it. In fewer than 400 words, she politely skewers so many problems with contemporary medical office practice.

The strongest message I take from this letter is this:  As physicians, we need to change the perspective we have about delivery of care.

Brainstorm

Last week, we had a celebratory lunch meeting with our office staff. It turned out to be a goldmine of ideas.

Karen presented our latest 3rd NAA stats. Still looking good:

Now we need to take the waits down to our 14 day target. Time for some small tests of change.

Contagious

I’m leading with the stats (as of February 27) this week, because they are sweet!

Two weeks ago, I met with one of the university-based surgery groups to discuss Advanced Access. It felt like I was in that TV commercial where a man travels into the past to give advice to his younger self. Their group looked just like our group did one year ago when we first considered starting this process.

The division head was interested in Advanced Access because he (and his colleagues) realized that their patients were waiting too long for consultation appointments. Perhaps he'll be the clinical champion.

Other surgeons appeared skeptical. Again, this had a familiar air to it. Several openly expressed their skepticism. They began listing the reasons why Advanced Access wouldn't work for them: I’m too busy. I have research and teaching commitments. I can't increase my clinical load to work down backlog. We're already working as hard as we can.

Start Spreading the News

What a rewarding month I've had!  I’m seeing signs of achieving our two goals:  shortening our wait times, and engaging other physicians in this initiative.

I started February with a visit to Calgary to present our Advanced Access experience.  The audience was very receptive. (Admittedly, their attendance at conference pre-selected them as having an interest in this topic, but still…)   As I mentioned last time, Alberta is already showing great results in their prostate cancer care access project.

On my return, Karen unveiled our latest 3rd next available appointment data:

Is this the time we shift to a new stable system of shorter wait times?  It looks promising!

Alberta Bound

Last week, I had the opportunity to present some of our Advanced Access results at a Prostate Cancer conference in Calgary. Alberta has a province-wide initiative to improve prostate cancer care, and the theme of this conference was improving access. While I was pleased to present our experience with a single aspect of improving access (pooled referrals from family physicians), I'm sure that I learned more than I contributed.

Calgary has developed a Rapid Access Clinic (RAC) for men suspected of having prostate cancer. Men sent to the RAC (a somewhat unfortunate acronym) can be assessed and have tests and biopsies completed in under 2 weeks rather than the previous standard of 3 months. Great work!

Another innovative part of RAC (really guys, let's work on that acronym!) is the group information session. When a man's prostate biopsy shows prostate cancer, he and his family need a lot of information about the nature of the disease and treatment options. In my practice, I generally book a 45-minute appointment to discuss this. This week, I've had 4 such sessions. That eats up a lot of office visit capacity.

In Calgary, men are invited to attend a group information session presented by several specialists, including a urologist and radiation oncologist. Offered several times a month, this program is an effective way to present consistent and comprehensive information using a standard curriculum. After this session, men are better prepared for a private discussion with their own urologist.

Blog's Breakfast

Here’s a smorgasbord of our recent results. Bon appetit!

It looks like we’re back in the swing of things after the holidays. The number of backlog patients seen was really down in November and December, coinciding with many of our group being away on vacation. We have a goal of seeing 60 backlog patients every week, and we topped that last week. First time in 5 months!

Back in November, we got excited about the 3rd next available appointment times dropping. We were disappointed to see the line climb back up again. Well, here we go again. The latest 3NAA has dropped “significantly”, but will it stay down?  Stay tuned!

At our team meeting yesterday, we reviewed some preliminary results from measuring recall intervals.  For the last few weeks, we’ve been tracking how frequently our urologists recall patients for office visits. We’re recording 3, 6, and 12-month recall intervals. I was surprised to see that I had a high number of 3-month recalls. So much for setting an example!

Darwin's Cystoscope

What's wrong with this picture?

This is the printer ink cartridge aisle at my local office supply store. Or rather, it's just one brand's section of cartridges.

This...

...is the entire aisle. (Actually just one side of it!)

Do I need so many choices? Are these even choices? I spent several minutes hunting for the particular cartridge that suits my printer model. Finally, I had to ask for help. (I'm a guy. That hurt!)

I just want my printer to work. Having to pick through all these cartridges is a nuisance.

I'd be happier with this experience:

"Hi. I need an ink cartridge for my Nagamatsu BG154."

"Here you go."

"Um, are you sure? It looked like you just grabbed the first cartridge that was handy."

"I sure did. Nagamatsu only makes one type of cartridge."

Sometimes "choice" is just noise. Clutter. Fruitless variation. Muda.

Naturally, shopping for ink cartridges makes me think about inserting tubes up urethras.