Friday, April 18, 2008

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.

What a great example of "push design," that is, creating a system that automatically leads to the desired result, rather than relying on components of the system (referring physicians, in this case) to change behavior.

Why didn't I think of it? After all, I'm often griping about poor design. If you've checked out my Plain Brown Wrapper blog, you've seen the "What's wrong with this picture?" feature in which I ridicule (er, constructively criticize) poor design (mainly in hospitals). I'm usually railing about push design, like how we could fix slick floors and faulty doors in the OR.

Oh well, no matter who came up with it, it's well worth trying. That's the beauty of collaboration.

It'll be interesting to see how many referring physicians and patients actually use the "No Substitutes" option. Why do referring physicians favor one specialist over another, anyway? Do they know that specialist has an interest or training in a certain area? Do they have first-hand knowledge of a surgeon's technical expertise? I suppose someone out there has studied the complexities of referral patterns, but it's a mystery to me.

This week, we got a first look at our group’s recall stats. Back in January, I wrote about our interest in the various recall patterns among urologists, and how this would affect our wait times. If one urologist recalls patients every 3 months to review condition X, he/she will have fewer appointment slots available to see new referrals than will the urologist who reviews condition X patients annually (or not at all, if they are returned to the care of their family physician, with appropriate recommendations).

We don't have enough data points yet to say that we're dealing with stable systems, but there are some interesting initial trends. We looked at the percent of recalls (3, 6, and 12-months) out of all patients seen. Among our group, 3-month recalls varied from 1.72 to 19.42 percent. For 6-month recalls, the range is 1.12 to 12.88 percent. For 12-month recalls, it's 0 to 11.24 percent. There's no consistent "offender" (oops, shouldn't be judgmental!) here. In each category, the heavy recall-er is a different doc.

There may be some opportunities to reduce variation by sharing our individual guidelines for recalls. Perhaps just hearing about the way a colleague manages recalls will help us to reconsider our own management. More collaboration!

And, finally, here's our latest 3rd NAA chart.

My stats team tells me that we don't need to use red dots anymore because we have a new stable system, so...

Our average 3rd NAA is now 39 days (down from 61 days). We have more work to do, but this is very exciting!

New stable system = Culture change = This is the way we do things now!

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