Friday, November 14, 2008

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:

72 days!!! Now you understand the sour taste.

What's going on? Our wait times are back up to where we started! We thought about this at our last AA team meeting and came up with a few explanations:
  • Last summer and early fall, we had a similar rise in wait times, presumably due to physician holidays reducing our capacity. After that, wait times didn't drop until November/December. The same factors are likely contributing this year.
  • Our department is being restructured in the New Year. Over the summer, I was at a lot of meetings about that change, and wasn't available for clinical work.
  • Over the last 9 months, we've noticed a marked increase in the number of surgical cases that our group has scheduled. While we're not completely sure why this is, it has reduced our office work capacity. OR time is a scarce commodity, and if we're offered extra operating time, we jump on it. That means canceling office appointments to free up surgeons for the OR.

The first 2 factors are temporary. The final one might be, but we don't know what's behind the trend toward increased OR bookings. It may be partly due to our increased workload (backlog workdown), or getting patients in more quickly. However, several other surgery departments that are not working on Advanced Access have also increased their OR bookings, so there may be other factors at play.

We're still working on all our initiatives - backlog, no-shows, reducing recalls, shaping demand – but it is discouraging to see these results.

But yesterday, I attended HQC's Clinical Practice Redesign Workshop and got a booster of enthusiasm and reassurance. Amanda (from our project team) presented our results to the conference and received some very useful feedback from the invited speaker, Catherine Tantau. Catherine's message: It's common to see these “setbacks,” and they illustrate the need to adapt to changing situations and to have a contingency plan ready.

At the CPR Workshop, I also heard from Mark Ogrady, the Regina ENT surgeon who first interested me in Advanced Access. At one point, he had his wait times down to 1 day! But now they're back up to 3 months. He explained that one of 4 Regina ENT surgeons retired, markedly increasing the demand in Mark's practice. He mentioned that the longer wait times filled up his office schedule again and made it difficult to schedule time away – to attend the CPR Workshop, for example. He's considering options that will drop his wait times again. He didn't sound discouraged.

Who knows what the future holds for our practice? We anticipate some retirements in the near future. But there may also be surprises. One of us might win the lottery and decide to quit work. While the demand for our services appears steady, our capacity to meet that demand may change suddenly. I think the CPR Workshop also gave me an answer to the problem of unpredictability.

Several of us were discussing a question from a medical resident, who was attending the workshop to learn how to structure her upcoming, brand-new medical practice. She wants to avoid the dysfunctional habits that clog up many physicians' offices. We tossed around several suggestions about setting up a new practice, but realized that there was too much uncertainty about what her actual situation would be, and how it would change during the first few year of her career.

We eventually decided this: Rather than developing an extensive list of specific procedures and policies at the start of practice, she should create a culture of measurement and change among her office staff. Hire people with an interest in improving on the status quo. Engage them in the exciting and satisfying work of CPR.

That's how our office will weather the unpredictable future – with flexibility and resilience, through the capacity to track key measures, and with the will to make changes that will keep us on the path of improved service. Change will happen; we need a culture that adapts to the inevitable.


1 comment:

  1. Originally posted by Steven Lewis, (Access Consulting) 11/18/08 1:00 PM

    Kishore, your (and Mark O'Grady's) recent experiences raise a number of interesting possibilities:
    1. One silver lining is that since both of you have processes that minimize wait times, the fact that they've gone up makes it far more likely that you have a (temporary at least) capacity problem rather than a disorganization problem. That's a big step forward in terms of system planning.
    2. The queuing theory literature and common sense suggest that systems are more stable and predictable once they've achieved a certain critical mass. Smaller systems (or clinics, or groups) are much more prone to capacity perturbations due to departures, illnesses, vacations, short-term alternate claims on their time, variations in need, etc. So one could probably model the likely variations in wait times for appointments based on practice characteristics. Where the confidence intervals are large, one wouldn't get too discouraged by peaks or too complacent about valleys.
    3. And now for the heretical part. The norm in Canadian health care practice is for most professionals to work at the lower rather than the higher end of their knowledge and capacities. The division of labour is "skewed downwards" for lots of reasons, including financial incentives, occupational territoriality, traditional assumptions more credentials being the key to better quality, etc. I wonder if as a next step it might be worth looking at the possibility of having nurses play a larger role in some follow-up visits, monitoring, etc. Anecdotally we hear lots of grumbling from specialists that GPs are referring patients they should be looking after themselves. I know you've been interested in reducing GP referrals; is it conceivable that a multidisciplinary team might expand effective capacity? Or put another way, what do you think would be the optimal composition of a urological team if you had free rein (and a business model that worked) to configure the practice to achieve the best combination of quality and efficiency?