Friday, April 17, 2009


Before I tell you about what’s exciting me this week, I want to share an exceptional service experience with you. Last month, I attended the Institute for Healthcare Improvement’s 10th Annual International Summit on Redesigning the Clinical Office Practice. (Great meeting, unwieldy name.) Deservedly, IHI has a reputation for providing outstanding value at their conferences. Virtually every session I attended was terrific, with energetic presenters and great ideas.

But, one session didn’t live up to its billing. Powerpoint slides overloaded with bullet points, presenters reading directly from slides while facing away from the audience, an uninspiring message unrelated to the course description in the conference handbook – all the vices I’ve repeatedly griped about, rolled up into one dreary session.

So I walked out. Life’s too short.

The conference guide offered a money-back satisfaction guarantee, so I decided to see what would happen if I actually complained. I talked to the staff at the registration desk, and they called the conference manager. She immediately offered me a full refund of my registration fee – no questions asked. That’s more than $1000! I backpedaled and said I would be satisfied to be refunded only the amount for the unsatisfactory seminar. She insisted that the guarantee promised a full refund, and that she would arrange it.

Wow! I was impressed (and a little worried that this might get me black-listed with IHI), especially since IHI has very little control over the independent contractors who present the seminars. I couldn’t wait to tell this story to everyone I knew at the conference. I admit to being a little skeptical about whether it would really happen, so I checked with the Health Quality Council (who sponsored my trip). The money had been refunded, almost before we returned from the meeting.

What a great example of customer-centred service:
  • Trust your front-line staff to keep promises that your organization has made.
  • Don’t make your customer jump through hoops after they’ve had a bad experience.
  • Recognize that, even though your organization may not directly control every aspect of the process, it is still responsible for the outcome and the customer’s experience.

Okay, IHI, I get it – you model good behaviour. Nicely done. But are you going far enough with this guarantee?

An analogous situation would be the complaint process of a professional licensing body. Some people who have a bad experience with a physician don’t realize that they can register a complaint with the College of Physicians and Surgeons, or think it’s too much trouble to go through the process. The complaint is never filed and so their dissatisfaction festers, and the physician’s (alleged!) skill deficit or inappropriate behaviour goes unresolved. I spoke with some other people who attended the seminar that I walked out of, and I know that some of them found it unrewarding, for the same reasons I’ve given. But even after they heard that I had been offered a full refund, none of them decided to claim a refund. They were uncomfortable with the idea.

No doubt, they’ll be spreading their unsatisfactory experience by word-of-mouth when they return home. I imagine that IHI would agree that a $1000 refund is a small price to pay for maintaining goodwill. Maybe IHI should promote the money-back guarantee more vigorously! If more people were willing to walk out of sessions and claim a refund, imagine the incentive the conference organizers would have to ensure excellent presentations...

And, as a last dig at poor quality presentations, could IHI take the lead in tutoring the health care sphere in the art and science of public speaking? Quality improvement enthusiasts from around the world attend IHI conferences. It’s unconscionable to squander these attendees’ potential by having them sit through rambling, didactic sessions. At the very least, potential speakers should have their slides frisked for Death by Powerpoint.

‘Nuff said.

Now on to the exciting stuff. At the IHI meeting, I attended a workshop on Shared Medical Appointments (SMA). Enthusiastically and very capably facilitated by Brent Jaster, this session alone was almost worth the price of admission. (If there had been one…) I hadn’t thought a lot about SMAs before, and if I did, group psychotherapy/ counselling sessions came to mind. SMAs didn’t seem pertinent to a surgical specialty practice. Apparently other specialists have different ideas.

SMAs bring together groups of patients who have similar health concerns. The SMA is different from a seminar or lecture format in which a specific issue – diabetic foot care, for example – is reviewed for an audience. In an SMA, patients are invited to discuss their personal health concerns and a resource person (physician, nurse, dietician, etc.) will pursue a solution. All group members hear and participate in the discussion. I won’t review all the benefits and principles of SMAs; you can read experts discussing them here and here.

I often repeat the same information to patients several times during a day in the office. That’s the nature of specialty practice – we see the same problems over and over. That kind of repetition wastes time and office capacity. If I identified conditions suitable for SMAs, then I could invite those patients to attend a group session and only give the information once. Of course, physical examinations and discussion of intimate details would still take place privately.

The first situation that came to mind was men referred for vasectomy. We receive up to 20 vasectomy referrals every month. Consolidating those 20 visits would release office capacity to see other new referrals. Because each of the men would need a quick examination at the start of the visit, we could allot 45 minutes for each vasectomy SMA. A reasonable number of men to see in one SMA would be eight to 10. So, that’s two 45-minute visits rather than 20 15-minute visits. That opens up 14 15-minute appointment slots every month. (Individual results may vary.)

Also, because each patient had individual attention and physical examination, we would bill for each person in attendance, making the SMA at least cost-neutral. We could probably spring for coffee and juice!

The problem that I saw was that we don’t have room in our office to accommodate that many people for a group discussion. None of our individual offices is large enough, and our waiting room is busy all day. Also, because our office is set up with one consultation room for each urologist, with a single exam room attached to that consultation room, we don’t have a pool of exam rooms we could use to quickly move patients in and out of. I thought we would have to work out an arrangement with one of the hospital’s ambulatory clinics. That was the mental corner I had painted myself into.

Then came the beauty of group problem-solving. After I presented the idea to our Advanced Access working group, Amanda suggested that we schedule the vasectomy SMA at 5 pm when regular office appointments are finished and the waiting room is empty. Also, at that time, the physicians wouldn’t be using their individual exam rooms, so we could have a staff member shuttle patients in and out. It might be slightly disruptive for the urologists to have a patient zipping in and out of their exam room, but it’s all for a good cause! Also, she suggested a template that would include a confidentiality agreement, personal medical information form, physical examination findings, and a check-box to indicate that the patient had attended the discussion of the procedure, success, complications, etc. That sheet would be faxed back to the family doctor in lieu of dictating a separate letter for each patient. Brilliant!

Our next step is to develop a protocol for vasectomy SMAs, collect several vasectomy referrals, and invite those men to attend. The benefit for the men is that they will be seen sooner than they would have previously. Of course, they will still have the option to stick with our traditional approach of individual appointments. Once we get the hang of SMAs through this trial, we’ll want to try them with other common urologic conditions: hydrocoeles, spermatocoeles, recurrent bladder infections, and prostate cancer.


  1. Originally posted 04/20/09 10:45 AM

    It's great that the IHI conference manager gave you a full refund of your registration fee, no questions asked. But how can they seek to improve their conference, if they don't know what made you complain?

  2. Originally posted by Joy Dobson (Regina Qu’Appelle Health Region) 04/20/09 10:50 AM

    Again, no shortage of good ideas for us to try! A Regina gynecologist has found this concept useful in her practice too. I bet the patients will come up with even more suggestions for efficiency.