Friday, June 12, 2009

Backlog, Schmacklog

“Get your body beach-ready!” trumpet the magazines lining the supermarket checkout. It’s an annual ritual for Canadians: Emerge from hibernation, decide to tone up and trim down, then embark on a crash diet and/or exercise.

But, to what end? Is a “beach-ready body” the ultimate goal? For some, it is; quick and dirty does the trick for them. For others, a slim physique is the eventual (but not certain) by-product of a different goal: a sustainable healthy diet and exercise program to achieve long-term wellbeing.

We continue to struggle with our pesky backlog. Trimming the backlog will not only satisfy the primary goal of our Advanced Access project – improving patient access – but will also let us benefit from reduced administrative load and increased flexibility in physician scheduling. But, as Advanced Access evolved into a broader Clinical Practice Redesign project, our goal has changed also. Improving patient access alone (although a worthwhile goal on its own) doesn’t necessarily give our patients better care.

Liposuction can rapidly reduce someone’s corporeal backlog, yet they may continue to clog their arteries with cheeseburgers. In medical practice, a “brute force” approach to backlog reduction is the equivalent of liposuction. By working longer hours, cramming more patients into appointment slots, or recruiting temporary locum help, we can have a buff-looking practice, pronto. But when patients come through the door in 7 days rather then 70 days, they’re getting the same type of care as before the wait list slimmed down. (And having learned a lesson in my last post, let me point out that our current care is not bad. But, there’s always room for improvement.)

Our efforts to reduce external and internal demand (information sheets sent to patients in lieu of “educational consultations”, turning over follow-up care to primary care practitioners) are supposed to give a sustainable improvement in the quality of care we provide. But, as with sensible diet and exercise, as opposed to crash dieting, it will take longer to achieve our ultimate goal. For example, when we reduce our patient recall rates, it takes at least 3 months to see the increased clinical capacity. That’s when (no-longer-recalled) Mr. X’s 3-month appointment slot becomes available for Mrs. Y’s new consultation. In our urology practice, most of our recalls occur at 6- and (more often) 12- month intervals. As our project to reduce recall rates began 12 months, we may be just now starting to see some of the effects. However, several doctors’ recall rates have just recently started to fall, so it will be 6 to 12 months before those benefits accrue.

The vasectomy reversal, patient education trial is underway and may open up appointment slots. However, our long-term goal is a sustainable improvement in patient service (as judged by the satisfaction survey). If men prefer a face-to-face consultation, then we’ll provide it.

In a similar vein, we’ve reconsidered our approach to seeing vasectomy consultations. In Sharing, I gushed about using Shared Medical Appointments to accommodate patients with common urologic problems. Two of us were ready to try group visits for vasectomy consultations. On reflection, we realized that this would be a “binge” approach that might not be easily accepted by all the urologists. In the interests of quick, simple and sustainable change, we’ve decided to try scheduling 2 vasectomy visits back-to-back, with each one scheduled for half the time of a regular consultation. Each visit tends to be brief, and this has worked well so far. It’s not much of a stretch from our current practice, so it should translate easily to other urologists. And, ultimately, we want to combine the consultation with the vasectomy procedure so as to save the man a trip to our office.

Of course, the same principle applies to any wait list reduction plan, such as surgical wait lists. Vigorously sweating off years of accumulated demand will make a surgical wait list look tanned and toned, but fundamental changes to the system are necessary for its long-term wellbeing. The entire journey from onset of disease to postoperative recovery must be considered. Patients and their referring physicians need access to information on individual surgeon’s wait times and specialty interests. Demand should be spread evenly and equitable among surgeons with similar capabilities. Patients should have access to unbiased, up-to-date information on all options – whether surgical or not - for treatment of their condition. Some conditions may be managed as well (or better) by non-surgical therapy.

Crash diets to drop unsightly backlogs may give sexy results, but slow and steady may still win this race.


  1. Originally posted by Bronwynn (Alberta Health Services) 06/12/09 3:20 PM

    So true! We need to consider the political pressures to make some of these changes, including decreasing wait times and dealing with backlogs. The reality is that society has much higher expectations of care in addition to higher acuity needs than they did even 50 years ago. With those changed expectations and demands comes a need for more services, but can we continue to do slash and burn tactics to try to deal with these pressures and really make a difference in the overall health of society? All of the research says NO! I am not suggesting for a minute that we consider what and who should receive treatments, or to what degree we would treat someone, not at all. I am just saying that with the changes in expectations and the resources we have, that I believe it is the small changes in process that will make the biggest changes in backlogs and wait lists. Slow and steady wins the race.

  2. Originally posted by Jan Horton (Government of Yukon, Health and Social Services) 06/14/09 10:20 AM

    Love the analogy you're using. It's like the difference between a fling and the long term commitment of a good marriage.