Sunday, December 5, 2010

Check a box, Tame a Line

A couple of weeks ago, I met some people who have the power to change Canadian healthcare. And, they can do it by June 2012.

There wasn’t a deputy minister among them.

They were the University of Saskatchewan College of Medicine Class of 2014. That’s right – first-year medical students! Skeptical? I think they were, too.

I had the chance to participate in the first-year students’ “Civic Professionalism and Physician Leadership” course. The course exposes students to aspects of healthcare beyond the traditional, disease-oriented clinical curriculum. I was addressing the quality improvement theme, specifically Clinical Practice Redesign.

I had planned just to tell the story of Saskatoon Urology Associates’ Advanced Access/Clinical Practice Redesign (CPR) journey. Essentially, the presentation is a distillation of this blog. The story starts with the reason why we started the project: Frustration over the wait times our patients experienced. Then, I talk about some of our most successful initiatives: pooled referrals, shaping demand/referrals, and reducing recalls.

Usually, I’m giving this presentation to a group of physicians who have recognized an access problem in their practices, as evidenced by long wait times and frustrated patients. They are already motivated to seek solutions, and the discussion centres around how to implement CPR in their practices.

However, medical students in their first few months of training are years away from the challenges of clinical practice. Their perspective is informed by their own or their family and friends’ experiences with health care, media reports, and opinions from authorities. The message they hear: Long wait times are caused by inadequate resources. The solution: More resources. More doctors. More MRI machines. More OR time.

But, our successes with CPR indicate otherwise. There are plenty of opportunities to improve access, quality and value for patients by rethinking how we use current resources. That’s the message I wanted to get across to the students.

But, after recently reading Check a box, Save a Life, I thought that my presentation might be an opportunity to do more than just tell our story. I thought that these students had the potential to drive change, rather than just bear witness to it.

Check a box, Save a Life tells the story of a international group of medical students who launched an initiative to lead implementation of surgical checklists at their respective institutions. After attending the release of the safety checklist at an IHI conference, the core group used their existing organizations and social networks to promote uptake of the checklist. Some students actually participated in, or lead, the use of the checklist in the operating room.

They were sparked by their realization that, even as medical students, they had the power to effect change that would have an immediate and significant impact on patient care. What an amazing story of leadership and activism!

That story convinced me that the U of S first-year medical school class could do the same. Actually… they could do more. While surgical safety checklists promise the more dramatic result of saved lives, implementing CPR nationally could improve access to care for many more patients, improve work-life balance for physicians, and ensure sound stewardship of our healthcare system’s resources.

Whew! That sounds pretty daunting. But once you hear what these students bring to the table, you’ll agree with me that they’re up to this challenge.

First of all, they get it. They understand CPR, and the problems it tries to address. I don’t mean that they listened to what I had to say and understood the techniques of pooling referrals and shaping demand. Certainly they understood the technical part, but that’s the easy stuff. I mean that, from the questions they asked, it was obvious that they understood the deeper issues. They wondered about how reducing specialist recall rates by returning care to family physicians would affect the FP’s workload. They asked whether there was any resistance to introducing CPR into our practice, and how we managed that. They realized that the current fee-for-service payment system was a disincentive to some CPR changes.

These questions showed me an impressive degree of analysis from people completely lacking in clinical exposure. And that’s the next thing they have going for them.

They have no exposure to medical practice. We haven’t brainwashed them yet. Their minds and eyes are open. I’ve posted before about a junior medical student who challenged me to reconsider one of my office practices. An elderly man drove 3 hours for an appointment to discuss a test result. The student asked why that discussion couldn’t have been done over the phone. A more seasoned student would likely already have been indoctrinated into our system to the extent that the visit wouldn’t have raised an eyebrow. They would already know that that’s the way we do business. But the new ones spot our foibles. (Classic: The Emperor’s New Clothes!)

Next, they have powerful social networks. They attend clinical rotations in groups of up to 5 people. That’s a great opportunity to share their impressions of what they’ve seen, and collaborate on solutions. I spend most of my day doing my work the same way I’ve done it for years, without comparing notes with colleagues on how they run their office practice. On the occasions when we do compare our practices, the results have been startling. When we measured our internal demand/recall rates, we were surprised to find the degree of variation in our practices. Once we recognized the variation, and began to explore the reasons behind it, as well as possible solutions, our recall rates dropped. Two (or five) heads are better than one.

Plus, electronic social networks expand that interaction far beyond the physical confines of the U of S. (One thousand heads are better than five!)

Finally, medical students are everywhere. Their rotations take them from the operating room to rural primary care clinics. And they’re observers. They rarely have clinical duties, so they are free to be flies on the wall. Once they understand they type of problems CPR tries to fix, they will see examples of those problems everywhere.

And, as their questions during my presentation convinced me, they will be able to create solutions to the problems they identify.

I would love to be part of this initiative, but as I’ll explain below, it’s important that I stay out of it. But, that doesn’t stop me from giving my version of how I see it developing!

Imagine this: While on their clinical rotations, students from across Canada apply the insights they have gained from CPR advisors to identify potential areas for improvements for individual clinicians. They collect their observations in an online database. Via social networks, they brainstorm solutions. The next students who spend time with that particular clinician ask to try out the solution, and then submit the results to the online community for refinement.

They would harness the curiosity, creativity and energy of hundreds of their colleagues for the benefit of thousands of patients. And for the gratitude of hundreds of clinicians whose practices would be made more efficient and effective.

A project like this, if conceived at the government or national medical association level, would take years to produce results. The Class of 2014 can produce tangible results by June 2012. Their first significant clinical rotations start in their 2nd year – the fall of 2011. By using the rest of this academic year to organize, develop a network, and recruit mentors, the students would be ready to collect data by the time their first rotations start. Small tests of change could start almost immediately.

But, if this initiative is to succeed (in whatever form it eventually takes), it must be conceived, driven and executed by students. They should struggle with recruiting participants, fret about how to engage physicians in the effort, and worry about keeping up their enthusiasm once the initial excitement of a new project dies down. They must fail, and learn from their failure. Their achievements will be even sweeter for all of their sweat.

On the surface, this project is about implementing Clinical Practice Redesign across the country. That will be the easy part. The real work in this project will be harder, but will be much more valuable for the students. The real work is in becoming leaders.

And you can’t do that in a classroom.

Come on, Class of 2014. Show us what you’ve got!

Monday, November 8, 2010

Time for a change

It’s time for a change!

For over 3 years, our practice has been working on shortening patient’s wait time for consultation. We’ve learned about measuring capacity and demand, pooling referrals, shaping demand and improving capacity. While individual urologist’s 3rd next available appointment times vary considerably, our clinic’s shortest 3rd NAA is now around 20 days. This is the wait time for patients who accept the first available pooled referral.

We will work to maintain these gains and improve service for our patients. But now, we want to tackle another wait time – the wait for diagnostic testing, specifically cystoscopy. Cystoscopy – endoscopic bladder examination – is one of the most common urologic procedures. Used to diagnose conditions ranging from bladder cancer to urinary incontinence, about 350 cystoscopies are performed every month in Saskatoon.

This spring, the Saskatoon Health Region (SHR) updated sterilizing procedures for cystoscopes. Previously, we had soaked endoscopes in sterilizing chemicals between uses. This process was performed in the cystoscopy suite in 10-15 minutes, meaning that a small inventory of equipment could be rapidly turned over. In contrast, the current sterilizing procedure takes several hours to complete, and is performed by technicians in the central processing department. Because of this, we needed a larger inventory of scopes. Expensive scopes, that is.

By consolidating cystoscopies from 3 sites to 2, and by rescheduling times of cystoscopy clinics, we were able to maintain service volumes while purchasing the minimum number of new cystoscopes. Or so we thought…

Complex systems like a cystoscopy clinic are organic. They change and adapt over time. Incremental changes accumulate. And, when we impose a major realignment (even a carefully considered one), unintended consequences can result.

In the case at hand, everything looked good on paper. Overall cystoscopy capacity was the same; only locations and clinic times had changed. But, since this spring, patient wait times for cystoscopy have been getting longer. Initially, we thought it was a result of summer holidays reducing capacity. But, the lengthy waits have persisted. And so, we want to use our Advanced Access tools to tackle cystoscopy wait times.

Our team met last week to plan our approach. Having previous experience with wait times certainly helped – so much so that Donna and Delores had already collected a lot of baseline data. Our starting cystoscopy 3rd NAA is 32 days. They also looked at the number of cystoscopies performed for certain diagnoses: bladder tumor checkups, hematuria (blood in urine) and urinary retention (inability to pass urine). We see a significant variation among urologists, in the raw data they have collected. We don’t know yet what the implications of this are, or if understanding the reason for the variation will help improve the cystoscopy system.

Our initial review also showed that we’re not using all the available cystoscopy time. In the previous system, we had a fine balance between competing demands for urologists’ time. Now that schedules have changed, on some days there aren’t enough urologists to go around. Our default decision is to use all the available OR time first, even if it means leaving cystoscopy time unused. Fixing this demand-supply mismatch would be a big win.

Our EMR has the capability to track cystoscopies by diagnosis/reason for procedure. We’ll start tagging each procedure and see if this will uncover any interesting patterns.

Also, and importantly, as we’ve started this new work, we’ll stop collecting weekly data on office consultation wait times. We’ll check in on those times occasionally, to make sure we’re not losing ground. Staff time is a limited resource, and we want to use it wisely.

A new project. This is kind of exciting!

Sunday, October 24, 2010

Canadian Patient Safety Week - Welcoming our second-degree guests

Canadian Patient Safety Week is next week, but its theme – Ask.Listen.Talk - was on my mind a lot this week. And it made me think about a party we held last New Year’s Day.

We invited several friends over for brunch. At the last minute, one family called and said they wouldn’t be able to come. Weather conditions had prevented their visiting relatives from returning home, and they didn’t want to leave them alone. Of course, they were welcome to come to the party, so we set a few extra places at the table.

If you’ve ever been a “second-degree guest”, that is, accompanying someone who was invited by the host, you know it can be awkward. You may not know the host. You would rather suffer in silence rather than put the host out by asking for something. You don’t feel comfortable.

We recognized that our second-degree guests felt that way. All the other guests had been in our home previously and knew their way around. They felt comfortable with helping themselves to cutlery or serving themselves drinks. They made themselves at home, and we invited our new friends to do the same.

But that wasn’t enough.

If I’m visiting someone’s home for the first time, and am told to make myself at home, I won’t. Because I don’t know what “making myself at home” means in that home. Can I poke through the fridge looking for leftovers? Can I flick on the TV and watch the game? I don’t know what their micro-culture accepts, and so I will err on the side of sitting quietly on the couch.

Recognizing that our second-degree guests felt the same way, we did what any host would do, and made sure to pay extra attention to their needs. Would you like another drink? What do your kids like to eat? Like any host would, we wanted them to feel welcome and comfortable.

CPSW’s theme - “Ask.Listen.Talk.” - suggests that communication between patients/families and caregivers, and among caregivers, improves patient safety. No argument from me. But I think we need to consider how we implement Ask.Listen.Talk. in our practices.

Patients and their families are like second-degree guests visiting the healthcare system. Everything from our facilities to the language we use is unfamiliar and intimidating to them. While healthcare workers bustle about around them, visitors worry that even a wrong turn in a hallway may take them into an unauthorized area. They feel awkward.

And then, next week, we want them to “Ask.Listen.Talk.” Maybe we’ll put up some posters, or hand out a brochure. That will be the equivalent of saying “Make yourself at home!” Patients/families won’t know what is acceptable in the healthcare culture. Is it OK to ask the doctor whether or not she washed her hands before examining my mother? Will she be upset with me for asking? I don’t take a red pill at home, but I’m sure it’s OK here at the hospital, because the nurse must have checked it before she gave it to me. She looks too busy for me to bother her.

It’s nowhere near enough just to publicize our belief that communication improves patient safety. We need to actively seek out patient and family comments and participation, like we would for second-degree guests in our home. And when those comments arrive, we need to receive them positively and consistently. A sour look in response to a voiced concern speaks much more loudly than an Ask.Listen.Talk pamphlet on a bedside table.

Last week, I spent some time with a medical student, and we observed what we considered to be a breach of a patient’s dignity. We talked about it after we left that care area, and I asked him how he would address that with the caregiver responsible. He laughed. I laughed too. We both realized that I was being absurd. It would be a rare medical student who would comment on a breach of patient privacy, dignity or safety. At best, they would be ignored. At worse, they would be excoriated for their impertinence. How dare you…

He felt – undoubtedly correctly – that the caregiver would not accept such a comment from someone who was without standing in their culture. But we did explore possible approaches. I thought that he would need to test out – role-play – some options with like-minded colleagues before “going live”. Perhaps the old just-trying-to-be-helpful gambit: Would you like me to pull the curtain around the patient’s bed while you examine him?

I used a similar approach with our second-degree brunch guests. I wanted my 10-year-old son to find out if our guests needed anything, but I realized that giving him that vague instruction would be useless. It wasn’t that he didn’t want to help, or that he is unfriendly. It’s just that it was a new situation for him, and he felt uncomfortable. He needed some coaching and a specific script.

“Ask them ‘May I get you something to drink?’”, I suggested.

“’May I get you something to drink?’”, he repeated.

And off he went.

Coaching and scripting to encourage dialogue around patient safety will help us demonstrate to patients and families that we are serious about engaging them as active participants in safe care.

The day after my student and I had discussed impediments to his commenting on the breach of dignity, he joined me in the operating room. As I introduced him to the personnel in the room, the anaesthetist said this to him: If you see anything going on in here that you think is unsafe, please speak up. We value your eyes on what we’re doing.

That was a big step in the right direction.

Monday, October 11, 2010

Joy at work

It’s not often that I have a moment of joy in the middle of a cystoscopy clinic, but I had one last week.

A cystoscopy clinic makes for a busy morning. Over the course of 4 hours, I’ll see 12 to 14 patients. Each visit involves – at minimum - an endoscopic bladder examination, discussion of the findings, and sending the results to the referring physician. It may also involve meeting a patient for the first time, asking about their medical history, arranging further testing or scheduling surgery.

I’m constantly aware of wanting to stay on schedule so as not to keep people waiting. Unfortunately, that time pressure will sometimes make me feel rushed, and that can affect my patient’s experience.

Why not schedule more time for each patient, you may ask. For some patients, rather than the standard 15 minutes, I will allot 30, especially if I anticipate that someone may require additional procedures. However, each extra time slot assigned to one patient means that another patient waits longer for their cystoscopy. And, wait times are already lengthy. It’s a difficult balance to strike.

But, during one examination last week, I found myself in the unusual situation of being ahead of schedule. Even though it was my first meeting with this patient, and I needed extra time to ask about her medical history, discuss test results (she had a tumour in her bladder) and recommend surgery, I wasn’t rushed. In the middle of that discussion, I had my moment of joy.

While explaining to the lady about what I had found, and the recommended treatment, I realized that I felt relaxed and confident. I was paying attention to her reaction to my explanation. Was she upset? Was I using medical jargon? Had she understood? Did she have any questions? I wanted to reassure her.

This was how I wanted all my consultations to go. Not only because it made me feel good about myself, but because I’m convinced that I’m a better doctor when I feel that way. I may provide the same technical results regardless of my mood (maybe…), but I think patients have a better experience when I’m relaxed.

As I thought about this, I began to wonder why I couldn’t feel this way, and offer my patients a better experience, on a regular basis. I think there are internal and external factors. Internally, I may allow myself to become flustered. That’s a habit I can work on. Externally, it comes down to an access problem. Long wait lists translate into pressure to fit in as many patients as possible in a given clinic. That increases the chance of running late, and forces me to rush, leading to an unsatisfying experience for both me and my patients. (And for any staff who may be unfortunate enough to be in the vicinity…)

So, if we work on improving our cystoscopy access problem – applying the same principles of managing capacity and demand as we have in our office practice – patients may benefit not only through shorter waits, but also through the quality of their experience. And our doctors may be more satisfied.

I think we’ve found our next access project.

And a selling point: Bring the joy!

Sunday, September 26, 2010

Loose lips

Hi, fellow health-care providers! Were your ears burning this week? They should have been, because people were talking about us.

Earlier this week, I met a man who, while not a health-care worker, is involved in a provincial health organization. Our conversation came around to a recent experience he had while one of his family members was being cared for in a local emergency department. His opinion was that there was a lack of professionalism demonstrated by the staff – physicians and nurses – in that ER. He had no complaints about the care provided to his relative. What troubled him was the seeming lack of concern for patient privacy and confidentiality.

He said it was impossible to ignore loud discussions that included details of other patient’s medical history and treatment, as well as staff’s “editorial comments” of their impressions about a patient’s demeanor. Some whispered comments were followed by laughter, which he admitted could have been innocent, but naturally made him wonder if some patients were being ridiculed.

His family member was admitted to hospital where he observed similar incidents on the ward. He was particularly annoyed that he regularly heard staff discussing their social lives at length, presumably while “on the clock”.

His final comments were that he was reluctant to raise his concerns with staff because he worried that it might have repercussions for his relative’s care, and also that he wondered who was responsible for overseeing appropriate staff behaviour.

Ouch! The truth hurts.

I’ve been guilty of these lapses, and see them regularly in the ER, hospital wards and other patient care areas. But, my first impulse was to explain to this man – who didn’t work in health-care – why this behaviour is sometimes unavoidable.

First of all, certain patient care areas – especially ERs, recovery rooms and critical care areas – bring together multiple patients, their families and medical staff in a confined space. Because staff needs to closely monitor the patients’ conditions, it’s not always possible to step away to a more private area to discuss care. Also, in order to be efficient, it’s sometimes more convenient for staff to have conversations about patients in the hallway outside a ward room, rather than searching for a more private spot.

However, I didn’t offer these reasons to the man, because my heart wasn’t in it. I knew they were more excuse than reason. We can do better. This experience had obviously affected his confidence in health-care providers, and empty explanations would only compound the problem.

Later in the week, I attended a meeting of our health region’s Patient and Family Centred Care advisory council. We heard a presentation about a proposed change in the ERs with the implementation of an electronic “white board”. Many ERs use a white board to keep track of patient status, pending tests, tentative diagnosis and consultations requested. While intended for staff use, they are often posted in very visible locations that anyone can see. As we move toward using a district-wide electronic medical record, these white boards will be replaced with large computer monitors that display the most current information about each ER patient. For example, if blood test results are ready, an alert would be displayed, letting staff know immediately that results can be reviewed. At present, staff need to remember to check intermittently to see if results are back, and this delays the next step in diagnosis and treatment.

While current (and proposed electronic versions) white boards don’t display patient names, that’s small comfort. Bed numbers are shown, so it’s easy to match the patient to the diagnosis. We rely on the anonymity granted by being a large urban centre, and the fact that it’s unlikely that ER visitors will know anyone who is currently being treated. But, what about smaller towns? And, good luck to you if you are a health-care worker being treated in the ER of your own workplace.

Imagine this scenario: You’re a consultant called down to the ER to see a patient. As you walk in, you see a colleague lying on a stretcher. As you walk by the white board, are you going to take a quick peek at his bed number to see what’s going on? Even if there isn’t a diagnosis given, you can see what tests are pending, and which medical service has been consulted. Cardiology? Uh-oh, probably a heart attack. Psychiatry? Hmm, interesting. Are you going to take a peek? No? C’mon, really?

The electronic white boards would not identify patients and, as was explained to us, the symbols on them would be somewhat cryptic so as to foil easy interpretation by unauthorized viewers. Well, short of using Klingon, I’m not sure we’ll have much success in disguising the symbols’ meaning. In any case, we don’t want staff to be confused as to their meaning as that would defeat the purpose of displaying them in the first place.

As one of the council’s community members pointed out, families might actually find white boards useful as a way to monitor their relative’s status and progress in the ER. In order to do that, they would need to understand the information and would naturally ask medical staff what it all meant, thus exposing the status of all ER patients.

Several community members commented that they would accept the display of patient information if it would improve the efficiency in the ER. Hearing that comment made me realize that we (health-care workers) are framing discussion about privacy issues in a way that makes patients and families feel that they are obliged to accept violation of their privacy in return for efficient and high-quality care. The impression that our community representatives had (because that’s the impression we gave them) was that, if we don’t prominently display private patient information, an ER can’t function properly. Take it or leave it. And, of course, when put like that, they’ll take it.

But, it’s a false dichotomy. There are more than 2 choices here. The beauty of digital information is that up-to-date data can populate many different devices simultaneously. We don’t need a Jumbotron blurting out patient status. Instead, display it on desktop monitors and iPhones. That’s my quick take on how to address the problem – someone else has likely solved it more elegantly. My point is that we shouldn’t ask patients to give up an important aspect of their care because it will be simpler (for us) to maintain the status quo. As another community representative put it, patients shouldn’t have to “settle”.

Now, back to the first gentleman’s observations about medical staff’s behaviour. He didn’t confront anyone at the time because he didn’t want his relative’s care to be affected. He also mentioned that he thought it wouldn’t make any difference even if he did raise it with the offenders. His rationale was that if people were far enough out of touch with appropriate professional behaviour that they were compromising privacy, they probably had a mindset that would not react well to criticism. Our system forced him to “settle”.

I asked him how he would fix the problem. He suggested that senior staff should be setting an example, by insisting that conversations take place in private locations, or at least by keeping voices low and being aware of who is within earshot.

Great idea, but not so easy to do. This behaviour is so much a part of our local culture that I think even senior staff would hesitate to be perceived as being critical of colleagues’ behaviour and labeled as “oversensitive”.

Maybe having staff hear about privacy concerns in patients’ and families’ own words would have an effect, in the same way this gentleman’s story had an effect on me. We could solicit feedback from clients regarding their impression of how their privacy was respected while they received medical care. Two or three questions would probably do it. This wouldn’t be a secret undertaking. On the contrary, we would inform staff that the survey was going on, and that they would see the results.

And, of course, we would post the results for the public to see. On the white board.

Sunday, September 12, 2010

The dark side of pooled referrals: Let's play monopoly!

After reading yet another post extolling the virtues of pooled referrals, an anonymous reader asked: “If all the urologists in Saskatoon work in a group practice in one clinic, how can a patient get a second opinion, without causing any unintended displeasure to the first physician?”

Great question! Plenty of meat on that bone.

There’s a simple answer for our group, a longer discussion about physician attitudes toward second opinions, and a dilemma around consolidating medical (or any service, for that matter) into one source.

First, let me address the reader’s actual question. In our group, patients are welcome to seek a second opinion from another member of the group. As the reader points out, we’re the only urology group in Saskatoon and, other than one urologist in Prince Albert, the only ones in the “north” of the province. While patients are free to travel anywhere in the province (or out of the province, or country) to obtain a second opinion, we recognize that this may be a significant burden for some and so provide the option inside our group. (Some may prefer not to seek second opinion within the same group, for fear that our practices may be too homogeneous. Or, they may worry that we don’t want to contradict one another.)

That’s the quick answer, but I’d like to turn the question back to the reader and ask this: “Why do you assume that a physician would be displeased if a patient sought a second opinion?” It’s disingenuous to ask, because I know that some docs do get bent out of shape if someone asks to consult another specialist.

Patient care may suffer when patients fear that a request for second opinion may displease their doctor. Most obviously, the first physician’s diagnosis and/or recommended treatment may be incorrect. A fresh evaluation may reveal the true problem.

Even when the first physician’s assessment is correct, patient and physician may not have an established a relationship of trust and respect. This can be particularly important if treatment involves something as dramatic as surgery, where stakes are higher. If a patient is uncomfortable with the physician’s manner or demeanor, they may have a good technical result from treatment, but their overall experience of care will suffer.

It’s not unusual for patients to see me for a “stealth” second opinion, that is, they will be referred for assessment and not reveal that they’ve previously seen another urologist. (As our group shares an electronic medical record, they would have seen a urologist in another centre.) Their motivation is that they want a fresh viewpoint, and worry that I’ll take the shortcut of accepting the other urologist’s opinion if I have access to his/her notes. The problem with that approach is that there may be clinical information, test results or xray findings not made available to me. That results in unnecessary repeat testing, or incorrect assessment because of incomplete data.

So, if some physicians balking at requests for second opinions can harm patients, why would docs behave that way? Apart from the very rare case of Munchausen’s syndrome, where people feign illness to gain attention, or doctor-shoppers seeking prescriptions for narcotics, its hard to posit a logical argument against a second opinion.

However, logic doesn’t necessarily get in the way of behaviour.

Physicians may feel slighted by the request. We take pride in our professional ability and may be upset at the thought that someone has questioned our diagnostic acumen. The message here: I get it right every time.

Perhaps a physician is insecure about his ability. This may be subconscious, or a conscious realization of inadequate skills and/or knowledge that could be revealed under scrutiny by another physician.

Some docs may have financial motivations. If being paid fee-for-service, there is an incentive (particularly for surgeons) to keep patients in their practice. If a surgeon is flush with referrals, and has a long wait list for surgery, he has enough “inventory” to maintain his income. If not, he may be tempted to “maintain control” of patients.

Physician paternalism is another factor. Docs pride themselves on having their patient’s best interest at heart, even to the point of making decisions on behalf of the patient. They may see the request for a second opinion as a rejection of their caring.

As physicians, we need to remind ourselves that we don’t own our patients - they choose to consult us. The therapeutic relationship can be strengthened by our openness to seeking a second opinion, as it demonstrates our humility and willingness to learn, as well as our true concern for the well-being of our patients, rather than our egos.

The other issue this reader’s question raises is that of detrimental effects of consolidating medical services in one place. I’ve already flogged the benefits including efficiency, improved access and standardization of procedures. But, there is a dark side.

There have been practical problems for our patients, stemming from our practice structure. While we are open to patients seeking second opinions from within our group, there are circumstances where we have to end a relationship with a patient. This is rare, but there have been instances of personality conflicts between a patient and one of our docs that make it impossible for them to continue in a physician-patient relationship. Because our partnerships shares call and patient care responsibilities, our policy in those rare cases is that we decline to provide any care for that patient. They would then need to travel outside Saskatoon to obtain urologic care. Because of the significant burden that may place on a patient, we haven’t made that decision lightly and without considerable discussion.

Our group (and others like ours) is essentially a monopoly. Take it or leave it. Drive 3 hours to see another urologist. If you can get an appointment, that is.

Well, that’s not our attitude, but what if it were? What’s to stop any monopoly from doing exactly as it pleases for its own benefit? Customer be damned! And when I say monopoly, that could be our group, the entire medical profession, or the government-administered health care system.

In the case of medical groups, there are internal and external checks against degradation of service.

Internally, we rely on a culture of professionalism and altruism. This stems from our perception of our roles in society, and from behaviour we’ve internalized throughout our training and practice. In our group, peer expectations drive a desire to provide current and competent care. We (both physicians and office staff) pride ourselves on considering our patients’ needs and convenience. But, it’s also possible that a different culture could prevail, and lead to very different behaviour.

Externally, there are implicit expectations from peers, patients and society. Explicit expectations come from regulatory/licensing bodies that produce and enforce practice standards.

If internal influences weren’t working to maintain excellent standards of care, how would the external checks become involved? For example, what if we decided to “coast” on our knowledge and skills, and not offer the most current surgical techniques (and not inform our patients of the more up-to-date options)?

First, someone would need to recognize the problem. That may be our patients, but there is a significant inequality of access to information between patients and physicians (pace Internet), and I think it would be years before any but the most discriminating and ├╝ber-informed patient would realize anything was amiss.

Peer-review programs conducted by regulatory bodies would pick up some problems, such as gross misdiagnosis or out-of-date treatment. But, peer reviewers would be unlikely to identify quality problems such as poor access, as some are so pervasive that they are accepted as inevitable!

Patients may be reluctant to report a perceived problem for fear of being ostracized, tied up in red tape, or jeopardizing the sole source of medical care (no matter how inadequate) in their community.

When a monopoly’s internal culture fails to ensure appropriate service (or whatever its stated purpose may be), it falls to external influences to apply incentives. In the case of our practice, that would mean the health region, College of Physicians of Surgeons, or the courts. In the case of the entire country’s health care system, well, maybe someone needs to go all 1789 on it.

Thanks for the question!

Sunday, August 29, 2010

Summer in the Pool

Summertime has traditionally been a challenge for our efforts to improve access. As we are working with half the number of urologists, patient wait times usually increase in the summer and early fall. This reduced office capacity is slightly tempered by the fact that the hospitals close some operating rooms in the summer, meaning that surgeons can spend more time seeing patients in their offices. Of course, this just transfers the bottleneck of patient flow further up the line by lengthening waits for surgery. Zero sum game.

Here’s how things look at the end of the summer:

As anticipated, wait times climbed after the success of the springtime “blitz”. I expect them to fall again as all the docs get back from holidays.

But, here’s an interesting chart that Erin, one of our office staff, has put together:

The top line is the clinic average for 3rd next available appointment (3NAA). The bottom line is the shortest 3rd NAA. Erin selected the doc with the shortest wait for each date and plotted it against the average wait. Because we offer pooled referrals, I think the lower line more closely reflects actual patient experience.

Our pooled referral philosophy is this: We will automatically assign a newly referred patient to see the urologist with the shortest wait time, unless the patient/referring physician choose otherwise (they rarely do). If the patient requires the special expertise of one of us, we will make the appointment with that urologist. If a patient already has a relationship with one of our urologists, we will maintain continuity of care for them, and schedule them to see their regular urologist.

This comparison graph alone should convince patients and physicians of the benefits of a pooled referral system.

I wonder about the “zero” 3NAA points. This means that the doc had 3 open slots on the day of measurement. Because our demand comes from external physician referrals, it’s unlikely we would have filled those slots.

Once we receive a referral, we would have to contact the patient immediately in order for them to be seen on the same day. Unless the referring physician had phoned us about an urgent/emergency consultation for a patient who was still in their office, and then sent that patient right over to see us, they would likely wait for at least a day or two before being seen. As such, we may be wasting some capacity. We’ll review this to make sure we’re filling all available slots.

Sunday, July 18, 2010

Adopting voice-recognition software – Am I an innovator or am I reckless?

Sometimes, adapting to new technology can challenge even the most enthusiastic gadget freaks. I have long been anticipating trying voice-recognition software for office dictation. Three weeks ago, several of us installed Dragon voice recognition software and have been trying it out. There have definitely been some growing pains.

Our traditional dictation and transcription system in the office had been used for several decades. We dictated our correspondence on to cassette tapes and this was transcribed by our staff in the office. In addition to dictating letters and consultations, we would also include any instructions such as x-rays to schedule or follow-up office appointments. We generate a lot of letters every day in the office, as this is a consulting practice and we try to communicate promptly back to referring physicians. We were finding that our office transcriptionists were having difficulty keeping up on the volume of transcription generated every day.

Several years ago, we switched to using digital voice recorders and sending the files offshore to be transcribed. Our dictation would be transcribed into a word document which was then returned to us electronically. Our staff would still have to paste the document into our electronic medical record so that it was assigned to the correct patient. They would also add the referring doctor’s address and the patient identifying information. A letter would then be printed out and given to the doctor to proofread. Staff would then fax it to the referring physician.

When we switched to a different EMR system last fall, we stopped printing out letters, but the letter would still be placed in an electronic queue that had to be reviewed by each urologist before being faxed to the referring doctor. If I were to be away from the office for more than one week, I would leave instructions for staff to send out letters "dictated but not read". This would speed the process of getting the consultation letter back to the referring physician, rather than waiting until I returned to work. However, even though our transcriptionists are very diligent in looking for errors in our letters, a misplaced decimal point in a drug dosage or laboratory result, or the word "not" inserted, or omitted, by accident can completely change the context of a sentence. As such, I prefer to proofread all my letters. The downside of this is that the letter has to come back to me and I have to spend the time reading it, sometimes referring back to the patient's chart to see whether the information contained in the letter is correct.

At best, the time from dictation to receipt of the letter by the referring physician would be 48 hours. That's a pretty good turnaround time. However, reviewing dictation tends to be a low priority as compared with reviewing lab reports, or returning patients phone calls. As such, letters would sometimes wait a week before being faxed to the referring physician.

With the Dragon voice recognition software, we hoped to be able to dictate consultation letters directly into our EMR. Because the EMR takes the text of our consultation and then generates all the "fixin's" for the letter (e.g. letterhead, date, referring physician name and address, salutation, patient identifying information), we wouldn't need our transcription staff to do that. It's a matter of only a few mouse clicks to get a consultation letter faxed directly to the referring physician.

That means that our consultation letters get to the referring physician almost immediately after we've seen the patient. But, this improvement in turnaround time isn't the main reason that we decided to try voice-recognition software.

Being able to see my dictation immediately lets me correct any errors right away rather than needing to see the letter again for proofreading. While proofreading usually only takes a few seconds, I sometimes need to return to the patient's chart to double check lab or x-ray results. When there are 20 or 30 letters to check at a time, this review can take 10 or 15 minutes. So, voice-recognition software may be a way to improve our workflow.

Also, our current dictation system involves the cost of offshore transcription and also our office transcriptionists who receive the transcribed text and generate letters in our EMR. The voice recognition software is a onetime cost and we should be able to save the fee from our offshore transcription service.


While the latest version of Dragon is quite impressive right out of the box, it does take some training to allow the software to recognize your voice and patterns of speech. The software comes with several prepared texts that the user reads to train the software. We are using the medical version of Dragon and it has several medical scripts to read. It's a fairly lengthy process that takes 2 or 3 hours to go through. However, it was immediately obvious that training the software made a big difference in how we could recognize my voice.

Also, as I do daily dictation, any errors that the software makes can be corrected and the program can be "trained" to recognize how I pronounce certain words. This has been very important with some medical vocabulary. However, I have found that, even with repeat training on the same word, Dragon keeps making the same mistake. For urologists, having to repeatedly correct "nephrostomy" (often misspelled as "frosty me") and "bladder" (often misspelled as "blatter") can be quite annoying. However, in this 3rd week that I've been using Dragon, I've been noticing marked improvements in how it recognizes my voice and gets the spelling correct. Or, perhaps I have become more accustomed to speaking slowly and clearly with better diction. Either way, I'm more satisfied this week than I was in the 1st 2 weeks.

Even so, it's obvious to me that using Dragon voice recognition takes a little bit longer than our traditional system of dictating into a recorder and then handing that recorder to our staff. Many of the corrections and all of the formatting of letters are then done by our transcription staff. The question is whether overall workflow improves (including initial dictation, proofreading and getting the letter out to the referring physician) with voice recognition software. After I had been using Dragon for 2 weeks, I did a little trial on this. I wanted to compare how long it took to dictate a consultation letter using Dragon versus how long our traditional dictation would take.

Initially, I thought I would measure the difference by timing how long it took to dictate a letter in Dragon, including any corrections. I would then do a "simulated dictation" by reading the Dragon letter that I had just dictated at about the same speed that I was used to dictating into a digital recorder. I expected that the 2nd reading would be quicker. But, it seemed it would be somewhat artificial because the 2nd reading would not require any references back to the chart to look up x-ray results or lab data.

With that in mind, I decided to do the simulated dictation first, including pauses to look back at chart results or think about what I wanted to say in the next sentence. I would then dictate the same consultation letter (from memory) in Dragon, trying to re-create the same content. I would pause to make corrections and also include the time for review/proofreading at the end of the Dragon dictation. This method probably wouldn't stand up to scientific scrutiny, but it seemed like a reasonable comparison for my needs.

I measured dictation for 4 patients (admittedly, a small sample size) on July 9. The average "simulated" dictation time (mm:ss) was 1:54, and the average Dragon time was 2:48.

I felt that 2 minutes would be the average time I would take to dictate a full consultation letter. The Dragon dictation took almost twice as long as that or, an additional 2 minutes. While this doesn't sound like much time, it's an extra half-hour of dictation for a half-day clinic of 16 patients. In one case, the Dragon dictation was especially lengthy as there were many medical/urologic terms that I had to correct, train the program for, or typed in by hand. This was quite frustrating.

Then, I realized that I had missed out one part of the workflow, namely receiving the simulated dictation back for proofreading. I didn't want to do a simulated proofreading immediately after I had just dictated these letters, as I felt it would not realistically represent the 2 to 3 day time lag between dictation (and familiarity with the patient's medical record) and review. I wanted to leave some time before reviewing the letters so that I would not remember details of lab results and x-ray reports. If it was necessary to refer back to the chart, I would include that time in the "review time".

The average review time for these 4 letters was 0:27.

This was somewhat artificial as well, because all the letters that I was reviewing were ones that I had already proofread as I dictated them in Dragon. I've corrected all the mistakes been, so it was just a case of reading straight through the letter. I did not need to stop and make corrections. Also, these particular letters didn't correspond to cases where there was a lot of lab data or x-ray information to review. So, the review time I have measured is probably the shortest possible time.

Even factoring in the review time, Dragon dictation is taking longer. As I mentioned before, I made these measurements when I had been using the voice recognition software for about 2 weeks. Over the last week, I have noticed a definite improvement in accuracy and my ability to dictate at a more rapid and natural pace of speech. In fact, I've been dictating all of this blog post in Dragon and have been quite pleased with the software's accuracy. Of course, I'm not using a lot of medical jargon and that does seem to make a difference.

During a trial period, 4 of us are testing the Dragon software. It's fairly expensive, and we didn't want to implement it for the whole office if it looked like it would not be useful. At this point, I think I will be sticking with the Dragon software, but I don't think it would be suitable for all of our partners. It required a lot of extra work for the 1st 2 weeks and there was a lot of frustration with having to make corrections and train the software properly. Unfortunately, all of that extra work has to be done while conducting all of our regular clinical work. If there were an obvious and pronounced workflow improvement, I think this would be a big selling point for my partners who are less "technologically keen". Perhaps I will get to the stage using Dragon that I can make that claim to them, but at present, I don't think it will be worth the frustration to them to try this software.

Obviously, we selected the 4 partners who were most keen on new technology to try out the Dragon voice recognition software. Even so, there have been different levels of enthusiasm and it's not clear that everyone is going to stick with using it. We will only know in retrospect whether it was worth trying. Even if just a few of us are using it however, we should save a significant amount of money on the transcription that we were previously outsourcing.

The uncertainty as to whether our trial of voice recognition software will turn out to be a success or failure made me think about that classic representation of diffusion of innovation -- the Rogers curve. Even if you don't recognize the name, you've likely seen this bell-shaped curve before. At one end of the curve are the innovators who take a risk in adopting changes very quickly. Early adopters are next, followed by the early majority. The late majority and laggards accept change last. The subtext of this model is that the innovators are brilliant and the laggards are Luddites.

This interpretation depends on which innovation you choose. For something that has, in retrospect, changed lives for the better, such as electricity or handwashing, then the Rogers curve makes sense. But, what if we choose an innovation that turns out to be unsuccessful or harmful, such as thalidomide or drilling a deep water oil well in the Gulf of Mexico? In that case, I propose a different version of the innovation uptake curve. (If you want to start calling it the Visvanathan curve, who am I to stop you?)

In this curve, the innovators would be "reckless", early adopters would be "foolhardy", and the early majority would be "conformists". The late majority would be "skeptics", and the laggards would be renamed "fine, sensible folk - brilliant, in fact!" It would all depend on whether or not time and society judged the particular innovation to be successful.

It remains to be seen whether trying the Dragon voice recognition software is going to rank me as an innovator or as reckless.

Sunday, July 4, 2010

Private CT clinics: Cornucopia or Juggernaut?

Get your reading glasses on. And get ready to rumble. It’s time for health policy cagefighting! In this corner – the Advanced Access Afficionado. In the other corner – politicians, bureaucrats and political commentators. Guess who’s wearing black?

Last month, the Saskatchewan government announced that it was looking for a 3rd party supplier to provide CT scan services (1). The intent is to reduce wait times. Of course, that got my attention.

(Note: Because some links to media sources seem to vanish unpredictably, I’ve included the text of all the stories referenced in this post in an appendix. If you try a link and it doesn’t lead anywhere, scroll down to the end of the post. P.S. July12,2010 -because of some concerns about copyright, have removed the text that was initially pasted at the end of this post. So, sorry if the links to op-eds turn into deadends. KV)

The article focused on the response from the opposition NDP party, namely that this was a step toward the piece-by-piece privatization of health care. Commentary by the Leader-Post’s Murray Mandryk (2) lambasted the NDP for being hypocritical and dogmatic in their opposition to privately-operated CT clinics.

Whether or not the NDP is hypocritical in opposing this CT clinic is beside the point. The clinic has been portrayed as necessary because Saskatchewan needs more CT scanning capacity. Fans of wait time reduction strategies should smell a rat. Healthcare wait times sometimes result from inadequate capacity, but more often result from a mismatch between demand and capacity. Over time, backlog builds, even when demand and capacity are balanced.

Adding permanent capacity to manage backlog will be successful, but in the end, is wasteful. Once the backlog is dealt with, you need to mothball that extra capacity. Expensive CT scanners, professional staff and clinic investors don’t like mothballs. That’s the point I tried to make in an op-ed response (3), giving our clinic’s experience with Advanced Access as an example of ways to cut wait times without permanently adding capacity.

Weighing in on the same issue was Steven Lewis who, in addition to providing some analysis around safety and appropriateness of CT scans (4), called for open discussion around the risks and benefits of a privately-operated clinic. Stan Rice expressed his skepticism (5) with a financial analysis of private vs public CT scanners.

Mandryk responded to the op-ed pieces with “Informed health debate overdue” (6). While his statement “Like me, many of you might be troubled by the underlying premise that we can somehow turn back the clock by performing fewer diagnostic tests” puts him firmly in the “more is better” camp, I agree with his call for debate around this issue. I don’t think it’s going to happen, though.

The government has already stated its intention to support the privately-operated CT clinic, and has called for proposals. Sask Health doesn’t lack expertise around wait time reduction strategies, so I can’t imagine that this decision was made without full (internal) discussion of alternatives. If I were in the decision-maker’s shoes, I can see the appeal of the private option. It’s actually easier to take this approach than opt for the drawn out process of increasing efficiency and appropriateness of testing. To saying nothing of having to change the culture of “more is better”!

I don’t doubt that this strategy is going to work. Wait times will drop. It will make for some very satisfying headlines. And, as long as that’s as deep as the analysis goes, certain skeptics will be invited to eat their words.

It’s very tempting to wonder why “they just don’t get it”. Why can’t “they” see this issue as clearly as me? But, as soon as I start thinking that way, I play the Switch game in my head. What is it in this situation that I’m missing? If I’m truly convinced that Advanced Access methods can reduce wait times and provide appropriate, timely testing for Saskatchewan, and that building privately-operated capacity is not the answer, what’s the appropriate forum for debate? What’s the best way to illustrate the admittedly counterintuitive principles of Advanced Access so that policy-makers will embrace them over the more expeditious solution?

If politicians are driven by the belief that citizens need the quick fix afforded by an extra CT scanner, maybe the audience to be convinced is the entire (voting) population of Saskatchewan. I think I’m in over my head.

In answer to the question in the title of this post, it’s both. It’s a juggernaut because it seems unstoppable. It’s a cornucopia because many patients will benefit from the bounty of increased capacity.

But, can you have such a bountiful harvest without some of the fruit going to waste? How much goes to waste, and whether anyone bothers to keep track, remains to be seen.

Sunday, June 20, 2010

It's a start

Congratulations to Sask Health on a big step in the right direction.

I mentioned in a previous post that I think pooled referrals should be facilitated not by "forcing" patients to see the first available specialist, but rather by providing them with accurate, up-to-date information about specialist wait times. Each person will then make their own informed decision. Sask Health has made a start toward achieving that. A website that lists specialist wait times has recently been released for public viewing. Now that we have transparency covered, we need to work on accuracy.

The website contains information on how long you could expect to wait for surgery with a given surgeon, had also how long he would wait for initial consultation with that surgeon. The surgery wait time information is updated monthly and is based on accurate information from health region databases. The consultation wait time information, only other hand, is self-reported by physicians. The biggest problem with this is that most physicians don't really know how long patients are waiting to see them. Also, physicians may be using different measures to estimate wait times.

For example, the "industry standard" for reporting patient wait times is the 3rd next available appointment (3rd NAA). This requires some basic understanding of Advanced Access principles and also takes some effort to calculate. There is no explicit incentive to make the effort to calculate 3rd NAA time.

Some electronic medical record programs have the ability to calculate 3rd NAA. However, when we tried it in our EMR, we got a result that was very different from our hand-calculated number. When we investigated that further we found that it was due to the way we book appointments in the electronic scheduler. Because our practice consists of scheduling office, cystoscopy, OR, lithotripsy and outpatient visits, the EMR software was finding openings in bookings other than just office appointments. It would have saved us a lot of time if we could just press a button and have a reliable 3rd NAA measurement but we are still unable to do that. Perhaps family physicians or specialists who only work in their office would have more luck. Unfortunately, virtually all surgeons will be working in more than one location.

Until all surgeons are involved with Advanced Access (someday soon!), the wait times listed on the website are unlikely to be reliable. Even so, that unreliability of the data is likely to be unintentional. There may be reasons why surgeons might"cook the data".

In our urology practice, we have the luxury of being the only group in Saskatoon. We are not competing for work. In fact, as I mentioned in my last post, there may even be a disincentive for us to improve our wait times because it will likely generate more and more consultations from outside of our traditional practice area. However, some specialty groups may be in direct competition with each other. In that case, they may gain a competitive advantage if they were to list consultation wait times as being shorter than reality.

Who will audit the wait times? How will they audit the wait times? If we agree that 3rd NAA should be the provincial standard, then an auditor would need to have access to each surgeon’s office scheduling records. They will likely need to do a manual calculation because EMR programs don't seem to be able to churn out accurate 3rd NAA figures (given complex schedules that are the norm in surgical practices). I suppose that the website managers could mandate that each surgeon's office must submit an accurate 3rd NAA figure on a monthly basis (and then do random audits to ensure compliance), but it would also be necessary to provide some financial reimbursement for surgeons to make that effort.

All of this presumes that the website actually has some value for patients and family physicians. The purpose of disseminating this information is to allow patients, along with their family physicians, to make better decisions as to which specialist they wish to be referred to. In order to be sure that this information is useful, and being used, the administrators would need to sit down with some focus groups to see what conclusions patients draw from this information, and how it influences their choice of specialist. Without knowing how consumers really use this information, and how they navigate the website, it's impossible to know whether it's of any value.

So, unless an investment is made in gathering accurate and timely wait time information, and also in determining how to make the website valuable for consumers, this is an exercise in public relations. Consumers need to know how the information is gathered (e.g. calculated 3rd NAA versus "best guess") and when it was last updated.

Let me revise my initial statement: Sask health has taken a baby step. But, it's still in the right direction!

Monday, June 7, 2010

Come one, come all

We’re still riding the crest of the backlog blitz’s success. Or maybe, the trough, given the curve on our 3rd NAA chart:

This shows an average of all our urologists’ 3rd NAA. Many patients are being scheduled within 10 days of referral. I wonder if it will last? Summer holidays temporary drop our capacity. Backlog may creep up again.

A factor outside our control is demand from outside our traditional service area. While patients can be referred from anywhere in Saskatchewan, most of our referrals are from the “north” of the province. Early on in our Advanced Access project, however, publicity around our quest for improved access garnered us attention from referring physicians in the south. Seeking prompt urologic consultation for their patients lead some of them to refer patients to Saskatoon rather than somewhat urologically under-serviced Regina.

As our new, shorter wait times become widely known (perhaps someone should keep his blogging mouth shut!), this will likely recur. Each patient will have an individual tipping point (based on pain and suffering, or perception of disease seriousness) that will convince them to travel the extra miles to see us. As our access improves, more patients will be referred to us. Our efforts will be “rewarded” with more work!

The outstanding success stories of Advanced Access are achieved in closed systems, known as capitation. Physicians or, more often, large practice groups are assigned a set number of patients for whom they have responsibility for providing care. They receive set funding and so have strong motivation to develop systems that are efficient, while still satisfying patient needs. If these physicians successfully implement Advanced Access (and more broadly, Clinical Practice Redesign), they may be rewarded with financial bonuses and less hectic practices.

But, if their practices are open to any and all new patients, any time freed up by effective practice management will be quickly filled. So, why would they make the effort in the first place?

As our docs are essentially private contractors being paid fee-for-service, there’s no geographic boundary on which patients can be referred to us. If we did negotiate an “alternate payment plan” (a term used to allay physician’s distaste of “salary”) with the government, it would include clear boundaries for how many patients and for what health regions we were to service. That would be a big motivation for us to pursue further CPR efforts, because, although we wouldn’t be paid more, our practice could be less busy and we could have more time off.

But, what would happen in areas of Saskatchewan that were under-serviced? There would be a lot of pressure on local healthcare administrators, and on the government, to deal with the problem at the regional level, rather than relying on our group to pick up the slack. That might get pretty uncomfortable for them.

I wonder if the government realizes what a sweet deal they are getting with fee-for-service physicians?

Tuesday, May 25, 2010


Remember Gilligan’s Island? No? Well, the rest of us will wait here while you catch up.

Part of the fun I had while watching that TV show was seeing the incredible contraptions – from a washing machine to a pedal-powered car - the castaways constructed to make their life easier. (I still enjoy hearing about ingenious solutions to everyday problems. That’s part of what has made our Clinical Practice Redesign project satisfying to me.)

But, the Gilligan’s Island community had its limitations. Even though each of the 7 residents played a unique role (only 6 roles, if you count the Howell’s as one amalgamated upper-class twit), they never managed to reach their goal of leaving the island. Even though the island was idyllic, both naturally and due to their bamboo gadgetry, they still wanted to go home. But, they were never able to muster the resources to do so. The castaways occasionally had visitors from the outside world, but circumstances were comically contrived so that escape remained elusive.

I think we’re in a Gilligan’s Island situation in our office. We’ve made a lot of successful internal changes. Our practice is more efficient and (we hope!) more effective. But, there are some changes that we can’t make on our own island. We rely on other practitioners and services to provide a continuum of patient care. But circumstances remain not-so-comically contrived to that improved patient access remains elusive.

The wait time for specialist consultation has been our main target. But, that’s only one part of what makes up the patient’s experience. Patients wait to see their GP, then for testing, then to review the tests with their GP, then for a specialist referral, and so on, until they have their problem resolved. A more patient-centred metric would be to measure the time between onset of symptoms to complete recovery. Attempts to measure this time illustrate the complexity of our healthcare system, and the interrelationships between individual departments.

Our recent office blitz made us more aware of the way our private practice meshes with other parts of Saskatoon Health Region (SHR). We anticipated that we would need better access to xray procedures – mainly CT scans – in order to be able to schedule patients on short notice. The SHR xray department was very helpful when we approached them about this, and allotted specific times for our blitz patients to receive CT scans.

However, the increased patient volume over the blitz period caused a surge in the number of other procedures being scheduled, and we haven’t received additional resources to deal with that. Cystoscopies have been particularly challenging to complete in a timely fashion. Also, many of our patients still wait up to a year for certain kinds of surgery.

The problem is that we’re all living on individual healthcare islands, each with its own culture. On some of the islands, conditions are rough and the inhabitants are motivated to make changes to improve their lot. I’ve been told that family practitioners are among the first to adopt Clinical Practice Redesign because they are overwhelmed by patient load and the need help to deal with multiple, chronic medical problems in their patients.

On other islands/practices, life is good – perfect weather, low-hanging fruit, no annoying insects. Why would anyone ever want to change? I’m not suggesting that anyone working in healthcare has this perfect situation, but some of us are more comfortable than others. And so, when the hard-living inhabitants of one island call for help from their more fortunate neighbors, what’s in it for those living the easy life? We market Clinical Practice Redesign by telling doctors “Trust us. If you try it, things will be better!” (Disclaimer: I think it is better!) If you were living in paradise, would you want to take a chance that the next island over was an even better paradise?

To get everyone working toward the same goal, someone has to turn up the heat. On Gilligan’s Island, it would be a plot device like rumbling and smoke coming from the island’s volcano. In healthcare, motivation could come from various sources:

- Make public, transparent and accurate reports of wait times for GP and specialist visits, cancer treatment, surgical and other procedures. Report by practitioner and health region. We’re a competitive bunch, and no one wants to be at the back of the pack.

- Make it financially disadvantageous to ignore long wait times. Reward practitioners who manage their resources wisely. Put your money where your mouth is.

- Offer support and education to help practitioners apply Advanced Access principles. People can’t improve the system if they don’t know what tools are available (see “Juice”).

- Prove that paradise does exist – showcase examples of successful initiatives that have improved the lives of patients and practitioners.

Anyone know where we can find an angry volcano god?

Monday, May 10, 2010

Scratching the Itch

I know you’re excited to find out how the blitz weeks went. I’m excited too. I’ll show you in a minute.

First, I want to tell you about the latest change we’re going to try in our practice. It’s so simple, and is already standard in many practices, so I was unsure if this change was even worth mentioning. But then I realized, That’s exactly the point!

When trying to implement Clinical Practice Redesign (CPR), simpler is better. This is especially true for practices that are new to CPR. Learning the processes, measurements and jargon of CPR can be intimidating and overwhelming. A simple practice change involves minimal investment of time and manpower, and minimal loss if the trial doesn’t succeed the first time.

Trying something that is already in place elsewhere also improves the chance of success. Someone else has already worked out the kinks and shown that the procedure is viable - in their practice, at least! While it can be very satisfying to develop a novel idea to solve a problem, it also requires a lot of effort. Better to borrow shamelessly.

So, here’s the plan: For men referred to have a vasectomy, we’re going to offer them a single-visit consultation and procedure. Yeah, I know – it’s a little underwhelming. But consider what this change involves, and what the process illustrates about making these changes in clinical practice.

1. Feel the itch

In general, I think of the whole change process as “Scratching the Itch”. (An iffy metaphor in a urology practice, but bear with me…) The specific itch I wanted to scratch this time was the value (or, lack thereof) my patients received when referred for a vasectomy. Our tradition is to see the man for a consultation in our office, ask about his medical history, examine him to determine suitability for the procedure, and then discuss what’s involved. If he is in agreement to go ahead, we schedule the vasectomy date, often 3 or 4 months from the initial visit.

Many men are surprised and disappointed to find out that they are not scheduled to have the vasectomy performed right then and there. I have offered several reasons why that doesn’t happen:

I perform vasectomies in the hospital outpatient clinic, and don’t have the necessary equipment at our office.

I need to examine the man first, as some men’s anatomy precludes doing the vasectomy under local anaesthetic in the outpatient clinic, and may require a booking in the operating room under general anaesthetic.

Some men only want to come for a consultation to find out what the procedure involves, and choose not to book the vasectomy at that time. If I scheduled an “all-in-one” visit, then the additional time scheduled to do the procedure would be wasted.

I’m sure those reasons often rang hollow with my patients, because they sure felt that way to me. The rebuttals were obvious:

Well, then, get some equipment in your office! Or, do everything in one visit at the hospital. I just drove 3 hours for a 5 minute visit! Now, I find out that I’ll have to come back for a second visit.

My own doctor examined me before he sent you the referral. He said everything was normal. How often do men need a general anaesthetic for a vasectomy, anyway? That can’t be too common.

I definitely want the vasectomy done. I would have told you that, if you had asked.

There was definitely an itch ready for scratching!

2. First, a gentle scratch

A couple of us scheduled a few vasectomy/consult all-in-one visits to work out any hitches. Hitches, what hitches? In fact, there was immediate, positive feedback from our patients who welcomed having everything done in one trip. We had sent all of them our vasectomy information pamphlet at the time we made their booking, so they were well-informed about what to expect during and after the procedure.

3. Then, scratch it hard

We presented the idea to our entire group. The selling points were better patient service and satisfaction, and fewer low-value (for the patient) office visits (which equals more capacity to see new consultations). We also addressed the potential problems with this change:

A no-show patient “wastes” valuable procedure time.

The man may not be suitable for vasectomy done with local anaesthetic, and need to be rebooked at a later date with a general anaesthetic. More wasted procedure time.

Combining the consultation with the procedure may take longer than the usual 30 minutes scheduled for a vasectomy alone, making us run late.

I think it’s important to present a balanced view of proposed changes. If skeptics sense that enthusiasts are charging blindly ahead, they step hard on the brakes. If that is their first impression of the proposal, negativity becomes entrenched and difficult to overcome. However, if you can show skeptics that you’ve considered and addressed potential risks, I think the proposal is judged on its own merits, rather than becoming a pawn in the broader skeptic vs. enthusiast tug-of-war. (In which battle, the skeptics have the huge advantage of inertia.)

Here’s how we addressed the potential risks:

We would require that men confirm their appointment time, in the same way patients have to confirm their date for surgery. This should reduce no-shows. However, we’ll track no-shows, and consider phone reminders if the numbers are significant.

If a referring GP comments on potential anatomical challenges in his referral letter, or the GP has unsuccessfully attempted the vasectomy, then we’ll arrange to see the man for a prior consultation in the office, rather than booking the vasectomy at the same visit.

We’ll schedule 45 minutes for a vasectomy/consultation, or 2 hours for 3 procedures.

The outcome? Everyone agreed to try it, and actually seemed quite keen.

4. “Does this rash look infected to you?” – Get a second opinion

I was pretty pleased with how it had gone, and how all the bases had been covered. But, I had forgotten one thing. I didn’t ask the people who know how our system really works – out staff. Delores pointed out to me that, in our current system, men receive their office appointment notification quite soon after they are referred. Even though they may wait several weeks to see us, they know that we have received the referral letter and have made arrangements. They will not find out about the date for the vasectomy until after the office visit, and may need to wait several months to have the procedure.

Delores went on to say that, in our new system, patients wouldn’t hear from us for several months. We schedule surgery up to several months in advance, and then plan office schedules and minor procedures (like vasectomies) around our OR time. Scheduling vasectomies comes last. Delores predicted that we would be swamped with phone calls from men who were wondering whether or not we had received their GP’s referral. That’s a waste of both the man’s and our staff’s time and energy.

Her solution was that, upon receipt of a vasectomy referral, staff would send the man a letter to let him know that we had his information and would be sending out an appointment in several weeks. Great idea!

I think this change will stick because it doesn’t involve a big change in physician behaviour. We’re taking 2 established practices – office visit, and vasectomy procedure – with which our docs are already comfortable, and redesigning them both to improve patient satisfaction and practice efficiency. Initially, I felt embarrassed to mention that we were making this change. I know it’s already standard procedure in many practices, so I thought someone would read this lengthy dissection, slap himself on the forehead and say “Duh! What took you so long?”

The point here, and in any practice that is trying to improve, is that the changes that make a difference are small and mundane. Individually, they seem trifling, but will eventually coalesce into something powerful.

Let’s celebrate each other’s small victories.

And now, blitz week results! These are hot off the press. The last data point is from May 6 – the end of 7 weeks of extra office capacity.


The trend looks good!

And means nothing. Seven weeks of office blitz will only have been worth it if we can maintain the gains. We need to see the long-term results, and our annual nemesis is almost upon us. Curse you, summertime, with your unquenchable 30-new-referrals-a-day demand and capacity-hobbling holidays, curse you!