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!