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!