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!


  1. Kishore- thanks for tackling this and for your continued leadership. I think it is important to note that the change in sterilization process was required in order to meet national infection control standards, which is part of our commitment to patient safety. This is also required to meet accreditation standards and our accountability to the Ministry of Health.

    Maura Davies,
    President and CEO, SHR

  2. I must add to Maura's statement and address a given in the health care system today. It stands around the regulatory bodies making changes in techniques as the processing of the scopes, without having profound data to support and advocate their decision. The sterilization increase in time has caused much greater harm to those patients having to wait longer. I am also willing to believe based on our data at some surgery centers that possibly more harm than good in oncology alone. Regulators jump on the band wagon of increasing regulation versus increasing the surveillance of the regulatory bodies. I also believe that the majority of centers did not practice the best sterilization techniques of their instruments, thus the outcome is negative and with infectious results. Observe more places making their everyday routine to be the standard versus adding to the standard is where health care reform needs to start. Regretfully, patients suffer because of the lack of supervision that endoscopic centers have in that we all know that "while the cat is away, the mice will play". Cutting corners is what we do in health care, I am not proud of it, but it is what it is. What is the answer? The answer is that we need to get back to the basics of providing care and do our jobs and do them well. To do our jobs, we need the time to do them and with all the cuts, downsizing that happens religiously these days, we must pump more volume in without ensuring the quality of our outcomes are increased with the pump. Troy Lair, The Compliance Doctor, LLC

  3. This is a fascinating challenge. It shows the complexity of a surgeon's life. Any scheduling change in one area creates a "ripple effect" for other areas. In this case, there is a touch choice: OR vs. cystoscopy suite. The OR wins because the potential resource wastage is greater there than for the cysto suite. There are still the same number of urologists, in town, so someone is doing fewer scopes!

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