Monday, December 12, 2011

Raising expectations in healthcare: Scotland NHS central line infections bottom out

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.

     - Arthur Schopenhauer

My son and I were browsing through the electronics store yesterday.

He picked up an Amazon Kindle e-reader and tried to make the text scroll by touching the screen.  He was puzzled when it didn't work.  We discovered that this model had button controls.  That is so 5 minutes ago!

He's used to touch-screens through playing with his brother's iPod Touch and Grandma's iPad, so he's come to expect that every electronic device works that way.  It's like the classic scene in Star Trek IV, when the crew goes back in time and Scotty tries to use an early-model computer:

As Schopenhauer predicted, Scotty is ridiculed for having expectations (his "truth") beyond what was thought possible in that era.

Last week, at the IHI National Forum, I had my expectations raised by someone else's truth.

Jason Leitch, NHS Scotland's National Clinical Lead for Quality, gave an energetic presentation about Scotland's healthcare quality strategy and results.  One slide stood out.  It showed the drop in central line infection rates since 2008.  The March 2011 data point was annotated "zero central line infections in whole country".

Entire country of Scotland.  Central line infections. None.

It's like getting rid of polio or smallpox.

I was imagining what it must be like to be a physician inserting a central line, or a nurse caring for one, in Scotland.  The motivation to follow standardized protocol meticulously must be tremendous.  The country's reputation is on the line!  Expectations are sky-high.

What if patients and families in other countries found out that central line infections can be avoided?  If they got hold of Scotland's data and the care bundle they use, expectations everywhere would be sky-high.  Then, after the ridicule and opposition (from healthcare professionals), it would become self-evident that these infections are a defect in care, and not inevitable.

Central line infections - how quaint!

Sunday, December 11, 2011

Give the people what they want! I'm experimenting with social media

I had the privilege to act as host for some of the Saskatchewan participants at last week's IHI National Forum.  As the organizers planned the trip, we discussed ways to communicate with each other while at the conference.  It's a huge venue with over 5000 attendees, so keeping in touch can be challenging.

We decided to try Twitter.  I was a little nervous as I had never tweeted before.  As you can see by the newly-added Twitter feed in the right column of this blog, I've become a convert.

Not everyone signed up for Twitter, but those who did found it very useful.  We were able to arrange impromptu meetings and share pearls from the sessions we attended.  We also made a fortuitous contact with Paul Levy.

You may be familiar with Paul Levy through his blog "Not Running a Hospital" (formerly "Running a Hospital").  As CEO (now retired) of Beth Israel Deaconess Hospital in Boston, Levy pioneered transparency by blogging about his hospital's complication rates.  He noticed that Sask IHI attendees were actively tweeting (hashtag #saskihi11) and tweeted his way to joining us for dinner.

It was a terrific opportunity to meet someone who has been a leader in using social media in health care.  As it turned out, Levy was IHI's social media guru-at-large, and conducted several well-attended sessions on using Twitter, Facebook and blogs.

His recommendations for bloggers got my attention: 300 words 3 times a week.  Levy suggested that frequent, shorter blog posts were more palatable for readers than infrequent, longer pieces (my usual style...).

Here's my next social media experiment: I would like you to tell me which form you prefer.  In the right hand column, I'll post a survey that will stay up for the next few days.  If there seems to be interest in more frequent posts, I'll do my best to change things up for several weeks, then repeat the survey.

Thanks for your help, and thanks for taking time to read this blog!

Saturday, December 10, 2011

Surgical checklist - Trying some changes I learned at IHI National Forum

"What can we do by Tuesday?"

You'll hear this phrase a lot when you're at the IHI National Forum, or similar QI events.  It's shorthand for:

 "We're all really excited about the possibilities for improvement that we've talked about.  We have the will to change and we've come up with some great ideas.  But, now comes the hard part: execution.  Once we all get back into our regular work lives, the enthusiasm we're feeling right now can be swept away by the relentless current of clinical tasks.  So, let's deliberately think about execution right now, before we're distracted by our "real work".  What can we try out first thing next week?  Let's make a commitment to a test of change, but make it a small one.  Try it one time, with one patient or colleague."

I made one of those commitments, but I couldn't wait for Tuesday.

While at last week's IHI meeting, I had attended several sessions discussing the surgical safety checklist.  All the speakers emphasized that the real value of the checklist in promoting communication and team building among OR staff.   So, while checking on antibiotic administration and the correct side for the procedure are critical, the checklist holds potential for a deeper benefit. 

The speakers talked about creating a "psychologically safe" environment in which everyone in the OR theatre has permission - in fact, is invited (required?) - to raise any concerns about patient safety. One surgeon told the story of a medical student who called a stop to preparation for surgery because he thought the patient's wrong ear was being operated on.  The staff reviewed the patient's record and determined that they were operating on the correct side, and the medical student was mistaken.  However, the surgeon praised the student for his courage and commitment to patient safety, and asked staff to applaud the student!  Now that's dedication to psychological safety!

In Saskatoon Health Region's current checklist, there's no explicit invitation to speak up like this.  The first version of our checklist began with having all staff in the room introduce themselves to each other and to the patient, but that component was dropped.  I wanted to try reintroducing that element, and also adding a personal invitation to everyone in the room to raise patient safety concerns. I decided to try it Friday (yesterday) morning, with one case. I planned to collect the staff's impressions of the expanded checklist after the surgery was completed.

I started by telling everyone in the room (an anesthetist and 2 OR nurses) about the IHI meeting and what I wanted to test.  We discussed this before we brought the patient into the room.  They agreed to try it.  

Once the patient joined us in the room, I explained that we would do our usual surgical checklist, but that we were also going to add the 2 elements.  We introduced ourselves by name and role, and I invited everyone to use the phrase "I have a concern..." if they had any safety concerns.  

After the surgery was finished and the patient went to the recovery room, we discussed the trial.  (Coincidentally, the nurses had talked about this issue at morning report, so it was fresh on their minds.)  Everyone was keen to have the introductions, particularly as there are often students, residents or other trainees in the room, and this is a way to be sure that everyone know everyone else, as well as their role.  The idea of the safety phrase was also well-received.

Next week, I'll try this again in a new room.  I'll likely be working with a different team. As the idea was well-received yesterday, I don't anticipate having to "sell" it by giving the IHI story again.  What I'm really interested in is the day when someone uses the "I have a concern..." safety phrase.  How will I respond to that interruption?  Will I ensure psychological safety?

Also, I'll be vigilant for occasions where someone could have used the safety phrase, yet didn't.  I suspect that will be the more common situation.  That could happen because of differing views on what a "patient safety concern" is, or because staff don't yet trust that I will be receptive to them raising a concern.

Wednesday, December 7, 2011

IHI lightning strikes again!

Before I left home for this week's IHI National Forum, I wondered if I would have as dramatic an experience as I did at my first IHI visit.  I'm not sure if you're allowed more than one epiphany.

5 years ago, the National Forum changed my career.  Seeing better ways of providing care, and learning the tools to implement those changes led to the improvement work our practice has undertaken.  It led to the chance to meet QI enthusiasts across the country.  It led to this blog.  So, I had high expectations that something at this year's meeting would show me yet a new direction for my QI journey.  

Until yesterday afternoon, I had been disappointed.

I've heard some incredible stories from presenters at the Forum, but they are all variations on themes I've heard before.  I was hoping for something earth-shaking.  

Then, I started hearing stories from other Saskatchewan attendees.  We're over 30 Saskatchewan-strong at the Forum, and to a person, thrilled to be here.   First-time attendees are enthusing about their experiences, like I did at my first visit.  They're talking about testing change ideas at home next week.  They're also anticipating some of the barriers they'll face: lack of time, inadequate resources, no team support.

That's when it struck me: The next step for me is to support others' work.  Making connections. Smoothing paths.  

Working on improving one practice has been satisfying; playing a part in improving many practices... I can hardly wait!

 IHI - you did it again!

Wednesday, November 30, 2011

Will lightning strike twice? My QI journey takes me back to IHI

My QI journey started 5 years ago at the IHI National Forum.  It was literally a life-changing experience for me.   This weekend, I'm going to the IHI National Forum again.  Will lightning strike twice?

That first visit opened my eyes to different ways of delivering and thinking about health care.  It sparked my interest in Clinical Practice Redesign (CPR), and through that work, gave rise to this blog. (Before you follow the link to my very first blog post - about my IHI visit - I want to say that I'd like to believe that my writing has... evolved since then.  Here it is.)  

CPR and QI work led to a relationship with Saskatchewan's Health Quality Council (HQC), which eventually resulted in the incredible opportunity to take a half-time, year-long consulting position with them.  

I've been privileged to be invited to share the results of our CPR work in Saskatchewan and across Canada.  Through these engagements, I've developed relationships with many other people who are likewise committed to improving Canadian health care.

My first IHI visit started me on this journey by showing me that there is a better way, and that there are robust methods by which to plot a new course and then make haste.  My career path has been radically altered by that experience.

What will next week bring?

Perhaps the last 5 years were "low-hanging fruit".  I was likely an easy convert.  I was already primed for the IHI experience and what followed.  Saskatoon Health Region wouldn't have sponsored my attendance if I hadn't expressed some interest in learning about QI.  I doubt that every attendee experiences the same epiphany that I did.  Unless they're putting something in the food. (That egg salad sandwich did taste a little funny.)

Last time, I learned to see a whole new world.  After having been immersed in QI for 5 years, can there possibly be another surprising experience waiting for me?

I hope so.

Wednesday, November 23, 2011

Major professorial cringe moment!

This morning, I had the opportunity to address the first year medical student class about Clinical Practice Redesign and our urology office project.  (I told you about last year's visit with the first year students in this post.  By the way, one of last year's students did contact me and we've been working on a practice redesign project since the summer.)   The best part of the presentation (for me, anyway) is the students' participation.  I've presented our practice work to many different audiences over the last 4 years, and first year medical students reliably ask the most probing questions.  Perhaps it's because we haven't yet brainwashed them into thinking about things "our way".

I try to encourage their participation with regular pauses and prompts.  And with a little bribery (Tim Hortons gift cards for randomly selected hand-raisers).  This group of students were enthusiastic with their questions and comments.

About 30 minutes into the session, I realized that we had spent so much time with questions that I was not going to finish my presentation on time.  Two students had their hands up, and I indicated we had time for one question, and then I would move on.

At the end of the session, the course instructor - who had been distributing the gift cards on my behalf - had reserved one of the cards and announced that it was for the student who I had passed over when she raised her hand.

I mentally kicked myself.  I realized that I had "got through the material" and finished showing the slide show I had created, but it was at the cost of stepping on the contribution of the students - the contribution that I had explicitly encouraged at the beginning of my presentation.  These students wouldn't have been worse off if they missed hearing just one of the half-dozen practice redesign examples I brought along.  The questions they asked were insightful enough to spark a discussion that was more enlightening than the slides I had to show.

And, after telling them that it was essential to focus on the patient's needs when redesigning their work, I had been totally "provider-centric" by satisfying my own compulsion to slog through my slide deck.  This is the product I have, and I'm going to give it to you, no matter what you want!

That wasn't the worst part.

After the lecture, I went over to the student to apologize for cutting her off and to hear her question.  She asked how we could tell if our practice's improvement efforts could make us "too efficient".

She illustrated her point with a personal story.  She had waited many months for a consultation with a specialist.  At the visit, the doctor made a diagnosis and gave her a sheet of paper containing information about the condition.  The doctor told her that this would give her the information she needed to manage her problem, and sent her on her way.

The student's comment was that although this was a very efficient way to use the specialist's time, she felt somewhat short-changed by not having adequate opportunity to interact and ask questions.

Her insight is known as "balancing measures".  Whenever we make a change in a system with the intent of improving one aspect of it, there may be unanticipated and unwanted consequences in another area.  For example, if I want to reduce the wait time for cystoscopic bladder examinations, I may decide to increase our daily capacity by 50%.  We'll reduce our wait time, but the nursing staff who assist me in the exam room will be run ragged.  They may take more sick time, or even ask for a transfer.  We could check this balancing measure by doing a staff satisfaction survey before and after the system change.

I reminded the student that her unsatisfactory consultant visit was a reminder that, when implementing system changes, we should always consider our primary goal: Putting the patient first.

That's when the cringe hit me.

In my quest to zip efficiently through my presentation, I lost sight of the real reason I was there: Putting the students first and encouraging a sense of curiosity around different ways of delivering care.

Maybe I'll get it right next year.

Monday, October 31, 2011

How to ask the right question the right way. Or fake it convincingly.

When I bought a pair of running shoes last week, the salesman said I could try them for a month and return them if I didn't like them, as long as I kept them clean by running on a treadmill or an indoor track.  I decided to try out the track at the Field House.

As it was my first experience there, I asked the staff at the admissions desk about the track rules.

"Just follow the instructions on the sign," they said.

It couldn't have been simpler.  I warmed up in lane 5, then switched direction to run in lane 6.  It didn't matter much, because I had the track to myself.

After 10 minutes, a man joined me on the track.  In lane 6.  Running the opposite direction to me.

As we crossed paths, I stepped into lane 5 and then back into lane 6.  A minute later, as we both circled the track, the same thing happened.

What the heck is this guy doing, I thought.  Surely he would have figured it out the first time.

Before we met again, I stepped off the track and re-examined the lane direction sign.  No question about it - I was going the right direction.   I got back on the track and pondered what to do.  According to the sign, I had to stay in lane 6.  I had no choice: I would have to confront this other fellow.

I had recently read a very interesting article, The Art of Powerful Questions.  It came to mind as I deliberated about how to approach this rogue runner.  While the authors' technique of constructing illuminating questions was a little high-powered for this encounter, it made me think about using "humble inquiry" as a way to show this guy the error of his ways.  Rather than ask "Did you know you were running the wrong direction?" (a rhetorical question if ever there was one!), I thought I would ask something more open-ended.

As we crossed paths again, I stopped and waved at him.

"Hi, I'm new to this track," I said.  "How does the running lane direction work?"

He smiled and said "Yeah, it's a little confusing.  Looks like the lane sign got turned around again."

Turned around?  Uh-oh.

He motioned me to follow him and we walked back to the lane direction sign.

I saw now that the sign was mounted on a wheeled stand.

"See," he said. "It's supposed to face toward you as you enter the room, but it got turned around so that you see it as you're running on the track."

I had been running the wrong direction.

I thanked him and we resumed our run.  In the same direction.

As I ran, I cringed mentally to think about how that encounter could have gone if I had asserted myself/been a jerk.  And I had every right to do that, because I was right!  I had the evidence (the lane arrow) on my side.

The spirit of humble inquiry saved me.  Or did it?  I wasn't truly interested to find out about how the rules of the track worked.  I wasn't truly open-minded about what he might have to say.  I simply phrased the question that way to be polite.

But, it worked and saved me significant embarrassment.

I wonder if it matters that my actions weren't backed up by sincere intent?  Maybe "humbly" asking "powerful questions" can be faked.

Although, I think if I keep faking it, and have it pay off like it did at the running track, I'll become a sincere convert.

Sunday, October 2, 2011

An important Division of Urology project comes home to roost

A couple of years ago, I attended a presentation about implementing change.  The speaker showed us this slide:

And waited...

At first, there was silence as we examined the picture for some hidden meaning.  Then came nervous laughter as the speaker remained silent.  After what seemed like 5 or 10 minutes (but was likely only 2 or 3), there was annoyed muttering around the room.

Finally, she moved on to this slide:

"It takes 21 days for a chicken egg to hatch," she told us.  "How much of the chick's development do you think happens on the 21st day?"

Her point was that, in change initiatives, even though we celebrate the dramatic final outcome, much of the ongoing effort toward achieving the goal is under-appreciated, yet critical to eventual success.

Last week, in the division of urology, one of our eggs hatched.

Thanks to the efforts of St. Paul's Hospital Foundation several years ago, generous donors have contributed to the establishment of a Urology Centre of Health.  While there will be a bricks-and-mortar aspect to this Centre, the real value is the service we'll provide for patients.  A crucial part of that is the development of a staff position that is new to our division and the Saskatoon Health Region: Nurse Navigator.  Our Nurse Navigator, Nicole, works on a range of quality improvement projects in our division, and one of those projects recently broke out of its shell.  A little background information is in order.

A common reason for urologic consultation is so a man can be evaluated for the possibility that he may have prostate cancer.  Our current process is for the man to see one of us in the office for discussion and examination.  We then decide whether or not he needs to undergo a prostate biopsy.   We contact him with the biopsy results and, if cancer is found, arrange an appointment to discuss treatment options.

Because of the nature of prostate cancer and the available treatments, that discussion takes between 45 and 60 minutes.  For some urologic cancers, such as kidney tumours, there is a single effective treatment, and so the discussion is fairly brief.  However, prostate cancer may be treated with surgery, radiation (with 2 varieties offered), or even observation.  It's a complex discussion that involves not only the technical aspects of treatment, statistics about success rates, but also men's relative preference/aversion for various side-effects.

Not only does it take a significant amount of specialist time to have the discussion, it is challenging to find time in our schedules to have this urgent conversation.  As such, men, having just been informed that they have cancer, may wait up to 2 weeks to hear about their treatment options.  We offer written and online material so they can inform themselves before the discussion, but those resources don't take the place of individual consultation.

Since the spring, we've been working toward having Nicole carry out those discussions.  Over several months, she's familiarized herself with the details of prostate cancer treatment.  Her previous work on the inpatient urology ward gave her experience with surgical treatment. She's visited the Cancer Clinics in Saskatoon and Vancouver to learn about radiation treatments.  Much of her time has been spent "shadowing" urologists as we discuss prostate cancer treatment with our patients.

After spending time as an observer in those discussions, Nicole then started to lead the discussion, with the urologist present as a resource.  More recently, she has been meeting with men independently.   Nicole had shadowed me on several occasions, but 2 weeks ago was the first time I had been solely the observer, with her leading the conversation.  All 4 of us - the man and his wife, Nicole and I - then reviewed any questions that arose.  I was completely satisfied that the man had received the same information I would have given him, and in an unbiased fashion.

The next day, another man was scheduled for "the talk".  Nicole met with him and his wife, and I joined them afterward.   The questions they asked of Nicole and me showed me that they had gained a good understanding of the complexities around the decision for prostate cancer treatment.

I had a sudden appreciation of how this new process would change things for our patients and our practice.  Having Nicole available to lead these discussions would free up 45-60 minutes of specialist time.  Those appointments had usually been scheduled during the most precious hours of our workday, that is, late afternoon, after we had finished operating and were wanting to return phone calls and review lab results.  Each of our 8 urologists may see 2 to 4 men a month with newly diagnosed prostate cancer.  Also, because our schedules are usually filled weeks in advance, our staff have to scramble to find openings in which we can have these urgent discussions, and the available openings are rarely as soon as we/our patients would like.  Nicole's ability to schedule more prompt appointments means that men will save up to 2 weeks in the journey from diagnosis to treatment.

When I thought about this a-ha/hatching moment, I also knew that a lot of work had gone into achieving a very satisfying result.  Nicole had designed her own education program, as there was no formal curriculum to guide her.  Several of my partners had spent time with Nicole, discussing the complexities of prostate cancer treatment.  My office staff made sure that Nicole knew about upcoming appointments for her to attend.

But, in the developmental stages of a project, team members may find it difficult to keep up their motivation when the final goal seems far away.   Going back to our egg-hatching example, this would be the equivalent of trying to keep a group of kindergarten students interested in incubating and hatching baby chicks.  When they see an unchanging shell day after day, their enthusiasm will wane.

To keep them interested, you could do this:

If you shine a bright light through an egg, you can see what's going on inside.  That will help our young students to understand that the chick is developing.

For our next divisional project, perhaps we should give all stakeholders regular peeks at progress by setting milestones and reporting when they're reached.  While it's a nice surprise for everyone to see a project finally hatch, those who are less immediately involved may be more inclined to nurture and protect the fragile work-in-progress if they can see what's going on inside the shell.

Now, let's drop the egg analogy.  We've learned something else through our Nurse Navigator's work.  And this may have more important benefits than the improved timeliness she brings to discussions around prostate cancer treatment.  As Nicole has observed all our urologists discussing treatment with men, she's noted differences in individual practices.  Some of the variation she's noticed involves recommendations for treatment and followup.  She wants to give consistent, best practice information to men, but also doesn't want to confuse them by telling them something that an individual urologist may contradict later, based on his/her own practice habits.

This is an opportunity for us to decide, as a group, whether there is a standard, best practice that our division should follow when advising men about prostate cancer treatment and followup.  Because we manage our individual office practices in isolation, we rarely have conversations about these more mundane (to us...) aspects of urology.  In academic centres with residency training programs, the postgraduate trainee serves as the bee, cross-pollinating ideas and practices from one staff urologist to another.  We don't have a residency program, so it looks like our Nurse Navigator will be the one to point out areas in which we can address practice variation.

Sunday, September 25, 2011

An ounce of prevention

My sons' tastes run to the macabre.

We were on holidays in Newfoundland in August, and climbed Gros Morne Mountain.  As we were scrambling up the scree, they began to discuss the chance of an avalanche.  Specifically, they wondered about the possibility that we would be trapped by boulders.

"Hey, it would be just like that guy who got trapped when he was hiking and he had to cut off his own arm with a pocket knife!" said one.

"Yeah, he's famous now," replied his brother.  "They just made a movie about him."

In 2003, Aron Ralston had gone hiking alone in Utah without telling anyone where he was going.  After having his arm pinned by a dislodged boulder and spending 5 days (the movie is called 127 Hours) without food or water, he freed himself by amputating his forearm.  He was found by other hikers, and taken to safety.

I remember thinking back then, as Ralston was celebrated as a hero on TV news and talk shows, that although he had showed incredible will and courage, perhaps his ordeal could have been prevented or shortened if he had taken the elementary precaution of telling someone where he was going, and when he could be expected to return.

An ounce of prevention...

This story came to mind again at the end of our holidays when we were visiting in Newmarket, Ontario.  I was walking by Southlake Regional Health Centre and saw these signs:

Before I go any further, let me make this clear: I am not making light of the contribution of this Health Centre.  I am not minimizing any illness that the pictured lady or any other patient suffered, nor the important role medical care plays in treating and curing serious disease.  These signs are representative of many others used in hospital fundraising campaigns across the country.  I am not singling out Southlake; it was just a coincidence that I was passing by their hospital while thinking about this issue.

In healthcare, most of our attention is on acute and chronic care: heart disease, cancer, diabetes and trauma, for example.  Our taxes and charitable donations build hospitals and furnish them with the latest technology.  We pay specialists handsomely to perform complex, life-saving procedures.  We marvel at the latest advances in medical science.

Many people will say, "Of course our attention is on acute and chronic care! What else is there?"  There is Acute and Chronic's demure sibling, Prevention.

It's often said that prophylactic measures, such as clean water and vaccinations, have had more impact on improved health than any other intervention.  But, how many $500 a plate dinners raise funds to promote eating more fruits and vegetables?

Prevention gets less attention for a number of reasons:

Its beneficial effects are not seen for many years, making it difficult for us to link preventative measures to beneficial outcomes.  Those in charge of health care budgets may find it difficult to allocate scarce funds today, when the benefits will not accrue for decades.

Its value is measured across populations. When individuals enjoy good health, it's seen as a normal, baseline state, and not because of some intervention on their behalf. 
The least economically and politically powerful among us may be the ones who benefit most from preventative measures such as smoking cessation, and education about diet and exercise.  

I've heard acute care medicine (derisively) referred to as "rescue medicine".  The point is that health care systems include the maintenance of healthy populations in their mandate, yet they spend many of their resources saving people whose disease could have been prevented in the first place.   What if that kind of contrarian thinking became the norm?  What if we noted the known risk factors for every condition that forced someone's hospital admission, and so kept a running tally of the daily cost of each risk factor?  We would expect hefty government investment in smoking cessation, and promotion of healthy diet and exercise, as a start.

Perhaps the information on Southlake's signs ("40,000 patients and counting") should be seen as a sign of our health care system's failure to prevent disease, rather than a rallying cry to promote expansion of health care facilities.

Wednesday, September 21, 2011

Full awareness at work

I was walking home after a run last week and decided to take out my earphones.  I usually keep a podcast playing until I walk in the front door of our house, but this time, I thought I would let my own thoughts keep me company.  I was struck by what I noticed when I didn't have something playing in my ears.

I keep the volume low so I can hear bike riders coming up the trail behind me.  Even so, as soon as the earphones came out, I was acutely aware of sounds I had been missing: wind blowing through tall grass, and a small animal in the underbrush.  Hearing the sounds didn't surprise me, but the change in my overall awareness did.  Without earphones, I paid more attention to things I saw along the trail, in addition to things I heard.  Listening to something in earphones had turned my attention inward more than I realized.

I mention this because of a conversation I had last week with a health administrator from another province. We had both noted how some medical personnel seemed to be distracted at work by their various electronic devices.  I have particularly noted that, in Saskatoon's hospitals, some of the housekeeping staff wear earphones while performing their duties.  She told me that the practice had been banned in her health region.

The main concern was around workplace safety.  As I found out after my run last week, not only is your hearing affected, but listening through headphones impairs your overall awareness of your surroundings.  She also mentioned that, even though they are not considered "clinical staff", housekeepers work in patient care areas and may hear (and then respond to) patients in distress.

I wonder if workplace headphones also have a less obvious opportunity cost.  Housekeepers perform an essential role in keeping our facilities clean, safe and functional.  In order to do that, they need access to all areas of the hospital.  As such, they regularly cross paths with staff and patients.  They have the opportunity to greet visitors, answer questions and give directions.

However, if I see someone wearing headphones, I take it as a sign that they don't want to interact.  They're sending a message that they prefer solitude.  I suspect that patients and visitors will make the same assumption if they see hospital staff wearing headphones.  They may hesitate to ask for help.

This no-headphones rationale won't resonate with staff unless they've been explicitly given permission and encouraged to interact with patients and visitors.  Unless housekeeping staff see themselves as goodwill ambassadors, it won't matter whether they wear headphones or not.   And if they don't see themselves in that role, then staff are missing opportunities for joy and satisfaction through richer interaction with our clients, and we're missing the chance to use our staff's talent to full advantage.

Monday, September 5, 2011

Long wait times for surgery? Never again!

There is absolutely no inevitability as long as there is a willingness to contemplate what is happening.

- Marshall McLuhan

When someone decides they want to have surgery performed, they usually want to know details: What will happen? Will it be painful? What are the complications?  But, even if they don't have a lot of questions about How and What, they almost always ask about When.

And that is often an awkward question to answer.

Our surgical booking system divides patients into 4 categories: emergency,cancer, urgent and elective.  While the first 3 categories denote pressing need for surgery, "elective" surgery indicates that the procedure can be delayed without significantly compromising the person's health or chance for a good outcome.  It's an arbitrary definition, and varies from surgeon to surgeon.  The perception of what should be considered "elective" certainly varies between surgeon and patient.

The Saskatchewan Surgical Initiative's (SkSI) goal is that, by 2014, all patients will have the option to have their surgery within 3 months.  ("Option", because some people may choose to delay their surgery until a more convenient time).  By the end of 2011-2012, the goal is to reduce all surgical wait times to less than 12 months.

A 12 month wait for surgery is shocking, and some people wait 18 months or longer!  The amazing thing about that is that we (patients, surgeons, administrators) have accepted this as inevitable.

But, we won't accept these waits for much longer.  Take a look at this trend: 

This is the number of people waiting longer than 12 months (top line) and 18 months (bottom line).  Over the last year, the numbers in each group have been halved!  While this trend had started (due to other provincial initiatives) even prior to SkSI's formal start in 2010, it has been bolstered by SkSI.  Additional OR time, as well as more effective use of that time, are helping to clear the "long wait" backlog.

This success isn't without a cost.  In our practice, we've been assigned additional OR time to provide service for our patients who have been waiting for over 12 months.  This means that the urologist will not be available to provide other important services, such as office consultation or cystoscopy clinics.  As such, wait times in those areas have increased.

There's nothing magical about how this wait time success is being achieved.  Health system leaders decided that this would be a strategic priority, and put attention and resources toward fixing it.  Leaders and managers are accountable for achieving targets.  With this approach, SkSI will meet its goals - whether by 2014 or not is just a quibble.  Then, once the SkSI goals are met, our healthcare system can focus on another strategic priority.

And that's when all SkSI's work will be in danger.

We can only concentrate on a few major initiatives at a time.  A fairly small number of people are involved in moving these projects ahead, and only have so much time and attention to go around.  Once we declare "Mission Accomplished" on surgical wait times, and move on to, say, Primary Care Reform, surgical wait times may creep back up.

In addition to reducing the surgical backlog, we need to build in sustainability, such as ongoing surveillance and transparent reporting of wait times.  More important is a critique of current practices - keeping the effective parts and redesigning the rest.  We need to create processes (e.g. pooled referrals, assessment and treatment pathways) that will survive the inevitable dimming of the spotlight currently illuminating the surgical system.  We can't rely on the hyper-vigilance associated with being the provincial priority du jour.

I look forward to the day when, as I hold forth in front of a group of medical students, they shake their heads and smile wryly at the old-timer's tall-tales of surgical wait lists longer than 3 months.

Tuesday, August 30, 2011

Should I stay or should I go? A real mid-life crisis

It was like taking a ride in a time machine.

I had the chance, last week, to meet the incoming class of medical students at the University of Saskatchewan.  Just over 30 years ago, I sat where they were sitting, likewise listening to some old-timer blather on about what he had done during his career and what I had to look forward to.  

At that point, I hadn't yet examined a patient, written a prescription, or even taken an anatomy class.  In retrospect, I had no idea what I was getting into.  I was thrilled to be in the class, yet totally bewildered.  I recognized the same look on some of the faces of these new medical students.

I felt a mid-life crisis well up.

I've joked about mid-life crisis before, but I think I'm beginning to appreciate what it's really all about.  I've been practicing urology for almost 20 years.   That means I'm beyond the half-way point of my surgical career.  My upcoming birthday is a noteworthy one, in an over-the-hill way.  So, I've been thinking a lot lately about what I should be doing with the 2nd half of my career.  The topic I was addressing with the students only fueled my angst.

I was part of a panel discussion about physician leader and civic professionalism.  Our group included 2 practicing physicians (myself included), a physician administrator, a resident and a 3rd year medical student.  The course instructor had asked us to reflect on our own leadership experiences - why we took leadership roles, what we found satisfying about them, and what challenges physician leaders face.

I confessed that I spent my time in medical school, and the first 10 years of my practice, actively avoiding these roles.  In fact, one of the first leadership positions I took on was our office's Advanced Access/Clinical Practice Redesign work - the same work you've seen documented in this blog for the last 4 years.  That experience has taught me a lot about leadership, and encouraged me to seek out further leadership training and opportunities.  The other panel members related similar stories.

Giving the positive side of leadership work is easy and fun. And misleading.  Being a physician leader is hard work.  There are a lot of barriers to success, and talking about those reminded me of the questions I've been struggling with about my career’s direction.

Physician leaders are not readily recognized and valued for the work they do.  Brent Thoma, the ER resident on the panel, made this point when he spoke about his own experience as a class leader during medical school.  He pointed out that there are many scholarships for students who excel academically.  Top students in basic and clinical sciences receive recognition and rewards.  But, other students who choose to spend some of their valuable time in organizing class gatherings, charity fundraisers or the provision of healthcare to under-serviced communities don't get the same acknowledgement.  He was pleased to report that the College of Medicine had a new scholarship for such medical student leaders.

It's not any easier for practicing physicians.  First and foremost, doctors value clinical work, followed by teaching and research.  Administration and leadership are often  look upon with distain.  "He's gone over to the Dark Side" is a common jibe.  

Also, many physicians take a pay cut if they sacrifice clinical work to take on leadership roles.  For other health professions, an administrative/leadership role might mean greater opportunity for career advancement, with increased compensation and status. That's usually not the case for physicians.

Physicians have often been thrust into leadership roles without adequate preparation.   Until recently, leadership training was not a part of the formal medical school curriculum.  In the same way that doctors starting medical practice are presumed (by virtue of their doctor-ness) to be competent to teach medical students, they are presumed to be naturally competent leaders.  This assumption leads to uninspiring results for the healthcare system, and frustration and discouragement for the unprepared physician leader.

After the panel discussion, all these impediments to physician leadership were swirling inside my head, only to be accentuated by my reading, later that day, Andre Picard's interview with outgoing CMA president, Jeff Turnbull.  The piece's title, When even Dr. Optimism is losing faith in medicare, it's time to fix it, tells the story. Turnbull reports his frustration with "the lack of leadership, co-ordinated management, accountability and responsibility and, yes, needless waste.  Worse, we allow staggering inefficiency, ineffective management processes, incoherent decision-making and practice variations that undermine quality and safety."

While Turnbull insists that he remains optimistic, imagine what resolve it must take to maintain that outlook, given the dysfunction he has seen at every level of healthcare, from the highest level of health policy to individual patient care.

Turnbull's sentiments, while on a grander scale, are similar to mine as I've been trying to decide what direction to take.  While the leadership work I've undertaken so far has been very rewarding, it can be stressful, and takes me away from the clinical work that I also enjoy.  Improvement projects never seem to move as quickly as I would like.  

It would be so much easier to keep my head down and retreat to the familiar trenches of clinical practice.  After 20 years, there’s a comfortable level of competence.  While there’s enough variety and challenge to keep things stimulating, the learning curve has flattened.  I have a great group of partners and staff to work with.  I could give up the meetings and committees and projects.  I could be home for supper more reliably.  And, the money is good.  Great, actually.

It’s a little disturbing to acknowledge the allure of the familiar ground of clinical medicine.

The question I’ve been asking myself is: Why fight it? Why not give up leadership work? 

I think I have the answer:  Medical leadership is not separate from clinical practice; it is an extension of clinical practice.  The will to lead flows from the desire to bring about change.  Once I understood that changing only my own practice severely limited the improvement my patients could experience, I was compelled to try to influence change beyond each single physician-patient encounter.

Experiencing, on a daily basis, the frustrations that Dr. Turnbull described, fuels my will to change things.  But, I don’t intend to change The System - that amorphous, slippery, anonymous, maddening thing.  I don’t think I can change that.

But, people made The System, and they – we - remake it everyday.  I think I can help, convince and cajole people (and myself!) to work differently, and through collective effort, we can replace The System with something we will be proud to be part of.

There’s great joy in that.

And so, crisis resolved. 

I'm turning 50, and I’m not turning back.

Sunday, August 21, 2011

Safety deserves more than lip service

Earlier this month, my family and I flew home after a holiday in Newfoundland.  As we boarded the flight in Deer Lake, my 2 sons led the way onto the plane and took the first two seats we had been assigned.  Unfortunately, their seats were in the exit row and, as they were too young to sit there, we moved them to our other assigned seats.  My wife and I took the exit row seats.

The flight attendant arrived to give the exit row passengers instructions on how to open the emergency exit in case of the need to evacuate the airplane.

"Pull down the handle, pull the door inward, then throw it clear outside the airplane.  Are you OK with that?"

She looked expectantly at me and my wife.  I hesitated.

Before the flight attendant had arrived to brief us, I had noticed that the opposite exit row window seat was occupied by an elderly lady, perhaps in her late 70's, and very slightly built.  The emergency exit instructions noted that the door weighed 40 pounds.  I thought it was unlikely that this lady would be able to manhandle a 40-pound door.

The flight attendant was waiting for my reply.

"Are you OK with that," she repeated.

I was unsure what to say.  My wife and I could certainly handle our exit, but I was convinced that the lady opposite couldn't.  Was it any of my business to point this out?  Surely the flight attendant could see the same problem that I did.  Perhaps I was overreacting.  After all, she must have been trained to assess a passenger's ability to help in case of an emergency.

The easiest route would have been to nod my head and let her get on with departure preparations.  But, the situation was so obviously inappropriate, I couldn't let it go.  But, I was unsure how to proceed.  If I explicitly related my concern, I may offend or upset the elderly lady sitting across from me.  The flight attendant was already puzzled at my silence, and I certainly didn't want to upset her.  I tried to drop a hint.

"Well, I'm OK, but I'm not sure everyone else is..."

I glanced across the aisle, and she followed my gaze.  She took the hint.

Or, so I thought.

She caught the elderly lady's attention and asked her "Are you comfortable with that?"

"Oh, yes," was her reply.

I wasn't sure that the elderly passenger had actually understood what the flight attendant was asking her. The question was ambiguous and she may have simply been indicating that she was comfortable in her seat.

"Anyway," the flight attendant assured us, "It's extremely unlikely that we would need to evacuate."

The flight attendant was obviously uncomfortable with addressing the situation.  My impression was that she did not wish to upset the lady in the window seat.  But, her reassurance that an emergency evacuation was unlikely seemed to me to be an acknowledgment that there was a problem.

I was stuck.  Now that I had pointed out this situation, could I let it go unresolved?  Was this my responsibility to pursue, when a crew member did not seem overly concerned?

The answer came from the couple seated in front of the elderly woman.  They had heard the conversation and offered to change seats.  The flight attendant seemed relieved at this resolution.

Some thoughts on this vignette:

The emergency exit briefing procedure reminded me of the preop surgical checklist.  Both can be technically completed by reciting the prescribed list of questions.  However, each procedure achieves its goal of improved safety if all parties openly communicate.  Everyone has to be confident that safety concerns will be acknowledged and addressed.  The intent of the safety checklist must be satisfied.
While the flight attendant seemed to recognize my concern that the elderly passenger couldn't carry out the evacuation procedure, she seemed unsure of how to address this with the lady.  She didn't want to embarrass the lady by singling her out.  Perhaps a formal script would be useful: In case of an emergency, you will need to assist with evacuating the plane.  Are you capable of lifting the 40-pound door and throwing it out of the airplane? Pose this question to all exit row passengers, regardless of their age and size.  
I wondered if I am sufficiently open to hearing safety concerns in the OR.  If other members of the OR team see a problem, yet think I am not receptive to hearing their input (as was my impression of the flight attendant's approach to my concern), they will hesitate to speak up.  
Safety policies should be followed consistently.  Excuses that an adverse event is "extremely unlikely" undermine everyone's commitment to the safety process.

Sunday, July 31, 2011

I ♥ Calgary's online ER wait times project

I have a huge (data-) crush on Calgary's Health Region!

They have captured and posted online the ER wait times at the city's healthcare facilities.

The website shows estimated wait times for 4 hospitals and 2 health centres.  The information is automatically updated every 2 minutes.  There's a comprehensive disclaimer that reminds people that ERs are unpredictable places, that wait times may change significantly within a short period, and that patients will be see according to the severity of their condition.

Health region representatives said they hope that making this information easily available will help patients to decide whether to go to the closest ER, or the one with the shortest wait time, and thus distribute the workload more evenly.

There's an interesting "behind the scenes" page linked to the main page.  It explains more about the online system and how the wait times are calculated.  The wait times displayed online are calculated based on the number of patients waiting to be seen, their disease acuity, and the number of medical staff available to see patients.

The times are automatically calculated by Calgary Health's IT system, so there's no additional clerical work needed.  Nice!

A few thoughts on this national first:

I'd be interested to see how the calculated wait time correlates with the actual patient experience.  This will likely be studied and posted as part of the evaluation phase of this project.

Might patients be discouraged from seeking urgent medical care if they see how long the wait will be?  People already realize they will have to wait for ER attention, but if they have already invested the time and effort to get to the ER, I suspect they are more likely to stick around until they are seen.  Will advance knowledge of ER wait times change patient's behaviour?  If so, is this necessarily a bad thing? That is, might some people be more likely to seek care for less urgent problems from their family physician if the ER is "less convenient"?  This would be a tough one to measure because the patient's experience won't be captured at an ER visit.  Maybe family medicine clinics will anecdotally report that patients are deciding not to go to the ER.

Power to the people!  Now that this information is available publicly and in real-time, I'm keen to see who will be the first to use it for other than its stated purpose.  I don't mean using the information for a nefarious reason (although there may be some way to do that...), I mean a mashup, combining online data sets to produce new functionality beyond the original intent.  For example, someone could combine Calgary traffic and transit system data with the ER wait time to show the patient's real wait time experience.  (Similar to how we now consider patient's entire wait for surgery to be "Wait 1" - wait for consultation with surgeon - plus "Wait 2" - the time from the OR booking being submitted to the actual date of surgery.)  
Depending on where someone lives and the transportation available to them, it might make more sense to visit the ER that nominally has a longer wait time, because the total patient wait (combined transit + ER wait) is actually shorter.  If that were the case, and it resulted in more congestion in an already busy ER, perhaps Calgary Health IT would communicate with Calgary Transit and more buses could be put on the routes that lead to the less congested ER.   (Mmm, mmm, mmm! System integration!)
Some enterprising computer science student will create an app that pulls the data to smart phones, so a single click will let people know which ER they should head for.  As long as that app is in the works, why not link it to a health advice FAQ site (official Alberta Health, of course) that gives suggestions for self-management of common conditions that often lead to low-acuity ER visits.  
Similarly enterprising engineering or business students will track the publicly posted data and identify trends of ER congestion.  Queue theory experts insist that, even in the unpredictable world of the ER, there is enough predictability to guide staffing plans.  Analyzing the trends in Calgary's ERs would be a great student project.

The greatest thing about this project is just that they did it.  Plain and simple, they did it!  Alberta has shown that meaningful, real-time health system data can be collected and displayed in a way that helps the public make better decisions about their health care.  Once the bugs are worked out, this can be spread across Alberta.  Soon, people in other provinces will come to expect this service.

We can use the Alberta's ER model to help manage other health care congestion, for example, hospital beds.  Hospital ward managers tell me they spend a big part of their day figuring out which patients are ready for discharge and then facilitating discharge or transfer.  Sometimes, a message will be posted in the OR: "Please arrange patient discharge as soon as possible today.  Wards are full and surgery may be cancelled."  By the time word gets around, it's at least 10 am, and the prime opportunities for deciding about discharge have passed.

How about pushing real-time data to each hospital physician?  Include the number of patients he/she has in hospital, the "national expected length of stay" for each patient's condition, the current length of stay, hospital occupancy and an indicator as to whether the physician has indicated a planned date of discharge.  This information could be sent to the physician's phone every evening so discharge planning can be done that night, or early in the morning.  The information is already available; it just needs to be aggregated.

Show us the way, Alberta!

Tuesday, July 19, 2011

Physician funding: Let's try an evolutionary model

Dilbert's Guide to Health Economics!

Yesterday's Dilbert cartoon reminded me of a health care story from Prince Edward Island. In May, PEI's Health Minister took salaried doctors to task for lack of productivity.  Apparently, fee-for-service doctors were seeing many more patients than salaried docs.  The same phenomenon was noted even if it were the same doctor, working after-hours in a fee-for-service clinic, after finishing a day's work in a salaried position.

Paul MacNeill's op-ed illuminates the economic and political issues around the Minister's actions.

Whether or not the accused docs are actually slackers is beside the point.  The reduced throughput for salaried physicians is exactly the result that the Minister should expect from these different payment schemes (neither of which is perfect).  Fee-for-service (FFS) encourages the provision of more services or visits.  Salaried positions are supposed to encourage physicians to provide more preventative care and counselling, spend more time with each patient, and engage in multidisciplinary care.  This means fewer patients will be seen, yet their quality of care should be higher.  Unfortunately, salaried positions are open to abuse, and some physicians (like other human beings!) may be tempted to do as little work as possible.

To judge physician performance, the Minister should look beyond patient volumes.  More appropriate measures would be patient satisfaction, health outcomes and wait times.  Of course, these are more difficult to measure and interpret.

What is the best payment system for docs?  (Oops - that should read "best payment system for patient care"!) Here are some thoughts from an expert.

And here are some thoughts from an amateur:

We can't create a foolproof physician reimbursement system in one shot.  It's too complex.  It should be an experiment where both sides (payer and physician) trust each other and that they have a common goal of excellent patient experience and outcomes.  The system would evolve to suit the needs of patients, physicians and the payer.  Start with our best guess of a suitable payment model, agree on goals, and get going.  Be flexible and make adjustments on the fly.

Don't try to create a definitive system.  Rather, create the conditions that will allow for a suitable system to develop:

  • Physicians are assured of a stable income and work-life balance. 
  • Payer is assured that at least the current level of service will be maintained. (This might mean making baseline measures of the current state using the new measurement system.  See below.) 
  • Agree on appropriate measures that suit the desired outcomes.  As noted above, patient satisfaction, health outcomes and wait times could be measured. 
  • Don't penalize docs when they run up against barriers in parts of the system beyond their control. 
  • Stop measuring volume of service.  Completely stop.  Don't make docs "shadow bill" to make sure that they are keeping up a certain volume of patient visits.  This wastes administrative effort that could be directed to quality improvement and patient service. 
  • Time spent on improving care delivery is as important as care delivery itself.  Quality improvement work is included as part of the physicians' duties.  (Likewise, education, research and administration.)
  • Fail forward.  Encourage reasoned experimentation.  Import best practices from around the world.  Expect failures.  Embrace failures.
I'm sure Dilbert would approve.

Sunday, July 17, 2011

How we keep score determines how the game is played

“Don’t let him in, Dad!”

I was driving my son to his soccer game when we ran into road construction.  Signs indicated that the right lane was closed ahead, so we merged into the left lane.  The very congested left lane. 

As we crawled along, a few cars zipped ahead in the right lane, which wasn’t blocked off for another 10 car lengths.  When these drivers reached the barricade, they signaled their intent to merge into the left lane.  My son’s sense of justice was offended by this “butting in line”, and he exhorted me to keep driving and prevent the right-lane bandit from merging.

To be fair to my son, his attitude has been informed by my own kvetching about drivers who don’t play by the rules.  Well, by my rules, anyway.  Why should this guy get to cut in when I’ve been stuck in this lane for all of 3 minutes?!  He can just sit there for another few minutes. 

I talked tough, but when it came down to it, I let the other driver merge.  My son was disgusted with me.

This led to a discussion about which method would get more cars through the construction zone more quickly: Option 1 - everyone merging into the left lane as soon as they saw the “Right Lane Closed Ahead” sign, or Option 2 - some drivers continuing in the right lane until it was barricaded, and then merging.  We couldn’t figure out the answer, but my son told me it didn’t really matter.  What mattered to him was how fast we got through, so he could get to soccer on time. 


I can see how he would come to that conclusion.  Getting to his game on time was the only benchmark he had.  In fact, maneuvering through the construction-zone traffic had become a game unto itself, and our goal was to get through in the shortest time possible.  Setting that goal lead to our (fantasized) tactic of blocking other drivers who wished to merge into our lane.  That tactic would get us through the line a little quicker, but at the expense of the other driver.

What if the game were played differently?  If there were evidence that Option 2 is actually more efficient, traffic engineers may want to promote it.  They could post signs asking drivers to continue in the right lane until the last moment, and then encourage courteous merging.  But, even if this option is more efficient for the driving collective, individual drivers will still “win” if they are selfish and refuse to allow anyone to merge in front of them.

Maybe we need a different way of keeping score, and a scoreboard to let drivers know how the game is going.  The engineers could set up an electronic sign that indicated how many cars per minute (CPM) are passing through the construction zone.  Perhaps every time a driver exhibited the desired merging behaviour, a happy face would flash and the CPM number would increase.  If someone blocked a merge, the opposite would happen.  I’m not sure what the most effective sign/scoreboard would be, but whatever it was, it should give this message: We’re all in this together!

Last week, I spoke with a friend who works in a chronic disease management program.  Her program had been trying to secure funding for an initiative that would engage patients in their own care, with the intent of reducing disease progression and hospital admission.  She was frustrated because the acute-care department that managed patients in hospital had received funding for a high-tech intervention that would benefit a few patients with severe disease, yet her program had been unable to obtain a fraction of that amount to promote an intervention that would keep many more people from being hospitalized in the first place.

This will be a familiar story to clinicians who see behaviour in another department affecting their own department (e.g. surgeons griping about medical specialists’ discharge patterns – see this recent post), yet feel powerless to influence that behaviour because it’s happening “outside their silo”.  Everyone is playing the game for themselves, sometimes to the detriment of the system/patient.

Healthcare organizations often use “dashboards” to show key performance indicators at various levels, e.g. mortality rates over the entire organization, consultation wait times at the department level, or complication rates for individual surgeons.  The trick is to make all these dashboard/scoreboards relevant for what really matters: the patient’s experience. 

It’s the patient’s experience that cuts across all of healthcare’s self-imposed boundaries, yet our current scorekeeping emphasizes those boundaries.  Budgets are assigned according to categories created for provider convenience – medicine vs. surgery, inpatient vs. outpatient, acute care vs. prevention.  I think that most providers, if in a conflict over behaviour or budget, would let a colleague “merge” ahead of them, if they could see that it would be better for the collective effort. 

The challenge, then, is to set up dashboards/scorecards that emphasize (and reward!) that collective effort, rather than individual success.   We're all in this together!

P.S.  If you want the answer to the “Late Merge” question that my son and I couldn’t figure out, take a look at this interesting explanation by a Minnesota traffic engineer.

Sunday, June 26, 2011

Don't want a shiny, new hospital ward? Then, it's time for me to walk the talk.

It's one thing to identify a problem, another to solve it.

In my last post, I worried that one of our hospital wards was about to undergo an expensive renovation without a full exploration of the alternatives.  The stated motivation for the renovation is to expand surgical bed capacity to accommodate an increased volume of procedures.  The increased volume results from the Saskatchewan Surgical Initiative goal of offering surgical dates within 3 months of booking by 2014.

My concern is that spending this money on renovations supports the status quo.  It will give a false sense of accomplishment and quell the urgency to implement innovative solutions that hasten postop recovery, so as to reduce the need for hospital beds.

Now that I've convinced myself of the huge opportunity cost of investing in bricks and mortar rather than process improvement, I feel compelled to act. (Curse you, Conscience!)  But, what to do?  In a big organization like Saskatoon Health Region (SHR), decisions are made from the top down.  Once resources are committed to a significant project like this, positions are entrenched and minds unlikely to change. I might as well just keep my head down, do my own work, and keep my nose clean until retirement.  Right?

That's a victim mentality.  I reject it.  I may not be able to influence all the decisions that I would like to, but if I remain passive, I will influence none of them.  The victim mentality is a self-fulfilling prophecy: If you think you can't, then you are right. (attrib. Henry Ford).

Where to start?

With myself, of course.  Have I understood the whole situation?  Have I jumped to conclusions?   First, I need to talk to the administrators charged with the daunting task of matching surgical volumes and bed capacity.  I need to hear their side of this story.

What can I contribute to finding a solution?  I can bring a clinical perspective.  I can suggest what improvements can be implemented within a reasonable time.  I can have conversations with my medical and surgical colleagues in ways that are generally inaccessible to non-clinicians.  I can bring knowledge of and experience in using improvement techniques.  I can bring a mile-wide stubborn streak.

Then I need to understand how to engage administrators in the quality agenda.  Oooh, snap!  That phrase usually reads "engage physicians in the quality agenda" and is spoken by administrators.  I hate the implications of the phrase and I'll bet administrators don't like it pointed at them either.  I've griped in previous posts that, doggone it,  physicians are already "engaged" in the quality agenda, and that healthcare leaders need to remove the obstacles that prevent us from achieving our goals.  Maybe there's a similar situation with administrators.

What if, contrary to what many clinicians believe, administrators actually are interested in improving the quality of care, and there are obstacles in their path also?  What are the obstacles?

Insufficient current clinical knowledge is a significant impediment.  While many administrators have a clinical background, they may not have up-to-date information on the latest techniques in perioperative care and surgical techniques that can speed patient recovery.  They may not know what is possible to achieve.

Daily operational pressures crowd into the time needed to deeply contemplate solutions to complex problems.  A manager explained to me last week that "bed rounds" - a meeting of most the hospital's managers - happen twice a day.  Twice a day!  These managers are just trying to keep their heads above water.  How can they possibly free up the time to be innovative?

Goals and objectives are set by administrators at the next level up in SHR's hierarchy.  If senior leaders set a goal of increasing surgical volumes, and give very tight timelines to achieve that goal, then managers and directors will grasp at the first, most obvious solution.  While they may have considered other options (see the last post), they may reject them as too unwieldy or time-consuming.  It may be more expeditious to spend lots of money, and build our way out of this problem.

I can help with the clinical information, but for each of the other obstacles, SHR's senior leaders will have to remove the barriers the managers and directors face: overwhelming operational responsibilities that consume cognitive resources, and perverse incentives that lead us to deliver greater volumes of status quo rather than the exceptional care of which SHR is capable.

Wednesday, June 22, 2011

Raise your hand if you want a shiny, new hospital ward!

Twenty-five years ago, when I was an intern on the surgery service, the dreaded part of the day was the late afternoon.  That was when all the patients were admitted to the hospital.   For surgery the next day.

Yes, you heard me right - admitted the day before scheduled surgery.  Sounds crazy, huh?

Interns were expected to document the medical history, examine the patient, arrange lab testing, obtain consent for surgery, and discuss the case with the attending surgeon.  There could be dozens of scheduled admissions in an afternoon.  I'm not telling you this to gripe about the workload in the "good old days", but to point out that nowadays, if any surgeon planned to admit all patients to hospital the day before surgery, he/she would be pilloried.  It would be rightly noted as wasteful of resources as well as being a needless discomfort for patients.

But, back then, there were many reasons why it had to be so:

  • Patients needed a history and physical completed
  • Nurses had to do preop teaching
  • Patients couldn't be trusted not to eat or drink after midnight (i.e. NPO for surgery/anaesthetic)
  • Preop sedation had to be administered to prevent undue preop anxiety
  • Patients couldn't manage their own bowel prep (powerful laxatives used prior to colon surgery)
  • Patients had to "acclimatize" to the hospital (I never understood that one, but accepted it because the staff surgeon said it with great conviction.)

That's just the way it was done for everything from an aortic aneurysm repair to tonsillectomy.

Well, there were exceptions.  I remember admitting a local GP who was having hemorrhoid surgery the next day.  He patiently submitted to the routine, having served as an intern in the same hospital several years previously.  After being "admitted", he asked if he could go home on an "overnight pass" - highly irregular!  His surgeon agreed out of professional courtesy.  He returned the next morning and underwent uneventful surgery, even without being "acclimatized".

Then, the chief of surgery decided that we would do things differently.  Based on day surgery practices at other hospitals, he lead the development of a system that allowed patients to be operated on and discharged on the same day for "minor" procedures, and admitted to hospital on the day of surgery for "major" cases.  I can only imagine the consternation this caused when first proposed, even though it was a proven and established practice in many other centres.  Now, day surgery is standard practice for many conditions.

I've taken you down Memory Lane because it seems to me that the past is repeating itself.  Thinking about changing deeply entrenched practices remains a jarring experience.

At a meeting this week, I learned that there are plans to renovate a currently unused floor at our hospital.  This new unit will be designated for surgery patients and will expand surgical bed capacity.  The impetus for this expanded capacity is the Saskatchewan Surgical Initiative (SkSI).  As part of SkSI's mandate to reduce surgery wait time, the health regions are increasing the volume of surgery they perform.  As some patients will require a postop hospital stay, and surgical wards are currently usually full to capacity, increasing the surgical volume means we need more beds for patients to stay in postop.  That's simple math.

But, as a friend of mine likes to say "For every complicated problem, there's a simple solution.  And, it's wrong."

Renovating a new hospital ward will be expensive, but simple.  Simple, in the sense that there are prescribed building codes, architectural principles and construction practices that can be applied.  If we sign the cheque (Whaddaya figure? Over $1M, at least?), a contractor will deliver a shiny new surgical floor.  Everyone will be pleased.  Photo-ops will abound.

And, the status quo will be cemented.

I believe that building extra inpatient bed capacity is not only the wrong solution, but will actually be a harmful solution.

The solution to a mismatch of demand (number of surgeries requiring hospitalization X number of days spent in hospital) and capacity (number of bed-days available) involves reducing demand, increasing capacity, or creating a better balance of demand and capacity.

Here's some ways to increase capacity:

1) A new surgical ward increases capacity.  It's relatively easy to do (see above) and gives fairly quick results (within a year?).  But, it's expensive, and taking this route reinforces the notion that we don't need to change our processes, as long as we can throw enough money at a problem.

2) New capacity for surgical patients can also come from existing hospital capacity.  "Medical" patients also occupy hospital beds, and there is always a tension between medical and surgical services over bed usage.  To an outsider, it may seem petty that surgeons and medical specialists covet hospital resources that are intended for patient care, but each physician wants to ensure that his/her patients have access to a bed when needed.  Medical patients tend to be acutely ill when admitted, often presenting to the emergency department.  That means that there is little choice other than to have them stay in a hospital bed.  Elective surgical patients, in contrast, are generally in reasonable health when they come to the hospital (although the surgery they undergo upsets that condition to varying degrees).  However, if there is only one bed available, it will be assigned to the acutely ill "medical" patient, and the person expecting to have their elective (sometimes urgent) surgery performed will be sent home and have the procedure rescheduled.

Surgeons love to demonize medical specialists around bed usage.  We surgeons flatter ourselves that we're diligent in preparing our patients for prompt discharge, assessing them early in the morning so that necessary preparations can be made, and even developing care maps that anticipate the date of discharge.  At our meeting earlier this week, it was pointed out that most of Saskatoon's surgical services have average length of postop stays at or below national averages.  So, perhaps our surgeons have the right to feel smug about this.

We're convinced that, if our medical colleagues could implement similar discharge planning practices, their patients' average length of hospital stay could also be shortened.  As hospital beds are a global resource, any reduction in length of stay means increased bed capacity for all services, medical and surgical.

Surgeons have multiple incentives to help their patients recover promptly and return home in good condition as soon as possible.  Of course, the main reason is that this is good patient care - our prime objective.  But, we also have a responsibility to the next patient who is scheduled for surgery.  If there are no available beds, then their surgery will be cancelled.

Medical specialists share the same mandate to provide good patient care.  But, if a new, acutely ill patient comes into the emergency department, a bed will be found for that person.  Perhaps they will be assigned to a "surgical" bed, or they may stay in the emergency room overnight.  Either way, they will not be sent home.  That means there's relatively little incentive for medical specialists to hasten discharge of recovered patients.

This issue raises much rancour in surgical meetings.  However, because it crosses the boundaries between surgery and medicine, it's a difficult conversation to have.  As such, we come up with work-around solutions, like "protected" surgery beds (no medical patients allowed, even if the bed isn't needed by a surgery patient), or adding more beds to the hospital.

Managing demand is more challenging.  Here are some options:

1) Do more surgery on an outpatient basis.  At a conference earlier this month, SkSI hosted representatives from the health system of South Devon in the UK.  One of their presentations was about "enhanced recovery", essentially helping patients get better more quickly after surgery.  One part of this talk surprised - even shocked - me.

At the start of the presentation, they showed their traditional list of procedures suitable for day surgery.  I noted that there were several urology procedures on the list: circumcision, bladder tumor removal, ureteroscopy - all procedures we already do on a day surgery basis.  I began compiling a mental list of urology procedures that could never, ever be done on a day surgery basis.  My intent was to think of ways that all other procedures could be changed from inpatient to day surgery cases.  The list of never, ever procedures was pretty clear: cystectomy, prostatectomy and laparoscopic nephrectomy - respectively, removal of the bladder, prostate and kidney.

Then, the South Devon team showed their current list of procedures considered suitable for day surgery.  Laparoscopic nephrectomy was on the list!

I had already closed the door on the possibility of doing that procedure as day surgery, yet surgeons from South Devon had achieved it.

They used a combination of anaesthetic and surgical techniques - all accessible and fairly low-tech, but applied rigorously and consistently - to achieve this.  But, the real power of their approach was that they improved the entire process from family doctor to home care support after discharge.  As soon as the family doctor thought that surgery might be required, they supplied the patient with consistent information about the entire process including expectations around pre-op medical optimization, hospital stay and at-home recovery.  Nurses followed patients with at-home visits and phone calls.

The South Devon team was careful to point out that the processes they use are easily accessible in developed countries, but implementation requires coordinated will over the entire system.  Our current "silo view" of surgery makes this difficult to achieve.

2) Help patients recover more quickly, so they can achieve their discharge goal sooner.  Again, the South Devon team challenged us with their approach.  They showed the wide variation in hospital stays for patients undergoing colon surgery.  By adopting the best practices from centres with shorter hospital stays, they were able to likewise help patients recover more quickly.  They emphasized that their goal for patients was always "Better, quicker", and not just earlier discharge.  The fact that patients went home more rapidly was just a reflection of their more rapid recuperation.

During discussion at our surgical meeting this week, it was pointed out that we're already meeting, or exceeding, national benchmarks around expected length of hospital stay.  This demonstrates the danger of benchmarking!  These benchmarks are national averages, and the philosophy they tacitly encourage is "Let's be mediocre!" That is, as long as we're average, we can excuse ourselves from trying any harder.  Surely, if we're going to use benchmarks, we should choose the best performers and try to match their results.

And now, back to the potential hazard of spending millions of dollars to add surgical bed capacity rather than do the more challenging work of process redesign.  Adding capacity reinforces the notion that the status quo is fine - we just need more of it.  Adding capacity carries a huge opportunity cost.  Imagine how much system-wide change $1M would support.  Adding capacity takes away the incentive for providers, managers and leaders to have the difficult conversations about turf protection and changing habits.

Our patients trust us not only to provide care, but to constantly improve that care.  They rely on us to seek out the possible and think beyond the traditional.  Henry Ford, when commenting on the invention of the automobile, said,  "If I had asked people what they wanted, they would have said faster horses."

A shiny, new hospital ward will be welcomed by patients, staff, administrators and politicians.  It's what we want.

But, not what we need.