Where's my real-time data?

"Your exit - 10 miles back"

How would you like to see this sign on your next road trip?  What a ridiculous idea - telling drivers that they should have turned off 10 miles ago!  Imagine the confusion and wasted time and gas.  We wouldn't stand for it.  We'd be on the phone to the Department of Highways demanding that the signage be improved.

Yet, in healthcare, we put up with this every day.

Timely feedback is essential for change to progress efficiently and steadily.  PDSA (plan-do-study-act) cycles often involve very small tests of change (e.g. one patient, one time) followed by analysis and then implementation of another change.  Without prompt feedback, we don't know what direction to take for our next cycle.

HQC's Quality Insight provincial dashboard is an ambitious effort to track results ranging from surgical wait times to patient experience in healthcare.  Many of the results are only 4 months old.   While 4 months could barely be considered real-time data, it shines when compared with the 3-year-old data on prostatectomy readmission rates.

This data is from CIHI and indicates how many men are readmitted to hospital after undergoing prostate surgery.  It's a quality indicator (albeit, a rough one) in urology.  Several years ago, Saskatoon's prostatectomy readmission rate was quite high, prompting our department to review our practices.  Since the "latest" data was available, we have adopted a different technology for prostate surgery.  Yet, we don't have any current road signs to guide us.

You may quite rightly point out that our department could do a chart review and make our own calculations of readmission rates.  And, if I griped that it would take time - likely in the evening or weekend - to conduct that review, you would again be right in noting that quality review is part of our professional responsibility for quality improvement.

But, there are many quality indicators for which we would like regular information: wound infection, admission length of stay, pulmonary embolism, perioperative mortality.  Urologists could spend hours combing through charts to collect this data.  And there are many other specialties interested in their own quality indicator reports.  Our health region doesn't have the resources to make all these measurements.

Or, perhaps it's more accurate to say that our resources haven't been allocated toward real-time, automated collection and reporting of quality data.  And that sends the message that we settle for learning about our exit 10 miles too late.

Should we expand the surgical checklist to include "patient-centredness"?

Dave's comment on my last post made me think further about checklists in the OR.   In Saskatoon, we use our version of the WHO surgical checklist.  It took a while to implement, but now it is firmly part of the local culture.

The surgical checklist addresses the technical aspects of surgery - perioperative antibiotic use, anaesthetic preparation, correct side and site of surgery - but, maybe there should be a "patient-centredness" checklist as well.  It could include items that focus on the patient's experience of care.

For example:

Communication needs (language barrier, impaired hearing)

Family/friends accompanying patient - how to contact them after surgery, who will do that

Team commitment to be attentive during key parts of procedure (induction of anaesthetic, awakening, patient transfers)

Consideration for patient's feelings (avoid loud personal conversations, etc.)

This would let the OR team discuss some of these difficult behaviour/culture issues within the safer context of "what's important for the patient" rather than "what's wrong with your behaviour".

What would you add to an operating room patient-centredness checklist?

Multitasking in the OR? We're fooling ourselves!

I was in the middle of a case in the OR on Friday when a conversation caught my ear.  Apple’s iPad 2 was being released that day, and the anaesthetist and his resident were excitedly talking about it.  I’m coveting an iPad 2, so I’ve also been looking forward to its arrival.

But, as much as I would have loved to share the excitement with them, I was a wet blanket.

“Hey, guys.  No iPad talk in here”, I said, semi-jokingly.

Without an objection, they stopped their conversation.  A little later, the anaethetist asked (semi-jokingly) why he couldn’t mention “that thing we can’t talk about.”

I explained that I was so interested in the iPad gossip that I thought it would likely distract me from a tricky part of the procedure that I had been starting at the time.  After the case was finished, we compared notes on how we each planned to acquire the new toy.

My request to change the topic of conversation had been slightly tongue-in-cheek, but I had noticed I became slightly distracted when they dropped the i-bomb.  I don’t insist that the OR theatre be silent during all my cases, but there are times when it is appropriate, in order to let the team focus on critical activities.

As I thought about that situation, which was somewhat light-hearted, I recalled another recent situation in which the OR team’s attention may have wandered from the prime task: patient care.

We were transferring an anaesthetized patient from the operating table back to a stretcher at the end of the surgery.  At this stage, patients are usually still unconscious and completely reliant on us to safely move them.  The anaesthetist is in charge of this patient movement as they control the patient’s head, neck and airway.  Once everyone is ready, the anaesthetist will signal “On 3”, and then count to 3.  The team will move slide the patient from the table to the stretcher.

It seems simple, and usually is, but involves a coordinated effort to make sure the patient is safe and also that any attached tubes and IVs don’t get dislodged.  There was a conversation going on between some of us and not all the staff heard the anaesthetist’s countdown.  The patient was moved safely, but it wasn’t the usual smooth transfer we’re used to.

No harm was done, but as I commented to 2 medical students who were observing in the room, I thought it could have gone better if we were all concentrating on the important task.  Also, I told them that I should have addressed it with the OR team right at the time but, frankly, wasn’t sure how to raise the concern without offending anyone or seeming overly picky.  (I hasten to admit that I have been guilty of participating in distracting side conversations also.)

Most non-medical conversations in the OR are positive – they promote a good team relationship, and often relieve tension during a long or difficult procedure.  None of us maliciously distract our teammates in the OR, but it’s easy to fall into a habit of chatting during critical times.  We may not even identify them as critical times because they are routine to us (e.g. patient transfers, induction of anaesthetic). 

I would like to think of critical times in the OR in the same way as critical times in aviation.  (Note: this is total fantasy on my part, as I have no aviation experience!  If any readers have such experience, or know someone who does, please leave a comment to correct any misconceptions I have.)  I’m sure that in the cockpit during takeoff, landing and turbulence, the conversation is sparse and professional.  But, while at cruising altitude, the pilots likely swap a yarn or two.

What’s the difference between the two situations?  The difference is culture – the mutual understanding and unspoken agreement of how we behave at work.  The pilots likely have it drummed into them from the start of their career about the importance of attentiveness during critical maneuvers.  They would have to agree on what those maneuvers were.  They likely also have some shorthand way of telling each other that something critical, yet unexpected, is happening.  The fact that there are only 2 of them in the cockpit, likely reduces the complexity of communication. 

I’m not sure that we all agree on what points during surgery are critical for everyone’s attention.  But, we’ve made a start with checklists.

We’ve taken a page from aviation safety with our surgical safety checklist.  Prior to every case in the OR, the surgeon, anaesthetist and nurse review a list of items important for the safe and efficient care of the patient.  It’s lead by the surgeon, who has the responsibility to make sure that the other team members are participating.  Sometimes, the anaesthetist may be in the middle of starting an IV, or giving a medication, or checking the patient’s chart and will give me a wave saying, “Go ahead, I’m listening”.  At the risk of offending my colleague, I usually decline to start and invite them to finish the important task at hand before we complete the checklist.  One anaesthetist told me “Go ahead with the checklist. I can multitask.”  Really?  (Here’s a brief AORN Journal commentary on “multitasking” in the OR.)

A stumbling block in the OR is communication (surprise!).  And, as the surgeon leads the team, a big part of the responsibility for open and appropriate communication lies with me.  If I’ve allowed myself to get stressed, I tend to speak sharply.  I get annoyed when the flow of preparations doesn’t go the way I envision it (as if the team should be reading my mind!).  I don’t always speak up in situations where I think team members should be avoiding distractions.  And, I don’t invite feedback on how my own behaviour affects the rest of the team.

If you have any suggestions on how to get these important conversations going safely and productively, please leave a comment.  When we’ve let it slide for so long, it seems so hard to get started.  But, for our patients’ sake, I would like to try.

Solution to dumping unwanted medical records: drop-off boxes

Saskatchewan made the national news!

Not good.  Abandoned medical records found in a dumpster.  Privacy Commissioner "astonished".

This has happened before, and predictably, the Commissioner and blog commentators trot out the applicable penalties and want to find someone to blame.

This is definitely an breach of patients' privacy and completely unprofessional.  But, maybe we should look beyond finger-pointing and try to find a solution to this recurring problem.  For whatever reason, the custodian of these records decided to move them from the original doctor's office.  Perhaps the doctor moved or retired.  Maybe they were culling out-of-date charts.  Regardless of what journey the charts took from the file room to the dumpster, they were unwanted.  And, we already have models for managing valuable, sensitive, yet unwanted items whose current owners cannot manage for various reasons, including inadequate resources.

Baby drop-off programs.

No questions asked.  Leave the baby and we'll look after her.  No blame, no penalty.

Unsecured medical records will continue to be a problem because of physician retirement, relocation (particularly a problem in Saskatchewan!) or lack of filing space in medical offices.  It is clearly the professional responsibility of physicians to securely store, then appropriately dispose of patient records.

But, for a variety of reasons, some docs are not going to fulfill their responsibilities.  So the question is, do we want to try to force them to do it (good luck with that if the doc is retired or deceased), or do we want a mechanism to secure and dispose of orphaned records?

How about this: Set up locked drop boxes around the province.  Use hospitals/medical centres, as doctors know where they are and have access to them.  The Privacy Commissioner would have to decide whether records would be automatically shredded or whether someone would have to screen them first.

Yes, the doctor is ethically responsible to provide storage.  Yes, the doctor is obliged to pay for secure shredding and disposal.  The vast majority of docs do so and will continue to do so.  But, for the rare few whose circumstances may lead them to ditch records and run, wouldn't it be worthwhile to provide a secure alternative?

P.S. Electronic medical records, anyone?

97% is not a passing mark! (More to CIHI report on wait times than meets the eye)

Can you score 97% on a test and still fail?

CIHI just released its 2010 results on which provinces are meeting national benchmarks on wait times for specified procedures.   I took vague note of the results for hip and knee replacement, surgery for fractured hips, cataracts and cardiac bypass.  I don't have much to do with those procedures in my urology practice.

But, I was interested in the Star-Phoenix's report that 97% of Saskatchewan patients receive radiotherapy (for cancer) within the benchmark time (4 weeks).   Nice!  But, wait...

I regularly refer patients for radiation treatment, usually for prostate cancer.  My impression is that patients usually wait longer than 4 weeks for their treatment.  I often get phone calls from patients I've referred, asking when their treatment will start.  I usually quote a wait of 8-10 weeks from when I send a referral letter to when they start their treatment.

Perhaps I'm not speaking the same language as CIHI.

The CIHI report states that the 4 week wait is measured from when patients are "ready to receive care".  Interesting.  I would consider most of my patients to be ready to receive care from the moment I refer them.  Some still require xray testing to be completed, but there would be very few men who are medically unfit to receive treatment.  So, why the discrepancy between my perception of patient wait and CIHI's report?

On the Saskatchewan Cancer Agency website, "ready to treat" is explained as "the date that the patient is ready to be treated, taking into account clinical factors and patient preference".  So, "ready to treat" equals "ready to be treated"...

I was no further ahead after reading this, so I asked a senior physician at our Cancer Clinic what "ready to treat" meant.  His answer was more enlightening:

Ready to Treat means the patient has been assessed by a Radiation Oncologist with all necessary work-up completed, treatment options considered and a consent for Radiation therapy signed.  It means that if simulation and planning could be done in minutes the patient is ready to start treatment that day. It means the patient is available and willing to start.

OK, now I get it.  It means we've stacked the measurement deck by ignoring all the heavy lifting necessary to get the patient to the point of "ready to treat".  Here's what goes on before the official clock starts:

Referral letter generated and sent to Cancer Clinic

Letter reviewed by triage clerk

Letter reviewed by Radiation Oncologist

Appointment date assigned

Consultation with Radiation Oncologist

Further testing (possibly)

Patient decision to proceed with treatment

Each of the spaces in the above list equals its own wait time.  Who is measuring those waits?  Our patients sure are, but CIHI isn't.  I have no doubt that CIHI recognizes the importance of each of these wait times.  But, there isn't a system in place to track them.

It's relatively easy to track wait times once a patient is in the Cancer Clinic system.  It's harder to track all the other times.  It's even more difficult if you want to measure the patient's real waiting experience, that is, from the time the patient is referred by their family doctor, or even when they first consult their doctor with symptoms.  Who decided on this benchmark anyway?  Did anyone ask patients whether this was truly reflective of what was important to them?

There's a chance that making these easy measurements could actually hamper efforts at overall system improvement.  What if health administrators and politicians look at the "success story" of radiotherapy across the country and decide that it's "fixed", and that attention and resources can be moved elsewhere?

If my son came home from his basketball game and told me that he had scored 50 points, I'd be curious how that had happened.  I wouldn't be surprised to find out that the baskets had been lowered to 6 feet high.  Easy slam dunk.

In a health care system that has universal struggles with access, we should be suspicious when one area seemingly slam dunks the access problem.  Their basket is too low.

97% = Fail.

A generic referral template is a better idea than specialty-specific templates

A lot of people have been thinking about how to improve the GP-specialist consultation process.  It's going on at the national level.  It's going on at the local level.  And, as part of the Saskatchewan Surgical Initiative, there's interest provincially.

Recently, I had a conversation with someone about what would be the best first step on a provincial level.  Should we develop a general referral template that the referring doc could use for any specialty, or is it better to make specific referral forms that address the information needs of each specialty?

My first thought was that specialty-specific forms would be best.  They would give more useful information to allow the receiving specialist to anticipate the patient's need for special testing or procedures.  They would also allow inclusion of a management algorithm (suggested by each specialty group) to help the referring physician complete the initial steps in diagnosis and therapy.

I still think a specialty-specific form would be ideal, but on further consideration, it's not the best first step.

With respect and gratitude to all my colleagues who make the effort to write a complete referral letter, I receive many inadequate referral letters.  At our office, our staff spends a lot of time calling back to referring docs' clinics to ask for lab and xray results, and details of the patient's condition.  The really annoying thing is that the results we need are actually available, but the referring doc didn't think to send them along.  This slows down the assessment process as I can't give a final opinion without these results.   Also, we may schedule more testing, only to find out that it has already been completed.  

From conversations with specialist colleagues locally and nationally, I know that this is a universal problem.  As such, I think that all specialists (and patients!) could benefit from a generic referral form that prompts referring docs to give the basic information needed in a referral letter:

Reason for referral/clinical question to be answered

History of present problem including treatments tried and the outcome

Past medical history

Medications

Allergies

Test results (lab and xray)

Other information could include urgency of the consultation, any special conditions of note (physical or mental limitations).

Perhaps a specialty-specific form would be developed later, although it would take exponentially more work to create.  Getting each specialty group to agree about the minutia on such a form would take a long time.   Also, in the absence of an electronic storage system, GPs would likely find it cumbersome to file myriad specialty-specific forms.  I'm not sure that the marginal utility of developing a specific form would warrant the effort.

However, given the above-griped-about scarcity of information on many referral letters, all specialists would get at least some benefit out of a global, generic referral template.  

I suggest starting with a basic form, including the information noted above.  The form should be clearly marked "DRAFT #X.  EXPIRY DATE: XXX".  This would prevent having multiple (confusing) iterations of the form drifting around a doctor's office.  

There would be a mechanism for feedback from both the GP and specialist.  Perhaps it would be tear-off section, or a second page that could be faxed back to the developers.

Start small - perhaps with two or three GPs.  Getting feedback from them would be simple, as they are small group, chosen by the developers.  Blank forms could be sent out to specialists for comment, or the GPs could complete some forms with simulated patients so as to solicit reviews from specific specialists.

Run short PDSA cycles - two weeks at most.  Collect feedback on which content is most useful, and also what design makes the form easy to complete (for the GP) and read (for the specialist).  Make it clear that this is not meant to be an all-encompassing form.  The project will get bogged down if everyone gets to add their "pet peeve" to the mix.  The developers need to be ruthless about this.  

After each cycle, expand the GP user group.  I think we would have a pretty useful (not perfect!) form within 3 months.  

I wouldn't blame any family docs who might be reading this for getting cheesed off at my impertinence and stopping several paragraphs back.  But, if you're still with me, let me say that I think this should be a two-way street.  Half of the consultation process is the information contained in the referral letter.  The other half is the information the specialist provides in a consultation report.  Specialists are not squeaky clean here.  GPs point out they often wait a long time to receive reports.  Their clinical question may not be answered.  The consultation letter may be difficult to read as it may be several pages long, with any requests for further testing or recommendations for management buried inside the text.  There may be no indication as to whether the GP is expected to provide ongoing care, or whether the specialist will do it. 

Specialists can do better too. 

There should be a similar template to help specialists provide good quality consultation reports that will help the GP manage the patient's care.  We could run parallel PDSA's to address this side of the equation.

We could have a generic referral form and consultation report template ready within 6 months.  The biggest barrier would be too much fine-tuning.

Perfect is the enemy of good.

A crisis of healthcare access in Wakaw, Saskatchewan

There is a crisis in Wakaw, Saskatchewan. Not because its hospital is losing inpatient care, but because no one is asking the right questions.

Wakaw is a town of about 1000 people, located 100 km northeast of Saskatoon. Like many small prairie towns, it has been struggling to retain family physicians to provide care to its citizens. Retirement and relocation has overwhelmed recruitment, and now, without any resident physicians, the local hospital will no longer offer inpatient services.

The comments in the Star-Phoenix article centred around the inability of Wakaw and the Saskatoon Health Region (SHR) to recruit physicians, citing physician unwillingness to take on heavy on-call responsibilities.

VP of community services for SHR, Shan Landry, is quoted saying:

Most (doctors) now are looking for a lifestyle that does not include that kind of demand on their time.

Wakaw mayor, Ed Kidd, responds:

In reality, the more they tout it, the more these doctors agree with them. We’ve had doctors in our community forever that have done on-call. I understand emergency services could be an issue, but on-call, I think you can get doctors that are still compassionate and believe in their patients. I think the health region makes a mistake by continually prescribing this to the doctors.”

With respect to Mr. Kidd, times have changed.

This is a particularly poignant issue for me because of some advice my father gave me. He had served as a GP/general surgeon in a small Saskatchewan city for about 30 years. He earned the respect and admiration of his fellow citizens through his total dedication to their medical care. As I began my own practice 20 years ago, he said to me “My only regret is that I didn’t spend enough time with my family. Don’t make that mistake.”

Even when you’re not actually seeing emergency patients while on-call, you always feel a low-level tension at needing to be available at all times. You can’t travel. You can’t be the sole caregiver for your children. You can’t have a drink. Most physicians would find it onerous to be on-call more than 1 in 4 nights.

So, the question they are asking is: Where can Wakaw recruit 3 or 4 physicians?

But, is that the right question to be asking?

Before I suggest some other questions, I should say that all I know about this situation is what I read in the paper. I’m sure some of these questions have already been considered, but I haven’t seen them discussed publicly.

What do Wakaw citizens really need? Are physicians the only providers who can meet these needs? Are they the best suited to meet these needs?

How have circumstances changed so that newly-recruited physicians will stay?

How do other similar Saskatchewan towns manage without physicians, or a hospital?

Are inpatient hospital admissions the most appropriate way to provide care?

This is a complex and emotional issue for a small town. An aging population worries about access to the care they need. The town is concerned about job loss.

This is also a political minefield. (In an election year, no less!) Imagine being a politician who’s sincerely concerned for the well-being of Wakaw residents, and wants to raise some of these questions. Would you risk being pilloried by political opponents with accusations of insensitivity to the healthcare needs of the rural electorate?

It seems unlikely that Wakaw will be able to maintain a resident group of physicians. It’s time for someone to lead the discussion toward a more suitable, contemporary and sustainable solution.

Good process design - We all do it every day

Designing a system that allows (or forces) the desired outcome sounds intimidating. We probably need a degree in Engineering or Business Administration to do it.

Or, we could rethink what system design really means and realize that we already do it every day.

I've been thinking/obsessing about system design since a couple of posts last week(1, 2). Rather than calling it "system design", I've tried to think more about "Making it easier to do the right thing". That makes it more accessible for me. I think we all do this every day. We just don't make a fuss about it.

Several months ago, I decided that I would take some vitamin and mineral supplements every day. I started off taking them reliably every morning, but after a couple of weeks, I was missing most days.

I was still committed to taking the supplements, but found it a nuisance to add one more item to my morning routine.

I keep these 3 vitamin bottles in a bathroom drawer. Getting them out, opening each bottle and shaking out the pills takes about 2 minutes, but it seems like it's a lot longer when I'm in a rush to get to work. Plus, taking the vitamins isn't a critical part of the morning flow (like breakfast or showering), so it's easy to convince myself that I can skip a day.

I re-engineered my system by getting a pill box.

I fill it on the weekend when I'm not so rushed. I keep it next to my toothbrush so it's accessible and also linked to another part of my regular morning flow. Works like a charm.

Good system design - It's not just for breakfast anymore.

Should doctors charge patients who "no-show" for appointments? No.

A recent Medical Post column, “Finding Value” (March 8, p.26), caught my eye. Written by Dr. Jonathan Marcus, (bio: ... a family doctor and entrepreneur in Toronto. He writes and speaks on practice management with an emphasis on uninsured services) “How to explain no-show charges to patients” offers docs a script to encourage patients to pay for appointments they missed.

Before I share some of Dr. Marcus' tips, I want to say that it is accepted business practice in some professions (including medicine) to charge clients who don't keep their appointments. The rationale is solid: You reserved my time and have to pay for it regardless of whether or not you attended the appointment.

Having said that, I think there are 2 ways to look at no-shows. The traditional approach is that the patient is at fault and should bear the cost. Another approach is to consider how the appointment system a medical office uses may be a factor in missed appointments.

In specialty practices, long wait times for consultation mean some patients will honestly forget about their appointment. In Saskatchewan, some of our patients travel from the north and may have limited travel resources. We may have sent an appointment time that is inconvenient because of work, school, child care, etc.

In our practice, we've decided not to charge patients for missed appointments for various reasons, not the least of which is we don't want the nuisance of running a collection agency.

I think I could agree to disagree with Dr. Marcus on the relative merits of charging for no-shows. But, I'm uncomfortable when I read his suggested script for convincing patients to pay up. As I can't find a link to the article, I'll quote liberally and try to be true to the context.

In a previous article, he had offered suggestions on how office staff can collect outstanding bills. In the current article, the bill is still outstanding.

However, if your staff is unsuccessful, here's what you can do to get paid most of the time while maintaining a good doctor-patient relationship.

This is part most doctors are going to be uneasy with. We don't often have experience with the nitty-gritty business side of medical practice, and are worried that we'll affect the relationship with our patients.

During your patient's appointment, deal with his or her health concerns first, of course. Then bring up the outstanding bill.

We're off to a good start. I would be very uncomfortable with asking my patient for money before dealing with their medical problem. I think it would sour the entire visit. Also, I wouldn't want to surprise my patient with a no-show charge. I suspect that one of Dr. Marcus' previous articles suggested posting a waiting-room notice explaining the no-show policy.

Patients may give reasons for missing appointments and I recommend you waive bills for excuses such as family illness, etc. You might want to reduce rather than waive fees if the patient has financial difficulties. Paying a few dollars keeps patients accountable and reduces future no-shows, while respecting their financial situation.

Now I'm in the judge and jury. I have to decide if their story is worthy of a break. (In the case of a family illness, would my patient have to bring a doctor's note? To a doctor?) How will I judge their degree of financial hardship?

It’s important that you discuss outstanding charges in a nonjudgmental, relaxed manner. The first thing I say to patients is, “I’ve been your doctor for (however many) years. I love our doctor-patient relationship and hate to have to charge you for this.”

Is this a mixed message? I love our relationship, but I’m going to charge you for missing an appointment.

I may add, “This fee is not a punishment. It just covers the cost of running my practice.”…

…By this point, most patients have agreed to pay.

Some patients may still hold out. When this happens, I remind them I usually see patients on time for their appointments and I’m able to do so because I don’t double-book. The flip side is that I expect them to respect my time by paying for appointments they miss.

Dr. Marcus runs his clinic on time, but what about the other doctors to whom he is offering advice. If they don’t run on time, and/or double-book, are they still entitled to bill for no-shows? The real “flip side” is allowing patients to submit an invoice for the time they spend in the waiting room beyond their scheduled appointment.

At this point the situation is usually resolved. Rarely, patients continue to protest. If they do, I then say, “Someone has to be responsible for the missed appointment and there are only two people in the room – you and me. Who should it be?” It’s incredibly difficult for a patient to look you in the eye and decline to accept financial responsibility when you say this.

I mentally role-played saying this line to a patient, and it made me cringe. If a patient couldn’t look me in the eye because of something I said, I would be ashamed of myself. I have all the power in the relationship. Surely my patient would be concerned that their care may suffer if they don’t whip out their wallet, pronto.

What’s the next step if a patient digs in their heels and refuses to pay? The implication is that the doctor will end their relationship. (The relationship he loves…)

Having this conversation with patients reminds them of important aspects of the doctor-patient relationship: commitment, concern for patients’ well-being, reliability, timeliness and responsibility. This strengthens the relationship, decreases future no-shows, and helps you collect payment smoothly.

I’m not sure how this policy demonstrates concern for patients’ well-being, but it certainly does put the onus on them for timeliness. However, timeliness in the doctor-patient relationship cuts both ways. Patients will sometimes semi-jokingly say they feel like sending me a bill for the time I kept them waiting. If I were to charge them for missing an appointment, I bet I would actually see some similar invoices from them.

I suspect this tactic will decrease no-shows, but perhaps by driving patients away from the practice. Of course, given the difficulty people have in finding a family doctor or seeing a specialist, patients are unlikely to abandon a doctor, regardless of how they are treated. Once again, all the power is in the doctor’s hands.

If Dr. Marcus and I have such opposite views, then who’s right? We could argue, or we could collect the evidence. The evidence we look at depends on our goal.

If we implement his strategy with the intent of maximizing practice income, then we should compare the additional revenue from no-show patients with the cost of collecting that revenue. Include staff time and the even-more expensive physician time spent convincing patients to pay up. The value of the missed appointment should be discounted in the equation as the time was likely spent in some other useful activity, such as returning calls or reviewing lab results. Is there some way to calculate the value of lost goodwill?

If our goal is to reduce no-shows, then we could compare the no-show rates in two similar practices with different no-show charge policies. Comparing my Saskatoon urology practice with Dr. Marcus’ Toronto family practice is apples and oranges, but it’s interesting to note that he reports a no-show rate of 10-15%. Our clinic’s rate is the same.

It’s easy to be critical, so let me offer a suggestion for an alternate script for “no-show patients”:

I noticed that you missed your last appointment. Because your well-being is important to me, I want to find out how I can help you with appointments in the future. Is there a particular time of day that you prefer? Could my staff call you the day before the appointment as a reminder?

If you can’t make an appointment, I appreciate it if you can call as soon as possible. That will let me schedule another patient in that time, and that helps shorten our clinic’s wait time. Then, the next time you call for an appointment, I’ll be able to see you promptly.

Dr. Marcus’ advice may win the battle, but I fear it will lose the war.

Safety is in the eye of the beholder

As I was leaving Royal University Hospital on the weekend, I was about to cross the road to get to the parking lot when this -

- crossed in front of me. The driver had meticulously scraped the ice from her side of the windshield, but was relying on the defroster to clear the passenger side. It hadn't quite done the trick. In order to see better, she was hunched forward over the steering wheel, peering through the patch of clear glass.

As she approached, I stopped on the path and let her go by, convinced that she wouldn't see me crossing from her blind side.

I'm sure she thought she was being safe. After all, who gets in a car thinking that they're going to cause an accident? And, maybe she was driving safely. Maybe her view was actually unobstructed. It just didn't look that way to me, and so I started to extrapolate about her overall personality and behaviour based on my perception. It wasn't a flattering assessment.

This morning in my cystoscopy clinic, one of my patients commented on this:

It's a temporary support post in the middle of the room. You can see them in several locations in that department. I say temporary, but it's been there for at least a year.

The man asked what was going on and commented that it didn't look very safe. Without a pause, both the nurse and I reassured him that everything was fine and that there was some work going on. But truthfully, we don't know that. We don't know what the underlying problem is or whether it is being fixed. We also don't have any way to judge how safe this solution is. We just trust the engineers who placed them.

Regardless of what the actual safety situation is, my patient had reason to question what was going on. He had formed a perception of how our hospital approached safety issues. Maybe he wondered if there were any other practices for which we were using jury-rigged safety procedures. Did this affect his confidence in us?

In both situations, the observers formed an opinion based on appearances. While the opinion may have been incorrect, it left a powerful impression.

The safety solutions we saw were both obviously makeshift and not sustainable. Particularly in the case of the partially-blinded driver, pedestrians' well-being relied on her maintaining an uncomfortable position to see through her partially-scraped window. In her haste to start driving, she had convinced herself that she could forgo the usual window-scraping routine because she would be extra careful on her drive to work.

When we break established routine (whether out of necessity or convenience) and instead rely on spur-of-the-moment hypervigilance (AKA "winging it"), patient safety is at risk. Even if everything goes well, consider the impression have we left on our patients who, most likely, have nodded compliantly but remained inwardly skeptical upon hearing our unconvincing reassurances.

** Update (March 24, 2011) Hmmm.  Today, I notice that the support post (see above picture) has been removed from the cysto suite.  Are the structural problems fixed?  What was the problem in the first place?

Good design makes it easy to do the right thing

Every system is perfectly to achieve exactly the results it gets.


- (attributed to) Don Berwick

Here are a couple of examples of how design affects behaviour.

First, a picture of the entrance to a Walmart in Calgary. (Sorry it's a little fuzzy.)





There's a huge floormat that you must walk across as you enter the store. There's no way around it. It's long enough to let the big chunks of snow drop off your boots, and also absorb a fair bit of water from them. It must save them a lot of mopping during the spring and winter, and make it safer for customers and staff.


Nobody deliberately makes the floor slick with the runoff from their winter boots. This "push" design makes it easier to do the right thing.


Here's the tap running in one of our cystoscopy suites.







You probably can't tell from the photo, but the water is glacial- absolutely freezing. How long can someone spend washing their hands when the water temperature is so unpleasant? I know it's cold because I do wash my hands in it - over a dozen times in a morning. But, I think I would spend a little extra time under the water if it were warm. (Mmmm, warm water...) And, yes, we have called maintenance about the water temperature.


What are the little things in your workplace that stand in the way of you doing your job the way you want to do it? Why not leave a comment about it ("Anonymous" is fine!) so that we can create a list of simple changes that will improve patient care. What's bugging you?



**Update (March 15, 2011): The water in the cysto unit today started out freezing, but warmed up a lot sooner than usual. Thank you Water Heater Fairy.

**Update (March 24, 2011):  Freezing again today!  Curse you Water Heater Fairy!

Prevention = Simplicity

Health: A state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity.

- World Health Organization

I figured out the connection between my recent anti-smoking tirade and simplicity in healthcare: Prevention = Simplicity.

So much of what we consider modern medicine is acute-care, high-tech, expensive rescue treatment for conditions related to behaviour. Think of sun exposure and skin cancer, obesity, driving while intoxicated, and of course, all the illness caused by tobacco addiction.

I wonder if some health economist has done the math on the relative cost of interventions to prevent disease and interventions to rescue us from the effects of disease? I suppose it would be (relatively) simple to tally up the cost of chemotherapy drugs or ICU stays, but I wonder how human suffering fits into that equation?

The ultimate simplicity is to avoid all those illnesses with primary prevention. But, healthy living is so boring. How can you compete with all those commercials for fast food? (Mmmmm, bacon.) Look how much fun those guys are having at the bar. ("Drink responsibly")

We need a marketing campaign for healthy living.

Maclean's interview with Sholom Glouberman: More on PFCC, EMR and patient experience

Here's a great interview with Sholom Glouberman, founder of the Patients' Association of Canada, is yet another illustration of how poor system design interferes with patient care.

Points of note:

He is an intelligent, confident man with extensive experience in
healthcare, yet he describes his experience as "passive".

Physicians weren't aware of key clinical information, even though it was apparently written in his chart.

Staff signatures were often illegible. His take on the possible
reason for that is interesting. I always thought it was just poor habit,
but he has reason to suggest it may be deliberate.

I particularly note one of his final points. When he is asked whether patients are being asked to participate on healthcare planning and operational committees, he says:

It’s beginning to happen. There are patients on boards of hospitals and health care organizations now. But the patients have to be trained up so that they’re not taken over by the system, and they have to have support. That’s why we need a patients’ organization that stands behind them and is a place where they can come to for resources and for help.

A mother's voice speaks loudly and clearly for EMR and PFCC

"Anonymous" left a powerful comment on a recent post "Leaders: Clear the path and your team will do their best work". As she tells the story of taking her daughter for treatment of a chronic condition, you can feel her frustration at a system that can't move a simple piece of information from one provider to another within 36 hours.

Implementing an EMR might move providers closer to patient and family-centred care, but it would certainly help patients/families overcome resistance to PFCC. A PFCC-aligned EMR would be accessible to the patient. (How could it not be?! We own our medical history!) With the same access to information as any caregiver, patients/families can choose the role they play in their own care. If you want the old "You're the doctor" approach, you can have it. If you want all your test results - explained in plain language (see this Wired magazine article for a suggestion on how this can be done) - you can have them. (Without needing to lug around a "medical binder".)

Anonymous, you speak clearly and passionately on your daughter's behalf. Your points are respectful. You don't lay blame. I can rant endlessly about the benefits of EMR, in person and on this blog, but I won't have nearly the impact that you can have. Oddly, even though power in healthcare usually rests with providers, in this case, it's the opposite. You, Anonymous, have the power to advocate for EMR. You can make the point that patient care will improve. You can tell your family's story about how your daughter's care is impeded by the lack of EMR.

Talk to the decision-makers who can make EMR happen in Saskatchewan. Tell your story to your MLA. Write to the Minister of Health and the Premier. Ask to have 5 minutes at the start of your regional health authority's board meeting to explain what an impact the lack of an EMR is having on your daughter's care. The comment you wrote is already a powerful letter-to-the-editor for your local paper. Speak to your daughter's patient support group about how EMR could make all of their lives easier.

EMR = PFCC. Spread the word, Anonymous.

Not a smoker? Too bad – smoking is still killing you!

I am FURIOUS!

I have just come back from the hospital where I attended a man with serious complications of a chronic disease. He was the 3^rd person I saw today with similar complications from the same disease.

I am furious because none of these people needed to suffer. This disease is completely preventable.

The disease is tobacco addiction.

Perhaps you’re wondering what smoking-related disease urologists treat? You know that cigarettes cause heart disease and lung cancer, but those areas are far removed from urology territory. Give up? It’s bladder cancer – one of the top 10 types of cancer, and primarily caused by tobacco abuse.

The most serious bladder cancers are treated with major surgery: bladder removal and creation of a urinary stoma. It’s a long operation with significant complications. Many of those complications are related to other problems faced by smokers: heart and lung disease, poor wound healing, etc.

During the last month, I’ve had long conversations with 2 patients who were agonizing over their decision to undergo surgery for their bladder cancers. Both were long-time smokers and had severe lung disease. They knew that surgery would be risky, but were also facing certain death if the cancer spread. One man’s wife was in tears as we spoke on the phone.

The maddening thing is that the twin diseases they face never had to happen. They would be spared the physical and emotional suffering if they never smoked.

But, smoking affects non-smokers too. I don’t mean disease caused by second-hand smoke. I’m talking about the money and effort wasted treating largely preventable diseases. Cancer, heart and lung disease, and stroke burn up huge amounts of healthcare resources. That’s money from everyone’s taxes. It means longer wait lists as provider time is taken up managing chronic, tobacco-related disease.

None of this is news to you. We’re inundated with anti-smoking information from the time we’re in grade school. Yet, about 20% Canadians continue to smoke. This despite warning labels, funding for smoking cessation medications, and restrictions on smoking in public places.

These efforts aren’t enough. We’re all suffering the effects of smoking. Smokers suffer personally and dreadfully. Non-smokers pay the price through wasted healthcare resources.

I’m upset enough (and politically naïve enough) to demand a direct solution. And, I won’t direct this to “the system” or “the government”. I say this to the 4 people responsible for preventing smoking-related illness in Canada and Saskatchewan: Prime Minister Stephen Harper, federal Minister of Health Leona Aglukkaq, Premier Brad Wall and provincial Minister of Health Don McMorris.

Stop thinking about tobacco abuse as a personal choice to use a legal product. Tobacco is legal only if your government allows it to be. If you doubt that tobacco use is an addiction, visit my hospital in January when patients smoke outside, shivering in cotton gowns in -30C weather.

Warnings on cigarette packs and public smoking restrictions are not enough.

Choke this problem at its source: Make tobacco illegal in Canada. Wait a year before implementing the law. During that year, lavish free smoking cessation products and support on smokers.

There’s a long list of problems with this plan. We look to you – our leaders – to solve those problems.

Tobacco companies will fight you, literally for their survival. So what? They poison our neighbors. They profit on the back of your healthcare budget.

Save lives. Lead the world.

Put me out of a job. Please.

(April 19, 2011 - I received a response from Don McMorris, Sask Minister of Health.  He outlined Sask's initiatives to reduce smoking - no pharmacy sales, no smoking in cars with children,etc.  Thanks, Minister.)

Leaders: Clear the path and your team will do their best work

Something a healthcare senior leader said recently gave me pause for thought.

As part of a group discussion around healthcare improvement, the perennial topic of electronic medical records (EMR) came up. While everyone at the meeting agreed that EMR would be hugely beneficial to patient care, X opined that technology couldn’t change attitudes.

Here’s the context: The group had already agreed that the primary driver behind healthcare improvement should be the philosophy of patient and family-centred care (PFCC). X’s point was that having EMR would be great, but it wouldn’t convert anyone from being provider-centred to patient-centred.

I spent the next few minutes of the meeting on a thought tangent.

X’s assumption was that providers are fixed in a self-centred existence. They have to be “re-educated” and convinced to embrace PFCC. EMR and other technology don’t influence behaviour.

But, what if there’s a different explanation? Let’s assume that every nurse, doctor, clerk and housekeeper would get tremendous satisfaction from applying PFCC principles in their daily work. They may not be familiar with the formalities of PFCC, but they understand what it means to be kind and caring. Further, assume that all newly-hired providers come to their first day of work with the desire to do their best to serve their patients. What happens after that?

We beat the PFCC out of them! We put obstacles in their path, fail to reward (or even punish) sincere efforts to put patients first. We make it easier to be self-centred than patient-centred.

Here’s an EMR-related example from my practice: A man is referred to me with pain in his side, possibly related to a kidney stone. I recommend a CT scan to locate the kidney stone. He tells me that he already had a CT scan done at his local hospital. The referral letter didn’t indicate that a CT had been done, so I didn’t have the opportunity to look at it prior to this visit. I try to access the CT films using the online x-ray viewing system, but as is frequently the case when we try to do this from our office, the system is not working. I tell the man that I will check his CT the next day when I’m at the hospital and can use that system. He leaves without a definite diagnosis or treatment plan.

Another common example is the “missing” lab test. When a patient has already had a certain blood test performed, but the attending physician doesn’t have access to it (e.g. it’s a weekend and the family doctor’s office is closed), it’s just “easier” to poke the patient with another needle and repeat the test. The physician ordering the repeat test isn’t deliberately cruel; if the results were easily available (EMR!), it wouldn’t be necessary to stick the patient again, and it wouldn’t be done.

My conclusion was that X should think about healthcare providers’ behaviour differently. Rather than presuming the worst, X should assume that providers naturally want to provide PFCC, and that “the system” impedes them. If we assume the best, then our approach would change from one of trying to educate providers in PFCC, to one of trying to remove the barriers that prevent them from fulfilling their natural inclinations.

Here’s what this means for a leader: If your staff isn’t delivering PFCC, it’s not because they don’t want to. It’s because you have not created an environment that lets them do their best work.

Clear the path. Unleash the potential.

Simplicity is its own reward

Sarah posted an interesting comment about the GP-specialist referral process:

I often wonder if simplification from the patient view can contribute to simplification from the doc's point of view.

Hmmm. Ideally, yes, but I have some reservations.

An elegantly designed system completes tasks reliably, consistently and with minimal waste. The simplicity of such a system would be evident to all users.

However, if the system is poorly designed, then not all users will “see” the simplicity. One user group may end up doing more work in order to use the system, or may suffer confusion, extra expense, and/or wasted time. Often, as healthcare tends to be provider-centred, it’s the patient who is saddled with the extra work and waste.

However, there are instances where providers will take on the extra work for the benefit of patients. This makes the process simpler for patients, but more complicated for providers. I would call this “faux-simplicity”. An example of this would be the Navigator role in healthcare.

A Navigator – often a nurse - guides patients through the complex journey of diagnosis and treatment. For example, a man who is suspected of having prostate cancer may have multiple contacts with the healthcare system including prostate biopsy, CT and bone scans, one (or more) specialty consultations, radiation treatment and surgery. It’s a huge help for the man to have the Navigator coordinate testing and travel for the man.

But, the presence of a Navigator doesn’t make the system simpler.

The patient may perceive less work and worry, but the system remains complex, and the Navigator and other providers still struggle with its waste and inefficiency. (Perhaps the perceived need for a Navigator is an admission that the system is badly broken!)

Does it matter that providers have to do more work, as long as patients are freed from the burden? Yes, it does matter. More time and resources spent wrestling with an inefficient, poorly coordinated system means less time and resources spent giving value to patients.

Ideally, a Navigator position is created as part of a broader, patient and family-centred system redesign. The Navigator would help with that improvement process and, once the system is truly simple and efficient, the Navigator should be out of a job!

An example of patient-centred simplicity that would also be simple for providers is a multidisciplinary cancer clinic. If a man were diagnosed with prostate cancer, he would visit the clinic – perhaps for several hours - where all the necessary testing and consultation would be done in one session. This would involve using Advanced Access principles to ensure same-day access to CT and bone scans. The man could see a urologist, oncologist, nurse specialist, dietician and social worker. The providers’ work is simpler because they can confer at once (with the man and his family, of course) and decide on the preferred treatment.

With current disjointed systems, each provider sees the man independently and then corresponds with other providers. This wastes the man’s time, delays treatment and is prone to miscommunication. Doctors waste more effort when they revisit the man’s chart repeatedly as each new report comes in from other consultants.

So, Sarah, I agree that simpler for the patient can mean simpler for the doctor, but it’s not necessarily so. Watch out for faux-simplicity: kludging another layer of service onto a dysfunctional process, rather than tearing it down and redesigning it so that it is truly patient-centred.

And simpler for everyone.