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.

Tuesday, June 14, 2011

Urban renewal at Royal University Hospital

If you haven't visited the mall at Royal University Hospital (RUH) lately, it's worth the trip.  For those of you not familiar with RUH mall, the far end of it had fallen on hard times.  It used to house an outpatient pharmacy, which was converted into a mail distribution kiosk, then became an empty, derelict husk of a structure, and finally, a bleak open space.  It was the type of place where, when walking by, you'd lock the doors and roll up your windows.

But, from barren ground has sprung a blossom!

Several weeks ago, as I prepared to hustle through no-man's-land, I was surprised to find that someone had installed a fireplace in the middle of the empty space.  Over the subsequent weeks, decorative dividers appeared, followed by plants, tables and seating.

I usually pass by this area in the evening, when the mall is quiet.  But today, I walked through at midday and it was alive with people!  Staff, visitors and patients were having lunch at tables, reading in armchairs, and enjoying the river view by the big windows.

It's a complete renewal of this space!

I wish I had "before" pictures to show you, to demonstrate what an improvement this is.

The best thing about this space was this: I felt proud to walk through it.  Frankly, the old space was an eyesore.  I would go out of my way to avoid it if I were showing someone around the hospital.  Now, it will be an attraction.  What's next in the mall? Concerts at noon? Art shows? Public lectures?

As I admired the area, 3 friends of mine passed by.  We chatted and I asked what they thought of this new common area.  They were all very happy with it, and pointed out that it has become a gathering point for people working, visiting and being cared for at RUH.

But, I asked myself this:  How the heck did someone sell this idea?  We seem to be chronically underfunded in healthcare, and I'm sure there would be many demands on the money that went toward this renovation.  You could make a case that it was frivolous, that our business is healthcare, not interior design.

After seeing all the people enjoying themselves in the mall today, I realized that an investment like this is important for healthcare - perhaps not the technical side, but certainly the caring side.   We traditionally measure success in healthcare through outcomes - mortality, infection, hemoglobin A1c.   But, taking into account the entire experience of healthcare is at least as important as outcomes measures.

The RUH mall renovation shows that someone recognized the importance of experience in healthcare.  To the person who championed this face- and spirit-lift: Well done!

Sunday, June 12, 2011

Cloud-computing and electronic medical records: We're missing the boat

When we finally get our electronic medical record (EMR) in Saskatoon Health Region, will it already be out-of-date?

Last Friday's Globe and Mail business section was buzzing with news about "cloud computing".  Apple's recent announcement of iCloud - while not the first cloud-based storage service - might, according to one analyst, do to that market what the iPod did previously to the MP3 player market.  iCloud will let you store data on remote servers and access it from anywhere you have internet access.  That means remote access to music, photos, video and documents.

How about your medical records?  Not so much.

Another article about cloud-computing focused on EMRs.   Bottom line: We're struggling.

Several years ago, in a blog far, far away, I pouted about the lack of a functional, province-wide EMR.  Since then, I have achieved on-line access to all x-rays done in Saskatchewan hospitals, except Regina.  Lab results ordered by one of our urologists, or copied to one of us, are sent electronically to our office EMR.  I usually get results on my inpatients even before the hospital ward receives them.  It also saves our staff the nuisance of manually assigning results to patient files.  I can also access patient pharmacy records, that is, if I can remember password #37.

There has been progress, but it's slow and local.  I have access to test results that I've ordered or another physician has thought to copy me on.  Otherwise, if I want x-ray reports, lab results and, most importantly, patients' medical history from another physician's office, I have to retrieve the information manually.  This usually involves me writing a letter, or my staff phoning a referring doctor's office.  It sometimes requires a follow-up request.  Then, if the information isn't forthcoming, we give up and repeat the test.

It's a frustrating waste of time and money.

An EMR that lived in the cloud would give me access (with appropriate permission) to all of a patient's records.  What's the roadblock?  According to the Globe and Mail piece: interoperability and security/privacy.

But, banks seem to have cracked this problem, and they deal with pretty important information.  Different industry, you say?  Well, Toronto's Sunnybrook has already put the power of an EMR into patients' hands with MyChart.

I hope that an EMR will arrive in Saskatoon Health Region in the near future.  But, if the data lives on local servers and isn't remotely available (to the patient, and any caregiver around the world who may be providing health services to them) then I fear our patients and staff will be saddled with an EMR that is DOA.