Wednesday, August 14, 2013

A new beginning

It’s difficult to tell this story.  It’s a story of failure and disappointment.  It’s about letting people down.  I only have the courage to tell it now because it is also a story of learning and inspiration.  I think it will have a happy ending.

The tenacious few who have followed this blog from the beginning know that it started as a record of Saskatoon Urology Associates’ work to improve patient access to specialist consultation.  Starting in 2007, with support from the Health Quality Council, we learned about, and applied the Model for Improvement.  We implemented pooled referrals (centralized referral intake), reduced our missed appointment rate, and requested standardized referral information from family physicians.  We discovered the ubiquity of practice variation in our group, began to discuss the reasons behind variation, and then agreed on best practices. 

At its nadir, our average consultation wait time was one month – down from 4 months or longer.  Even though we never reached our original target of 2 weeks, we were very pleased with the process and results.  Then, circumstances changed.  Wait times ballooned.  The frustration that sparked our work in the first place was back.

Our urologist manpower has changed significantly. Early in our improvement work, we had 8 full-time urologists.  Due to retirement and semi-retirement, we now have 6.5 full-time urologists.

How we distribute work has changed over the last 3 years.  The Saskatchewan Surgical Initiative has focused attention on surgical wait times, that is, the time patients wait from being booked to having the procedure performed.  The initiative has been hugely successful in reducing the surgical backlog.  And how do you reduce a backlog?  Hard work, i.e. more surgeons in the operating room more often.  This has taken us away from seeing patients for office consultation.  Predictably, our patients’ wait time for surgery has dropped, but wait time for consultation has burgeoned.

We’ve seen this happening over the last 2 years.  It meant that we started to see (again!) all the phenomenon that go along with long wait times: more calls from patients and referring physicians, referring physicians sending repeat consult requests detailing worsening of patient symptoms, and more urologist effort into triaging consultation requests.  Long wait lists make more work for everyone.  Most disheartening are the comments from family physician colleagues: What happened to you guys?  I used to tell my patients that you had done such a good job of reducing your wait times.  Now I don’t know what to tell them about how long they’ll wait to see you!

We were frustrated by the poor service we were providing to patients and referring physicians.  We regularly griped to each other about it.  The situation was very similar to the one we found ourselves in back in 2007 when we started our improvement work.  The difference now was this: We knew that positive change was possible.  We had experienced the Model for Improvement and had success with it.  We knew we weren’t powerless.  And so, last October, our docs got together to document our concerns.

Rather than jump back into the game with the sole goal of reducing our consultation wait times, however, we decided to look at all the areas of our practice that we were dissatisfied with.  Each urologist recorded 2 or 3 problems on sticky notes that we grouped into themes.  We did a second round of this after major themes had been identified.

It was a long list with some of the main themes being:

  • workload/workflow processes
  • human resources (lack thereof)
  • quality improvement
  • partner communication
  • office practice management

But, the biggest thing to come out of that meeting was an agreement that we wanted to revitalize our quality improvement commitment and that we needed help to do it.  We needed someone to show us how to get back on track and how to create a sustainable system of improvement.  We needed a quality improvement coach.

We hired one!  And that starts a new chapter in this story.

P.S. Thanks to Greg, Kunal and Katherine for encouraging me to start telling our story again – warts and all.


  1. Thanks for coming back and having the guts to tell your story, even though you feel it's not as positive as many of your other posts. But it is so much more valuable for it not being positive. Have you ever heard that poem,
    "I walked a mile with Pleasure;
    She chatted all the way;
    But left me none the wiser
    For all she had to say.
    I walked a mile with Sorrow,
    And ne’er a word said she;
    But, oh! The things I learned from her,
    When sorrow walked with me."
    -Robert Browning Hamilton

    That is how i feel listening to you tell us of your struggles, so that we don't feel discouraged when we hit a bump. We pick ourselves up and try a different route.
    Thanks for telling your tale!

  2. You know what they say about great leaders...they lead with humility. “Humility is not thinking less of yourself, it’s thinking of yourself less” -C. S. Lewis.

    In a humble state, you learn better. Kishore, thank you to you and your colleagues for being humble and thinking of what 's best for your patients. Good luck as you journey to get back to where you know you can be!

  3. Way to go, Kishore, you and your colleagues have great courage! I know that many (and I mean many) practices and organizations have the same struggles, we just have a habit of only wanting to talk about success. I have had this feeling for awhile that QI is suffering as a result of not naming the struggles, exploring the 'failures', or putting on the table the wicked questions we can't seem to crack. If we keep only highlighting sanitized versions of what it means to engage in improvement, I think we risk holding ourselves back from true and deep change. I hope one year at IHI to see a session on "the questions we just can't seem to answer" or "how my QI work failed" :-) Keep up the great and honest work my friend.

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  5. I have had this feeling for awhile that QI is suffering as a result of not naming the struggles,

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