Sunday, October 6, 2013

Lay of the Land

As I mentioned last time, when we decided to rejuvenate our office improvement work, we wanted to address issues more broad than access to urology consultation.  Urology Associates QI 1.0 – focused on access - had many successes including pooled referrals, improved communication with referring physicians, and reducing unwarranted practice variation.  But, we didn’t sustain the process. 

While we’ve continued to pick away at smaller QI initiatives in our practice, we needed to get back to a formal QI process lead by a core team.  We did not want to fall off the wagon again.  Helping us on that path was the task we set for our new QI coach, Katherine Stevenson, principal of The Groundwork Strategy.  (Disclaimer: Katherine and I co-teach the Canadian Medical Association’s Physician Management Institute course “Prescribing Quality Improvement”.  Like I said in the last post, “Right under our noses…”)

While many of the broad strokes of the process Katherine has lead us through are similar to our initial Advanced Access work (e.g. form a core QI team with staff and physician members, regular meetings, document our work, communicate with the other stakeholders), I see many contrasts.  The Advanced Access project came with a preset goal: Improve access to urology care.  With our QI reboot, Katherine suggested that we look at our entire office system before deciding what was the most pressing need. 

This involved surveys and in-person interviews of every urologist and staff member.  We were asked about our impressions of how our system was working, what frustrated us and what we’d like to see improved.  This step had to be performed by someone from outside our office.  Aside from the time and expertise needed to conduct these interviews, it was apparent that uneven power dynamics between physicians (employers) and staff (employees) would make free discussion of at-work frustration difficult, if we tried to carry out the interviews on our own. 

Among the several common themes that Katherine extracted from the interviews, virtually everyone mentioned problems with office communication.  There was frustration and uncertainty around communication between staff and physicians, between staff and patients, and between physicians and patients.  Physicians weren’t sure which staff member was responsible for specific tasks (e.g. booking tests, arranging appointments, billing for procedures), and this lead to a lot of variation in how each of us would assign those tasks.  Staff felt that a lot of time was taken up by answering phone calls that could be dealt with by other means (e.g. office address or fax number, or appointment confirmations).  Physicians felt that staff could deal with many requests that were currently addressed by asking the physician to return the patient’s phone call (e.g. normal test results).

My observations about these discoveries:

-       Leaders shouldn’t presume that everyone in their organization shares their view of the most pressing issues in the workplace. 

-       Medical office staff and physicians don’t necessarily understand the challenges of each others’ work

-       Small, repetitive annoyances can weigh heavier on us than “big ticket items” like improved access to care

-       We had found common ground between staff and physicians.  Perhaps this was a topic that would get our QI work going with a quick win that would improve work life for everyone.

Before we could start with improvements in office communication though, we needed a robust process for our core improvement team.