tag:blogger.com,1999:blog-82580009519542350352024-03-18T07:38:52.808-06:00Adventures in Improving AccessIn spring 2007, Dr. Kishore Visvanathan and his colleagues at Saskatoon Urology Associates implemented a strategy called Advanced Access. The goal was to reduce the time patients waited for a specialist consultation. As the project progressed, their efforts widened to embrace a broader strategy known as Clinical Practice Redesign. They now look at all areas of their practice to improve efficiency and service for their patients.Unknownnoreply@blogger.comBlogger188125tag:blogger.com,1999:blog-8258000951954235035.post-72000848379993467032013-10-06T22:24:00.000-06:002013-10-06T22:24:48.085-06:00Lay of the Land
<!--[if gte mso 9]><xml>
<o:DocumentProperties>
<o:Template>Normal</o:Template>
<o:Revision>0</o:Revision>
<o:TotalTime>0</o:TotalTime>
<o:Pages>1</o:Pages>
<o:Words>558</o:Words>
<o:Characters>2903</o:Characters>
<o:Lines>49</o:Lines>
<o:Paragraphs>5</o:Paragraphs>
<o:CharactersWithSpaces>3907</o:CharactersWithSpaces>
<o:Version>11.1287</o:Version>
</o:DocumentProperties>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:DoNotShowRevisions/>
<w:DoNotPrintRevisions/>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:UseMarginsForDrawingGridOrigin/>
</w:WordDocument>
</xml><![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
As I mentioned <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/09/what-makes-good-qi-coach.html">last time</a>, when we decided to rejuvenate our
office improvement work, we wanted to address issues more broad than access to
urology consultation.<span style="mso-spacerun: yes;"> </span>Urology
Associates QI 1.0 – focused on access - had many successes including pooled
referrals, improved communication with referring physicians, and reducing
unwarranted practice variation.<span style="mso-spacerun: yes;">
</span>But, we didn’t sustain the process.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>We did not want to fall off
the wagon again.<span style="mso-spacerun: yes;"> </span>Helping us on
that path was the task we set for our new QI coach, Katherine Stevenson,
principal of <a href="http://groundworkstrategy.ca/">The Groundwork Strategy</a>.<span style="mso-spacerun: yes;"> </span>(Disclaimer: Katherine and I co-teach
the Canadian Medical Association’s Physician Management Institute course
“Prescribing Quality Improvement”.<span style="mso-spacerun: yes;">
</span>Like I said in the last post, “Right under our noses…”)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>The Advanced Access project came with a
preset goal: Improve access to urology care.<span style="mso-spacerun: yes;"> </span>With our QI reboot, Katherine suggested that we look at our
entire office system before deciding what was the most pressing need.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This involved surveys and in-person interviews of every
urologist and staff member.<span style="mso-spacerun: yes;"> </span>We
were asked about our impressions of how our system was working, what frustrated
us and what we’d like to see improved.<span style="mso-spacerun: yes;">
</span>This step had to be performed by someone from outside our office.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Among the several common themes that Katherine extracted
from the interviews, virtually everyone mentioned problems with office
communication.<span style="mso-spacerun: yes;"> </span>There was
frustration and uncertainty around communication between staff and physicians,
between staff and patients, and between physicians and patients.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>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).<span style="mso-spacerun: yes;">
</span>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).</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My observations about these discoveries:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<!--[if !supportLists]--><span style="mso-font-width: 0%;">-<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Leaders
shouldn’t presume that everyone in their organization shares their view of the
most pressing issues in the workplace.<span style="mso-spacerun: yes;">
</span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<span style="mso-spacerun: yes;"><br /></span></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<!--[if !supportLists]--><span style="mso-font-width: 0%;">-<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Medical
office staff and physicians don’t necessarily understand the challenges of each
others’ work</div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<!--[if !supportLists]--><span style="mso-font-width: 0%;">-<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->Small,
repetitive annoyances can weigh heavier on us than “big ticket items” like
improved access to care</div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -.25in;">
<!--[if !supportLists]--><span style="mso-font-width: 0%;">-<span style="font: 7.0pt "Times New Roman";"> </span></span><!--[endif]-->We
had found common ground between staff and physicians.<span style="mso-spacerun: yes;"> </span>Perhaps this was a topic that would get our QI work going
with a quick win that would improve work life for everyone.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Before we could start with improvements in office
communication though, we needed a robust process for our core improvement team.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Unknownnoreply@blogger.com6tag:blogger.com,1999:blog-8258000951954235035.post-64646738129629173022013-09-02T21:17:00.000-06:002013-09-02T21:17:06.217-06:00What makes a good QI coach?<!--[if gte mso 9]><xml>
<o:DocumentProperties>
<o:Template>Normal</o:Template>
<o:Revision>0</o:Revision>
<o:TotalTime>0</o:TotalTime>
<o:Pages>1</o:Pages>
<o:Words>707</o:Words>
<o:Characters>4033</o:Characters>
<o:Lines>33</o:Lines>
<o:Paragraphs>8</o:Paragraphs>
<o:CharactersWithSpaces>4952</o:CharactersWithSpaces>
<o:Version>11.1287</o:Version>
</o:DocumentProperties>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:DoNotShowRevisions/>
<w:DoNotPrintRevisions/>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:UseMarginsForDrawingGridOrigin/>
</w:WordDocument>
</xml><![endif]-->
<!--StartFragment-->
<br />
<br />
<blockquote class="tr_bq">
<i>Give a man a fish and he eats for a day.</i></blockquote>
<blockquote class="tr_bq">
<i></i><i>Teach a man to fish and he eats for a lifetime.</i></blockquote>
<blockquote class="tr_bq">
<i>Show a man how to use a phone and he can order pizza.<span style="mso-spacerun: yes;"> </span>Who wants fish everyday?</i></blockquote>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
How do you go about selecting a quality improvement coach?<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
A coach could be a mentor, guide, cheerleader, or teacher
(and probably all these at different times).<span style="mso-spacerun: yes;"> </span>The origin of the word gives insight into its true
meaning.<span style="mso-spacerun: yes;"> </span>“Coach”, in its original
use, refers to a carriage or means of transportation.<span style="mso-spacerun: yes;"> </span>Later, it referred to someone who helped students (or,
carried them) through exams.<span style="mso-spacerun: yes;"> </span>In
both usages, a coach helps someone reach their goal.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I distinguish a coach from a consultant.<span style="mso-spacerun: yes;"> </span>I see a consultant as someone who
assesses the problem and prescribes a solution.<span style="mso-spacerun: yes;"> </span>We were interested in working with someone who could help us
develop (or rekindle…) an independent capacity to identify and solve the
problems in our practice.<span style="mso-spacerun: yes;"> </span>Also, we
wanted to develop a sustainable quality improvement process.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
While we wanted someone to help us eventually develop our
own capacity, we recognized that this coach would likely need to do some of the
initial diagnostic work to jumpstart the process.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In retrospect, after having been in the coaching process for
almost 9 months now, I judge the 2 key qualities of a QI coach to be patience
and breadth of experience.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Novices make mistakes; it’s a powerful way to learn.<span style="mso-spacerun: yes;"> </span>The coach may be tempted to curtail
exploration and experimentation, intending to speed the journey along.<span style="mso-spacerun: yes;"> </span>Feeding the student the “correct”
answer may shorten the process, but deprives him of the experience of
understanding what <i>doesn’t</i><span style="font-style: normal;"> work.<span style="mso-spacerun: yes;"> </span>This is particularly important in QI
work where the solution(s) may not be known and experimentation (PDSA cycles,
action research, etc.) is the only way forward.<span style="mso-spacerun: yes;"> </span>An experienced coach may have seen certain initiatives fail
in other settings, but must be patient in allowing students to conduct learning
trials and develop their own understanding about what works in their system.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The coach’s patience was particularly important as we
started to rank the importance of problems areas to be improved.<span style="mso-spacerun: yes;"> </span>I suspect our coach had preferences as
to which improvements would have the greatest impact on patient, staff and
physician satisfaction, but kept quiet about it.<span style="mso-spacerun: yes;"> </span>Instead, we were shown methods to reach a consensus around
which projects were <i>our</i><span style="font-style: normal;"> priorities.<span style="mso-spacerun: yes;"> </span>This has been an important factor in
maintaining enthusiasm around the work: The projects we’re working on are
meaningful for us, not ones foisted on us from outside.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This relates to the “give a man a fish” aphorism that I
tweaked at the start of this post.<span style="mso-spacerun: yes;">
</span>The kernel of wisdom in the original saying is very much the philosophy
of coach over consultant.<span style="mso-spacerun: yes;"> </span>A
consultant may give you the fish/answer, whereas a coach will show you how to
get the fish/answer for yourself.<span style="mso-spacerun: yes;">
</span>I think the next step in QI independence and sustainability is to give
the team the tools to decide what they want to have for dinner.<span style="mso-spacerun: yes;"> </span>And that means the coach has to give up
control of the direction of the work.<span style="mso-spacerun: yes;">
</span>Therefore, we wanted a coach who was not personally invested in “fish
for dinner”, i.e. a predetermined direction that our QI work would take.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
A coach’s breadth of experience is important when the QI
team wants to develop an independent, sustainable capacity.<span style="mso-spacerun: yes;"> </span>This relates most closely to the common
use of “coach” in athletic training.<span style="mso-spacerun: yes;">
</span>Athletes who specialize in a particular event seek out coaches with expertise
in that area.<span style="mso-spacerun: yes;"> </span>A specialized coach
may help elite athletes reach their potential in individual events, but these
athletes may not have well-rounded fitness, may be prone to certain injuries,
or find that they cannot sustain that level of training in the long-term.<span style="mso-spacerun: yes;"> </span>A particular training technique may
work for some athletes, but a coach who is familiar with a variety of
techniques will be able to help many athletes achieve their goals.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In Saskatchewan, our health system has adopted Lean as our
quality improvement system and is investing heavily in training providers and
administrators.<span style="mso-spacerun: yes;"> </span>I’m excited that
we have a consistent method to guide our QI work.<span style="mso-spacerun: yes;"> </span>At the same time, I’m conscious that “when all you have is a
hammer, everything looks like a nail.”<span style="mso-spacerun: yes;">
</span>Lean may not be the right hammer for all our nails.<span style="mso-spacerun: yes;"> </span>Rather than signing up our QI team for
Lean training, we decided to take a non-denominational approach that would let
us pick and choose from various QI models.<span style="mso-spacerun: yes;"> </span>That required a coach with broad exposure and experience
with different QI systems.<span style="mso-spacerun: yes;"> </span>Also,
we wanted to start our QI work immediately rather than spend weeks in formal
training.<span style="mso-spacerun: yes;"> </span>This approach demanded a
coach who was confident and expert enough to give us just-in-time training as
we proceeded.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Whew! That is a tall order for a QI coach.<span style="mso-spacerun: yes;"> </span>Where would you find such a person?</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Right under our noses…</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Unknownnoreply@blogger.com17tag:blogger.com,1999:blog-8258000951954235035.post-3740186019229720112013-08-14T22:54:00.001-06:002013-08-14T22:54:47.316-06:00A new beginning
<!--[if gte mso 9]><xml>
<o:DocumentProperties>
<o:Template>Normal</o:Template>
<o:Revision>0</o:Revision>
<o:TotalTime>0</o:TotalTime>
<o:Pages>1</o:Pages>
<o:Words>604</o:Words>
<o:Characters>3446</o:Characters>
<o:Lines>28</o:Lines>
<o:Paragraphs>6</o:Paragraphs>
<o:CharactersWithSpaces>4231</o:CharactersWithSpaces>
<o:Version>11.1287</o:Version>
</o:DocumentProperties>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:DoNotShowRevisions/>
<w:DoNotPrintRevisions/>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:UseMarginsForDrawingGridOrigin/>
</w:WordDocument>
</xml><![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
It’s difficult to tell this story.<span style="mso-spacerun: yes;"> </span>It’s a story of failure and disappointment.<span style="mso-spacerun: yes;"> </span>It’s about letting people down.<span style="mso-spacerun: yes;"> </span>I only have the courage to tell it now
because it is also a story of learning and inspiration.<span style="mso-spacerun: yes;"> </span>I think it will have a happy ending.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>Starting in 2007, with support from the
Health Quality Council, we learned about, and applied the Model for
Improvement.<span style="mso-spacerun: yes;"> </span>We implemented pooled
referrals (centralized referral intake), reduced our missed appointment rate,
and requested standardized referral information from family physicians.<span style="mso-spacerun: yes;"> </span>We discovered the ubiquity of practice
variation in our group, began to discuss the reasons behind variation, and then
agreed on best practices.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
At its nadir, our average consultation wait time was one
month – down from 4 months or longer.<span style="mso-spacerun: yes;">
</span>Even though we never reached our original target of 2 weeks, we were
very pleased with the process and results.<span style="mso-spacerun: yes;"> </span>Then, circumstances changed.<span style="mso-spacerun: yes;"> </span>Wait times ballooned.<span style="mso-spacerun: yes;">
</span>The frustration that sparked our work in the first place was back.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Our urologist manpower has changed significantly. Early in
our improvement work, we had 8 full-time urologists.<span style="mso-spacerun: yes;"> </span>Due to retirement and semi-retirement, we now have 6.5
full-time urologists.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
How we distribute work has changed over the last 3
years.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The initiative has been hugely
successful in reducing the surgical backlog.<span style="mso-spacerun: yes;"> </span>And how do you reduce a backlog?<span style="mso-spacerun: yes;"> </span>Hard work, i.e. more surgeons in the operating room more
often.<span style="mso-spacerun: yes;"> </span>This has taken us away from
seeing patients for office consultation.<span style="mso-spacerun: yes;">
</span>Predictably, our patients’ wait time for surgery has dropped, but wait
time for consultation has burgeoned.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We’ve seen this happening over the last 2 years.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>Long wait lists make more work for everyone.<span style="mso-spacerun: yes;"> </span>Most disheartening are the comments from family physician
colleagues: <i>What happened to you guys?<span style="mso-spacerun: yes;">
</span>I used to tell my patients that you had done such a good job of reducing
your wait times.<span style="mso-spacerun: yes;"> </span>Now I don’t know
what to tell them about how long they’ll wait to see you!<o:p></o:p></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We were frustrated by the poor service we were providing to
patients and referring physicians.<span style="mso-spacerun: yes;">
</span>We regularly griped to each other about it.<span style="mso-spacerun: yes;"> </span>The situation was very similar to the one we found ourselves
in back in 2007 when we started our improvement work.<span style="mso-spacerun: yes;"> </span>The difference now was this: We knew that positive change
was possible.<span style="mso-spacerun: yes;"> </span>We had experienced
the Model for Improvement and had success with it.<span style="mso-spacerun: yes;"> </span>We knew we weren’t powerless.<span style="mso-spacerun: yes;"> </span>And so, last October, our docs got together to document our
concerns.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>Each urologist recorded 2 or 3 problems on sticky notes that
we grouped into themes.<span style="mso-spacerun: yes;"> </span>We did a
second round of this after major themes had been identified.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It was a long list with some of the main themes being:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
</div>
<ul>
<li>workload/workflow processes</li>
<li>human resources (lack thereof)</li>
<li>quality improvement</li>
<li>partner communication</li>
<li>office practice management</li>
</ul>
<o:p></o:p><br />
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>We
needed someone to show us how to get back on track and how to create a
sustainable system of improvement.<span style="mso-spacerun: yes;">
</span>We needed a quality improvement coach.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We hired one!<span style="mso-spacerun: yes;">
</span>And that starts a new chapter in this story.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
P.S. Thanks to Greg, Kunal and Katherine for encouraging me
to start telling our story again – warts and all.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Unknownnoreply@blogger.com7tag:blogger.com,1999:blog-8258000951954235035.post-88839453174498128442013-05-27T23:47:00.002-06:002013-05-27T23:47:59.440-06:00I get it! I'm a fish! - Communication as a prerequisite to improvementI had an interesting conversation last week with someone who shares my enthusiasm/impatience to move ahead with health system improvement. He offered me a new perspective on a point that has been frustrating me for years, that is, we seem to be able to make fairly rapid improvements within our Urology group, but change at the provincial level is often slow. <br />
<br />
Even though Saskatchewan is seeing amazing improvements through some focussed initiatives (see <a href="http://www.sasksurgery.ca/index.html">Sask Surgical Initiative</a> and <a href="http://www.sasksurgery.ca/tableau/sp90th.html">wait time trends chart</a>), I want the changes to be faster and deeper. "Faster" speaks for itself, but "deeper" is a little elusive. <br />
<br />
Many of the changes we've made in Saskatchewan are "first-order", that is they're incremental and happen within the existing structure. For example, we're doing more surgery to reduce the backlog and waiting list. But, if the underlying mechanisms and culture that created the backlog in the first place aren't themselves changed, we're in danger of backsliding. As the Surgical Initiative enters its last of 4 years, we're going to invest in processes designed to maintain surgical wait times at the desired levels. That is, we're going to spend money pushing back against a resistant system. <br />
<br />
A second-order change involves new ways of working and thinking about a process. In the context of reducing surgical wait times, we might reward (not necessarily financial!) providers for their ability to deliver timely care. Or, we might look closely at whether or not a particular operation is actually appropriate for a given patient. If someone is unlikely to benefit from surgery, or, after being fully informed of risks, benefits and alternatives, decides against having surgery, wait times may be maintained by reducing demand. Ultimately, we might change the system deeply enough that the disease currently treated with surgery no longer exists (quit smoking!).<br />
<br />
Of course, second-order change requires a profound commitment to improvement, and investment in building communication and cooperation. That's where my friend offered me insight into why I'm frustrated by the generally slow pace of change in the provincial healthcare system. <br />
<br />
He follows some of the work described in this blog, and in particular our recent work on <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/03/5-minute-improvement-huddles-part-iii.html">rapid improvement through 5-minute huddles.</a> He knows that I've challenged the need for week-long RPIWs (Rapid Process Improvement Workshops) that occupy huge amounts of staff and administrator time, sometimes to accomplish seemingly trivial results. If our Urology service can move forward an improvement project over 1-2 weeks in 5 minute daily aliquots, why can't other services/departments do the same? His answer to me: Much RPIW time is spent establishing the team and setting context, whereas our urology team is already highly functional and knowledgeable about our own practice. <br />
<br />
A-ha! Our Urology group is already used to working cooperatively and collegially, discussing issues frankly, and developing consensus. We've have regular times to meet and expectations that process improvement is part of our daily work. In the same way that fish don't see the water they're swimming in, we're so used to being immersed in a supportive environment that we don't notice it anymore! <br />
<br />
So, how do we make more fish? Or, maybe it's the water we need...<br />
<br />
Training all healthcare staff and administrators in process improvement techniques is a toe in the water; it's first order change. To get everyone to jump into the pool will take a more profound intervention. I think that formal communication training is the key. I flattered myself a couple of paragraphs back when I congratulated us for our collegial urology environment. But, it's easy to get along when you all live essentially the same professional life: hospital rounds, take out a kidney, clinic, repeat. Urologists have similar training, goals and professional culture. It's much more difficult trying to communicate with someone from a different tribe. <br />
<br />
A proposal: Rather than investing in training lots of people deeply in a specific process improvement methodology that they may use only occasionally, let's train everyone in healthcare in a common communication methodology. That training would be used every day. Healthcare would be safer, and better communication would obviate some of the process messes we're trying to fix. Smaller numbers of process improvement experts could then be deployed to coach others in project teams, which would hit the water swimming because communication and teamwork would already be second nature to them.<br />
<br />Unknownnoreply@blogger.com14tag:blogger.com,1999:blog-8258000951954235035.post-27509482563824077322013-04-07T21:13:00.000-06:002013-04-07T21:13:36.251-06:00Execution is a killerOur urology ward's <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/03/low-tech-rules.html">standard work for morning rounds </a>has evolved and is now stable. These are the steps:<br />
<br />
<br />
<ul>
<li>Good morning!</li>
<li>Report</li>
<li>Discharge planning (prescriptions, Home Care)</li>
<li>Discharge date</li>
<li>M&M book</li>
<li>Followup (testing/imaging) assigned to ...</li>
<li>Off-service patients</li>
<li>Improvement work</li>
<li>Thank you!</li>
</ul>
<br />
<br />
The reminders I find most useful are about discharge planning and followup of testing. Prior to having the checklist, the docs didn't consistently let nursing staff know when to expect a patient to be discharged, so advance planning (patient education, transportation, Home Care referral) wasn't done. The "followup" reminder requires the docs to be explicit about which of us is responsible to check Mrs. Smith's chest x-ray. This important work is less likely to slip through the cracks when one person is accountable.<br />
<br />
"Improvement work" refers to our <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/03/5-minute-improvement-huddles-part-iii.html">5-minute huddles</a>, both for new initiatives and followup of ongoing work.<br />
<br />
<br />
The next step is to make this checklist part of our routine. This is the stage where we need to move from the "champion" leading the checklist to anyone on the team being able to do it, and having the expectation that we will use it at every morning round. Many worthwhile improvement ideas falter at this "execution" step.<br />
<br />
We started with the idea of assigning a specific person to lead the checklist. One of the docs suggested that our "ward doc" should do it. Each week, a urologist is assigned to be the ward doc, with responsibility for new patients admitted to hospital who don't have a previously assigned urologist. We tried this 2 weeks ago.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDIe5dMRDrkBpNXGCdIWe0fgCzsuTUdjCYbYLYuVm4-97gNxKmEt6C4q6rhJEOluOxAozvvsex6CDyWJQy4fzsXwqKBh1Ly0k1PnHKY_zdabUh4VGbsOHcWvzkD6_MALuoEQJkm7-JkSu4/s1600/IMG_0909.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDIe5dMRDrkBpNXGCdIWe0fgCzsuTUdjCYbYLYuVm4-97gNxKmEt6C4q6rhJEOluOxAozvvsex6CDyWJQy4fzsXwqKBh1Ly0k1PnHKY_zdabUh4VGbsOHcWvzkD6_MALuoEQJkm7-JkSu4/s320/IMG_0909.jpg" width="240" /></a></div>
<br />
<br />
I thought this would be an easy one, because there is always an assigned ward doc. As it turned out, the reality was slightly different. Because of the vagaries of our holiday schedule, the assigned ward doc was away on Monday. On Tuesday, the ward doc didn't attend rounds because he was at a meeting. On Wednesday, we recognized that assigning leadership of the checklist to the ward doc may not be reliable, so we asked the nurse who was leading patient rounds (by reading the ward census) to lead the checklist. It was this nurse's first time seeing the checklist and she wasn't familiar with what each of the items meant. We had not recognized that there is enough turnover in nursing staff attending morning rounds that some are not aware of the ongoing 5-minute improvement work. On Thursday, we were back to one of the doctors leading the checklist. (Friday was a holiday.)<br />
<br />
Looks like we'll carry on with the docs taking turns to lead the checklist. I'm away from the practice a fair bit this month, so it will be interesting to see whether we've already reached a tipping point with this work and whether it will continue while the "champion" is not around.<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />Unknownnoreply@blogger.com3tag:blogger.com,1999:blog-8258000951954235035.post-74093080027705475102013-03-18T21:39:00.000-06:002013-03-18T21:39:04.376-06:00Low tech rules!Still no <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/03/5-minute-improvement-huddles-part-iii.html">communication whiteboard</a>! Oh, well - we decided to get the ball rolling with pen and paper instead.<br />
<br />
Every weekday morning, our urologists make inpatient rounds and then do a group report with the ward nurses. (This is also the setting for our 5-minutes quality huddle.) One of the morning tasks is to record any complications or adverse events in a log book. While we usually discuss management of any complications immediately at rounds, one doc is assigned to review the book from time to time and report any trends or gaps in management. <br />
<br />
Last week, while recording in the book, one of my partners pointed out that there had been nothing recorded for 2 weeks.<br />
<br />
"Were there no complications, or did we forget to record them?"<br />
<br />
We weren't sure. Hmmm - how to get surgeons to remember to do important stuff? Checklist, anyone?<br />
<br />
I thought our new whiteboard would be a great place to develop a morning rounds checklist (AKA standard work). But, this is how our whiteboard's (future) spot on the wall looked this morning:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCrCQWjdQN3lf-QR0HyHhSdJ3Cxt2g5VCpLlqMjj4Z0-QrgCymZVtpBeqnv3Z7mIVmQOwi-ecZ9YDU-idyB98r998rdTNMP8txAE6X9Hd6CaEDnVep9JNWDy6xUIMUk_Txp1GYN8NV6Z6j/s1600/IMG_0891.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCrCQWjdQN3lf-QR0HyHhSdJ3Cxt2g5VCpLlqMjj4Z0-QrgCymZVtpBeqnv3Z7mIVmQOwi-ecZ9YDU-idyB98r998rdTNMP8txAE6X9Hd6CaEDnVep9JNWDy6xUIMUk_Txp1GYN8NV6Z6j/s320/IMG_0891.JPG" width="320" /></a></div>
<br />
<br />
So we tried this:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicCmYtkinK1fL5LtgUCEU2r1w3Hp7C3cQBez6aD91RzKiiNGpm9bvKDQT04IwP-MFay3r8KiGSMutdWTcBMcEtq-ENSW8vlpg1AIZALBUbWhMgP-ofFx2plLOGIDGr_ZIOBCQTZCUfvnYM/s1600/IMG_0892.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicCmYtkinK1fL5LtgUCEU2r1w3Hp7C3cQBez6aD91RzKiiNGpm9bvKDQT04IwP-MFay3r8KiGSMutdWTcBMcEtq-ENSW8vlpg1AIZALBUbWhMgP-ofFx2plLOGIDGr_ZIOBCQTZCUfvnYM/s320/IMG_0892.JPG" width="320" /></a></div>
<br />
<br />
Paper and felt pen. We quickly sketched out a list of morning tasks and posted them for review tomorrow. <br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjstg0g9Dxo45dEFAhyFeTsPn3OLl32sYZ_5b8r_e6M0wDkxAcLt8H5TDRQu_wp3lvPLnWRiF63mZQ0NF5zz6OcWwvvDUzWvTdIXlwyIluAMYgOksyWCV5XsPkx1pWOZlk0nZEzKHvBQlru/s1600/IMG_0893.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjstg0g9Dxo45dEFAhyFeTsPn3OLl32sYZ_5b8r_e6M0wDkxAcLt8H5TDRQu_wp3lvPLnWRiF63mZQ0NF5zz6OcWwvvDUzWvTdIXlwyIluAMYgOksyWCV5XsPkx1pWOZlk0nZEzKHvBQlru/s320/IMG_0893.JPG" width="320" /></a></div>
<br />
<br />
We'll try out the list and see if anything needs to be added. Once we've tried it on a few occasions and with different mixes of staff present, we can turn it into something prettier and have it laminated.<br />
<br />
That went so well (and quickly) that we took a stab at improving and standardizing the format for logging adverse events.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJlrNVUj0lsMG02klZD0BxNORZQIVyS2zk0s4WF1nhU1jdSLiGxtkLFOUC_Eji3bxp7xT_OKUx0Wj2PaxAR_jQT4TGbROIO3078MGvf_wFFHXH7EasD4giwUK86-0e9MqUfGqMOMOIR3jO/s1600/IMG_0894.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJlrNVUj0lsMG02klZD0BxNORZQIVyS2zk0s4WF1nhU1jdSLiGxtkLFOUC_Eji3bxp7xT_OKUx0Wj2PaxAR_jQT4TGbROIO3078MGvf_wFFHXH7EasD4giwUK86-0e9MqUfGqMOMOIR3jO/s320/IMG_0894.JPG" width="320" /></a></div>
<br />
<br />
Take that, whiteboard!Unknownnoreply@blogger.com3tag:blogger.com,1999:blog-8258000951954235035.post-87843556366272611272013-03-03T20:16:00.000-06:002013-03-03T20:16:27.551-06:005-minute improvement huddles - part III. Sustainability(Note: links to <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/01/5-minute-process-improvement-huddles-on.html">Part I</a> and <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/02/5-minute-improvement-huddles-part-ii.html">Part II</a>)<br />
<br />
The changes to our voiding trial process have taken root. Here are some data from the week after post "Part II".<br />
<br />
<br />
<!--[if gte mso 9]><xml>
<o:DocumentProperties>
<o:Template>Normal</o:Template>
<o:Revision>0</o:Revision>
<o:TotalTime>0</o:TotalTime>
<o:Pages>1</o:Pages>
<o:Words>32</o:Words>
<o:Characters>188</o:Characters>
<o:Lines>1</o:Lines>
<o:Paragraphs>1</o:Paragraphs>
<o:CharactersWithSpaces>230</o:CharactersWithSpaces>
<o:Version>11.1287</o:Version>
</o:DocumentProperties>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:DoNotShowRevisions/>
<w:DoNotPrintRevisions/>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:UseMarginsForDrawingGridOrigin/>
</w:WordDocument>
</xml><![endif]-->
<!--StartFragment-->
<table border="1" cellpadding="0" cellspacing="0" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt;">
<tbody>
<tr>
<td style="border: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Time catheter removal ordered<o:p></o:p></div>
</td>
<td style="border-left: none; border: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Time catheter removed<o:p></o:p></div>
</td>
<td style="border-left: none; border: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Saline instilled?<o:p></o:p></div>
</td>
<td style="border-left: none; border: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Time of first void<o:p></o:p></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0730<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0800<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Yes<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Immediate (pt incontinent)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0730<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0815<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Yes<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
1100<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0910<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0910 (removed by doc)<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Yes<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0925<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0940<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0940 (removed by doc)<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Yes<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0950<o:p></o:p></div>
</td>
</tr>
</tbody></table>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The key changes here are that catheters are being removed promptly and voiding trials are successful earlier due to the new process of filling bladders with saline just before catheter removal. We'll measure again after 2 months, both to see what time catheters are being removed and how staff and docs feel about the new process.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Now, back to my <a href="http://adventuresinimprovingaccess.blogspot.ca/2013/01/5-minute-process-improvement-huddles-on.html">hidden agenda</a>!</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I want to see if we can improve our urology ward processes without establishing formal teams. More complex changes may require formation of teams, but I wonder if we can get more people involved using the 5-minute improvement huddles at our morning reports. Shared involvement means shared shared responsibility and ownership of an initiative. Unfortunately, I have been a barrier to that in the past.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Throughout much of our practice's improvement work, I've been the "champion". The champion's role is to provide enthusiasm and momentum. However, if the champion is the only person driving the work forward, it's difficult to sustain the effort when his attention is directed elsewhere. I don't mean this to be derogatory to my partners and staff - they are certainly committed to improvement. Rather, it is a comment about the fact that we haven't been deliberate about developing an improvement infrastructure. To be sustainable, improvement work needs a process that drives it forward independently of individual effort. I've been guilty of taking sole responsibility for projects, taking on too much, and then dropping the ball. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
On the urology ward, I'm not always present for morning rounds. If I'm the only one keeping track of a process improvement, things will falter.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Also, we need to build capacity for this work. Everyone should have a chance to participate and lead these improvement huddles. I can't be greedy about the "champion" role!</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We discussed how to sustain our improvement efforts and we're going to start with a communication board in our meeting room. We can document current initiatives along with next steps, data to be collected, etc. I think this will give day-to-day continuity for our work without needing to rely on one person's presence. We'll post reminders about followup on previous efforts, such as the voiding trial process. I'm also interested to create standard work for our morning report, including time for the 5-minute huddles.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It's a multi-use room that patients and visitors use as a lounge, so we can't post any confidential information. There were some questions about whether or not it was appropriate to display our improvement efforts publicly. One of the nurses pointed out that staff already publicly display many quality measures on the ward, and that patients and visitors seem quite pleased to see that we are making efforts at improvement. (Also, this blog has been sort of public...)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Unknownnoreply@blogger.com5tag:blogger.com,1999:blog-8258000951954235035.post-61760556532900925852013-02-03T23:52:00.000-06:002013-02-03T23:52:13.360-06:005-minute improvement huddles – Part II. Trying out new voiding trials.
<!--[if gte mso 9]><xml>
<o:DocumentProperties>
<o:Template>Normal</o:Template>
<o:Revision>0</o:Revision>
<o:TotalTime>0</o:TotalTime>
<o:Pages>1</o:Pages>
<o:Words>603</o:Words>
<o:Characters>3440</o:Characters>
<o:Lines>28</o:Lines>
<o:Paragraphs>6</o:Paragraphs>
<o:CharactersWithSpaces>4224</o:CharactersWithSpaces>
<o:Version>11.1287</o:Version>
</o:DocumentProperties>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:DoNotShowRevisions/>
<w:DoNotPrintRevisions/>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:UseMarginsForDrawingGridOrigin/>
</w:WordDocument>
</xml><![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Our story so far… (<a href="http://adventuresinimprovingaccess.blogspot.ca/2013/01/5-minute-process-improvement-huddles-on.html">See last week’s post</a>.)</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This week: What we learned, and some insightful comments on
the last post.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Last week’s suggestions for process improvement (PI) were
well-received by nursing and medical staff.<span style="mso-spacerun: yes;"> </span>Our quality improvement nurse lead reported that nursing
staff were keen to expedite voiding trials once they appreciated the
implications for patient flow.<span style="mso-spacerun: yes;"> </span>I
think this initiative was accepted because it was only a minor departure from
current practice (i.e. night staff removing catheters before leaving their
shift, filling bladders before removing catheters).<span style="mso-spacerun: yes;"> </span>Both of these ideas have previously been successful, either
on our ward, or in other local settings.<span style="mso-spacerun: yes;">
</span>If we had started with the idea of shifting the decision for catheter
removal from physicians to nurses, it would have been a much bigger change in
practice.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We have data! </div>
<div class="MsoNormal">
<br /></div>
<table border="1" cellpadding="0" cellspacing="0" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt;">
<tbody>
<tr>
<td style="border: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Order Time</div>
</td>
<td style="border-left: none; border: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Foley Removal Time</div>
</td>
<td style="border-left: none; border: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Time of first void</div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Am rounds</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0720</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0800</div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Am rounds</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0845</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
1300</div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Order to d/c in am</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0600</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0730</div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Am rounds</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0825</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
1030</div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Am rounds</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0705</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0915</div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Am rounds</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0740</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
1245</div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Am rounds</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
0800</div>
</td>
<td style="border-bottom: solid windowtext .5pt; border-left: none; border-right: solid windowtext .5pt; border-top: none; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
Unable to void</div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is not a “control” group.<span style="mso-spacerun: yes;"> </span>We had already discussed making process changes while making
these measurements.<span style="mso-spacerun: yes;"> </span>Measurement wonks
will have spotted something missing from this table: Dates!<span style="mso-spacerun: yes;"> </span>We’re interested to see change over
time, so we’ll need to start recording the date of each voiding trial.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The absence of this important information illustrates a
peril of the informal, 5-minute PI.<span style="mso-spacerun: yes;">
</span>We didn’t spend time refining what information we wanted to
collect.<span style="mso-spacerun: yes;"> </span>On the other hand, it was
a small trial of measurement using minimal resources and we learned something
for next time.<span style="mso-spacerun: yes;"> </span>Also, we’ll need to
record whether or not the man had his bladder filled before catheter removal.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Thanks to Susan Shaw and Katherine Stevenson for their
insights.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="http://blog.hqc.sk.ca/2012/05/14/transforming-health-care-four-and-a-half-seconds-at-a-time/">Ever looking for ways to improve the client’s experience</a>,
Susan wondered if we had asked our patients for any suggestions on how to
improve our processes.<span style="mso-spacerun: yes;"> </span>No, we
haven’t.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Ironically, on the same day that I read Susan’s comment, I
was being reminded – in another setting - of the value of soliciting client
feedback.<span style="mso-spacerun: yes;"> </span>We welcomed our first
patients at the new Urology Centre of Health at St. Paul’s Hospital, and were
finding that, even with extensive planning, there were still rough spots to be
smoothed.<span style="mso-spacerun: yes;"> </span>The nurse and I asked
one of the first clients about her impressions and suggestions.<span style="mso-spacerun: yes;"> </span>She had striking insights about things
we hadn’t considered, such as the distance between our examining rooms and the
washroom, given that many of our patients often have urgency to void.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So, Susan, thanks for the reminder that we may be missing
out on a valuable source of PI ideas.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
On further thought, why is it that I had to be reminded
about the importance of asking clients about their experience?<span style="mso-spacerun: yes;"> </span>Perhaps we haven’t explicitly valued
client feedback.<span style="mso-spacerun: yes;"> </span>Our hospitals
conduct client satisfaction surveys, but they produce aggregate data and we
wouldn’t be able to dissect the results to determine whether our PI changes had
helped or hindered.<span style="mso-spacerun: yes;"> </span>Also, the
feedback comes many months after those patients had been in the hospital.<span style="mso-spacerun: yes;"> </span>On the other hand, managers, physicians
and staff are made aware regularly of the pressure to maintain patient
flow.<span style="mso-spacerun: yes;"> </span>We have daily feedback about
bed occupancy, surgical cancellations and patients waiting in the ER.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Katherine pointed out that, while our 5-minute huddles may
have been informal, they weren’t completely unstructured.<span style="mso-spacerun: yes;"> </span>She’s right that I was trying to apply
the principles of teamwork, measurement and learning cycles (PDSA) to the
process without clubbing anyone over the head with these PI tools.<span style="mso-spacerun: yes;"> </span>I agree that there should be at least
one person who has formal training and experience in quality improvement
methodology involved in the process.<span style="mso-spacerun: yes;">
</span>Otherwise, there’s a high risk of failure.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Perhaps it’s a little like playing jazz.<span style="mso-spacerun: yes;"> </span>Jazz musicians must have deep technical
knowledge so they can improvise (and fail!) with the confidence that they can
find their way back when things get dissonant.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Unknownnoreply@blogger.com3tag:blogger.com,1999:blog-8258000951954235035.post-10082511342827829502013-01-27T19:53:00.000-06:002013-01-27T19:53:09.209-06:005 minute Process Improvement huddles on our urology ward
<!--[if gte mso 9]><xml>
<o:DocumentProperties>
<o:Template>Normal</o:Template>
<o:Revision>0</o:Revision>
<o:TotalTime>0</o:TotalTime>
<o:Pages>1</o:Pages>
<o:Words>1341</o:Words>
<o:Characters>5635</o:Characters>
<o:Lines>112</o:Lines>
<o:Paragraphs>27</o:Paragraphs>
<o:CharactersWithSpaces>9391</o:CharactersWithSpaces>
<o:Version>11.1287</o:Version>
</o:DocumentProperties>
<o:OfficeDocumentSettings>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:WordDocument>
<w:Zoom>0</w:Zoom>
<w:DoNotShowRevisions/>
<w:DoNotPrintRevisions/>
<w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery>
<w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery>
<w:UseMarginsForDrawingGridOrigin/>
</w:WordDocument>
</xml><![endif]-->
<!--StartFragment-->
<br />
<div class="MsoNormal">
Here’s a fresh process improvement (PI) project.<span style="mso-spacerun: yes;"> </span>And a hidden agenda or two.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Last week, a staff member on our urology ward approached me
with a concern about how we were managing voiding trials for men after prostate
surgery.<span style="mso-spacerun: yes;"> </span>TURP (transurethral
prostatectomy) is a commonly-performed operation for men who are having
difficulty passing urine because their prostate gland is enlarged.<span style="mso-spacerun: yes;"> </span>After the surgery, men stay overnight
in the hospital with a catheter (rubber drainage tube) in their bladder.<span style="mso-spacerun: yes;"> </span>Most men have the catheter removed the
next morning.<span style="mso-spacerun: yes;"> </span>After the catheter
is removed, we want to be sure that the man can pass his urine – a “voiding
trial”.<span style="mso-spacerun: yes;"> </span>After a successful voiding
trail, the man can go home later that day.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Because the bladder is kept empty by the catheter, it may
take several hours for it to fill enough for the man to pass urine.<span style="mso-spacerun: yes;"> </span>Also, some men may have difficulty
urinating initially and it may take several attempts before we’re confident
that they are voiding well.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The problem:<span style="mso-spacerun: yes;">
</span>It’s unpredictable how long a voiding trial will last.<span style="mso-spacerun: yes;"> </span>It may take several hours.<span style="mso-spacerun: yes;"> </span>This means that it’s difficult to be
sure what time the man should arrange to be picked up at the hospital - a
significant issue in Saskatchewan when family members may be traveling several
hours to reach Saskatoon.<span style="mso-spacerun: yes;"> </span>Also,
it’s difficult to know when the man’s hospital room will be vacated and be
ready for use by another postoperative patient.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As the staff member informed me, in order to expedite room
turnover, some postop men had been asked to wait in our ward’s common room
while conducting their voiding trial.<span style="mso-spacerun: yes;">
</span>This meant that they would use a public washroom to void and then bring
the urinal to the nurse for measurement.<span style="mso-spacerun: yes;">
</span>If there was any question about how well they were emptying their
bladder, the nurse may perform a bladder ultrasound scan.<span style="mso-spacerun: yes;"> </span>If the bladder isn’t emptying well, the
nurse may reinsert a catheter to drain the residual urine.<span style="mso-spacerun: yes;"> </span>All these steps can be performed
comfortably and privately when men are in their own hospital room.<span style="mso-spacerun: yes;"> </span>(Our ward is extremely fortunate to be
able to provide private rooms for all patients.) The process may not be so
comfortable and private when men are waiting in the common room.<span style="mso-spacerun: yes;"> </span>This was the staff member’s concern.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I agreed with that concern, and at the same time I
appreciate the pressure that managers feel to serve the next patient who needs
to be admitted to an open bed later in the day.<span style="mso-spacerun: yes;"> </span>We want to make sure that patients being admitted through the
operating room or emergency department can have a bed promptly, both for their
own comfort and also to reduce congestion in other areas of the hospital.<span style="mso-spacerun: yes;"> </span>We agreed that we weren’t satisfied
with the solution being tried currently, but there was still a problem to be
addressed. We need a new process.</div>
<div class="MsoNormal">
<br /></div>
<blockquote class="tr_bq">
<i>Hidden agenda: Process improvement can move at a glacial
pace.<span style="mso-spacerun: yes;"> </span>Sometimes the formal
structure around quality improvement (project charters, team assignments) can
be so daunting that people are too intimidated to try to make a change.<span style="mso-spacerun: yes;"> </span>I accept that large-scale projects are
more successful with a formal structure, but smaller process improvements may
never see the light of day.<span style="mso-spacerun: yes;"> </span>This
has been a concern for me as I watch our health region’s managers and leaders
participate in Lean training.<span style="mso-spacerun: yes;">
</span>Rapid Process Improvement Workshops (RPIWs) take up 100% of the team’s
time for the week of the workshop.<span style="mso-spacerun: yes;">
</span>In addition, the team leaders spend significant time in preparation
before the RPIW week.<span style="mso-spacerun: yes;"> </span>I like
structure and discipline in my work (just ask anyone who has to work with me in
the OR…), but I wonder if this degree of investment pays off adequate returns
in process improvement.<span style="mso-spacerun: yes;"> </span>Time will
tell.<br /><br />While time is telling, however, we need to continue
improving our services at the microsystem level.<span style="mso-spacerun: yes;"> </span>If our ward, or particular clinical problem, isn’t chosen
for one of the initial RPIWs, we still need to make changes.<span style="mso-spacerun: yes;"> </span>So, I want to explore a less formal
approach to PI.</i></blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Every weekday morning, our urologists make rounds to visit
inpatients on our ward.<span style="mso-spacerun: yes;">
</span>Immediately following that, the urologists and nurses meet to discuss
patient management plans.<span style="mso-spacerun: yes;"> </span>(No, we
haven’t quite graduated to multidisciplinary bedside rounds.<span style="mso-spacerun: yes;"> </span>Yet.)<span style="mso-spacerun: yes;"> </span>The urologists need to get to the office or the OR, and the
nurses are ready to go off shift, so we don’t have time to have a formal (read:
lengthy) PI meeting.<span style="mso-spacerun: yes;"> </span>On Tuesday, I
asked for 5 minutes at the end of rounds to present the problem (see
above).<span style="mso-spacerun: yes;"> </span>There was agreement that
we could improve this process.<span style="mso-spacerun: yes;"> </span>The
initial idea was that urologists should “pre-program” catheter removal by
leaving orders the night before about what conditions needed to be met in order
for the nurse to remove the catheter the next morning.<span style="mso-spacerun: yes;"> </span>We’re interested in things such as
whether or not a man has a fever (an objective measure) and how much blood is
mixed with his urine (a more subjective measure).<span style="mso-spacerun: yes;"> </span>If the criteria are satisfied, the nurse will remove the
man’s catheter early in the morning (perhaps 0500) to start the voiding trial.<span style="mso-spacerun: yes;"> </span>The downside of this plan is that
the man would be wakened early in the morning, and it would also require
introducing a new process, i.e. delegating the decision for catheter removal
from urologist to nurse.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That was pretty good work for a 5 minute session.<span style="mso-spacerun: yes;"> </span>And a classic case of jumping to solutions
without first looking at the system!</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
On Thursday morning, we reconsidered the PI in light of new
information from nursing staff.<span style="mso-spacerun: yes;">
</span>While physicians may be writing the order by 0730, catheters may not
actually be removed until 0900 or 1000.<span style="mso-spacerun: yes;">
</span>This is because nursing shift change happens around 0730 and the day
shift start their work with administering medications and helping patients
prepare for breakfast.<span style="mso-spacerun: yes;"> </span>It’s a very
busy time for them.<span style="mso-spacerun: yes;"> </span>However, if
catheters were consistently removed by 0800, perhaps it wouldn’t be necessary
to develop a new process to remove them at 0500.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That was our 5 minutes for PI on Thursday.<span style="mso-spacerun: yes;"> </span>We decided the next step would be for
the ward’s quality improvement nurse to collect data as to when catheters were
actually being removed.<span style="mso-spacerun: yes;"> </span>TURP is a
common enough operation that we may have 3 or 4 men on the ward over the next 3
days.<span style="mso-spacerun: yes;"> </span>I’d like to see this data on
a simple chart that we’ll post in our meeting room.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
After rounds finished on Thursday, another nurse approached
me with some research she had been doing.<span style="mso-spacerun: yes;">
</span>A colleague of hers worked with urologists in another part of the
hospital and mentioned that one member of our group sometimes expedites voiding
trials by instilling saline into the man’s bladder via the catheter just before
removing it.<span style="mso-spacerun: yes;"> </span>This cuts down on the
time needed to fill his bladder the “natural” way.<span style="mso-spacerun: yes;"> </span>This would be simple to do on the urology ward.<span style="mso-spacerun: yes;"> </span>I’ll bring this idea forward in our
next PI huddle this week.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<blockquote class="tr_bq">
<i>Hidden agenda: On Friday of last week, we received a memo
from our health region administration that, due to GI virus-related ward
closures, our hospital is running “over-capacity”.<span style="mso-spacerun: yes;"> </span>This means, among other things, that surgeries may be
cancelled.<span style="mso-spacerun: yes;"> </span>We’ve been encouraged
to discharge patients promptly (yet, of course, appropriately).<span style="mso-spacerun: yes;"> </span>If we can demonstrate rapid changes to
our care processes without the need for a formal RPIW, perhaps this PI model
can help other wards deal with their patient flow issues.</i></blockquote>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’ll keep you posted.<o:p></o:p></div>
<!--EndFragment-->Unknownnoreply@blogger.com26tag:blogger.com,1999:blog-8258000951954235035.post-23311939304268752112012-12-30T22:50:00.001-06:002012-12-30T22:50:09.380-06:00Holiday enlightenmentChristmas holidays enlightened me about a couple of things.<br />
<br />
<br />
My usual practice while on holiday is to spend some time every day answering work-related emails, reading professional papers, or just contemplating clinical or improvement work. I decided to try something different last week. Over the Christmas break, our family spent 4 days at Elkridge Resort, near Prince Albert National Park, and I deliberately disconnected from work. I left my laptop at home. There was no Wi-Fi in our cabin. My cellular network doesn't reliably cover that part of the province, so I couldn't sneak email peeks on my phone.<br />
<br />
When we first arrived, my kids rapidly assessed the telecommunication situation. No Wi-Fi for 4 days! Barbaric.<br />
<br />
"Looks like you'll have to walk up to the main hotel lobby to check your emails," my wife told me. I guess my holiday routine was predictable. <br />
<br />
It was surprisingly difficult to give myself permission to slack off. It wasn't a problem while we were outside tobogganing, skiing or hiking. But inside the cabin, I had a nagging feeling that I should be doing something... productive. If I would have had my laptop or other work paraphernalia with me, I'm sure I would have succumbed to the temptation! Instead, I played board games, watched TV and read a book. <br />
<br />
Lesson learned: I have to work at relaxing.<br />
<br />
<br />
<br />
During the school year, our home life is very busy (our own doing!). Much of our time in evenings and weekends is spent rushing to children's activities, then back home to get ready for the next day. This can lead to some stressful family interaction (<i>Hurry up! We're going to be late!</i>).<br />
<br />
Even on holiday, old habits die hard, and we over-schedule our vacation activities. (<i>Get your boots on - we're going tobogganing at 2:45.</i>) I surprised myself a couple of times when the kids weren't ready to head outside, by flopping back down on the sofa rather than cracking the whip. We got to the sledding hill eventually, and everyone was in a better mood when we got there. <br />
<br />
I also enjoyed a switch in some traditional family roles. We decided to try cross-country skiing - which I hadn't done for over 20 years. After we rented the skis, one of my sons announced that he had been skiing at school recently and showed me how to clip my boots into the bindings. It was a very satisfying change in our usual parent-child / mentor-student relationship.<br />
<br />
Lesson learned: There are other ways of being that are hidden by the self-imposed flurry of daily life.<br />
<br />
<br />
Back to work tomorrow - I hope these lessons stick with me.<br />
<br />
<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8258000951954235035.post-18973111186186956242012-12-12T06:24:00.000-06:002012-12-12T06:24:24.825-06:00Improving healthcare by learning about hotel management - IHI Forum Excursion
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">Who would have thought that you could improve healthcare by
learning about hotel operations?</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">The organizers of IHI’s 24<sup><span style="font-size: x-small;">th</span></sup> annual National
Forum, that’s who.</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">The Forum Excursions are a very popular item on the menu in
Orlando this week.<span style="mso-spacerun: yes;"> </span>I had the chance to
visit behind-the-scenes at the Marriott World Centre, with the intent of
linking best practices in other service industries to healthcare.<span style="mso-spacerun: yes;"> </span>(Yes, we are a service industry!)</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">A few lessons learned:</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">Visual management –<span style="mso-spacerun: yes;">
</span>hotel staff used visual management extensively to relay information such
as daily guest volume, special events and that day’s guest service focus (that
day, it was “anticipating guests’ needs).<span style="mso-spacerun: yes;">
</span>There were no fancy computer displays, just white boards, markers,
colored paper and tape.</span><o:p><span style="font-family: Calibri;"> </span></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">Eliminate variation – at a buffet service, every item –
right down to bread and salad – is placed at the same location, every
time.<span style="mso-spacerun: yes;"> </span>This makes it easier to tell at a
glance when items need to be replenished and makes it less likely that a certain
dish will be overlooked.<span style="mso-spacerun: yes;"> </span>Staff can work
together more efficiently as each person knows ahead of time where their
partner will be placing the dish that they are carrying.<span style="mso-spacerun: yes;"> </span>Less confusion and rework.</span></div>
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">Relations with staff – Marriott staff are called “associates”.<span style="mso-spacerun: yes;"> </span>Managers all said the same thing: Take care
of your associates and they will take care of the guests.<span style="mso-spacerun: yes;"> </span>I asked if the hotel was unionized.<span style="mso-spacerun: yes;"> </span>It isn’t.<span style="mso-spacerun: yes;">
</span>One manager commented “If we look after our associates, there’s no need
for 3<sup><span style="font-size: x-small;">rd</span></sup> parties to be involved.”</span></div>
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">Standard work – A great quote from the executive chef: Open
the kitchen with a list; Close the kitchen with a list.<span style="mso-spacerun: yes;"> </span>He told us that staff were required to use a
series of lists for every aspect of running the kitchen.<span style="mso-spacerun: yes;"> </span>Even if a cook had worked in the same area
for 20 years, they would still use a checklist to start the day, and be accountable
for each task by initialling it.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">The most surprising insights about hearing the customer’s
voice came from an unlikely area – Lost and Found.<span style="mso-spacerun: yes;"> </span>These associates gather, store and (hopefully)
return items found on hotel property.<span style="mso-spacerun: yes;"> </span>The
manager told us that they keep every (legal) item no matter how worn out it
looks.<span style="mso-spacerun: yes;"> </span>She gave the example of a scrap
of worn and stained blanket that had been left in a room.<span style="mso-spacerun: yes;"> </span>Frantic parents called the hotel looking for
their young daughter’s special “blankie” and were thrilled to hear that Lost
and Found had it.<span style="mso-spacerun: yes;"> </span>The manager told us that
only the customer could decide the whether an item was valuable or not.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">We asked whether the hotel staff telephone guests to let
them know that an item was found in their room.<span style="mso-spacerun: yes;">
</span>We were surprised to hear that they don’t do this.<span style="mso-spacerun: yes;"> </span>The manager explained that, if they were to
call a guest’s home and say “This is the Marriott in Orlando.<span style="mso-spacerun: yes;"> </span>We found your cellphone in your room,” the
spouse answering the call might be surprised to find out that their partner had
been in a hotel room – without them.<span style="mso-spacerun: yes;">
</span>Calling the guest’s home seemed like it would be an innocent and helpful
thing to do, but hotel staff realized that it was a potential violation of
privacy.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0cm 0cm 10pt;">
<span style="font-family: Calibri;">Forum Excursions – highly recommended!<o:p></o:p></span></div>
Unknownnoreply@blogger.com7tag:blogger.com,1999:blog-8258000951954235035.post-85594150803302435642012-11-07T21:29:00.000-06:002012-11-07T21:29:36.589-06:00Show me that you care. With sticky notes!I knew I was in good hands when I saw this on the table:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5Fpp2CI-xs4so6zC9NEJbQbjC9XjspvS7SOtxzPe6czj3fgCSIvI20TPdyCLs3YGuGzl9ZWTitHN0ZsrtzXeEX1JoJn-EFr0QTlhubwZkp2-iyenAw7DODjV7iZmHnfWBgzYuFOyfY8Ok/s1600/sticky+notes.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5Fpp2CI-xs4so6zC9NEJbQbjC9XjspvS7SOtxzPe6czj3fgCSIvI20TPdyCLs3YGuGzl9ZWTitHN0ZsrtzXeEX1JoJn-EFr0QTlhubwZkp2-iyenAw7DODjV7iZmHnfWBgzYuFOyfY8Ok/s320/sticky+notes.jpg" width="240" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
"Yay! Sticky notes! Today is going to be a good day." <br />
<br />
I was only half-joking to my table mates as I sat down to start a day-long meeting. In the centre of the table was a plastic bin full of coloured sticky notes and marking pens. And the sight really did give me a warm feeling.<br />
<br />
Sticky notes and marking pens mean that audience participation is planned. Usually, participants are invited to write comments and contributions on the notes, then post them on a flipchart where they form the basis of, well, just about any kind of planning work. They also usually indicate that there will be discussion and debate. That's fun. (Also, occasionally, productive.)<br />
<br />
But most importantly, their presence means that someone prepared for this meeting. Somebody thought about what needed to be accomplished and how the attendees could be active participants. Somebody wanted to hear our opinions.<br />
<br />
Somebody cared about the day's outcome.<br />
<br />
That's the real reason I was excited; the sticky notes were just an indicator. An epiphenomenon.<br />
<br />
<br />
The meeting's closing speaker related a story that linked my sticky note experience to my daily clinical work. She told us about a man who had gone through 2 joint replacement surgeries. At the first surgery, he remembered that the OR staff had been laughing and joking when he entered the room and he felt that they weren't paying attention to him.<br />
<br />
Several years later, at the time of his second operation, the surgical safety checklist had been used. Staff all stopped what they were doing and focussed on hearing the plan for his surgery. The man related that he felt everyone really cared about what happened to him that day. <br />
<br />
Completion of the surgical safety checklist didn't guarantee a better outcome for him. But he (rightly) interpreted its use as an indicator that someone had put effort into planning for his safe care.<br />
<br />
<br />
What other indicators - positive or negative - are patients reading as they traverse the healthcare system? Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8258000951954235035.post-36669466785597177332012-10-14T19:58:00.000-06:002012-10-14T19:58:02.500-06:00Making it easier to do the right thing - Is there an app for that?I was out running this morning and came across this:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEidP1x-wJyP_1_8q-5t45Q2JIKkZky92svv_mCaMQdzHz0gQf9UVCXnVhHzz6K_1R7tmhoDyHXuzkpTOMcvs2DTiz2Rd0soHhaCCMxrZjDF2uLSWuppekzenD3zn6DoE9dBsJx1Iepyl_Xg/s1600/IMG_0764.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEidP1x-wJyP_1_8q-5t45Q2JIKkZky92svv_mCaMQdzHz0gQf9UVCXnVhHzz6K_1R7tmhoDyHXuzkpTOMcvs2DTiz2Rd0soHhaCCMxrZjDF2uLSWuppekzenD3zn6DoE9dBsJx1Iepyl_Xg/s320/IMG_0764.jpg" width="240" /></a></div>
<br />
A beer can on the road.<br />
<br />
I'll pick up the occasional piece of garbage while I'm out and about, but I don't want to lug it all the way home with me. I definitely didn't want to run very far carrying a beer can because, you know, people would talk.<br />
<br />
I happened to be on a familiar path and knew that there was a garbage can right around the next corner, so:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitG1WQA3DQ74qJy7VgiLXA9UkLFuG8yoD2GAylikYB0aOsRSoSXJxQSP0KtVCDmdPzU2ALUCY_b4aonBQQYXqSqdSFWjv3PdvQZ811ydHtMcC6IMwUPDczNsR9LSKbNTak1rqtDGvcpFnh/s1600/IMG_0767.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitG1WQA3DQ74qJy7VgiLXA9UkLFuG8yoD2GAylikYB0aOsRSoSXJxQSP0KtVCDmdPzU2ALUCY_b4aonBQQYXqSqdSFWjv3PdvQZ811ydHtMcC6IMwUPDczNsR9LSKbNTak1rqtDGvcpFnh/s320/IMG_0767.jpg" width="240" /></a></div>
<br />
That made me think that there must be plenty of like-minded people walking around Saskatoon, that is, people who will pick up a piece of garbage, but only if they know a garbage can is handy. They may be motivated to do the right thing (clean up their neighbourhood) but need a little help to follow through.<br />
<br />
Here's a suggestion for some entrepreneurial programmer:<br />
<br />
Smartphone app that people activate when they are in an outdoor public space. The GPS-enabled phone signals when a garbage can is within X metres (X varies according to individual preference). Maybe there would be a recorded voice encouraging the user to "Pick it up" or "Let's clean up". <br />
<br />
Each city would need to enter the locations of garbage cans. This could be done by municipal employees who geo-locate garbage cans, once again with GPS-enabled phones. Or, public users could contribute the locations. This might be a revenue source for the app developer, as each city would need a unique database of garbage cans, licensed on the developer's server. <br />
<br />
Individual users could record their contribution by logging the number of pieces of garbage they pick up. Nothing like a little competition to encourage participation! Users could submit pictures of the trash they pick up, with prizes for the most unusual object. <br />
<br />
I'm not sure if there are researchers studying trash, but if there are, they could ask users to log the type of litter they find (e.g. fast food packaging including the restaurant name) to better understand the source of the garbage, and lobby the responsible businesses to reduce packaging.<br />
<br />
Anyone up for this?Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-8258000951954235035.post-87779086806834204422012-10-07T16:43:00.000-06:002012-10-07T16:43:13.972-06:00Wasting time and money on a long weekendI often hear stories about physicians repeating lab tests or x-rays because it's inconvenient to get results from other hospitals or physician offices. I flatter myself that I'll make a concerted effort to track down test results before subjecting patients to repeat testing. Sometimes however, "the system" will not yield.<br />
<br />
<br />Here is a little story:<br />
<br />
Earlier in the week, I saw a lady who was passing a kidney stone. We agreed that she would give it a few days but if the pain continued, we would do emergency surgery over the holiday long weekend. The complicating factor was that she lives in a community that is more than a 5 hour drive away from Saskatoon and she didn't want to come to Saskatoon if she didn't have to (that is, if she passed the stone in the meantime). For that reason, she had an x-ray done in her home community late in the week. The written x-ray report came down to me by fax and there was no mention of a kidney stone. (This can either mean that the stone is gone or that the radiologist has not noticed the stone on the x-ray.) Also, she was still having some discomfort, making us both suspicious that the stone might still be present. I needed to compare the x-ray to the one she had done earlier in the week to see if the stone truly had passed.<br />
<br />
<br />
The challenge was that her home community is not connected with our electronic access system for x-rays (PACS). PACS allows online access to x-rays done in many places around the province as soon as they are completed. This innovation has markedly improved the speed with which we can make appropriate diagnosis. In her case, however, she would need to have the hospital make a CD with her x-ray on it and then send the CD to me. With this being a holiday long weekend, it would be well into next week before I could make a diagnosis.<br />
<br />
She called me back to let me know that her plans had changed and she was planning to come to Saskatoon for the long weekend. She would drop a CD off at one of the hospitals when she arrived and I would pick it up in the morning.<br />
<br />
The next morning turned out to be a vignette of frustration.<br />
<br />
I searched around the department where my patient said she had left the CD but no one knew where was. I called her to check that she had actually dropped off and she assured me she had. I returned to the department and someone remembered where it was. I tried to open the x-ray files on a computer but was unable to do so. (Usually, loading the CD on a computer automatically opens the x-ray pictures.) I hunted down the on-call radiologist to see if he could open the pictures. He spent 10 minutes trying but was also unsuccessful.<br />
<br />
I called my patient and told her we would need to repeat the x-ray. She came to the emergency department and registered herself. She had the x-ray repeated and I checked the results. After comparing to the previous x-ray, I could see that the stone had actually passed. I met her in the emergency department and gave her the good news.<br />
<br />
I estimate the time I spent with phone calls, searching for the disc, and trying to open it with the radiologist was about 30 minutes. That's 30 minutes of completely non-value added time.<br />
<br />
Also, there is the real cost of registering my patient in the emergency department, doing another x-ray, paying the radiologist fee for interpreting the x-ray, and paying my bill for seeing the patient in the emergency department. (I've ignored any patient costs...) If I would have had access to the x-ray electronically, I would have phoned her and the additional cost to "the system" would be zero. There is also a non-tangible cost of frustration both on my and my patient's part. When a similar situation comes up in the future, I'll be tempted to make things easier for myself by insisting that the patient come to Saskatoon to have another x-ray done.<br />
<br />
Multiply these costs by the number of times similar scenarios play out across our health care system and you begin to see the money and resources we are squandering by not having a fully integrated electronic medical record. What a waste!<br />
<br />
<br />
<br />
Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8258000951954235035.post-23395006118621651962012-09-15T16:33:00.002-06:002012-09-15T16:33:29.757-06:00Asking family physicians how we can help them provide careWe've been working on improving patient care and access for over 5 years. While we continue to improve processes in our practice, it's been frustrating to see that, after our initial success in improving access, patients have been waiting longer over the last 2 years. This is partly because of reduced manpower in our group (retirements and semi-retirements) and a shift in focus of urologists' time (provincial emphasis on reducing surgical wait times takes urologists away from office consultations and puts them in the operating room).<br />
<br />
Wait times have crept up enough that patients and referring physicians are feeling a strain. We recently received several calls from family physicians commenting on our wait time and the problems it's causing. Not only do patients have to put up with the anxiety and suffering from their medical condition, but family physicians have to spend more time reassessing patients and then sending "re-referral" letters to us. Sometimes these letters are indicating a change in the patient's condition and asking for a more urgent appointment. Sometimes these letters are just checking that our office has actually received the initial referral. Either way, it's more work for the GP, the urologist (who has to reveiw the second letter) and our respective staffs.<br />
<br />
Last week, I visited one of Saskatoon's large family physician group practices. I attended their regular practice management meetings to acknowledge the difficulty they were having in getting access to urology services and to ask for their advice. They had some useful suggestions:<br />
<br />
While they would prefer to have rapid access for their patients, if there is going to be a wait, they would like to be able to give their patients an accurate idea of how long the wait would be. They felt that this would reduce anxiety and the number of repeat phone calls from patients wondering when their appointment would be. One doctor commented that, when our urology clinic had initally improved wait times, family physicians had become used to the rapid access and were still telling patients that "it shouldn't be too long to get in". Unfortunately, this isn't consistent with our current access, so patients become concerned when they don't get a prompt appointment.<br />
<br />
The family physicians were interested in a more collaborative approach to the consultation process. They asked if we could provide guidelines to help them carry out appropriate investigations prior to their patient seeing the urologist. I mentioned our hematuria evaluation guidelines (requesting that the GP arrange an ultrasound and certain lab testing, so that we can arrange a "one-stop" consultation for the patient to undergo cystoscopy/bladder examination) and they agreed that more of the same would be useful. They suggested a urology referral template that would list common conditions and symptoms along with suggested pre-consultation testing and management. They could load the template onto their EMR for easy access.<br />
<br />
One of the senior group members made a frank observation. He said that, over the years, he's come to rely on our practice to manage his patients' urologic conditions, so much so that he may have become a little "lazy" in managing some of the conditions himself. He wondered if he could have a "refresher" about common urologic conditions, such as erectile dysfunction and enlarged prostate. Several of the clinic members agreed that they would like to have guidelines on how to manage these common problems in primary care. <br />
<br />
They also made an interesting observation about the utility of clinical guidelines. Many guidelines and protocols are available from various sources, including family physician and specialty organizations at both the local and national levels. The GPs indicated that the multitude of available guidelines becomes confusing for them and their patients. They were particularly conscious of the fact that if they chose to follow a legitimate national guideline in managing say, bladder infections, and later refer their patient to the local urologist who follows a different guideline, their patient may be distressed and question the GP's aptitude. For this reason, they preferred that any guidelines bear the "stamp of approval" of local specialists so as to take into consideration local practices and resources. This doesn't mean that we would have to generate recommendations independent of national standards, but rather that we would review available practice guidelines, and adjust appropriately for local practice before disseminating them.<br />
<br />
They also suggested that a variety of continuing professional development tools would be helpful. In addition to having specialists make presentations at local family practice conferences, opportunistic instruction ("teachable moment") could also be used. For example, if our urology clinic received a referral regarding a patient with a common condition that can be managed by the primary care practitioner (recurrent bladder infection, for example), rather than making the patient wait to hear the treatment advice from the urologist, we would fax back to the referring practitioner a treatment algorithm, along with an educational module and patient information. <br />
<br />
None of these ideas is earth-shattering, but they demonstrate family physicians' genuine appetite to break out of the current consultation model in which we are stuck, and is not serving our patients well. Unknownnoreply@blogger.com8tag:blogger.com,1999:blog-8258000951954235035.post-33583829773227529742012-09-03T14:16:00.001-06:002012-09-15T15:21:48.508-06:00Leaders' work: Removing barriers to success<!--StartFragment--><br />
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<span lang="EN-CA">Don't it always seem to go </span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<span lang="EN-CA">That you don't know what you've got </span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<span lang="EN-CA">'T</span>il its gone</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<i>Big Yellow Taxi</i></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<i><span class="Apple-style-span" style="font-style: normal;">Joni Mitchell</span></i></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<span lang="EN-CA">This summer, I rediscovered the joy<span style="mso-spacerun: yes;"> </span>of cycling.<o:p></o:p></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<span lang="EN-CA">Last weekend, I went for a long ride with my neighbor, an experienced cyclist. As we were returning home, it began to cloud over and the wind picked up.</span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<span lang="EN-CA">"Why don't you try riding about 8 inches behind me," Bruce suggested.<o:p></o:p></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
As I experienced drafting for the first time, I immediately found that riding was easier. Because Bruce was blocking the wind for me, I went faster using the same energy. I realized how much extra effort it had been to fight the head wind.<br />
<br />
It was a much more enjoyable ride after that.</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br />
<span lang="EN-CA">This week, I rediscovered the joy of using technology in my work.<o:p></o:p></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
Our urology clinic has used electronic medical records (EMR) for many years. Among the many benefits, having remote access to our records is one of the most useful. This is particularly helpful for specialists who split their time between various physical sites such as an office and<span style="mso-spacerun: yes;"> </span>the hospital.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
Prior to converting to using an EMR, we would transcribe notes from the paper chart in our office so that we could refer to them the next day at the hospital. (We had a policy prohibiting removal of paper charts from the office, both to maintain chart security and also to give our office staff access to the charts for record keeping and billing purposes.) Not only was this time-consuming, but we had no access to the original chart once we left the office.</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<span lang="EN-CA">Now that we have remote access to our EMR, we can check patient information, lab results and staff communication from any site. We even have access using our smart phones. </span>This has become such an integral part of our practice that it's hard to imagine what work was like before the EMR. That is, until the technology fails.</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
Over the last few months, remote access to our EMR has been painfully slow. At a typical cystoscopy clinic at the hospital, I would see up to 15 patients during the course of a morning, each scheduled in a 15-minute slot. That 15 minutes includes time for preparing the examination room, greeting the patient, discussing their problem and the cystoscopy procedure, performing the cystoscopy, discussing the results and treatment, dictating a consultation letter to the referring physician, then reviewing the next patient's records. </div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
My laptop connects to our office via the hospital's wireless network to the internet and then to our office server. When something is awry in that connection, loading each patient's record can take several minutes. No amount of hammering on the keyboard changes this. Many times, the nurse will already have brought the next patient to the cystoscopy room, at which time we all wait for the EMR to work its laborious magic. At one point, I reverted back to old-fashioned note-making the night before a cystoscopy clinic. (Blasphemy!)</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
During the summer, we overhauled our office's computer system with a faster server and upgraded laptops. This seemed to make a difference initially, but then the problem recurred. Two weeks ago, in a last ditch effort, we replaced our modem. Hallelujah! We now have remote EMR access at almost the same speed as when we're plugged directly into our office network. Now, I can review my next patient's chart and still have time to review incoming labwork, reports and consultation requests - all while the nurse prepares the cystoscopy room and brings in the next patient. </div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
Once again, it is a pleasure to let the EMR make my work easier.</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
On our bike ride, Bruce recognized that, in order to reach our goal (get home before it started raining), we needed to move faster. He could have encouraged me to work harder and pedal faster, but I was already tired and wouldn't have been able to maintain additional effort. Also, I would have felt badly for letting him down. Instead, he found a way to remove the barrier that was preventing me from achieving our mutual goal.</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
That's great leadership!</div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none;">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment-->Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-8258000951954235035.post-71237682657915422382012-08-04T10:38:00.002-06:002012-08-04T10:38:37.523-06:00Perverse incentives - Don't shoot the messenger!I don't follow international badminton as closely as perhaps I should, but maybe we've all been a little guilty of that. However, the recent disqualifications of Olympic players got my attention. It seems that some top badminton teams were <a href="http://sports.nationalpost.com/2012/08/01/expelled-olympic-badminton-players-cant-even-get-cheating-right/">blatantly trying to <i>lose</i> their matches</a>.<br />
<br />
Puzzling, huh? It is until you read about the tournament system and strategy around match play. It seems that the top-ranked teams don't want to face each other until the finals, and so they conspire to throw preliminary games so that they are matched with less expert opponents. This strategy improves their chances to make the finals, and end up with a medal of some sort. When you think of it like that, it makes sense, except that it was so obvious to spectators and officials that the teams were flubbing games, that they were disqualified for not living up to the competitive Olympic spirit. <br />
<br />
I wonder what the athletes were told before they left for London: <i>Your country expects you to give your best in ever match</i>, or <i>Your country expects you to bring home a gold medal</i>? Even if it wasn't explicitly voiced, I suspect the second is strongly implied. <br />
<br />
<a href="http://sports.nationalpost.com/2012/08/01/expelled-olympic-badminton-players-cant-even-get-cheating-right/">Commentators pointed out</a> that the format of the tournament - round-robin - encouraged this type of "cheating" as athletes knew that this would be their best chance to win a medal. So who is to blame? Is it disingenuous of Olympic officials to expect athletes to give their all in every match when it could deny them a chance at a medal? Why do the Olympics only recognize the three top teams with medals if grit and determination are more important? This is a classic perverse incentive.<br />
<br />
It made me think of the current fee-for-service remuneration system for physicians. Provincial health insurance plans "reward" us for providing more visits and procedures, yet at the same time, we're told we need to provide better quality of care (which sometimes means doing fewer interventions...). At present, our monthly billings are the only scorecard we have, yet health care commentators ask us to "give 110%" to patient-centred care. <br />
<br />
If physicians can legally maximize their billings without compromising patient care, then it's only natural that we will do so. (Note that there is a difference between passively "not compromising"- i.e. <i>status quo</i> - and actively optimizing care. The latter is preferred, but needs an incentive...) In the same way that the Olympic officials should consider the influence of tournament structure on player behaviour, officials responsible for maintaining the current physician incentive structure should do the same. <br />
<br />
Leaving a dysfunctional structure in place is not a passive choice. It is an active decision to avoid taking the steps to make a positive change.<br />
<br />
Don't shoot the messenger!Unknownnoreply@blogger.com2tag:blogger.com,1999:blog-8258000951954235035.post-26957259368417621942012-07-24T22:01:00.000-06:002012-07-24T22:01:03.749-06:00Drone on! Making standard work standardA couple of months ago, a colleague told me that he had watched the <a href="http://adventuresinimprovingaccess.blogspot.ca/2012/04/variation-in-clinical-practice.html">video of my presentation</a> at the BCPSQC Quality Forum. In it, I had highlighted the detrimental effects of variation in clinical practice.<br />
<br />
"Pretty good," he said, "but I'm not sure that everyone should do things the same way. I mean, I didn't study for all those years just to be some kind of drone!"<br />
<br />
It's interesting to hear this free-wheeling sentiment from surgeons. I can't imagine any health professional more fussy about consistent practice than surgeons. (<i>Why aren't all the scalpels pointing due north!?</i>) We develop a reliable method though training and experience, and we like to stick with it. We know we're more prone to mistakes when we deviate from habit.<br />
<br />
Coincidentally, my colleague had just completed 2 somewhat finicky procedures that day. Actually, it was the same procedure performed on 2 different patients. The operation required specialized equipment, nursing expertise and patient preparation. Quite sensibly, he likes to do the procedure the same way every time. <br />
<br />
I asked him how the cases went. He saw where I was going.<br />
<br />
"I do it the same way every time because that's what works for me. I don't want to have to do it your way," he said.<br />
<br />
He genuinely wants to give patients the best care he can, and uses his experience to best advantage. From the viewpoint of his own practice, his personal "standard work" serves him fine. He's convinced about the value of <i>intra-practitioner</i> consistency.<br />
<br />
How to convince him that <i>inter-practitioner</i> consistency can further improve quality and safety?<br />
<br />
As we discovered in our practice (see the <a href="http://adventuresinimprovingaccess.blogspot.ca/2012/04/variation-in-clinical-practice.html">video</a>), <a href="http://adventuresinimprovingaccess.blogspot.ca/2008/07/bang-for-your-buck.html">demonstrating to practitioners that there is significant variation </a>in clinical practice is illuminating. (There's no shortage of variation to measure!) Approach the information with curiosity rather than judgment. In most cases, physicians will have never seen this aspect of clinical work, that is comparisons between practitioners. For us, it lead to sharing our individual "best practices". <br />
<br />
Telling stories about the negative side of clinical variation has been powerful in our practice. Our staff told us that they found having <a href="http://adventuresinimprovingaccess.blogspot.ca/2012/03/variety-is-spice-of-confusion-and-waste.html">8 different ways</a> (8 urologists!) of doing the same task was confusing. They worried that patients might receive the wrong information or be missed for followup. Solution: Consistency.<br />
<br />
Finally, doctors need to have a role in developing standard work. Last fall, I heard a great comment from Intermountain Health's Chris Wood. "Yes, it's cookbook medicine. And you get to write the cookbook!"<br />
<br />
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGBrHSnzbksDIoIqSffvalG7pDkTxckk6PXleFE0BvlmnYHN093NKoVhv_J44Nih1GF8oEg8Mhu7UOiZL0in5u_EnmLdKkln3n3G4X7Xww3wlJj6R3-kkNXDxwua5YSdms4K8LO1LD2FNL/s1600/drone+on+shirt.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGBrHSnzbksDIoIqSffvalG7pDkTxckk6PXleFE0BvlmnYHN093NKoVhv_J44Nih1GF8oEg8Mhu7UOiZL0in5u_EnmLdKkln3n3G4X7Xww3wlJj6R3-kkNXDxwua5YSdms4K8LO1LD2FNL/s1600/drone+on+shirt.jpg" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg54JBKs5Z-VD0LT7V0w68bCKf64OTTQkM1ZrqxoY9zK_7UwRsVtKUgzagNjrFtJuohIwCgouQ0TqF4DqXxctpliNPmamIJp8P-2z_BdSod2Qoato8hthJbjh-RgxgCAWFa0ym6FM_l-FEl/s1600/standard+work+rules.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg54JBKs5Z-VD0LT7V0w68bCKf64OTTQkM1ZrqxoY9zK_7UwRsVtKUgzagNjrFtJuohIwCgouQ0TqF4DqXxctpliNPmamIJp8P-2z_BdSod2Qoato8hthJbjh-RgxgCAWFa0ym6FM_l-FEl/s1600/standard+work+rules.jpg" /></a></div>
<br />
<br />
<br />Unknownnoreply@blogger.com6tag:blogger.com,1999:blog-8258000951954235035.post-50392961427636251792012-07-09T23:50:00.001-06:002012-07-09T23:50:02.502-06:00What is "necessary" in health care?It must be a tough time to be an American astronaut. <div>
<br /></div>
<div>
Since the US Space Shuttle program shut down a year ago, their opportunities for spaceflight are limited to hitching a ride with the Russians. It must be incredibly frustrating. Consider the years of training, childhood dreams, and self-sacrifice - all for naught. That is, unless they can convince the American government that space travel is a necessity, and a worthy recipient of public funding.</div>
<div>
<br /></div>
<div>
I imagine that US astronauts must be passionate advocates for funding space flights. After all, their careers - and self-images - are at stake.</div>
<div>
<br /></div>
<div>
<br /></div>
<div>
<br /></div>
<div>
I don't think the astronauts would behave any differently than any of us, should we suffer a similar change in fortune. A recent on-line conversation has me thinking about how professional self-image (or perhaps self-interest) affects what we consider "necessary" in healthcare. The discussion started with a post on <a href="http://healthydebate.ca/opinions/punishing-all-self-referral-is-not-the-solution">Healthy Debate</a> (see the comments), then Irfan Dhalla and Mark MacLeod stepped outside. To Twitter. The discussion was about fee-for-service and whether it leads to provision of "unnecessary" services. Dr. MacLeod, an Ontario orthopedic surgeon and OMA past-president, offered this <a href="https://twitter.com/macleodmarkd/status/219774904264962048">tweet</a>: </div>
<div>
<br /></div>
<blockquote class="tr_bq">
<span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="color: #333333; line-height: 28px;"><a class="twitter-atreply pretty-link" href="https://twitter.com/IrfanDhalla" style="color: #0084b4; outline-color: initial; outline-style: initial; outline-width: 0px; text-decoration: none;"><s style="color: #66b5d2; text-decoration: none;">@</s></a></span><b style="color: inherit; font-weight: normal;">IrfanDhalla</b><span class="Apple-style-span" style="color: #333333; line-height: 28px;"> </span><span class="Apple-style-span" style="color: #333333; line-height: 28px;">I open my practice completely to anyone who wants to come and tell me the services I provide that are not necessary. Anyone</span></span></blockquote>
<br />
<br />
It's a generous offer from Dr. MacLeod, but I'd rather explore whether or not I'm providing unnecessary service in my own practice. I took a look at this 2 years ago in <a href="http://adventuresinimprovingaccess.blogspot.ca/2010/03/fast-food.html">this post</a>. I reviewed 57 new consultations over a 2 week period and tried to judge whether or not they were "appropriate". (To be fair, "appropriate" and "necessary" may be different classifications. Read on.) I judged that 8 (14%) of the consultations weren't necessary, that is, the condition referred for wasn't serious, was for a false-positive test result, etc.<br />
<br />
But, who should decide whether the consultation was necessary or not? The various interested parties may have differing opinions. I decided (according to a subjective review) that they weren't necessary. The referring physician felt they were necessary (by definition, I think, otherwise he wouldn't have referred them...). In most cases, the patient likely felt the referral was necessary but, for asymptomatic patients (in the case of the false-positive test result), the perception of necessity would have been influenced by the referring physician's appraisal. How did our provincial health insurance payment agency feel about it? I don't know, and I kind of hope they didn't read my blog post about it.<br />
<br />
The point is that it is easy to make a case that any health service is "necessary", as long as someone wants it. Patients may want the service to improve their health, relieve symptoms, or just give them reassurance that everything is normal. Referring physicians may want the service because they have diagnosed a condition that is beyond their expertise to manage, or because they are uncertain of the diagnosis and/or treatment, or to satisfy a patient request to see a specialist.<br />
<br />
That bring us to the consultants. And the astronauts.<br />
<br />
Both groups are highly-trained professionals who genuinely believe that their skills are necessary in society. Naturally, either group would feel threatened if someone suggested that some of their services were not necessary. Under those circumstances, a natural reaction is to be defensive and rationalize that one's services are, in fact, essential in society.<br />
<br />
The debate will just deteriorate from there, with the main point of contention being the definition of "necessary service". <br />
<br />
Perhaps we can avoid that divisive debate by rejecting the idea of necessity and instead considering value. Let patients be the judges of how much value a given service if worth to them. You might say that substituting "value" for "necessity" is just sophistry. After all, if something is necessary, it will be considered valuable, and vice versa. Well, let's go one level deeper to find out what patients are really seeking.<br />
<br />
When a patient comes to see me with a kidney tumour, they may ask me to perform surgery to remove their kidney. But, in truth, they don't <i>want</i> surgery. After all, surgery is painful, stressful and carries significant risks. What they really want is to have the kidney tumour treated and trust my advice that surgery is the best treatment. They then reluctantly <i>submit</i> to surgery.<br />
<br />
But, do they really want the kidney tumour treated? Popular health culture dictates that cancers must be treated. But, one of the vagaries of kidney tumours is that not all of them - even though they may be cancerous - require treatment. For elderly patients with small tumours, the risk of surgery may vastly outweigh any benefit, and we often recommend observing the tumour. This is because the patient's real goal is to preserve quality and quantity of life. It's not always correct to assume that a kidney tumour will affect either parameter. Yet, without a full discussion about the patient's desires (the patient is the expert here) and the medical facts (the doctor is the expert here), we can't truly know what course will be most valuable for patients (AKA shared decision-making).<br />
<br />
In our practice redesign work, we've tried to think about what value we're providing for patients. Back to that <a href="http://adventuresinimprovingaccess.blogspot.ca/2010/03/fast-food.html">2-year-old post.</a> Many men were being referred to us for "vasectomy reversal". We found that the men would come for their consultation, listen to us explain the reversal procedure, then tell us they didn't want it done. Some men were dissuaded by the fact that it is a non-insured procedure and they would have to pay for it. Others were discouraged by the success rates. Others were just interested to hear what the surgery involved. In any case, many of them travelled up to 8 hours round-trip just for a 15-minute discussion. <br />
<br />
The men, and their referring physicians, thought they "needed" a face-to-face urologic consultation. But, when we dug deeper into it, we realized that the value was in the information, not in meeting the urologist. We created an information pamphlet summarizing the vasectomy reversal information, and began sending men the pamphlet instead of booking a consultation. We invited men to make an appointment for surgical consultation if they still wanted to go ahead after considering the information. About 10% of men made those appointments. They had their need addressed without having to travel.<br />
<br />
I told you another (slightly discomfiting) story of poor patient value in <a href="http://adventuresinimprovingaccess.blogspot.ca/2009/03/awkward.html">this pos</a>t. An elderly man and his wife came to see me to get his CT scan results. A medical student called me on the fact that they could have received the results in a different, more convenient fashion. The system (my system!) had only provided them with one option - face-to-face with me. It was a necessary service, but I could have given better value.<br />
<br />
I suspect that most medical practices (perhaps even Dr. MacLeod's) would yield similar examples if subjected to scrutiny. But such attention to other's work would be counterproductive as it would be perceived (correctly) as judgemental, and would lead to defensiveness. I would rather encourage curiosity about how we can change our own practices to provide better value to our patients. That also requires scrutiny, but we only need to open our practices completely to ourselves to achieve it.<br />
<br />
<br />
<br />
<br />
American astronauts who see their mission solely to be to ride into space must be devastated. But, those who see their mission to be to use their talent to serve society according to the public's need and desire, and are capable of adapting to fit changing circumstance... they will land on their feet.<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />Unknownnoreply@blogger.com7tag:blogger.com,1999:blog-8258000951954235035.post-46942760859465012862012-06-18T00:08:00.001-06:002012-06-18T00:08:05.767-06:00What if we didn't care? (What really motivates healthcare workers?)<br />
<br />
<br />
During my medical school application interview, I was asked why I wanted to be a doctor. I gave the answer that I thought was expected of me: <i>Because I want to help people</i>.<br />
<br />
I don't know what the interview committee thought about that answer. Did they mentally roll their eyes as they listened to that rote response for the umpteenth time? <i>How can this 18-year-old kid know anything about caring for sick people?</i><br />
<br />
If they wondered that, then they were right. In retrospect, I had very little idea what I was in for, what a life in medicine would involve. It's been a happy coincidence that I've found this career very fulfilling. And I hope I channel that satisfaction into a genuine caring for the wellbeing of my patients.<br />
<br />
But what if I didn't genuinely care about my patients? Could I fake it? Would it matter?<br />
<br />
At many conferences and meetings, I've heard speakers remind us that "we all got into this job to care for people". But, is it true? I've never heard anyone publicly question it. Imagine the horrified response if someone did take exception to that dogma!<br />
<br />
<strike>I have no doubt that the majority of healthcare workers truly do care for their patients and clients. </strike><br />
<strike><br /></strike><br />
Wow - that sentence came out almost without me thinking about it. It's so appalling to even suggest that healthcare workers might not actually care ("care" is written right into health care, for goodness sake!), that I reflexively wanted to avoid insulting anyone by even having suggested it. But, after I read the words, I realized that I don't know how to judge if someone truly cares for a patient's wellbeing.<br />
<br />
Let's say caring means a genuine concern about another person's welfare. That's a state of mind. We could measure "caring" by asking a person about their feelings or attitudes. If they answered honestly, we could decide whether they were concerned about a patient's welfare. But, if they thought they were expected to answer in a certain way, they might not be frank.<br />
<br />
Perhaps their actions could be a surrogate measure. If we observed them to be friendly, solicitous and gentle then we could conclude that they genuinely cared. But, could they fake that? And if they faked it, would it matter? As long as the patient perceived the person as being caring, what difference would it make?<br />
<br />
I think it is important to recognize how healthcare workers truly feel because it speaks to their real motivation to carry out their duties in a way that patients and clients want. If we delude ourselves that everyone in healthcare is motivated solely by genuine caring for their patients' wellbeing, then we may be missing opportunities to unleash workers' potential. And more importantly, we may be missing opportunities to let workers find joy in their relationships with their patients and clients.<br />
<br />
My own motivation includes a mixture of (not an exhaustive list, and in no particular order...) financial reward, technical mastery, peer approval, and caring for others. <br />
<br />
I don't know what my cutoff for remuneration would be before I decided to find another job. I know I wouldn't sweat over a tough surgery or be on weekend call for free, but I get enough satisfaction from the job that I would likely do it for less than I get paid now. (You didn't hear that from me.) I suspect there is little direct relationship between remuneration and caring, as evidenced by some of the fabulous volunteers I know in our community.<br />
<br />
For me, as with most surgeons, technical mastery is a tremendous motivator. Last month, I was called on to repair an injury a patient had suffered during a previous emergent and difficult operation. If I could fix it endoscopically, she would be spared an additional operation and weeks of recovery. I cared about sparing her that additional burden, but I was also intrigued by the puzzle before me. What instruments would I need? What staff should be in the OR? I visualized the procedure to decide how to arrange my instruments for easy access in the order I would need them. When the challenging procedure went well and I was able to accomplish my goal, I felt tremendous satisfaction. And, by another happy coincidence, accomplishing my goal meant that my patient would have a faster recovery.<br />
<br />
Peer approval is a powerful force among physicians. If, after I successfully complete a challenging operation or clinch an obscure diagnosis, one of my partners says simply "Good job", it's deeply rewarding. When we've discovered variation in clinical practice among our group, there's been a desire to conform to the majority's behaviour<i>. </i>If the majority are already performing according to best practice, then the task of standardizing behaviour is made easier by the outliers' desire to conform.<br />
<br />
(Imagine what a crafty, yet well-intentioned, administrator could do with this information. Just as one example, they could create easy access to performance metrics and encourage comparison between individual physicians and departments.) <br />
<br />
Everyone will have their individual formula that motivates them to behave in a caring way. (Note that "behaving in a caring way" is different from "caring", which presumes a state of mind.) If we unquestioningly accept that all healthcare providers are primarily motivated by "caring", then we may be missing the chance to address all the other sources of motivation that could bring more joy to their work and greater satisfaction and better outcomes for their patients.<br />
<br />
And, greater joy in work will lead to true caring. As a friend recently told me, "You can act your way to a new way of thinking". <br />
<br />
Or more plainly, "Fake it 'til you make it!"<br />
<br />
<br />Unknownnoreply@blogger.com2tag:blogger.com,1999:blog-8258000951954235035.post-59515857156792495472012-05-21T21:25:00.001-06:002012-05-21T21:25:47.728-06:00Pooled referral gains momentum in SaskatchewanSpecialist "pooled referral" implementation is sweeping the province! Here's a <a href="http://www.paherald.sk.ca/Local/News/2012-04-16/article-2955418/Surgeons-adopt-cutting-edge-pooling-system/1">great story in the Prince Albert Herald</a> about PA's orthopedic surgeons offering pooled access as of March, and general surgeons planning to implement it at the end of May. The Regina Obstetrics and Gynecology department are also offering this option to their patients.<div>
<br /></div>
<div>
Pooled referral, also known as centralized referral intake (CRI), involves collecting referrals in a central location and then distributing the referrals so that patients have access to the specialist with the shortest wait time. When our urology group implemented this system several years ago, the reception from referring physicians was very positive. (<a href="http://adventuresinimprovingaccess.blogspot.ca/2010/08/summer-in-pool.html">Here's the post looking at wait times for pooled referrals</a>.) They liked the fact that they didn't need to do the "heavy lifting" of figuring out which urologist had the shortest waiting list, or which one of us subspecializes in a certain problem. </div>
<div>
<br /></div>
<div>
When I have the chance to share our practice's learning and improvements, the idea of pooled referrals has an immediate appeal to both referring and consulting physicians. However, physicians do have some trepidation about the system.</div>
<div>
<br /></div>
<div>
First, they're concerned about patients (and referring physicians) having the choice of which consultant they will see. Our group's philosophy has been that patients and referring physicians have the choice of which urologist they see. We don't require participation in pooled referrals, however, if someone "opts out" of pooled referrals, they may wait longer to see the urologist of their choice.</div>
<div>
<br /></div>
<div>
Continuity of care is also a consideration. Physicians recognize that time and effort is wasted, and important clinical details may be overlooked, when patients switch between specialists. A pooled system should try to maintain any previously-established patient-physician relationships (as long as the patient wishes to do so).</div>
<div>
<br /></div>
<div>
Finally, I'm often asked a very thorny question: How can a pooled referral system ensure that patients will have a consistent experience no matter which specialist they see (AKA not all docs are created equal)? This applies to the interpersonal, as well as technical, skills of the specialist. This is very difficult to answer as there is often no formal tracking and reporting of individual surgeon's treatment outcomes and complications. Communication skills, empathy, and affability may only be judged through word of mouth.</div>
<div>
<br /></div>
<div>
This raises an ethical question: If we promote a new referral management system, and that system has the potential to adversely affect the experience and outcome of some patients, what is our responsibility to assess and improve the abilities of the specialists so that patients receive consistent, competent care that is constantly being improved? </div>
<div>
<br /></div>
<div>
I think that, by its very existence, a pooled referral/CRI system begins to address this concern. In order to implement this system, specialists must be prepared to communicate and collaborate, often to a degree that they previously didn't do. This lets them share information about, and expose differences in, individual practices. In our urology practice, <a href="http://adventuresinimprovingaccess.blogspot.ca/2012/03/variety-is-spice-of-confusion-and-waste.html">learning about differences in our practice habits</a> made us curious about what could be considered "best practice" and how we could offer more consistent care. </div>
<div>
<br /></div>
<div>
Pooled referral/CRI has the potential to improve patients' access to specialist care, and make sure that they receive care from the appropriate practitioner. However, it's not without drawbacks, and we must proceed with eyes wide open.</div>
<div>
<br /></div>
<div>
<br /></div>Unknownnoreply@blogger.com3tag:blogger.com,1999:blog-8258000951954235035.post-54572220711013134062012-05-08T22:26:00.000-06:002012-05-08T22:26:08.809-06:00Great comment from a nurse about managing the drug shortage<br />
<div class="comment-content" id="bc_0_0MC" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px; margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
This comment (made on the <a href="http://adventuresinimprovingaccess.blogspot.ca/2012/04/getting-feedback-on-drug-shortage-do-we.html">last post about the national injectable drug shortage</a>) is great on several levels:</div>
<div class="comment-content" id="bc_0_0MC" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px; margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
<br /></div>
<blockquote class="tr_bq">
<i>I am an Lpn at sch on the gyne ward.. I haven't noticed that my patients are suffering any more since the cut back on IV meds.. the use of gravol supps for nausea, regular use of oral analgesics and pain and nausea rating on rounds has I think ensured patient comfort..Patients seem hesitant at first but are reassured that if the oral or pr routes don't work we will go with the intervenous option. I wonder if Pre op clinic could instruct patients on the shortage so that they are less apprehensive post op when their nurse suggests something other than IV drugs..</i></blockquote>
<div class="comment-content" id="bc_0_0MC" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px; margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
<br /></div>
<div class="comment-content" id="bc_0_0MC" style="margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
</div>
<ul>
<li style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px;">It's feedback from a front-line care provider telling us about how care-givers are perceiving the situation's effect on their patients' care. </li>
</ul>
<div>
<span class="Apple-style-span" style="color: #333333; font-family: Verdana, sans-serif;"><span class="Apple-style-span" style="font-size: 14px;"><br /></span></span></div>
<ul>
<li><span class="Apple-style-span" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px;">The nurse tells us that pain and nausea rating is done in order to ensure patient comfort.</span></li>
</ul>
<div>
<span class="Apple-style-span" style="color: #333333; font-family: Verdana, sans-serif;"><span class="Apple-style-span" style="font-size: 14px;"><br /></span></span></div>
<ul>
<li><span class="Apple-style-span" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px;">We get some insight into how patients are being affected by the changes. They may be anxious about the effectiveness of pain-killers or anti-nauseants being given other than intravenously. The nurses on this ward are reassuring patients that they will switch to intravenous medications if the alternate forms aren't adequate. I don't know if there has been formal training in a "script" to use when explaining the situation to patients, but I suspect that having such a script may be useful for nurses when counselling patients about these changes in practice. This would also ensure that patients receive a consistent message across the entire health region.</span></li>
</ul>
<div>
<span class="Apple-style-span" style="color: #333333; font-family: Verdana, sans-serif;"><span class="Apple-style-span" style="font-size: 14px;"><br /></span></span></div>
<ul>
<li><span class="Apple-style-span" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px;">Finally, what a great suggestion to prepare patients preoperatively! Hearing about our change in medication practice in advance would certainly be easier than hearing about it when a person needs relief from pain or nausea. Transparency? Check! Respect for patients? Check!</span></li>
</ul>
<br />
<div class="comment-content" id="bc_0_0MC" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px; margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
<br /></div>
<div class="comment-content" id="bc_0_0MC" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px; margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
Sounds like the gyne ward staff at SCH have some great ideas. Maybe a <a href="http://en.wikipedia.org/wiki/Gemba">gemba</a> walk is in order...</div>
<div class="comment-content" id="bc_0_0MC" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px; margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
<br /></div>
<div class="comment-content" id="bc_0_0MC" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px; margin-bottom: 8px; margin-left: 0px; margin-right: 0px; margin-top: 0px; text-align: justify;">
<br /></div>
<div>
<br /></div>
<span class="Apple-style-span" style="color: #333333; font-family: Verdana, sans-serif; font-size: 14px;"><span class="comment-actions secondary-text" id="bc_0_0MN" kind="m"></span></span>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-8258000951954235035.post-29948486829011900682012-04-29T22:44:00.000-06:002012-04-29T22:44:05.196-06:00Variation in Clinical Practice revisited - the video!How long have you got for lunch today? 37 minutes and 48 seconds? Perfect!<br />
<br />
The latest work we're doing in our office (to improve care for patients with bladder cancer) inspired <a href="http://adventuresinimprovingaccess.blogspot.ca/2012/03/variety-is-spice-of-confusion-and-waste.html">a post in March about variation in clinical practice.</a> It was also the spark for a presentation I had the pleasure to give at the <a href="http://www.bcpsqc.ca/">BCPSQC</a> Quality Summit. Thanks to Christina Krause and her team for putting on a terrific meeting and for producing this video (37m 48s).<br />
<br />
If you're not sure about investing 37 minutes, try the first 7 - that should give you a good idea what to expect from the rest.<br />
<br />
(Yes, the screen shot could have been marginally less goofy-looking. Or <a href="http://dictionary.reference.com/browse/you+can't+make+a+silk+purse+from+a+sow's+ear">perhaps not</a>.)<br />
<br />
<br />
<iframe allowfullscreen="" frameborder="0" height="315" src="http://www.youtube.com/embed/J9uEmAGicwk?rel=0" width="560"></iframe>Unknownnoreply@blogger.com2tag:blogger.com,1999:blog-8258000951954235035.post-83017046904482848282012-04-22T22:39:00.002-06:002012-04-22T22:39:54.362-06:00Customer voice changes my thinking on changing our office practiceLast week, several of my partners and I had been talking about whether we should change a long-standing office procedure. Most medical practices use a nurse or receptionist to show patients into examination rooms, where the patient waits until the doctor arrives. In our office, we don't employ a nurse. Instead, the doctor greets the patient at the entrance to the waiting room and shows him back to the consultation/examination room.<br />
<br />
I'm sure that Lean practitioners would cringe to hear this.<br />
<br />
Think about the steps in this procedure:<br />
<br />
<blockquote class="tr_bq">
Doctor walks down the hallway from his consultation room to the examining room. </blockquote>
<blockquote class="tr_bq">
Doctor calls the patient's name. (Repeat as needed) </blockquote>
<blockquote class="tr_bq">
Patient packs up reading material, closes cell phone, removes and hangs up coat, etc. </blockquote>
<blockquote class="tr_bq">
Doctor greets patient. </blockquote>
<blockquote class="tr_bq">
They walk back down the hallway to the consultation room.</blockquote>
<br />
That takes from 1-3 minutes to complete. It doesn't sound like much, but it's a significant proportion of our "standard" 15 minute visit. It's time that could be spent finishing dictation of the previous consultation report, reviewing the next patient's chart, checking in-coming reports, etc.<br />
<br />
I had recently read about the practice of "self-rooming", where patients are given instructions by the receptionist and then make their own way down to the assigned consultation room. This would let our receptionist remain at her desk, save us the need to hire additional staff, and give the docs a few minutes of extra time between each patient visit. <br />
<br />
What a great idea! I ran it by a few of my partners and started thinking about how we could do try out the concept in our office. <br />
<br />
Then, late last week, I met a man who changed my thinking entirely.<br />
<br />
I was attending <a href="http://www.qualitysummit.ca/">Saskatchewan's Health Quality Summit</a>, and introduced myself to the man (I'll call him Ken) sitting next to me at one of the workshop sessions. <br />
<br />
"Oh, yes," Ken said. "I've visited one of your partners. You know what impressed me about your office? That the doctor actually came out himself to the waiting room to call for me."<br />
<br />
<i>What a coincidence</i>, I told him. <i>We were just thinking about changing that practice because it's inefficient. </i>I explained the amount of time it took for doctors to perform that task.<br />
<br />
He agreed that it may take a few extra minutes to do, but that he found it to be an important part of building the doctor-patient relationship. He felt it showed a degree of respect and caring.<br />
<br />
"When I meet a doctor for the first time, I make a judgment as to whether I can trust that doctor. I think the first impression your staff make is a very good way to build that relationship," Ken said.<br />
<br />
That was a very powerful thing for me to hear. I have often commented to medical students and residents that specialists need to be deliberate about building a trusting relationship with patients. Unlike family physicians who have years in which to develop a bond with patients, specialists have only a short time to do so. This is especially important for surgeons, who may meet someone for the first time and, within the course of that visit, inform the patient about a serious diagnosis - such as cancer - and discuss performing a life-changing procedure. <br />
<br />
Ken was telling me that the simple habit of escorting my own patients to my consultation room was a valuable step in building a trusting relationship. <br />
<br />
That doesn't change the fact that the procedure requires an investment of time, but it does mean that, if we're going to make a change, we can't measure the outcome solely on the basis of time saved. We would also need to consider the impact on patient experience. As Ken went on to say, "Spending a few minutes more up front is probably saving you time later on because patients feel you are considerate and caring."<br />
<br />
What a valuable lesson! (Even if I do have to keep learning it over and over again...)<br />
<br />
<br />Unknownnoreply@blogger.com4tag:blogger.com,1999:blog-8258000951954235035.post-34068474338947412732012-04-15T20:05:00.000-06:002012-04-15T20:05:46.832-06:00"Doing the Wife's Tummy Tuck" - An informal survey of surgeons' reactionsAbout 2 weeks ago, an American plastic surgeon told the story of how he performed his own wife's "tummy tuck" - a cosmetic surgical procedure to remove excess, sagging skin from the abdomen. The blog post is on the popular medical blog aggregator site, <a href="http://www.kevinmd.com/blog/2012/03/wifes-tummy-tuck.html">KevinMD</a>, and also on <a href="http://www.cosmeticsurgerytruth.com/blog/?p=15024">Dr. Di Saia's own website.</a> Rather than having me recount the story, I encourage you to follow one of the links and read the brief post for yourself. Reading it on <a href="http://www.cosmeticsurgerytruth.com/blog/?p=15024">Dr. Di Saia's website</a> may give you a better appreciation of his practice context and expertise.<br />
<br />
I shopped this story around the surgeons' lounge last week and the response was vigorous and unanimous: Bad idea. The surgeons expressed several concerns:<br />
<br />
First, while the outcome for the patient/wife was good in this case, any surgeon knows that this will not always be so. In the rare case when things go wrong in the operating room, it becomes an extremely stressful and dangerous situation very rapidly. In those cases, the patient's best asset is a calm, dispassionate surgical team that can think clearly and act decisively. Every surgeon I spoke with admitted that their judgement would suffer if they were called upon to lead the team managing their loved one's surgical crisis.<br />
<br />
Next, many of the surgeons wondered about the possible effects on a marriage if the results of the surgery were not exemplary. Would the wife be comfortable in raising a concern to her husband? If her own lifestyle depended on her husband's professional reputation, would she admit that she was dissatisfied with the outcome? How would the surgeon/husband balance his professional appraisal of the cosmetic result against his personal satisfaction with his partner's appearance? <br />
<br />
One surgeon commented that there is a ethical prohibition against physicians establishing intimate relationships with their patients, and wondered how that principle should be applied in this case. The intertwining of professional and personal relationships can be messy.<br />
<br />
During the discussions, almost everyone commented that they had, at one time or another, rendered some medical care to their family members: antibiotics for strep throat, sutures for a cut suffered while at the cabin, or various and sundry slings, splints and bandages. And, most agreed that, in case of an emergency with absolutely no other suitable care available, they would operate on a loved one to save their life. But this doesn't apply to a tummy tuck - the ultimate in elective, cosmetic surgery.<br />
<br />
Some other comments:<br />
<br />
<blockquote class="tr_bq">
How would Dr. Di Saia obtain full, informed and free consent to blog/tell the world about his wife's surgery? </blockquote>
<br />
<blockquote class="tr_bq">
Was there any commercial incentive to perform this surgery, and then tell the story (i.e. "I'm so confident of my skills that I operated on my own wife!")?</blockquote>
<br />
<blockquote class="tr_bq">
Did the facility where the surgery was performed have any rules about this situation? How did the rest of the surgical team feel about this? </blockquote>
<br />
What do you think? Are we over-reacting to this story?<br />
<br />Unknownnoreply@blogger.com47