Adventures in Improving Access

Sober second thought about Saskatchewan's healthcare transformation plan

2012-01-17T22:49:00.002-06:00

There's many a slip 'twixt cup and lip.

Thanks to Mary "Wet Blanket" Smillie for cooling my ardour over Saskatchewan's healthcare transformation plan. Here's Mary's comment/sober second thought:

I agree with the parts of the press release you've highlighted,Kishore. I too am excited about the opportunities to shift the focus of healthcare to the best way to care for people rather than continuing to equate carewith visits to a single health professional. The promise of primary care teamswith physicians is great. Accessing specialists in a timely way - also great.The promise of no waits for Emergency care concerned me however without usfirst significantly improving primary care. Without a redesign of primary care,with improvements to coordinating better with specialists, the Emergency waittime targets are unrealistic and may detract us from our focus on gettingprimary care right.

I absolutely agree. While the plan looks promising, implementation will be challenge. Your example is a great one.

Primary care is the bedrock of healthcare, and getting it right will reduce the demand on ERs. People who are currently using ERs as their default primary care site will have access to a primary care team when they need it. More people will receive appropriate care for their chronic medical conditions, have fewer acute exacerbations, and therefore have less need to visit the ER. Primary care redesign will achieve a reduction in ER demand, and thereby contribute to shorter ER wait time.

Attempts to shorten ER wait times without making significant investment in primary care reform may expend unnecessary resources.

But, primary care redesign will take time. Its effects on ER usage/wait times won't be immediately apparent. Do we have the patience to let the benefits cascade up through the system? Which effort makes a better headline?

Cross your fingers, Mary!

Wish granted! Saskatchewan's healthcare plan leads the way

2012-01-15T19:54:00.000-06:00

My apologies to anyone who, over the weekend, asked me how work was going. I probably talked your ear off about this exciting healthcare news: Saskatchewan's plan for transformation and innovation.

This is exactly what I was wishing for 2 weeks ago.

There is so much hope and potential packed into this brief press release that I've been savouring it all weekend. Many points deserve comment, but for now I'll pick out a couple of doozies.

"Better care, better health, better value".

Has the Triple Aim ever passed through the lips of the leader of a North American geopolitical unit? (Actually, yes. Google says (key words "governor triple aim", "premier triple aim") Oregon Governor Kitzhaber (a physician) is a proponent of Triple Aim. But still, it was a nice piece of hyperbole while it lasted...)

"All people are connected to a care team that includes a family physician".

I don't want to read too much into this phrase, but I know that the people who write these speeches are mighty careful about their choice of words. So, I see "care team" and "includes" (rather than "lead by") as significant.

"A five per cent decrease in the rate of obesity in children and youth"

This acknowledges that health care should not solely focus on high-tech, institutional "rescue care". Tackling childhood obesity will involve all the social determinants of health, such as education, income, and social resources. Can a tobacco-free Saskatchewan be far behind?

"All people will have access to a specialist and diagnostics within one week"

One week to see a specialist? That's a stretch goal. And I want in on it! As the release points out, other systems have achieved this already. Again, the careful choice of words here doesn't say that a person necessarily needs to see the specialist in person. They could have a telephone or videoconference consult, or their primary care team could consult with the specialist and then provide specialist-directed care locally.

But, words are cheap, and press releases are priced to clear. What makes me think that this isn't just rhetoric in advance of the premiers' meeting this week? I've heard similar lofty goals when Saskatchewan announced its Surgical Initiative. Giving everyone the option to have their surgery within 3 months? And making that change within 4 years? Audacious!

But, as I've had the privilege to work with the patients, providers and administrators involved with the Surgical Initiative, I've seen an absolute commitment to achieving this goal. Ideas for clinical innovation come from the front-line providers and patients. Support and resources come from administrators. Even after one year, the changes were impressive.

So, I'm excited about this new vision because of our track record so far.

You have been warned: Best to steer clear of this topic with me this week. Unless you've got an hour or so to spare!

Clinicians and administrators need to share the sandbox

2012-01-08T23:41:00.000-06:00

Thanks to Trish Livingstone for helping me clarify my thinking on starting quality initiatives at the grassroots level. Trish (Director, Health System Quality and Efficiency Management for the Government of Saskatchewan) left this comment:

Agreed, Kishore, don't wait for permission - start now! As administrators, we often create barriers but our role should be to facilitate these changes at the front-line by providing support, incentives, opportunities for training, etc. In the words of Berwick, the administration's role should be to "help those who help patients." So, start without us but even better - let's do this together!

You can't go wrong by quoting Berwick!

This comment illustrates the tension between letting front-line workers initiate improvement work and needing some degree of administrative support and coordination so resources aren't wasted and efforts aren't duplicated. We definitely need to work together and cooperate.

But, frankly, it doesn't feel like an equal relationship (yet!). I think many clinicians feel that the administrator/manager/director's job is to say "No." Are managers actively soliciting ideas from their staff? How much time are managers spending walking around the wards, visiting clinics, talking with support staff, or asking clients about their experience? How much enthusiasm and expertise is being wasted because managers are in meetings with other managers, rather than being available to "help those who help patients"? How many managers are encouraging their staff to try something and give permission to fail (AKA: learn)?

I had a taste of this earlier in the week. As part of our clinic's new improvement project (to which I alluded in the last post), I visited nurses at an outpatient treatment clinic. I wanted to find out if they had any ideas on how we could improve delivery of a certain cancer treatment. Did they ever have ideas!

I thought I would have to drag suggestions out of them, but instead I found that they were brimming with ideas. They showed me system dysfunction that I was unaware of. Plus, they had already been thinking of ways to fix the problems. But, they had no mechanism (no invitation) to communicate the problems or initiate improvement.

They were thrilled that someone was actually asking for their insights into this part of patient care.

How much missed opportunity exists in wards, clinics and care homes? How much potential could be tapped by (as Trish says) "providing support, incentives and opportunities for training"?

You're right, Trish. If we're going to start quality improvement work at the front-line, we need help from administrators. So, managers and directors, please be part of this grassroots work. Trish has challenged you to "help those who help patients". Will you say "Yes" to trying an improvement suggestion rather than waiting for approval from higher up? Will you weigh the value of attending another regularly scheduled meeting vs. visiting the ward to solicit change ideas from your staff?

Vive la Revolution!

Provinces, schmovinces! This is a chance for front-line workers to shine!

2012-01-05T22:41:00.000-06:00

Anonymous left a cryptic comment on my "Feds, schmeds!" post:

"I agree Kishore .... let's start today!"

Silly Anonymous, whatever do you mean? In the post, I exhorted provincial governments to quit relying on the feds for leadership around national healthcare change. But, I don't have anything to do with the provincial government, so it's not my responsibility to get the process going.

Unless you're suggesting, Anon., that in the same way that provincial governments shouldn't wait for the feds to get the ball rolling, clinicians (and patients!) shouldn't wait for provincial governments to make the first move. Is that what you're getting at, you closet subversive?

But without funding and administration, how can front-line workers (especially private practice clinicians like our urology group) ever make a significant impact on patient care? You're probably going to quote Margaret Mead:

"Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that has."

Alright, Anon., you're on! As it turns out, we're starting a new improvement project in our office. While it will involve changes for Saskatoon Health Region policies and staff (as well as our own staff and physicians), we're not waiting for outside permission to get started. I'll commit to telling the story of our progress in this blog, if you, Anonymous, will commit to spreading the word to front-line workers that we can all start making small changes without waiting for permission from Leaders With Titles.

Deal?

Feds, schmeds! This is a chance for provinces to shine!

2012-01-03T22:54:00.000-06:00

Hi, guys! Anything interesting happen while I was away? What? The federal government unilaterally imposed a healthcare funding plan on the provinces? Ha, ha. Sure they did.

Oh, I see they did.

Like many of the provincial finance ministers, I wasn't thrilled with this strategy, but perhaps for different reasons:

Too much money! Transfer payments continue to increase by 6% annually until 2017. Then, increases are tied to economic growth. That much dough is a recipe for whittling at the edges of the status quo, not an incentive for radical redesign of healthcare.

No airing of dirty laundry! A negotiation process would have been as much about outcomes and accountability as it was about dollars and cents. We should have had a national, bare-knuckles brawl about the waste, perverse incentives and lack of patient-centredness in our health system. We've been deprived of the chance to let the public have a real say in restructuring healthcare.

No master plan! If each province takes its no-strings-attached loot bag and hunkers down in its respective corner, we could end up with widely disparate models of care delivery. We need a national clearinghouse for improvement ideas and innovation so we can learn from each other's experience.

Wait a minute! Who says we need the federal government's permission to do these things? This is a golden moment for the provinces. Mr. Harper is going out of town and giving us the keys to the house. We can fight over the liquor cabinet, or we can pull together.

Some will see a crisis. Real leaders will see opportunity.

I hope we start hearing their voices soon.

Raising expectations in healthcare: Scotland NHS central line infections bottom out

2011-12-12T23:53:00.000-06:00

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.

- Arthur Schopenhauer

My son and I were browsing through the electronics store yesterday.

He picked up an Amazon Kindle e-reader and tried to make the text scroll by touching the screen. He was puzzled when it didn't work. We discovered that this model had button controls. That is so 5 minutes ago!

He's used to touch-screens through playing with his brother's iPod Touch and Grandma's iPad, so he's come to expect that every electronic device works that way. It's like the classic scene in Star Trek IV, when the crew goes back in time and Scotty tries to use an early-model computer:

As Schopenhauer predicted, Scotty is ridiculed for having expectations (his "truth") beyond what was thought possible in that era.

Last week, at the IHI National Forum, I had my expectations raised by someone else's truth.

Jason Leitch, NHS Scotland's National Clinical Lead for Quality, gave an energetic presentation about Scotland's healthcare quality strategy and results. One slide stood out. It showed the drop in central line infection rates since 2008. The March 2011 data point was annotated "zero central line infections in whole country".

Entire country of Scotland. Central line infections. None.

It's like getting rid of polio or smallpox.

I was imagining what it must be like to be a physician inserting a central line, or a nurse caring for one, in Scotland. The motivation to follow standardized protocol meticulously must be tremendous. The country's reputation is on the line! Expectations are sky-high.

What if patients and families in other countries found out that central line infections can be avoided? If they got hold of Scotland's data and the care bundle they use, expectations everywhere would be sky-high. Then, after the ridicule and opposition (from healthcare professionals), it would become self-evident that these infections are a defect in care, and not inevitable.

Central line infections - how quaint!

Give the people what they want! I'm experimenting with social media

2011-12-11T21:23:00.001-06:00

I had the privilege to act as host for some of the Saskatchewan participants at last week's IHI National Forum. As the organizers planned the trip, we discussed ways to communicate with each other while at the conference. It's a huge venue with over 5000 attendees, so keeping in touch can be challenging.

We decided to try Twitter. I was a little nervous as I had never tweeted before. As you can see by the newly-added Twitter feed in the right column of this blog, I've become a convert.

Not everyone signed up for Twitter, but those who did found it very useful. We were able to arrange impromptu meetings and share pearls from the sessions we attended. We also made a fortuitous contact with Paul Levy.

You may be familiar with Paul Levy through his blog "Not Running a Hospital" (formerly "Running a Hospital"). As CEO (now retired) of Beth Israel Deaconess Hospital in Boston, Levy pioneered transparency by blogging about his hospital's complication rates. He noticed that Sask IHI attendees were actively tweeting (hashtag #saskihi11) and tweeted his way to joining us for dinner.

It was a terrific opportunity to meet someone who has been a leader in using social media in health care. As it turned out, Levy was IHI's social media guru-at-large, and conducted several well-attended sessions on using Twitter, Facebook and blogs.

His recommendations for bloggers got my attention: 300 words 3 times a week. Levy suggested that frequent, shorter blog posts were more palatable for readers than infrequent, longer pieces (my usual style...).

Here's my next social media experiment: I would like you to tell me which form you prefer. In the right hand column, I'll post a survey that will stay up for the next few days. If there seems to be interest in more frequent posts, I'll do my best to change things up for several weeks, then repeat the survey.

Thanks for your help, and thanks for taking time to read this blog!

Surgical checklist - Trying some changes I learned at IHI National Forum

2011-12-10T15:27:00.001-06:00

"What can we do by Tuesday?"

You'll hear this phrase a lot when you're at the IHI National Forum, or similar QI events. It's shorthand for:

"We're all really excited about the possibilities for improvement that we've talked about. We have the will to change and we've come up with some great ideas. But, now comes the hard part: execution. Once we all get back into our regular work lives, the enthusiasm we're feeling right now can be swept away by the relentless current of clinical tasks. So, let's deliberately think about execution right now, before we're distracted by our "real work". What can we try out first thing next week? Let's make a commitment to a test of change, but make it a small one. Try it one time, with one patient or colleague."

I made one of those commitments, but I couldn't wait for Tuesday.

While at last week's IHI meeting, I had attended several sessions discussing the surgical safety checklist. All the speakers emphasized that the real value of the checklist in promoting communication and team building among OR staff. So, while checking on antibiotic administration and the correct side for the procedure are critical, the checklist holds potential for a deeper benefit.

The speakers talked about creating a "psychologically safe" environment in which everyone in the OR theatre has permission - in fact, is invited (required?) - to raise any concerns about patient safety. One surgeon told the story of a medical student who called a stop to preparation for surgery because he thought the patient's wrong ear was being operated on. The staff reviewed the patient's record and determined that they were operating on the correct side, and the medical student was mistaken. However, the surgeon praised the student for his courage and commitment to patient safety, and asked staff to applaud the student! Now that's dedication to psychological safety!

In Saskatoon Health Region's current checklist, there's no explicit invitation to speak up like this. The first version of our checklist began with having all staff in the room introduce themselves to each other and to the patient, but that component was dropped. I wanted to try reintroducing that element, and also adding a personal invitation to everyone in the room to raise patient safety concerns. I decided to try it Friday (yesterday) morning, with one case. I planned to collect the staff's impressions of the expanded checklist after the surgery was completed.

I started by telling everyone in the room (an anesthetist and 2 OR nurses) about the IHI meeting and what I wanted to test. We discussed this before we brought the patient into the room. They agreed to try it.

Once the patient joined us in the room, I explained that we would do our usual surgical checklist, but that we were also going to add the 2 elements. We introduced ourselves by name and role, and I invited everyone to use the phrase "I have a concern..." if they had any safety concerns.

After the surgery was finished and the patient went to the recovery room, we discussed the trial. (Coincidentally, the nurses had talked about this issue at morning report, so it was fresh on their minds.) Everyone was keen to have the introductions, particularly as there are often students, residents or other trainees in the room, and this is a way to be sure that everyone know everyone else, as well as their role. The idea of the safety phrase was also well-received.

Next week, I'll try this again in a new room. I'll likely be working with a different team. As the idea was well-received yesterday, I don't anticipate having to "sell" it by giving the IHI story again. What I'm really interested in is the day when someone uses the "I have a concern..." safety phrase. How will I respond to that interruption? Will I ensure psychological safety?

Also, I'll be vigilant for occasions where someone could have used the safety phrase, yet didn't. I suspect that will be the more common situation. That could happen because of differing views on what a "patient safety concern" is, or because staff don't yet trust that I will be receptive to them raising a concern.

IHI lightning strikes again!

2011-12-07T05:47:00.001-06:00

Before I left home for this week's IHI National Forum, I wondered if I would have as dramatic an experience as I did at my first IHI visit. I'm not sure if you're allowed more than one epiphany.

5 years ago, the National Forum changed my career. Seeing better ways of providing care, and learning the tools to implement those changes led to the improvement work our practice has undertaken. It led to the chance to meet QI enthusiasts across the country. It led to this blog. So, I had high expectations that something at this year's meeting would show me yet a new direction for my QI journey.

Until yesterday afternoon, I had been disappointed.

I've heard some incredible stories from presenters at the Forum, but they are all variations on themes I've heard before. I was hoping for something earth-shaking.

Then, I started hearing stories from other Saskatchewan attendees. We're over 30 Saskatchewan-strong at the Forum, and to a person, thrilled to be here. First-time attendees are enthusing about their experiences, like I did at my first visit. They're talking about testing change ideas at home next week. They're also anticipating some of the barriers they'll face: lack of time, inadequate resources, no team support.

That's when it struck me: The next step for me is to support others' work. Making connections. Smoothing paths.

Working on improving one practice has been satisfying; playing a part in improving many practices... I can hardly wait!

IHI - you did it again!

Will lightning strike twice? My QI journey takes me back to IHI

2011-11-30T22:45:00.001-06:00

My QI journey started 5 years ago at the IHI National Forum. It was literally a life-changing experience for me. This weekend, I'm going to the IHI National Forum again. Will lightning strike twice?

That first visit opened my eyes to different ways of delivering and thinking about health care. It sparked my interest in Clinical Practice Redesign (CPR), and through that work, gave rise to this blog. (Before you follow the link to my very first blog post - about my IHI visit - I want to say that I'd like to believe that my writing has... evolved since then. Here it is.)

CPR and QI work led to a relationship with Saskatchewan's Health Quality Council (HQC), which eventually resulted in the incredible opportunity to take a half-time, year-long consulting position with them.

I've been privileged to be invited to share the results of our CPR work in Saskatchewan and across Canada. Through these engagements, I've developed relationships with many other people who are likewise committed to improving Canadian health care.

My first IHI visit started me on this journey by showing me that there is a better way, and that there are robust methods by which to plot a new course and then make haste. My career path has been radically altered by that experience.

What will next week bring?

Perhaps the last 5 years were "low-hanging fruit". I was likely an easy convert. I was already primed for the IHI experience and what followed. Saskatoon Health Region wouldn't have sponsored my attendance if I hadn't expressed some interest in learning about QI. I doubt that every attendee experiences the same epiphany that I did. Unless they're putting something in the food. (That egg salad sandwich did taste a little funny.)

Last time, I learned to see a whole new world. After having been immersed in QI for 5 years, can there possibly be another surprising experience waiting for me?

I hope so.

Major professorial cringe moment!

2011-11-23T19:02:00.001-06:00

This morning, I had the opportunity to address the first year medical student class about Clinical Practice Redesign and our urology office project. (I told you about last year's visit with the first year students in this post. By the way, one of last year's students did contact me and we've been working on a practice redesign project since the summer.) The best part of the presentation (for me, anyway) is the students' participation. I've presented our practice work to many different audiences over the last 4 years, and first year medical students reliably ask the most probing questions. Perhaps it's because we haven't yet brainwashed them into thinking about things "our way".

I try to encourage their participation with regular pauses and prompts. And with a little bribery (Tim Hortons gift cards for randomly selected hand-raisers). This group of students were enthusiastic with their questions and comments.

About 30 minutes into the session, I realized that we had spent so much time with questions that I was not going to finish my presentation on time. Two students had their hands up, and I indicated we had time for one question, and then I would move on.

At the end of the session, the course instructor - who had been distributing the gift cards on my behalf - had reserved one of the cards and announced that it was for the student who I had passed over when she raised her hand.

I mentally kicked myself. I realized that I had "got through the material" and finished showing the slide show I had created, but it was at the cost of stepping on the contribution of the students - the contribution that I had explicitly encouraged at the beginning of my presentation. These students wouldn't have been worse off if they missed hearing just one of the half-dozen practice redesign examples I brought along. The questions they asked were insightful enough to spark a discussion that was more enlightening than the slides I had to show.

And, after telling them that it was essential to focus on the patient's needs when redesigning their work, I had been totally "provider-centric" by satisfying my own compulsion to slog through my slide deck. This is the product I have, and I'm going to give it to you, no matter what you want!

That wasn't the worst part.

After the lecture, I went over to the student to apologize for cutting her off and to hear her question. She asked how we could tell if our practice's improvement efforts could make us "too efficient".

She illustrated her point with a personal story. She had waited many months for a consultation with a specialist. At the visit, the doctor made a diagnosis and gave her a sheet of paper containing information about the condition. The doctor told her that this would give her the information she needed to manage her problem, and sent her on her way.

The student's comment was that although this was a very efficient way to use the specialist's time, she felt somewhat short-changed by not having adequate opportunity to interact and ask questions.

Her insight is known as "balancing measures". Whenever we make a change in a system with the intent of improving one aspect of it, there may be unanticipated and unwanted consequences in another area. For example, if I want to reduce the wait time for cystoscopic bladder examinations, I may decide to increase our daily capacity by 50%. We'll reduce our wait time, but the nursing staff who assist me in the exam room will be run ragged. They may take more sick time, or even ask for a transfer. We could check this balancing measure by doing a staff satisfaction survey before and after the system change.

I reminded the student that her unsatisfactory consultant visit was a reminder that, when implementing system changes, we should always consider our primary goal: Putting the patient first.

That's when the cringe hit me.

In my quest to zip efficiently through my presentation, I lost sight of the real reason I was there: Putting the students first and encouraging a sense of curiosity around different ways of delivering care.

Maybe I'll get it right next year.

How to ask the right question the right way. Or fake it convincingly.

2011-10-31T22:24:00.000-06:00

When I bought a pair of running shoes last week, the salesman said I could try them for a month and return them if I didn't like them, as long as I kept them clean by running on a treadmill or an indoor track. I decided to try out the track at the Field House.

As it was my first experience there, I asked the staff at the admissions desk about the track rules.

"Just follow the instructions on the sign," they said.

It couldn't have been simpler. I warmed up in lane 5, then switched direction to run in lane 6. It didn't matter much, because I had the track to myself.

After 10 minutes, a man joined me on the track. In lane 6. Running the opposite direction to me.

As we crossed paths, I stepped into lane 5 and then back into lane 6. A minute later, as we both circled the track, the same thing happened.

What the heck is this guy doing, I thought. Surely he would have figured it out the first time.

Before we met again, I stepped off the track and re-examined the lane direction sign. No question about it - I was going the right direction. I got back on the track and pondered what to do. According to the sign, I had to stay in lane 6. I had no choice: I would have to confront this other fellow.

I had recently read a very interesting article, The Art of Powerful Questions. It came to mind as I deliberated about how to approach this rogue runner. While the authors' technique of constructing illuminating questions was a little high-powered for this encounter, it made me think about using "humble inquiry" as a way to show this guy the error of his ways. Rather than ask "Did you know you were running the wrong direction?" (a rhetorical question if ever there was one!), I thought I would ask something more open-ended.

As we crossed paths again, I stopped and waved at him.

"Hi, I'm new to this track," I said. "How does the running lane direction work?"

He smiled and said "Yeah, it's a little confusing. Looks like the lane sign got turned around again."

Turned around? Uh-oh.

He motioned me to follow him and we walked back to the lane direction sign.

I saw now that the sign was mounted on a wheeled stand.

"See," he said. "It's supposed to face toward you as you enter the room, but it got turned around so that you see it as you're running on the track."

I had been running the wrong direction.

I thanked him and we resumed our run. In the same direction.

As I ran, I cringed mentally to think about how that encounter could have gone if I had asserted myself/been a jerk. And I had every right to do that, because I was right! I had the evidence (the lane arrow) on my side.

The spirit of humble inquiry saved me. Or did it? I wasn't truly interested to find out about how the rules of the track worked. I wasn't truly open-minded about what he might have to say. I simply phrased the question that way to be polite.

But, it worked and saved me significant embarrassment.

I wonder if it matters that my actions weren't backed up by sincere intent? Maybe "humbly" asking "powerful questions" can be faked.

Although, I think if I keep faking it, and have it pay off like it did at the running track, I'll become a sincere convert.

An important Division of Urology project comes home to roost

2011-10-02T15:00:00.000-06:00

A couple of years ago, I attended a presentation about implementing change. The speaker showed us this slide:

And waited...

At first, there was silence as we examined the picture for some hidden meaning. Then came nervous laughter as the speaker remained silent. After what seemed like 5 or 10 minutes (but was likely only 2 or 3), there was annoyed muttering around the room.

Finally, she moved on to this slide:

"It takes 21 days for a chicken egg to hatch," she told us. "How much of the chick's development do you think happens on the 21st day?"

Her point was that, in change initiatives, even though we celebrate the dramatic final outcome, much of the ongoing effort toward achieving the goal is under-appreciated, yet critical to eventual success.

Last week, in the division of urology, one of our eggs hatched.

Thanks to the efforts of St. Paul's Hospital Foundation several years ago, generous donors have contributed to the establishment of a Urology Centre of Health. While there will be a bricks-and-mortar aspect to this Centre, the real value is the service we'll provide for patients. A crucial part of that is the development of a staff position that is new to our division and the Saskatoon Health Region: Nurse Navigator. Our Nurse Navigator, Nicole, works on a range of quality improvement projects in our division, and one of those projects recently broke out of its shell. A little background information is in order.

A common reason for urologic consultation is so a man can be evaluated for the possibility that he may have prostate cancer. Our current process is for the man to see one of us in the office for discussion and examination. We then decide whether or not he needs to undergo a prostate biopsy. We contact him with the biopsy results and, if cancer is found, arrange an appointment to discuss treatment options.

Because of the nature of prostate cancer and the available treatments, that discussion takes between 45 and 60 minutes. For some urologic cancers, such as kidney tumours, there is a single effective treatment, and so the discussion is fairly brief. However, prostate cancer may be treated with surgery, radiation (with 2 varieties offered), or even observation. It's a complex discussion that involves not only the technical aspects of treatment, statistics about success rates, but also men's relative preference/aversion for various side-effects.

Not only does it take a significant amount of specialist time to have the discussion, it is challenging to find time in our schedules to have this urgent conversation. As such, men, having just been informed that they have cancer, may wait up to 2 weeks to hear about their treatment options. We offer written and online material so they can inform themselves before the discussion, but those resources don't take the place of individual consultation.

Since the spring, we've been working toward having Nicole carry out those discussions. Over several months, she's familiarized herself with the details of prostate cancer treatment. Her previous work on the inpatient urology ward gave her experience with surgical treatment. She's visited the Cancer Clinics in Saskatoon and Vancouver to learn about radiation treatments. Much of her time has been spent "shadowing" urologists as we discuss prostate cancer treatment with our patients.

After spending time as an observer in those discussions, Nicole then started to lead the discussion, with the urologist present as a resource. More recently, she has been meeting with men independently. Nicole had shadowed me on several occasions, but 2 weeks ago was the first time I had been solely the observer, with her leading the conversation. All 4 of us - the man and his wife, Nicole and I - then reviewed any questions that arose. I was completely satisfied that the man had received the same information I would have given him, and in an unbiased fashion.

The next day, another man was scheduled for "the talk". Nicole met with him and his wife, and I joined them afterward. The questions they asked of Nicole and me showed me that they had gained a good understanding of the complexities around the decision for prostate cancer treatment.

I had a sudden appreciation of how this new process would change things for our patients and our practice. Having Nicole available to lead these discussions would free up 45-60 minutes of specialist time. Those appointments had usually been scheduled during the most precious hours of our workday, that is, late afternoon, after we had finished operating and were wanting to return phone calls and review lab results. Each of our 8 urologists may see 2 to 4 men a month with newly diagnosed prostate cancer. Also, because our schedules are usually filled weeks in advance, our staff have to scramble to find openings in which we can have these urgent discussions, and the available openings are rarely as soon as we/our patients would like. Nicole's ability to schedule more prompt appointments means that men will save up to 2 weeks in the journey from diagnosis to treatment.

When I thought about this a-ha/hatching moment, I also knew that a lot of work had gone into achieving a very satisfying result. Nicole had designed her own education program, as there was no formal curriculum to guide her. Several of my partners had spent time with Nicole, discussing the complexities of prostate cancer treatment. My office staff made sure that Nicole knew about upcoming appointments for her to attend.

But, in the developmental stages of a project, team members may find it difficult to keep up their motivation when the final goal seems far away. Going back to our egg-hatching example, this would be the equivalent of trying to keep a group of kindergarten students interested in incubating and hatching baby chicks. When they see an unchanging shell day after day, their enthusiasm will wane.

To keep them interested, you could do this:

If you shine a bright light through an egg, you can see what's going on inside. That will help our young students to understand that the chick is developing.

For our next divisional project, perhaps we should give all stakeholders regular peeks at progress by setting milestones and reporting when they're reached. While it's a nice surprise for everyone to see a project finally hatch, those who are less immediately involved may be more inclined to nurture and protect the fragile work-in-progress if they can see what's going on inside the shell.

Now, let's drop the egg analogy. We've learned something else through our Nurse Navigator's work. And this may have more important benefits than the improved timeliness she brings to discussions around prostate cancer treatment. As Nicole has observed all our urologists discussing treatment with men, she's noted differences in individual practices. Some of the variation she's noticed involves recommendations for treatment and followup. She wants to give consistent, best practice information to men, but also doesn't want to confuse them by telling them something that an individual urologist may contradict later, based on his/her own practice habits.

This is an opportunity for us to decide, as a group, whether there is a standard, best practice that our division should follow when advising men about prostate cancer treatment and followup. Because we manage our individual office practices in isolation, we rarely have conversations about these more mundane (to us...) aspects of urology. In academic centres with residency training programs, the postgraduate trainee serves as the bee, cross-pollinating ideas and practices from one staff urologist to another. We don't have a residency program, so it looks like our Nurse Navigator will be the one to point out areas in which we can address practice variation.

An ounce of prevention

2011-09-25T22:48:00.000-06:00

My sons' tastes run to the macabre.

We were on holidays in Newfoundland in August, and climbed Gros Morne Mountain. As we were scrambling up the scree, they began to discuss the chance of an avalanche. Specifically, they wondered about the possibility that we would be trapped by boulders.

"Hey, it would be just like that guy who got trapped when he was hiking and he had to cut off his own arm with a pocket knife!" said one.

"Yeah, he's famous now," replied his brother. "They just made a movie about him."

In 2003, Aron Ralston had gone hiking alone in Utah without telling anyone where he was going. After having his arm pinned by a dislodged boulder and spending 5 days (the movie is called 127 Hours) without food or water, he freed himself by amputating his forearm. He was found by other hikers, and taken to safety.

I remember thinking back then, as Ralston was celebrated as a hero on TV news and talk shows, that although he had showed incredible will and courage, perhaps his ordeal could have been prevented or shortened if he had taken the elementary precaution of telling someone where he was going, and when he could be expected to return.

An ounce of prevention...

This story came to mind again at the end of our holidays when we were visiting in Newmarket, Ontario. I was walking by Southlake Regional Health Centre and saw these signs:

Before I go any further, let me make this clear: I am not making light of the contribution of this Health Centre. I am not minimizing any illness that the pictured lady or any other patient suffered, nor the important role medical care plays in treating and curing serious disease. These signs are representative of many others used in hospital fundraising campaigns across the country. I am not singling out Southlake; it was just a coincidence that I was passing by their hospital while thinking about this issue.

In healthcare, most of our attention is on acute and chronic care: heart disease, cancer, diabetes and trauma, for example. Our taxes and charitable donations build hospitals and furnish them with the latest technology. We pay specialists handsomely to perform complex, life-saving procedures. We marvel at the latest advances in medical science.

Many people will say, "Of course our attention is on acute and chronic care! What else is there?" There is Acute and Chronic's demure sibling, Prevention.

It's often said that prophylactic measures, such as clean water and vaccinations, have had more impact on improved health than any other intervention. But, how many $500 a plate dinners raise funds to promote eating more fruits and vegetables?

Prevention gets less attention for a number of reasons:

Its beneficial effects are not seen for many years, making it difficult for us to link preventative measures to beneficial outcomes. Those in charge of health care budgets may find it difficult to allocate scarce funds today, when the benefits will not accrue for decades.

Its value is measured across populations. When individuals enjoy good health, it's seen as a normal, baseline state, and not because of some intervention on their behalf.

The least economically and politically powerful among us may be the ones who benefit most from preventative measures such as smoking cessation, and education about diet and exercise.

I've heard acute care medicine (derisively) referred to as "rescue medicine". The point is that health care systems include the maintenance of healthy populations in their mandate, yet they spend many of their resources saving people whose disease could have been prevented in the first place. What if that kind of contrarian thinking became the norm? What if we noted the known risk factors for every condition that forced someone's hospital admission, and so kept a running tally of the daily cost of each risk factor? We would expect hefty government investment in smoking cessation, and promotion of healthy diet and exercise, as a start.

Perhaps the information on Southlake's signs ("40,000 patients and counting") should be seen as a sign of our health care system's failure to prevent disease, rather than a rallying cry to promote expansion of health care facilities.

Full awareness at work

2011-09-21T21:36:00.000-06:00

I was walking home after a run last week and decided to take out my earphones. I usually keep a podcast playing until I walk in the front door of our house, but this time, I thought I would let my own thoughts keep me company. I was struck by what I noticed when I didn't have something playing in my ears.

I keep the volume low so I can hear bike riders coming up the trail behind me. Even so, as soon as the earphones came out, I was acutely aware of sounds I had been missing: wind blowing through tall grass, and a small animal in the underbrush. Hearing the sounds didn't surprise me, but the change in my overall awareness did. Without earphones, I paid more attention to things I saw along the trail, in addition to things I heard. Listening to something in earphones had turned my attention inward more than I realized.

I mention this because of a conversation I had last week with a health administrator from another province. We had both noted how some medical personnel seemed to be distracted at work by their various electronic devices. I have particularly noted that, in Saskatoon's hospitals, some of the housekeeping staff wear earphones while performing their duties. She told me that the practice had been banned in her health region.

The main concern was around workplace safety. As I found out after my run last week, not only is your hearing affected, but listening through headphones impairs your overall awareness of your surroundings. She also mentioned that, even though they are not considered "clinical staff", housekeepers work in patient care areas and may hear (and then respond to) patients in distress.

I wonder if workplace headphones also have a less obvious opportunity cost. Housekeepers perform an essential role in keeping our facilities clean, safe and functional. In order to do that, they need access to all areas of the hospital. As such, they regularly cross paths with staff and patients. They have the opportunity to greet visitors, answer questions and give directions.

However, if I see someone wearing headphones, I take it as a sign that they don't want to interact. They're sending a message that they prefer solitude. I suspect that patients and visitors will make the same assumption if they see hospital staff wearing headphones. They may hesitate to ask for help.

This no-headphones rationale won't resonate with staff unless they've been explicitly given permission and encouraged to interact with patients and visitors. Unless housekeeping staff see themselves as goodwill ambassadors, it won't matter whether they wear headphones or not. And if they don't see themselves in that role, then staff are missing opportunities for joy and satisfaction through richer interaction with our clients, and we're missing the chance to use our staff's talent to full advantage.

Long wait times for surgery? Never again!

2011-09-05T19:57:00.000-06:00

There is absolutely no inevitability as long as there is a willingness to contemplate what is happening.

- Marshall McLuhan

When someone decides they want to have surgery performed, they usually want to know details: What will happen? Will it be painful? What are the complications? But, even if they don't have a lot of questions about How and What, they almost always ask about When.

And that is often an awkward question to answer.

Our surgical booking system divides patients into 4 categories: emergency,cancer, urgent and elective. While the first 3 categories denote pressing need for surgery, "elective" surgery indicates that the procedure can be delayed without significantly compromising the person's health or chance for a good outcome. It's an arbitrary definition, and varies from surgeon to surgeon. The perception of what should be considered "elective" certainly varies between surgeon and patient.

The Saskatchewan Surgical Initiative's (SkSI) goal is that, by 2014, all patients will have the option to have their surgery within 3 months. ("Option", because some people may choose to delay their surgery until a more convenient time). By the end of 2011-2012, the goal is to reduce all surgical wait times to less than 12 months.

A 12 month wait for surgery is shocking, and some people wait 18 months or longer! The amazing thing about that is that we (patients, surgeons, administrators) have accepted this as inevitable.

But, we won't accept these waits for much longer. Take a look at this trend:

This is the number of people waiting longer than 12 months (top line) and 18 months (bottom line). Over the last year, the numbers in each group have been halved! While this trend had started (due to other provincial initiatives) even prior to SkSI's formal start in 2010, it has been bolstered by SkSI. Additional OR time, as well as more effective use of that time, are helping to clear the "long wait" backlog.

This success isn't without a cost. In our practice, we've been assigned additional OR time to provide service for our patients who have been waiting for over 12 months. This means that the urologist will not be available to provide other important services, such as office consultation or cystoscopy clinics. As such, wait times in those areas have increased.

There's nothing magical about how this wait time success is being achieved. Health system leaders decided that this would be a strategic priority, and put attention and resources toward fixing it. Leaders and managers are accountable for achieving targets. With this approach, SkSI will meet its goals - whether by 2014 or not is just a quibble. Then, once the SkSI goals are met, our healthcare system can focus on another strategic priority.

And that's when all SkSI's work will be in danger.

We can only concentrate on a few major initiatives at a time. A fairly small number of people are involved in moving these projects ahead, and only have so much time and attention to go around. Once we declare "Mission Accomplished" on surgical wait times, and move on to, say, Primary Care Reform, surgical wait times may creep back up.

In addition to reducing the surgical backlog, we need to build in sustainability, such as ongoing surveillance and transparent reporting of wait times. More important is a critique of current practices - keeping the effective parts and redesigning the rest. We need to create processes (e.g. pooled referrals, assessment and treatment pathways) that will survive the inevitable dimming of the spotlight currently illuminating the surgical system. We can't rely on the hyper-vigilance associated with being the provincial priority du jour.

I look forward to the day when, as I hold forth in front of a group of medical students, they shake their heads and smile wryly at the old-timer's tall-tales of surgical wait lists longer than 3 months.

Should I stay or should I go? A real mid-life crisis

2011-08-30T06:40:00.001-06:00

It was like taking a ride in a time machine.

I had the chance, last week, to meet the incoming class of medical students at the University of Saskatchewan. Just over 30 years ago, I sat where they were sitting, likewise listening to some old-timer blather on about what he had done during his career and what I had to look forward to.

At that point, I hadn't yet examined a patient, written a prescription, or even taken an anatomy class. In retrospect, I had no idea what I was getting into. I was thrilled to be in the class, yet totally bewildered. I recognized the same look on some of the faces of these new medical students.

I felt a mid-life crisis well up.

I've joked about mid-life crisis before, but I think I'm beginning to appreciate what it's really all about. I've been practicing urology for almost 20 years. That means I'm beyond the half-way point of my surgical career. My upcoming birthday is a noteworthy one, in an over-the-hill way. So, I've been thinking a lot lately about what I should be doing with the 2nd half of my career. The topic I was addressing with the students only fueled my angst.

I was part of a panel discussion about physician leader and civic professionalism. Our group included 2 practicing physicians (myself included), a physician administrator, a resident and a 3rd year medical student. The course instructor had asked us to reflect on our own leadership experiences - why we took leadership roles, what we found satisfying about them, and what challenges physician leaders face.

I confessed that I spent my time in medical school, and the first 10 years of my practice, actively avoiding these roles. In fact, one of the first leadership positions I took on was our office's Advanced Access/Clinical Practice Redesign work - the same work you've seen documented in this blog for the last 4 years. That experience has taught me a lot about leadership, and encouraged me to seek out further leadership training and opportunities. The other panel members related similar stories.

Giving the positive side of leadership work is easy and fun. And misleading. Being a physician leader is hard work. There are a lot of barriers to success, and talking about those reminded me of the questions I've been struggling with about my career’s direction.

Physician leaders are not readily recognized and valued for the work they do. Brent Thoma, the ER resident on the panel, made this point when he spoke about his own experience as a class leader during medical school. He pointed out that there are many scholarships for students who excel academically. Top students in basic and clinical sciences receive recognition and rewards. But, other students who choose to spend some of their valuable time in organizing class gatherings, charity fundraisers or the provision of healthcare to under-serviced communities don't get the same acknowledgement. He was pleased to report that the College of Medicine had a new scholarship for such medical student leaders.

It's not any easier for practicing physicians. First and foremost, doctors value clinical work, followed by teaching and research. Administration and leadership are often look upon with distain. "He's gone over to the Dark Side" is a common jibe.

Also, many physicians take a pay cut if they sacrifice clinical work to take on leadership roles. For other health professions, an administrative/leadership role might mean greater opportunity for career advancement, with increased compensation and status. That's usually not the case for physicians.

Physicians have often been thrust into leadership roles without adequate preparation. Until recently, leadership training was not a part of the formal medical school curriculum. In the same way that doctors starting medical practice are presumed (by virtue of their doctor-ness) to be competent to teach medical students, they are presumed to be naturally competent leaders. This assumption leads to uninspiring results for the healthcare system, and frustration and discouragement for the unprepared physician leader.

After the panel discussion, all these impediments to physician leadership were swirling inside my head, only to be accentuated by my reading, later that day, Andre Picard's interview with outgoing CMA president, Jeff Turnbull. The piece's title, When even Dr. Optimism is losing faith in medicare, it's time to fix it, tells the story. Turnbull reports his frustration with "the lack of leadership, co-ordinated management, accountability and responsibility and, yes, needless waste. Worse, we allow staggering inefficiency, ineffective management processes, incoherent decision-making and practice variations that undermine quality and safety."

While Turnbull insists that he remains optimistic, imagine what resolve it must take to maintain that outlook, given the dysfunction he has seen at every level of healthcare, from the highest level of health policy to individual patient care.

Turnbull's sentiments, while on a grander scale, are similar to mine as I've been trying to decide what direction to take. While the leadership work I've undertaken so far has been very rewarding, it can be stressful, and takes me away from the clinical work that I also enjoy. Improvement projects never seem to move as quickly as I would like.

It would be so much easier to keep my head down and retreat to the familiar trenches of clinical practice. After 20 years, there’s a comfortable level of competence. While there’s enough variety and challenge to keep things stimulating, the learning curve has flattened. I have a great group of partners and staff to work with. I could give up the meetings and committees and projects. I could be home for supper more reliably. And, the money is good. Great, actually.

It’s a little disturbing to acknowledge the allure of the familiar ground of clinical medicine.

The question I’ve been asking myself is: Why fight it? Why not give up leadership work?

I think I have the answer: Medical leadership is not separate from clinical practice; it is an extension of clinical practice. The will to lead flows from the desire to bring about change. Once I understood that changing only my own practice severely limited the improvement my patients could experience, I was compelled to try to influence change beyond each single physician-patient encounter.

Experiencing, on a daily basis, the frustrations that Dr. Turnbull described, fuels my will to change things. But, I don’t intend to change The System - that amorphous, slippery, anonymous, maddening thing. I don’t think I can change that.

But, people made The System, and they – we - remake it everyday. I think I can help, convince and cajole people (and myself!) to work differently, and through collective effort, we can replace The System with something we will be proud to be part of.

There’s great joy in that.

And so, crisis resolved.

I'm turning 50, and I’m not turning back.

Safety deserves more than lip service

2011-08-21T23:10:00.000-06:00

Earlier this month, my family and I flew home after a holiday in Newfoundland. As we boarded the flight in Deer Lake, my 2 sons led the way onto the plane and took the first two seats we had been assigned. Unfortunately, their seats were in the exit row and, as they were too young to sit there, we moved them to our other assigned seats. My wife and I took the exit row seats.

The flight attendant arrived to give the exit row passengers instructions on how to open the emergency exit in case of the need to evacuate the airplane.

"Pull down the handle, pull the door inward, then throw it clear outside the airplane. Are you OK with that?"

She looked expectantly at me and my wife. I hesitated.

Before the flight attendant had arrived to brief us, I had noticed that the opposite exit row window seat was occupied by an elderly lady, perhaps in her late 70's, and very slightly built. The emergency exit instructions noted that the door weighed 40 pounds. I thought it was unlikely that this lady would be able to manhandle a 40-pound door.

The flight attendant was waiting for my reply.

"Are you OK with that," she repeated.

I was unsure what to say. My wife and I could certainly handle our exit, but I was convinced that the lady opposite couldn't. Was it any of my business to point this out? Surely the flight attendant could see the same problem that I did. Perhaps I was overreacting. After all, she must have been trained to assess a passenger's ability to help in case of an emergency.

The easiest route would have been to nod my head and let her get on with departure preparations. But, the situation was so obviously inappropriate, I couldn't let it go. But, I was unsure how to proceed. If I explicitly related my concern, I may offend or upset the elderly lady sitting across from me. The flight attendant was already puzzled at my silence, and I certainly didn't want to upset her. I tried to drop a hint.

"Well, I'm OK, but I'm not sure everyone else is..."

I glanced across the aisle, and she followed my gaze. She took the hint.

Or, so I thought.

She caught the elderly lady's attention and asked her "Are you comfortable with that?"

"Oh, yes," was her reply.

I wasn't sure that the elderly passenger had actually understood what the flight attendant was asking her. The question was ambiguous and she may have simply been indicating that she was comfortable in her seat.

"Anyway," the flight attendant assured us, "It's extremely unlikely that we would need to evacuate."

The flight attendant was obviously uncomfortable with addressing the situation. My impression was that she did not wish to upset the lady in the window seat. But, her reassurance that an emergency evacuation was unlikely seemed to me to be an acknowledgment that there was a problem.

I was stuck. Now that I had pointed out this situation, could I let it go unresolved? Was this my responsibility to pursue, when a crew member did not seem overly concerned?

The answer came from the couple seated in front of the elderly woman. They had heard the conversation and offered to change seats. The flight attendant seemed relieved at this resolution.

Some thoughts on this vignette:

The emergency exit briefing procedure reminded me of the preop surgical checklist. Both can be technically completed by reciting the prescribed list of questions. However, each procedure achieves its goal of improved safety if all parties openly communicate. Everyone has to be confident that safety concerns will be acknowledged and addressed. The intent of the safety checklist must be satisfied.

While the flight attendant seemed to recognize my concern that the elderly passenger couldn't carry out the evacuation procedure, she seemed unsure of how to address this with the lady. She didn't want to embarrass the lady by singling her out. Perhaps a formal script would be useful: In case of an emergency, you will need to assist with evacuating the plane. Are you capable of lifting the 40-pound door and throwing it out of the airplane? Pose this question to all exit row passengers, regardless of their age and size.

I wondered if I am sufficiently open to hearing safety concerns in the OR. If other members of the OR team see a problem, yet think I am not receptive to hearing their input (as was my impression of the flight attendant's approach to my concern), they will hesitate to speak up.

Safety policies should be followed consistently. Excuses that an adverse event is "extremely unlikely" undermine everyone's commitment to the safety process.

I ♥ Calgary's online ER wait times project

2011-07-31T19:25:00.000-06:00

I have a huge (data-) crush on Calgary's Health Region!

They have captured and posted online the ER wait times at the city's healthcare facilities.

The website shows estimated wait times for 4 hospitals and 2 health centres. The information is automatically updated every 2 minutes. There's a comprehensive disclaimer that reminds people that ERs are unpredictable places, that wait times may change significantly within a short period, and that patients will be see according to the severity of their condition.

Health region representatives said they hope that making this information easily available will help patients to decide whether to go to the closest ER, or the one with the shortest wait time, and thus distribute the workload more evenly.

There's an interesting "behind the scenes" page linked to the main page. It explains more about the online system and how the wait times are calculated. The wait times displayed online are calculated based on the number of patients waiting to be seen, their disease acuity, and the number of medical staff available to see patients.

The times are automatically calculated by Calgary Health's IT system, so there's no additional clerical work needed. Nice!

A few thoughts on this national first:

I'd be interested to see how the calculated wait time correlates with the actual patient experience. This will likely be studied and posted as part of the evaluation phase of this project.

Might patients be discouraged from seeking urgent medical care if they see how long the wait will be? People already realize they will have to wait for ER attention, but if they have already invested the time and effort to get to the ER, I suspect they are more likely to stick around until they are seen. Will advance knowledge of ER wait times change patient's behaviour? If so, is this necessarily a bad thing? That is, might some people be more likely to seek care for less urgent problems from their family physician if the ER is "less convenient"? This would be a tough one to measure because the patient's experience won't be captured at an ER visit. Maybe family medicine clinics will anecdotally report that patients are deciding not to go to the ER.

Power to the people! Now that this information is available publicly and in real-time, I'm keen to see who will be the first to use it for other than its stated purpose. I don't mean using the information for a nefarious reason (although there may be some way to do that...), I mean a mashup, combining online data sets to produce new functionality beyond the original intent. For example, someone could combine Calgary traffic and transit system data with the ER wait time to show the patient's real wait time experience. (Similar to how we now consider patient's entire wait for surgery to be "Wait 1" - wait for consultation with surgeon - plus "Wait 2" - the time from the OR booking being submitted to the actual date of surgery.)

Depending on where someone lives and the transportation available to them, it might make more sense to visit the ER that nominally has a longer wait time, because the total patient wait (combined transit + ER wait) is actually shorter. If that were the case, and it resulted in more congestion in an already busy ER, perhaps Calgary Health IT would communicate with Calgary Transit and more buses could be put on the routes that lead to the less congested ER. (Mmm, mmm, mmm! System integration!)

Some enterprising computer science student will create an app that pulls the data to smart phones, so a single click will let people know which ER they should head for. As long as that app is in the works, why not link it to a health advice FAQ site (official Alberta Health, of course) that gives suggestions for self-management of common conditions that often lead to low-acuity ER visits.

Similarly enterprising engineering or business students will track the publicly posted data and identify trends of ER congestion. Queue theory experts insist that, even in the unpredictable world of the ER, there is enough predictability to guide staffing plans. Analyzing the trends in Calgary's ERs would be a great student project.

The greatest thing about this project is just that they did it. Plain and simple, they did it! Alberta has shown that meaningful, real-time health system data can be collected and displayed in a way that helps the public make better decisions about their health care. Once the bugs are worked out, this can be spread across Alberta. Soon, people in other provinces will come to expect this service.

We can use the Alberta's ER model to help manage other health care congestion, for example, hospital beds. Hospital ward managers tell me they spend a big part of their day figuring out which patients are ready for discharge and then facilitating discharge or transfer. Sometimes, a message will be posted in the OR: "Please arrange patient discharge as soon as possible today. Wards are full and surgery may be cancelled." By the time word gets around, it's at least 10 am, and the prime opportunities for deciding about discharge have passed.

How about pushing real-time data to each hospital physician? Include the number of patients he/she has in hospital, the "national expected length of stay" for each patient's condition, the current length of stay, hospital occupancy and an indicator as to whether the physician has indicated a planned date of discharge. This information could be sent to the physician's phone every evening so discharge planning can be done that night, or early in the morning. The information is already available; it just needs to be aggregated.

Show us the way, Alberta!

Physician funding: Let's try an evolutionary model

2011-07-19T23:21:00.000-06:00

Dilbert's Guide to Health Economics!

Yesterday's Dilbert cartoon reminded me of a health care story from Prince Edward Island. In May, PEI's Health Minister took salaried doctors to task for lack of productivity. Apparently, fee-for-service doctors were seeing many more patients than salaried docs. The same phenomenon was noted even if it were the same doctor, working after-hours in a fee-for-service clinic, after finishing a day's work in a salaried position.

Paul MacNeill's op-ed illuminates the economic and political issues around the Minister's actions.

Whether or not the accused docs are actually slackers is beside the point. The reduced throughput for salaried physicians is exactly the result that the Minister should expect from these different payment schemes (neither of which is perfect). Fee-for-service (FFS) encourages the provision of more services or visits. Salaried positions are supposed to encourage physicians to provide more preventative care and counselling, spend more time with each patient, and engage in multidisciplinary care. This means fewer patients will be seen, yet their quality of care should be higher. Unfortunately, salaried positions are open to abuse, and some physicians (like other human beings!) may be tempted to do as little work as possible.

To judge physician performance, the Minister should look beyond patient volumes. More appropriate measures would be patient satisfaction, health outcomes and wait times. Of course, these are more difficult to measure and interpret.

What is the best payment system for docs? (Oops - that should read "best payment system for patient care"!) Here are some thoughts from an expert.

And here are some thoughts from an amateur:

We can't create a foolproof physician reimbursement system in one shot. It's too complex. It should be an experiment where both sides (payer and physician) trust each other and that they have a common goal of excellent patient experience and outcomes. The system would evolve to suit the needs of patients, physicians and the payer. Start with our best guess of a suitable payment model, agree on goals, and get going. Be flexible and make adjustments on the fly.

Don't try to create a definitive system. Rather, create the conditions that will allow for a suitable system to develop:

Physicians are assured of a stable income and work-life balance.

Payer is assured that at least the current level of service will be maintained. (This might mean making baseline measures of the current state using the new measurement system. See below.)

Agree on appropriate measures that suit the desired outcomes. As noted above, patient satisfaction, health outcomes and wait times could be measured.

Don't penalize docs when they run up against barriers in parts of the system beyond their control.

Stop measuring volume of service. Completely stop. Don't make docs "shadow bill" to make sure that they are keeping up a certain volume of patient visits. This wastes administrative effort that could be directed to quality improvement and patient service.

Time spent on improving care delivery is as important as care delivery itself. Quality improvement work is included as part of the physicians' duties. (Likewise, education, research and administration.)

Fail forward. Encourage reasoned experimentation. Import best practices from around the world. Expect failures. Embrace failures.

I'm sure Dilbert would approve.

How we keep score determines how the game is played

2011-07-17T23:35:00.000-06:00

“Don’t let him in, Dad!”

I was driving my son to his soccer game when we ran into road construction. Signs indicated that the right lane was closed ahead, so we merged into the left lane. The very congested left lane.

As we crawled along, a few cars zipped ahead in the right lane, which wasn’t blocked off for another 10 car lengths. When these drivers reached the barricade, they signaled their intent to merge into the left lane. My son’s sense of justice was offended by this “butting in line”, and he exhorted me to keep driving and prevent the right-lane bandit from merging.

To be fair to my son, his attitude has been informed by my own kvetching about drivers who don’t play by the rules. Well, by my rules, anyway. Why should this guy get to cut in when I’ve been stuck in this lane for all of 3 minutes?! He can just sit there for another few minutes.

I talked tough, but when it came down to it, I let the other driver merge. My son was disgusted with me.

This led to a discussion about which method would get more cars through the construction zone more quickly: Option 1 - everyone merging into the left lane as soon as they saw the “Right Lane Closed Ahead” sign, or Option 2 - some drivers continuing in the right lane until it was barricaded, and then merging. We couldn’t figure out the answer, but my son told me it didn’t really matter. What mattered to him was how fast we got through, so he could get to soccer on time.

Hmmm…

I can see how he would come to that conclusion. Getting to his game on time was the only benchmark he had. In fact, maneuvering through the construction-zone traffic had become a game unto itself, and our goal was to get through in the shortest time possible. Setting that goal lead to our (fantasized) tactic of blocking other drivers who wished to merge into our lane. That tactic would get us through the line a little quicker, but at the expense of the other driver.

What if the game were played differently? If there were evidence that Option 2 is actually more efficient, traffic engineers may want to promote it. They could post signs asking drivers to continue in the right lane until the last moment, and then encourage courteous merging. But, even if this option is more efficient for the driving collective, individual drivers will still “win” if they are selfish and refuse to allow anyone to merge in front of them.

Maybe we need a different way of keeping score, and a scoreboard to let drivers know how the game is going. The engineers could set up an electronic sign that indicated how many cars per minute (CPM) are passing through the construction zone. Perhaps every time a driver exhibited the desired merging behaviour, a happy face would flash and the CPM number would increase. If someone blocked a merge, the opposite would happen. I’m not sure what the most effective sign/scoreboard would be, but whatever it was, it should give this message: We’re all in this together!

Last week, I spoke with a friend who works in a chronic disease management program. Her program had been trying to secure funding for an initiative that would engage patients in their own care, with the intent of reducing disease progression and hospital admission. She was frustrated because the acute-care department that managed patients in hospital had received funding for a high-tech intervention that would benefit a few patients with severe disease, yet her program had been unable to obtain a fraction of that amount to promote an intervention that would keep many more people from being hospitalized in the first place.

This will be a familiar story to clinicians who see behaviour in another department affecting their own department (e.g. surgeons griping about medical specialists’ discharge patterns – see this recent post), yet feel powerless to influence that behaviour because it’s happening “outside their silo”. Everyone is playing the game for themselves, sometimes to the detriment of the system/patient.

Healthcare organizations often use “dashboards” to show key performance indicators at various levels, e.g. mortality rates over the entire organization, consultation wait times at the department level, or complication rates for individual surgeons. The trick is to make all these dashboard/scoreboards relevant for what really matters: the patient’s experience.

It’s the patient’s experience that cuts across all of healthcare’s self-imposed boundaries, yet our current scorekeeping emphasizes those boundaries. Budgets are assigned according to categories created for provider convenience – medicine vs. surgery, inpatient vs. outpatient, acute care vs. prevention. I think that most providers, if in a conflict over behaviour or budget, would let a colleague “merge” ahead of them, if they could see that it would be better for the collective effort.

The challenge, then, is to set up dashboards/scorecards that emphasize (and reward!) that collective effort, rather than individual success. We're all in this together!

P.S. If you want the answer to the “Late Merge” question that my son and I couldn’t figure out, take a look at this interesting explanation by a Minnesota traffic engineer.

Don't want a shiny, new hospital ward? Then, it's time for me to walk the talk.

2011-06-26T22:39:00.000-06:00

It's one thing to identify a problem, another to solve it.

In my last post, I worried that one of our hospital wards was about to undergo an expensive renovation without a full exploration of the alternatives. The stated motivation for the renovation is to expand surgical bed capacity to accommodate an increased volume of procedures. The increased volume results from the Saskatchewan Surgical Initiative goal of offering surgical dates within 3 months of booking by 2014.

My concern is that spending this money on renovations supports the status quo. It will give a false sense of accomplishment and quell the urgency to implement innovative solutions that hasten postop recovery, so as to reduce the need for hospital beds.

Now that I've convinced myself of the huge opportunity cost of investing in bricks and mortar rather than process improvement, I feel compelled to act. (Curse you, Conscience!) But, what to do? In a big organization like Saskatoon Health Region (SHR), decisions are made from the top down. Once resources are committed to a significant project like this, positions are entrenched and minds unlikely to change. I might as well just keep my head down, do my own work, and keep my nose clean until retirement. Right?

That's a victim mentality. I reject it. I may not be able to influence all the decisions that I would like to, but if I remain passive, I will influence none of them. The victim mentality is a self-fulfilling prophecy: If you think you can't, then you are right. (attrib. Henry Ford).

Where to start?

With myself, of course. Have I understood the whole situation? Have I jumped to conclusions? First, I need to talk to the administrators charged with the daunting task of matching surgical volumes and bed capacity. I need to hear their side of this story.

What can I contribute to finding a solution? I can bring a clinical perspective. I can suggest what improvements can be implemented within a reasonable time. I can have conversations with my medical and surgical colleagues in ways that are generally inaccessible to non-clinicians. I can bring knowledge of and experience in using improvement techniques. I can bring a mile-wide stubborn streak.

Then I need to understand how to engage administrators in the quality agenda. Oooh, snap! That phrase usually reads "engage physicians in the quality agenda" and is spoken by administrators. I hate the implications of the phrase and I'll bet administrators don't like it pointed at them either. I've griped in previous posts that, doggone it, physicians are already "engaged" in the quality agenda, and that healthcare leaders need to remove the obstacles that prevent us from achieving our goals. Maybe there's a similar situation with administrators.

What if, contrary to what many clinicians believe, administrators actually are interested in improving the quality of care, and there are obstacles in their path also? What are the obstacles?

Insufficient current clinical knowledge is a significant impediment. While many administrators have a clinical background, they may not have up-to-date information on the latest techniques in perioperative care and surgical techniques that can speed patient recovery. They may not know what is possible to achieve.

Daily operational pressures crowd into the time needed to deeply contemplate solutions to complex problems. A manager explained to me last week that "bed rounds" - a meeting of most the hospital's managers - happen twice a day. Twice a day! These managers are just trying to keep their heads above water. How can they possibly free up the time to be innovative?

Goals and objectives are set by administrators at the next level up in SHR's hierarchy. If senior leaders set a goal of increasing surgical volumes, and give very tight timelines to achieve that goal, then managers and directors will grasp at the first, most obvious solution. While they may have considered other options (see the last post), they may reject them as too unwieldy or time-consuming. It may be more expeditious to spend lots of money, and build our way out of this problem.

I can help with the clinical information, but for each of the other obstacles, SHR's senior leaders will have to remove the barriers the managers and directors face: overwhelming operational responsibilities that consume cognitive resources, and perverse incentives that lead us to deliver greater volumes of status quo rather than the exceptional care of which SHR is capable.

Raise your hand if you want a shiny, new hospital ward!

2011-06-22T23:28:00.000-06:00

Twenty-five years ago, when I was an intern on the surgery service, the dreaded part of the day was the late afternoon. That was when all the patients were admitted to the hospital. For surgery the next day.

Yes, you heard me right - admitted the day before scheduled surgery. Sounds crazy, huh?

Interns were expected to document the medical history, examine the patient, arrange lab testing, obtain consent for surgery, and discuss the case with the attending surgeon. There could be dozens of scheduled admissions in an afternoon. I'm not telling you this to gripe about the workload in the "good old days", but to point out that nowadays, if any surgeon planned to admit all patients to hospital the day before surgery, he/she would be pilloried. It would be rightly noted as wasteful of resources as well as being a needless discomfort for patients.

But, back then, there were many reasons why it had to be so:

Patients needed a history and physical completed
Nurses had to do preop teaching
Patients couldn't be trusted not to eat or drink after midnight (i.e. NPO for surgery/anaesthetic)
Preop sedation had to be administered to prevent undue preop anxiety
Patients couldn't manage their own bowel prep (powerful laxatives used prior to colon surgery)
Patients had to "acclimatize" to the hospital (I never understood that one, but accepted it because the staff surgeon said it with great conviction.)

That's just the way it was done for everything from an aortic aneurysm repair to tonsillectomy.

Well, there were exceptions. I remember admitting a local GP who was having hemorrhoid surgery the next day. He patiently submitted to the routine, having served as an intern in the same hospital several years previously. After being "admitted", he asked if he could go home on an "overnight pass" - highly irregular! His surgeon agreed out of professional courtesy. He returned the next morning and underwent uneventful surgery, even without being "acclimatized".

Then, the chief of surgery decided that we would do things differently. Based on day surgery practices at other hospitals, he lead the development of a system that allowed patients to be operated on and discharged on the same day for "minor" procedures, and admitted to hospital on the day of surgery for "major" cases. I can only imagine the consternation this caused when first proposed, even though it was a proven and established practice in many other centres. Now, day surgery is standard practice for many conditions.

I've taken you down Memory Lane because it seems to me that the past is repeating itself. Thinking about changing deeply entrenched practices remains a jarring experience.

At a meeting this week, I learned that there are plans to renovate a currently unused floor at our hospital. This new unit will be designated for surgery patients and will expand surgical bed capacity. The impetus for this expanded capacity is the Saskatchewan Surgical Initiative (SkSI). As part of SkSI's mandate to reduce surgery wait time, the health regions are increasing the volume of surgery they perform. As some patients will require a postop hospital stay, and surgical wards are currently usually full to capacity, increasing the surgical volume means we need more beds for patients to stay in postop. That's simple math.

But, as a friend of mine likes to say "For every complicated problem, there's a simple solution. And, it's wrong."

Renovating a new hospital ward will be expensive, but simple. Simple, in the sense that there are prescribed building codes, architectural principles and construction practices that can be applied. If we sign the cheque (Whaddaya figure? Over $1M, at least?), a contractor will deliver a shiny new surgical floor. Everyone will be pleased. Photo-ops will abound.

And, the status quo will be cemented.

I believe that building extra inpatient bed capacity is not only the wrong solution, but will actually be a harmful solution.

The solution to a mismatch of demand (number of surgeries requiring hospitalization X number of days spent in hospital) and capacity (number of bed-days available) involves reducing demand, increasing capacity, or creating a better balance of demand and capacity.

Here's some ways to increase capacity:

1) A new surgical ward increases capacity. It's relatively easy to do (see above) and gives fairly quick results (within a year?). But, it's expensive, and taking this route reinforces the notion that we don't need to change our processes, as long as we can throw enough money at a problem.

2) New capacity for surgical patients can also come from existing hospital capacity. "Medical" patients also occupy hospital beds, and there is always a tension between medical and surgical services over bed usage. To an outsider, it may seem petty that surgeons and medical specialists covet hospital resources that are intended for patient care, but each physician wants to ensure that his/her patients have access to a bed when needed. Medical patients tend to be acutely ill when admitted, often presenting to the emergency department. That means that there is little choice other than to have them stay in a hospital bed. Elective surgical patients, in contrast, are generally in reasonable health when they come to the hospital (although the surgery they undergo upsets that condition to varying degrees). However, if there is only one bed available, it will be assigned to the acutely ill "medical" patient, and the person expecting to have their elective (sometimes urgent) surgery performed will be sent home and have the procedure rescheduled.

Surgeons love to demonize medical specialists around bed usage. We surgeons flatter ourselves that we're diligent in preparing our patients for prompt discharge, assessing them early in the morning so that necessary preparations can be made, and even developing care maps that anticipate the date of discharge. At our meeting earlier this week, it was pointed out that most of Saskatoon's surgical services have average length of postop stays at or below national averages. So, perhaps our surgeons have the right to feel smug about this.

We're convinced that, if our medical colleagues could implement similar discharge planning practices, their patients' average length of hospital stay could also be shortened. As hospital beds are a global resource, any reduction in length of stay means increased bed capacity for all services, medical and surgical.

Surgeons have multiple incentives to help their patients recover promptly and return home in good condition as soon as possible. Of course, the main reason is that this is good patient care - our prime objective. But, we also have a responsibility to the next patient who is scheduled for surgery. If there are no available beds, then their surgery will be cancelled.

Medical specialists share the same mandate to provide good patient care. But, if a new, acutely ill patient comes into the emergency department, a bed will be found for that person. Perhaps they will be assigned to a "surgical" bed, or they may stay in the emergency room overnight. Either way, they will not be sent home. That means there's relatively little incentive for medical specialists to hasten discharge of recovered patients.

This issue raises much rancour in surgical meetings. However, because it crosses the boundaries between surgery and medicine, it's a difficult conversation to have. As such, we come up with work-around solutions, like "protected" surgery beds (no medical patients allowed, even if the bed isn't needed by a surgery patient), or adding more beds to the hospital.

Managing demand is more challenging. Here are some options:

1) Do more surgery on an outpatient basis. At a conference earlier this month, SkSI hosted representatives from the health system of South Devon in the UK. One of their presentations was about "enhanced recovery", essentially helping patients get better more quickly after surgery. One part of this talk surprised - even shocked - me.

At the start of the presentation, they showed their traditional list of procedures suitable for day surgery. I noted that there were several urology procedures on the list: circumcision, bladder tumor removal, ureteroscopy - all procedures we already do on a day surgery basis. I began compiling a mental list of urology procedures that could never, ever be done on a day surgery basis. My intent was to think of ways that all other procedures could be changed from inpatient to day surgery cases. The list of never, ever procedures was pretty clear: cystectomy, prostatectomy and laparoscopic nephrectomy - respectively, removal of the bladder, prostate and kidney.

Then, the South Devon team showed their current list of procedures considered suitable for day surgery. Laparoscopic nephrectomy was on the list!

I had already closed the door on the possibility of doing that procedure as day surgery, yet surgeons from South Devon had achieved it.

They used a combination of anaesthetic and surgical techniques - all accessible and fairly low-tech, but applied rigorously and consistently - to achieve this. But, the real power of their approach was that they improved the entire process from family doctor to home care support after discharge. As soon as the family doctor thought that surgery might be required, they supplied the patient with consistent information about the entire process including expectations around pre-op medical optimization, hospital stay and at-home recovery. Nurses followed patients with at-home visits and phone calls.

The South Devon team was careful to point out that the processes they use are easily accessible in developed countries, but implementation requires coordinated will over the entire system. Our current "silo view" of surgery makes this difficult to achieve.

2) Help patients recover more quickly, so they can achieve their discharge goal sooner. Again, the South Devon team challenged us with their approach. They showed the wide variation in hospital stays for patients undergoing colon surgery. By adopting the best practices from centres with shorter hospital stays, they were able to likewise help patients recover more quickly. They emphasized that their goal for patients was always "Better, quicker", and not just earlier discharge. The fact that patients went home more rapidly was just a reflection of their more rapid recuperation.

During discussion at our surgical meeting this week, it was pointed out that we're already meeting, or exceeding, national benchmarks around expected length of hospital stay. This demonstrates the danger of benchmarking! These benchmarks are national averages, and the philosophy they tacitly encourage is "Let's be mediocre!" That is, as long as we're average, we can excuse ourselves from trying any harder. Surely, if we're going to use benchmarks, we should choose the best performers and try to match their results.

And now, back to the potential hazard of spending millions of dollars to add surgical bed capacity rather than do the more challenging work of process redesign. Adding capacity reinforces the notion that the status quo is fine - we just need more of it. Adding capacity carries a huge opportunity cost. Imagine how much system-wide change $1M would support. Adding capacity takes away the incentive for providers, managers and leaders to have the difficult conversations about turf protection and changing habits.

Our patients trust us not only to provide care, but to constantly improve that care. They rely on us to seek out the possible and think beyond the traditional. Henry Ford, when commenting on the invention of the automobile, said, "If I had asked people what they wanted, they would have said faster horses."

A shiny, new hospital ward will be welcomed by patients, staff, administrators and politicians. It's what we want.

But, not what we need.

Urban renewal at Royal University Hospital

2011-06-14T22:47:00.000-06:00

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

But, from barren ground has sprung a blossom!

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

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

It's a complete renewal of this space!

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

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

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

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

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

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

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

2011-06-12T22:43:00.000-06:00

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

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

How about your medical records? Not so much.

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

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

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

It's a frustrating waste of time and money.

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

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

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

Keeping patients at home - Redesigning care delivery

2011-05-26T07:58:00.000-06:00

The innovative telehealth programs described in this Globe and Mail article resonated with me this week as we continue to work on similar issues in our urology practice, namely, what is the best way and location to deliver patient care.

The article mentions programs in BC and Ontario where patients with heart disease monitor their own symptoms and vital signs, submit the data via phone or computer, and have regular follow-up by automated phone call. Of course, all this is in addition to access to traditional, "live" care providers. The classic model of care for these patients would be to travel to a large centre where specialist care congregates, and then have professionals do all the work. The telehealth model delivers care in patients' homes, and engages them in their own healthcare. It saves travel time, stress and expense. While this delivery model wouldn't suit everyone, the patients interviewed for the article were very pleased with the programs.

In our urology practice, we're (once again) experiencing capacity challenges. The combination of an impending retirement and several urologists working half-time (I'm a guilty party!), along with changes in OR time allocation, means our patients are waiting longer for consultation appointments. As part of the Sask Surgical Initiative, our department has been given additional operating room time so we can complete surgeries for people who have been waiting a long time (many over 12 months). However, as more of us are in the OR, it means that fewer are available to see new patients in the office.

We're reviewing several aspects of our office care delivery to see how we can be more effective. We've had success previously with trying to deliver care "closer to home". We've had success previously with an alternate way of informing men about vasectomy reversal surgery. We found that men referred to us regarding vasectomy reversal weren't actually asking for the surgery, but were using the office visit as a way to get information about the procedure, its success rate, costs and complications. We developed an information package about the surgery, and when we received a referral, we send the man and his referring physician that package. We invite the man to arrange an appointment with us if he has any further questions, or if he is convinced that he wants the surgery. In the trial period, 2 out of 22 men arranged appointments. The other 20 men were saved a trip to our office.

We want to identify other situations that can be managed in a similar way. It may involve information sent to patients, or to family physicians to support them delivering care in their own practice. This week, two of us reviewed several weeks of office visits to identify common reasons for urologic referral that we think could be managed by the primary care practitioner, for example, uncomplicated bladder infections, scrotal cysts, and enlarged prostates. We've identified a few likely conditions and will develop information packages regarding investigation and management. Importantly, we plan to discuss these packages with referring physicians to see what information is helpful for them, and to identify any other issues around the referral (e.g. patient "demands" specialist opinion, no local facilities for testing).

We hope to identify situations where the patient's needs can be met closer to home, by the provider with whom they already have a relationship.

Better care for patients with back and neck pain - an appropriateness success story. With a Saskatchewan flavour.

2011-05-18T06:17:00.000-06:00

Here's a great story about the potential to improve care and reduce waste through system redesign. And, it recognizes a Saskatchewan initiative as leading the way.

The traditional approach to wait times has been to throw resources at the problem. If people are waiting too long for surgery, we open more ORs, train more nurses and recruit more surgeons. There's a superficial appeal to this method: Let's do more of what we already know how to do.

The problem is that this solution deals with the supply of services but ignores the demand. Specifically, it ignores whether or not the demand for a service is appropriate. As reported in last week's Globe and Mail, a new way of thinking about treatment of back pain takes the bold step of addressing appropriateness of care.

The problem:

Patients with severe back and neck pain wait a long time to see spine surgeons

Many patients don't need to see the surgeon in the first place. They need exercise, physiotherapy or back supports.

Millions of dollars are spent on unnecessary imaging (CT and MRI)

Quotes from Hamilton Hall, executive director of the Canadian Spine Society:

In an unscreened practice, where the surgeon sees 100 patients, no more than 10 would be surgical candidates.

As a screening tool for back pain, MRIs are worse than useless.

The solution:

Establish a multidisciplinary screening/triage program to evaluate patients

Refer to appropriate treatment without unnecessary waiting for MRIs and surgical consultations

The benefits

Quicker access to appropriate treatment

Shorter wait times to see surgeons for patients who will benefit from surgery

Fewer unnecessary MRIs

Shorter wait times for MRIs for patients who will benefit from this testing

As the Globe and Mail story points out, Saskatchewan is leading the way by training family doctors to assess which patients need referral to a back surgeon, and providing the trained physicians special access to the multidisciplinary clinic, appropriate imaging and surgical referrals.

The Globe and Mail followed up with this editorial earlier this week.

Tales from the Representative Assembly II - Appropriateness of testing

2011-05-09T23:40:00.000-06:00

A story in today's Star-Phoenix about possible overuse of CT scans in kids reminded me of some more discussion from the weekend's RA.

One doc spoke about his frustration in not being allowed to order certain tests for his patients, specifically CT scans. In some health regions, only "specialists" can order CTs and MRIs. Rationale: reduce overuse/misuse. Side effect: delayed diagnosis for patients. He felt that he had been practicing for long enough that his clinical judgement should be trusted.

The next doc to speak told the RA that it was nearly impossible for him not to order certain tests or treatments because patients demanded them. He gave the example of PSA for prostate cancer screening in men aged 80 and over, multiple repeats of cholesterol testing, and antibiotics for viral infections - all of questionable value. If he didn't order the test, then they would be angry at him, and just see another doctor to get them done.

The juxtaposition of these views was puzzling. On one hand, docs are feeling powerless to refuse requests from patients, even though their clinical judgement tells them the testing is not helpful. On the other hand, docs are making a case for broader privileges to order more expensive, possibly risky tests.

I think these are different sides of the same clinical problem: appropriateness. Tests and interventions may be underused (insufficient use of a test that has been proven to be beneficial, like cervical cancer screening), but most inappropriate use falls into the category of overuse (like the CT scans in the SP article). The restrictions to ordering CT scans that the first doc complained about are in place to reduce inappropriate testing. Even with long years of experience behind him, I doubt that even the most clever doc would consider himself up-to-date on the indications for CT scanning in all subspecialties. And, given the second docs comments about the pressure felt to acquiesce to patient requests for testing, we can expect that opening the CT floodgates would, in fact, bring a flood.

So, how can we assure appropriate testing, based on best practice, yet allow timely access for patients?

We can't all be experts, but we can have access to expert opinions. But, rather than having family docs call up specialists to get "clearance" to order certain tests, there are clinical decision tools. The Ottawa Ankle Rules are an example of validated guidelines that reduce unnecessary testing without negatively affecting outcomes. Similar guidelines could be developed for situations that commonly lead the primary care physician to consider whether a CT scan is indicated. If the guidelines/clinical decision tools were agreed upon by GPs, relevant specialists and radiologists, then patients could get the appropriate study done promptly without the wait and expense of seeing a specialist first.

Would docs feel it was an insult to their clinical acumen if they had to use a clinical decision tool? No, they would understand the importance of appropriate decision-making for the benefit of their patient, and would not let misguided professional pride get in the way. A well-crafted set of guidelines could also be a valuable educational tool for the second doc who was frustrated with patient "demands" for testing. While he may feel he doesn't have enough time to give a thorough explanation of why he recommends against certain testing, he could send the patient home with the guidelines and ask them to reconsider after studying the expert opinions.

Tales from the Representative Assembly

2011-05-08T22:50:00.000-06:00

I haven't regularly attended the SMA's biannual Representative Assembly (RA). But, after attending yesterday's session, I'm going to make an effort to attend in the future. What a fantastic and frank exchange of ideas!

Canadian Medical Association Past President, Anne Doig, asked the physicians present to think about whether the healthcare system was giving good value for money, and what responsibility physicians and patients had toward the system. Several of my colleagues told about abuse of emergency services with patients arriving at 2 am with trivial problems that could have waited until the morning. The phrase that characterized these patients was "demanding".

Even though I think "demanding patients" is an unfortunate choice of words, I was glad to see that this was a forum where doctors felt able to express strong feelings about how the healthcare system is not working. It's tempting to tut-tut these docs and conclude that "they just don't get it". That would be a mistake.

My colleagues are expressing their frustration with the poor functioning of the healthcare system. However, rather than seeing it as a system problem, they've framed it as a behaviour problem with patients. There may be many reasons why someone turns up in the ER with a seemingly trivial medical problem in the middle of the night. Perhaps they tried to see the doctor during working hours, but appointment wait times are 2 weeks. They may have phoned the ER for advice on how to manage their earache and been told that the nurse couldn't give out advice over the phone. Whatever the reason may be, I think it's safe to conclude that no one wants to be in the ER at 2 am, so their presence could indicate an unmet need.

I sympathize with my family practice colleagues, however. I have the luxury of having my 2 am ER calls come from the ER doc, who has already assessed and treated the patient, and now is calling for specialist consultation. The rural family docs, in particular, face regular sleep disruptions which must be maddening.

In private discussion, several docs assured me that in fact there do exist truly demanding patients who aren't satisfied by the best efforts to provide timely and appropriate care. I don't doubt it. But, I think that, however we define inappropriately demanding patients, they make up a very small part of the larger group of people who are being tarred with the same brush. It seems to me to be too easy to label someone as being inappropriately demanding rather than exploring what their needs truly are, and how we have failed to meet them.

I can't be angry at either the patient who "demands" care at 2 am, or the physician who considers this behaviour inappropriate. Rather, I'm upset at the system that pits physician and patient against each other. It's a dysfunctional system that:

- doesn't offer timely clinic appointments to deal with minor problems at convenient hours

- doesn't allow non-physician care-givers to work at top of licence, and provide advice and care independently

- doesn't reward or encourage efforts to educate patients on self-management of common conditions

What can we do? Philosophically, we can try to convince docs that the problem is with the system, and not with patient behaviour. We could explain that the healthcare system's purpose is to provide appropriate care, where and when the patient needs it.

We could try that, but I think it would be cold comfort for the doc who's wakened from a sound sleep. Instead, measure the problem and, in doing so, identify the barriers that the system has thrown in our path. Rural ERs could survey patients arriving after midnight to find out their perceived problem, its duration and whether they had tried to access any other sources of care. Ask these questions with genuine interest in improving care delivery. Don't judge or disapprove. Aggregate data from several (all!) rural hospitals so as to get the big picture more quickly. Once the barriers to timely, appropriate care start to reveal themselves, so will potential solutions.

I welcome comments from my GP colleagues who struggle with this issue every night they are on call.

"Medical Justice" makes no sense on so many levels

2011-05-05T20:52:00.000-06:00

Hi, I'm Dr. Visvanathan. Please come into my office. Before I provide you with high-quality, compassionate care, I'd like you to sign this agreement that you won't bad-mouth me publicly.

According to the American company, Medical Justice, this is how all my patient visits should start.

This story is a jaw-dropper. Medical Justice markets itself as protector of physicians' reputations. The problem, they say, is that anyone can anonymously blacken a physician's reputation via the internet, particularly on doctor rating sites (such as RateMDs). The physician has limited recourse. Medical Justice's solution is to have all a physician's patients sign an agreement that allows the physician to remove from the internet any unwanted comments the patient may post.

Doctor rating sites - and their use and misuse - aren't a new story. Back when (now defunct) Plain Brown Wrapper was the international sensation everyone was talking about, I posted about an experiment I tried using RateMD, one of the doctor rating services. Rather than try to shut down patient comments, I left a message on my rating page inviting comments, but challenging people to leave constructively critical comments.

My post on the site said: "Hi, it's Kishore Visvanathan here. Thanks for leaving a comment on RateMD. I'd like to use your comments as a way to improve the service I give. If you have any concerns about the care I provided to you, please make a constructive comment about how I can improve."

Actually, I'm paraphrasing, because when I visited the site for the first time in a long time (prompted by writing this post), I found that my invitation for constructive criticism had been removed. Interesting... I wonder if they are concerned that doctors might subvert the original purpose of RateMDs, and actually turn it into a way that doctors and patients could have a dialogue about improving quality?

Other doctors have different approaches to RateMDs. As do some medical students.

I digress.

If Medical Justice wants docs to worry about anonymous comment posting, how will "asking" patients to sign their agreement help. Anonymous posting is... difficult to track. I presume they're willing to make the effort to force website managers to cough up the names of the offending posters.

Most importantly, if a doctor is so worried about his/her reputation, why not earn that reputation through consistent efforts to improve service? Sure, there will always be people who have an unhappy experience and want to gripe publicly about it. I doubt that they would be thwarted by the Medical Justice gag agreement.

Medical Justice's legal circling-the-wagons drives a wedge between physician and patient. We should invite feedback from our patients. Some comments may be personal and painful to hear. Those are the ones to pay close attention to.

Focusing on patient needs in the OR

2011-05-05T06:17:00.000-06:00

I had a great conversation with a group of OR nurses last week. We were talking about "multitasking" in the OR, and how we wanted to make sure our attention was on our patient during critical times. It's not always as simple as just saying "Let's pay attention". There are a lot of subtle factors at play.

Some interesting suggestions and comments came out of the discussion:

Agree on a “safe” word/phrase that anyone could use to remind everyone in the room to focus on the task at hand. One suggestion was “focus”. The word would have to be non-judgmental and non-threatening.

Perhaps part of the surgical checklist could be stating a commitment/reminder that everyone in the room would be attentive to the patient’s needs.

Concern that some people may take such reminders personally and be upset with the other person. This subtly intimidates people into keeping their concerns to themselves.

There is a mix of people in the room including nurses, surgeons, anaesthetists, residents, students and there are often lots of conversations going on. Who can judge which conversations are important for patient care and which ones could wait until later?

Maybe we should set aside “critical times” like takeoff and landing a plane where conversations are only about the task at hand, ie safe patient care

Staff noted that patients may overhear “inappropriate” conversations while they are awake and it may be upsetting to them. Even though their surgical outcome may be good, they may be left with an overall bad impression of their care.

We didn't solve anything that morning, but I was encouraged to hear the level of interest in pursing this opportunity to improve patient care. Next step: gather suggestions from the entire OR staff. Maybe an invitation to discuss this at a weekly inservice meeting? Hint, hint.

Don't ask people if they're satisfied with the status quo until you've shown them what's possible

2011-05-02T06:28:00.000-06:00

As I walked by my son's room, I heard a familiar song playing on his radio.

"Hey", I said, "That's a classic!. Alone, by Heart, right?"

"Who's Heart," he asked. "Anyway, this isn't them."

As I listened to the song, I realized it was a remake of the Heart tune. A passable remake, workmanlike, but missing the beautiful original arrangement and powerful vocals. I told him so.

"Well, I think this is a good version," he replied.

I whipped out my iPod and cued up the original version.

"Oh, yeah," he said, seeing the light (circa 1987). "That is better!"

So, how do you know how good something can be if you've never experienced it?

Provincial patient surveys show a high rate of satisfaction with healthcare. A survey late last year, showed that half of Saskatchewan residents surveyed rated their healthcare as good - the highest rating in the country.

But, "good" compared to what? How many people surveyed know what's actually possible?

What would the results be if we showed people how their care could be delivered, such as using the US Veterans' Administration comprehensive electronic medical record? Or Jonkoping's streamlining of patient flow through consideration of the needs of their prototype patient, Esther? Or Alberta's systems innovations in providing joint replacement surgery?

Here's an interesting experiment: Educate one group of people about healthcare's best practices around the world. Leave another group uninformed. Then give them the healthcare satisfaction survey.

Fee-for-service is the wrong way to keep score

2011-04-28T23:15:00.003-06:00

In today’s Globe and Mail, André Picard points out the foibles of Canada’s (mainly) fee-for-service (FFS) physician payment system. Good points, but nothing new:

FFS is open-ended

FFS doesn’t value efficiency or cost-effectiveness

FFS creates an incentive for over-consumption/production

Alternatives to FFS carry their own baggage. Capitation systems pay physicians a lump sum to provide all care for a group of patients. That removes the incentive to over-treat, but there may still be gaming of the system. Physicians may “skim the cream” by enrolling only healthy patients in their practice. Same money, less work. There’s also a temptation to offload patients with complicated/time-consuming conditions to specialists.

Pay-for-performance models compensate physicians when their patients achieve certain outcomes, often using surrogate measures like rates of screening mammographies or hemoglobin A1c. There has to be reliable data collection in place, in addition to a way to disentangle the involvement of multiple care-givers. Also, doctors may give attention to conditions whose outcomes are measured, while neglecting other problems.

Picard concludes:

There is no magic bullet waiting to be grasped, no single alternative payment scheme that will rein in health care costs.

But there is a need to have the discussion, to experiment, to find a model that remunerates doctors fairly yet allows cost controls and improves delivery of health care to patients.

Very polite. How about something a little more pointed…

In The Best Practice, Charles Kenney quotes George Halvorson, CEO of Kaiser Permanente, lamenting “a fundamental flaw in American health care: improperly aligned financial incentives.”:

“As a pure business model, health care is winning,” he says. “Health care is taking all…your money and is doing it without having to be particularly accountable in how the money’s spent. Based on that, health care will never, ever reform itself. The model is too lucrative.”

“There are no billing codes for cures. There are no billing codes for outcomes. There are no billing codes for care improvement.”

“Providers,” he adds, “don’t do what they’re not paid to do.”

Of course, he’s talking about American medicine – things are different in Canada, right?

If we were to take André Picard up on his challenge to “experiment”, what would that experiment look like? Maybe I’m mentally constrained by the fact that my income would be at stake in such an experiment, but I think the government/payor should be prepared to take the big risk first.

If there is a trial of pay-for-performance, provincial medicare should totally abandon tracking volumes of service. For most of the “alternate funding plans” (read: salaries, but don’t say it out loud because it spooks the docs) that I’m aware of, the physicians are obliged to “shadow bill”, that is, they continue to track their service volumes. They have to do this because the health ministry thinks they will slack off if they are on salary. And, truth be told, they might do just that.

Which is exactly what we want!

FFS fosters over-service. Over-service means inappropriate care and fruitless cost. Taking away the incentive for over-service is exactly the reason for an alternate funding plan. So, get rid of shadow billing.

But, how can we make sure the docs aren’t golfing all day? Actually, golfing half the day would be fine, as long as the other half is spent providing appropriate, high-quality, timely, patient-centred care. Measure it. Report it.

Celebrate the fact that doctors are working less, as long as they are producing the results we want. And, for goodness sake, keep paying them the same. It's a bargain. Docs who are over-servicing generate tremendous downstream costs - CT scans, inappropriate surgery, unnecessary prescriptions. Appropriate, high-quality care will be cheaper.

Perhaps we’re doing doctors a disservice by making money the sole outcome measure for their work. If doctors seem to always have their eye on the dollar sign, maybe it’s because it’s the only target we’re giving them.

Who has the nerve to rewrite the rules of this game?

50ish man, loves long walks on the beach, and Quality Improvement

2011-04-27T22:40:00.000-06:00

Last week, someone asked me what was new and exciting in urology.

I dread that question.

Usually, I have to rack my brain for some new technique or piece of equipment that will wow the person. Surgical lasers are a good bet, but new technology isn't as riveting to civilians as it is to surgeons.

But this time, I blurted out "Doing things better in the OR". And I realized that I really am excited about quality improvement - even more so than getting a new laser. And the best part was that he was excited to hear about quality improvement as well.

We talked about the surgical checklist and about the ways the Saskatchewan Surgical Initiative aims to improve care. He was genuinely interested. I think it was because he could see the impact QI could have on him and his family and friends. While a new surgical technique or instrument may help a limited number of people, system changes affect everyone.

Before this conversation, I avoided talking about QI in healthcare because, frankly, it sounds a little nerdy. Now, I think it may turn into my go-to ice-breaker.

Don't hide your passion!

Inspire! hits it out of the park!

2011-04-24T22:30:00.001-06:00

Saskatchewan’s Inspire! Healthcare Quality Summit (April 20-21) in Regina was amazing! About 650 people visited poster displays, attended workshops, heard “Saskatchewan stories”, and participated in a CEO/leadership roundtable discussion.

The highlights for me were the keynote addresses from Maureen Bisognano, John Toussaint and Richard Shannon. Each brought their own perspective to healthcare quality improvement and patient safety, but they all have a common attribute: They tell a compelling story. Their presentations revolve around the experience(s) of actual patients. They introduced us to these people, and told us about their lives and how they had been affected by defects in healthcare. That was the springboard to presenting systemic data and solutions, and then return to the individual patient’s story to remind us all of why we were there: Improving care for each patient. Memorable!

Many people describe themselves as being passionate about a cause; Richard Shannon wears his passion on his sleeve. He is on a crusade against hospital-acquired infection. You can read about his story in the excellent book, The Best Practice, but if you have a chance to listen to him in person, take it.

A welcome surprise was Premier Brad Wall visiting the summit and expressing his appreciation for the quality improvement work being done in Saskatchewan healthcare. It was very gratifying.

There are already plans for a 2012 Inspire! event in Saskatoon. I think we can make it even better than 2011.

I would like to hear more patient voices. Perhaps each day could start with a short presentation from a patient, or their family, highlighting the impact (whether positive or not) healthcare has had on their lives. There were excellent poster presentations from healthcare workers, highlighting various quality improvement and patient safety initiatives. Maybe there is a way to invite patients and families to create posters about their experiences, both telling their story and making suggestions for improvement. There could be workshops specifically for patients: story-telling, advocating for your own care, community involvement and political advocacy.

Front-line caregivers should be more involved. It may be difficult to take a lot of staff away from clinical responsibilities, and there will be limitations on physical space at the venue, but perhaps the keynote sessions could be broadcast around the province, or recorded and made available to staff.

Inspire! has started off on such a high note, it’s exciting to imagine where we can take this event next year.

Poll results are in! Minority victory declared.

2011-04-22T07:50:00.000-06:00

Thanks for voting in the Dark Side poll. Here are the totally unscientific results:

Be perkier and cheerier: 12%
Keep the same tone: 56%
Dig deeper and get darker: 30%

(39 respondents)

These questions weren't validated with a test audience, so they may have been ambiguously worded. For example, the "Dig deeper and get darker" people may be encouraging me to work in my garden and get a tan this summer. Who knows?

While the majority think that status quo is good, I'm intrigued that 30% want to see more depth in my writing. I'm going to declare a minority victory. What was the point of a poll if you're not going to abide by the results? Well, this is a blog and not a constitutional democracy.

I'm going to interpret "digging deeper" as meaning plumbing internal depths rather than more intensive reportage. I'll try to be more thoughtful my own feelings and behaviour around my work and healthcare in general.

Thanks again for taking part.

97% fail - redux

2011-04-19T00:02:00.000-06:00

"Bohica" throws down the gauntlet with a passionate comment about 97% is not a passing mark! She's from Saskatchewan and now lives in the US. She'd like to retire in Sask., but is worried about access to medical care. She describes specialist availability where she lives like this: I get an apology if I wait longer than a week.

Enviable. But, she also has suggestions on how to achieve this. Essentially, we need to get rid of all the triage steps in the referral process. As she says:

Remove First Referral Letter, which can be sent while waiting for your first appointment (appointment having already been made).

Remove Referral by Triage

Remove Letter reviewed by oncologist (he will have the letter by the time your appointment rolls around).
Your GP gets your results and calls the triage clerk and says, "I have this person with prostate cancer/symptoms of prostate cancer. When can I get him in?

Great idea. Make the appointment first, then fill in the details later. I like it, probably because it's very much what our clinic already tries to do.

If all consultants were to implement this process, there's one element essential for its success: Trust. I need to trust that the referring doctor is going to send all the necessary information if I "give up" one of my time slots. It's not quite as selfish as it sounds.

Occasionally, a referred patient may not actually have a urology problem. For example, I will sometimes have patients referred to me with a hernia or kidney failure. When I receive such a referral, I'll let the referring doctor know which specialist would be more suitable for their patient's needs. It would have been a waste of time for that patient to see me. (FYI: I would still get paid for the visit.)

Sometimes, a referred patient may have a problem that could be dealt with by the referring doc, with advice from the urologist. In this case, a reply letter obviates a consultation visit.

Most of the time, I want to know about the patient's situation ahead of time so that I can coordinate necessary testing with the consultation appointment. This saves the patient travel time and expense, and let's me provide "one-stop-shop" service.

Although it feels uncomfortable to put it this way, specialists are reluctant to give referring docs (or rather, patients) free access to our available time, because we don't trust that the patient has a problem that needs our attention, or that appropriate investigations will be done prior to our consultation.

We can build that trust through better communication. Our best example of this is our streamlined hematuria referral process. We provide family doctors with a template of tests that we ask to be completed when they refer someone with blood in the urine. If these tests are done in advance of the consultation (and if the doctor has our hematuria template, they usually are done), then we can consolidate the visit and necessary testing into one visit.

In 97% is not a passing mark, I mentioned that one of the few doctors I, as a specialist, refer patients to is an oncologist. Even though my referral letters are (I think) quite complete, they still have to go through the triage process, which delays the patient's visit. This means that the oncologist doesn't trust me.

I'm very pleased to see the wait time targets mentioned by Colum Smith in today's Star-Phoenix.

(Saskatchewan Cancer Agency) has set aggressive goals for patient care during the next five years — including that every patient be contacted within 24 hours of referral and that 90 per cent of them be seen within one week after referral, said Dr. Colum Smith, vice-president of medical affairs for the cancer agency

Developing trust between referring physicians and consultants will surely play a big role in reaching that goal.

Great design in the strangest places

2011-04-16T16:06:00.000-06:00

For the 50% of you who have not had the pleasure, let me explain what a urinal is. A urinal is a porcelain bathroom fixture that marks the location of a pool of urine on the floor.

I wish I were joking.

Urinal designers have done their best to encourage "accuracy". Urinals are almost wrap-around in their design, but still... Don't wear your good shoes. Something is missing. (Ha! Good one.)

I came across an interesting innovation while I was in Amsterdam earlier this month. I'd heard of this concept before, but had never seen it. This urinal was in the convention centre:

And in close-up:

The image is a little blurry (one doesn't linger over composing the shot when holding a cellphone over the urinal in a public washroom. FYI.), so I'll point out that it's a fly on the side of the urinal. Or rather, it's a sticker with a picture of a fly, stuck on the bottom of the urinal. (The protruding, and somewhat off-putting, shadow near the bottom is from the flush handle. Don't let your imagination run away with you.)

This urinal was in a restaurant:

A picture of a candle! Nice.

These elegant (!) examples of innovative design are supposed to encourage the user to be more accurate. I didn't actually collect data on this, as I thought I had already pushed my luck enough by taking photos in the washroom. However, according to this article (read down to the end), Amsterdam's Schiphol airport noted 80% less spillage after implementing the urinal targets.

Good design can be delightfully simple (recent examples here and here).

Now if only someone could design a way to stop guys from talking on their cellphones while using the urinal.

I wish I were joking.

Have I gone over the the Dark Side? Cast your vote!

2011-04-13T23:54:00.002-06:00

Can anyone lend me one of those donut-shaped pillows to sit on?

'Cause I just got spanked!

Check out Dale's comments about a recent post regarding CIHI's reporting on wait times. As you see from my response, I stand by my opinion, but something else he said - "Swing back to the positives you used to write..." - got me thinking.

The content and tone of this blog has evolved over 4 years. Longtime readers know that I started with straightforward reporting of our Advanced Access/Clinical Practice Redesign work. It was pretty peppy stuff. We were able to accomplish a lot and make some significant improvements in our urology practice.

Then, as we realized that factors outside our practice limited what we could change, I started to become interested in the broader healthcare system. I remain committed to working for quality improvement and want to be a positive influence, but every day, I see many examples of how the system fails patients and wastes resources.

I write this blog for a few reasons. First, writing helps me clarify my thoughts on a subject. I may start with a vague notion in my mind, and the discipline of writing about it helps organize my thoughts. Many a post has been started, then discarded when a seemingly blinding insight evaporated.

I also want to spark discussion. It's really satisfying to me when someone tells me they read something here and talked with a friend or coworker about it. A controversial topic is more likely to be discussed.

Finally, I want to challenge myself to be open with my thoughts and feelings. While I am truly encouraged to see the efforts and successes of others working to improve healthcare quality, I wouldn't be honest to myself if I were just cheerleading in this blog. There's so much to be done, and the pace of change is frustrating.

But, let's see what you think. Maybe you feel I should go back to the good old days of rah-rah. Or maybe you prefer my "Blue Period". Take the poll at the top of the right-hand column.

Oh, about that pillow...

Multi-tasking one more time: This time it's evidence-based!

2011-04-10T20:13:00.002-06:00

Serendipity strikes!

I'm just back from a fantastic week at the International Forum on Quality and Safety in Healthcare in Amsterdam. (By the way, if as the first assignment of a new job, your boss flies you to Europe, take that job!) In addition to all the terrific presentations and discussion around quality improvement and patient safety, a major topic of conversation was the popularity of bike-riding in the Netherlands. Aside from the novelty of seeing people cycling to work in suits and lugging briefcases, many of us commented on the prevalence of people using their cell phones while biking. It looked like pretty unsafe multi-tasking!

Which reminded me of my recent experience of averted multi-tasking in the OR.

Which had led to comments on an advisory from the British Columbia College of Physicians and Surgeons on the same topic.

And then, while I was catching up on one of my favorite podcasts - CBC's Spark - I found a discussion of multitasking while bike-riding, followed by a review of research on multi-tasking. By a Stanford professor, no less! Check out the podcast here (the first 15 minutes are about multi-tasking), but here's the spoiler: "Multi-tasking" is rapid-transition distraction. Stop it.

(Unabashed gushing: I love the Spark podcast. It's about technology, but as they describe themselves "It’s not just technology for gearheads, it’s about the way technology affects our lives, and the world around us." You can subscribe here.

OR chatter: Let your patient be your guide

2011-04-09T13:10:00.000-06:00

In follow-up to a recent post about paying attention in the OR, Greg Basky posted a comment about an incident in B.C. A patient was concerned that intraoperative hockey chatter would distract the surgeon from the operation, done under local anaesthetic. A couple of things struck me about this story.

First, this type of chatter goes on all the time. I usually talk with men while I'm performing their vasectomy and they often comment that it helps them relax and distracts them from what's going on. For a routine procedure, it doesn't distract me. If I need to focus more on the procedure, I'll stop talking. There's only the two of us in the room, so I wouldn't be having a conversation with a third person.

But, this is utterly beside the point. It doesn't matter that I can chat without being distracted. What matters is how the patient feels about the conversation.

I engage in the conversation just enough to get the man talking about something he's interested in: family, work - even hockey... It's a deliberate technique to make him more relaxed. (I've heard people suggest that, when driving a car, you're less distracted by a conversation with a passenger than you would be by talking to someone on your cellphone, even with hands-free. I'm not sure why, but I think it's a similar situation if the surgeon is having a conversation with the patient vs. a third party.)

However, some men prefer that we not chat, and instead want to use their own method of relaxation. That's fine with me.

Surgeons and OR staff may scoff at the idea that they could be distracted by mere conversation. I disagree with that, but would let that point stand in the absence of evidence to the contrary. However, we can't ignore the effect it has on patients and their perception of care. The case reported to the B.C. College of Physicians and Surgeons is undoubtably the tip of the iceberg.

As I mentioned in the previous post, I think that casual chatter in the OR can be relaxing during a long case. It has its place. But, when patients are awake during procedures, we need to be aware - to the point of hyper-sensitivity - of their needs and perceptions. (Note to the OR staff in my room: That's the reason why, when we're operating on someone using spinal anaesthetic, you might think the cat's got my tongue. I prefer not to chat unless it's related to the operation we're doing or about to do. You may think I'm giving you the silent treatment because I'm upset about something. I'm not (usually). I guess I could have explained that to you previously. Like 20 years ago.)

The second thing that struck me was the content of different articles on this story. Take a look at the National Post and the Leader-Post versions. The Leader-Post (and Calgary Herald and Vancouver Sun) versions included Registrar Heidi Oetter's comments that our behaviour in the OR should be patient-centred, whether related to conversations or choice of music. I would be interested to know why the National Post editors chose to strike those comments in their version. Those comments are the soul of this issue.

I'm catching the Saskatchewan wave!

2011-04-03T10:15:00.000-06:00

What's new with you? How about me? Oh, not much... Just a NEW JOB!

As of this month, and for the next year, I'm going to spend half my time doing my usual clinical work in urology, and dedicate the other half to working with Saskatchewan's Health Quality Council (HQC). HQC has contracted with me to develop a physician quality improvement fellowship program, support HQC's Clinical Practice Redesign (CPR™) work and, I suppose, be general clinician-about-town.

It's an incredible opportunity for me. I'm excited about it, yet anxious at the same time.

I'm excited because it's a chance to have dedicated time to work on a large-scale quality improvement (QI) effort. I've enjoyed working "informally" with HQC for over 4 years. Our office's Advanced Access/CPR™work has benefitted hugely from HQC's support. But, even with the generous donation of time (mine and theirs) from my partners, it's still work that's done off the side of my desk. Clinical responsibilities always trump quality improvement work. (If that last sentence made you cringe, then join the club!)

I'm excited because HQC does an amazing job of promoting QI work in Saskatchewan, and I know that they're never satisfied with the pace with which QI is moving. They are steeped in QI and measurement and I look forward to learning from all the enthusiastic staff.

I'm excited because creating a physician QI fellowship has the potential to expand QI expertise and leadership widely in Saskatchewan.

I'm excited because this is the first major professional upheaval I've had in 20 years of practice.

And, I'm anxious because this is the first major professional upheaval I've had in 20 years of practice.

For 2 decades, I've been the boss and the expert. In my office, the hospital and the OR, I usually have the final say. Technically, I am accountable to my patients, colleagues, regulatory groups, health region, and the government insurance board, but no one has ever explicitly told me what they want me to do, nor what the specific deliverables of my job are. In my HQC consulting work, there will be explicit expectations and timelines. My work will be scrutinized on a peer-to-peer basis. I am utterly unaccustomed to this degree of transparency.

I'll be learning on the job. I have no experience in developing training programs. I feel uneasy about it already. In my regular work, I like the fact that I have previously come across most clinical conditions and don't have to struggle with a management plan. After 20 years, urology is comfortable.

And that's what motivated me to take this leap. I felt comfortable.

I've heard it said that it takes 10-15 years for surgeons to develop their practice to the point where they feel comfortable. Even though there is always ongoing professional development - learning new techniques and treatments, and abandoning outdated ones - the ride does get smoother after that many years. Why not just enjoy the ride until retirement?

I'm taking this job partly because I see so much that we can do better for our patients (ourselves!). There is so much untapped energy and potential in clinicians. We all want to do a great job, but don't have the time or tools we need to make improvement changes. I have felt the great satisfaction that comes with making clinical improvements, and I'd like to share that with colleagues.

I'm taking this job partly because of the example set by my senior partners. The two of them - one retired, one on the cusp of retirement - have been deeply involved in medical politics and quality improvement all through their careers. They recognized that their responsibility and influence extended beyond the one-to-one patient encounter of clinical practice.

I'm taking this job partly because of the incredible support of my other partners. When I proposed switching to half-time clinical practice, we all knew that it would be a significant burden for them. Their response? Unanimous and without hesitation (well, that they let show to me, anyway!): Do it! Thank you all.

But, mostly, I'm taking this job because there's something palpable happening in Saskatchewan healthcare. The government is supporting the Sask Surgical Initiative. Specialty practices are starting to explore pooled referrals and other aspects of CPR™. Health policy makers regularly refer to the Patient First review as a basis for decision making. Momentum is building.

I want to paddle out and catch this wave.

Wish me luck!

Where's my real-time data?

2011-03-31T23:51:00.000-06:00

"Your exit - 10 miles back"

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

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

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

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

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

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

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

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

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

2011-03-29T20:41:00.000-06:00

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

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

For example:

Communication needs (language barrier, impaired hearing)

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

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

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

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

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

Multitasking in the OR? We're fooling ourselves!

2011-03-27T22:16:00.000-06:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Solution to dumping unwanted medical records: drop-off boxes

2011-03-24T19:47:00.000-06:00

Saskatchewan made the national news!

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

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

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

Baby drop-off programs.

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

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

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

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

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

P.S. Electronic medical records, anyone?

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

2011-03-23T21:16:00.000-06:00

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

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

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

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

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

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

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

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

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

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

Referral letter generated and sent to Cancer Clinic

Letter reviewed by triage clerk

Letter reviewed by Radiation Oncologist

Appointment date assigned

Consultation with Radiation Oncologist

Further testing (possibly)

Patient decision to proceed with treatment

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

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

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

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

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

97% = Fail.

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

2011-03-22T22:40:00.000-06:00

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

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

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

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

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

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

Reason for referral/clinical question to be answered

History of present problem including treatments tried and the outcome

Past medical history

Medications

Allergies

Test results (lab and xray)

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

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

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

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

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

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

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

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

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

Specialists can do better too.

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

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

Perfect is the enemy of good.

A crisis of healthcare access in Wakaw, Saskatchewan

2011-03-20T21:33:00.003-06:00

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

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

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

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

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

Wakaw mayor, Ed Kidd, responds:

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

With respect to Mr. Kidd, times have changed.

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

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

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

But, is that the right question to be asking?

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

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

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

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

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

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

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

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

Good process design - We all do it every day

2011-03-19T08:53:00.008-06:00

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

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

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

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

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

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

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

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

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

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

2011-03-16T22:22:00.004-06:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Safety is in the eye of the beholder

2011-03-15T20:18:00.008-06:00

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

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

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

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

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

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

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

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

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

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

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

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

Good design makes it easy to do the right thing

2011-03-14T20:09:00.007-06:00

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

- (attributed to) Don Berwick

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

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

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

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

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

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

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

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

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

Prevention = Simplicity

2011-03-14T06:28:00.003-06:00

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

- World Health Organization

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

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

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

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

We need a marketing campaign for healthy living.

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

2011-03-13T13:06:00.003-06:00

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

Points of note:

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

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

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

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

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

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

2011-03-13T08:10:00.006-06:00

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

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

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

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

EMR = PFCC. Spread the word, Anonymous.

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

2011-03-12T00:05:00.003-06:00

I am FURIOUS!

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

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

The disease is tobacco addiction.

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

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

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

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

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

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

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

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

Stop thinking about tobacco abuse as a personal choice to use a legal product. Tobacco is legal only if your government allows it to be. If you doubt that tobacco use is an addiction, visit my hospital in January when patients smoke outside, shivering in cotton gowns in -30C weather.
Warnings on cigarette packs and public smoking restrictions are not enough.
Choke this problem at its source: Make tobacco illegal in Canada. Wait a year before implementing the law. During that year, lavish free smoking cessation products and support on smokers.
There’s a long list of problems with this plan. We look to you – our leaders – to solve those problems.
Tobacco companies will fight you, literally for their survival. So what? They poison our neighbors. They profit on the back of your healthcare budget.
Save lives. Lead the world.

Put me out of a job. Please.

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

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

2011-03-09T21:38:00.002-06:00

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

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

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

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

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

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

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

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

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

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

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

Clear the path. Unleash the potential.

Simplicity is its own reward

2011-03-05T17:05:00.003-06:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And simpler for everyone.

Listening to my FP colleagues - Part 2

2011-02-17T23:09:00.002-06:00

Last month, I heard from family practitioners (FP) from across Canada about what they thought was lacking in the FP-specialist referral process. Last week, I had another opportunity to learn what’s on the minds of my FP colleagues.

As part of the Sask Surgical Initiative (SkSI), care pathways are being created for conditions like back pain or hip problems. I’m participating in developing a prostate cancer pathway. Our working group has mapped out the current state in the province, that is what path men currently follow when diagnosed and treated for prostate cancer. Now we want to explore changes that could make the journey quicker, smoother and more effective, or as SkSI puts it “Sooner, safer, smarter”.

An important part of the working group’s next step is broad representation of interested parties, and FPs play a central role in the process. They do the initial testing that raises suspicion that a man may have prostate cancer. They make the referral to a specialist. They provide education, support and ongoing care as a man has treatment. They are often responsible for long-term follow-up after the man’s treatment.

We need the perspective of an FP on our working group, so I met with the executive council of Saskatchewan’s section of family practice to ask for their help in recruiting one of their members. While supportive of the prostate cancer pathway, they made a couple of pointed comments.

Make our work simpler. Many well-intentioned groups are developing guidelines, checklists, templates and standardized forms to help manage specific conditions. While each of these efforts makes sense in the context of that condition, when FPs are bombarded by dozens of documents, it’s bewildering. Without consistent design, the learning curve starts anew when completing each form.

Perhaps the end users of these documents (in this case, FPs) should insist that any new forms adhere to a common template. If a template is too restrictive, then a set of design principles such as font size, page layout and completion instructions could be used. As one of the FPs pointed out, “Poorly designed forms may only take me an extra 30 seconds to fill out, but that adds up over the course of a day.”

Ultimately, an electronic medical record would solve these problems by “imposing” a style template and virtually filing all documents in one location.

Compensate us appropriately. There were strong feelings about this one. Because of their central role in patient care, FPs are asked to participate on a multitude of committees, boards, and working groups. This work often happens outside of regular work hours and so interferes with family life. When the meetings occur during regular work hours, fee-for-service FPs are often asked to sacrifice practice income.

One of the FPs pointed out that when committees didn’t pay him for his attendance, they undervalued his time. He had been asked to sit for hours through deliberations that didn’t involve him, just so he could participate in discussion of a single relevant issue. He felt that if he were being reimbursed at the same hourly rate he could earn working in his office, the committee would be more careful to schedule the meetings so he was present only when truly necessary.

Others pointed out that most administrators sitting on health-related committees are salaried employees, and so don’t pay any financial penalty for the time they spend at meetings.

I’ve been relatively insulated from the financial burden imposed by participating in administrative work. The pooled revenue-sharing nature of our urology practice means that our group can support one or more individuals taking on non-clinical work that we see as important for advancing patient care. However, if I were a solo, fee-for-service practitioner, taking a day away from my practice could end up costing over $1000 in lost income, with overhead expenses continuing to mount in my absence.

The executive committee indicated they would support our effort to recruit FP representatives for our prostate cancer pathway initiative if our recruiting message included the offer of a stipend. To be fair, I think that stipend should be offered to all non-salaried participants, including specialists and community representatives.

That puts the ball squarely back into the government/SkSI’s court. What other consultants provide their expertise for free?

P.S. I received a stipend for attending the CMA meeting last month...

Improving the FP-specialist referral process

2011-02-06T19:44:00.002-06:00

Last week, I attended a joint conference of the Canadian Medical Association’s specialty and family practice (FP) representatives. This was the second year of the joint meeting and the theme was the same: How to improve the referral process between specialists and FPs.

The main task was to identify problems with the current system. There was no shortage of suggestions/complaints.

From the specialists:

Inadequate information in the referral letter (e.g. no medical history or list of medications)

No clear clinical question to be answered by the specialist

Tests results not included in the referral letter

Illegible writing

Inappropriate referral (to the wrong specialist)

No indication as the urgency of the problem

Referral initiated too late in the course of the patient’s illness

Treatment recommendations or requests for further testing not carried out (“I don’t think anyone read the consultation letter I sent back.”)

FP not willing to manage chronic conditions, even with specific recommendations in my consultation letter

And just so specialists don’t get too smug, the FPs shot back with:

Don’t know if the specialist has received my referral letter

Not clear if the specialist will contact the patient with an appointment, or whether I should do it

Don’t know how long the wait times are

Don’t know what tests the specialist wants done ahead of time

Delay in receiving consultation report

Clinical question not answered in consultation report

Not clear who is responsible for providing ongoing care for chronic conditions

Don’t know what each specialist’s sub-specialty interests are

Some comments that came up during general discussion were interesting:

Calling the process a “referral” implies the necessity of a face-to-face visit between specialist and patient. We should consider the process a “consultation” which suggests an exchange of information between FP and specialist. This could be accomplished by phone, email or hallway conversation.

Funding mechanisms (such as fee-for-visit) limit solutions. Several practitioners who worked under alternate funding programs talked about using telehealth, phone calls and email to great advantage. This is (financially) unattractive for fee-for-visit specialists, unless their jurisdiction has fee codes covering these options.

Some of the solutions aimed to improve the content and quality of the referral letter using standardized templates and checklists. Our clinic’s microhematuria algorithm is an example of this with its request for specific testing to be completed before the urologic consultation.

I’m most encouraged by efforts that go beyond just the fine-tuning of the current process. Some people are trying to make referrals more appropriate, or even render them unnecessary.

For example, the Saskatchewan Surgical Initiative’s back pain pathway trains FPs on how to better distinguish surgical and nonsurgical candidates. Patients who are unlikely to benefit from surgery can be immediately directed to the appropriate treatment (physiotherapy, exercise) rather than languishing on a surgeon’s wait list, only to be eventually given the same advice.

A clinic in Northwest Territories is looking at common reasons for specialist referral, and then targeting FP professional development around those topics. Increased FP expertise and confidence for treating common “specialty” conditions will reduce specialist referral rates and allow patients more prompt treatment.

The patient referral process is the key interface between FPs and specialists, and as with many of the “hand-offs” in healthcare, it’s fraught with problems. After attending this conference, the two biggest problems I see are these:

There’s no feedback system to educate either FPs or specialists as to the quality of their contribution to the referral process. In the current system, a FP can send me a referral letter with inadequate clinical information, yet will get a complete consultation report in return. From his/her point of view, the referral letter got exactly the intended result, so why should they change their behaviour? As one of my partners is fond of saying, “What you permit, you promote”! Of course, it works both ways; if I don’t answer the FPs clinical question or help the patient with their problem, I will only know about it if the patient is referred back to me for further assessment. Neither of us can improve unless we’re shown – in an objective and constructive way – where we need to improve. I know that peer feedback would be a strong incentive for me to provide a better service.

An even deeper problem is lack of patient involvement in improving the referral process. The FP/specialist conference clearly focused on perceived physician needs. As healthcare workers, we often flatter ourselves that we can represent our patients’ interests in these matters. My experience in working with patient representatives on similar groups is that they bring a perspective that we lack. As such, I recognize that I can’t predict what a patient would add to the discussion. But, I’ll take a stab at it anyway:

No clear clinical question? I’ll tell you the question, because I’m the one with the problem.

Not enough medical history on the referral? Let me fill that out for you.

I’m being referred for pain in my knee. You “don’t do knees”? Well, then you better make that crystal clear right away, because I don’t want to wait 9 months to hear it.

I drove 4 hours and stayed in a hotel overnight to have a 10-minute discussion with you. Why couldn’t we do that over the phone? Because you get paid more if I turn up in person!? If I knew that ahead of time, I would have made the phone call, paid you the difference and still come out ahead.

Maybe next year we can get some input from the people who are truly affected by a dysfunctional referral process.

An informal telephone survey

2011-01-23T22:48:00.006-06:00

Other than face-to-face discussion, what is the most effective way for me to communicate with my patients? Most frequently, I use the phone, but will occasionally send patients a letter, particularly if I’m reporting test results and recommending followup. I’ve dabbled with email, but found the “secure messaging system” available to me somewhat cumbersome.

Recently, I gathered data on how I was using phone calls to reach or respond to patients. Before I share the results and some interpretations, here’s how I collected the information.

From December 16, 2010 to January 14, 2011 (excluding my holiday week of December 20-24), I recorded data on all calls with patients and family members. I used the database program, Bento, on my iPhone. Bento makes it quick and simple to set up a basic data collection template (“library” in Bento-speak). Setting up a user-friendly template requires some forethought so as to make data collection simple. You can create a new library either directly on the iPhone, or on your computer and then sync the library between computer and iPhone.

The computer-version of Bento lets you search and sort the database, or export the information to a spreadsheet.

I prefer to limit the number of choices in each data field so that I can use pull-down lists and checkboxes. If all the information can be entered/confirmed with one touch on the screen, it speeds data entry and makes for consistent responses. I was interested in a snapshot rather than a lot of detail.

I used these categories:

Date – touch on date selects today’s date as default.

Duration of call (minutes) – I used the screen keyboard to enter the number. I could also have used a pull-down list of numbers from 1 to 20.

Reason for call – Pull-down list included:

Patient initiated – results (e.g. calling for lab reports)

Patient initiated – postop problem (e.g. concerned about infection after surgery)

Patient initiated – other question

Physician initiated – results (e.g. biopsy reports)

Physician initiated – followup (e.g. recovery after surgery)

Physician initiated – other

Time of call – one touch to record the current time

Local/Out-of-town

Call unsuccessful/busy/not in

Comments (always handy to have a “miscellaneous” column in a database!)

If you spend your whole work-day in front of your computer, you could just set up this database in Excel. Because I travel between several sites at several hospitals, in addition to my office, I’m much more likely to consistently record information on a single device, and my iPhone is always at hand.

Results

Time period: 3 weeks

Number of calls: 39

Total call time: 179 minutes

Average time per call: 4.6 minutes (range 1-12 minutes)

Average call time per week: 59.7 minutes

Unsuccessful calls: 4 (10.3%) – (1,1,2 and 2 minutes respectively for these calls)

Average time per call (excluding unsuccessful calls): 4.9 minutes

Frequency distribution of successful call duration (chart below):

Local calls: 17 (43.6%)

Physician initiated: 16 (41%)

Time of day calls made (chart below):

Interpretation

My impression was that I made fewer calls than usual during the measurement period, likely because it was over the holidays. Less surgery is done during that time, so there would be fewer calls about post-op concerns. Also, it may be that patients were traveling, or busy with holiday visitors and so less likely to have time to call to discuss non-urgent concerns.

Concerns discussed in shorter calls (5 minutes or less) could probably be dealt with via email. These calls tend to be straightforward, single-question discussions. However, longer discussions are not conducive to email as there is a lot of back-and-forth with more involved discussion. Trying to conduct these discussions through email is probably not effective.

Three calls were quite lengthy (1 of 11 minutes and 2 of 12 minutes). Most of the time, I could anticipate that a call would be lengthy and so tried to make the call when I had adequate time for the discussion. However, this sometimes means that I would postpone making the call until I was going to be free for a longer period. I return many calls in the short breaks between OR cases or between seeing patients in the office. These short breaks aren’t adequate to discuss, say, a biopsy report showing cancer and the testing and treatment that will follow. These would be circumstances where scheduling time for a call (or office visit if convenient for the patient) would be helpful in reducing unsuccessful calls, and also making sure patients receive the information in a timely fashion.

In the study period, I spent about an hour per week speaking with patients on the phone. As I mentioned above, I think this was less than usual. This is one heck of a good deal for the patients’ insurance plan (AKA Sask Health) as I do not receive reimbursement for this work.

I’ve also been struck by the occasional patient’s comment that they are very pleased to be able to reach me by phone, as they didn’t think they could call directly to speak with “the doctor”. I know that many family practices insist that patients set up appointments to discuss concerns. If they didn’t have this rule, those family doctors could spend most of their day on the phone, gratis. But, if patients have been acclimatized to the idea that they can’t reach their doctor to ask questions, maybe some of them don’t even bother to make a call in the first place. If the problem were urgent, I suspect they would seek out help. But, for less-urgent problems, the questions may be going unasked. Perhaps I’m missing opportunities to provide better service/answer questions by not giving the level of accessibility that email would afford.

Check a box, Tame a Line

2010-12-05T21:24:00.003-06:00

A couple of weeks ago, I met some people who have the power to change Canadian healthcare. And, they can do it by June 2012.

There wasn’t a deputy minister among them.

They were the University of Saskatchewan College of Medicine Class of 2014. That’s right – first-year medical students! Skeptical? I think they were, too.

I had the chance to participate in the first-year students’ “Civic Professionalism and Physician Leadership” course. The course exposes students to aspects of healthcare beyond the traditional, disease-oriented clinical curriculum. I was addressing the quality improvement theme, specifically Clinical Practice Redesign.

I had planned just to tell the story of Saskatoon Urology Associates’ Advanced Access/Clinical Practice Redesign (CPR) journey. Essentially, the presentation is a distillation of this blog. The story starts with the reason why we started the project: Frustration over the wait times our patients experienced. Then, I talk about some of our most successful initiatives: pooled referrals, shaping demand/referrals, and reducing recalls.

Usually, I’m giving this presentation to a group of physicians who have recognized an access problem in their practices, as evidenced by long wait times and frustrated patients. They are already motivated to seek solutions, and the discussion centres around how to implement CPR in their practices.

However, medical students in their first few months of training are years away from the challenges of clinical practice. Their perspective is informed by their own or their family and friends’ experiences with health care, media reports, and opinions from authorities. The message they hear: Long wait times are caused by inadequate resources. The solution: More resources. More doctors. More MRI machines. More OR time.

But, our successes with CPR indicate otherwise. There are plenty of opportunities to improve access, quality and value for patients by rethinking how we use current resources. That’s the message I wanted to get across to the students.

But, after recently reading Check a box, Save a Life, I thought that my presentation might be an opportunity to do more than just tell our story. I thought that these students had the potential to drive change, rather than just bear witness to it.

Check a box, Save a Life tells the story of a international group of medical students who launched an initiative to lead implementation of surgical checklists at their respective institutions. After attending the release of the safety checklist at an IHI conference, the core group used their existing organizations and social networks to promote uptake of the checklist. Some students actually participated in, or lead, the use of the checklist in the operating room.

They were sparked by their realization that, even as medical students, they had the power to effect change that would have an immediate and significant impact on patient care. What an amazing story of leadership and activism!

That story convinced me that the U of S first-year medical school class could do the same. Actually… they could do more. While surgical safety checklists promise the more dramatic result of saved lives, implementing CPR nationally could improve access to care for many more patients, improve work-life balance for physicians, and ensure sound stewardship of our healthcare system’s resources.

Whew! That sounds pretty daunting. But once you hear what these students bring to the table, you’ll agree with me that they’re up to this challenge.

First of all, they get it. They understand CPR, and the problems it tries to address. I don’t mean that they listened to what I had to say and understood the techniques of pooling referrals and shaping demand. Certainly they understood the technical part, but that’s the easy stuff. I mean that, from the questions they asked, it was obvious that they understood the deeper issues. They wondered about how reducing specialist recall rates by returning care to family physicians would affect the FP’s workload. They asked whether there was any resistance to introducing CPR into our practice, and how we managed that. They realized that the current fee-for-service payment system was a disincentive to some CPR changes.

These questions showed me an impressive degree of analysis from people completely lacking in clinical exposure. And that’s the next thing they have going for them.

They have no exposure to medical practice. We haven’t brainwashed them yet. Their minds and eyes are open. I’ve posted before about a junior medical student who challenged me to reconsider one of my office practices. An elderly man drove 3 hours for an appointment to discuss a test result. The student asked why that discussion couldn’t have been done over the phone. A more seasoned student would likely already have been indoctrinated into our system to the extent that the visit wouldn’t have raised an eyebrow. They would already know that that’s the way we do business. But the new ones spot our foibles. (Classic: The Emperor’s New Clothes!)

Next, they have powerful social networks. They attend clinical rotations in groups of up to 5 people. That’s a great opportunity to share their impressions of what they’ve seen, and collaborate on solutions. I spend most of my day doing my work the same way I’ve done it for years, without comparing notes with colleagues on how they run their office practice. On the occasions when we do compare our practices, the results have been startling. When we measured our internal demand/recall rates, we were surprised to find the degree of variation in our practices. Once we recognized the variation, and began to explore the reasons behind it, as well as possible solutions, our recall rates dropped. Two (or five) heads are better than one.

Plus, electronic social networks expand that interaction far beyond the physical confines of the U of S. (One thousand heads are better than five!)

Finally, medical students are everywhere. Their rotations take them from the operating room to rural primary care clinics. And they’re observers. They rarely have clinical duties, so they are free to be flies on the wall. Once they understand they type of problems CPR tries to fix, they will see examples of those problems everywhere.

And, as their questions during my presentation convinced me, they will be able to create solutions to the problems they identify.

I would love to be part of this initiative, but as I’ll explain below, it’s important that I stay out of it. But, that doesn’t stop me from giving my version of how I see it developing!

Imagine this: While on their clinical rotations, students from across Canada apply the insights they have gained from CPR advisors to identify potential areas for improvements for individual clinicians. They collect their observations in an online database. Via social networks, they brainstorm solutions. The next students who spend time with that particular clinician ask to try out the solution, and then submit the results to the online community for refinement.

They would harness the curiosity, creativity and energy of hundreds of their colleagues for the benefit of thousands of patients. And for the gratitude of hundreds of clinicians whose practices would be made more efficient and effective.

A project like this, if conceived at the government or national medical association level, would take years to produce results. The Class of 2014 can produce tangible results by June 2012. Their first significant clinical rotations start in their 2nd year – the fall of 2011. By using the rest of this academic year to organize, develop a network, and recruit mentors, the students would be ready to collect data by the time their first rotations start. Small tests of change could start almost immediately.

But, if this initiative is to succeed (in whatever form it eventually takes), it must be conceived, driven and executed by students. They should struggle with recruiting participants, fret about how to engage physicians in the effort, and worry about keeping up their enthusiasm once the initial excitement of a new project dies down. They must fail, and learn from their failure. Their achievements will be even sweeter for all of their sweat.

On the surface, this project is about implementing Clinical Practice Redesign across the country. That will be the easy part. The real work in this project will be harder, but will be much more valuable for the students. The real work is in becoming leaders.

And you can’t do that in a classroom.

Come on, Class of 2014. Show us what you’ve got!

Time for a change

2010-11-08T00:26:00.001-06:00

It’s time for a change!

For over 3 years, our practice has been working on shortening patient’s wait time for consultation. We’ve learned about measuring capacity and demand, pooling referrals, shaping demand and improving capacity. While individual urologist’s 3rd next available appointment times vary considerably, our clinic’s shortest 3rd NAA is now around 20 days. This is the wait time for patients who accept the first available pooled referral.

We will work to maintain these gains and improve service for our patients. But now, we want to tackle another wait time – the wait for diagnostic testing, specifically cystoscopy. Cystoscopy – endoscopic bladder examination – is one of the most common urologic procedures. Used to diagnose conditions ranging from bladder cancer to urinary incontinence, about 350 cystoscopies are performed every month in Saskatoon.

This spring, the Saskatoon Health Region (SHR) updated sterilizing procedures for cystoscopes. Previously, we had soaked endoscopes in sterilizing chemicals between uses. This process was performed in the cystoscopy suite in 10-15 minutes, meaning that a small inventory of equipment could be rapidly turned over. In contrast, the current sterilizing procedure takes several hours to complete, and is performed by technicians in the central processing department. Because of this, we needed a larger inventory of scopes. Expensive scopes, that is.

By consolidating cystoscopies from 3 sites to 2, and by rescheduling times of cystoscopy clinics, we were able to maintain service volumes while purchasing the minimum number of new cystoscopes. Or so we thought…

Complex systems like a cystoscopy clinic are organic. They change and adapt over time. Incremental changes accumulate. And, when we impose a major realignment (even a carefully considered one), unintended consequences can result.

In the case at hand, everything looked good on paper. Overall cystoscopy capacity was the same; only locations and clinic times had changed. But, since this spring, patient wait times for cystoscopy have been getting longer. Initially, we thought it was a result of summer holidays reducing capacity. But, the lengthy waits have persisted. And so, we want to use our Advanced Access tools to tackle cystoscopy wait times.

Our team met last week to plan our approach. Having previous experience with wait times certainly helped – so much so that Donna and Delores had already collected a lot of baseline data. Our starting cystoscopy 3rd NAA is 32 days. They also looked at the number of cystoscopies performed for certain diagnoses: bladder tumor checkups, hematuria (blood in urine) and urinary retention (inability to pass urine). We see a significant variation among urologists, in the raw data they have collected. We don’t know yet what the implications of this are, or if understanding the reason for the variation will help improve the cystoscopy system.

Our initial review also showed that we’re not using all the available cystoscopy time. In the previous system, we had a fine balance between competing demands for urologists’ time. Now that schedules have changed, on some days there aren’t enough urologists to go around. Our default decision is to use all the available OR time first, even if it means leaving cystoscopy time unused. Fixing this demand-supply mismatch would be a big win.

Our EMR has the capability to track cystoscopies by diagnosis/reason for procedure. We’ll start tagging each procedure and see if this will uncover any interesting patterns.

Also, and importantly, as we’ve started this new work, we’ll stop collecting weekly data on office consultation wait times. We’ll check in on those times occasionally, to make sure we’re not losing ground. Staff time is a limited resource, and we want to use it wisely.

A new project. This is kind of exciting!

Canadian Patient Safety Week - Welcoming our second-degree guests

2010-10-24T23:57:00.002-06:00

Canadian Patient Safety Week is next week, but its theme – Ask.Listen.Talk - was on my mind a lot this week. And it made me think about a party we held last New Year’s Day.

We invited several friends over for brunch. At the last minute, one family called and said they wouldn’t be able to come. Weather conditions had prevented their visiting relatives from returning home, and they didn’t want to leave them alone. Of course, they were welcome to come to the party, so we set a few extra places at the table.

If you’ve ever been a “second-degree guest”, that is, accompanying someone who was invited by the host, you know it can be awkward. You may not know the host. You would rather suffer in silence rather than put the host out by asking for something. You don’t feel comfortable.

We recognized that our second-degree guests felt that way. All the other guests had been in our home previously and knew their way around. They felt comfortable with helping themselves to cutlery or serving themselves drinks. They made themselves at home, and we invited our new friends to do the same.

But that wasn’t enough.

If I’m visiting someone’s home for the first time, and am told to make myself at home, I won’t. Because I don’t know what “making myself at home” means in that home. Can I poke through the fridge looking for leftovers? Can I flick on the TV and watch the game? I don’t know what their micro-culture accepts, and so I will err on the side of sitting quietly on the couch.

Recognizing that our second-degree guests felt the same way, we did what any host would do, and made sure to pay extra attention to their needs. Would you like another drink? What do your kids like to eat? Like any host would, we wanted them to feel welcome and comfortable.

CPSW’s theme - “Ask.Listen.Talk.” - suggests that communication between patients/families and caregivers, and among caregivers, improves patient safety. No argument from me. But I think we need to consider how we implement Ask.Listen.Talk. in our practices.

Patients and their families are like second-degree guests visiting the healthcare system. Everything from our facilities to the language we use is unfamiliar and intimidating to them. While healthcare workers bustle about around them, visitors worry that even a wrong turn in a hallway may take them into an unauthorized area. They feel awkward.

And then, next week, we want them to “Ask.Listen.Talk.” Maybe we’ll put up some posters, or hand out a brochure. That will be the equivalent of saying “Make yourself at home!” Patients/families won’t know what is acceptable in the healthcare culture. Is it OK to ask the doctor whether or not she washed her hands before examining my mother? Will she be upset with me for asking? I don’t take a red pill at home, but I’m sure it’s OK here at the hospital, because the nurse must have checked it before she gave it to me. She looks too busy for me to bother her.

It’s nowhere near enough just to publicize our belief that communication improves patient safety. We need to actively seek out patient and family comments and participation, like we would for second-degree guests in our home. And when those comments arrive, we need to receive them positively and consistently. A sour look in response to a voiced concern speaks much more loudly than an Ask.Listen.Talk pamphlet on a bedside table.

Last week, I spent some time with a medical student, and we observed what we considered to be a breach of a patient’s dignity. We talked about it after we left that care area, and I asked him how he would address that with the caregiver responsible. He laughed. I laughed too. We both realized that I was being absurd. It would be a rare medical student who would comment on a breach of patient privacy, dignity or safety. At best, they would be ignored. At worse, they would be excoriated for their impertinence. How dare you…

He felt – undoubtedly correctly – that the caregiver would not accept such a comment from someone who was without standing in their culture. But we did explore possible approaches. I thought that he would need to test out – role-play – some options with like-minded colleagues before “going live”. Perhaps the old just-trying-to-be-helpful gambit: Would you like me to pull the curtain around the patient’s bed while you examine him?

I used a similar approach with our second-degree brunch guests. I wanted my 10-year-old son to find out if our guests needed anything, but I realized that giving him that vague instruction would be useless. It wasn’t that he didn’t want to help, or that he is unfriendly. It’s just that it was a new situation for him, and he felt uncomfortable. He needed some coaching and a specific script.

“Ask them ‘May I get you something to drink?’”, I suggested.

“’May I get you something to drink?’”, he repeated.

And off he went.

Coaching and scripting to encourage dialogue around patient safety will help us demonstrate to patients and families that we are serious about engaging them as active participants in safe care.

The day after my student and I had discussed impediments to his commenting on the breach of dignity, he joined me in the operating room. As I introduced him to the personnel in the room, the anaesthetist said this to him: If you see anything going on in here that you think is unsafe, please speak up. We value your eyes on what we’re doing.

That was a big step in the right direction.

Joy at work

2010-10-11T23:31:00.001-06:00

It’s not often that I have a moment of joy in the middle of a cystoscopy clinic, but I had one last week.

A cystoscopy clinic makes for a busy morning. Over the course of 4 hours, I’ll see 12 to 14 patients. Each visit involves – at minimum - an endoscopic bladder examination, discussion of the findings, and sending the results to the referring physician. It may also involve meeting a patient for the first time, asking about their medical history, arranging further testing or scheduling surgery.

I’m constantly aware of wanting to stay on schedule so as not to keep people waiting. Unfortunately, that time pressure will sometimes make me feel rushed, and that can affect my patient’s experience.

Why not schedule more time for each patient, you may ask. For some patients, rather than the standard 15 minutes, I will allot 30, especially if I anticipate that someone may require additional procedures. However, each extra time slot assigned to one patient means that another patient waits longer for their cystoscopy. And, wait times are already lengthy. It’s a difficult balance to strike.

But, during one examination last week, I found myself in the unusual situation of being ahead of schedule. Even though it was my first meeting with this patient, and I needed extra time to ask about her medical history, discuss test results (she had a tumour in her bladder) and recommend surgery, I wasn’t rushed. In the middle of that discussion, I had my moment of joy.

While explaining to the lady about what I had found, and the recommended treatment, I realized that I felt relaxed and confident. I was paying attention to her reaction to my explanation. Was she upset? Was I using medical jargon? Had she understood? Did she have any questions? I wanted to reassure her.

This was how I wanted all my consultations to go. Not only because it made me feel good about myself, but because I’m convinced that I’m a better doctor when I feel that way. I may provide the same technical results regardless of my mood (maybe…), but I think patients have a better experience when I’m relaxed.

As I thought about this, I began to wonder why I couldn’t feel this way, and offer my patients a better experience, on a regular basis. I think there are internal and external factors. Internally, I may allow myself to become flustered. That’s a habit I can work on. Externally, it comes down to an access problem. Long wait lists translate into pressure to fit in as many patients as possible in a given clinic. That increases the chance of running late, and forces me to rush, leading to an unsatisfying experience for both me and my patients. (And for any staff who may be unfortunate enough to be in the vicinity…)

So, if we work on improving our cystoscopy access problem – applying the same principles of managing capacity and demand as we have in our office practice – patients may benefit not only through shorter waits, but also through the quality of their experience. And our doctors may be more satisfied.

I think we’ve found our next access project.

And a selling point: Bring the joy!