97% fail - redux

"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.

Simplicity is its own reward

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.

Summer in the Pool

Summertime has traditionally been a challenge for our efforts to improve access. As we are working with half the number of urologists, patient wait times usually increase in the summer and early fall. This reduced office capacity is slightly tempered by the fact that the hospitals close some operating rooms in the summer, meaning that surgeons can spend more time seeing patients in their offices. Of course, this just transfers the bottleneck of patient flow further up the line by lengthening waits for surgery. Zero sum game.

Here’s how things look at the end of the summer:

As anticipated, wait times climbed after the success of the springtime “blitz”. I expect them to fall again as all the docs get back from holidays.

But, here’s an interesting chart that Erin, one of our office staff, has put together:

The top line is the clinic average for 3^rd next available appointment (3NAA). The bottom line is the shortest 3^rd NAA. Erin selected the doc with the shortest wait for each date and plotted it against the average wait. Because we offer pooled referrals, I think the lower line more closely reflects actual patient experience.

Our pooled referral philosophy is this: We will automatically assign a newly referred patient to see the urologist with the shortest wait time, unless the patient/referring physician choose otherwise (they rarely do). If the patient requires the special expertise of one of us, we will make the appointment with that urologist. If a patient already has a relationship with one of our urologists, we will maintain continuity of care for them, and schedule them to see their regular urologist.

This comparison graph alone should convince patients and physicians of the benefits of a pooled referral system.

I wonder about the “zero” 3NAA points. This means that the doc had 3 open slots on the day of measurement. Because our demand comes from external physician referrals, it’s unlikely we would have filled those slots.

Once we receive a referral, we would have to contact the patient immediately in order for them to be seen on the same day. Unless the referring physician had phoned us about an urgent/emergency consultation for a patient who was still in their office, and then sent that patient right over to see us, they would likely wait for at least a day or two before being seen. As such, we may be wasting some capacity. We’ll review this to make sure we’re filling all available slots.

Private CT clinics: Cornucopia or Juggernaut?

Get your reading glasses on. And get ready to rumble. It’s time for health policy cagefighting! In this corner – the Advanced Access Afficionado. In the other corner – politicians, bureaucrats and political commentators. Guess who’s wearing black?

Last month, the Saskatchewan government announced that it was looking for a 3^rd party supplier to provide CT scan services (1). The intent is to reduce wait times. Of course, that got my attention.

(Note: Because some links to media sources seem to vanish unpredictably, I’ve included the text of all the stories referenced in this post in an appendix. If you try a link and it doesn’t lead anywhere, scroll down to the end of the post. P.S. July12,2010 -because of some concerns about copyright, have removed the text that was initially pasted at the end of this post. So, sorry if the links to op-eds turn into deadends. KV)

The article focused on the response from the opposition NDP party, namely that this was a step toward the piece-by-piece privatization of health care. Commentary by the Leader-Post’s Murray Mandryk (2) lambasted the NDP for being hypocritical and dogmatic in their opposition to privately-operated CT clinics.

Whether or not the NDP is hypocritical in opposing this CT clinic is beside the point. The clinic has been portrayed as necessary because Saskatchewan needs more CT scanning capacity. Fans of wait time reduction strategies should smell a rat. Healthcare wait times sometimes result from inadequate capacity, but more often result from a mismatch between demand and capacity. Over time, backlog builds, even when demand and capacity are balanced.

Adding permanent capacity to manage backlog will be successful, but in the end, is wasteful. Once the backlog is dealt with, you need to mothball that extra capacity. Expensive CT scanners, professional staff and clinic investors don’t like mothballs. That’s the point I tried to make in an op-ed response (3), giving our clinic’s experience with Advanced Access as an example of ways to cut wait times without permanently adding capacity.

Weighing in on the same issue was Steven Lewis who, in addition to providing some analysis around safety and appropriateness of CT scans (4), called for open discussion around the risks and benefits of a privately-operated clinic. Stan Rice expressed his skepticism (5) with a financial analysis of private vs public CT scanners.

Mandryk responded to the op-ed pieces with “Informed health debate overdue” (6). While his statement “Like me, many of you might be troubled by the underlying premise that we can somehow turn back the clock by performing fewer diagnostic tests” puts him firmly in the “more is better” camp, I agree with his call for debate around this issue. I don’t think it’s going to happen, though.

The government has already stated its intention to support the privately-operated CT clinic, and has called for proposals. Sask Health doesn’t lack expertise around wait time reduction strategies, so I can’t imagine that this decision was made without full (internal) discussion of alternatives. If I were in the decision-maker’s shoes, I can see the appeal of the private option. It’s actually easier to take this approach than opt for the drawn out process of increasing efficiency and appropriateness of testing. To saying nothing of having to change the culture of “more is better”!

I don’t doubt that this strategy is going to work. Wait times will drop. It will make for some very satisfying headlines. And, as long as that’s as deep as the analysis goes, certain skeptics will be invited to eat their words.

It’s very tempting to wonder why “they just don’t get it”. Why can’t “they” see this issue as clearly as me? But, as soon as I start thinking that way, I play the Switch game in my head. What is it in this situation that I’m missing? If I’m truly convinced that Advanced Access methods can reduce wait times and provide appropriate, timely testing for Saskatchewan, and that building privately-operated capacity is not the answer, what’s the appropriate forum for debate? What’s the best way to illustrate the admittedly counterintuitive principles of Advanced Access so that policy-makers will embrace them over the more expeditious solution?

If politicians are driven by the belief that citizens need the quick fix afforded by an extra CT scanner, maybe the audience to be convinced is the entire (voting) population of Saskatchewan. I think I’m in over my head.

In answer to the question in the title of this post, it’s both. It’s a juggernaut because it seems unstoppable. It’s a cornucopia because many patients will benefit from the bounty of increased capacity.

But, can you have such a bountiful harvest without some of the fruit going to waste? How much goes to waste, and whether anyone bothers to keep track, remains to be seen.

It's a start

Congratulations to Sask Health on a big step in the right direction.


I mentioned in a previous post that I think pooled referrals should be facilitated not by "forcing" patients to see the first available specialist, but rather by providing them with accurate, up-to-date information about specialist wait times. Each person will then make their own informed decision. Sask Health has made a start toward achieving that. A website that lists specialist wait times has recently been released for public viewing. Now that we have transparency covered, we need to work on accuracy.

The website contains information on how long you could expect to wait for surgery with a given surgeon, had also how long he would wait for initial consultation with that surgeon. The surgery wait time information is updated monthly and is based on accurate information from health region databases. The consultation wait time information, only other hand, is self-reported by physicians. The biggest problem with this is that most physicians don't really know how long patients are waiting to see them. Also, physicians may be using different measures to estimate wait times.

For example, the "industry standard" for reporting patient wait times is the 3rd next available appointment (3rd NAA). This requires some basic understanding of Advanced Access principles and also takes some effort to calculate. There is no explicit incentive to make the effort to calculate 3rd NAA time.

Some electronic medical record programs have the ability to calculate 3rd NAA. However, when we tried it in our EMR, we got a result that was very different from our hand-calculated number. When we investigated that further we found that it was due to the way we book appointments in the electronic scheduler. Because our practice consists of scheduling office, cystoscopy, OR, lithotripsy and outpatient visits, the EMR software was finding openings in bookings other than just office appointments. It would have saved us a lot of time if we could just press a button and have a reliable 3rd NAA measurement but we are still unable to do that. Perhaps family physicians or specialists who only work in their office would have more luck. Unfortunately, virtually all surgeons will be working in more than one location.

Until all surgeons are involved with Advanced Access (someday soon!), the wait times listed on the website are unlikely to be reliable. Even so, that unreliability of the data is likely to be unintentional. There may be reasons why surgeons might"cook the data".

In our urology practice, we have the luxury of being the only group in Saskatoon. We are not competing for work. In fact, as I mentioned in my last post, there may even be a disincentive for us to improve our wait times because it will likely generate more and more consultations from outside of our traditional practice area. However, some specialty groups may be in direct competition with each other. In that case, they may gain a competitive advantage if they were to list consultation wait times as being shorter than reality.

Who will audit the wait times? How will they audit the wait times? If we agree that 3rd NAA should be the provincial standard, then an auditor would need to have access to each surgeon’s office scheduling records. They will likely need to do a manual calculation because EMR programs don't seem to be able to churn out accurate 3rd NAA figures (given complex schedules that are the norm in surgical practices). I suppose that the website managers could mandate that each surgeon's office must submit an accurate 3rd NAA figure on a monthly basis (and then do random audits to ensure compliance), but it would also be necessary to provide some financial reimbursement for surgeons to make that effort.

All of this presumes that the website actually has some value for patients and family physicians. The purpose of disseminating this information is to allow patients, along with their family physicians, to make better decisions as to which specialist they wish to be referred to. In order to be sure that this information is useful, and being used, the administrators would need to sit down with some focus groups to see what conclusions patients draw from this information, and how it influences their choice of specialist. Without knowing how consumers really use this information, and how they navigate the website, it's impossible to know whether it's of any value.

So, unless an investment is made in gathering accurate and timely wait time information, and also in determining how to make the website valuable for consumers, this is an exercise in public relations. Consumers need to know how the information is gathered (e.g. calculated 3rd NAA versus "best guess") and when it was last updated.


Let me revise my initial statement: Sask health has taken a baby step. But, it's still in the right direction!

Islands

Remember Gilligan’s Island? No? Well, the rest of us will wait here while you catch up.

Part of the fun I had while watching that TV show was seeing the incredible contraptions – from a washing machine to a pedal-powered car - the castaways constructed to make their life easier. (I still enjoy hearing about ingenious solutions to everyday problems. That’s part of what has made our Clinical Practice Redesign project satisfying to me.)

But, the Gilligan’s Island community had its limitations. Even though each of the 7 residents played a unique role (only 6 roles, if you count the Howell’s as one amalgamated upper-class twit), they never managed to reach their goal of leaving the island. Even though the island was idyllic, both naturally and due to their bamboo gadgetry, they still wanted to go home. But, they were never able to muster the resources to do so. The castaways occasionally had visitors from the outside world, but circumstances were comically contrived so that escape remained elusive.

I think we’re in a Gilligan’s Island situation in our office. We’ve made a lot of successful internal changes. Our practice is more efficient and (we hope!) more effective. But, there are some changes that we can’t make on our own island. We rely on other practitioners and services to provide a continuum of patient care. But circumstances remain not-so-comically contrived to that improved patient access remains elusive.

The wait time for specialist consultation has been our main target. But, that’s only one part of what makes up the patient’s experience. Patients wait to see their GP, then for testing, then to review the tests with their GP, then for a specialist referral, and so on, until they have their problem resolved. A more patient-centred metric would be to measure the time between onset of symptoms to complete recovery. Attempts to measure this time illustrate the complexity of our healthcare system, and the interrelationships between individual departments.

Our recent office blitz made us more aware of the way our private practice meshes with other parts of Saskatoon Health Region (SHR). We anticipated that we would need better access to xray procedures – mainly CT scans – in order to be able to schedule patients on short notice. The SHR xray department was very helpful when we approached them about this, and allotted specific times for our blitz patients to receive CT scans.

However, the increased patient volume over the blitz period caused a surge in the number of other procedures being scheduled, and we haven’t received additional resources to deal with that. Cystoscopies have been particularly challenging to complete in a timely fashion. Also, many of our patients still wait up to a year for certain kinds of surgery.

The problem is that we’re all living on individual healthcare islands, each with its own culture. On some of the islands, conditions are rough and the inhabitants are motivated to make changes to improve their lot. I’ve been told that family practitioners are among the first to adopt Clinical Practice Redesign because they are overwhelmed by patient load and the need help to deal with multiple, chronic medical problems in their patients.

On other islands/practices, life is good – perfect weather, low-hanging fruit, no annoying insects. Why would anyone ever want to change? I’m not suggesting that anyone working in healthcare has this perfect situation, but some of us are more comfortable than others. And so, when the hard-living inhabitants of one island call for help from their more fortunate neighbors, what’s in it for those living the easy life? We market Clinical Practice Redesign by telling doctors “Trust us. If you try it, things will be better!” (Disclaimer: I think it is better!) If you were living in paradise, would you want to take a chance that the next island over was an even better paradise?

To get everyone working toward the same goal, someone has to turn up the heat. On Gilligan’s Island, it would be a plot device like rumbling and smoke coming from the island’s volcano. In healthcare, motivation could come from various sources:

- Make public, transparent and accurate reports of wait times for GP and specialist visits, cancer treatment, surgical and other procedures. Report by practitioner and health region. We’re a competitive bunch, and no one wants to be at the back of the pack.

- Make it financially disadvantageous to ignore long wait times. Reward practitioners who manage their resources wisely. Put your money where your mouth is.

- Offer support and education to help practitioners apply Advanced Access principles. People can’t improve the system if they don’t know what tools are available (see “Juice”).

- Prove that paradise does exist – showcase examples of successful initiatives that have improved the lives of patients and practitioners.

Anyone know where we can find an angry volcano god?

Scratching the Itch

I know you’re excited to find out how the blitz weeks went. I’m excited too. I’ll show you in a minute.

First, I want to tell you about the latest change we’re going to try in our practice. It’s so simple, and is already standard in many practices, so I was unsure if this change was even worth mentioning. But then I realized, That’s exactly the point!

When trying to implement Clinical Practice Redesign (CPR), simpler is better. This is especially true for practices that are new to CPR. Learning the processes, measurements and jargon of CPR can be intimidating and overwhelming. A simple practice change involves minimal investment of time and manpower, and minimal loss if the trial doesn’t succeed the first time.

Trying something that is already in place elsewhere also improves the chance of success. Someone else has already worked out the kinks and shown that the procedure is viable - in their practice, at least! While it can be very satisfying to develop a novel idea to solve a problem, it also requires a lot of effort. Better to borrow shamelessly.

So, here’s the plan: For men referred to have a vasectomy, we’re going to offer them a single-visit consultation and procedure. Yeah, I know – it’s a little underwhelming. But consider what this change involves, and what the process illustrates about making these changes in clinical practice.

1. Feel the itch

In general, I think of the whole change process as “Scratching the Itch”. (An iffy metaphor in a urology practice, but bear with me…) The specific itch I wanted to scratch this time was the value (or, lack thereof) my patients received when referred for a vasectomy. Our tradition is to see the man for a consultation in our office, ask about his medical history, examine him to determine suitability for the procedure, and then discuss what’s involved. If he is in agreement to go ahead, we schedule the vasectomy date, often 3 or 4 months from the initial visit.

Many men are surprised and disappointed to find out that they are not scheduled to have the vasectomy performed right then and there. I have offered several reasons why that doesn’t happen:

I perform vasectomies in the hospital outpatient clinic, and don’t have the necessary equipment at our office.

I need to examine the man first, as some men’s anatomy precludes doing the vasectomy under local anaesthetic in the outpatient clinic, and may require a booking in the operating room under general anaesthetic.

Some men only want to come for a consultation to find out what the procedure involves, and choose not to book the vasectomy at that time. If I scheduled an “all-in-one” visit, then the additional time scheduled to do the procedure would be wasted.

I’m sure those reasons often rang hollow with my patients, because they sure felt that way to me. The rebuttals were obvious:

Well, then, get some equipment in your office! Or, do everything in one visit at the hospital. I just drove 3 hours for a 5 minute visit! Now, I find out that I’ll have to come back for a second visit.

My own doctor examined me before he sent you the referral. He said everything was normal. How often do men need a general anaesthetic for a vasectomy, anyway? That can’t be too common.

I definitely want the vasectomy done. I would have told you that, if you had asked.

There was definitely an itch ready for scratching!

2. First, a gentle scratch

A couple of us scheduled a few vasectomy/consult all-in-one visits to work out any hitches. Hitches, what hitches? In fact, there was immediate, positive feedback from our patients who welcomed having everything done in one trip. We had sent all of them our vasectomy information pamphlet at the time we made their booking, so they were well-informed about what to expect during and after the procedure.

3. Then, scratch it hard

We presented the idea to our entire group. The selling points were better patient service and satisfaction, and fewer low-value (for the patient) office visits (which equals more capacity to see new consultations). We also addressed the potential problems with this change:

A no-show patient “wastes” valuable procedure time.

The man may not be suitable for vasectomy done with local anaesthetic, and need to be rebooked at a later date with a general anaesthetic. More wasted procedure time.

Combining the consultation with the procedure may take longer than the usual 30 minutes scheduled for a vasectomy alone, making us run late.

I think it’s important to present a balanced view of proposed changes. If skeptics sense that enthusiasts are charging blindly ahead, they step hard on the brakes. If that is their first impression of the proposal, negativity becomes entrenched and difficult to overcome. However, if you can show skeptics that you’ve considered and addressed potential risks, I think the proposal is judged on its own merits, rather than becoming a pawn in the broader skeptic vs. enthusiast tug-of-war. (In which battle, the skeptics have the huge advantage of inertia.)

Here’s how we addressed the potential risks:

We would require that men confirm their appointment time, in the same way patients have to confirm their date for surgery. This should reduce no-shows. However, we’ll track no-shows, and consider phone reminders if the numbers are significant.

If a referring GP comments on potential anatomical challenges in his referral letter, or the GP has unsuccessfully attempted the vasectomy, then we’ll arrange to see the man for a prior consultation in the office, rather than booking the vasectomy at the same visit.

We’ll schedule 45 minutes for a vasectomy/consultation, or 2 hours for 3 procedures.

The outcome? Everyone agreed to try it, and actually seemed quite keen.

4. “Does this rash look infected to you?” – Get a second opinion

I was pretty pleased with how it had gone, and how all the bases had been covered. But, I had forgotten one thing. I didn’t ask the people who know how our system really works – out staff. Delores pointed out to me that, in our current system, men receive their office appointment notification quite soon after they are referred. Even though they may wait several weeks to see us, they know that we have received the referral letter and have made arrangements. They will not find out about the date for the vasectomy until after the office visit, and may need to wait several months to have the procedure.

Delores went on to say that, in our new system, patients wouldn’t hear from us for several months. We schedule surgery up to several months in advance, and then plan office schedules and minor procedures (like vasectomies) around our OR time. Scheduling vasectomies comes last. Delores predicted that we would be swamped with phone calls from men who were wondering whether or not we had received their GP’s referral. That’s a waste of both the man’s and our staff’s time and energy.

Her solution was that, upon receipt of a vasectomy referral, staff would send the man a letter to let him know that we had his information and would be sending out an appointment in several weeks. Great idea!

I think this change will stick because it doesn’t involve a big change in physician behaviour. We’re taking 2 established practices – office visit, and vasectomy procedure – with which our docs are already comfortable, and redesigning them both to improve patient satisfaction and practice efficiency. Initially, I felt embarrassed to mention that we were making this change. I know it’s already standard procedure in many practices, so I thought someone would read this lengthy dissection, slap himself on the forehead and say “Duh! What took you so long?”

The point here, and in any practice that is trying to improve, is that the changes that make a difference are small and mundane. Individually, they seem trifling, but will eventually coalesce into something powerful.

Let’s celebrate each other’s small victories.

And now, blitz week results! These are hot off the press. The last data point is from May 6 – the end of 7 weeks of extra office capacity.

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The trend looks good!

And means nothing. Seven weeks of office blitz will only have been worth it if we can maintain the gains. We need to see the long-term results, and our annual nemesis is almost upon us. Curse you, summertime, with your unquenchable 30-new-referrals-a-day demand and capacity-hobbling holidays, curse you!

The way to a urologist’s heart

Only 2 more blitz weeks to go. Until they are completed, I’m not sure we’re able to assess whether we’ve made an impact on our 3^rd NAA numbers. But, we have already learned something important from this initiative.

We were all dreading our full week of seeing new consultations – whether in the office or at the cystoscopy unit. Our clinics are busy enough when there is a mix of follow-up visits (usually easy to complete in the scheduled 15 minutes) and new referrals (more intense and time-consuming). Having a clinic of all new referrals seemed daunting.

As expected, it was hard work, but several of the urologists commented on their very positive experience with blitz week.

While each doc was working the extra week, staff treated them as if they were actually on holiday. That is, that doc didn’t take calls from the hospital or referring physicians. He/she could focus entirely on completing consultations. This made the day’s work much more enjoyable. Freedom from interruptions meant I could move from one patient visit to the next without having to return phone calls in-between. I was able to stay on schedule, and left the office promptly once I’d seen my last patient. One of my partners commented that he enjoyed “spending more time with patients.” He felt less rushed with this arrangement.

Each doc had clinic scheduled from 0900 to 1200 and 1300 to 1600. (We took a lunch hour!) This was unanimously well-received. Our morning schedule usually consists of 0700 hospital rounds followed by surgery or office. If we have a morning office, there’s often a mad dash to make it there by 0800. Starting late means you will likely run late all morning. That’s very frustrating. Perhaps we need to change our 0800 habit to 0830. Of course, that will cut into our capacity, so we’ll see how our wait times are over the next few months. Having an extra 15-20 minutes before starting patient visits would also be a great time to make some phone calls, and get them out of the way before starting a morning office.

Now that we’ve had a taste of how pleasant it is to conduct a clinic in an unhurried fashion (and don’t think that our patients can’t tell when we’re feeling rushed!), it’ll be tough to go back to business as usual. I would like to pursue some changes that will improve our docs’ job satisfaction. Switching to a 0830 start is pretty simple; we just have to say the word to our staff. But, will the loss of 2 appointment slots per morning office have a big impact on our capacity? Just over 10% lost capacity – not a trifle. But perhaps we could compensate for that lost capacity by increasing the ratio of new consults to recalls. We’ve had success with that over the last year, but there’s room for further change. Also, there’s still considerable variation in recall rates among the urologists. Maybe we could link the number of new patients you see to the time your office starts in the morning. If a particular urologist sees a higher ratio of new patients, then he/she could be rewarded by a later start to his/her office. This would give an additional incentive (beyond altruism and peer pressure) for each doc to carefully consider their own recall practices and encourage them to adopt (or even just ask about) other’s methods.

We could also build in empty slots into the clinic schedule, to be used for phone calls, catching up on dictation, or spending extra time with a patient.

It was really valuable to learn this from blitz week. Coming up with ways to make our docs less harried is good for both physician and patient. We may provide the same technical care while dealing with repeated interruptions and late starts, but a happy, unhurried physician gives patients a better experience.

Plays well with others

The backlog blitz is coming soon! Not soon enough, of course, but we still have some preparations to make.

Our biggest challenge comes from outside our office. Many patients referred to us require medical imaging – ultrasound or CT scanning – as part of their evaluation. If one of these tests is necessary, we try to coordinate it with the person’s first visit with us. For people traveling from out-of-town, that means the test needs to be scheduled on the same day as their office visit.

The problem? Medical imaging clinics have backlogs too. Wait times for ultrasounds and CTs can be weeks long. As we start to schedule appointments within 7-14 days, we’ll need better access to these tests. And it looks like we’re going to get it!

We contacted several of the private medical imaging clinics (for ultrasounds) and the health region’s medical imaging department (for CTs) to explain our situation and ask for their help. The response was gratifying. They have offered to hold a number of appointment slots for us. If the slots aren’t filled 7 days in advance, they will release the slots. This will be particularly valuable in the case of CT scans. Our staff spends a significant amount of time coordinating CTs and office appointments. Knowing in advance when CT times are available will simplify scheduling.

An in-house consideration is how we can streamline our appointment approval process. Currently, consultation requests arrive by fax and are reviewed by staff. A tentative appointment date is set, and staff forward the request to the urologist. Our staff is experienced in triaging consultation letters and anticipating what testing the patient may require. The urologist will review the letter and accept the arrangements, or ask for an earlier appointment time, or additional testing.

This process has worked for us in the current climate of 4-6 weeks wait times. That is, the physicians can leave the appointment approvals in their inboxes for several days without throwing off the scheduling process. However, when wait times are as short as 1-2 weeks, approvals will need to be much more prompt. We’re reminding the physicians of this and will track performance so as to offer individual encouragement as needed.

Ideally, turnaround time for appointment approval would be instantaneous. We can do this by setting guidelines for approving appointments for certain urologic conditions. With clear guidelines, staff can set up appointments and testing without needing to check with the physicians. Setting up this “pre-approval” process requires:

1. Clear and accurate description of the clinical problem in the referral letter

Sometimes, this is straightforward, as in the case of vasectomy referrals. The single word “vasectomy” is sufficient to let us know the purpose of the visit. Staff set up vasectomy appointments without needing review by the doc.

On other occasions, it’s not clear what the clinical problem is. This may be because there is uncertainty as to what the patient’s symptoms indicate, or what the test results mean. In this case, it’s up to the specialist to work toward a diagnosis. On other occasions, the information needed to make a diagnosis is available, but hasn’t been sent with the referral letter. For one common urologic problem – blood in the urine (hematuria) – we’ve had success with sending a diagnostic algorithm to referring physicians. Circulating this algorithm has greatly increased the amount of information we receive along with the initial referral letter. Setting up similar algorithms for common urologic conditions will simplify things for our staff and for referring physicians.

2. Consistent evaluation process by urologists

The hematuria algorithm was approved by our entire group. Ideally, we would have similar agreement on other diagnostic pathways. It’s not always easy, though.

I recently surveyed our group about how we should approach referrals about several common, benign urologic conditions. There was considerably more variation than I anticipated. Some of the docs supported giving guidelines to staff, while others want to review the referral letter and decide for themselves whether additional testing should be coordinated with the consultation appointment. Those urologists falling in the second group cited their desire for patients to have a single visit, whenever possible. They were concerned that they may miss the opportunity to schedule necessary testing at the time of that visit.

We may be able to reach consensus around pre-consultation testing, but in the meantime, I’ll try to determine individual preferences and compile them for our staff. Even though it’s somewhat complicated to deal with 8 different preferences, it should still speed up the appointment approval process.

Semi-transparent

I’ve been feeling guilty since my last post. I hadn’t shown you our 3^rd NAA/wait time chart for many months, and if you’ve been following our adventures, you know that the 3^rd NAA was the raison d’être of this project. When I finally posted the recent data, it was in anticipation of our upcoming backlog blitz that should drop the 3^rd NAA to our target level of 2 weeks.

Our Advanced Access project has broadened to a Clinical Practice Redesign effort, and so has a wider range of goings-on to share in this blog. However, I’m aware that I’ve used that wealth of material as an excuse to avoid exposing our biggest failure: we have not beaten the backlog, and our patients continue to wait too long for their consultations.

I rationalized it beautifully in the last post, didn’t I? I pointed out that the number of FTE urologists in Saskatchewan had dropped over the last few years, and that we were lucky the wait times hadn’t soared as a result of the manpower situation. And, I sweetened the bitterness of showing a stagnant 3^rd NAA trend by breaking the exciting news of the backlog blitz.

Why did I keep this under wraps for so long? Here are a few reasons:

As the project lead, I find it frustrating and embarrassing to admit that, while we’ve had success in other areas (there’s that rationalization again!), the main goal eludes us.

When I share our results at meetings and with colleagues, I feel it undermines my credibility as a “champion” for this type of quality improvement.

Other physicians may be reluctant to start similar projects if they see early adopters are struggling to achieve durable results.

Blog posts about an unchanging 3^rd NAA would be pretty dry. (Lame reason, I admit.)

I have no malicious intent, and I have never knowingly posted misleading data. However, I recognize that withheld information can affect decisions, impressions and outcomes as much as incorrect information can.

In this case, our Clinical Practice Redesign project continues because we’re excited about the positive changes that we see coming from it. The 3^rd NAA data is simply a way we measure our progress and consider other improvements that we can make. As such, apart from the reasons noted above, there’s little risk in sharing the data (flattering or not) with you.

But that’s the case in our group; what if the situation were different? What if we were part of a “pay-for-performance” compensation plan, where our remuneration was dependent on providing prompt consultation? Or, if there were another urology group in town, there would be competition for referrals, and a shorter wait time would be a potent marketing tool.

Most importantly, what does a lack of transparency mean for patients? If all else (demeanor, aptitude and location) were equal, people would likely choose the specialist with the shortest wait time. Perhaps wait time would be the prime criterion for some to make their choice. Controlling access to the information then takes on a new importance.

So who controls the access? Ontario and Alberta share some of their acute care wait times online. Information about wait times to see Saskatchewan surgeons is already collated in an online database and available to referring physicians. They could (and are intended to!) share this information with their patients, to assist in making an informed decision about a specialist referral. The information, therefore, is not considered a secret yet, at present, it is password-protected.

If a patient wished to obtain wait time information, she could do so without relying on a physician to grant her access to the database. The information is available, but not without doing a lot of work. She would call all the offices of that particular specialty and ask what the wait time would be for a new referral appointment. (This is essentially the same process used to fill the database, i.e. self-reported wait time.) If she required a sub-specialty consultation (such as a shoulder problem, rather than a knee problem), she would also ask if that surgeon dealt with that area – also information contained in the database.

So why would we make our patients jump through hoops to gain access to information that we already have, and that they can laboriously obtain of their own accord? (Could anyone make a case that they have a right to the information?) There are good reasons why we might restrict access. We want to be sure that the self-reported data is accurate. After all, if livelihoods may be affected by this information, even the most earnest professional may be tempted to fudge the figures slightly.

But, surely the information physician’s clinics would report to the database would be the same as they would give our to our fictional, diligent patient over the phone. If so, she’s no worse off. I suspect that information reported by physicians to the Department of Health would be at least as accurate as that given out ad hoc to curious patients, as physicians would realize that there would be some auditing/confirmation process applied eventually.

If I have been reluctant to share our wait time data for reasons that bear trivial consequences for me, how will people behave when the stakes are higher? What expectations and rights do patients have about access to information that is critical in their informed decision-making around their healthcare?

Blitz

I haven’t showed you this in a while:






I groaned when I saw the spike in mid-November, but the mid-December peak was even more discouraging. I remember how exciting it was to see the results we had in early 2008. What’s gone on since then to put our wait times up?

Around the time 3rd NAA started to climb in 2008, 3 of our partners had switched to half-time practice. This moved us from 9 FTE to 7.5 FTE. Coincident with that change, we noted an increase in the number of referrals from Regina. There were only 2 urologists in Regina at that time, and their wait times were lengthy. This has been a longstanding situation, but we found that some Regina GPs had recently “discovered” us and were suggesting to their patients that they could see a urologist in Saskatoon more promptly. As word spread in Regina, more GPs (and their patients) would take advantage of our services.

So, it seemed to be a combination of reduced capacity and increased demand. In that context, one could conclude that, even though our 3rd NAA has risen since 2008 (now equaling our original baseline), that our overall processes must have improved because we’re doing more with less. If we hadn’t made some the changes through Advanced Access, our 3rd NAA would likely be much higher.

Well, that’s cold comfort. We remain committed to our goal of a 2-week wait time for all consultations. And, we know what the barrier is.

Because the wait times have been pretty steady this year, the problem remains the same: backlog. In a stable system, if we can trim the backlog, our system should drop to a new, lower level. And that’s where the recent spikes in 3rd NAA turn out to be a blessing in disguise.

In November, several of us noted that some patients were waiting until March to see us. The 3rd NAA is an average, so some unfortunate patients at the far end of the curve have very long waits. We know what a burden that is for our patients, and it’s not the way we want to provide service. This prompted Peter Lau to surprise us with a proposal.

We know the backlog is our big challenge. We’ve picked away at the edges of it by having half-time partners come in to work on their months off, staying late to see more patients, and filling in any open slots in the docs’ calendars. But, still the backlog eludes us. It just doesn’t look like we have any extra capacity to work with. Until Peter found it for us.

He proposed that we each give up a week out of our annual holiday allotment, and spend that week in the office seeing patients. We take our holiday time pretty seriously in our practice; it’s one of the main perqs of working in a large group. So, before taking the idea to the group, we wanted to be confident that it had a (theoretical) chance of success.

Our current backlog is about 800-850 patients. If one urologist spent 5 8-hour days in the office seeing, on average, 3 patients per hour, he or she would see 120 patients in that week. As one of our half-time partners has just retired, we now have 7 FTE docs, so the proposed backlog blitz would deal with about 840 patients. What a coincidence!

Our proposal to the group was that, starting in the spring, we would schedule each of us to work one of 7 consecutive weeks. In order to make this more palatable, we suggested that during each urologist’s week, they would focus solely on office work – no call, no surgery, no fielding phone calls from referring docs. Staff would behave as if that urologist were actually away from the office on holiday. We felt this would be an important feature of a blitz week, otherwise, the doc in the office would become the go-to person for every phone call and query that came into the office.

Rather than spring the idea on the group, we informally shopped it around a bit first. We felt it was a radical enough proposal that surprising everyone with it at an office meeting could trigger a negative (and understandable) response. I was nervous as Peter made the pitch. What could possibly motivate the group to give up an entire week of holidays?

The response: Let’s do it. Immediate and unanimous! It’s difficult to express the pride I felt at being a part of a group that would so readily give up personal, family time in order to improve patient care.

So, from March 22 to May 7, we will be crushing our backlog. However, as we plan for the blitz, we see that this means a significant change in our office practices, from notifying patients to booking ancillary tests, such as CT scans and ultrasounds. We’re working on identifying these challenges and creating new processes. More on that next time.

Seven-year Itch

My partners and I had under our care a man with a life-threatening problem. His urinary bleeding was severe enough that he required blood transfusions every few days. Surgery seemed the only option that would help him. The complicating factor was that he had suffered a heart attack a week earlier. Giving him an anaesthetic would put him in danger of a second, more serious heart attack.

If we put off the surgery, his condition would gradually deteriorate. At that point, if surgery was performed, he would be weaker and more susceptible to the stress of the operation. Both courses – continuing observation and blood transfusions, or performing surgery – were risky.

Surgeons have a predilection toward intervention over observation. Maybe it’s because physicians with that temperament choose surgery as a specialty. Or, maybe surgeons develop that trait because the medical system triages patients who will benefit from intervention, and streams them into our hands. Whatever the reason, we recommended surgery to our patient. We prepared him as best we could and then took him to the operating room. The bleeding was stopped and he went home 2 days later.

That was a very gratifying and immediate result.

_______________________________________________


Over the last 3 years, coincident with our urology group’s Advanced Access project, I’ve become involved in other quality improvement efforts, both in the Saskatoon Health Region and also on a provincial scale. As does our office project, these other initiatives address significant deficiencies in health care. I continue to work on all these projects because I strongly believe that, when implemented, they will transform the way patients experience care in Saskatoon and Saskatchewan.

“When implemented”, that is, because it is taking a long time to see results!

In all these projects, the first phase was very exciting: Working with excited and motivated colleagues, and imagining possibilities. But initial planning has given way to the long slog. We meet regularly, but I’m getting discouraged at the lack of progress that I perceive.

I don’t mean that there isn’t action on these projects. Policies and protocols are being written, and subcommittees are formed. But I want to see changes that improve patient care. Pronto. Or I want to focus my efforts on something that will make a difference.

Maybe I’ve been spoiled by Advanced Access. After all, our office project is on a smaller scale, in an environment where I have a fair bit of direct influence, and involves a group of motivated people who directly provide patient care. (I include the docs and our staff in that group.) We’ve had quick payoffs from changes like pooled referrals, better communication with referring docs, and optimizing our patient recall practices. It’s very gratifying to see prompt results from implementation of these changes.

Perhaps physicians’ temperaments (selected by medical schools, or nurtured in medical schools – your choice) are more suited to the satisfaction of immediate results: Surgery for appendicitis, or penicillin for strep throat, for example.

I’m griping partly out of frustration, but I also want to explore my discouragement in order to understand how to maintain other physicians’ engagement in change initiatives. If enthusiasts/early adopters become disenchanted with the slow pace of change, then it’s going to be exponentially more difficult to keep the next echelon of physician champions engaged.

If you’re an administrator, you may be reading this and thinking “Well, what’s so special about Kishore’s time and effort? I sit on the same committees and share the same frustration.” Yes, I’m sure you do. But, there is a significant difference between us. I have another job – my clinical work – and in that job, I get to see the results of my actions regularly and promptly. Almost every consultation requires coming up with a management plan, and then putting the plan promptly into action. Even when the outcomes aren’t the desired ones, there’s still a satisfaction in working through a problem and executing a plan on your patient’s behalf.

So, if I (and other physicians) don’t find satisfaction in tangible results from quality improvement efforts, I can devote all my time to clinical work.

I’m an action junkie. Give me my fix.

Blessing in Disguise

Our fridge conked out two weeks ago. Not the main kitchen fridge, mind you; it was the basement auxiliary fridge that died. So, it wasn’t an absolute crisis, but it has made us rethink some of our habits.

The luxury of having a 2nd fridge gives us extra food-storage capacity. But that extra capacity has made us a little careless. Here’s what’s changed at our house over the last 2 weeks:

• We actively consider what’s in the fridge. Usually, leftovers would get pushed to the back of the shelf and, unless someone was specifically looking for that item, would often be discovered weeks later (inedible!). We’re wasting less food.
• If food does go stale, it gets thrown out before it gets too disgusting.
• I pack leftovers in my lunch more frequently. My intent is to make room in the fridge, but I’ve discovered that it also saves time when I’m putting a lunch together. Putting leftovers in a container is usually quicker than making a sandwich. It saves even more time if I remember to put some leftovers directly into a small container when I’m cleaning up after supper.
• We’re more careful about the size of storage containers we use. Rather than grabbing the first available container and then filling it halfway, we’ll pick a smaller container that will be filled completely.

Do You Recall

At the IHI Clinical Practice Redesign Summit in Vancouver, Advanced Access guru Catherine Tantau suggested that the gold-standard for specialist wait times is 1 week.
When wait times are that short, practices start reaping the benefits such as less wasted administrative effort, fewer no-shows and greater flexibility in physician schedules.

One week? It boggles the mind!

In early 2008, we were on our way with our 3rd NAA down to 30 days from our starting point of 70 days. Then, one partner switched to half-time work. Our 3rd NAA crept up a little until July 2008 when 2 more partners switched to half-time. Since then, our 3rd NAA has gradually climbed back to its original level. Aaaaaargh!

Mea Culpa

Did you ever have the experience of having an idea that was vivid and compelling when you saw it in your mind’s eye, only to have it fall flat when you gave it voice? Maybe, when you tried to express yourself, you were tired. Or in a rush. Or not quite as clever as you thought you were. That’s what happened with my last post, Wasted. (Heavy on the 3rd excuse.)

After the post went up, someone emailed me another meeting invitation, with the comment I see you like to have plenty of notice for these invitations! A similar remark about how upset I seemed, received a few days later, along with some of the comments on the blog, made me realize I need to clarify my intentions about that posting.

I Love Lines

I love standing in line.

Or, more accurately, I love what I learn from standing in line. Being stuck in traffic, waiting at the grocery store checkout – they're all golden learning experiences if you're a student of queues. But nothing beats air travel...

Over the holidays, I enjoyed a tremendous learning opportunity courtesy of a leading national airline. So many of the problems I observed at Toronto airport were analogous to the situation in physicians' offices. Because so many people have experienced the frustration of waiting in line at the airport, perhaps this could be an effective model to explain Advanced Access/Clinical Practice Redesign to novices.

Before we even arrived at the airport, we had been primed to expect a long wait. Airlines establish cultural norms with the advisory printed on every ticket: Be at the airport at least 60 (or 90, or 120) minutes before your flight departure. So we shrug our shoulders and drag our suitcases to the end of the line, because... that's the way it's always been!

Sound familiar?  It takes forever to get in to see my doctor. You'll wait a long time to see a specialist. Health care sets the same norms. Earlier this week, I heard a presentation about a new project in the Saskatoon Health Region, aimed at reducing patient wait times when they come for assessment and education at the Pre-operative Clinic. The project coordinator showed a sign currently posted at the entrance of the clinic. It showed a drawing of a man resigned to his fate (shrugging his shoulders in a C'est la vie kind of way) and said: Your visit to the pre-operative clinic may take 4-5 hours. Those are the expectations we establish for our patients. That's the promise of service we give as our patients come through our door.