Major professorial cringe moment!

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.

I'm catching the Saskatchewan wave!

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!

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.

Improving the FP-specialist referral process

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.

Check a box, Tame a Line

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!

Adopting voice-recognition software – Am I an innovator or am I reckless?

Sometimes, adapting to new technology can challenge even the most enthusiastic gadget freaks. I have long been anticipating trying voice-recognition software for office dictation. Three weeks ago, several of us installed Dragon voice recognition software and have been trying it out. There have definitely been some growing pains.

Our traditional dictation and transcription system in the office had been used for several decades. We dictated our correspondence on to cassette tapes and this was transcribed by our staff in the office. In addition to dictating letters and consultations, we would also include any instructions such as x-rays to schedule or follow-up office appointments. We generate a lot of letters every day in the office, as this is a consulting practice and we try to communicate promptly back to referring physicians. We were finding that our office transcriptionists were having difficulty keeping up on the volume of transcription generated every day.

Several years ago, we switched to using digital voice recorders and sending the files offshore to be transcribed. Our dictation would be transcribed into a word document which was then returned to us electronically. Our staff would still have to paste the document into our electronic medical record so that it was assigned to the correct patient. They would also add the referring doctor’s address and the patient identifying information. A letter would then be printed out and given to the doctor to proofread. Staff would then fax it to the referring physician.

When we switched to a different EMR system last fall, we stopped printing out letters, but the letter would still be placed in an electronic queue that had to be reviewed by each urologist before being faxed to the referring doctor. If I were to be away from the office for more than one week, I would leave instructions for staff to send out letters "dictated but not read". This would speed the process of getting the consultation letter back to the referring physician, rather than waiting until I returned to work. However, even though our transcriptionists are very diligent in looking for errors in our letters, a misplaced decimal point in a drug dosage or laboratory result, or the word "not" inserted, or omitted, by accident can completely change the context of a sentence. As such, I prefer to proofread all my letters. The downside of this is that the letter has to come back to me and I have to spend the time reading it, sometimes referring back to the patient's chart to see whether the information contained in the letter is correct.

At best, the time from dictation to receipt of the letter by the referring physician would be 48 hours. That's a pretty good turnaround time. However, reviewing dictation tends to be a low priority as compared with reviewing lab reports, or returning patients phone calls. As such, letters would sometimes wait a week before being faxed to the referring physician.

With the Dragon voice recognition software, we hoped to be able to dictate consultation letters directly into our EMR. Because the EMR takes the text of our consultation and then generates all the "fixin's" for the letter (e.g. letterhead, date, referring physician name and address, salutation, patient identifying information), we wouldn't need our transcription staff to do that. It's a matter of only a few mouse clicks to get a consultation letter faxed directly to the referring physician.


That means that our consultation letters get to the referring physician almost immediately after we've seen the patient. But, this improvement in turnaround time isn't the main reason that we decided to try voice-recognition software.

Being able to see my dictation immediately lets me correct any errors right away rather than needing to see the letter again for proofreading. While proofreading usually only takes a few seconds, I sometimes need to return to the patient's chart to double check lab or x-ray results. When there are 20 or 30 letters to check at a time, this review can take 10 or 15 minutes. So, voice-recognition software may be a way to improve our workflow.

Also, our current dictation system involves the cost of offshore transcription and also our office transcriptionists who receive the transcribed text and generate letters in our EMR. The voice recognition software is a onetime cost and we should be able to save the fee from our offshore transcription service.

Theoretically...

While the latest version of Dragon is quite impressive right out of the box, it does take some training to allow the software to recognize your voice and patterns of speech. The software comes with several prepared texts that the user reads to train the software. We are using the medical version of Dragon and it has several medical scripts to read. It's a fairly lengthy process that takes 2 or 3 hours to go through. However, it was immediately obvious that training the software made a big difference in how we could recognize my voice.

Also, as I do daily dictation, any errors that the software makes can be corrected and the program can be "trained" to recognize how I pronounce certain words. This has been very important with some medical vocabulary. However, I have found that, even with repeat training on the same word, Dragon keeps making the same mistake. For urologists, having to repeatedly correct "nephrostomy" (often misspelled as "frosty me") and "bladder" (often misspelled as "blatter") can be quite annoying. However, in this 3rd week that I've been using Dragon, I've been noticing marked improvements in how it recognizes my voice and gets the spelling correct. Or, perhaps I have become more accustomed to speaking slowly and clearly with better diction. Either way, I'm more satisfied this week than I was in the 1st 2 weeks.

Even so, it's obvious to me that using Dragon voice recognition takes a little bit longer than our traditional system of dictating into a recorder and then handing that recorder to our staff. Many of the corrections and all of the formatting of letters are then done by our transcription staff. The question is whether overall workflow improves (including initial dictation, proofreading and getting the letter out to the referring physician) with voice recognition software. After I had been using Dragon for 2 weeks, I did a little trial on this. I wanted to compare how long it took to dictate a consultation letter using Dragon versus how long our traditional dictation would take.

Initially, I thought I would measure the difference by timing how long it took to dictate a letter in Dragon, including any corrections. I would then do a "simulated dictation" by reading the Dragon letter that I had just dictated at about the same speed that I was used to dictating into a digital recorder. I expected that the 2nd reading would be quicker. But, it seemed it would be somewhat artificial because the 2nd reading would not require any references back to the chart to look up x-ray results or lab data.

With that in mind, I decided to do the simulated dictation first, including pauses to look back at chart results or think about what I wanted to say in the next sentence. I would then dictate the same consultation letter (from memory) in Dragon, trying to re-create the same content. I would pause to make corrections and also include the time for review/proofreading at the end of the Dragon dictation. This method probably wouldn't stand up to scientific scrutiny, but it seemed like a reasonable comparison for my needs.

I measured dictation for 4 patients (admittedly, a small sample size) on July 9. The average "simulated" dictation time (mm:ss) was 1:54, and the average Dragon time was 2:48.


I felt that 2 minutes would be the average time I would take to dictate a full consultation letter. The Dragon dictation took almost twice as long as that or, an additional 2 minutes. While this doesn't sound like much time, it's an extra half-hour of dictation for a half-day clinic of 16 patients. In one case, the Dragon dictation was especially lengthy as there were many medical/urologic terms that I had to correct, train the program for, or typed in by hand. This was quite frustrating.

Then, I realized that I had missed out one part of the workflow, namely receiving the simulated dictation back for proofreading. I didn't want to do a simulated proofreading immediately after I had just dictated these letters, as I felt it would not realistically represent the 2 to 3 day time lag between dictation (and familiarity with the patient's medical record) and review. I wanted to leave some time before reviewing the letters so that I would not remember details of lab results and x-ray reports. If it was necessary to refer back to the chart, I would include that time in the "review time".

The average review time for these 4 letters was 0:27.

This was somewhat artificial as well, because all the letters that I was reviewing were ones that I had already proofread as I dictated them in Dragon. I've corrected all the mistakes been, so it was just a case of reading straight through the letter. I did not need to stop and make corrections. Also, these particular letters didn't correspond to cases where there was a lot of lab data or x-ray information to review. So, the review time I have measured is probably the shortest possible time.

Even factoring in the review time, Dragon dictation is taking longer. As I mentioned before, I made these measurements when I had been using the voice recognition software for about 2 weeks. Over the last week, I have noticed a definite improvement in accuracy and my ability to dictate at a more rapid and natural pace of speech. In fact, I've been dictating all of this blog post in Dragon and have been quite pleased with the software's accuracy. Of course, I'm not using a lot of medical jargon and that does seem to make a difference.

During a trial period, 4 of us are testing the Dragon software. It's fairly expensive, and we didn't want to implement it for the whole office if it looked like it would not be useful. At this point, I think I will be sticking with the Dragon software, but I don't think it would be suitable for all of our partners. It required a lot of extra work for the 1st 2 weeks and there was a lot of frustration with having to make corrections and train the software properly. Unfortunately, all of that extra work has to be done while conducting all of our regular clinical work. If there were an obvious and pronounced workflow improvement, I think this would be a big selling point for my partners who are less "technologically keen". Perhaps I will get to the stage using Dragon that I can make that claim to them, but at present, I don't think it will be worth the frustration to them to try this software.

Obviously, we selected the 4 partners who were most keen on new technology to try out the Dragon voice recognition software. Even so, there have been different levels of enthusiasm and it's not clear that everyone is going to stick with using it. We will only know in retrospect whether it was worth trying. Even if just a few of us are using it however, we should save a significant amount of money on the transcription that we were previously outsourcing.

The uncertainty as to whether our trial of voice recognition software will turn out to be a success or failure made me think about that classic representation of diffusion of innovation -- the Rogers curve. Even if you don't recognize the name, you've likely seen this bell-shaped curve before. At one end of the curve are the innovators who take a risk in adopting changes very quickly. Early adopters are next, followed by the early majority. The late majority and laggards accept change last. The subtext of this model is that the innovators are brilliant and the laggards are Luddites.

This interpretation depends on which innovation you choose. For something that has, in retrospect, changed lives for the better, such as electricity or handwashing, then the Rogers curve makes sense. But, what if we choose an innovation that turns out to be unsuccessful or harmful, such as thalidomide or drilling a deep water oil well in the Gulf of Mexico? In that case, I propose a different version of the innovation uptake curve. (If you want to start calling it the Visvanathan curve, who am I to stop you?)

In this curve, the innovators would be "reckless", early adopters would be "foolhardy", and the early majority would be "conformists". The late majority would be "skeptics", and the laggards would be renamed "fine, sensible folk - brilliant, in fact!" It would all depend on whether or not time and society judged the particular innovation to be successful.

It remains to be seen whether trying the Dragon voice recognition software is going to rank me as an innovator or as reckless.

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.

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.

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!

Juice

The backyard of my parents’ winter home in Arizona sports an orange tree.

That’s quite a novelty for grandchildren visiting from Saskatchewan.

Grandpa likes a glass of fresh-squeezed orange juice for breakfast and asked if his 2 young grandsons would make it for him. The next morning, the boys rushed outside, filled a bag with oranges, and brought them back to the kitchen. There, they had worked out an assembly-line system to get Grandpa his juice. The older one sliced each orange in half and the younger one squeezed. And squeezed. And squeezed.

But a 3-year-old only squeezes a dribble of juice out of each orange before moving on to the next half. It wasn’t long before they had to pick more oranges. And then run to the neighbor’s yard to pick those oranges. And still, Grandpa’s glass wasn’t full of juice.

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.