Joy at work

It’s not often that I have a moment of joy in the middle of a cystoscopy clinic, but I had one last week.

A cystoscopy clinic makes for a busy morning. Over the course of 4 hours, I’ll see 12 to 14 patients. Each visit involves – at minimum - an endoscopic bladder examination, discussion of the findings, and sending the results to the referring physician. It may also involve meeting a patient for the first time, asking about their medical history, arranging further testing or scheduling surgery.

I’m constantly aware of wanting to stay on schedule so as not to keep people waiting. Unfortunately, that time pressure will sometimes make me feel rushed, and that can affect my patient’s experience.

Why not schedule more time for each patient, you may ask. For some patients, rather than the standard 15 minutes, I will allot 30, especially if I anticipate that someone may require additional procedures. However, each extra time slot assigned to one patient means that another patient waits longer for their cystoscopy. And, wait times are already lengthy. It’s a difficult balance to strike.

But, during one examination last week, I found myself in the unusual situation of being ahead of schedule. Even though it was my first meeting with this patient, and I needed extra time to ask about her medical history, discuss test results (she had a tumour in her bladder) and recommend surgery, I wasn’t rushed. In the middle of that discussion, I had my moment of joy.

While explaining to the lady about what I had found, and the recommended treatment, I realized that I felt relaxed and confident. I was paying attention to her reaction to my explanation. Was she upset? Was I using medical jargon? Had she understood? Did she have any questions? I wanted to reassure her.

This was how I wanted all my consultations to go. Not only because it made me feel good about myself, but because I’m convinced that I’m a better doctor when I feel that way. I may provide the same technical results regardless of my mood (maybe…), but I think patients have a better experience when I’m relaxed.

As I thought about this, I began to wonder why I couldn’t feel this way, and offer my patients a better experience, on a regular basis. I think there are internal and external factors. Internally, I may allow myself to become flustered. That’s a habit I can work on. Externally, it comes down to an access problem. Long wait lists translate into pressure to fit in as many patients as possible in a given clinic. That increases the chance of running late, and forces me to rush, leading to an unsatisfying experience for both me and my patients. (And for any staff who may be unfortunate enough to be in the vicinity…)

So, if we work on improving our cystoscopy access problem – applying the same principles of managing capacity and demand as we have in our office practice – patients may benefit not only through shorter waits, but also through the quality of their experience. And our doctors may be more satisfied.

I think we’ve found our next access project.

And a selling point: Bring the joy!

Loose lips

Hi, fellow health-care providers! Were your ears burning this week? They should have been, because people were talking about us.

Earlier this week, I met a man who, while not a health-care worker, is involved in a provincial health organization. Our conversation came around to a recent experience he had while one of his family members was being cared for in a local emergency department. His opinion was that there was a lack of professionalism demonstrated by the staff – physicians and nurses – in that ER. He had no complaints about the care provided to his relative. What troubled him was the seeming lack of concern for patient privacy and confidentiality.

He said it was impossible to ignore loud discussions that included details of other patient’s medical history and treatment, as well as staff’s “editorial comments” of their impressions about a patient’s demeanor. Some whispered comments were followed by laughter, which he admitted could have been innocent, but naturally made him wonder if some patients were being ridiculed.

His family member was admitted to hospital where he observed similar incidents on the ward. He was particularly annoyed that he regularly heard staff discussing their social lives at length, presumably while “on the clock”.

His final comments were that he was reluctant to raise his concerns with staff because he worried that it might have repercussions for his relative’s care, and also that he wondered who was responsible for overseeing appropriate staff behaviour.

Ouch! The truth hurts.

I’ve been guilty of these lapses, and see them regularly in the ER, hospital wards and other patient care areas. But, my first impulse was to explain to this man – who didn’t work in health-care – why this behaviour is sometimes unavoidable.

First of all, certain patient care areas – especially ERs, recovery rooms and critical care areas – bring together multiple patients, their families and medical staff in a confined space. Because staff needs to closely monitor the patients’ conditions, it’s not always possible to step away to a more private area to discuss care. Also, in order to be efficient, it’s sometimes more convenient for staff to have conversations about patients in the hallway outside a ward room, rather than searching for a more private spot.

However, I didn’t offer these reasons to the man, because my heart wasn’t in it. I knew they were more excuse than reason. We can do better. This experience had obviously affected his confidence in health-care providers, and empty explanations would only compound the problem.

Later in the week, I attended a meeting of our health region’s Patient and Family Centred Care advisory council. We heard a presentation about a proposed change in the ERs with the implementation of an electronic “white board”. Many ERs use a white board to keep track of patient status, pending tests, tentative diagnosis and consultations requested. While intended for staff use, they are often posted in very visible locations that anyone can see. As we move toward using a district-wide electronic medical record, these white boards will be replaced with large computer monitors that display the most current information about each ER patient. For example, if blood test results are ready, an alert would be displayed, letting staff know immediately that results can be reviewed. At present, staff need to remember to check intermittently to see if results are back, and this delays the next step in diagnosis and treatment.

While current (and proposed electronic versions) white boards don’t display patient names, that’s small comfort. Bed numbers are shown, so it’s easy to match the patient to the diagnosis. We rely on the anonymity granted by being a large urban centre, and the fact that it’s unlikely that ER visitors will know anyone who is currently being treated. But, what about smaller towns? And, good luck to you if you are a health-care worker being treated in the ER of your own workplace.

Imagine this scenario: You’re a consultant called down to the ER to see a patient. As you walk in, you see a colleague lying on a stretcher. As you walk by the white board, are you going to take a quick peek at his bed number to see what’s going on? Even if there isn’t a diagnosis given, you can see what tests are pending, and which medical service has been consulted. Cardiology? Uh-oh, probably a heart attack. Psychiatry? Hmm, interesting. Are you going to take a peek? No? C’mon, really?

The electronic white boards would not identify patients and, as was explained to us, the symbols on them would be somewhat cryptic so as to foil easy interpretation by unauthorized viewers. Well, short of using Klingon, I’m not sure we’ll have much success in disguising the symbols’ meaning. In any case, we don’t want staff to be confused as to their meaning as that would defeat the purpose of displaying them in the first place.

As one of the council’s community members pointed out, families might actually find white boards useful as a way to monitor their relative’s status and progress in the ER. In order to do that, they would need to understand the information and would naturally ask medical staff what it all meant, thus exposing the status of all ER patients.

Several community members commented that they would accept the display of patient information if it would improve the efficiency in the ER. Hearing that comment made me realize that we (health-care workers) are framing discussion about privacy issues in a way that makes patients and families feel that they are obliged to accept violation of their privacy in return for efficient and high-quality care. The impression that our community representatives had (because that’s the impression we gave them) was that, if we don’t prominently display private patient information, an ER can’t function properly. Take it or leave it. And, of course, when put like that, they’ll take it.

But, it’s a false dichotomy. There are more than 2 choices here. The beauty of digital information is that up-to-date data can populate many different devices simultaneously. We don’t need a Jumbotron blurting out patient status. Instead, display it on desktop monitors and iPhones. That’s my quick take on how to address the problem – someone else has likely solved it more elegantly. My point is that we shouldn’t ask patients to give up an important aspect of their care because it will be simpler (for us) to maintain the status quo. As another community representative put it, patients shouldn’t have to “settle”.

Now, back to the first gentleman’s observations about medical staff’s behaviour. He didn’t confront anyone at the time because he didn’t want his relative’s care to be affected. He also mentioned that he thought it wouldn’t make any difference even if he did raise it with the offenders. His rationale was that if people were far enough out of touch with appropriate professional behaviour that they were compromising privacy, they probably had a mindset that would not react well to criticism. Our system forced him to “settle”.

I asked him how he would fix the problem. He suggested that senior staff should be setting an example, by insisting that conversations take place in private locations, or at least by keeping voices low and being aware of who is within earshot.

Great idea, but not so easy to do. This behaviour is so much a part of our local culture that I think even senior staff would hesitate to be perceived as being critical of colleagues’ behaviour and labeled as “oversensitive”.

Maybe having staff hear about privacy concerns in patients’ and families’ own words would have an effect, in the same way this gentleman’s story had an effect on me. We could solicit feedback from clients regarding their impression of how their privacy was respected while they received medical care. Two or three questions would probably do it. This wouldn’t be a secret undertaking. On the contrary, we would inform staff that the survey was going on, and that they would see the results.

And, of course, we would post the results for the public to see. On the white board.

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!

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.

Show me the money

The latest Saskatchewan Medical Association “President’s Letter” had some encouraging tidbits in it. The SMA and Government are negotiating physicians’ fee-for-service agreement. Usually the focus is on the percent increase in global funding to physicians, but this time the newsletter mentions some initiatives the Ministry of Health is proposing around Quality and Access. “Clinical Practice Redesign” and “Dedicated Quality Improvement Work” are noted as areas for targeted funding. They’re both laudable, if as-yet undefined, goals.

But, I’m most interested in the suggestion that funding may be given for “Physician contacts with patients via telephone and email”. I think this has great potential for improving patient access and satisfaction.

I’ve heard from many patients that they have trouble reaching their family physician (or specialist) over the phone. They may have a quick question that could be handled over the phone, but instead are required by “office policy” to make an appointment to see the doctor in person. Last month, my wife was quite annoyed at being subjected to this approach when she wanted to find out the results (normal, as it turned out) of my son’s xrays. She drove across town, and waited to be seen, all to receive 30 seconds worth of information. That’s not good value.

We shouldn’t be surprised that doctors require patients to come in for a “face-to face”. (See a previous post about this: “Awkward”) There’s no value (i.e. fee code) assigned to alternate ways of communicating with patients. I spend between 30 and 60 minutes daily returning phone calls and emails, as well as writing patients letters about results or follow-up. That’s an unpaid hour of work. I’m sure that lawyers and accountants would shake their heads at that.

Even though I plan to continue to communicate with my patients like this, whether I get paid for it or not, I can envision ways that I might change my practice if this alternate communication gets its own fee code. At present, I see phone calls as “extras” that I fit in between “real” (i.e. billable) visits. If I were to be paid for phone calls, I might schedule blocks of time to make them. I could get calls done during regular hours rather than after the end of the scheduled workday. Also, my staff could tell my patients when they should expect a call. That would be more convenient for patients, and would likely reduce the amount of phone tag frustration. I don’t like it when the cable guy says he’ll be around “sometime between 9 and 5 on Wednesday”, and I’m sure patients don’t like to hear a similar message about when the doctor will return their call.

Dreamer

What part of your job don't you like?

A medical student asked me that as part of a Career Dialogue Q&A session last week. I'm lucky to have a great work-life, so I had to think a bit about that question. Later that afternoon, back at my office, I was reminded about one of the worst parts of my job: Telling my patients they have to wait.

Wait to see me. Wait for tests. Wait for results. Wait for treatment.

It really shouldn't bother me to have to do this. After all, it's so easy to do – my patients actually expect to hear it! When I apologize for wait times, they are usually sympathetic and rarely press the matter any further.

Sharing

Before I tell you about what’s exciting me this week, I want to share an exceptional service experience with you. Last month, I attended the Institute for Healthcare Improvement’s 10th Annual International Summit on Redesigning the Clinical Office Practice. (Great meeting, unwieldy name.) Deservedly, IHI has a reputation for providing outstanding value at their conferences. Virtually every session I attended was terrific, with energetic presenters and great ideas.

But, one session didn’t live up to its billing. Powerpoint slides overloaded with bullet points, presenters reading directly from slides while facing away from the audience, an uninspiring message unrelated to the course description in the conference handbook – all the vices I’ve repeatedly griped about, rolled up into one dreary session.

So I walked out. Life’s too short.

The conference guide offered a money-back satisfaction guarantee, so I decided to see what would happen if I actually complained. I talked to the staff at the registration desk, and they called the conference manager. She immediately offered me a full refund of my registration fee – no questions asked. That’s more than $1000! I backpedaled and said I would be satisfied to be refunded only the amount for the unsatisfactory seminar. She insisted that the guarantee promised a full refund, and that she would arrange it.

Wow! I was impressed (and a little worried that this might get me black-listed with IHI), especially since IHI has very little control over the independent contractors who present the seminars. I couldn’t wait to tell this story to everyone I knew at the conference. I admit to being a little skeptical about whether it would really happen, so I checked with the Health Quality Council (who sponsored my trip). The money had been refunded, almost before we returned from the meeting.

What a great example of customer-centred service:

• Trust your front-line staff to keep promises that your organization has made.
• Don’t make your customer jump through hoops after they’ve had a bad experience.
• Recognize that, even though your organization may not directly control every aspect of the process, it is still responsible for the outcome and the customer’s experience.

Okay, IHI, I get it – you model good behaviour. Nicely done. But are you going far enough with this guarantee?

Resolutions

In the spirit of January, let's first take a look back, and then see what the upcoming year promises.

Responses to my last post reinforced for me the idea that illustrating the principles of wait time management with examples from everyday life may be a powerful way to engage people in tackling similar problems in health care.

My experience in an airline's check-in queue led me to conclude that organizations sometimes make the conscious choice to give their clients bad experiences. The words that an organization's leaders and employees choose when communicating with clients can reinforce this dysfunction. When a clerk tells a customer, We can't do that, “can't” suggests the customer's request is a physical impossibility, something not only unreasonable, but fantastical.

When the response is We don't do that, the clerk retreats behind the corporate mantle. What you're asking is possible, but it's not part of our culture.

What's the honest phrase? Which words acknowledge the conscious choices service providers make? We won't do that. Or, even better, I won't do that. My organization chooses not to provide the service you're requesting. (Of course, this may be a completely reasonable statement for an employee to make, i.e., don't pull up to the Tim Horton's drive-through window and demand an oil change). Won't makes the individual and organization take responsibility for their action/inaction.

Here's my idea for a (snarky) T-shirt logo, suitable to be worn anytime you're at risk of receiving poor service:

Can't

Don't

Won't

At least be honest with me!

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.