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!

Collateral damage

If you work in Saskatchewan healthcare, Budget Day, March 24^th, may be an early April 1^st for you. We’ve been living high on the potash hog, but no longer. The government has been dropping broad hints about holding the line on healthcare spending. And with fixed costs increasing, “holding the line” really means “cutting back”. We immediately think of job losses, program shutdowns and spending freezes. But the most profound and prolonged impact of budget cuts will come from the least heralded casualty: Quality improvement.

With healthcare spending (rumored to be) capped at a 3% increase, and layoffs already starting in some health regions, it’s only a matter of time before someone opines “We need to work smarter”, or “We need to do more with less”. Nice slogans, but it’s not going to happen in a climate of financial restraint and job-security anxiety.

Saskatchewan has the capability to provide exceptional healthcare. The Patient First review, while outlining many of the deep flaws in the system, also told the stories of patients who received exceptional care. By definition, exceptional care required providers to go above and beyond what the system would routinely provide. The system in which we work constrains the level of care that we can provide. It needs to change.

Individual providers - nurses, doctors, physiotherapists, pharmacists, housekeeping staff and all the other people who provide health care - are rarely the problem. We want to give the best care we can to our patients – our neighbors, friends and family. Marshall McLuhan said “There are no passengers on spaceship Earth. We are all crew.” The same idea applies to healthcare. Although we often draw an arbitrary line between patient and provider, we’re all just an icy sidewalk or a Big Mac away from becoming healthcare clients. We all want to improve the system, even if it’s for purely selfish reasons.

So, how will we improve the care we provide? Perhaps through traditional methods like seminars, on-the-job mentoring and reading journal articles. Regardless of how we go about it, improvement requires individual effort, time and resources. But, individual effort can only take us so far. Coordinated efforts to improve the broader system pay greater dividends, and also require greater investment.

In Saskatoon Health Region, there are many quality improvement (QI) initiatives underway - Electronic Health Records, Quality as a Business Strategy, Patient and Family-Centred Care – to name a few. But these efforts are largely still in the planning stages, and haven’t been rolled out to staff and patients. They creep along underneath the radar. And, as such, are prime targets for the budgetary axe.

It almost makes sense to cut QI initiatives. Canceling meetings frees up the time of busy administrators and managers. Conferences and workshops cost money that could be directed toward patient care. And what’s the point in developing an Electronic Health Record strategy when the provincial government isn’t going to fund it in the near future? If any of these arguments seem convincing to you, then welcome back to the bad old days when QI work was just a garnish on the meat and potatoes of providing clinical services.

Even if the QI budget isn’t actually cut, crisis management distracts us from improvement work. As a recent example, preparing for the H1N1 flu “crisis” became a priority in the health regions, resulting in several month’s of cancelled quality improvement project meetings. Planning layoffs and program cuts will be even more time-consuming.

I’ve heard suggestions that the economic downturn will be very short-lived and that potash revenues will soon rebound. If we hunker down, put QI on hold for a year, then start up again, we won’t have lost much, right? Wrong.

While we can dust off the QI projects and start again where we left off, the irretrievable opportunity cost will be staff engagement. In “Seven-year Itch”, I whined about how impatient I was getting at (my perception of) the slow progress on the QI front. If current projects screech from glacial to full-stop, it will be extremely difficult to convince staff, and especially physicians, to re-engage once the budget freeze is over. Salaried SHR employees will be back, certainly, but what about those of us who work at QI projects in addition to running our full-time, fee-for-service clinical practices? Only the most ridiculously committed enthusiasts (AKA suckers for punishment) will step up for a second round.

Cutting resources to QI work will cement the status quo. And the status quo is like keeping your money under your mattress – inflation keeps chipping away at its value.

So, just give healthcare a 10% budget increase, and everything will be fine, right? Wrong again. Budget cuts squash change, but the current method of funding rewards painfully slow improvement. In the same way that the care we provide needs to improve, we need to change the methods we use to implement those improvements. We need strong incentives to promote change. We need clear direction from political leaders.

Here’s a surgeon’s politically naïve take on the problem:

Gangrene is a serious infection. It needs prompt treatment to save life and limb. Administering antibiotics may buy some time, but the patient needs radical surgery.

An inexperienced surgeon is tempted to trim away a little of the gangrenous tissue, not wanting to damage healthy tissue, and hoping to save the patient disfigurement. And so, the infection persists, and the patient returns to the operating room for more extensive surgery, now further weakened by the infection.

Our patient has the best chance for recovery in the hands of an aggressive surgeon, who cuts deeply – sometimes to the astonishment of those observing – until healthy tissue is widely exposed. Some healthy tissue must be sacrificed, to ensure thoroughness. Our patient will need plenty of care and attention to promote healing, but he will survive.

So, maybe we need deeper budget cuts. Timid budget restrictions encourage administrators to nibble away small pieces in each department. As I noted above, some novice observers are surprised at the extent of surgery needed to excise gangrene. But, the same observers would be rightly horrified if the surgeon began to cut away tissue from body parts unaffected by disease.

So go ahead with deeper cuts, but offer to make up the difference through targeted funding. Clear direction and strong incentives from politicians and governing boards will direct administrators to make deep, yet appropriate changes. Require health regions to measure and produce outcomes around quality and patient experience. Fund efforts to achieve those outcomes. Insist on prompt timelines. Encourage cooperation between regions. Recognize that positive change requires significant investment.

Don’t waste a good crisis. Save this patient.

Seven-year Itch

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

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

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

That was a very gratifying and immediate result.

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

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

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

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

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

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

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

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

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

I’m an action junkie. Give me my fix.

Mea Culpa

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

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