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

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

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

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

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

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

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

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

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

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

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

Referral letter generated and sent to Cancer Clinic

Letter reviewed by triage clerk

Letter reviewed by Radiation Oncologist

Appointment date assigned

Consultation with Radiation Oncologist

Further testing (possibly)

Patient decision to proceed with treatment

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

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

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

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

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

97% = Fail.

Stick It

You can’t manage what you don’t measure.

Q:  What’s more annoying than a worn-out cliché?

A:  A worn-out cliché that keeps on proving itself right.

Measurement is a key component of Advanced Access. For us, it’s been a source of enlightenment and discovery. While we continue to use many of the same measuring sticks that we started off with, we’ve added some new measuring sticks that have yielded some surprises.

I’ve been telling you about our efforts to reduce recall rates/internal demand. Those tests of change (call them PDSAs if you must) arose after we tallied the number of patients each urologist was asking to come back for a repeat visit. I presumed that all of us had pretty similar practice habits, but some of our staff thought that those habits varied considerably. So we did some counting. The initial data is in “Bang for your Buck”. While we don’t know whether the higher rates or lower rates of recall are more clinically appropriate, our guess was that we could provide the same quality of care, yet have necessary follow-up provided in a setting other than a specialist office.