Don't ask people if they're satisfied with the status quo until you've shown them what's possible

As I walked by my son's room, I heard a familiar song playing on his radio.

"Hey", I said, "That's a classic!. Alone, by Heart, right?"

"Who's Heart," he asked. "Anyway, this isn't them."

As I listened to the song, I realized it was a remake of the Heart tune. A passable remake, workmanlike, but missing the beautiful original arrangement and powerful vocals. I told him so.

"Well, I think this is a good version," he replied.

I whipped out my iPod and cued up the original version.

"Oh, yeah," he said, seeing the light (circa 1987). "That is better!"

So, how do you know how good something can be if you've never experienced it?


Provincial patient surveys show a high rate of satisfaction with healthcare.  A survey late last year, showed that half of Saskatchewan residents surveyed rated their healthcare as good - the highest rating in the country.

But, "good" compared to what?  How many people surveyed know what's actually possible?

What would the results be if we showed people how their care could be delivered, such as using the US Veterans' Administration comprehensive electronic medical record?  Or Jonkoping's streamlining of patient flow through consideration of the needs of their prototype patient, Esther?  Or Alberta's systems innovations in providing joint replacement surgery?

Here's an interesting experiment: Educate one group of people about healthcare's best practices around the world.  Leave another group uninformed. Then give them the healthcare satisfaction survey.

OR chatter: Let your patient be your guide

In follow-up to a recent post about paying attention in the OR, Greg Basky posted a comment about an incident in B.C.   A patient was concerned that intraoperative hockey chatter would distract the surgeon from the operation, done under local anaesthetic.  A couple of things struck me about this story.

First, this type of chatter goes on all the time.  I usually talk with men while I'm performing their vasectomy and they often comment that it helps them relax and distracts them from what's going on.  For a routine procedure, it doesn't distract me.  If I need to focus more on the procedure, I'll stop talking.  There's only the two of us in the room, so I wouldn't be having a conversation with a third person.

But, this is utterly beside the point.  It doesn't matter that I can chat without being distracted.  What matters is how the patient feels about the conversation.

I engage in the conversation just enough to get the man talking about something he's interested in: family, work - even hockey...  It's a deliberate technique to make him more relaxed.  (I've heard people suggest that, when driving a car, you're less distracted by a conversation with a passenger than you would be by talking to someone on your cellphone, even with hands-free.  I'm not sure why, but I think it's a similar situation if the surgeon is having a conversation with the patient vs. a third party.)

However, some men prefer that we not chat, and instead want to use their own method of relaxation.   That's fine with me.

Surgeons and OR staff may scoff at the idea that they could be distracted by mere conversation.  I disagree with that, but would let that point stand in the absence of evidence to the contrary.  However, we can't ignore the effect it has on patients and their perception of care.  The case reported to the B.C. College of Physicians and Surgeons is undoubtably the tip of the iceberg.

As I mentioned in the previous post, I think that casual chatter in the OR can be relaxing during a long case.  It has its place.  But, when patients are awake during procedures, we need to be aware - to the point of hyper-sensitivity - of their needs and perceptions.  (Note to the OR staff in my room: That's the reason why, when we're operating on someone using spinal anaesthetic, you might think the cat's got my tongue.  I prefer not to chat unless it's related to the operation we're doing or about to do.  You may think I'm giving you the silent treatment because I'm upset about something.  I'm not (usually).  I guess I could have explained that to you previously.  Like 20 years ago.)

The second thing that struck me was the content of different articles on this story.  Take a look at the National Post and the Leader-Post versions.  The Leader-Post (and Calgary Herald and Vancouver Sun) versions included Registrar Heidi Oetter's comments that our behaviour in the OR should be patient-centred, whether related to conversations or choice of music.  I would be interested to know why the National Post editors chose to strike those comments in their version.  Those comments are the soul of this issue.

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.

Come on in… The water’s fine!

Since we started encouraging pooled referrals, we’ve never looked back. If you’ve been following our Clinical Practice Redesign work, you know that we consider the pooled referral to be our default condition, that is, anyone referred to our group is automatically scheduled for the earliest appointment available with any urologist. (Caveats: If the problem requires subspecialty expertise, we look after triaging to the appropriate urologist. If the patient already has a relationship with one of our physicians, we try to maintain continuity of care by scheduling the appointment with the same physician. Most importantly, the patient or referring physician can specify which urologist they prefer, and we will schedule the appointment with that doc. The wait may be longer in that case.)

I like the analogy of an ice-cube tray to illustrate the advantages of a pooled referral system. When you pour water (referred patients/demand) into one compartment of an ice-cube tray (specialists/capacity), the water automatically spills over into the other compartments until they are all filled. The result will be even and efficient distribution of water. Unless overall demand exceeds the tray’s total capacity, all the water will be accommodated. Overflowing water represents excess wait times.

The alternate model is to cut up the tray into separate ice-cube compartments, and then fill the compartments individually. Not only does that require more effort (you have to move the water jug from one compartment to the next), but also there is more risk of overflow. In this model, if individual compartment capacity is exceeded, water will spill. Some compartments may be underfilled. This model is inefficient because the compartments don’t work as a system.

One day soon, you’ll be thanking me for providing this sweet analogy, because I think pooled referrals are soon going to be a topic of conversation in Saskatchewan. And, when someone mentions them at a party, you’ll be knocking socks off with the ice-cube tray story. You’re welcome.

Why the interest in pooled referrals? Because of the Saskatchewan Surgical Initiative! SSI says that by 2014, no one in Saskatchewan will wait more than 3 months for surgery. That’s bold. But, other health systems have achieved it. The methods they used are well-known, and applicable to Saskatchewan. One of the most powerful methods is pooled referrals. (Still don’t believe me? Check the 2-pager highlighting the SSI plan.)

So how will SSI get us from here to there? First, we need to know what “here” and “there” are.

“Here”

Our current state is the 2nd ice-cube tray model (see above). Most specialists are “organized” in solo or small-group practices. Even when they are physically congregated as a larger group, the individual members of that group still behave as solo practitioners as far as distribution of referrals is concerned. Often, large specialty groups are just a device to share office expenses and on-call duties. Not that there’s anything wrong with that.

Most Saskatchewan specialists have plenty of work to do, so there’s very little perceived incentive to share a common pool of referrals. They may even be worried that they will be “giving away work” if they participate in a pooled referral scheme.

GPs often have established referral patterns based on their experience with a certain specialist, and their judgment of that surgeon’s expertise. Or, they may be golf buddies. GPs who are new to the province, and are practicing in solo, rural practices, may not have developed a personal relationship with many specialists, and may be uncertain as to which one will best serve their patient’s needs effectively and promptly. There are recent efforts to make referral-to-consultation wait times available to GPs via a website, but the information is self-reported by specialists. Participation by specialists is not mandatory, nor is the information audited or verifiable.

Patients are even more in the dark. They rely on their GP’s advice, or talk to friends and family who may have been referred to a certain specialist. They have virtually no information on individual wait times. They may not receive confirmation of the appointment for several weeks.

The system is working great for us specialists, because we always have plenty of work, and it’s delivered straight to our front door. Everyone else… not so good.

“There”

The “ideal” state I’ve most often heard described goes something like this:

GPs submit referrals through a centralized online system. Artificial intelligence (AI) software asks for key clinical information to ascertain which specialty would deal with the patient’s condition. The system tracks all available specialists’ wait times and subspecialty interests. The patient is then assigned to the appropriate specialist with the shortest wait time, and receives the appointment date before leaving the GP’s office.

Whoa. Ease up on the 1984, Jackboots! This system would be maximally efficient, but very restrictive. There would be little choice given to patients, even though they would be assured of the shortest wait time possible.

If we imagine a system guided by patient-centredness, we may sacrifice some efficiency, yet improve overall satisfaction. Keep the centralized online system with AI. When GP and patient jointly submit clinical information, have the AI suggest alternatives to specialist referral (alternate provider, care pathways, patient education resources). If a specialist referral is appropriate, the system gives the patient all the information he/she needs to make a choice. Some patients may still prefer that their GP choose a specialist. Others may want to know wait time information, subspecialty interests, results of patient satisfaction surveys, and even condition- or procedure-specific outcome data. The choice remains up to the fully-informed patient.

Because concern over long wait times tends to trump all other considerations, we generally ignore the other factors that affect patient choice of a consultant. (During a famine, one overlooks a little mold on a loaf of bread.) Once wait times are better managed, and therefore shorter, patients will behave more like well-informed consumers. The balance will shift from a seller’s market (favoring specialists) to a buyer’s market (more choice for users). Patients will start to consider geographic convenience, surgeon experience and outcomes, other patient’s satisfaction with that specialist, in addition to the wait time.

The trip from here to there

How do we make our way through the wilderness to reach this utopia of patient-centredness? First, we could talk to people who’ve already made the journey.

While many specialists consider pooled referrals to be a radical change, they are actually more familiar with the concept than they may realize. Some specialties already use a pooled referral model. Radiology is a prime example. When I order an xray, I accept that the test will be interpreted by the radiologist on duty that day. Because of subspecialty interests, some work may be streamed toward a specific radiologist. I have the option to have the xray films reviewed by another radiologist if I choose.

In order to be confident in the pooled radiology system, I have to be satisfied that the quality of work is consistent among all the radiologists. This is a tricky subject to raise if we’re considering implementing a pooled referral system, yet it’s critical that we address it. All specialists are not created equal. Differences in knowledge, skills and attitude all affect performance. How will a pooled system function if some of the participants don’t perform to a common standard? This is an important consideration for patients using the pooled system, but also for the specialists in the pool.

An objection sometimes voiced by specialists, regarding pooled referrals, is that they don’t want to work with Dr. X because they don’t respect his/her abilities. (Note: This is rarely stated at the meeting, and sometimes requires administration of a few drinks after the meeting. In vino, veritas.) Whether this objection is based on actual clinical shortcomings, or just personality conflicts, it’s still important to acknowledge it as a barrier to implementing pooled referrals.

Next, we need to think of a way to get everyone into the car, i.e. incentives. For patients, we should offer something beyond just the shortest wait time possible. The referral system should direct the patient toward appropriate care (which may not be referral to a specialist) within a reasonable time frame, with the provider of their choice.

For GPs, our system should reduce their paperwork burden, and increase job satisfaction. An electronic referral system that lists all specialists’ interests and wait times, as well as the information specialists want to accompany the referral request, would simplify the GPs job. If the electronic referral system also included expert information on how to manage common clinical problems before considering referral, GPs could provide more service to their patients in their own practice.

Incentives for specialists are a little trickier. We already have plenty of work to do. We are, for the most part, well paid. We value our autonomy, i.e. I choose my own practice group.

Honestly, I don’t know how to motivate specialists to participate in a province-wide, pooled referral system. And that’s why I think we should let patients and GPs drive this initiative. They are the ones with the most to gain.

First steps

Start by collecting reliable information that patients and GPs want. Of course, we first need to ask them what they want, but I have a few suggestions. Collect information from all surgeons regarding their specialty and subspecialty. Develop a method to measure and verify wait times from referral to consultation. Post all this information on an open-access website. Publicize the website. Eventually, the site could include patient satisfaction survey results, and outcome data.

Next, implement an electronic referral system. Other provinces have a headstart on these systems, so we should beg, borrow or steal. Or offer to collaborate. Pay a premium to GPs and specialists who use this system, but make sure the system is useful and user-friendly enough that they want to use it even without being paid extra.

Finally, don’t try to push specialists into a pooled referral system. Instead, set clear and realistic expectations for wait times and offer specific incentives to achieve those goals. Provide support and training for specialists who wish to implement changes (including, but not limited to, pooled referrals) in their practices. Acknowledge and address real barriers (personal and professional) to adopting pooled referrals. Do not expect busy clinicians to implement these changes on their own. Praise – publicly and frequently - the practices that achieve the goals.

Establish a new level of expectation in Saskatchewan: Patients are entitled to the information necessary to make a decision about which specialist they wish to see.

Turn up the heat until everyone wants to jump into the pool.

A Thousand Cuts

Initiatives to reduce wait times for surgery generally focus on the interval from when the surgeon submits a booking to when the surgery is completed. It's hard to imagine a less client-centred measurement.

The time from booking to surgery describes the system’s awareness of the client's need. But, that person has been aware of their need since the onset of symptoms, or the finding of an abnormal lab or x-ray result by their primary care practitioner. A common example of this in urologic practice is the man who has an abnormal PSA (prostate-specific antigen) blood test during his annual medical review. This triggers a series of other events (read: waits) that may culminate in the diagnosis and treatment of prostate cancer.

The series of events looks like this:

1. PSA blood test
   
2. Consultation with Urologist
   
3. Prostate biopsy
   
4. Definitive treatment (radiation or surgery), if cancer is diagnosed

That's a pretty high-level view of the man's journey through the system. Of course, I mean that's how the system usually looks at the process. The man may see it like this: