An important Division of Urology project comes home to roost

A couple of years ago, I attended a presentation about implementing change.  The speaker showed us this slide:

And waited...

At first, there was silence as we examined the picture for some hidden meaning.  Then came nervous laughter as the speaker remained silent.  After what seemed like 5 or 10 minutes (but was likely only 2 or 3), there was annoyed muttering around the room.

Finally, she moved on to this slide:

"It takes 21 days for a chicken egg to hatch," she told us.  "How much of the chick's development do you think happens on the 21st day?"

Her point was that, in change initiatives, even though we celebrate the dramatic final outcome, much of the ongoing effort toward achieving the goal is under-appreciated, yet critical to eventual success.

Last week, in the division of urology, one of our eggs hatched.


Thanks to the efforts of St. Paul's Hospital Foundation several years ago, generous donors have contributed to the establishment of a Urology Centre of Health.  While there will be a bricks-and-mortar aspect to this Centre, the real value is the service we'll provide for patients.  A crucial part of that is the development of a staff position that is new to our division and the Saskatoon Health Region: Nurse Navigator.  Our Nurse Navigator, Nicole, works on a range of quality improvement projects in our division, and one of those projects recently broke out of its shell.  A little background information is in order.

A common reason for urologic consultation is so a man can be evaluated for the possibility that he may have prostate cancer.  Our current process is for the man to see one of us in the office for discussion and examination.  We then decide whether or not he needs to undergo a prostate biopsy.   We contact him with the biopsy results and, if cancer is found, arrange an appointment to discuss treatment options.

Because of the nature of prostate cancer and the available treatments, that discussion takes between 45 and 60 minutes.  For some urologic cancers, such as kidney tumours, there is a single effective treatment, and so the discussion is fairly brief.  However, prostate cancer may be treated with surgery, radiation (with 2 varieties offered), or even observation.  It's a complex discussion that involves not only the technical aspects of treatment, statistics about success rates, but also men's relative preference/aversion for various side-effects.

Not only does it take a significant amount of specialist time to have the discussion, it is challenging to find time in our schedules to have this urgent conversation.  As such, men, having just been informed that they have cancer, may wait up to 2 weeks to hear about their treatment options.  We offer written and online material so they can inform themselves before the discussion, but those resources don't take the place of individual consultation.

Since the spring, we've been working toward having Nicole carry out those discussions.  Over several months, she's familiarized herself with the details of prostate cancer treatment.  Her previous work on the inpatient urology ward gave her experience with surgical treatment. She's visited the Cancer Clinics in Saskatoon and Vancouver to learn about radiation treatments.  Much of her time has been spent "shadowing" urologists as we discuss prostate cancer treatment with our patients.

After spending time as an observer in those discussions, Nicole then started to lead the discussion, with the urologist present as a resource.  More recently, she has been meeting with men independently.   Nicole had shadowed me on several occasions, but 2 weeks ago was the first time I had been solely the observer, with her leading the conversation.  All 4 of us - the man and his wife, Nicole and I - then reviewed any questions that arose.  I was completely satisfied that the man had received the same information I would have given him, and in an unbiased fashion.

The next day, another man was scheduled for "the talk".  Nicole met with him and his wife, and I joined them afterward.   The questions they asked of Nicole and me showed me that they had gained a good understanding of the complexities around the decision for prostate cancer treatment.

I had a sudden appreciation of how this new process would change things for our patients and our practice.  Having Nicole available to lead these discussions would free up 45-60 minutes of specialist time.  Those appointments had usually been scheduled during the most precious hours of our workday, that is, late afternoon, after we had finished operating and were wanting to return phone calls and review lab results.  Each of our 8 urologists may see 2 to 4 men a month with newly diagnosed prostate cancer.  Also, because our schedules are usually filled weeks in advance, our staff have to scramble to find openings in which we can have these urgent discussions, and the available openings are rarely as soon as we/our patients would like.  Nicole's ability to schedule more prompt appointments means that men will save up to 2 weeks in the journey from diagnosis to treatment.

When I thought about this a-ha/hatching moment, I also knew that a lot of work had gone into achieving a very satisfying result.  Nicole had designed her own education program, as there was no formal curriculum to guide her.  Several of my partners had spent time with Nicole, discussing the complexities of prostate cancer treatment.  My office staff made sure that Nicole knew about upcoming appointments for her to attend.

But, in the developmental stages of a project, team members may find it difficult to keep up their motivation when the final goal seems far away.   Going back to our egg-hatching example, this would be the equivalent of trying to keep a group of kindergarten students interested in incubating and hatching baby chicks.  When they see an unchanging shell day after day, their enthusiasm will wane.

To keep them interested, you could do this:

If you shine a bright light through an egg, you can see what's going on inside.  That will help our young students to understand that the chick is developing.

For our next divisional project, perhaps we should give all stakeholders regular peeks at progress by setting milestones and reporting when they're reached.  While it's a nice surprise for everyone to see a project finally hatch, those who are less immediately involved may be more inclined to nurture and protect the fragile work-in-progress if they can see what's going on inside the shell.



Now, let's drop the egg analogy.  We've learned something else through our Nurse Navigator's work.  And this may have more important benefits than the improved timeliness she brings to discussions around prostate cancer treatment.  As Nicole has observed all our urologists discussing treatment with men, she's noted differences in individual practices.  Some of the variation she's noticed involves recommendations for treatment and followup.  She wants to give consistent, best practice information to men, but also doesn't want to confuse them by telling them something that an individual urologist may contradict later, based on his/her own practice habits.

This is an opportunity for us to decide, as a group, whether there is a standard, best practice that our division should follow when advising men about prostate cancer treatment and followup.  Because we manage our individual office practices in isolation, we rarely have conversations about these more mundane (to us...) aspects of urology.  In academic centres with residency training programs, the postgraduate trainee serves as the bee, cross-pollinating ideas and practices from one staff urologist to another.  We don't have a residency program, so it looks like our Nurse Navigator will be the one to point out areas in which we can address practice variation.

Plays well with others

The backlog blitz is coming soon! Not soon enough, of course, but we still have some preparations to make.

Our biggest challenge comes from outside our office. Many patients referred to us require medical imaging – ultrasound or CT scanning – as part of their evaluation. If one of these tests is necessary, we try to coordinate it with the person’s first visit with us. For people traveling from out-of-town, that means the test needs to be scheduled on the same day as their office visit.

The problem? Medical imaging clinics have backlogs too. Wait times for ultrasounds and CTs can be weeks long. As we start to schedule appointments within 7-14 days, we’ll need better access to these tests. And it looks like we’re going to get it!

We contacted several of the private medical imaging clinics (for ultrasounds) and the health region’s medical imaging department (for CTs) to explain our situation and ask for their help. The response was gratifying. They have offered to hold a number of appointment slots for us. If the slots aren’t filled 7 days in advance, they will release the slots. This will be particularly valuable in the case of CT scans. Our staff spends a significant amount of time coordinating CTs and office appointments. Knowing in advance when CT times are available will simplify scheduling.

An in-house consideration is how we can streamline our appointment approval process. Currently, consultation requests arrive by fax and are reviewed by staff. A tentative appointment date is set, and staff forward the request to the urologist. Our staff is experienced in triaging consultation letters and anticipating what testing the patient may require. The urologist will review the letter and accept the arrangements, or ask for an earlier appointment time, or additional testing.

This process has worked for us in the current climate of 4-6 weeks wait times. That is, the physicians can leave the appointment approvals in their inboxes for several days without throwing off the scheduling process. However, when wait times are as short as 1-2 weeks, approvals will need to be much more prompt. We’re reminding the physicians of this and will track performance so as to offer individual encouragement as needed.

Ideally, turnaround time for appointment approval would be instantaneous. We can do this by setting guidelines for approving appointments for certain urologic conditions. With clear guidelines, staff can set up appointments and testing without needing to check with the physicians. Setting up this “pre-approval” process requires:

1. Clear and accurate description of the clinical problem in the referral letter

Sometimes, this is straightforward, as in the case of vasectomy referrals. The single word “vasectomy” is sufficient to let us know the purpose of the visit. Staff set up vasectomy appointments without needing review by the doc.

On other occasions, it’s not clear what the clinical problem is. This may be because there is uncertainty as to what the patient’s symptoms indicate, or what the test results mean. In this case, it’s up to the specialist to work toward a diagnosis. On other occasions, the information needed to make a diagnosis is available, but hasn’t been sent with the referral letter. For one common urologic problem – blood in the urine (hematuria) – we’ve had success with sending a diagnostic algorithm to referring physicians. Circulating this algorithm has greatly increased the amount of information we receive along with the initial referral letter. Setting up similar algorithms for common urologic conditions will simplify things for our staff and for referring physicians.

2. Consistent evaluation process by urologists

The hematuria algorithm was approved by our entire group. Ideally, we would have similar agreement on other diagnostic pathways. It’s not always easy, though.

I recently surveyed our group about how we should approach referrals about several common, benign urologic conditions. There was considerably more variation than I anticipated. Some of the docs supported giving guidelines to staff, while others want to review the referral letter and decide for themselves whether additional testing should be coordinated with the consultation appointment. Those urologists falling in the second group cited their desire for patients to have a single visit, whenever possible. They were concerned that they may miss the opportunity to schedule necessary testing at the time of that visit.

We may be able to reach consensus around pre-consultation testing, but in the meantime, I’ll try to determine individual preferences and compile them for our staff. Even though it’s somewhat complicated to deal with 8 different preferences, it should still speed up the appointment approval process.

See the Light

Last time, I told you about our plan to record the number of new consultations seen by each urologist, and then share the results with the whole group. The number of new consultations seen could be considered the basic currency of our practice, that is, each new consultation holds the same relative value. Once we're confident that our data is representative, we'll share it with all the urologists.

We did the same thing with our patient recall rates. That project revealed significant variations in recall rates among our docs. Although we never set actual target rates, we did encourage docs to come up with their own ways to modify their practices to reduce recall rates. I think much of that project's success resulted from showing the frequent-recallers that there was another way to do business. Their peers, working in the same environment, shared their ideas on making changes to engrained practice habits.

I hope for the same success with the latest project. I predict that we will find (once again) a significant variation, this time in the number of new consultations seen per physician. (Yes, I have peeked at the preliminary results.) We'll circulate that information and let the docs with low numbers formulate their own plans on how to modify their practices.

That's the plan I put forward at our office meeting this week. Some docs' response to that plan was pretty pointed.

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.