Long wait times for surgery? Never again!

There is absolutely no inevitability as long as there is a willingness to contemplate what is happening.

- Marshall McLuhan

When someone decides they want to have surgery performed, they usually want to know details: What will happen? Will it be painful? What are the complications?  But, even if they don't have a lot of questions about How and What, they almost always ask about When.

And that is often an awkward question to answer.

Our surgical booking system divides patients into 4 categories: emergency,cancer, urgent and elective.  While the first 3 categories denote pressing need for surgery, "elective" surgery indicates that the procedure can be delayed without significantly compromising the person's health or chance for a good outcome.  It's an arbitrary definition, and varies from surgeon to surgeon.  The perception of what should be considered "elective" certainly varies between surgeon and patient.

The Saskatchewan Surgical Initiative's (SkSI) goal is that, by 2014, all patients will have the option to have their surgery within 3 months.  ("Option", because some people may choose to delay their surgery until a more convenient time).  By the end of 2011-2012, the goal is to reduce all surgical wait times to less than 12 months.

A 12 month wait for surgery is shocking, and some people wait 18 months or longer!  The amazing thing about that is that we (patients, surgeons, administrators) have accepted this as inevitable.

But, we won't accept these waits for much longer.  Take a look at this trend: 

This is the number of people waiting longer than 12 months (top line) and 18 months (bottom line).  Over the last year, the numbers in each group have been halved!  While this trend had started (due to other provincial initiatives) even prior to SkSI's formal start in 2010, it has been bolstered by SkSI.  Additional OR time, as well as more effective use of that time, are helping to clear the "long wait" backlog.

This success isn't without a cost.  In our practice, we've been assigned additional OR time to provide service for our patients who have been waiting for over 12 months.  This means that the urologist will not be available to provide other important services, such as office consultation or cystoscopy clinics.  As such, wait times in those areas have increased.

There's nothing magical about how this wait time success is being achieved.  Health system leaders decided that this would be a strategic priority, and put attention and resources toward fixing it.  Leaders and managers are accountable for achieving targets.  With this approach, SkSI will meet its goals - whether by 2014 or not is just a quibble.  Then, once the SkSI goals are met, our healthcare system can focus on another strategic priority.

And that's when all SkSI's work will be in danger.

We can only concentrate on a few major initiatives at a time.  A fairly small number of people are involved in moving these projects ahead, and only have so much time and attention to go around.  Once we declare "Mission Accomplished" on surgical wait times, and move on to, say, Primary Care Reform, surgical wait times may creep back up.

In addition to reducing the surgical backlog, we need to build in sustainability, such as ongoing surveillance and transparent reporting of wait times.  More important is a critique of current practices - keeping the effective parts and redesigning the rest.  We need to create processes (e.g. pooled referrals, assessment and treatment pathways) that will survive the inevitable dimming of the spotlight currently illuminating the surgical system.  We can't rely on the hyper-vigilance associated with being the provincial priority du jour.

I look forward to the day when, as I hold forth in front of a group of medical students, they shake their heads and smile wryly at the old-timer's tall-tales of surgical wait lists longer than 3 months.

Private CT clinics: Cornucopia or Juggernaut?

Get your reading glasses on. And get ready to rumble. It’s time for health policy cagefighting! In this corner – the Advanced Access Afficionado. In the other corner – politicians, bureaucrats and political commentators. Guess who’s wearing black?

Last month, the Saskatchewan government announced that it was looking for a 3^rd party supplier to provide CT scan services (1). The intent is to reduce wait times. Of course, that got my attention.

(Note: Because some links to media sources seem to vanish unpredictably, I’ve included the text of all the stories referenced in this post in an appendix. If you try a link and it doesn’t lead anywhere, scroll down to the end of the post. P.S. July12,2010 -because of some concerns about copyright, have removed the text that was initially pasted at the end of this post. So, sorry if the links to op-eds turn into deadends. KV)

The article focused on the response from the opposition NDP party, namely that this was a step toward the piece-by-piece privatization of health care. Commentary by the Leader-Post’s Murray Mandryk (2) lambasted the NDP for being hypocritical and dogmatic in their opposition to privately-operated CT clinics.

Whether or not the NDP is hypocritical in opposing this CT clinic is beside the point. The clinic has been portrayed as necessary because Saskatchewan needs more CT scanning capacity. Fans of wait time reduction strategies should smell a rat. Healthcare wait times sometimes result from inadequate capacity, but more often result from a mismatch between demand and capacity. Over time, backlog builds, even when demand and capacity are balanced.

Adding permanent capacity to manage backlog will be successful, but in the end, is wasteful. Once the backlog is dealt with, you need to mothball that extra capacity. Expensive CT scanners, professional staff and clinic investors don’t like mothballs. That’s the point I tried to make in an op-ed response (3), giving our clinic’s experience with Advanced Access as an example of ways to cut wait times without permanently adding capacity.

Weighing in on the same issue was Steven Lewis who, in addition to providing some analysis around safety and appropriateness of CT scans (4), called for open discussion around the risks and benefits of a privately-operated clinic. Stan Rice expressed his skepticism (5) with a financial analysis of private vs public CT scanners.

Mandryk responded to the op-ed pieces with “Informed health debate overdue” (6). While his statement “Like me, many of you might be troubled by the underlying premise that we can somehow turn back the clock by performing fewer diagnostic tests” puts him firmly in the “more is better” camp, I agree with his call for debate around this issue. I don’t think it’s going to happen, though.

The government has already stated its intention to support the privately-operated CT clinic, and has called for proposals. Sask Health doesn’t lack expertise around wait time reduction strategies, so I can’t imagine that this decision was made without full (internal) discussion of alternatives. If I were in the decision-maker’s shoes, I can see the appeal of the private option. It’s actually easier to take this approach than opt for the drawn out process of increasing efficiency and appropriateness of testing. To saying nothing of having to change the culture of “more is better”!

I don’t doubt that this strategy is going to work. Wait times will drop. It will make for some very satisfying headlines. And, as long as that’s as deep as the analysis goes, certain skeptics will be invited to eat their words.

It’s very tempting to wonder why “they just don’t get it”. Why can’t “they” see this issue as clearly as me? But, as soon as I start thinking that way, I play the Switch game in my head. What is it in this situation that I’m missing? If I’m truly convinced that Advanced Access methods can reduce wait times and provide appropriate, timely testing for Saskatchewan, and that building privately-operated capacity is not the answer, what’s the appropriate forum for debate? What’s the best way to illustrate the admittedly counterintuitive principles of Advanced Access so that policy-makers will embrace them over the more expeditious solution?

If politicians are driven by the belief that citizens need the quick fix afforded by an extra CT scanner, maybe the audience to be convinced is the entire (voting) population of Saskatchewan. I think I’m in over my head.

In answer to the question in the title of this post, it’s both. It’s a juggernaut because it seems unstoppable. It’s a cornucopia because many patients will benefit from the bounty of increased capacity.

But, can you have such a bountiful harvest without some of the fruit going to waste? How much goes to waste, and whether anyone bothers to keep track, remains to be seen.

Scratching the Itch

I know you’re excited to find out how the blitz weeks went. I’m excited too. I’ll show you in a minute.

First, I want to tell you about the latest change we’re going to try in our practice. It’s so simple, and is already standard in many practices, so I was unsure if this change was even worth mentioning. But then I realized, That’s exactly the point!

When trying to implement Clinical Practice Redesign (CPR), simpler is better. This is especially true for practices that are new to CPR. Learning the processes, measurements and jargon of CPR can be intimidating and overwhelming. A simple practice change involves minimal investment of time and manpower, and minimal loss if the trial doesn’t succeed the first time.

Trying something that is already in place elsewhere also improves the chance of success. Someone else has already worked out the kinks and shown that the procedure is viable - in their practice, at least! While it can be very satisfying to develop a novel idea to solve a problem, it also requires a lot of effort. Better to borrow shamelessly.

So, here’s the plan: For men referred to have a vasectomy, we’re going to offer them a single-visit consultation and procedure. Yeah, I know – it’s a little underwhelming. But consider what this change involves, and what the process illustrates about making these changes in clinical practice.

1. Feel the itch

In general, I think of the whole change process as “Scratching the Itch”. (An iffy metaphor in a urology practice, but bear with me…) The specific itch I wanted to scratch this time was the value (or, lack thereof) my patients received when referred for a vasectomy. Our tradition is to see the man for a consultation in our office, ask about his medical history, examine him to determine suitability for the procedure, and then discuss what’s involved. If he is in agreement to go ahead, we schedule the vasectomy date, often 3 or 4 months from the initial visit.

Many men are surprised and disappointed to find out that they are not scheduled to have the vasectomy performed right then and there. I have offered several reasons why that doesn’t happen:

I perform vasectomies in the hospital outpatient clinic, and don’t have the necessary equipment at our office.

I need to examine the man first, as some men’s anatomy precludes doing the vasectomy under local anaesthetic in the outpatient clinic, and may require a booking in the operating room under general anaesthetic.

Some men only want to come for a consultation to find out what the procedure involves, and choose not to book the vasectomy at that time. If I scheduled an “all-in-one” visit, then the additional time scheduled to do the procedure would be wasted.

I’m sure those reasons often rang hollow with my patients, because they sure felt that way to me. The rebuttals were obvious:

Well, then, get some equipment in your office! Or, do everything in one visit at the hospital. I just drove 3 hours for a 5 minute visit! Now, I find out that I’ll have to come back for a second visit.

My own doctor examined me before he sent you the referral. He said everything was normal. How often do men need a general anaesthetic for a vasectomy, anyway? That can’t be too common.

I definitely want the vasectomy done. I would have told you that, if you had asked.

There was definitely an itch ready for scratching!

2. First, a gentle scratch

A couple of us scheduled a few vasectomy/consult all-in-one visits to work out any hitches. Hitches, what hitches? In fact, there was immediate, positive feedback from our patients who welcomed having everything done in one trip. We had sent all of them our vasectomy information pamphlet at the time we made their booking, so they were well-informed about what to expect during and after the procedure.

3. Then, scratch it hard

We presented the idea to our entire group. The selling points were better patient service and satisfaction, and fewer low-value (for the patient) office visits (which equals more capacity to see new consultations). We also addressed the potential problems with this change:

A no-show patient “wastes” valuable procedure time.

The man may not be suitable for vasectomy done with local anaesthetic, and need to be rebooked at a later date with a general anaesthetic. More wasted procedure time.

Combining the consultation with the procedure may take longer than the usual 30 minutes scheduled for a vasectomy alone, making us run late.

I think it’s important to present a balanced view of proposed changes. If skeptics sense that enthusiasts are charging blindly ahead, they step hard on the brakes. If that is their first impression of the proposal, negativity becomes entrenched and difficult to overcome. However, if you can show skeptics that you’ve considered and addressed potential risks, I think the proposal is judged on its own merits, rather than becoming a pawn in the broader skeptic vs. enthusiast tug-of-war. (In which battle, the skeptics have the huge advantage of inertia.)

Here’s how we addressed the potential risks:

We would require that men confirm their appointment time, in the same way patients have to confirm their date for surgery. This should reduce no-shows. However, we’ll track no-shows, and consider phone reminders if the numbers are significant.

If a referring GP comments on potential anatomical challenges in his referral letter, or the GP has unsuccessfully attempted the vasectomy, then we’ll arrange to see the man for a prior consultation in the office, rather than booking the vasectomy at the same visit.

We’ll schedule 45 minutes for a vasectomy/consultation, or 2 hours for 3 procedures.

The outcome? Everyone agreed to try it, and actually seemed quite keen.

4. “Does this rash look infected to you?” – Get a second opinion

I was pretty pleased with how it had gone, and how all the bases had been covered. But, I had forgotten one thing. I didn’t ask the people who know how our system really works – out staff. Delores pointed out to me that, in our current system, men receive their office appointment notification quite soon after they are referred. Even though they may wait several weeks to see us, they know that we have received the referral letter and have made arrangements. They will not find out about the date for the vasectomy until after the office visit, and may need to wait several months to have the procedure.

Delores went on to say that, in our new system, patients wouldn’t hear from us for several months. We schedule surgery up to several months in advance, and then plan office schedules and minor procedures (like vasectomies) around our OR time. Scheduling vasectomies comes last. Delores predicted that we would be swamped with phone calls from men who were wondering whether or not we had received their GP’s referral. That’s a waste of both the man’s and our staff’s time and energy.

Her solution was that, upon receipt of a vasectomy referral, staff would send the man a letter to let him know that we had his information and would be sending out an appointment in several weeks. Great idea!

I think this change will stick because it doesn’t involve a big change in physician behaviour. We’re taking 2 established practices – office visit, and vasectomy procedure – with which our docs are already comfortable, and redesigning them both to improve patient satisfaction and practice efficiency. Initially, I felt embarrassed to mention that we were making this change. I know it’s already standard procedure in many practices, so I thought someone would read this lengthy dissection, slap himself on the forehead and say “Duh! What took you so long?”

The point here, and in any practice that is trying to improve, is that the changes that make a difference are small and mundane. Individually, they seem trifling, but will eventually coalesce into something powerful.

Let’s celebrate each other’s small victories.

And now, blitz week results! These are hot off the press. The last data point is from May 6 – the end of 7 weeks of extra office capacity.

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The trend looks good!

And means nothing. Seven weeks of office blitz will only have been worth it if we can maintain the gains. We need to see the long-term results, and our annual nemesis is almost upon us. Curse you, summertime, with your unquenchable 30-new-referrals-a-day demand and capacity-hobbling holidays, curse you!

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.

Blitz

I haven’t showed you this in a while:






I groaned when I saw the spike in mid-November, but the mid-December peak was even more discouraging. I remember how exciting it was to see the results we had in early 2008. What’s gone on since then to put our wait times up?

Around the time 3rd NAA started to climb in 2008, 3 of our partners had switched to half-time practice. This moved us from 9 FTE to 7.5 FTE. Coincident with that change, we noted an increase in the number of referrals from Regina. There were only 2 urologists in Regina at that time, and their wait times were lengthy. This has been a longstanding situation, but we found that some Regina GPs had recently “discovered” us and were suggesting to their patients that they could see a urologist in Saskatoon more promptly. As word spread in Regina, more GPs (and their patients) would take advantage of our services.

So, it seemed to be a combination of reduced capacity and increased demand. In that context, one could conclude that, even though our 3rd NAA has risen since 2008 (now equaling our original baseline), that our overall processes must have improved because we’re doing more with less. If we hadn’t made some the changes through Advanced Access, our 3rd NAA would likely be much higher.

Well, that’s cold comfort. We remain committed to our goal of a 2-week wait time for all consultations. And, we know what the barrier is.

Because the wait times have been pretty steady this year, the problem remains the same: backlog. In a stable system, if we can trim the backlog, our system should drop to a new, lower level. And that’s where the recent spikes in 3rd NAA turn out to be a blessing in disguise.

In November, several of us noted that some patients were waiting until March to see us. The 3rd NAA is an average, so some unfortunate patients at the far end of the curve have very long waits. We know what a burden that is for our patients, and it’s not the way we want to provide service. This prompted Peter Lau to surprise us with a proposal.

We know the backlog is our big challenge. We’ve picked away at the edges of it by having half-time partners come in to work on their months off, staying late to see more patients, and filling in any open slots in the docs’ calendars. But, still the backlog eludes us. It just doesn’t look like we have any extra capacity to work with. Until Peter found it for us.

He proposed that we each give up a week out of our annual holiday allotment, and spend that week in the office seeing patients. We take our holiday time pretty seriously in our practice; it’s one of the main perqs of working in a large group. So, before taking the idea to the group, we wanted to be confident that it had a (theoretical) chance of success.

Our current backlog is about 800-850 patients. If one urologist spent 5 8-hour days in the office seeing, on average, 3 patients per hour, he or she would see 120 patients in that week. As one of our half-time partners has just retired, we now have 7 FTE docs, so the proposed backlog blitz would deal with about 840 patients. What a coincidence!

Our proposal to the group was that, starting in the spring, we would schedule each of us to work one of 7 consecutive weeks. In order to make this more palatable, we suggested that during each urologist’s week, they would focus solely on office work – no call, no surgery, no fielding phone calls from referring docs. Staff would behave as if that urologist were actually away from the office on holiday. We felt this would be an important feature of a blitz week, otherwise, the doc in the office would become the go-to person for every phone call and query that came into the office.

Rather than spring the idea on the group, we informally shopped it around a bit first. We felt it was a radical enough proposal that surprising everyone with it at an office meeting could trigger a negative (and understandable) response. I was nervous as Peter made the pitch. What could possibly motivate the group to give up an entire week of holidays?

The response: Let’s do it. Immediate and unanimous! It’s difficult to express the pride I felt at being a part of a group that would so readily give up personal, family time in order to improve patient care.

So, from March 22 to May 7, we will be crushing our backlog. However, as we plan for the blitz, we see that this means a significant change in our office practices, from notifying patients to booking ancillary tests, such as CT scans and ultrasounds. We’re working on identifying these challenges and creating new processes. More on that next time.

Backlog, Schmacklog

“Get your body beach-ready!” trumpet the magazines lining the supermarket checkout. It’s an annual ritual for Canadians: Emerge from hibernation, decide to tone up and trim down, then embark on a crash diet and/or exercise.

But, to what end? Is a “beach-ready body” the ultimate goal? For some, it is; quick and dirty does the trick for them. For others, a slim physique is the eventual (but not certain) by-product of a different goal: a sustainable healthy diet and exercise program to achieve long-term wellbeing.

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We continue to struggle with our pesky backlog. Trimming the backlog will not only satisfy the primary goal of our Advanced Access project – improving patient access – but will also let us benefit from reduced administrative load and increased flexibility in physician scheduling. But, as Advanced Access evolved into a broader Clinical Practice Redesign project, our goal has changed also. Improving patient access alone (although a worthwhile goal on its own) doesn’t necessarily give our patients better care.

Liposuction can rapidly reduce someone’s corporeal backlog, yet they may continue to clog their arteries with cheeseburgers. In medical practice, a “brute force” approach to backlog reduction is the equivalent of liposuction. By working longer hours, cramming more patients into appointment slots, or recruiting temporary locum help, we can have a buff-looking practice, pronto. But when patients come through the door in 7 days rather then 70 days, they’re getting the same type of care as before the wait list slimmed down. (And having learned a lesson in my last post, let me point out that our current care is not bad. But, there’s always room for improvement.)