97% fail - redux

"Bohica" throws down the gauntlet with a passionate comment about 97% is not a passing mark!  She's from Saskatchewan and now lives in the US.  She'd like to retire in Sask., but is worried about access to medical care.  She describes specialist availability where she lives like this: I get an apology if I wait longer than a week.

Enviable.  But, she also has suggestions on how to achieve this.  Essentially, we need to get rid of all the triage steps in the referral process.  As she says:

Remove First Referral Letter, which can be sent while waiting for your first appointment (appointment having already been made).

Remove Referral by Triage 

Remove Letter reviewed by oncologist (he will have the letter by the time your appointment rolls around).

Your GP gets your results and calls the triage clerk and says, "I have this person with prostate cancer/symptoms of prostate cancer. When can I get him in?

Great idea.  Make the appointment first, then fill in the details later.  I like it, probably because it's very much what our clinic already tries to do.  

If all consultants were to implement this process, there's one element essential for its success: Trust.  I need to trust that the referring doctor is going to send all the necessary information if I "give up" one of my time slots.  It's not quite as selfish as it sounds.  

Occasionally, a referred patient may not actually have a urology problem.  For example, I will sometimes have patients referred to me with a hernia or kidney failure.  When I receive such a referral, I'll let the referring doctor know which specialist would be more suitable for their patient's needs.  It would have been a waste of time for that patient to see me.  (FYI: I would still get paid for the visit.) 

Sometimes, a referred patient may have a problem that could be dealt with by the referring doc, with advice from the urologist.  In this case, a reply letter obviates a consultation visit.

Most of the time, I want to know about the patient's situation ahead of time so that I can coordinate necessary testing with the consultation appointment.  This saves the patient travel time and expense, and let's me provide "one-stop-shop" service.

Although it feels uncomfortable to put it this way, specialists are reluctant to give referring docs (or rather, patients) free access to our available time, because we don't trust that the patient has a problem that needs our attention, or that appropriate investigations will be done prior to our consultation.

We can build that trust through better communication.  Our best example of this is our streamlined hematuria referral process.  We provide family doctors with a template of tests that we ask to be completed when they refer someone with blood in the urine.  If these tests are done in advance of the consultation (and if the doctor has our hematuria template, they usually are done), then we can consolidate the visit and necessary testing into one visit.

In 97% is not a passing mark, I mentioned that one of the few doctors I, as a specialist, refer patients to is an oncologist.  Even though my referral letters are (I think) quite complete, they still have to go through the triage process, which delays the patient's visit.   This means that the oncologist doesn't trust me.  

I'm very pleased to see the wait time targets mentioned by Colum Smith in today's Star-Phoenix.  

(Saskatchewan Cancer Agency) has set aggressive goals for patient care during the next five years — including that every patient be contacted within 24 hours of referral and that 90 per cent of them be seen within one week after referral, said Dr. Colum Smith, vice-president of medical affairs for the cancer agency

Developing trust between referring physicians and consultants will surely play a big role in reaching that goal.

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!

Semi-transparent

I’ve been feeling guilty since my last post. I hadn’t shown you our 3^rd NAA/wait time chart for many months, and if you’ve been following our adventures, you know that the 3^rd NAA was the raison d’être of this project. When I finally posted the recent data, it was in anticipation of our upcoming backlog blitz that should drop the 3^rd NAA to our target level of 2 weeks.

Our Advanced Access project has broadened to a Clinical Practice Redesign effort, and so has a wider range of goings-on to share in this blog. However, I’m aware that I’ve used that wealth of material as an excuse to avoid exposing our biggest failure: we have not beaten the backlog, and our patients continue to wait too long for their consultations.

I rationalized it beautifully in the last post, didn’t I? I pointed out that the number of FTE urologists in Saskatchewan had dropped over the last few years, and that we were lucky the wait times hadn’t soared as a result of the manpower situation. And, I sweetened the bitterness of showing a stagnant 3^rd NAA trend by breaking the exciting news of the backlog blitz.

Why did I keep this under wraps for so long? Here are a few reasons:

As the project lead, I find it frustrating and embarrassing to admit that, while we’ve had success in other areas (there’s that rationalization again!), the main goal eludes us.

When I share our results at meetings and with colleagues, I feel it undermines my credibility as a “champion” for this type of quality improvement.

Other physicians may be reluctant to start similar projects if they see early adopters are struggling to achieve durable results.

Blog posts about an unchanging 3^rd NAA would be pretty dry. (Lame reason, I admit.)

I have no malicious intent, and I have never knowingly posted misleading data. However, I recognize that withheld information can affect decisions, impressions and outcomes as much as incorrect information can.

In this case, our Clinical Practice Redesign project continues because we’re excited about the positive changes that we see coming from it. The 3^rd NAA data is simply a way we measure our progress and consider other improvements that we can make. As such, apart from the reasons noted above, there’s little risk in sharing the data (flattering or not) with you.

But that’s the case in our group; what if the situation were different? What if we were part of a “pay-for-performance” compensation plan, where our remuneration was dependent on providing prompt consultation? Or, if there were another urology group in town, there would be competition for referrals, and a shorter wait time would be a potent marketing tool.

Most importantly, what does a lack of transparency mean for patients? If all else (demeanor, aptitude and location) were equal, people would likely choose the specialist with the shortest wait time. Perhaps wait time would be the prime criterion for some to make their choice. Controlling access to the information then takes on a new importance.

So who controls the access? Ontario and Alberta share some of their acute care wait times online. Information about wait times to see Saskatchewan surgeons is already collated in an online database and available to referring physicians. They could (and are intended to!) share this information with their patients, to assist in making an informed decision about a specialist referral. The information, therefore, is not considered a secret yet, at present, it is password-protected.

If a patient wished to obtain wait time information, she could do so without relying on a physician to grant her access to the database. The information is available, but not without doing a lot of work. She would call all the offices of that particular specialty and ask what the wait time would be for a new referral appointment. (This is essentially the same process used to fill the database, i.e. self-reported wait time.) If she required a sub-specialty consultation (such as a shoulder problem, rather than a knee problem), she would also ask if that surgeon dealt with that area – also information contained in the database.

So why would we make our patients jump through hoops to gain access to information that we already have, and that they can laboriously obtain of their own accord? (Could anyone make a case that they have a right to the information?) There are good reasons why we might restrict access. We want to be sure that the self-reported data is accurate. After all, if livelihoods may be affected by this information, even the most earnest professional may be tempted to fudge the figures slightly.

But, surely the information physician’s clinics would report to the database would be the same as they would give our to our fictional, diligent patient over the phone. If so, she’s no worse off. I suspect that information reported by physicians to the Department of Health would be at least as accurate as that given out ad hoc to curious patients, as physicians would realize that there would be some auditing/confirmation process applied eventually.

If I have been reluctant to share our wait time data for reasons that bear trivial consequences for me, how will people behave when the stakes are higher? What expectations and rights do patients have about access to information that is critical in their informed decision-making around their healthcare?

Do You Recall

At the IHI Clinical Practice Redesign Summit in Vancouver, Advanced Access guru Catherine Tantau suggested that the gold-standard for specialist wait times is 1 week.
When wait times are that short, practices start reaping the benefits such as less wasted administrative effort, fewer no-shows and greater flexibility in physician schedules.

One week? It boggles the mind!

In early 2008, we were on our way with our 3rd NAA down to 30 days from our starting point of 70 days. Then, one partner switched to half-time work. Our 3rd NAA crept up a little until July 2008 when 2 more partners switched to half-time. Since then, our 3rd NAA has gradually climbed back to its original level. Aaaaaargh!