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.

Time for a change

It’s time for a change!

For over 3 years, our practice has been working on shortening patient’s wait time for consultation. We’ve learned about measuring capacity and demand, pooling referrals, shaping demand and improving capacity. While individual urologist’s 3rd next available appointment times vary considerably, our clinic’s shortest 3rd NAA is now around 20 days. This is the wait time for patients who accept the first available pooled referral.

We will work to maintain these gains and improve service for our patients. But now, we want to tackle another wait time – the wait for diagnostic testing, specifically cystoscopy. Cystoscopy – endoscopic bladder examination – is one of the most common urologic procedures. Used to diagnose conditions ranging from bladder cancer to urinary incontinence, about 350 cystoscopies are performed every month in Saskatoon.

This spring, the Saskatoon Health Region (SHR) updated sterilizing procedures for cystoscopes. Previously, we had soaked endoscopes in sterilizing chemicals between uses. This process was performed in the cystoscopy suite in 10-15 minutes, meaning that a small inventory of equipment could be rapidly turned over. In contrast, the current sterilizing procedure takes several hours to complete, and is performed by technicians in the central processing department. Because of this, we needed a larger inventory of scopes. Expensive scopes, that is.

By consolidating cystoscopies from 3 sites to 2, and by rescheduling times of cystoscopy clinics, we were able to maintain service volumes while purchasing the minimum number of new cystoscopes. Or so we thought…

Complex systems like a cystoscopy clinic are organic. They change and adapt over time. Incremental changes accumulate. And, when we impose a major realignment (even a carefully considered one), unintended consequences can result.

In the case at hand, everything looked good on paper. Overall cystoscopy capacity was the same; only locations and clinic times had changed. But, since this spring, patient wait times for cystoscopy have been getting longer. Initially, we thought it was a result of summer holidays reducing capacity. But, the lengthy waits have persisted. And so, we want to use our Advanced Access tools to tackle cystoscopy wait times.

Our team met last week to plan our approach. Having previous experience with wait times certainly helped – so much so that Donna and Delores had already collected a lot of baseline data. Our starting cystoscopy 3rd NAA is 32 days. They also looked at the number of cystoscopies performed for certain diagnoses: bladder tumor checkups, hematuria (blood in urine) and urinary retention (inability to pass urine). We see a significant variation among urologists, in the raw data they have collected. We don’t know yet what the implications of this are, or if understanding the reason for the variation will help improve the cystoscopy system.

Our initial review also showed that we’re not using all the available cystoscopy time. In the previous system, we had a fine balance between competing demands for urologists’ time. Now that schedules have changed, on some days there aren’t enough urologists to go around. Our default decision is to use all the available OR time first, even if it means leaving cystoscopy time unused. Fixing this demand-supply mismatch would be a big win.

Our EMR has the capability to track cystoscopies by diagnosis/reason for procedure. We’ll start tagging each procedure and see if this will uncover any interesting patterns.

Also, and importantly, as we’ve started this new work, we’ll stop collecting weekly data on office consultation wait times. We’ll check in on those times occasionally, to make sure we’re not losing ground. Staff time is a limited resource, and we want to use it wisely.


A new project. This is kind of exciting!

Joy at work

It’s not often that I have a moment of joy in the middle of a cystoscopy clinic, but I had one last week.

A cystoscopy clinic makes for a busy morning. Over the course of 4 hours, I’ll see 12 to 14 patients. Each visit involves – at minimum - an endoscopic bladder examination, discussion of the findings, and sending the results to the referring physician. It may also involve meeting a patient for the first time, asking about their medical history, arranging further testing or scheduling surgery.

I’m constantly aware of wanting to stay on schedule so as not to keep people waiting. Unfortunately, that time pressure will sometimes make me feel rushed, and that can affect my patient’s experience.

Why not schedule more time for each patient, you may ask. For some patients, rather than the standard 15 minutes, I will allot 30, especially if I anticipate that someone may require additional procedures. However, each extra time slot assigned to one patient means that another patient waits longer for their cystoscopy. And, wait times are already lengthy. It’s a difficult balance to strike.

But, during one examination last week, I found myself in the unusual situation of being ahead of schedule. Even though it was my first meeting with this patient, and I needed extra time to ask about her medical history, discuss test results (she had a tumour in her bladder) and recommend surgery, I wasn’t rushed. In the middle of that discussion, I had my moment of joy.

While explaining to the lady about what I had found, and the recommended treatment, I realized that I felt relaxed and confident. I was paying attention to her reaction to my explanation. Was she upset? Was I using medical jargon? Had she understood? Did she have any questions? I wanted to reassure her.

This was how I wanted all my consultations to go. Not only because it made me feel good about myself, but because I’m convinced that I’m a better doctor when I feel that way. I may provide the same technical results regardless of my mood (maybe…), but I think patients have a better experience when I’m relaxed.

As I thought about this, I began to wonder why I couldn’t feel this way, and offer my patients a better experience, on a regular basis. I think there are internal and external factors. Internally, I may allow myself to become flustered. That’s a habit I can work on. Externally, it comes down to an access problem. Long wait lists translate into pressure to fit in as many patients as possible in a given clinic. That increases the chance of running late, and forces me to rush, leading to an unsatisfying experience for both me and my patients. (And for any staff who may be unfortunate enough to be in the vicinity…)

So, if we work on improving our cystoscopy access problem – applying the same principles of managing capacity and demand as we have in our office practice – patients may benefit not only through shorter waits, but also through the quality of their experience. And our doctors may be more satisfied.

I think we’ve found our next access project.

And a selling point: Bring the joy!

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?

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.)