Leaders: Clear the path and your team will do their best work

Something a healthcare senior leader said recently gave me pause for thought.

As part of a group discussion around healthcare improvement, the perennial topic of electronic medical records (EMR) came up. While everyone at the meeting agreed that EMR would be hugely beneficial to patient care, X opined that technology couldn’t change attitudes.

Here’s the context: The group had already agreed that the primary driver behind healthcare improvement should be the philosophy of patient and family-centred care (PFCC). X’s point was that having EMR would be great, but it wouldn’t convert anyone from being provider-centred to patient-centred.

I spent the next few minutes of the meeting on a thought tangent.

X’s assumption was that providers are fixed in a self-centred existence. They have to be “re-educated” and convinced to embrace PFCC. EMR and other technology don’t influence behaviour.

But, what if there’s a different explanation? Let’s assume that every nurse, doctor, clerk and housekeeper would get tremendous satisfaction from applying PFCC principles in their daily work. They may not be familiar with the formalities of PFCC, but they understand what it means to be kind and caring. Further, assume that all newly-hired providers come to their first day of work with the desire to do their best to serve their patients. What happens after that?

We beat the PFCC out of them! We put obstacles in their path, fail to reward (or even punish) sincere efforts to put patients first. We make it easier to be self-centred than patient-centred.

Here’s an EMR-related example from my practice: A man is referred to me with pain in his side, possibly related to a kidney stone. I recommend a CT scan to locate the kidney stone. He tells me that he already had a CT scan done at his local hospital. The referral letter didn’t indicate that a CT had been done, so I didn’t have the opportunity to look at it prior to this visit. I try to access the CT films using the online x-ray viewing system, but as is frequently the case when we try to do this from our office, the system is not working. I tell the man that I will check his CT the next day when I’m at the hospital and can use that system. He leaves without a definite diagnosis or treatment plan.

Another common example is the “missing” lab test. When a patient has already had a certain blood test performed, but the attending physician doesn’t have access to it (e.g. it’s a weekend and the family doctor’s office is closed), it’s just “easier” to poke the patient with another needle and repeat the test. The physician ordering the repeat test isn’t deliberately cruel; if the results were easily available (EMR!), it wouldn’t be necessary to stick the patient again, and it wouldn’t be done.

My conclusion was that X should think about healthcare providers’ behaviour differently. Rather than presuming the worst, X should assume that providers naturally want to provide PFCC, and that “the system” impedes them. If we assume the best, then our approach would change from one of trying to educate providers in PFCC, to one of trying to remove the barriers that prevent them from fulfilling their natural inclinations.

Here’s what this means for a leader: If your staff isn’t delivering PFCC, it’s not because they don’t want to. It’s because you have not created an environment that lets them do their best work.

Clear the path. Unleash the potential.

Simplicity is its own reward

Sarah posted an interesting comment about the GP-specialist referral process:

I often wonder if simplification from the patient view can contribute to simplification from the doc's point of view.

Hmmm. Ideally, yes, but I have some reservations.

An elegantly designed system completes tasks reliably, consistently and with minimal waste. The simplicity of such a system would be evident to all users.

However, if the system is poorly designed, then not all users will “see” the simplicity. One user group may end up doing more work in order to use the system, or may suffer confusion, extra expense, and/or wasted time. Often, as healthcare tends to be provider-centred, it’s the patient who is saddled with the extra work and waste.

However, there are instances where providers will take on the extra work for the benefit of patients. This makes the process simpler for patients, but more complicated for providers. I would call this “faux-simplicity”. An example of this would be the Navigator role in healthcare.

A Navigator – often a nurse - guides patients through the complex journey of diagnosis and treatment. For example, a man who is suspected of having prostate cancer may have multiple contacts with the healthcare system including prostate biopsy, CT and bone scans, one (or more) specialty consultations, radiation treatment and surgery. It’s a huge help for the man to have the Navigator coordinate testing and travel for the man.

But, the presence of a Navigator doesn’t make the system simpler.

The patient may perceive less work and worry, but the system remains complex, and the Navigator and other providers still struggle with its waste and inefficiency. (Perhaps the perceived need for a Navigator is an admission that the system is badly broken!)

Does it matter that providers have to do more work, as long as patients are freed from the burden? Yes, it does matter. More time and resources spent wrestling with an inefficient, poorly coordinated system means less time and resources spent giving value to patients.

Ideally, a Navigator position is created as part of a broader, patient and family-centred system redesign. The Navigator would help with that improvement process and, once the system is truly simple and efficient, the Navigator should be out of a job!

An example of patient-centred simplicity that would also be simple for providers is a multidisciplinary cancer clinic. If a man were diagnosed with prostate cancer, he would visit the clinic – perhaps for several hours - where all the necessary testing and consultation would be done in one session. This would involve using Advanced Access principles to ensure same-day access to CT and bone scans. The man could see a urologist, oncologist, nurse specialist, dietician and social worker. The providers’ work is simpler because they can confer at once (with the man and his family, of course) and decide on the preferred treatment.

With current disjointed systems, each provider sees the man independently and then corresponds with other providers. This wastes the man’s time, delays treatment and is prone to miscommunication. Doctors waste more effort when they revisit the man’s chart repeatedly as each new report comes in from other consultants.

So, Sarah, I agree that simpler for the patient can mean simpler for the doctor, but it’s not necessarily so. Watch out for faux-simplicity: kludging another layer of service onto a dysfunctional process, rather than tearing it down and redesigning it so that it is truly patient-centred.

And simpler for everyone.

Listening to my FP colleagues - Part 2

Last month, I heard from family practitioners (FP) from across Canada about what they thought was lacking in the FP-specialist referral process. Last week, I had another opportunity to learn what’s on the minds of my FP colleagues.

As part of the Sask Surgical Initiative (SkSI), care pathways are being created for conditions like back pain or hip problems. I’m participating in developing a prostate cancer pathway. Our working group has mapped out the current state in the province, that is what path men currently follow when diagnosed and treated for prostate cancer. Now we want to explore changes that could make the journey quicker, smoother and more effective, or as SkSI puts it “Sooner, safer, smarter”.

An important part of the working group’s next step is broad representation of interested parties, and FPs play a central role in the process. They do the initial testing that raises suspicion that a man may have prostate cancer. They make the referral to a specialist. They provide education, support and ongoing care as a man has treatment. They are often responsible for long-term follow-up after the man’s treatment.

We need the perspective of an FP on our working group, so I met with the executive council of Saskatchewan’s section of family practice to ask for their help in recruiting one of their members. While supportive of the prostate cancer pathway, they made a couple of pointed comments.

Make our work simpler. Many well-intentioned groups are developing guidelines, checklists, templates and standardized forms to help manage specific conditions. While each of these efforts makes sense in the context of that condition, when FPs are bombarded by dozens of documents, it’s bewildering. Without consistent design, the learning curve starts anew when completing each form.

Perhaps the end users of these documents (in this case, FPs) should insist that any new forms adhere to a common template. If a template is too restrictive, then a set of design principles such as font size, page layout and completion instructions could be used. As one of the FPs pointed out, “Poorly designed forms may only take me an extra 30 seconds to fill out, but that adds up over the course of a day.”

Ultimately, an electronic medical record would solve these problems by “imposing” a style template and virtually filing all documents in one location.

Compensate us appropriately. There were strong feelings about this one. Because of their central role in patient care, FPs are asked to participate on a multitude of committees, boards, and working groups. This work often happens outside of regular work hours and so interferes with family life. When the meetings occur during regular work hours, fee-for-service FPs are often asked to sacrifice practice income.

One of the FPs pointed out that when committees didn’t pay him for his attendance, they undervalued his time. He had been asked to sit for hours through deliberations that didn’t involve him, just so he could participate in discussion of a single relevant issue. He felt that if he were being reimbursed at the same hourly rate he could earn working in his office, the committee would be more careful to schedule the meetings so he was present only when truly necessary.

Others pointed out that most administrators sitting on health-related committees are salaried employees, and so don’t pay any financial penalty for the time they spend at meetings.

I’ve been relatively insulated from the financial burden imposed by participating in administrative work. The pooled revenue-sharing nature of our urology practice means that our group can support one or more individuals taking on non-clinical work that we see as important for advancing patient care. However, if I were a solo, fee-for-service practitioner, taking a day away from my practice could end up costing over $1000 in lost income, with overhead expenses continuing to mount in my absence.

The executive committee indicated they would support our effort to recruit FP representatives for our prostate cancer pathway initiative if our recruiting message included the offer of a stipend. To be fair, I think that stipend should be offered to all non-salaried participants, including specialists and community representatives.

That puts the ball squarely back into the government/SkSI’s court. What other consultants provide their expertise for free?

P.S. I received a stipend for attending the CMA meeting last month...

Improving the FP-specialist referral process

Last week, I attended a joint conference of the Canadian Medical Association’s specialty and family practice (FP) representatives. This was the second year of the joint meeting and the theme was the same: How to improve the referral process between specialists and FPs.

The main task was to identify problems with the current system. There was no shortage of suggestions/complaints.

From the specialists:

Inadequate information in the referral letter (e.g. no medical history or list of medications)

No clear clinical question to be answered by the specialist

Tests results not included in the referral letter

Illegible writing

Inappropriate referral (to the wrong specialist)

No indication as the urgency of the problem

Referral initiated too late in the course of the patient’s illness

Treatment recommendations or requests for further testing not carried out (“I don’t think anyone read the consultation letter I sent back.”)

FP not willing to manage chronic conditions, even with specific recommendations in my consultation letter

And just so specialists don’t get too smug, the FPs shot back with:

Don’t know if the specialist has received my referral letter

Not clear if the specialist will contact the patient with an appointment, or whether I should do it

Don’t know how long the wait times are

Don’t know what tests the specialist wants done ahead of time

Delay in receiving consultation report

Clinical question not answered in consultation report

Not clear who is responsible for providing ongoing care for chronic conditions

Don’t know what each specialist’s sub-specialty interests are

Some comments that came up during general discussion were interesting:

Calling the process a “referral” implies the necessity of a face-to-face visit between specialist and patient. We should consider the process a “consultation” which suggests an exchange of information between FP and specialist. This could be accomplished by phone, email or hallway conversation.

Funding mechanisms (such as fee-for-visit) limit solutions. Several practitioners who worked under alternate funding programs talked about using telehealth, phone calls and email to great advantage. This is (financially) unattractive for fee-for-visit specialists, unless their jurisdiction has fee codes covering these options.

Some of the solutions aimed to improve the content and quality of the referral letter using standardized templates and checklists. Our clinic’s microhematuria algorithm is an example of this with its request for specific testing to be completed before the urologic consultation.

I’m most encouraged by efforts that go beyond just the fine-tuning of the current process. Some people are trying to make referrals more appropriate, or even render them unnecessary.

For example, the Saskatchewan Surgical Initiative’s back pain pathway trains FPs on how to better distinguish surgical and nonsurgical candidates. Patients who are unlikely to benefit from surgery can be immediately directed to the appropriate treatment (physiotherapy, exercise) rather than languishing on a surgeon’s wait list, only to be eventually given the same advice.

A clinic in Northwest Territories is looking at common reasons for specialist referral, and then targeting FP professional development around those topics. Increased FP expertise and confidence for treating common “specialty” conditions will reduce specialist referral rates and allow patients more prompt treatment.

The patient referral process is the key interface between FPs and specialists, and as with many of the “hand-offs” in healthcare, it’s fraught with problems. After attending this conference, the two biggest problems I see are these:

There’s no feedback system to educate either FPs or specialists as to the quality of their contribution to the referral process. In the current system, a FP can send me a referral letter with inadequate clinical information, yet will get a complete consultation report in return. From his/her point of view, the referral letter got exactly the intended result, so why should they change their behaviour? As one of my partners is fond of saying, “What you permit, you promote”! Of course, it works both ways; if I don’t answer the FPs clinical question or help the patient with their problem, I will only know about it if the patient is referred back to me for further assessment. Neither of us can improve unless we’re shown – in an objective and constructive way – where we need to improve. I know that peer feedback would be a strong incentive for me to provide a better service.

An even deeper problem is lack of patient involvement in improving the referral process. The FP/specialist conference clearly focused on perceived physician needs. As healthcare workers, we often flatter ourselves that we can represent our patients’ interests in these matters. My experience in working with patient representatives on similar groups is that they bring a perspective that we lack. As such, I recognize that I can’t predict what a patient would add to the discussion. But, I’ll take a stab at it anyway:

No clear clinical question? I’ll tell you the question, because I’m the one with the problem.

Not enough medical history on the referral? Let me fill that out for you.

I’m being referred for pain in my knee. You “don’t do knees”? Well, then you better make that crystal clear right away, because I don’t want to wait 9 months to hear it.

I drove 4 hours and stayed in a hotel overnight to have a 10-minute discussion with you. Why couldn’t we do that over the phone? Because you get paid more if I turn up in person!? If I knew that ahead of time, I would have made the phone call, paid you the difference and still come out ahead.

Maybe next year we can get some input from the people who are truly affected by a dysfunctional referral process.