An informal telephone survey

Other than face-to-face discussion, what is the most effective way for me to communicate with my patients? Most frequently, I use the phone, but will occasionally send patients a letter, particularly if I’m reporting test results and recommending followup. I’ve dabbled with email, but found the “secure messaging system” available to me somewhat cumbersome.

Recently, I gathered data on how I was using phone calls to reach or respond to patients. Before I share the results and some interpretations, here’s how I collected the information.

From December 16, 2010 to January 14, 2011 (excluding my holiday week of December 20-24), I recorded data on all calls with patients and family members. I used the database program, Bento, on my iPhone. Bento makes it quick and simple to set up a basic data collection template (“library” in Bento-speak). Setting up a user-friendly template requires some forethought so as to make data collection simple. You can create a new library either directly on the iPhone, or on your computer and then sync the library between computer and iPhone.

The computer-version of Bento lets you search and sort the database, or export the information to a spreadsheet.

I prefer to limit the number of choices in each data field so that I can use pull-down lists and checkboxes. If all the information can be entered/confirmed with one touch on the screen, it speeds data entry and makes for consistent responses. I was interested in a snapshot rather than a lot of detail.

I used these categories:

Date – touch on date selects today’s date as default.

Duration of call (minutes) – I used the screen keyboard to enter the number. I could also have used a pull-down list of numbers from 1 to 20.

Reason for call – Pull-down list included:

Patient initiated – results (e.g. calling for lab reports)

Patient initiated – postop problem (e.g. concerned about infection after surgery)

Patient initiated – other question

Physician initiated – results (e.g. biopsy reports)

Physician initiated – followup (e.g. recovery after surgery)

Physician initiated – other

Time of call – one touch to record the current time

Local/Out-of-town

Call unsuccessful/busy/not in

Comments (always handy to have a “miscellaneous” column in a database!)

If you spend your whole work-day in front of your computer, you could just set up this database in Excel. Because I travel between several sites at several hospitals, in addition to my office, I’m much more likely to consistently record information on a single device, and my iPhone is always at hand.

Results

Time period: 3 weeks

Number of calls: 39

Total call time: 179 minutes

Average time per call: 4.6 minutes (range 1-12 minutes)

Average call time per week: 59.7 minutes

Unsuccessful calls: 4 (10.3%) – (1,1,2 and 2 minutes respectively for these calls)

Average time per call (excluding unsuccessful calls): 4.9 minutes

Frequency distribution of successful call duration (chart below):

Local calls: 17 (43.6%)

Physician initiated: 16 (41%)

Time of day calls made (chart below):

Interpretation

My impression was that I made fewer calls than usual during the measurement period, likely because it was over the holidays. Less surgery is done during that time, so there would be fewer calls about post-op concerns. Also, it may be that patients were traveling, or busy with holiday visitors and so less likely to have time to call to discuss non-urgent concerns.

Concerns discussed in shorter calls (5 minutes or less) could probably be dealt with via email. These calls tend to be straightforward, single-question discussions. However, longer discussions are not conducive to email as there is a lot of back-and-forth with more involved discussion. Trying to conduct these discussions through email is probably not effective.

Three calls were quite lengthy (1 of 11 minutes and 2 of 12 minutes). Most of the time, I could anticipate that a call would be lengthy and so tried to make the call when I had adequate time for the discussion. However, this sometimes means that I would postpone making the call until I was going to be free for a longer period. I return many calls in the short breaks between OR cases or between seeing patients in the office. These short breaks aren’t adequate to discuss, say, a biopsy report showing cancer and the testing and treatment that will follow. These would be circumstances where scheduling time for a call (or office visit if convenient for the patient) would be helpful in reducing unsuccessful calls, and also making sure patients receive the information in a timely fashion.

In the study period, I spent about an hour per week speaking with patients on the phone. As I mentioned above, I think this was less than usual. This is one heck of a good deal for the patients’ insurance plan (AKA Sask Health) as I do not receive reimbursement for this work.

I’ve also been struck by the occasional patient’s comment that they are very pleased to be able to reach me by phone, as they didn’t think they could call directly to speak with “the doctor”. I know that many family practices insist that patients set up appointments to discuss concerns. If they didn’t have this rule, those family doctors could spend most of their day on the phone, gratis. But, if patients have been acclimatized to the idea that they can’t reach their doctor to ask questions, maybe some of them don’t even bother to make a call in the first place. If the problem were urgent, I suspect they would seek out help. But, for less-urgent problems, the questions may be going unasked. Perhaps I’m missing opportunities to provide better service/answer questions by not giving the level of accessibility that email would afford.

Check a box, Tame a Line

A couple of weeks ago, I met some people who have the power to change Canadian healthcare. And, they can do it by June 2012.

There wasn’t a deputy minister among them.

They were the University of Saskatchewan College of Medicine Class of 2014. That’s right – first-year medical students! Skeptical? I think they were, too.

I had the chance to participate in the first-year students’ “Civic Professionalism and Physician Leadership” course. The course exposes students to aspects of healthcare beyond the traditional, disease-oriented clinical curriculum. I was addressing the quality improvement theme, specifically Clinical Practice Redesign.

I had planned just to tell the story of Saskatoon Urology Associates’ Advanced Access/Clinical Practice Redesign (CPR) journey. Essentially, the presentation is a distillation of this blog. The story starts with the reason why we started the project: Frustration over the wait times our patients experienced. Then, I talk about some of our most successful initiatives: pooled referrals, shaping demand/referrals, and reducing recalls.

Usually, I’m giving this presentation to a group of physicians who have recognized an access problem in their practices, as evidenced by long wait times and frustrated patients. They are already motivated to seek solutions, and the discussion centres around how to implement CPR in their practices.

However, medical students in their first few months of training are years away from the challenges of clinical practice. Their perspective is informed by their own or their family and friends’ experiences with health care, media reports, and opinions from authorities. The message they hear: Long wait times are caused by inadequate resources. The solution: More resources. More doctors. More MRI machines. More OR time.

But, our successes with CPR indicate otherwise. There are plenty of opportunities to improve access, quality and value for patients by rethinking how we use current resources. That’s the message I wanted to get across to the students.

But, after recently reading Check a box, Save a Life, I thought that my presentation might be an opportunity to do more than just tell our story. I thought that these students had the potential to drive change, rather than just bear witness to it.

Check a box, Save a Life tells the story of a international group of medical students who launched an initiative to lead implementation of surgical checklists at their respective institutions. After attending the release of the safety checklist at an IHI conference, the core group used their existing organizations and social networks to promote uptake of the checklist. Some students actually participated in, or lead, the use of the checklist in the operating room.

They were sparked by their realization that, even as medical students, they had the power to effect change that would have an immediate and significant impact on patient care. What an amazing story of leadership and activism!

That story convinced me that the U of S first-year medical school class could do the same. Actually… they could do more. While surgical safety checklists promise the more dramatic result of saved lives, implementing CPR nationally could improve access to care for many more patients, improve work-life balance for physicians, and ensure sound stewardship of our healthcare system’s resources.

Whew! That sounds pretty daunting. But once you hear what these students bring to the table, you’ll agree with me that they’re up to this challenge.

First of all, they get it. They understand CPR, and the problems it tries to address. I don’t mean that they listened to what I had to say and understood the techniques of pooling referrals and shaping demand. Certainly they understood the technical part, but that’s the easy stuff. I mean that, from the questions they asked, it was obvious that they understood the deeper issues. They wondered about how reducing specialist recall rates by returning care to family physicians would affect the FP’s workload. They asked whether there was any resistance to introducing CPR into our practice, and how we managed that. They realized that the current fee-for-service payment system was a disincentive to some CPR changes.

These questions showed me an impressive degree of analysis from people completely lacking in clinical exposure. And that’s the next thing they have going for them.

They have no exposure to medical practice. We haven’t brainwashed them yet. Their minds and eyes are open. I’ve posted before about a junior medical student who challenged me to reconsider one of my office practices. An elderly man drove 3 hours for an appointment to discuss a test result. The student asked why that discussion couldn’t have been done over the phone. A more seasoned student would likely already have been indoctrinated into our system to the extent that the visit wouldn’t have raised an eyebrow. They would already know that that’s the way we do business. But the new ones spot our foibles. (Classic: The Emperor’s New Clothes!)

Next, they have powerful social networks. They attend clinical rotations in groups of up to 5 people. That’s a great opportunity to share their impressions of what they’ve seen, and collaborate on solutions. I spend most of my day doing my work the same way I’ve done it for years, without comparing notes with colleagues on how they run their office practice. On the occasions when we do compare our practices, the results have been startling. When we measured our internal demand/recall rates, we were surprised to find the degree of variation in our practices. Once we recognized the variation, and began to explore the reasons behind it, as well as possible solutions, our recall rates dropped. Two (or five) heads are better than one.

Plus, electronic social networks expand that interaction far beyond the physical confines of the U of S. (One thousand heads are better than five!)

Finally, medical students are everywhere. Their rotations take them from the operating room to rural primary care clinics. And they’re observers. They rarely have clinical duties, so they are free to be flies on the wall. Once they understand they type of problems CPR tries to fix, they will see examples of those problems everywhere.

And, as their questions during my presentation convinced me, they will be able to create solutions to the problems they identify.

I would love to be part of this initiative, but as I’ll explain below, it’s important that I stay out of it. But, that doesn’t stop me from giving my version of how I see it developing!

Imagine this: While on their clinical rotations, students from across Canada apply the insights they have gained from CPR advisors to identify potential areas for improvements for individual clinicians. They collect their observations in an online database. Via social networks, they brainstorm solutions. The next students who spend time with that particular clinician ask to try out the solution, and then submit the results to the online community for refinement.

They would harness the curiosity, creativity and energy of hundreds of their colleagues for the benefit of thousands of patients. And for the gratitude of hundreds of clinicians whose practices would be made more efficient and effective.

A project like this, if conceived at the government or national medical association level, would take years to produce results. The Class of 2014 can produce tangible results by June 2012. Their first significant clinical rotations start in their 2nd year – the fall of 2011. By using the rest of this academic year to organize, develop a network, and recruit mentors, the students would be ready to collect data by the time their first rotations start. Small tests of change could start almost immediately.


But, if this initiative is to succeed (in whatever form it eventually takes), it must be conceived, driven and executed by students. They should struggle with recruiting participants, fret about how to engage physicians in the effort, and worry about keeping up their enthusiasm once the initial excitement of a new project dies down. They must fail, and learn from their failure. Their achievements will be even sweeter for all of their sweat.

On the surface, this project is about implementing Clinical Practice Redesign across the country. That will be the easy part. The real work in this project will be harder, but will be much more valuable for the students. The real work is in becoming leaders.

And you can’t do that in a classroom.

Come on, Class of 2014. Show us what you’ve got!

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!

Canadian Patient Safety Week - Welcoming our second-degree guests

Canadian Patient Safety Week is next week, but its theme – Ask.Listen.Talk - was on my mind a lot this week. And it made me think about a party we held last New Year’s Day.

We invited several friends over for brunch. At the last minute, one family called and said they wouldn’t be able to come. Weather conditions had prevented their visiting relatives from returning home, and they didn’t want to leave them alone. Of course, they were welcome to come to the party, so we set a few extra places at the table.

If you’ve ever been a “second-degree guest”, that is, accompanying someone who was invited by the host, you know it can be awkward. You may not know the host. You would rather suffer in silence rather than put the host out by asking for something. You don’t feel comfortable.

We recognized that our second-degree guests felt that way. All the other guests had been in our home previously and knew their way around. They felt comfortable with helping themselves to cutlery or serving themselves drinks. They made themselves at home, and we invited our new friends to do the same.

But that wasn’t enough.

If I’m visiting someone’s home for the first time, and am told to make myself at home, I won’t. Because I don’t know what “making myself at home” means in that home. Can I poke through the fridge looking for leftovers? Can I flick on the TV and watch the game? I don’t know what their micro-culture accepts, and so I will err on the side of sitting quietly on the couch.

Recognizing that our second-degree guests felt the same way, we did what any host would do, and made sure to pay extra attention to their needs. Would you like another drink? What do your kids like to eat? Like any host would, we wanted them to feel welcome and comfortable.

CPSW’s theme - “Ask.Listen.Talk.” - suggests that communication between patients/families and caregivers, and among caregivers, improves patient safety. No argument from me. But I think we need to consider how we implement Ask.Listen.Talk. in our practices.

Patients and their families are like second-degree guests visiting the healthcare system. Everything from our facilities to the language we use is unfamiliar and intimidating to them. While healthcare workers bustle about around them, visitors worry that even a wrong turn in a hallway may take them into an unauthorized area. They feel awkward.

And then, next week, we want them to “Ask.Listen.Talk.” Maybe we’ll put up some posters, or hand out a brochure. That will be the equivalent of saying “Make yourself at home!” Patients/families won’t know what is acceptable in the healthcare culture. Is it OK to ask the doctor whether or not she washed her hands before examining my mother? Will she be upset with me for asking? I don’t take a red pill at home, but I’m sure it’s OK here at the hospital, because the nurse must have checked it before she gave it to me. She looks too busy for me to bother her.

It’s nowhere near enough just to publicize our belief that communication improves patient safety. We need to actively seek out patient and family comments and participation, like we would for second-degree guests in our home. And when those comments arrive, we need to receive them positively and consistently. A sour look in response to a voiced concern speaks much more loudly than an Ask.Listen.Talk pamphlet on a bedside table.

Last week, I spent some time with a medical student, and we observed what we considered to be a breach of a patient’s dignity. We talked about it after we left that care area, and I asked him how he would address that with the caregiver responsible. He laughed. I laughed too. We both realized that I was being absurd. It would be a rare medical student who would comment on a breach of patient privacy, dignity or safety. At best, they would be ignored. At worse, they would be excoriated for their impertinence. How dare you…

He felt – undoubtedly correctly – that the caregiver would not accept such a comment from someone who was without standing in their culture. But we did explore possible approaches. I thought that he would need to test out – role-play – some options with like-minded colleagues before “going live”. Perhaps the old just-trying-to-be-helpful gambit: Would you like me to pull the curtain around the patient’s bed while you examine him?

I used a similar approach with our second-degree brunch guests. I wanted my 10-year-old son to find out if our guests needed anything, but I realized that giving him that vague instruction would be useless. It wasn’t that he didn’t want to help, or that he is unfriendly. It’s just that it was a new situation for him, and he felt uncomfortable. He needed some coaching and a specific script.

“Ask them ‘May I get you something to drink?’”, I suggested.

“’May I get you something to drink?’”, he repeated.

And off he went.

Coaching and scripting to encourage dialogue around patient safety will help us demonstrate to patients and families that we are serious about engaging them as active participants in safe care.

The day after my student and I had discussed impediments to his commenting on the breach of dignity, he joined me in the operating room. As I introduced him to the personnel in the room, the anaesthetist said this to him: If you see anything going on in here that you think is unsafe, please speak up. We value your eyes on what we’re doing.

That was a big step in the right direction.