Lay of the Land

As I mentioned last time, when we decided to rejuvenate our office improvement work, we wanted to address issues more broad than access to urology consultation.  Urology Associates QI 1.0 – focused on access - had many successes including pooled referrals, improved communication with referring physicians, and reducing unwarranted practice variation.  But, we didn’t sustain the process. 

While we’ve continued to pick away at smaller QI initiatives in our practice, we needed to get back to a formal QI process lead by a core team.  We did not want to fall off the wagon again.  Helping us on that path was the task we set for our new QI coach, Katherine Stevenson, principal of The Groundwork Strategy.  (Disclaimer: Katherine and I co-teach the Canadian Medical Association’s Physician Management Institute course “Prescribing Quality Improvement”.  Like I said in the last post, “Right under our noses…”)

While many of the broad strokes of the process Katherine has lead us through are similar to our initial Advanced Access work (e.g. form a core QI team with staff and physician members, regular meetings, document our work, communicate with the other stakeholders), I see many contrasts.  The Advanced Access project came with a preset goal: Improve access to urology care.  With our QI reboot, Katherine suggested that we look at our entire office system before deciding what was the most pressing need. 

This involved surveys and in-person interviews of every urologist and staff member.  We were asked about our impressions of how our system was working, what frustrated us and what we’d like to see improved.  This step had to be performed by someone from outside our office.  Aside from the time and expertise needed to conduct these interviews, it was apparent that uneven power dynamics between physicians (employers) and staff (employees) would make free discussion of at-work frustration difficult, if we tried to carry out the interviews on our own. 

Among the several common themes that Katherine extracted from the interviews, virtually everyone mentioned problems with office communication.  There was frustration and uncertainty around communication between staff and physicians, between staff and patients, and between physicians and patients.  Physicians weren’t sure which staff member was responsible for specific tasks (e.g. booking tests, arranging appointments, billing for procedures), and this lead to a lot of variation in how each of us would assign those tasks.  Staff felt that a lot of time was taken up by answering phone calls that could be dealt with by other means (e.g. office address or fax number, or appointment confirmations).  Physicians felt that staff could deal with many requests that were currently addressed by asking the physician to return the patient’s phone call (e.g. normal test results).

My observations about these discoveries:

-       Leaders shouldn’t presume that everyone in their organization shares their view of the most pressing issues in the workplace. 

-       Medical office staff and physicians don’t necessarily understand the challenges of each others’ work

-       Small, repetitive annoyances can weigh heavier on us than “big ticket items” like improved access to care

-       We had found common ground between staff and physicians.  Perhaps this was a topic that would get our QI work going with a quick win that would improve work life for everyone.

Before we could start with improvements in office communication though, we needed a robust process for our core improvement team. 

What makes a good QI coach?

Give a man a fish and he eats for a day.

Teach a man to fish and he eats for a lifetime.

Show a man how to use a phone and he can order pizza.  Who wants fish everyday?

How do you go about selecting a quality improvement coach? 

A coach could be a mentor, guide, cheerleader, or teacher (and probably all these at different times).  The origin of the word gives insight into its true meaning.  “Coach”, in its original use, refers to a carriage or means of transportation.  Later, it referred to someone who helped students (or, carried them) through exams.  In both usages, a coach helps someone reach their goal. 

I distinguish a coach from a consultant.  I see a consultant as someone who assesses the problem and prescribes a solution.  We were interested in working with someone who could help us develop (or rekindle…) an independent capacity to identify and solve the problems in our practice.  Also, we wanted to develop a sustainable quality improvement process.

While we wanted someone to help us eventually develop our own capacity, we recognized that this coach would likely need to do some of the initial diagnostic work to jumpstart the process.

In retrospect, after having been in the coaching process for almost 9 months now, I judge the 2 key qualities of a QI coach to be patience and breadth of experience.

Novices make mistakes; it’s a powerful way to learn.  The coach may be tempted to curtail exploration and experimentation, intending to speed the journey along.  Feeding the student the “correct” answer may shorten the process, but deprives him of the experience of understanding what doesn’t work.  This is particularly important in QI work where the solution(s) may not be known and experimentation (PDSA cycles, action research, etc.) is the only way forward.  An experienced coach may have seen certain initiatives fail in other settings, but must be patient in allowing students to conduct learning trials and develop their own understanding about what works in their system.

The coach’s patience was particularly important as we started to rank the importance of problems areas to be improved.  I suspect our coach had preferences as to which improvements would have the greatest impact on patient, staff and physician satisfaction, but kept quiet about it.  Instead, we were shown methods to reach a consensus around which projects were our priorities.  This has been an important factor in maintaining enthusiasm around the work: The projects we’re working on are meaningful for us, not ones foisted on us from outside.

This relates to the “give a man a fish” aphorism that I tweaked at the start of this post.  The kernel of wisdom in the original saying is very much the philosophy of coach over consultant.  A consultant may give you the fish/answer, whereas a coach will show you how to get the fish/answer for yourself.  I think the next step in QI independence and sustainability is to give the team the tools to decide what they want to have for dinner.  And that means the coach has to give up control of the direction of the work.  Therefore, we wanted a coach who was not personally invested in “fish for dinner”, i.e. a predetermined direction that our QI work would take. 

A coach’s breadth of experience is important when the QI team wants to develop an independent, sustainable capacity.  This relates most closely to the common use of “coach” in athletic training.  Athletes who specialize in a particular event seek out coaches with expertise in that area.  A specialized coach may help elite athletes reach their potential in individual events, but these athletes may not have well-rounded fitness, may be prone to certain injuries, or find that they cannot sustain that level of training in the long-term.  A particular training technique may work for some athletes, but a coach who is familiar with a variety of techniques will be able to help many athletes achieve their goals. 

In Saskatchewan, our health system has adopted Lean as our quality improvement system and is investing heavily in training providers and administrators.  I’m excited that we have a consistent method to guide our QI work.  At the same time, I’m conscious that “when all you have is a hammer, everything looks like a nail.”  Lean may not be the right hammer for all our nails.  Rather than signing up our QI team for Lean training, we decided to take a non-denominational approach that would let us pick and choose from various QI models.  That required a coach with broad exposure and experience with different QI systems.  Also, we wanted to start our QI work immediately rather than spend weeks in formal training.  This approach demanded a coach who was confident and expert enough to give us just-in-time training as we proceeded.

Whew! That is a tall order for a QI coach.  Where would you find such a person?

Right under our noses…

A new beginning

It’s difficult to tell this story.  It’s a story of failure and disappointment.  It’s about letting people down.  I only have the courage to tell it now because it is also a story of learning and inspiration.  I think it will have a happy ending.

The tenacious few who have followed this blog from the beginning know that it started as a record of Saskatoon Urology Associates’ work to improve patient access to specialist consultation.  Starting in 2007, with support from the Health Quality Council, we learned about, and applied the Model for Improvement.  We implemented pooled referrals (centralized referral intake), reduced our missed appointment rate, and requested standardized referral information from family physicians.  We discovered the ubiquity of practice variation in our group, began to discuss the reasons behind variation, and then agreed on best practices. 

At its nadir, our average consultation wait time was one month – down from 4 months or longer.  Even though we never reached our original target of 2 weeks, we were very pleased with the process and results.  Then, circumstances changed.  Wait times ballooned.  The frustration that sparked our work in the first place was back.

Our urologist manpower has changed significantly. Early in our improvement work, we had 8 full-time urologists.  Due to retirement and semi-retirement, we now have 6.5 full-time urologists.

How we distribute work has changed over the last 3 years.  The Saskatchewan Surgical Initiative has focused attention on surgical wait times, that is, the time patients wait from being booked to having the procedure performed.  The initiative has been hugely successful in reducing the surgical backlog.  And how do you reduce a backlog?  Hard work, i.e. more surgeons in the operating room more often.  This has taken us away from seeing patients for office consultation.  Predictably, our patients’ wait time for surgery has dropped, but wait time for consultation has burgeoned.

We’ve seen this happening over the last 2 years.  It meant that we started to see (again!) all the phenomenon that go along with long wait times: more calls from patients and referring physicians, referring physicians sending repeat consult requests detailing worsening of patient symptoms, and more urologist effort into triaging consultation requests.  Long wait lists make more work for everyone.  Most disheartening are the comments from family physician colleagues: What happened to you guys?  I used to tell my patients that you had done such a good job of reducing your wait times.  Now I don’t know what to tell them about how long they’ll wait to see you!

We were frustrated by the poor service we were providing to patients and referring physicians.  We regularly griped to each other about it.  The situation was very similar to the one we found ourselves in back in 2007 when we started our improvement work.  The difference now was this: We knew that positive change was possible.  We had experienced the Model for Improvement and had success with it.  We knew we weren’t powerless.  And so, last October, our docs got together to document our concerns.

Rather than jump back into the game with the sole goal of reducing our consultation wait times, however, we decided to look at all the areas of our practice that we were dissatisfied with.  Each urologist recorded 2 or 3 problems on sticky notes that we grouped into themes.  We did a second round of this after major themes had been identified.

It was a long list with some of the main themes being:

• workload/workflow processes
• human resources (lack thereof)
• quality improvement
• partner communication
• office practice management

But, the biggest thing to come out of that meeting was an agreement that we wanted to revitalize our quality improvement commitment and that we needed help to do it.  We needed someone to show us how to get back on track and how to create a sustainable system of improvement.  We needed a quality improvement coach.

We hired one!  And that starts a new chapter in this story.

P.S. Thanks to Greg, Kunal and Katherine for encouraging me to start telling our story again – warts and all.

I get it! I'm a fish! - Communication as a prerequisite to improvement

I had an interesting conversation last week with someone who shares my enthusiasm/impatience to move ahead with health system improvement.  He offered me a new perspective on a point that has been frustrating me for years, that is, we seem to be able to make fairly rapid improvements within our Urology group, but change at the provincial level is often slow.

Even though Saskatchewan is seeing amazing improvements through some focussed initiatives (see Sask Surgical Initiative and wait time trends chart), I want the changes to be faster and deeper.  "Faster" speaks for itself, but "deeper" is a little elusive.

Many of the changes we've made in Saskatchewan are "first-order", that is they're incremental and happen within the existing structure.  For example, we're doing more surgery to reduce the backlog and waiting list.  But, if the underlying mechanisms and culture that created the backlog in the first place aren't themselves changed, we're in danger of backsliding.  As the Surgical Initiative enters its last of 4 years, we're going to invest in processes designed to maintain surgical wait times at the desired levels.  That is, we're going to spend money pushing back against a resistant system.

A second-order change involves new ways of working and thinking about a process.  In the context of reducing surgical wait times, we might reward (not necessarily financial!) providers for their ability to deliver timely care.  Or, we might look closely at whether or not a particular operation is actually appropriate for a given patient.  If someone is unlikely to benefit from surgery, or, after being fully informed of risks, benefits and alternatives, decides against having surgery, wait times may be maintained by reducing demand.  Ultimately, we might change the system deeply enough that the disease currently treated with surgery no longer exists (quit smoking!).

Of course, second-order change requires a profound commitment to improvement, and investment in building communication and cooperation.  That's where my friend offered me insight into why I'm frustrated by the generally slow pace of change in the provincial healthcare system.

He follows some of the work described in this blog, and in particular our recent work on rapid improvement through 5-minute huddles.   He knows that I've challenged the need for week-long RPIWs (Rapid Process Improvement Workshops) that occupy huge amounts of staff and administrator time, sometimes to accomplish seemingly trivial results.  If our Urology service can move forward an improvement project over 1-2 weeks in 5 minute daily aliquots, why can't other services/departments do  the same?  His answer to me: Much RPIW time is spent establishing the team and setting context, whereas our urology team is already highly functional and knowledgeable about our own practice.

A-ha!  Our Urology group is already used to working cooperatively and collegially, discussing issues frankly, and developing consensus.   We've have regular times to meet and expectations that process improvement is part of our daily work.  In the same way that fish don't see the water they're swimming in, we're so used to being immersed in a supportive environment that we don't notice it anymore!

So, how do we make more fish? Or, maybe it's the water we need...

Training all healthcare staff and administrators in process improvement techniques is a toe in the water; it's first order change.  To get everyone to jump into the pool will take a more profound intervention.  I think that formal communication training is the key.  I flattered myself a couple of paragraphs back when I congratulated us for our collegial urology environment.  But, it's easy to get along when you all live essentially the same professional life: hospital rounds, take out a kidney, clinic, repeat.  Urologists have similar training, goals and professional culture.  It's much more difficult trying to communicate with someone from a different tribe.

A proposal: Rather than investing in training lots of people deeply in a specific process improvement methodology that they may use only occasionally, let's train everyone in healthcare in a common communication methodology.  That training would be used every day.  Healthcare would be safer, and better communication would obviate some of the process messes we're trying to fix.  Smaller numbers of process improvement experts could then be deployed to coach others in project teams, which would hit the water swimming because communication and teamwork would already be second nature to them.