Collateral damage

If you work in Saskatchewan healthcare, Budget Day, March 24^th, may be an early April 1^st for you. We’ve been living high on the potash hog, but no longer. The government has been dropping broad hints about holding the line on healthcare spending. And with fixed costs increasing, “holding the line” really means “cutting back”. We immediately think of job losses, program shutdowns and spending freezes. But the most profound and prolonged impact of budget cuts will come from the least heralded casualty: Quality improvement.

With healthcare spending (rumored to be) capped at a 3% increase, and layoffs already starting in some health regions, it’s only a matter of time before someone opines “We need to work smarter”, or “We need to do more with less”. Nice slogans, but it’s not going to happen in a climate of financial restraint and job-security anxiety.

Saskatchewan has the capability to provide exceptional healthcare. The Patient First review, while outlining many of the deep flaws in the system, also told the stories of patients who received exceptional care. By definition, exceptional care required providers to go above and beyond what the system would routinely provide. The system in which we work constrains the level of care that we can provide. It needs to change.

Individual providers - nurses, doctors, physiotherapists, pharmacists, housekeeping staff and all the other people who provide health care - are rarely the problem. We want to give the best care we can to our patients – our neighbors, friends and family. Marshall McLuhan said “There are no passengers on spaceship Earth. We are all crew.” The same idea applies to healthcare. Although we often draw an arbitrary line between patient and provider, we’re all just an icy sidewalk or a Big Mac away from becoming healthcare clients. We all want to improve the system, even if it’s for purely selfish reasons.

So, how will we improve the care we provide? Perhaps through traditional methods like seminars, on-the-job mentoring and reading journal articles. Regardless of how we go about it, improvement requires individual effort, time and resources. But, individual effort can only take us so far. Coordinated efforts to improve the broader system pay greater dividends, and also require greater investment.

In Saskatoon Health Region, there are many quality improvement (QI) initiatives underway - Electronic Health Records, Quality as a Business Strategy, Patient and Family-Centred Care – to name a few. But these efforts are largely still in the planning stages, and haven’t been rolled out to staff and patients. They creep along underneath the radar. And, as such, are prime targets for the budgetary axe.

It almost makes sense to cut QI initiatives. Canceling meetings frees up the time of busy administrators and managers. Conferences and workshops cost money that could be directed toward patient care. And what’s the point in developing an Electronic Health Record strategy when the provincial government isn’t going to fund it in the near future? If any of these arguments seem convincing to you, then welcome back to the bad old days when QI work was just a garnish on the meat and potatoes of providing clinical services.

Even if the QI budget isn’t actually cut, crisis management distracts us from improvement work. As a recent example, preparing for the H1N1 flu “crisis” became a priority in the health regions, resulting in several month’s of cancelled quality improvement project meetings. Planning layoffs and program cuts will be even more time-consuming.

I’ve heard suggestions that the economic downturn will be very short-lived and that potash revenues will soon rebound. If we hunker down, put QI on hold for a year, then start up again, we won’t have lost much, right? Wrong.

While we can dust off the QI projects and start again where we left off, the irretrievable opportunity cost will be staff engagement. In “Seven-year Itch”, I whined about how impatient I was getting at (my perception of) the slow progress on the QI front. If current projects screech from glacial to full-stop, it will be extremely difficult to convince staff, and especially physicians, to re-engage once the budget freeze is over. Salaried SHR employees will be back, certainly, but what about those of us who work at QI projects in addition to running our full-time, fee-for-service clinical practices? Only the most ridiculously committed enthusiasts (AKA suckers for punishment) will step up for a second round.

Cutting resources to QI work will cement the status quo. And the status quo is like keeping your money under your mattress – inflation keeps chipping away at its value.

So, just give healthcare a 10% budget increase, and everything will be fine, right? Wrong again. Budget cuts squash change, but the current method of funding rewards painfully slow improvement. In the same way that the care we provide needs to improve, we need to change the methods we use to implement those improvements. We need strong incentives to promote change. We need clear direction from political leaders.

Here’s a surgeon’s politically naïve take on the problem:

Gangrene is a serious infection. It needs prompt treatment to save life and limb. Administering antibiotics may buy some time, but the patient needs radical surgery.

An inexperienced surgeon is tempted to trim away a little of the gangrenous tissue, not wanting to damage healthy tissue, and hoping to save the patient disfigurement. And so, the infection persists, and the patient returns to the operating room for more extensive surgery, now further weakened by the infection.

Our patient has the best chance for recovery in the hands of an aggressive surgeon, who cuts deeply – sometimes to the astonishment of those observing – until healthy tissue is widely exposed. Some healthy tissue must be sacrificed, to ensure thoroughness. Our patient will need plenty of care and attention to promote healing, but he will survive.

So, maybe we need deeper budget cuts. Timid budget restrictions encourage administrators to nibble away small pieces in each department. As I noted above, some novice observers are surprised at the extent of surgery needed to excise gangrene. But, the same observers would be rightly horrified if the surgeon began to cut away tissue from body parts unaffected by disease.

So go ahead with deeper cuts, but offer to make up the difference through targeted funding. Clear direction and strong incentives from politicians and governing boards will direct administrators to make deep, yet appropriate changes. Require health regions to measure and produce outcomes around quality and patient experience. Fund efforts to achieve those outcomes. Insist on prompt timelines. Encourage cooperation between regions. Recognize that positive change requires significant investment.

Don’t waste a good crisis. Save this patient.

Plays well with others

The backlog blitz is coming soon! Not soon enough, of course, but we still have some preparations to make.

Our biggest challenge comes from outside our office. Many patients referred to us require medical imaging – ultrasound or CT scanning – as part of their evaluation. If one of these tests is necessary, we try to coordinate it with the person’s first visit with us. For people traveling from out-of-town, that means the test needs to be scheduled on the same day as their office visit.

The problem? Medical imaging clinics have backlogs too. Wait times for ultrasounds and CTs can be weeks long. As we start to schedule appointments within 7-14 days, we’ll need better access to these tests. And it looks like we’re going to get it!

We contacted several of the private medical imaging clinics (for ultrasounds) and the health region’s medical imaging department (for CTs) to explain our situation and ask for their help. The response was gratifying. They have offered to hold a number of appointment slots for us. If the slots aren’t filled 7 days in advance, they will release the slots. This will be particularly valuable in the case of CT scans. Our staff spends a significant amount of time coordinating CTs and office appointments. Knowing in advance when CT times are available will simplify scheduling.

An in-house consideration is how we can streamline our appointment approval process. Currently, consultation requests arrive by fax and are reviewed by staff. A tentative appointment date is set, and staff forward the request to the urologist. Our staff is experienced in triaging consultation letters and anticipating what testing the patient may require. The urologist will review the letter and accept the arrangements, or ask for an earlier appointment time, or additional testing.

This process has worked for us in the current climate of 4-6 weeks wait times. That is, the physicians can leave the appointment approvals in their inboxes for several days without throwing off the scheduling process. However, when wait times are as short as 1-2 weeks, approvals will need to be much more prompt. We’re reminding the physicians of this and will track performance so as to offer individual encouragement as needed.

Ideally, turnaround time for appointment approval would be instantaneous. We can do this by setting guidelines for approving appointments for certain urologic conditions. With clear guidelines, staff can set up appointments and testing without needing to check with the physicians. Setting up this “pre-approval” process requires:

1. Clear and accurate description of the clinical problem in the referral letter

Sometimes, this is straightforward, as in the case of vasectomy referrals. The single word “vasectomy” is sufficient to let us know the purpose of the visit. Staff set up vasectomy appointments without needing review by the doc.

On other occasions, it’s not clear what the clinical problem is. This may be because there is uncertainty as to what the patient’s symptoms indicate, or what the test results mean. In this case, it’s up to the specialist to work toward a diagnosis. On other occasions, the information needed to make a diagnosis is available, but hasn’t been sent with the referral letter. For one common urologic problem – blood in the urine (hematuria) – we’ve had success with sending a diagnostic algorithm to referring physicians. Circulating this algorithm has greatly increased the amount of information we receive along with the initial referral letter. Setting up similar algorithms for common urologic conditions will simplify things for our staff and for referring physicians.

2. Consistent evaluation process by urologists

The hematuria algorithm was approved by our entire group. Ideally, we would have similar agreement on other diagnostic pathways. It’s not always easy, though.

I recently surveyed our group about how we should approach referrals about several common, benign urologic conditions. There was considerably more variation than I anticipated. Some of the docs supported giving guidelines to staff, while others want to review the referral letter and decide for themselves whether additional testing should be coordinated with the consultation appointment. Those urologists falling in the second group cited their desire for patients to have a single visit, whenever possible. They were concerned that they may miss the opportunity to schedule necessary testing at the time of that visit.

We may be able to reach consensus around pre-consultation testing, but in the meantime, I’ll try to determine individual preferences and compile them for our staff. Even though it’s somewhat complicated to deal with 8 different preferences, it should still speed up the appointment approval process.

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?