Sharing

Before I tell you about what’s exciting me this week, I want to share an exceptional service experience with you. Last month, I attended the Institute for Healthcare Improvement’s 10th Annual International Summit on Redesigning the Clinical Office Practice. (Great meeting, unwieldy name.) Deservedly, IHI has a reputation for providing outstanding value at their conferences. Virtually every session I attended was terrific, with energetic presenters and great ideas.

But, one session didn’t live up to its billing. Powerpoint slides overloaded with bullet points, presenters reading directly from slides while facing away from the audience, an uninspiring message unrelated to the course description in the conference handbook – all the vices I’ve repeatedly griped about, rolled up into one dreary session.

So I walked out. Life’s too short.

The conference guide offered a money-back satisfaction guarantee, so I decided to see what would happen if I actually complained. I talked to the staff at the registration desk, and they called the conference manager. She immediately offered me a full refund of my registration fee – no questions asked. That’s more than $1000! I backpedaled and said I would be satisfied to be refunded only the amount for the unsatisfactory seminar. She insisted that the guarantee promised a full refund, and that she would arrange it.

Wow! I was impressed (and a little worried that this might get me black-listed with IHI), especially since IHI has very little control over the independent contractors who present the seminars. I couldn’t wait to tell this story to everyone I knew at the conference. I admit to being a little skeptical about whether it would really happen, so I checked with the Health Quality Council (who sponsored my trip). The money had been refunded, almost before we returned from the meeting.

What a great example of customer-centred service:

• Trust your front-line staff to keep promises that your organization has made.
• Don’t make your customer jump through hoops after they’ve had a bad experience.
• Recognize that, even though your organization may not directly control every aspect of the process, it is still responsible for the outcome and the customer’s experience.

Okay, IHI, I get it – you model good behaviour. Nicely done. But are you going far enough with this guarantee?

Hidden Treasure

Last week, I attended 2 meetings that were goldmines. IHI’s Redesigning the Clinical Office Practice Summit and Taming of the Queue were high-yield for great ideas, both at the formal presentations and through informal discussions. While I was pleased to find out about some exciting quality improvement work being done across North America, I was a little annoyed that I only made these discoveries by virtue of attending the meetings.

For example, I’m interested in improving how information is shared between family doctors and specialists when a referral is made. At various meetings, I’ve happened on projects that are directly related to this area:

• Our hematuria referral information letter has improved the amount of information we receive, but a web-based referral system would be better. It turns out that Manitoba is already developing an electronic referral system that guides family doctors through the referral process.
• A Winnipeg radiologist reported on an electronic system to manage x-ray requests. Because of concerns that some x-rays may be ordered inappropriately, and not contribute significantly to patient care, the system provides decision support, based on clinical information entered by the physician. This is a potential educational tool that would give immediate feedback to a referring physician. Demand for consultation may be reduced if this feedback assists the physician in managing the patient’s condition in the primary care setting.
• A British Columbia physician showed me a template for specialists to list the appropriate investigations and information that should accompany a referral request. Specialists can indicate what tests should or should not (reducing unnecessary testing) be done.

It made me wonder how much other relevant QI work is going on under the radar. Are we missing opportunities for collaboration and reducing wasteful duplication? We need a central clearinghouse for quality improvement work being done across the country.

Rewarding

I was glad to see that I’m not the only one obsessed with the frequency with which specialists recall patients for review. A recent US study in the Annals of Family Medicine looked at over a billion (!) specialist visits and concluded “The results of our study suggest now that not all activity performed by specialists when in a specialist role may require specialized care.” The study found a high percentage of internal demand/patient recall among US specialists.

Our recall numbers caused a little consternation in December. We’re still not sure what was going on in our clinic to give a spike in recall rates. But, we’re happy to see that they’re back down in early 2009.

There’s still a marked variation in recall rates among our group, so I think there’s still a lot of juice to be wrung out of aligning practices in this area. As our recall rates drop, we’ll open up more capacity to see new referrals.

Awkward

The problem with first-year medical students is that they haven’t yet learned which questions not to ask.

Two weeks ago, I had a student spending the afternoon with me at my office. We met a patient and his wife, and talked with them about the results of a CT scan he had done earlier in the day. After the visit, the student asked me "Why did he have to come to your office today?" Her concern was that the man had difficulty walking and had recently moved into a care home an hour away from Saskatoon. It was a significant effort for them to travel, both to get to Saskatoon and then within the city.

My staff is diligent about scheduling CT scans (and other tests) on the same day as an office visit, so I can review the results with the patient. I pointed out to my student that this saves people an extra trip into town.

Then she got really impudent.