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?

Blitz

I haven’t showed you this in a while:






I groaned when I saw the spike in mid-November, but the mid-December peak was even more discouraging. I remember how exciting it was to see the results we had in early 2008. What’s gone on since then to put our wait times up?

Around the time 3rd NAA started to climb in 2008, 3 of our partners had switched to half-time practice. This moved us from 9 FTE to 7.5 FTE. Coincident with that change, we noted an increase in the number of referrals from Regina. There were only 2 urologists in Regina at that time, and their wait times were lengthy. This has been a longstanding situation, but we found that some Regina GPs had recently “discovered” us and were suggesting to their patients that they could see a urologist in Saskatoon more promptly. As word spread in Regina, more GPs (and their patients) would take advantage of our services.

So, it seemed to be a combination of reduced capacity and increased demand. In that context, one could conclude that, even though our 3rd NAA has risen since 2008 (now equaling our original baseline), that our overall processes must have improved because we’re doing more with less. If we hadn’t made some the changes through Advanced Access, our 3rd NAA would likely be much higher.

Well, that’s cold comfort. We remain committed to our goal of a 2-week wait time for all consultations. And, we know what the barrier is.

Because the wait times have been pretty steady this year, the problem remains the same: backlog. In a stable system, if we can trim the backlog, our system should drop to a new, lower level. And that’s where the recent spikes in 3rd NAA turn out to be a blessing in disguise.

In November, several of us noted that some patients were waiting until March to see us. The 3rd NAA is an average, so some unfortunate patients at the far end of the curve have very long waits. We know what a burden that is for our patients, and it’s not the way we want to provide service. This prompted Peter Lau to surprise us with a proposal.

We know the backlog is our big challenge. We’ve picked away at the edges of it by having half-time partners come in to work on their months off, staying late to see more patients, and filling in any open slots in the docs’ calendars. But, still the backlog eludes us. It just doesn’t look like we have any extra capacity to work with. Until Peter found it for us.

He proposed that we each give up a week out of our annual holiday allotment, and spend that week in the office seeing patients. We take our holiday time pretty seriously in our practice; it’s one of the main perqs of working in a large group. So, before taking the idea to the group, we wanted to be confident that it had a (theoretical) chance of success.

Our current backlog is about 800-850 patients. If one urologist spent 5 8-hour days in the office seeing, on average, 3 patients per hour, he or she would see 120 patients in that week. As one of our half-time partners has just retired, we now have 7 FTE docs, so the proposed backlog blitz would deal with about 840 patients. What a coincidence!

Our proposal to the group was that, starting in the spring, we would schedule each of us to work one of 7 consecutive weeks. In order to make this more palatable, we suggested that during each urologist’s week, they would focus solely on office work – no call, no surgery, no fielding phone calls from referring docs. Staff would behave as if that urologist were actually away from the office on holiday. We felt this would be an important feature of a blitz week, otherwise, the doc in the office would become the go-to person for every phone call and query that came into the office.

Rather than spring the idea on the group, we informally shopped it around a bit first. We felt it was a radical enough proposal that surprising everyone with it at an office meeting could trigger a negative (and understandable) response. I was nervous as Peter made the pitch. What could possibly motivate the group to give up an entire week of holidays?

The response: Let’s do it. Immediate and unanimous! It’s difficult to express the pride I felt at being a part of a group that would so readily give up personal, family time in order to improve patient care.

So, from March 22 to May 7, we will be crushing our backlog. However, as we plan for the blitz, we see that this means a significant change in our office practices, from notifying patients to booking ancillary tests, such as CT scans and ultrasounds. We’re working on identifying these challenges and creating new processes. More on that next time.

Seven-year Itch

My partners and I had under our care a man with a life-threatening problem. His urinary bleeding was severe enough that he required blood transfusions every few days. Surgery seemed the only option that would help him. The complicating factor was that he had suffered a heart attack a week earlier. Giving him an anaesthetic would put him in danger of a second, more serious heart attack.

If we put off the surgery, his condition would gradually deteriorate. At that point, if surgery was performed, he would be weaker and more susceptible to the stress of the operation. Both courses – continuing observation and blood transfusions, or performing surgery – were risky.

Surgeons have a predilection toward intervention over observation. Maybe it’s because physicians with that temperament choose surgery as a specialty. Or, maybe surgeons develop that trait because the medical system triages patients who will benefit from intervention, and streams them into our hands. Whatever the reason, we recommended surgery to our patient. We prepared him as best we could and then took him to the operating room. The bleeding was stopped and he went home 2 days later.

That was a very gratifying and immediate result.

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Over the last 3 years, coincident with our urology group’s Advanced Access project, I’ve become involved in other quality improvement efforts, both in the Saskatoon Health Region and also on a provincial scale. As does our office project, these other initiatives address significant deficiencies in health care. I continue to work on all these projects because I strongly believe that, when implemented, they will transform the way patients experience care in Saskatoon and Saskatchewan.

“When implemented”, that is, because it is taking a long time to see results!

In all these projects, the first phase was very exciting: Working with excited and motivated colleagues, and imagining possibilities. But initial planning has given way to the long slog. We meet regularly, but I’m getting discouraged at the lack of progress that I perceive.

I don’t mean that there isn’t action on these projects. Policies and protocols are being written, and subcommittees are formed. But I want to see changes that improve patient care. Pronto. Or I want to focus my efforts on something that will make a difference.

Maybe I’ve been spoiled by Advanced Access. After all, our office project is on a smaller scale, in an environment where I have a fair bit of direct influence, and involves a group of motivated people who directly provide patient care. (I include the docs and our staff in that group.) We’ve had quick payoffs from changes like pooled referrals, better communication with referring docs, and optimizing our patient recall practices. It’s very gratifying to see prompt results from implementation of these changes.

Perhaps physicians’ temperaments (selected by medical schools, or nurtured in medical schools – your choice) are more suited to the satisfaction of immediate results: Surgery for appendicitis, or penicillin for strep throat, for example.

I’m griping partly out of frustration, but I also want to explore my discouragement in order to understand how to maintain other physicians’ engagement in change initiatives. If enthusiasts/early adopters become disenchanted with the slow pace of change, then it’s going to be exponentially more difficult to keep the next echelon of physician champions engaged.

If you’re an administrator, you may be reading this and thinking “Well, what’s so special about Kishore’s time and effort? I sit on the same committees and share the same frustration.” Yes, I’m sure you do. But, there is a significant difference between us. I have another job – my clinical work – and in that job, I get to see the results of my actions regularly and promptly. Almost every consultation requires coming up with a management plan, and then putting the plan promptly into action. Even when the outcomes aren’t the desired ones, there’s still a satisfaction in working through a problem and executing a plan on your patient’s behalf.

So, if I (and other physicians) don’t find satisfaction in tangible results from quality improvement efforts, I can devote all my time to clinical work.

I’m an action junkie. Give me my fix.