Islands

Remember Gilligan’s Island? No? Well, the rest of us will wait here while you catch up.

Part of the fun I had while watching that TV show was seeing the incredible contraptions – from a washing machine to a pedal-powered car - the castaways constructed to make their life easier. (I still enjoy hearing about ingenious solutions to everyday problems. That’s part of what has made our Clinical Practice Redesign project satisfying to me.)

But, the Gilligan’s Island community had its limitations. Even though each of the 7 residents played a unique role (only 6 roles, if you count the Howell’s as one amalgamated upper-class twit), they never managed to reach their goal of leaving the island. Even though the island was idyllic, both naturally and due to their bamboo gadgetry, they still wanted to go home. But, they were never able to muster the resources to do so. The castaways occasionally had visitors from the outside world, but circumstances were comically contrived so that escape remained elusive.

I think we’re in a Gilligan’s Island situation in our office. We’ve made a lot of successful internal changes. Our practice is more efficient and (we hope!) more effective. But, there are some changes that we can’t make on our own island. We rely on other practitioners and services to provide a continuum of patient care. But circumstances remain not-so-comically contrived to that improved patient access remains elusive.

The wait time for specialist consultation has been our main target. But, that’s only one part of what makes up the patient’s experience. Patients wait to see their GP, then for testing, then to review the tests with their GP, then for a specialist referral, and so on, until they have their problem resolved. A more patient-centred metric would be to measure the time between onset of symptoms to complete recovery. Attempts to measure this time illustrate the complexity of our healthcare system, and the interrelationships between individual departments.

Our recent office blitz made us more aware of the way our private practice meshes with other parts of Saskatoon Health Region (SHR). We anticipated that we would need better access to xray procedures – mainly CT scans – in order to be able to schedule patients on short notice. The SHR xray department was very helpful when we approached them about this, and allotted specific times for our blitz patients to receive CT scans.

However, the increased patient volume over the blitz period caused a surge in the number of other procedures being scheduled, and we haven’t received additional resources to deal with that. Cystoscopies have been particularly challenging to complete in a timely fashion. Also, many of our patients still wait up to a year for certain kinds of surgery.

The problem is that we’re all living on individual healthcare islands, each with its own culture. On some of the islands, conditions are rough and the inhabitants are motivated to make changes to improve their lot. I’ve been told that family practitioners are among the first to adopt Clinical Practice Redesign because they are overwhelmed by patient load and the need help to deal with multiple, chronic medical problems in their patients.

On other islands/practices, life is good – perfect weather, low-hanging fruit, no annoying insects. Why would anyone ever want to change? I’m not suggesting that anyone working in healthcare has this perfect situation, but some of us are more comfortable than others. And so, when the hard-living inhabitants of one island call for help from their more fortunate neighbors, what’s in it for those living the easy life? We market Clinical Practice Redesign by telling doctors “Trust us. If you try it, things will be better!” (Disclaimer: I think it is better!) If you were living in paradise, would you want to take a chance that the next island over was an even better paradise?

To get everyone working toward the same goal, someone has to turn up the heat. On Gilligan’s Island, it would be a plot device like rumbling and smoke coming from the island’s volcano. In healthcare, motivation could come from various sources:

- Make public, transparent and accurate reports of wait times for GP and specialist visits, cancer treatment, surgical and other procedures. Report by practitioner and health region. We’re a competitive bunch, and no one wants to be at the back of the pack.

- Make it financially disadvantageous to ignore long wait times. Reward practitioners who manage their resources wisely. Put your money where your mouth is.

- Offer support and education to help practitioners apply Advanced Access principles. People can’t improve the system if they don’t know what tools are available (see “Juice”).

- Prove that paradise does exist – showcase examples of successful initiatives that have improved the lives of patients and practitioners.

Anyone know where we can find an angry volcano god?

Scratching the Itch

I know you’re excited to find out how the blitz weeks went. I’m excited too. I’ll show you in a minute.

First, I want to tell you about the latest change we’re going to try in our practice. It’s so simple, and is already standard in many practices, so I was unsure if this change was even worth mentioning. But then I realized, That’s exactly the point!

When trying to implement Clinical Practice Redesign (CPR), simpler is better. This is especially true for practices that are new to CPR. Learning the processes, measurements and jargon of CPR can be intimidating and overwhelming. A simple practice change involves minimal investment of time and manpower, and minimal loss if the trial doesn’t succeed the first time.

Trying something that is already in place elsewhere also improves the chance of success. Someone else has already worked out the kinks and shown that the procedure is viable - in their practice, at least! While it can be very satisfying to develop a novel idea to solve a problem, it also requires a lot of effort. Better to borrow shamelessly.

So, here’s the plan: For men referred to have a vasectomy, we’re going to offer them a single-visit consultation and procedure. Yeah, I know – it’s a little underwhelming. But consider what this change involves, and what the process illustrates about making these changes in clinical practice.

1. Feel the itch

In general, I think of the whole change process as “Scratching the Itch”. (An iffy metaphor in a urology practice, but bear with me…) The specific itch I wanted to scratch this time was the value (or, lack thereof) my patients received when referred for a vasectomy. Our tradition is to see the man for a consultation in our office, ask about his medical history, examine him to determine suitability for the procedure, and then discuss what’s involved. If he is in agreement to go ahead, we schedule the vasectomy date, often 3 or 4 months from the initial visit.

Many men are surprised and disappointed to find out that they are not scheduled to have the vasectomy performed right then and there. I have offered several reasons why that doesn’t happen:

I perform vasectomies in the hospital outpatient clinic, and don’t have the necessary equipment at our office.

I need to examine the man first, as some men’s anatomy precludes doing the vasectomy under local anaesthetic in the outpatient clinic, and may require a booking in the operating room under general anaesthetic.

Some men only want to come for a consultation to find out what the procedure involves, and choose not to book the vasectomy at that time. If I scheduled an “all-in-one” visit, then the additional time scheduled to do the procedure would be wasted.

I’m sure those reasons often rang hollow with my patients, because they sure felt that way to me. The rebuttals were obvious:

Well, then, get some equipment in your office! Or, do everything in one visit at the hospital. I just drove 3 hours for a 5 minute visit! Now, I find out that I’ll have to come back for a second visit.

My own doctor examined me before he sent you the referral. He said everything was normal. How often do men need a general anaesthetic for a vasectomy, anyway? That can’t be too common.

I definitely want the vasectomy done. I would have told you that, if you had asked.

There was definitely an itch ready for scratching!

2. First, a gentle scratch

A couple of us scheduled a few vasectomy/consult all-in-one visits to work out any hitches. Hitches, what hitches? In fact, there was immediate, positive feedback from our patients who welcomed having everything done in one trip. We had sent all of them our vasectomy information pamphlet at the time we made their booking, so they were well-informed about what to expect during and after the procedure.

3. Then, scratch it hard

We presented the idea to our entire group. The selling points were better patient service and satisfaction, and fewer low-value (for the patient) office visits (which equals more capacity to see new consultations). We also addressed the potential problems with this change:

A no-show patient “wastes” valuable procedure time.

The man may not be suitable for vasectomy done with local anaesthetic, and need to be rebooked at a later date with a general anaesthetic. More wasted procedure time.

Combining the consultation with the procedure may take longer than the usual 30 minutes scheduled for a vasectomy alone, making us run late.

I think it’s important to present a balanced view of proposed changes. If skeptics sense that enthusiasts are charging blindly ahead, they step hard on the brakes. If that is their first impression of the proposal, negativity becomes entrenched and difficult to overcome. However, if you can show skeptics that you’ve considered and addressed potential risks, I think the proposal is judged on its own merits, rather than becoming a pawn in the broader skeptic vs. enthusiast tug-of-war. (In which battle, the skeptics have the huge advantage of inertia.)

Here’s how we addressed the potential risks:

We would require that men confirm their appointment time, in the same way patients have to confirm their date for surgery. This should reduce no-shows. However, we’ll track no-shows, and consider phone reminders if the numbers are significant.

If a referring GP comments on potential anatomical challenges in his referral letter, or the GP has unsuccessfully attempted the vasectomy, then we’ll arrange to see the man for a prior consultation in the office, rather than booking the vasectomy at the same visit.

We’ll schedule 45 minutes for a vasectomy/consultation, or 2 hours for 3 procedures.

The outcome? Everyone agreed to try it, and actually seemed quite keen.

4. “Does this rash look infected to you?” – Get a second opinion

I was pretty pleased with how it had gone, and how all the bases had been covered. But, I had forgotten one thing. I didn’t ask the people who know how our system really works – out staff. Delores pointed out to me that, in our current system, men receive their office appointment notification quite soon after they are referred. Even though they may wait several weeks to see us, they know that we have received the referral letter and have made arrangements. They will not find out about the date for the vasectomy until after the office visit, and may need to wait several months to have the procedure.

Delores went on to say that, in our new system, patients wouldn’t hear from us for several months. We schedule surgery up to several months in advance, and then plan office schedules and minor procedures (like vasectomies) around our OR time. Scheduling vasectomies comes last. Delores predicted that we would be swamped with phone calls from men who were wondering whether or not we had received their GP’s referral. That’s a waste of both the man’s and our staff’s time and energy.

Her solution was that, upon receipt of a vasectomy referral, staff would send the man a letter to let him know that we had his information and would be sending out an appointment in several weeks. Great idea!

I think this change will stick because it doesn’t involve a big change in physician behaviour. We’re taking 2 established practices – office visit, and vasectomy procedure – with which our docs are already comfortable, and redesigning them both to improve patient satisfaction and practice efficiency. Initially, I felt embarrassed to mention that we were making this change. I know it’s already standard procedure in many practices, so I thought someone would read this lengthy dissection, slap himself on the forehead and say “Duh! What took you so long?”

The point here, and in any practice that is trying to improve, is that the changes that make a difference are small and mundane. Individually, they seem trifling, but will eventually coalesce into something powerful.

Let’s celebrate each other’s small victories.

And now, blitz week results! These are hot off the press. The last data point is from May 6 – the end of 7 weeks of extra office capacity.

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The trend looks good!

And means nothing. Seven weeks of office blitz will only have been worth it if we can maintain the gains. We need to see the long-term results, and our annual nemesis is almost upon us. Curse you, summertime, with your unquenchable 30-new-referrals-a-day demand and capacity-hobbling holidays, curse you!

The way to a urologist’s heart

Only 2 more blitz weeks to go. Until they are completed, I’m not sure we’re able to assess whether we’ve made an impact on our 3^rd NAA numbers. But, we have already learned something important from this initiative.

We were all dreading our full week of seeing new consultations – whether in the office or at the cystoscopy unit. Our clinics are busy enough when there is a mix of follow-up visits (usually easy to complete in the scheduled 15 minutes) and new referrals (more intense and time-consuming). Having a clinic of all new referrals seemed daunting.

As expected, it was hard work, but several of the urologists commented on their very positive experience with blitz week.

While each doc was working the extra week, staff treated them as if they were actually on holiday. That is, that doc didn’t take calls from the hospital or referring physicians. He/she could focus entirely on completing consultations. This made the day’s work much more enjoyable. Freedom from interruptions meant I could move from one patient visit to the next without having to return phone calls in-between. I was able to stay on schedule, and left the office promptly once I’d seen my last patient. One of my partners commented that he enjoyed “spending more time with patients.” He felt less rushed with this arrangement.

Each doc had clinic scheduled from 0900 to 1200 and 1300 to 1600. (We took a lunch hour!) This was unanimously well-received. Our morning schedule usually consists of 0700 hospital rounds followed by surgery or office. If we have a morning office, there’s often a mad dash to make it there by 0800. Starting late means you will likely run late all morning. That’s very frustrating. Perhaps we need to change our 0800 habit to 0830. Of course, that will cut into our capacity, so we’ll see how our wait times are over the next few months. Having an extra 15-20 minutes before starting patient visits would also be a great time to make some phone calls, and get them out of the way before starting a morning office.

Now that we’ve had a taste of how pleasant it is to conduct a clinic in an unhurried fashion (and don’t think that our patients can’t tell when we’re feeling rushed!), it’ll be tough to go back to business as usual. I would like to pursue some changes that will improve our docs’ job satisfaction. Switching to a 0830 start is pretty simple; we just have to say the word to our staff. But, will the loss of 2 appointment slots per morning office have a big impact on our capacity? Just over 10% lost capacity – not a trifle. But perhaps we could compensate for that lost capacity by increasing the ratio of new consults to recalls. We’ve had success with that over the last year, but there’s room for further change. Also, there’s still considerable variation in recall rates among the urologists. Maybe we could link the number of new patients you see to the time your office starts in the morning. If a particular urologist sees a higher ratio of new patients, then he/she could be rewarded by a later start to his/her office. This would give an additional incentive (beyond altruism and peer pressure) for each doc to carefully consider their own recall practices and encourage them to adopt (or even just ask about) other’s methods.

We could also build in empty slots into the clinic schedule, to be used for phone calls, catching up on dictation, or spending extra time with a patient.

It was really valuable to learn this from blitz week. Coming up with ways to make our docs less harried is good for both physician and patient. We may provide the same technical care while dealing with repeated interruptions and late starts, but a happy, unhurried physician gives patients a better experience.

Come on in… The water’s fine!

Since we started encouraging pooled referrals, we’ve never looked back. If you’ve been following our Clinical Practice Redesign work, you know that we consider the pooled referral to be our default condition, that is, anyone referred to our group is automatically scheduled for the earliest appointment available with any urologist. (Caveats: If the problem requires subspecialty expertise, we look after triaging to the appropriate urologist. If the patient already has a relationship with one of our physicians, we try to maintain continuity of care by scheduling the appointment with the same physician. Most importantly, the patient or referring physician can specify which urologist they prefer, and we will schedule the appointment with that doc. The wait may be longer in that case.)

I like the analogy of an ice-cube tray to illustrate the advantages of a pooled referral system. When you pour water (referred patients/demand) into one compartment of an ice-cube tray (specialists/capacity), the water automatically spills over into the other compartments until they are all filled. The result will be even and efficient distribution of water. Unless overall demand exceeds the tray’s total capacity, all the water will be accommodated. Overflowing water represents excess wait times.

The alternate model is to cut up the tray into separate ice-cube compartments, and then fill the compartments individually. Not only does that require more effort (you have to move the water jug from one compartment to the next), but also there is more risk of overflow. In this model, if individual compartment capacity is exceeded, water will spill. Some compartments may be underfilled. This model is inefficient because the compartments don’t work as a system.

One day soon, you’ll be thanking me for providing this sweet analogy, because I think pooled referrals are soon going to be a topic of conversation in Saskatchewan. And, when someone mentions them at a party, you’ll be knocking socks off with the ice-cube tray story. You’re welcome.

Why the interest in pooled referrals? Because of the Saskatchewan Surgical Initiative! SSI says that by 2014, no one in Saskatchewan will wait more than 3 months for surgery. That’s bold. But, other health systems have achieved it. The methods they used are well-known, and applicable to Saskatchewan. One of the most powerful methods is pooled referrals. (Still don’t believe me? Check the 2-pager highlighting the SSI plan.)

So how will SSI get us from here to there? First, we need to know what “here” and “there” are.

“Here”

Our current state is the 2nd ice-cube tray model (see above). Most specialists are “organized” in solo or small-group practices. Even when they are physically congregated as a larger group, the individual members of that group still behave as solo practitioners as far as distribution of referrals is concerned. Often, large specialty groups are just a device to share office expenses and on-call duties. Not that there’s anything wrong with that.

Most Saskatchewan specialists have plenty of work to do, so there’s very little perceived incentive to share a common pool of referrals. They may even be worried that they will be “giving away work” if they participate in a pooled referral scheme.

GPs often have established referral patterns based on their experience with a certain specialist, and their judgment of that surgeon’s expertise. Or, they may be golf buddies. GPs who are new to the province, and are practicing in solo, rural practices, may not have developed a personal relationship with many specialists, and may be uncertain as to which one will best serve their patient’s needs effectively and promptly. There are recent efforts to make referral-to-consultation wait times available to GPs via a website, but the information is self-reported by specialists. Participation by specialists is not mandatory, nor is the information audited or verifiable.

Patients are even more in the dark. They rely on their GP’s advice, or talk to friends and family who may have been referred to a certain specialist. They have virtually no information on individual wait times. They may not receive confirmation of the appointment for several weeks.

The system is working great for us specialists, because we always have plenty of work, and it’s delivered straight to our front door. Everyone else… not so good.

“There”

The “ideal” state I’ve most often heard described goes something like this:

GPs submit referrals through a centralized online system. Artificial intelligence (AI) software asks for key clinical information to ascertain which specialty would deal with the patient’s condition. The system tracks all available specialists’ wait times and subspecialty interests. The patient is then assigned to the appropriate specialist with the shortest wait time, and receives the appointment date before leaving the GP’s office.

Whoa. Ease up on the 1984, Jackboots! This system would be maximally efficient, but very restrictive. There would be little choice given to patients, even though they would be assured of the shortest wait time possible.

If we imagine a system guided by patient-centredness, we may sacrifice some efficiency, yet improve overall satisfaction. Keep the centralized online system with AI. When GP and patient jointly submit clinical information, have the AI suggest alternatives to specialist referral (alternate provider, care pathways, patient education resources). If a specialist referral is appropriate, the system gives the patient all the information he/she needs to make a choice. Some patients may still prefer that their GP choose a specialist. Others may want to know wait time information, subspecialty interests, results of patient satisfaction surveys, and even condition- or procedure-specific outcome data. The choice remains up to the fully-informed patient.

Because concern over long wait times tends to trump all other considerations, we generally ignore the other factors that affect patient choice of a consultant. (During a famine, one overlooks a little mold on a loaf of bread.) Once wait times are better managed, and therefore shorter, patients will behave more like well-informed consumers. The balance will shift from a seller’s market (favoring specialists) to a buyer’s market (more choice for users). Patients will start to consider geographic convenience, surgeon experience and outcomes, other patient’s satisfaction with that specialist, in addition to the wait time.

The trip from here to there

How do we make our way through the wilderness to reach this utopia of patient-centredness? First, we could talk to people who’ve already made the journey.

While many specialists consider pooled referrals to be a radical change, they are actually more familiar with the concept than they may realize. Some specialties already use a pooled referral model. Radiology is a prime example. When I order an xray, I accept that the test will be interpreted by the radiologist on duty that day. Because of subspecialty interests, some work may be streamed toward a specific radiologist. I have the option to have the xray films reviewed by another radiologist if I choose.

In order to be confident in the pooled radiology system, I have to be satisfied that the quality of work is consistent among all the radiologists. This is a tricky subject to raise if we’re considering implementing a pooled referral system, yet it’s critical that we address it. All specialists are not created equal. Differences in knowledge, skills and attitude all affect performance. How will a pooled system function if some of the participants don’t perform to a common standard? This is an important consideration for patients using the pooled system, but also for the specialists in the pool.

An objection sometimes voiced by specialists, regarding pooled referrals, is that they don’t want to work with Dr. X because they don’t respect his/her abilities. (Note: This is rarely stated at the meeting, and sometimes requires administration of a few drinks after the meeting. In vino, veritas.) Whether this objection is based on actual clinical shortcomings, or just personality conflicts, it’s still important to acknowledge it as a barrier to implementing pooled referrals.

Next, we need to think of a way to get everyone into the car, i.e. incentives. For patients, we should offer something beyond just the shortest wait time possible. The referral system should direct the patient toward appropriate care (which may not be referral to a specialist) within a reasonable time frame, with the provider of their choice.

For GPs, our system should reduce their paperwork burden, and increase job satisfaction. An electronic referral system that lists all specialists’ interests and wait times, as well as the information specialists want to accompany the referral request, would simplify the GPs job. If the electronic referral system also included expert information on how to manage common clinical problems before considering referral, GPs could provide more service to their patients in their own practice.

Incentives for specialists are a little trickier. We already have plenty of work to do. We are, for the most part, well paid. We value our autonomy, i.e. I choose my own practice group.

Honestly, I don’t know how to motivate specialists to participate in a province-wide, pooled referral system. And that’s why I think we should let patients and GPs drive this initiative. They are the ones with the most to gain.

First steps

Start by collecting reliable information that patients and GPs want. Of course, we first need to ask them what they want, but I have a few suggestions. Collect information from all surgeons regarding their specialty and subspecialty. Develop a method to measure and verify wait times from referral to consultation. Post all this information on an open-access website. Publicize the website. Eventually, the site could include patient satisfaction survey results, and outcome data.

Next, implement an electronic referral system. Other provinces have a headstart on these systems, so we should beg, borrow or steal. Or offer to collaborate. Pay a premium to GPs and specialists who use this system, but make sure the system is useful and user-friendly enough that they want to use it even without being paid extra.

Finally, don’t try to push specialists into a pooled referral system. Instead, set clear and realistic expectations for wait times and offer specific incentives to achieve those goals. Provide support and training for specialists who wish to implement changes (including, but not limited to, pooled referrals) in their practices. Acknowledge and address real barriers (personal and professional) to adopting pooled referrals. Do not expect busy clinicians to implement these changes on their own. Praise – publicly and frequently - the practices that achieve the goals.

Establish a new level of expectation in Saskatchewan: Patients are entitled to the information necessary to make a decision about which specialist they wish to see.

Turn up the heat until everyone wants to jump into the pool.