Pooled referral gains momentum in Saskatchewan

Specialist "pooled referral" implementation is sweeping the province!  Here's a great story in the Prince Albert Herald about PA's orthopedic surgeons offering pooled access as of March, and general surgeons planning to implement it at the end of May.  The Regina Obstetrics and Gynecology department are also offering this option to their patients.

Pooled referral, also known as centralized referral intake (CRI), involves collecting referrals in a central location and then distributing the referrals so that patients have access to the specialist with the shortest wait time.  When our urology group implemented this system several years ago, the reception from referring physicians was very positive.  (Here's the post looking at wait times for pooled referrals.)  They liked the fact that they didn't need to do the "heavy lifting" of figuring out which urologist had the shortest waiting list, or which one of us subspecializes in a certain problem.  

When I have the chance to share our practice's learning and improvements, the idea of pooled referrals has an immediate appeal to both referring and consulting physicians.  However, physicians do have some trepidation about the system.

First, they're concerned about patients (and referring physicians) having the choice of which consultant they will see.  Our group's philosophy has been that patients and referring physicians have the choice of which urologist they see.  We don't require participation in pooled referrals, however, if someone "opts out" of pooled referrals, they may wait longer to see the urologist of their choice.

Continuity of care is also a consideration.  Physicians recognize that time and effort is wasted, and important clinical details may be overlooked, when patients switch between specialists.  A pooled system should try to maintain any previously-established patient-physician relationships (as long as the patient wishes to do so).

Finally, I'm often asked a very thorny question: How can a pooled referral system ensure that patients will have a consistent experience no matter which specialist they see (AKA not all docs are created equal)?  This applies to the interpersonal, as well as technical, skills of the specialist.  This is very difficult to answer as there is often no formal tracking and reporting of individual surgeon's treatment outcomes and complications.  Communication skills, empathy, and affability may only be judged through word of mouth.

This raises an ethical question: If we promote a new referral management system, and that system has the potential to adversely affect the experience and outcome of some patients, what is our responsibility to assess and improve the abilities of the specialists so that patients receive consistent, competent care that is constantly being improved?  

I think that, by its very existence, a pooled referral/CRI system begins to address this concern.  In order to implement this system, specialists must be prepared to communicate and collaborate, often to a degree that they previously didn't do.  This lets them share information about, and expose differences in, individual practices.  In our urology practice, learning about differences in our practice habits made us curious about what could be considered "best practice" and how we could offer more consistent care.  

Pooled referral/CRI has the potential to improve patients' access to specialist care, and make sure that they receive care from the appropriate practitioner.  However, it's not without drawbacks, and we must proceed with eyes wide open.

Great comment from a nurse about managing the drug shortage

This comment (made on the last post about the national injectable drug shortage) is great on several levels:

I am an Lpn at sch on the gyne ward.. I haven't noticed that my patients are suffering any more since the cut back on IV meds.. the use of gravol supps for nausea, regular use of oral analgesics and pain and nausea rating on rounds has I think ensured patient comfort..Patients seem hesitant at first but are reassured that if the oral or pr routes don't work we will go with the intervenous option. I wonder if Pre op clinic could instruct patients on the shortage so that they are less apprehensive post op when their nurse suggests something other than IV drugs..

• It's feedback from a front-line care provider telling us about how care-givers are perceiving the situation's effect on their patients' care.  

• The nurse tells us that pain and nausea rating is done in order to ensure patient comfort.

• We get some insight into how patients are being affected by the changes.  They may be anxious about the effectiveness of pain-killers or anti-nauseants being given other than intravenously.  The nurses on this ward are reassuring patients that they will switch to intravenous medications if the alternate forms aren't adequate.  I don't know if there has been formal training in a "script" to use when explaining the situation to patients, but I suspect that having such a script may be useful for nurses when counselling patients about these changes in practice.  This would also ensure that patients receive a consistent message across the entire health region.

• Finally, what a great suggestion to prepare patients preoperatively!  Hearing about our change in medication practice in advance would certainly be easier than hearing about it when a person needs relief from pain or nausea.  Transparency? Check! Respect for patients? Check!

Sounds like the gyne ward staff at SCH have some great ideas.  Maybe a gemba walk is in order...

Variation in Clinical Practice revisited - the video!

How long have you got for lunch today?  37 minutes and 48 seconds? Perfect!

The latest work we're doing in our office (to improve care for patients with bladder cancer) inspired a post in March about variation in clinical practice.  It was also the spark for a presentation I had the pleasure to give at the BCPSQC Quality Summit.  Thanks to Christina Krause and her team for putting on a terrific meeting and for producing this video (37m 48s).

If you're not sure about investing 37 minutes, try the first 7 - that should give you a good idea what to expect from the rest.

(Yes, the screen shot could have been marginally less goofy-looking. Or perhaps not.)

Customer voice changes my thinking on changing our office practice

Last week, several of my partners and I had been talking about whether we should change a long-standing office procedure.  Most medical practices use a nurse or receptionist to show patients into examination rooms, where the patient waits until the doctor arrives.  In our office, we don't employ a nurse.  Instead, the doctor greets the patient at the entrance to the waiting room and shows him back to the consultation/examination room.

I'm sure that Lean practitioners would cringe to hear this.

Think about the steps in this procedure:

Doctor walks down the hallway from his consultation room to the examining room. 

Doctor calls the patient's name. (Repeat as needed) 

Patient packs up reading material, closes cell phone, removes and hangs up coat, etc. 

Doctor greets patient. 

They walk back down the hallway to the consultation room.

That takes from 1-3 minutes to complete.  It doesn't sound like much, but it's a significant proportion of our "standard" 15 minute visit.  It's time that could be spent finishing dictation of the previous consultation report, reviewing the next patient's chart, checking in-coming reports, etc.

I had recently read about the practice of "self-rooming", where patients are given instructions by the receptionist and then make their own way down to the assigned consultation room.  This would let our receptionist remain at her desk, save us the need to hire additional staff, and give the docs a few minutes of extra time between each patient visit.

What a great idea!  I ran it by a few of my partners and started thinking about how we could do try out the concept in our office.

Then, late last week, I met a man who changed my thinking entirely.

I was attending Saskatchewan's Health Quality Summit, and introduced myself to the man (I'll call him Ken) sitting next to me at one of the workshop sessions.

"Oh, yes," Ken said.  "I've visited one of your partners.  You know what impressed me about your office?  That the doctor actually came out himself to the waiting room to call for me."

What a coincidence, I told him.  We were just thinking about changing that practice because it's inefficient.  I explained the amount of time it took for doctors to perform that task.

He agreed that it may take a few extra minutes to do, but that he found it to be an important part of building the doctor-patient relationship.  He felt it showed a degree of respect and caring.

"When I meet a doctor for the first time, I make a judgment as to whether I can trust that doctor.  I think the first impression your staff make is a very good way to build that relationship," Ken said.

That was a very powerful thing for me to hear.  I have often commented to medical students and residents that specialists need to be deliberate about building a trusting relationship with patients.  Unlike family physicians who have years in which to develop a bond with patients, specialists have only a short time to do so.  This is especially important for surgeons, who may meet someone for the first time and, within the course of that visit, inform the patient about a serious diagnosis - such as cancer - and discuss performing a life-changing procedure.

Ken was telling me that the simple habit of escorting my own patients to my consultation room was a valuable step in building a trusting relationship.

That doesn't change the fact that the procedure requires an investment of time, but it does mean that, if we're going to make a change, we can't measure the outcome solely on the basis of time saved.  We would also need to consider the impact on patient experience.  As Ken went on to say, "Spending a few minutes more up front is probably saving you time later on because patients feel you are considerate and caring."

What a valuable lesson! (Even if I do have to keep learning it over and over again...)