Blessing in Disguise

Our fridge conked out two weeks ago. Not the main kitchen fridge, mind you; it was the basement auxiliary fridge that died. So, it wasn’t an absolute crisis, but it has made us rethink some of our habits.

The luxury of having a 2nd fridge gives us extra food-storage capacity. But that extra capacity has made us a little careless. Here’s what’s changed at our house over the last 2 weeks:

• We actively consider what’s in the fridge. Usually, leftovers would get pushed to the back of the shelf and, unless someone was specifically looking for that item, would often be discovered weeks later (inedible!). We’re wasting less food.
• If food does go stale, it gets thrown out before it gets too disgusting.
• I pack leftovers in my lunch more frequently. My intent is to make room in the fridge, but I’ve discovered that it also saves time when I’m putting a lunch together. Putting leftovers in a container is usually quicker than making a sandwich. It saves even more time if I remember to put some leftovers directly into a small container when I’m cleaning up after supper.
• We’re more careful about the size of storage containers we use. Rather than grabbing the first available container and then filling it halfway, we’ll pick a smaller container that will be filled completely.

Not Ready for Prime Time

Well, that was a bust!

I recently posted about my plans to expedite informing men about their prostate biopsy results by using the mydoctor.ca secure messaging service. Over the last month, I saw 7 men who required prostate biopsies. I told all of them about what I was trying to do, and offered them the choice of a phone call or email notification. Five of the men said either that they didn't have internet access or they didn't feel comfortable using the internet. Of the other 2 men who expressed interest, one of them took the initial step in accessing mydoctor.ca's system, but never followed through in signing up for the service (which, by the way, is free for a 30-day trial).

Dreamer

What part of your job don't you like?

A medical student asked me that as part of a Career Dialogue Q&A session last week. I'm lucky to have a great work-life, so I had to think a bit about that question. Later that afternoon, back at my office, I was reminded about one of the worst parts of my job: Telling my patients they have to wait.

Wait to see me. Wait for tests. Wait for results. Wait for treatment.

It really shouldn't bother me to have to do this. After all, it's so easy to do – my patients actually expect to hear it! When I apologize for wait times, they are usually sympathetic and rarely press the matter any further.

A Thousand Cuts

Initiatives to reduce wait times for surgery generally focus on the interval from when the surgeon submits a booking to when the surgery is completed. It's hard to imagine a less client-centred measurement.

The time from booking to surgery describes the system’s awareness of the client's need. But, that person has been aware of their need since the onset of symptoms, or the finding of an abnormal lab or x-ray result by their primary care practitioner. A common example of this in urologic practice is the man who has an abnormal PSA (prostate-specific antigen) blood test during his annual medical review. This triggers a series of other events (read: waits) that may culminate in the diagnosis and treatment of prostate cancer.

The series of events looks like this:

1. PSA blood test
   
2. Consultation with Urologist
   
3. Prostate biopsy
   
4. Definitive treatment (radiation or surgery), if cancer is diagnosed

That's a pretty high-level view of the man's journey through the system. Of course, I mean that's how the system usually looks at the process. The man may see it like this:

Spoonful of Sugar

I got a big dose of my own medicine last week. And it was bitter.

We've been waiting for our new electronic medical record (EMR) system for several years. We implemented our old EMR over 4 years ago, and I posted previously about some of the benefits. Unfortunately, the EMR program was "orphaned" about 2 years ago when the software company was bought by another company. It changed hands again, this time acquired by one of the companies applying for approval by the Saskatchewan Medical Association (SMA).

While software vendor approval has been drawn-out, it's an important process that helps ensure that vendors will be committed to and capable of providing service in the long-term, as well as expanding the capability of their EMR software to include connectivity with laboratories and between physician offices. We are fortunate that the company that owns our old EMR has received SMA approval, as they have all the necessary codes and knowledge to transfer records between the two systems. As far as we can tell, the transfer of patient information went smoothly. But that was the easy part...

Promised Land

My son's current bedtime book is a biography of Gandhi (his choice!) As I've been reading it with him, I've learned some things about Gandhi's struggle to free India from British colonialism. Previously, my understanding of his life came from the 1982 biographical film, Gandhi.

Born and raised in India, Gandhi studied law in England and then traveled to South Africa. There, as depicted near the beginning of the film, he suffered the indignities of racial discrimination. These experiences led him to develop his ideas of nonviolent resistance, the application of which improved the lot of South African Indians. He then returned to India.

And changed the world.

See the Light

Last time, I told you about our plan to record the number of new consultations seen by each urologist, and then share the results with the whole group. The number of new consultations seen could be considered the basic currency of our practice, that is, each new consultation holds the same relative value. Once we're confident that our data is representative, we'll share it with all the urologists.

We did the same thing with our patient recall rates. That project revealed significant variations in recall rates among our docs. Although we never set actual target rates, we did encourage docs to come up with their own ways to modify their practices to reduce recall rates. I think much of that project's success resulted from showing the frequent-recallers that there was another way to do business. Their peers, working in the same environment, shared their ideas on making changes to engrained practice habits.

I hope for the same success with the latest project. I predict that we will find (once again) a significant variation, this time in the number of new consultations seen per physician. (Yes, I have peeked at the preliminary results.) We'll circulate that information and let the docs with low numbers formulate their own plans on how to modify their practices.

That's the plan I put forward at our office meeting this week. Some docs' response to that plan was pretty pointed.

Goats and Apples

OK, one last post about our recall rates/internal demand. I’ve been fixated on this topic for many recent posts, and it’s probably time to move on… after I show you this chart:

Looking good!

In July, 6 out of the 8 docs who were working had patient recall rates in the single digits, and the clinic average recall rate was 6.8%. That’s the first time we’ve had a clinic average in the single digits. We need to maintain these gains, and I think we’ll be helped by a change coming to our office this fall.

Heaven

I’ve been to wait line heaven... it’s a Wal-Mart.

I studiously avoid shopping at Wal-Mart. I know it’s a popular spot, and that’s the problem – the more people who shop there, the longer the wait at the checkout. And I hate wait lines.

But, last month, while looking for a piece of summer camp equipment for my son, I paid my first visit to our local Wal-Mart outlet. They had the item in stock, so I prepared to brave the wait for the till. I headed for the express checkout line. There were over a dozen people in the first line. I looked around for a shorter line. But, there was only one queue for multiple cashiers. Now, that’s odd for a department store.

Whether by tradition, or based on hard statistical analysis and marketing research, various businesses manage wait lines differently; for example, grocery store lines vs. bank lines. At the bank, you form a single queue, at the front of which you look for the next available teller. At the grocery store (and most department stores), you size up individual lines, trying to judge who has the most groceries, which teller is the chattiest, and who will be paying with loose pennies dredged up from the bottom of their purse. Then, while standing in line, you kick yourself for not picking another line that seems to be zipping along. Queue-er’s remorse.

Stick It

You can’t manage what you don’t measure.

Q:  What’s more annoying than a worn-out cliché?

A:  A worn-out cliché that keeps on proving itself right.

Measurement is a key component of Advanced Access. For us, it’s been a source of enlightenment and discovery. While we continue to use many of the same measuring sticks that we started off with, we’ve added some new measuring sticks that have yielded some surprises.

I’ve been telling you about our efforts to reduce recall rates/internal demand. Those tests of change (call them PDSAs if you must) arose after we tallied the number of patients each urologist was asking to come back for a repeat visit. I presumed that all of us had pretty similar practice habits, but some of our staff thought that those habits varied considerably. So we did some counting. The initial data is in “Bang for your Buck”. While we don’t know whether the higher rates or lower rates of recall are more clinically appropriate, our guess was that we could provide the same quality of care, yet have necessary follow-up provided in a setting other than a specialist office.

Pyrrhic Victory

During recent lobbying for his health care reform platform, US President Obama praised organizations such as Intermountain Health for being role models in providing high-quality care, without skyrocketing costs. Obama echoed comments made by a senior Intermountain executive: “Much of the rest of the country tends to focus on the volumes of health care services they provide, because that's what the system rewards, rather than the care that's necessary to help the patient.”

Bingo.

Have you had the chance to read “On the folly of rewarding A, while hoping for B” yet? According to this classic essay, we should expect exactly the system we have, that is, pay me fee-for-service and I’ll give you lots of service. And don’t call me greedy; we’re all responsible (via elected politicians) for supporting this dysfunctional system of rewards.

Blue Skies

Great week!

Not because of this:

Our 3rd NAA is showing some improvement, but I’m not paying that much attention to it since I decided that “slow but steady” is going to win this race (see last post). We also discovered a measurement glitch last week. We use an electronic scheduling system and calculate the 3rd NAA using a “find next available appointment” feature. Last year we changed the way we use our electronic scheduler, to give doctors access to their surgical schedule via our EMR. We recently realized that this affected the way the program was identifying the next available appointment slot. The electronic result for 3rd NAA is slightly longer than the manually calculated 3rd NAA. This is a measurement artifact that will show up as a small drop in 3rd NAA as we start recording wait times calculated manually. It doesn’t change our patients’ experience of wait times.

No, the great thing about this week was a sign of a culture shift in our practice. We’ve been working to reduce our recall rates, in order to improve our capacity. In May, two of our partners had recall rates in single digits – down from their previous rates of around 20%. What happened?

Backlog, Schmacklog

“Get your body beach-ready!” trumpet the magazines lining the supermarket checkout. It’s an annual ritual for Canadians: Emerge from hibernation, decide to tone up and trim down, then embark on a crash diet and/or exercise.

But, to what end? Is a “beach-ready body” the ultimate goal? For some, it is; quick and dirty does the trick for them. For others, a slim physique is the eventual (but not certain) by-product of a different goal: a sustainable healthy diet and exercise program to achieve long-term wellbeing.

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We continue to struggle with our pesky backlog. Trimming the backlog will not only satisfy the primary goal of our Advanced Access project – improving patient access – but will also let us benefit from reduced administrative load and increased flexibility in physician scheduling. But, as Advanced Access evolved into a broader Clinical Practice Redesign project, our goal has changed also. Improving patient access alone (although a worthwhile goal on its own) doesn’t necessarily give our patients better care.

Liposuction can rapidly reduce someone’s corporeal backlog, yet they may continue to clog their arteries with cheeseburgers. In medical practice, a “brute force” approach to backlog reduction is the equivalent of liposuction. By working longer hours, cramming more patients into appointment slots, or recruiting temporary locum help, we can have a buff-looking practice, pronto. But when patients come through the door in 7 days rather then 70 days, they’re getting the same type of care as before the wait list slimmed down. (And having learned a lesson in my last post, let me point out that our current care is not bad. But, there’s always room for improvement.)

Tight Spot

A couple of summers ago, my family visited Scenic Caves near Collingwood, Ontario. As we hiked through the caves, we came to a cleft in the rock called “Fat Man’s Misery”. It’s a narrow gap in the rock that only slim people can squeeze through. The alternative route is to backtrack and take a slightly longer path.

My younger sons – then aged 8 and 10 – were amused at the thought of someone getting stuck in this crevasse. They thought it would be easy to pass through, and before I could stop them, they both did so. That left me with a problem.

A turn in the middle of the crevasse made it impossible for me to see the other end. I could see the passage narrowing as it turned. It looked like I would fit through the visible part, but I had no way of knowing whether it narrowed even further around the corner. Also, the passage was irregular and I would only be able to fit through facing one way. If there were any other rocky protrusions around the corner, I might get stuck in an awkward position.

Do You Recall

At the IHI Clinical Practice Redesign Summit in Vancouver, Advanced Access guru Catherine Tantau suggested that the gold-standard for specialist wait times is 1 week.
When wait times are that short, practices start reaping the benefits such as less wasted administrative effort, fewer no-shows and greater flexibility in physician schedules.

One week? It boggles the mind!

In early 2008, we were on our way with our 3rd NAA down to 30 days from our starting point of 70 days. Then, one partner switched to half-time work. Our 3rd NAA crept up a little until July 2008 when 2 more partners switched to half-time. Since then, our 3rd NAA has gradually climbed back to its original level. Aaaaaargh!

Juice

The backyard of my parents’ winter home in Arizona sports an orange tree.

That’s quite a novelty for grandchildren visiting from Saskatchewan.

Grandpa likes a glass of fresh-squeezed orange juice for breakfast and asked if his 2 young grandsons would make it for him. The next morning, the boys rushed outside, filled a bag with oranges, and brought them back to the kitchen. There, they had worked out an assembly-line system to get Grandpa his juice. The older one sliced each orange in half and the younger one squeezed. And squeezed. And squeezed.

But a 3-year-old only squeezes a dribble of juice out of each orange before moving on to the next half. It wasn’t long before they had to pick more oranges. And then run to the neighbor’s yard to pick those oranges. And still, Grandpa’s glass wasn’t full of juice.

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.

Mea Culpa

Did you ever have the experience of having an idea that was vivid and compelling when you saw it in your mind’s eye, only to have it fall flat when you gave it voice? Maybe, when you tried to express yourself, you were tired. Or in a rush. Or not quite as clever as you thought you were. That’s what happened with my last post, Wasted. (Heavy on the 3rd excuse.)

After the post went up, someone emailed me another meeting invitation, with the comment I see you like to have plenty of notice for these invitations! A similar remark about how upset I seemed, received a few days later, along with some of the comments on the blog, made me realize I need to clarify my intentions about that posting.

Wasted

From: Doe, John SktnHR
Sent: February 3, 2009 6:37 PM
To:   Kishore Visvanathan
Subject: Physician Input for Ambulatory Care

I dread these invitations. This week, I received 4 requests to attend meetings. It’s not that the meetings are terrible; I’d like to go to all of them. The problem is the effort it takes to get to the meetings.

All of the invitations were for meetings within the next 3 weeks. What were these people thinking?  Don’t they know I’m a busy clinician? My schedule is solidly booked at least 6 weeks in advance.  If these people want input from physicians, they need to plan ahead!

Look how much effort it takes to rearrange my schedule to attend a meeting on short notice:

Resolutions

In the spirit of January, let's first take a look back, and then see what the upcoming year promises.

Responses to my last post reinforced for me the idea that illustrating the principles of wait time management with examples from everyday life may be a powerful way to engage people in tackling similar problems in health care.

My experience in an airline's check-in queue led me to conclude that organizations sometimes make the conscious choice to give their clients bad experiences. The words that an organization's leaders and employees choose when communicating with clients can reinforce this dysfunction. When a clerk tells a customer, We can't do that, “can't” suggests the customer's request is a physical impossibility, something not only unreasonable, but fantastical.

When the response is We don't do that, the clerk retreats behind the corporate mantle. What you're asking is possible, but it's not part of our culture.

What's the honest phrase? Which words acknowledge the conscious choices service providers make? We won't do that. Or, even better, I won't do that. My organization chooses not to provide the service you're requesting. (Of course, this may be a completely reasonable statement for an employee to make, i.e., don't pull up to the Tim Horton's drive-through window and demand an oil change). Won't makes the individual and organization take responsibility for their action/inaction.

Here's my idea for a (snarky) T-shirt logo, suitable to be worn anytime you're at risk of receiving poor service:

Can't

Don't

Won't

At least be honest with me!

I Love Lines

I love standing in line.

Or, more accurately, I love what I learn from standing in line. Being stuck in traffic, waiting at the grocery store checkout – they're all golden learning experiences if you're a student of queues. But nothing beats air travel...

Over the holidays, I enjoyed a tremendous learning opportunity courtesy of a leading national airline. So many of the problems I observed at Toronto airport were analogous to the situation in physicians' offices. Because so many people have experienced the frustration of waiting in line at the airport, perhaps this could be an effective model to explain Advanced Access/Clinical Practice Redesign to novices.

Before we even arrived at the airport, we had been primed to expect a long wait. Airlines establish cultural norms with the advisory printed on every ticket: Be at the airport at least 60 (or 90, or 120) minutes before your flight departure. So we shrug our shoulders and drag our suitcases to the end of the line, because... that's the way it's always been!

Sound familiar?  It takes forever to get in to see my doctor. You'll wait a long time to see a specialist. Health care sets the same norms. Earlier this week, I heard a presentation about a new project in the Saskatoon Health Region, aimed at reducing patient wait times when they come for assessment and education at the Pre-operative Clinic. The project coordinator showed a sign currently posted at the entrance of the clinic. It showed a drawing of a man resigned to his fate (shrugging his shoulders in a C'est la vie kind of way) and said: Your visit to the pre-operative clinic may take 4-5 hours. Those are the expectations we establish for our patients. That's the promise of service we give as our patients come through our door.