Bob W will tell you that his life was saved from bowel cancer by his doctor. The surprising thing in Bob’s story is that he is referring to his orthopaedic surgeon!

Bob is one of 8.6 million people cared for by Kaiser Permanente, a US health care organisation that looks after 8.6 Million people, employing a staggering 14000 physicians, and 160000 other staff. They provide all aspects of their customers’ health care needs – acute, preventative, routine, hospital care, allied health care,investigation and chronic disease management. In this ‘vertically integrated system’, they run 431 office practices and 35 hospitals.

If you are a patient of Kaiser’s, all your care needs are ‘pre-paid’ – if they can keep you healthy, then it will be easier and less expensive to look after you. They have both the usual ethical interest in keeping you well, as well as a huge financial one!

Kaiser have developed a ‘Proactive Office Encounter’ protocol as part of their system. Dr Michael Kanter is a physician and the Proactive Care Group Leader with Kaiser. He and Dr Ozzie Martinex presented at the IHI Forum in Washington this morning.

“Every time a patient has any contact at any of our services, his or her record is checked to make sure that they have had all of the health screening activities that are indicated – given their age, sex, history and other medical problems.”

Dr Kanter says that

applying this integrated and coordinated care delivery process has resulted in a positive impact on the lives of members in areas of cancer screening, blood pressure control, cardiac health, diabetes, asthma management, immunizations, tobacco cessation, weight management, and exercise.

Go in to have a mammogram, and they’ll let you know that you are due for a cholesterol check. Go to the ED with an acutely swollen and painful knee, and the orthopaedic surgeon will fix your knee – and send you home with a bowel cancer screening kit, if it is due.

All Good Now

Bob saw his orthopaedic surgeon with his crook knee one afternoon in the urgent care centre. She fixed his knee- and handed him the kit for his bowel screening, which he’d put off for a year.

He was surprised to get a call a few days later by his regular primary care doctor. A colonoscopy had been arranged for the next week, as the screen was positive.

The colonoscopy did show a cancer. He was booked for surgery.

The night before he was due to go in, the surgeon rang him at home at 7pm. Bob tells this part of the story with a tear in his eye. The abdominal MRI had shown a large renal tumour, which had to be dealt with first.

Now, according to Bob, its all good. “I’ve lost one kidney and one foot of bowel. No problem – I’ve got another kidney and still have four feet of bowel left”

System Changes

Think about this system – how many processes have to be done just right for Bob’s cancer to have been discovered.

For a booked appointment at any of their facilities, the ‘Proactive Office Encounter’ begins a week before the appointment is scheduled. An automatic service lets the staff know that the patient should have some preventative activities or other tests. Where practical, these are arranged beforehand, so that the results will be available when they come in – or the necessary test booked on the same day they are coming in to save a revisit.

For acute and unscheduled appointments, the necessary tests are flagged when the patient arrives.

The Proactive Office Encounter system will flag any other activities that should be done when the patient has arrived and before they see the doctor. All of these are done by the ‘Medical Assistant’. Any ‘labs’ required are signed off by the doctor, and the need for them is reinforced by the doctor

When Bob was seen in the urgent care centre, the medical assistant was notified of Bob’s ‘care gap’, even though this was not the usual office that Bob attended. The assistant included the bowel test kit in his papers, and informed the orthopaedic surgeon when he handed Bob over to her. It was made very easy for the surgeon to provide comprehensive care – as it should be. A good system should not be dependent on the individual delivering the care.

Culture Change

Dr Kanter says that it requires quite a culture change for many specialists to participate in a program like this. The POE system monitors how effectively the ‘care gaps’ are filled in each facility and by each physician within the system. (the ‘care gap’ is not considered closed when the test is requested, only when it has actually been done! “You can’t get away with saying that its not your job”.)

Tools

The tools that have been developed for the Proactive Office Encounter program include

• Standardd Office Workflows
• Condition Specific Workflows
• Phyiscian Specific Workflows
• POE Skills Inventory for Staff
• Training for staff (including videos of each step)
• Skill Validation Tools
• Performance Monitioring Tools.
• Chart Review Tools
• Workflow Efficieny Audit Tools
• Physician Surveys

eHealth Investment

Kaiser has invested heavily in eHealth throughout their facilities, and programs like the POE demonstrate the opportunities that are only available when health records are linked across a system.

The electonic medical record system Kaiser Permanente HealthConnect is used in all their facilities nationwide. The data it contains is up to date, coded, and available anywhere. They have accurate disease registers and use these to facilitate proactive and systematic management. As well as preventative and disease specific preventative health prompts, physicians have decision support tools built in to the medical software.

Patients have access to their health information via their web portal kp.org. Post consultation instructions and follow up arrangements, including recommended screening tests, and available to the patients immediately after their visit. Patients can also be contacted by secure email through this system, and contact their clinicans.

Has it worked?

Dr Kanter says that measurement and data are the key to pulling a program like this together. They collect data at every level, including a “Successful Opportunities Report” and a “Clinical Strategic Goals Report” to make sure that the changes they have made are leading to improvements.

Kaiser has documented how many lives have been saved through their many screening programs.

Since the POE was introduced in 2007, there has been improvement in Kaisers clinical strategic goals. One thing I find amazing in these figures is from a very high base rate of screening – and still were not satisfied with that.

The POE system is supplemented by an ‘outreach system’ (mail and email) for people who have overdue tests and haven’t been in. Dr Kanter says that given the success of the POE they will soon introduce a Proactive Inpatient Encounter System for hospital patients.

Many practices are using Doctor’s Control Panel to match up the patient’s screening requirements with the RACGP ‘red book’. Imagine this being available proactively throughout the entire health system!

How are you going in your practice?

Do you deliver evidence based care to every single patient, every single time?

Please share your story, or your comments, below.

Each year the Institute of Healthcare Improvement hold a major forum on Improving Clinical Office Practice.

This year ‘Improving Patient Care in the Office Practice and the Community’ is the 11th such forum and will be held in Washington.

I’m currently posting from AA76 LA to Washington Dulles, so will keep ‘practice improvement’ informed of any new points of interest.

So far, I can report that in flight WiFi access ($12.95 per flight) works very well.

The NICS Gaps report

How can we bridge the ‘chasm’ between what the evidence tells us we should achieve in chronic disease, and what we manage to achieve in practice? (Cf NICS Gap Report)

This is perhaps the key question that we are collaborating to answer.

Ralph Audehm has directed us to a few recent articles that aim to identify the barriers to better care.

The BMC Family Practice reports on the results of sending case vignettes to 12,000 primary care physicians – of which 888 responded. (I am sure I would have been in the 11,112 majority that did not).

“Knowledge and attitudes of primary care physicians in the management of patients at risk for cardiovascular events”

An analysis of the responses to the case vignetter identified a low rate of adherence to guidelines (and I fall into the category least likely to provide best care – in practice more than 10 years and having a high proportion of patients with chronic disease!)

The following were some of the barriers to guideline adherence -

• Cost of medications (88%)
• Number of Medications for adequate blood pressure control (75%)
• Patient Adherence (74%)
• Inadequate time for counselling
• Inadequate patient education tools
• Inadequate knowledge and skills to recommend dietary changes

The study concludes that

Innovative educational approaches are needed to address barriers, and target specific groups of physicians to facilitate the implementation of guideline-based recommendations in CVD management.

Do you agree with that conclusion?

Is this really a deficiency of education? Would more educational opportunities for the physicians lead to different outcomes? Would this address the barriers that this very study identified?

Every system produces exactly the result it is designed to produce.
We know that ‘Doing more of the same’ is an ineffective way of producing better outcomes.

What would you recommend to produce better guideline adherence?

You can compare the results of the ‘Translate‘ study which changed the systems in use in a practice.

Ralph forwarded another study on ‘Physician Inertia’.

“Factors Associated With Intensification of Oral Diabetes Medications in Primary Care Provider-Patient Dyads: A Cohort Study”

121 patients with diabetes were followed over a 2 year period, during which time there were 575 consultations in which patients had a most recent HbA1C >=8. However, treatment was intensified on only 22% of these consultations.

Treatment was more likely to be increased the higher the HbA1C (as you would expect). Other positive factors included

• patients with visits that were “routine”
• patients taking two or more oral diabetes drugs
• patients with longer intervals between visits

In contrast, patients that were less likely to have treatment increased were those

• patients with less recent A1C measurements
• patients with a higher number of prior visits (OR per prior visit
• patients who were African American.

Your comments on these studies or other issues welcome below.

Do you wish it was easier to provide proactive care?
Do you get frustrated by the lack of features in your clinical software?

“Yes”, said Anton Knieriemen (Vic Collabs, current wave) to these questions. And then he decided to fix the flaming thing.

He wrote a computer program that links with Medical Director (or Best Practice) and lets you know which of the RACGP Preventative Activities are due for the patient you are seeing, according to that patient’s specific age and history.

Brilliant!

Anton’s program is called Doctors Control Panel, and is available from
pracsoftutilities.com

He writes-

I am passionate about preventive care and change principles. I leverage the software that I create to implement change in the way I practice medicine. A feedback loop for improvement has emerged. With better information access and workflow improvements new opportunities for innovation have arisen.

The program DCP continues to improve, and new features are added regularly. It can read your appointment list at the start of the day, so that your practice support team can see what needs to be done (Mr Jones needs his BP documented and his Pneumovax updated. Mrs Smith hasn’t had her weight measured.) They can then grab the patients while they wait to see you (and become a Time Lord?)

After Learning Workshop One, Anton was concerned that practices were having to create spreadsheets of their diabetic patients manually. He added the capability for DCP to create and export a spreadsheet of your diabetes patients, containing appropriate clinical information, colour-coded.

Doctors Control Panel is available as a free download. Anton suggests that if you find it useful you may like to donate to the charity of your choice.

Anton recently presented at APCC LW3 in Sydney – and it is the only breakout I have been to that has received a standing ovation! You can see his slides and hear his talk at this site.

You can also view a video demo of Doctors Clinical Desktop.

I’d value your comments and feedback.

In Japan, they talk about ‘Kaizen’ – continuous improvement.

Locally, the concept might be expressed as ‘Fix the Flaming Thing’ – FTFT for short.

Some improvements require wholescale system changes. (The American Healthcare System, for example).

But some very simple policy and procedural changes by the ‘powers that be’ in Austrlia could make it much easier for us to care for our patients.

So FTFT.

‘Lean Thinking’ challenges us to look for waste in our work processes so that we can better allocate resources to where they produce the most value.

What simple regulatory or legislative changes could be made that would make things better for you and your patients?

Let’s collate a list and then nail it to the church door.

To start, here are some of my suggestions.

1. The constant barrage of requests for repeat scripts for my nursing home patients takes me about an hour each week to complete. The patients already have medication charts that have to be regularly rewritten. This double handling detracts from patient safety – is the chart or the prescription the ‘record of truth’? In our private hospital, the medication chart also acts as a PBS prescription.

   So why can’t the PBS accept medication charts in Aged Care Facilities as prescriptions?

2. I have now attended 5 presentations from Medicare Australia about EPC items (lucky me).
   The need for collaboration before the Team Care Arrangement can be claimed is the major source of consternation at these presentations. It is a Catch 22, and a ridiculous administrative burden that adds nothing to patient care.

   The requirements for Item 723 should be changed so that the item can be claimed at the time the Team Care Arrangement is prepared. If they insist, they could instead make the TCA review (Item 727) dependent on having received feedback from at least two of the providers in the plan.

3. We are told by the Health Minister that we need to increase our use of practice teams. No argument from any of us.
   So the next step then should be to increase the number of eligible Allied Health Visits under the EPC scheme from 5 to 20, as previously flagged.

   This would significantly increase our ability to source appropriate care for our patients.

Please post your suggestions in the comments below.

Do you run on time?

In our discussion on achieving ‘Zen’ in general practice, time pressure was identified as one of the most significant factors that decrease our enjoyment at work. It is a chief ‘zen-zapper’.

No one benefits from a waiting room full of people. 

It is certainly not valued by the patients, who have better things to do (well, some of them, sometimes).

The more people, the more space required to accomodate them. And if people are hanging around you need to have up-to-date magazines, and toys for kids, and comfortable chairs, possibly coffee, a TV, and (in extreme cases) beds.

It is uncomfortable to be a receptionist when people are watching you for long periods. There is only so much of ”Are we there yet?” that you can take.

Does every consultation begin with an apology – “Sorry to keep you so long!”

It makes it harder to concentrate on the patient in front of you when you are aware there are a queue of people waiting to step into their seat. This is made worse by the fact that people who have been waiting for  a long time think that they need to make it all worthwhile, so launch into a long list of complaints and problems (fair enough!)

Running late in our appointment schedule is ‘muda’,(waste), and against all the principles of ‘Lean Thinking’.

Perspective

However, we need to keep our quest for running on time in perspective.

Would you prefer that patients complained that you always kept them waiting, or would you prefer that they complained that you don’t appear to listen to their concerns and that you are not thorough?

We strive for patient centred care. It is, as always, a matter of balance – in this case between the needs of the person we are seeing and the inconvenience of those waiting to be seen.

What can we do?

The Twelve Enlightened Paths to becoming a Time Lord

Some doctors (my partner for one) always run on time, and always seem to deal with all their patients’ issues. No matter how quickly they are seen, the patients come out saying ‘He is so thorough!’.

Doctors who can run to time and meet their patients needs are ‘Time Lords‘.

People in control of a situation do not look rushed. Top sportsmen seem to live in a different space / time continuum to the rest of us. ‘Time Lords’ also seem to find this place

Time Lords do not look rushed. They know to make sure that they identify and address the patients’ concerns. Importantly, the patient also perceives that they have done so.

(Did you know that the average patient visiting a physician gets only 22 seconds for his initial statement before the doctor interrupts. However, the ‘mean spontaneous talking time’ when the physician is instructed not to interrupt the patient is only 92 seconds -(did they gag the doc to do this study?).

For many years I’ve been seeking the Enlightened Path so that I too can become a ‘Time Lord’. I’ve spoken to a number of Masters, and though I can’t yet snatch a pebble from their hands, I can now file this report on what I have learned.

1. Fifteen Minutes Late does not mean you are early.

Running to time starts with an attitude.

Even though I turn up for my 9 O’Clock patient only a few(?) minutes after 9.00, there’s always time for a coffee and to have a chat and to check my emails and to tidy my desk before I call in the first patient, isn’t there?

Once you get behind you can *never* make those minutes up!

So take the example of Aesop’s tortoise and get a good start. In fact, jump the gun if you can.  Its not Bejing – noone will recall you for a false start.

At other times during the day we often get so used to running behind time that, when we are only being fifteen minutes late, it feels like we are running early. “Gee, I’m not doing too badly today, think I’ll have a rest and grab a coffee”

Have you noticed that when you absolutely must get away at a certain time – that you manage to do it. (say, to catch a plane, or to go to a Sportsman’s Lunch, or to hit off at 1.30). Robbie Deans says that winning is a habit. Get in the habit of doing all that you need to do (and not doing extraneous stuff) so that ‘running to schedule’ becomes an everyday occurrence. Out the Drive by Half Past Five! That’s the attitude.

2. Work your Appointment Book

Every Monday is really busy because too many people need to see us! 
Its been the same for years. Jeezzz. Bloody patients. Do you think they’ll ever learn?

It is silly to act surprised each Monday about how many people need acute appointments. It is an important principle of Lean Thinking that you don’t blame people – if you want different results, change your system.

Numerous studies have demonstrated that demand for appointments is both finite and predictable.

In our practice, we measured how many patients wanted an appointment on each Monday over a two year period – and the results were astonishing in their consistency!

Have you tried working to this hypothesis - 

The number of  acute appointments I will need to ‘carve out’ from my schedule on any particular day is predictable.

Measure how many acute apppointments are needed each day. Then have your receptionists keep an appropriate number of appointments free. Book routine follow ups on the days that are in least demand – for the 70% of people whose don’t care when they come in (except Wednesday which is Bingo and Friday which is bowls)

You can actually know what the demand is going to be on each day next week – so work your books like a game of Tetris – slot appointments where they fit best.

Use Double and Special Appointments sparingly

Some appointments undoubtably need to be double appointments. Those medicals for Veteran Affairs that require 24 pages to complete, for example. And there are some patients for whom we have to bite the bullet and accept that they are never going to compete a consultation in less than 30 minutes. However, Time Lords do not seem to find it necessary to make lots of double appointments. Like addressing one complaint at a time, double booking blows out the number of days it takes for patients to ‘get in’.

3. Max Pack

“I’m sorry. We are busy today. If you want fries and a coke with that you’ll have to go to the back of the queue”

I know that the GP registrars are often trained to deal with one quick problem at a time and make people come back if they have more than one problem or a more complicated issue. 

Is that a good solution? Maybe – if you are short of patients, or don’t have enough to do to fill your day.

I think it is disatrous. By making another appointment, the queue of people waiting to see us increases. Our backlog grows. The patient has to go to all the trouble of coming back – of not doing something else that they would more profitably be doing, and driving back to our surgery, and finding a park, and waiting again. In the interim their concerns remain unaddressed. 

And on the day that they come back,  we can’t see other patients that want to see us because we are still dealing with the problems that should have been dealt with last week. It is a vicious cycle.

In general, a Time Lord shuns the ‘quick-fix’ of one problem at a time and does all the ‘stuff’  that needs to be done in one visit. In America they call this ‘MaxPacking’.

A Time Lord knows to ‘Do Today’s Work Today’. 

To MaxPack you need to control the patient’s list.

4. Control the Patient’s List

You’ve spent 5 minutes checking out three benign naevi, and 5 minutes looking at a sore shoulder. Just when you think you’ll regain some time (you Time Lord, you), the patient says “What I’m really here for doctor is…..”.

If your patient brings in a written list, take it from them early in the consultation. Otherwise, before you spend a long time looking at the seborrhoeic keratosis on their temple so that they think they are getting value for money, check with them if there is anything else they are planning to ask you about today.

This gives you a chance to prioritise the time you need to spend on each of their concerns.

Wherever you can, MaxPack!

Often you’ll find that the last two items on the list will only take a minute or so. Do them, even if it puts you a little late. Do what you can to avoid them having to come back until the time that is clinically indicated. 

If there really are patient concerns that would be better addressed at another consultation, always express this in a patient-centred way. I’ve heard doctors say “Look, I don’t have time to deal with that today. You’ll have to come back”. What message would you take from that if you were the patient?

A Time Lord would frame it more like this. 

“That is a very important question. I think the best thing to do is for us to book a time now when we can deal with it appropiately and thoroughly”. 

Andrew Knight adds

I learnt a key strategy from Michael Greco a couple of years ago. As well as ‘controlling the list’ I now also ask the patient to prioritise…”of all of these issues which ones do you most want us to have dealt with before you leave today?”. This helps me be patient-centred and allows me to meet their pressing needs while having permission to confidently postpone less important issues if necessary.

Often having an established routine in your practice in which each patient has an ‘Annual Check’ gives us an appropriate time to which we can defer some issues.

5. Use the Annual Check

It is often recommended that we should opportunistically address preventative activities when patients come in with unrelated problems. This falls by the wayside when we are pressured by time.

Time Lords manage this differently, and are proactive in ensuring that every patient every year has ‘An Annual Check’. This consultation incorporates a full physical examination and addresses all the ‘red book’  recommended preventative activties. So when a patient comes in with a sore throat, you can address just that one issue, knowing that  everything else has been (or soon will be) taken care off.

This ‘Annual Check’ consultation can be improved by using the practice team to ‘get in the Red Zone’.

6. Get in the Red Zone- Use your practice teams

The value in a consultation is the time the patient spends with their doctor addressing their concerns. In America they call this ‘The Red Zone’.

Time spent finding the next patient and waiting for them to walk down the corridor, time spent looking for equipment, and time spent on interruptions take us out of the Red Zone. Such times are ‘muda’.

An extra three minutes per appointment adds up to 1 and a half hours late at the end of the day!

There are many activtities in a practice that can be done just as well (or better) by other members of our practice teams, rather than by the doctors. These include immunisations, taking observations, arranging appointments, ensuring preventative activities are up to date, and even ‘rooming’ the patient.

Make sure you have all the equipment you will need during the day readilly accessible. Better still, allocate that job to someone else.

Time Lords keep in the Red Zone by optimising their practice teams.

7. Engage the Patients in the Process

It is said that the greatest untapped resource in healthcare is the patients themselves.

Andrew Knight once wrote the ’12 minute slip’, which is available on the apcc site

This slip is handed to each patient when they arrive at the surgery. It confirms that running behind schedule is a problem that the clinic is trying to fix, and reminds the patient that the average appointment time is 12 minutes.

This engages the patients in the process of running to schedule, and was remarkably effective in changing patient expectations in a positive way.
Patients started looking at their watches and saying

‘Right Doc, that’s my time up. You’d better see the next bloke now”.

8. Breaking Up is Hard To Do

Andrew also writes about the psychology of being late.

“I find I spend more time and try harder with people to compensate them for waiting – net result run later, try harder etc. My unassertiveness prevented me from finishing the consultation because I treated it like a conversation and finishing seemed rude. It helped me to realise that by giving a patient and extra five minutes I was robbing the next person of five minutes. The person in front of me always seems to have more rights than the person in next!”

Running on time makes it easier to end the consultation in a timely way.

Make sure you have strategies to end consultations courteously, while affirming the importance of that patient’s concerns.

Conveyor belts and revolving floors are probably not recommended, nor is Gloria Gaynor’s approach.

“Go on now go, walk out the door
just turn around now
’cause you’re not welcome anymore”

9. Make Waiting Time Productive

When you are in the queue for the ‘Tower of Terror’ at Dreamland, they try and make it feel like part of the ride.  You go up and down in lifts and walk back and forth along corridors. You receive a video briefing about ‘the mission’ ahead. This distracts you from the wait, and builds up anticipation for the ride (which in fact takes less than 30 secs).

Even for Time Lords, variabilty in demand means that there will be many occasions when patients need to wait.

Can you make this time productive? Can it improve the health of your patient? Can it make your subsequent consultation easier?

Perhaps patients could complete a form about their health history to make sure that your records are complete and accurate. Does the medication list in your records have any passing similarity with what they actually take ? Could you do some ‘push polling’ – the form might ask them about the healthiness of their lifestyle? Perhaps they could write down the reasons for their visit today so you can control their list? Perhaps the form could include the 12 minute slip.

Perhaps you could utilise your practice team and have your nurse take the next patient into an empty room and assist the patient prepare for the visit.

10. Group your ‘Care-Families’

It is an important principle of ‘lean’ in healthcare to identify patients with similar values and needs – ‘care-families’.

Some practices use their appointment system to specifically separate ‘Acute’ and ‘Non-Acute’ care-families.

They have a ‘jeopardy’ (or on-call) doctor who starts the day with no bookings, and sees everyone who rings up and needs to be seen because of an acute condition. Because they are triaged to some extent on the basis of acuity, and because there is variability in demand, sometimes there will be a wait for those patients who have requested acute consultations. Patients understand this as they only rang up on that day themselves. They also understand that they will often not be able to see their particular physician.

Use of practice nurses can improve the efficiency of the on-call doctor significantly. Smaller practices can ‘carve out’ a part of the day that they devote to seeing only acute appointments.

The ‘care-family’ of acute patients value being seen by their practice on the same day that they have an acute need.

The other doctors in the practice see all the patients who have booked in specifically to see them. These bookings have often been made many days (or weeks) beforehand. It is easier to keep to time when patients arrive in a regulated way, and you do not always have to be worrying about fit ins and extras – a kid arriving needing stitches, the lady who has had a fall and needs a home visit, and a possible infarct in the sister’s room. Your ‘jeopardy’ colleague will take care of them.

The care-family of non-acute patients ‘value’ being seen by their doctor of choice on a day and time that suits them, when the doctor has time to focus on their problems.

11. You gotta dance with them what brung ya.

There comes a time to face facts. You’ve done what you can, but you find that every day you are well and truely late by the 3 O’Clock appointment. Lynne Davies measured for two weeks to find out what was the earliest time she ever saw the 4 O’Clock appt! There is great power in measuring this, so that you can demonstrate it to your staff.

So, why not book some ‘blockers’? If you find you consistently see the 3pm apptointment at 3:30, why not book the 3:00 and 3:15 appointments every day for ‘Mrs Catchup’, and see an extra two at the end of the day instead.

You will still see the same number of people, and see them at the same time you did anyway, and everyone will still get home at the same time.

The only difference is that you won’t be running late at 3.30.

That should improve your Zen.

12. Pain is inevitable. Suffering is optional.

A new patient told me about his previous doctor in another under-doctored town.

“I never waitied for less than three hours to see him and never saw him for more than three minutes!”

Undoubtably, there will be many circumstances in which there will be unavoidable waits for people to see us. Our patients accept this, and we need to accept this too.

Nonetheless, it remains good clinical practice to reduce our waiting times as much as we can. We should learn what we can from our colleagues who have become Time Lords.

I’d welcome your sugggestions and comments.

The RACGP has released a new ‘workbook’ on the subject
‘Rebirth of a Clinic: A design workbook for architecture in general practice and primary care’

You can download some sample pages from their site – the full Monty will set members back $199! The order page is here

Addendum: I have now purchased the workbook. Be aware that ‘workbook’ is just what it is, with lots of pages where you write down your own thoughts. There is a great deal of general design discussion and only a limited amount of practical specific design features that you will be able to pull out and use immediately. I would have preferred far more examples of good design and practical tips – this made it less useful for my purposes and to that extent I think it is significantly overpriced.

If you want to know the secret to not being overweight, you should ask a thin Texan. If the local environment promotes widespread obesity, you have to work hard to be a normal weight, and really understand the principles required. No point asking someone in Paris how to lose weight, where everyone naturally seems to be thin without effort. Similarly, the system in the US makes practicing family medicine difficult. To succeed, you need to be very efficient, and have a strong patient focus. There is therefore plenty of opportunity for us to learn from practices that are doing well.So, what are the latest hot topics?
 

US Health Policy

Remind me not to complain about the Australian health care system.The US health care system continues to cost twice as much per person as nearly all other developed countries (including ours) and delivers worse results.

John Kitzhaber was governor of Oregon when they introduced the Oregon Health Plan, which drew a ‘line in the sand’ as far as determing what procedures were of such demonstrated effectiveness that they would be funded in that state. He give a keynote speech on the legacy that the ‘Baby Boom’ generation was leaving for future generations – fiscal disaster.For historical reasons, the US health system is funded by an outdated mix of employer based health programs and government funded entitlement programs (Medicare and Medicaid). There are large segments of the community with no coverage – and health debt is the second commonest cause of bankruptcy in the US!Many practitioners look with envy at other countries that have universal health coverage, but such is the power of vested interest that there is no political will to significantly change the current system.

Some of the small clinics I spoke with have to deal with 60 different funding arrangements, all with different item numbers and different entitlements to particular medications and procedures. To have someone on Medicaid admitted to hospital involves ringing around all the local providers trying to negotiate a bed for them at the price Medicaid will pay – which normally is futile. Most now just send them off in an ambulance. An enormous amount of clinic resources are used in coding consultations and negotiating the billing minefield. Many practitioners work for very large health providers owned by medical insurance companies, with contracts stipulating the amount of clinic time they will do and the number of patients they will see.Many seem to find the conditions in primary care ‘toxic’.Medicare provides non means tested medical coverage for those over 65. At the time it was introduced, this was the poorest segment of the population. This is now now the most well off!

With the aging population, the unfunded medicare bill will rise to trillions of dollars.

Cathy, my wife, commented to a lady in a shop in Dallas how cheap the kid’s clothes were. The store mnagaer said she would gladly swap the health coverage we had in Australia for the abiltiy to buy cheap clothes. She was diabetic, and was only working to earn enough to pay for her family’s health insurance.On the other hand, we did have occasion to attend the local emergency department during our stay. We had to leave our weapons outside, as the sign on the door demanded, but received speedy, appropriate, friendly and excellent care.

The Medical Home

It was said that primary care had largely abjugated its responsibility over the last 20 years, and I’m still not sure that in the US they really ‘get it’. (I’m told that when you leave university after obtaining a medical degree, your debts are so high that you need to undertake a speciality to earn enough to pay them off.)The Patient Centred Medical Home is the concept that dominated the thinking of many of the attendees. This is a place where patients can access ‘the care they want and need whenever they want and need it’.

Many patients currently receive their care from a number of different providers – the cardiologist, the gastroenterologist, the endocrinologist, the orthopaedic surgeon – and there is little coordination and communication.The Medical Home is the place in which a patient has an ongoing personal relationship with a particular doctor, and the medical home will assist in integrating their care. (Sound familiar?) Apart from the use of medical assistants, nurses and ‘behavioualists’, there is little acknowledgement of the holistic multi-disciplinary team based approach to primary care that characterises the thinking in the UK and Australia.

However, there is a refreshing discussion concerning the need for a patietn-driven medical home – that it should focus on what is important for the patient, such as readilly available access, short waiting times, continuity of care and accurate communication, with quality and safety being key concerns. Many clinics actively engage patients in redesigning the care they offer. Many patients told their stories at the conference and I believe this approach is well worth exploring.

The Electronic Medical Record

It is astonishing that the US with all its resources has still not embraced the EMR, with uptake at less than 20%. The current packages cost thousands of dollars per month and are clunky for doctors to use, requiring hours of customising, and many mouse clicks to do even the simplest tasks. Again, much of this complication arises from the requirements of the different funding sources. Clinics that are computerised grapple with similar issues of poor interopearabiltiy that we have faced, there being no accepted standard for medical communication.

Lean Thinking

Lean thinking is a system of organising work practices based on the Toyota Production Systems. It aims to simplify complex processes and reduce waste by focusing on what is valued by the customer – in our case, the patient. Lean thinking aims to improve patient outcomes, make work flows easier, and to improve the ‘bottom-line’ for the practices. I think that there are significant improvements we could make in the way that we run our practices in Australia and that ‘lean thinking’ has much to offer.

Planned Care

In acute medicine, especially in the hospital setting, the medical practitioners have most of the ‘control’ in determining treatment and outcome.In chronic illness, by contrast, the patient has the ‘control’ in determining what happens – they decide whether to smoke, or go for a walk, or what they eat, or whether or not they take their medications. Therefore, if we don’t bring the patient with us, we will not achieve impovements in outcomes.

Patient education (as opposed to advice) should be the focus of our efforts in chronic disease.

Planned care was a topic at many of the presentations. This is the recalling of patients with chronic conditions for special appointments, to facilitate ‘blueprints’ or guideline driven care. This is the same process we use in our care planning and cycle-of-care programs, and is also therefore of increasing interest for us.Grapevine was great. The hotel had a 5 acre lobby with a river running through it and a replica Texan town. The steaks were as good as I’ve ever had – and I’m sure that I’ll soon have the 24 hour piped country music out of my head.

We will do the community an enormous service if we can increase the capacity of general practice to care for the health of that community.  

If we are to demonstrate an improvement in ‘access’ to general practice, we need to be able to measure the relationship between the demand for service and our capacity to meet that demand. 

As you know, we currently use the third available appointment (3AA), which is an international standard for measuring delay in a system. It measures the length of the ‘queue’ of people who have made an appt to see us – if the 3AA measure is 3 days, there are three days worth of people waiting to see us. In our practice that is a queue length of 75 people each. 

However, I have recently spoken to a mother who was very concerned about her sick child but was unable to get him seen by anyone in her usual general practice  (in-hours)  for three days – even after she had spoken to the GP directly. Their only option was to present to their local hospital – which, as advocates of primary care, we would consider a less satisfactory outcome health-wise. Other patients tell similar stories. 

In many cities and towns, people moving to a new area are unable to find practices with the capacity to take them on as new patients. Often the docs in a town (including mine) will tell me that they see all-comers, yet the patients tell us that they couldn’t get an appointment when they needed one. (I’m not sure how that happens.) 

If the patient never actually makes an appointment, none of these scenarios are captured by the 3AA. It would be better if we had systems in place that would improve our capacity to see our patients when they are sick, and to increase the size of the ‘panel’ we can service, without making our job any more frantic – or getting us home later than we already do!  Much of what we learn in the collaboratives is aimed at improved access to care, and many practices have made significant progress. Therefore for the next phase we are thinking about an additional measure for ‘access’ that would demonstrate an improvement in practice capacity – we tentatively call it ‘the John West’ measure. 

The John West Measure

The John West measure is a measure of unmet demand. It is a tally over a week of how many people call with the intention of seeking an appointment , but do not end up making one.  

This may be because

1) the practice is not taking on new patients (so they are rejected by the practice)

2) the practice has no vacant appointments at a time that fits the patient’s need (because, for example, they feel that they are too sick to wait three days, or because the doctor they want to see has a wait of two weeks and they are unwilling to accept an alternative appointment, or whatever reason) – so the patients ‘reject’ the practice) 

Either way, mark a tally on clipboard each time – and count the ticks at the end of the week. 

These patients are currently not picked up by the 3AA measure. They reflect some wasted opportunities for the practice and potential sub-optimal health outcomes. An improvement by the practice in capacity will be reflected by a decrease in the John West count.

It also acts as a balance to the 3AA measure. Some practices have a longish wait for routine appointments but serve the acute needs of their community well. You might improve your 3AA by seeing less acute patients – which is probably not a good thing  - the John West measure will pick that up. 

Collaborative practice have developed a number of strategies that may improve practice capacity – allowing us to deal with the same amount of patients in less time.
Such as - 

• using other members of the team to do jobs normally done by the rate determining step – the doctor
• improving practice efficiency (less time looking for things, less time spent negotiating on the phone)
• using systematic care to reduce the need for visits by people with chronic illness 
• increasing patient self management skills and thereby reducing unplanned appointments

These strategies, coupled with active management of our appointment scheduling, may free up some time to offer better acute services and to see new patients –  and to go home earlier (especially if you live in Natimuk.)  

We will measure this by an improvement in our John West count. Anyway, our latest  practice PDSA is to test it out for a one week period each month for the next two months and see how practical and useful it appears to be.

I predict that there will be more John West rejects than I anticipate – which will inspire my colleagues and myself to do something about it! 

Any other practices interested in having a trial are most welcome to give us feedback.  

Any suggestions or comments? 

I have recently had reason to think about Tom Marshall’s propositon that ”General Practice is the best job in the world – you get paid for talking to your friends.”

Certainly it is the most rewarding of professions. However, there are many times when it does not feel like the best job in the building, let alone the best job in the world. Within the hustle of the working day we can often feel frustrated and overwhemed, and find ourselves looking forward to the last patient out the door, or just hanging in there until our next holidays.

Sustainability of workforce is one of the key issues for general practice.How can we make every day an ‘in-the-zone’ day’?How can we make our life as general practitioners easier, for the benefit of our practices and ourselves?

The Serenity Project. Fill your working day with Zen-like calm.

In the collaboratives, we have learnt that every system produces exactly the result it was designed to produce. If our days are often stressful and frustrating, we need to change the system that produces those circumstances. The corollary of this is that if we keep doing what we are doing, we keep getting what we get. If we don’t change the stuff that frustrates us each day we are doomed to relive it.

The improvement model tells us that we need to identify a problem, make a change, and measure to make sure that change is an improvement. We need to identify our itches, and then scratch them.

OK. I propose we collaborate and apply these priniciples to making general practice ‘easier’, for the benefit of our patients and ourselves.   

Know Your Enemy. Identify Zen-zappers.

The first step is to identify the circumstances and events that act to decrease our serenity.Keep a sheet of paper on your desk and jot them down as they happen.Interestingly, I have found that many of the things that non-GPs may suspect cause us stress  often do not appear on the list – and some simple things do.

For example, seeing an unwell person with acute chest pain is not usually too Zen-zapping. If the diagnosis is probable cardiac chest pain, our nurses have the oxygen on and ECG done and have cannulated the patient and are just waiting for the nod to call the ambulance to provide transport to the base hospital. No arguments from the ambulance or AEC.

Seeing a person who is not unwell with a vague chest pain that may be cardiac but probably isn’t can be much more time consuming, require far more decisions and persuasion,  and be far more Zen-zapping.

Discussing depression and anxiety with patients is something we are privileged to do every day – it becomes Zen-zapping when we know that  it is going to take hours to chase up a psychologist who is able to assist in their treatment in a timely and affordable way.

The opposition teams

 
In my own prelimnary list I can see the stressors sorting themselves into five major categories

1) Insufficent Time 

Jobs that may be simple become complex when there is inadequate time for their completion. Having a chat to the last patient about their condition can be pleasant – having a chat when there are six other people waiting to see us is less so.      

2) Inadequate Focus

It is a zen principle that whatever you are doing at any point in time should have your complete attention. We should have ‘mindful acceptance of the present moment’. It is hard to do this when the nursing home is on line one, there is a patient in the sister’s room requiring suturing, the patient in front of you is concerned about the behaviour of her child at school, the hospital is on line two, and the ambulance has just arrived to pick up your patient with chest pain and you haven’t done the letter – and the computer has just crashed.      

3) Inadequate Teams

This patient is going to need to see an Ear Nose and Throat surgeon to sort out their acute hoarse voice. Great. There is already a waiting list for the waiting list for the waiting list.      

4) Inadequate Tools

I had the doppler earlier this morning so who took it from my room! Really, you can’t turn your back for a minute. And not only has this ear-looker-inner run out of batteries but there aren’t any paediatric ear pieces left.      

5) Incomplete knowledge.

Bugger. I probably should have gone to that refresher course on heart rhythms.      

6) Attitude

Oh no. Second on the list is Mrs Kapphups. She was ungreatful enough to be allergic to my last treatment. I suppose she’s going to complain about pain again. What does she expect is she’s going to break her back.      

7) Rework

I’ve already filled in five worker’s comp forms and now they fax me a letter asking me the same questions I put on the form. And I wrote up all these charts at the nursing home and now they want me to write exactly the same thing on prescriptions. And the information required on this form could be automatically generated from my computer if they didn’t insist on it being completed on their own paper!      

Phew! I feel my serenity fading away just writing that out.

Regaining Calm

We’ve begun to identify the enemy.Now we can improve our systems to successfully scratch our itch. Having written down the things that upset my day, solutions begin to be obvious.Together we can collaborate and ‘steal shamlessly’ to systematically and proactively decrease these triggers to stress.

The next few postings will share solutions to these issues. 

Please share your thoughts below.