Zen and the Art of General Practice Part Two
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.
buy cheap Lithium 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.
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