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.

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. 

Much of the work we do as clinicians involves behaviour change.

In a recent Health Report on Radio National, Norman Swan interviewed the American researcher Associate Professor Kent Harber. Prof Harber has done research on the affect the amount of social support and our available resources affect our perception on the challenges we face. Hills literally look steeper when we’re feeling down or isolated.

I wonder if this is helpful for us. This is why, for example, encouraging weight loss requires more than just telling our patients to ‘eat less – do more’. We need to deal with their psychology – the social supports they have available and their emotions about the challenges they face.

This helps to explain why having a friend participate in a healthy lifestyle program makes such a difference. Certainly, I know that I work much harder in a ’spin’ class when my wife takes me along with her than I ever would on an exercise bike at home.

Here is a snippet from their interview :

Kent Harber: There’s a researcher at University of Virginia named Dennis Proffitt who is a vision researcher not a social psychologist and his interest is how people perceive physical challenges like how steep a hill is because you’re going to hike it. And what he finds is that the physical state or the physical burden of the person shapes and affects their perception of how steep that hill is.

Norman Swan: Is it a physical or psychological burden?

Kent Harber: Well his interest is in physical so if a person is in very good shape they see a hill as less steep than if they are not in so good shape. Older people see the hill as steeper than younger people, someone wearing a heavy back pack sees a hill steeper than someone not wearing a heaving back pack. What our interest was OK if physical burdens effect how we see hills what about psychological burdens or the alleviation of them. So what we did is we had our participants standing at the base and we just got people who happened to be in the vicinity who are either all alone or with a friend and they estimated how steep was the hill. They gave us a verbal estimate – how steep is it in degrees, they gave us what’s called a visual estimate, we had a device that looks like a pizza pan that you can open up or shut and then there’s a third estimate which is called a haptic, where you put your hand at the angle you think the slope is, that’s how your body sees the hill. Proffitt always finds that people’s haptic measures are always accurate, your foot knows where to place itself on the hill but the visual estimates are those that tend to be exaggerated. What we found is that our subjects who were with their friend saw the hill as less steep than those who were not with a friend and the longer they knew their friend the less steep the hill became.

In the second stage we thought, well, you’ve got people here who show up with friends, people -

Norman Swan: It could be an accident of fate that they’ve turned up by themselves.

Kent Harber: Or maybe socially isolated people…………

Norman Swan: Don’t even go to the hill.

Kent Harber: Exactly, so the participants either thought about, as in the pain study, they thought about a very good person, a neutral person or a negative person, they went to the hill. People who thought about a positive person saw the hill as less steep, the closer they felt towards the person they thought about, the less steep the hill became; same hill, different social context.

I seem to be having a lot of conversations with patients about weight loss. We really want them to think about being fitter – many are only concerned about being fatter.

People, including health professionals who should know better, promote one fad after another. It is frustrating to see our patients lose weight, only to find that after some months they are bigger than before they started – and with less cash in their pockets.

It is no surprise that any diet people choose seems to work initially.

The book “Perfect Mess” describes the series of studies undertaken at the Hawsthorne plant of the Western Electric Company. These studies demonstrated that worker output improved when any change was introduced. Even meaningless changes had an effect – like turning the lights up and then later turning them down. People tend to work harder when they know they are being observed. It is the clipboard that matters most.

Successful weight loss, of course, as our colleague and GPSpeak medical editor Andrew Binns points out, requires the motivation to commit consistently to healthier choices.

It’s a pity it’s not as easy as Dr Rudi’s diet – “Eat less” or even the advanced diet “Eat less, do more”.

It requires sustained behaviour change.

I have been trying to track down a picture book I once owned about a land in which the king had to be able to jump to the very top of the castle. When it became time for the king to retire, he sought someone who could take his place. One little boy started at the bottom, and jumped one step by one step till he reached the top. In time, this wise boy became the new king.

In the collaboratives we have learnt about successful change management – incremental change, measuring what you’re doing, being systematic, being creative.

I am sure that using these principles we could collectively come up with a GP-based program that promoted genuinely healthier lifestyle changes, as well as sustainable weight loss.

We have excellent baseline resources to use like Lifescripts, Andrew’s series of articles in GPSpeak, and a lot of collective knowledge about behaviour change. Of course we will call our program by some fancy name. I’ll use FancyName® for the time being for illustrative purposes.

I imagine it works like this.

Kevin has heard of FancyName® and comes to see us, his GP, about weight loss. We chat about aims and goals and enrol him in the GP collaborative healthy lifestyle program, FancyName®.

We perform some baseline measurements and then give him a FancyCard®, which has on it the one change he is to make that week. This change is easy.

Perhaps week one he has to measure his weight each morning and night. (He finds his weight varies enormously – the lesson being that he shouldn’t take any notice of small fluctuations up and down and that weight is not the best way to monitor health and fitness).

He returns next week and sees the practice nurse, who gives him a pedometer and another FancyCard®, which suggests that he measure his steps each day.

When he sees us in week three we give him a new FancyCard® that suggests he have a fibre cereal each morning.

(I’m not an expert on weight loss, unlike Andrew, who has written ‘The Expert’s Guide to Weight Loss’. I think that there were three key factors shared by people who successfully lose weight – they have breakfast each morning, exercise every day and have a low fat diet.)

Week four he has to increase his steps by 1000 each day. Week five we introduce the concept of low GI foods.

Anyway, you get the idea. Our patient jumps to the top of the castle one step at a time.

Collectively, we produce a hundred or so simple steps that patients can adopt incrementally to achieve lasting improvements in their lifestyle. We use this program to manage these patients systematically and proactively, using our practice teams, including exercise physiologists and dieticians. We support their gradual adoption of changed behaviours. Instead of talking to them at length about fat intake, energy balance, low GI foods etc, we give them one simple task each week. We measure how they go, and how we go, and share information on what works well, and modify the program with this shared data.

I’m sure many practices already have such a program. I know that Tintenbar has an excellent activity program.

Anyone up to making suggestions for our collaborative effort? What should the real name of FancyName® be? What would you recommend for the weekly changes that go on the FancyCard®? I’ll collate the responses and share them. Email tony@lemlink.com.au.