By Susan Usher, Carla Eisenhauer, Vicky Holmes
As part of the 2008 program of the MUHC-ISAI, Health Innovation Forum prepared this case study of a clinical practice redesign, in collaboration with Drs Carla Eisenhauer and Vicky Holmes, along with staff at the Health Quality Council.
Thirteen percent of households in Saskatchewan report difficulty accessing routine or ongoing care and 17% have trouble getting care for a minor health problem. The consequences of physician access problems are worse for patients with chronic diseases, and the HQC’s Chronic Disease Management (CDM) Collaborative identified them as a priority in 2003.
The goal is to make it easier for patients to book appointments the same day they call or very soon after. The strategy requires that doctors study their practice, understand the variations and patterns of demand, and change some of the booking, recall and other practices that may contribute to backlogs. The principle borrows from those of advanced access scheduling developed in the 1990s by California physician Dr. Mark Murray and management consultant Catherine Tantau for the Institute for Healthcare Improvement. It is based on the premise that variation in demand, rather than excess demand, is at the root of backlogs, and that anticipating and managing variation can keep backlogs to a minimum. Of course, the first stage is eliminating the existing backlog; that requires a thoughtful approach and usually a combination of methods, for example improving efficiency, temporarily increasing work effort, and adding temporary capacity through a locum.
Saskatchewan clinics began experimenting with the idea in 2004. Dr. Carla Eisenhauer’s 13-physician Saskatoon Community Clinic became interested in improving access and approached the HQC for support. The pilot redesign was highly successful, with the average wait time for an appointment dropping from 17 to just two days. The HQC recognized the connection with improving chronic disease management and saw an opportunity to promote improved access throughout the province. Other early converts include urologist Dr. Kishore Visvanathan, who has tracked the implementation of the redesign of his eight-physician practice in a blog, ear, nose and throat specialist Dr. Mark O’Grady in Regina, and Dr. Vicky Holmes at Saskatoon’s Midtown Medical Centre. The HQC’s CDM Collaborative has now completed two waves of workshops involving over 200 physicians; HQC is now establishing a Clinical Practice Redesign School to train doctors interested in spearheading change in their practices.
Potential for expansion
Seventy-three medical practices from all 13 Saskatchewan health regions were exposed to clinical practice redesign in the HQC’s CDM Collaborative. As the project evolved, it became clear that, when looking to implement advanced access scheduling, practices saw the benefit of thinking more broadly of overall practice redesign and its usefulness in sustaining improvements and designing a patient-centred practice. Specifically, with chronic care requiring new ways of practicing — including group visits, planned care and self-management support — practice redesign offers a way to intelligently and safely move forward with data in hand. “Even those practices with no defined wait-time issue often struggle with how to anticipate and manage workload, with physicians often working excessively long hours to avoid a wait list,” says Katherine Stevenson at HQC. “Practice redesign tools are powerful in that they help you see your office system and that makes it easier to decide if and how to redesign, wait list or no wait list.”
Improved access has adherents among both fee-for-service and salaried physicians, and can be applied in general and family practice as well as specialty settings.
Other provinces, including Alberta and British Columbia, are also in the process of studying improved access, and the prospects for further expansion appear excellent, says Karen Barber, HQC director of quality improvement.
The HQC’s role in promoting clinical practice redesign is somewhat more difficult to replicate. There are only two other provincial quality councils, in Alberta and Ontario. Only Saskatchewan’s has a mandate to support quality improvement, as well as analyze and report on quality of care in the health system.