Superb access in a sustainable practice

September 22, 2006

24 7 access

“I can see you today and am available to you whenever you want and

need.”

The medical literature is rich in studies that demonstrate the direct

correlation between continuity of care and improved outcomes. Not

only does it result in more satisfactory experience of those seeking

care, studies have demonstrated reduced hospitalization, improved

preventive care measures, and those providing health care express more

satisfaction in their work.

So why would we create a system that breaks continuity? When we

have failed to create a reasonable balance between work and life we reach

for solutions. Quick fix solutions fail to address the systemic

flaws and usually have unintended consequences that exacerbate the

underlying problem and make the overall situation even worse.

24/7 access in the context of good work-life balance is possible if one

understands the systemic issues. Several factors make up the

foundation of access, continuity, and efficiency.

Factors that exacerbate the underlying problem:

Sharing call Supply deficit during regular business hours Overall supply/demand mismatch

Isn’t this burnout mode?

Not if you manage it right.

24/7 access means that those you serve feel that the typical barriers

between them and you have been eliminated. The typical barriers

include call groups (which also breaks continuity, leading to less

effective and less satisfactory care), answering services. This is

based on perceived scarcity. Senge[1]

and others discuss the concept they label the Tragedy of the Commons –

people demand more of a scarce resource than they truly need. They

do this because of the perception (or reality) of scarcity and the

personal need to assure access to that resource. We see this in

office practice systems: when we make access to clinical care difficult,

we make it look like a scarce resource & people demand more – this

becomes a vicious cycle. When we eliminate barriers to access we

see the virtuous cycle of decreased demand.

24/7 does not mean working beyond your capacity.

Burnout is based on working beyond your capacity, not on the

attributes of access. In fact, improved access to you results in

less unnecessary demand, improves continuity, and improves the work

load.

How in the world does total access result in less work?

If you are thinking from the context of a typical practice, this may

seem impossible. In typical systems we get used to fractured care,

covering for other doctors and getting calls after hours from

strangers.

1: Work load for strangers versus those we know:

We try to figure these folks out on the phone, laboriously asking

questions to find out what the caller really needs, and try to document

it all for the PCP. The work load of a stranger call is very much

larger than for a patient you know.

2: Work load based on mutual respect:

When doctors take their own call and convince their patients that “I’m

here for you whenever you want and need” the demonstration of respect is

matched by patients. The experience of those taking their own call

is that patients are extremely respectful.

3: Superb access from 9-5 M-F drives down evening and weekend

access. The typical practice has a significant amount of after

hours access driven by daytime access problems. Solve the daytime

problems and reap the after hours decompression. I can offer all

the after hours access in the world and do it easily when the demand is

minimal.

What about the patient with the outrageous request at 2AM?

There are exceptions, but they are rare, and the exceptions are dealt

with as exceptions. Rather than develop a policy that punishes all

by erecting barriers that end up creating more work, work with the

exception patient directly.

Take the 7PM call for a prescription refill as an example:

“Mr. S, could you call and leave me a message on my office machine for

your refill? I’m sitting down to dinner and don’t have a pen

handy.” The implication of having crossed an acceptable threshold

is clear in that interaction and will modify the behavior of the majority

of those who step outside the boundaries.

For those very rare individuals who continue to step outside the bounds,

you should sit down with them and have a frank and honest discussion

about the behavior. “Ms. J, you call me on my cell a lot in the

evenings and on weekends. While you have important issues to

discuss, I have a life outside of work as well. Please contact me

during my regular work hours, let’s spend the time to meet your needs,

but please reserve your after hours calls to those issues that truly

cannot wait.”

When I make myself superbly accessible, patient demand for me

increases as they realize they can come to me to fix problems that should

be fixed elsewhere in the health care system. Why should I be the

one? Am I not then enabling the dysfunctional system?

We do our best to deliver the best care for our patients. As

primary care clinicians, our responsibility is to the whole person, and

while our historic responsibility ended when they reached the door of the

specialist, this is not optimal.

Specialists are good at their specialty. If a specialist acts

outside their specialty, they run the risk of error for our

patients. Because we treat the whole person it is natural and

appropriate that we weigh in on anything that happens for our

patients.

This does enable a dysfunctional system, but at the benefit of helping

our patients. To get this out of pure enabling, our extra burden is

to raise our hands and let the source of dysfunction know. Think

about creating at the very least simple mechanisms of notification:

Fax a note to the specialist office:

“Dear Dr. :

We just heard from Mrs. X that she should call us to set up the PT in

follow up to the surgery you performed. She was unable to get

through to your office to find out where you prefer your total knee

patients to go, so she called us. We have arranged her PT. We

believe that your choice of PT and guidance is one of the key components

of appropriate post operative care. While we are always glad to

assist our patients in their care, this work should naturally be done

under your guidance. It would be best if your office created a

seamless system of entry into PT for your post op knee patients.”

If I ever sent a note like this to a specialist, they would kill

me.

I work with many specialist offices in my role with the Institute for

Healthcare Improvement and in other improvement initiatives. I hear

from surgeons all the time “I would never give my referring docs a hard

time – they are the ones who refer! If they are not happy with me,

I don’t get the cases I need.” Don’t underestimate your

leverage! If they come back at you with heat they may not be the

specialist for you and your patient.

If I cover the “whole person” for all their problems with other

offices and the mishaps and hurdles in health care, I’ll never reach

reasonable balance.

This is obviously a huge burden of work and I don’t mean that as of

this moment you should accompany your patient to specialist appointments,

follow them into the OR, etc. Judy and I are just exploring the

foot hills of this issue in our practice as we struggle with the

demand. I truly believe that the whole person responsibility does

rest with us, but it is going to be a long time before we can cover more

than a fraction.

[1] The Fifth

Discipline: The Art and Practice of the Learning Organization

Senge, 1990 ISBN 0-385-26095-4

September 22, 2006

I know I just posted the long bit below, but want to reassure folks that

I agree with Tim, and others who talk about appropriate

limits. I think that limits are critical.

The congruence between limit setting and 24/7 access is that I feel

comfortable setting limits once I've gone the distance in terms of

eliminating barriers to access.

My phone message states: " this is Dr. , our office is now

closed until Monday AM at 9. Please leave a message. If your

issue cannot wait, please call me on my cell phone XXXXXXX. "

This works for me and my patient population - resulting in an average of

one or two after hours call per week and one after bedtime call per

quarter.

Gordon

At 11:12 AM 9/22/2006, you wrote: