Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for January, 2010

How To Handle Emergency Visits In The Doctor’s Office?

We have an interesting problem a Skyvision Centers, one that we have all anticipated with a combination of longing and fear. We are about to become too busy to see emergency visits.

Let me back up a little bit and explain why the entire Skyvision crew is experiencing agita over this before it becomes some version of reality. Skyvision is that rare entity that continues to try to be exactly what it professes to be. In our case, while not unique, Skyvision is a rare example of true patient-centered medicine. You can read about our story here http://skyvisioncenters.com/blog/?p=108. I’ve also been very frank about how I feel about the mega-trends in medicine, trends that is seems will be magnified and accelerated in the coming “Healthcare Reform”. http://skyvisioncenters.com/blog/?p=145. None of these current fads or trends are terribly helpful blueprints for the solution to our new “problem” at Skyvision.

The ultimate consumer service industry is healthcare. Oddly enough, I wrote something about that: “The Ultimate Consumer Service Business” http://skyvisioncenters.com/blog/?p=56 (I’m clearly not above self-promotion here!). Everyone at Skyvision Centers is  on board with that concept. We’ve all quaffed the same Kool-Aid as it were. That’s how we have come to the conclusion that we are about to run out of time to see patients with an emergency, at least in the patient- centered way in which we have done so in our first 5 years. For you see, we have allowed our patients to define what it is that constitutes an emergency FOR THEM; we have not imposed any internal definition of “emergency” on our patients, and we have responded to every single patient-defined emergency with the same response: “come right in.” We have also evaluated and responded to every “oh by the way” additional problem that our patients brought up in the exam room but forgot to mention on the phone when they scheduled an appointment.

So how do we know that it’s a problem now, or about to become a problem really soon? Well, we still measure and evaluate all kinds of metrics that relate to the customer experience in the office. Some of those metrics are really kind of objective, like time and volume and such, and they lend themselves pretty easily to trend analysis. We know, for instance, that our average patient volume is dramatically up, especially over the last 6 months. We also know that the average time that a patient spends in the office for our core service has increased by 6 minutes over the last year, and that one of the internal intervals–how long it takes to be brought into the exam after your paperwork is ready–has increased by 4 minutes. We know that the average number of emergency visits (ER’s) is now 6/day, and that the range is 0-12; there is no meaningful pattern to the ER’s, no actionable mode.

We have been able to handle our ER load in the past because of our dedication to the concept of “process”, our adherence to clinical protocols and flow protocols, aspects of Skyvision Centers that were learned and adopted from the Toyota manufacturing processes. Our internal benchmarks for patient experience were established when we had so few patients and so much time to see them that I found myself telling childhood stories to entertain my patients, lest they feel they were getting the bum’s rush. We find that we have now bumped against the outer limit of “acceptable” by our own standards, standards which place us in the top 1% of patient experience, and must now make capital investments in order to remain there.

It is the ER load that has forced our hand, for it is the ER visits that have pushed us into the “discomfort zone” of longer patient waits and longer patient “transit times”. Without ER visits we would still be have “running times” like 2008 or 2007, even though our schedule volumes are dramatically higher, and we would perhaps be able to make smaller capital and staff investments more slowly. Adding more equipment and more staff is scary, especially in this economy and with all of the uncertainty surrounding Healthcare right now. Skyvision Centers is a business after all, and no one has received a raise in our first five years (indeed, I am still working for what amounts to an 80% pay CUT). Simply throwing more staff and more exam space at the problem isn’t so effective if it bankrupts the business. Kinda tough to provide a wonderful patient experience if the doors are padlocked.

So the question is now how do we handle ER visits? I know of a number of practices, probably the majority in our region, that simply give the ER patient the next available open appointment, whenever that may be, even if it is days or weeks ahead. Should we do that? Still others send patients to a local Emergency Room; it’s an emergency after all. One of our local institutions, widely lauded by DC gobbersnoppers including our President as the bellweather example of all that we should aspire to in healthcare, directs all patient-defined same-day ER visits to the World Class Hospital Emergency Room; even if you are an established patient with an established doctor-patient relationship their triage in the Emergency Room directs you to a doctor-in-training for your ER care. Should we simply “turf” our ER visits like World Class Hospital?

Thus far we have allowed our patients to define an emergency as anything they, the patient, feels is an emergency, and we have seen them right away that same day. Should we take back control of the definition of emergency and perform telephone triage? My staff and I certainly know the difference between emergency, urgency and inconvenience. We can define and ascertain what constitutes severe and what constitutes minor. Should we perform triage and schedule ER visits in open slots on subsequent office days according to long-established standards of severity and then availability? Tough call. A foreign body sensation is a “next couple of days” triage, but have you ever felt like you had something in your eye? It’s maddening. Imagine waiting a couple of days to be seen.

Should we openly state to all of our patients that we will continue to see ER visits as we have always done? Severity defined by the patient and “come on in” our response? In tandem with this will our scheduled patients agree to the implied contract that any increased wait they experience is an “investment” in their own future ER care? That they are agreeing to wait a little longer for their scheduled visit because of the “there, but for the Grace of God” phenomenon, that they, too, will go to the front of the line should an emergency befall them?

We’re all patients; I fear that that we  will all experience this in the near and not so near future, especially if the DC gobbersnoppers get their way with “Healthcare Reform”. We at Skyvision Centers are quite frankly way better at providing an enjoyable patient experience to go along with best in class medical outcomes already, and I fear that we are going to find the going even more lonely as we agonize over issues like this. I don’t see a whole lot of folks on the “service” side or the finance side of this equation spending too very much time thinking about the effect of emergencies in the medical office and how they affect our experiences as a patient, the person receiving the service.So what do you think? You’re a patient. From the patient’s point of view what would YOU have us do?

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