"But I Don't Have Time To Change" - Frontline Service Improvements In US Healthcare

Rob Davis

White coat doctor

Urgent tasks are the enemy of process improvement, says columnist Rob Davis, but there are many opportunities at the frontline of healthcare to find improvements if we are only willing to take the time.

I spent last week with physicians from across the United States. These are dedicated professional focused on improved patient outcomes. But one conversation that kept coming up was how time pressures on physicians affects patient care. One primary care physician, for instance, told me about the time pressures he faces every day:

"These days I see a patient at least every 15 minutes," he said. "So there is no time for any frills or extra conversation. And so much electronic paperwork must be completed."

He continued to complain that electronic medical records (which I wrote about in my last column A Dose of Data A Day don’t really help, because they are only additional boxes to check and a hindrance in the race against the clock.

This is a familiar commentary.

"What processes have you improved to give you more time?" I asked him.

After thinking a few seconds, and not finding a good answer, he said none.

I suggested we talk about one activity that consumes his time. This led to a discussion of the seemingly simple process of taking a patient’s blood pressure (BP), which happens in almost every patient visit. It’s also an important indicator of cardiovascular health. In most patients it is relatively easy to control with diet, exercise and medication. Even when the diet and exercise fall awry, a pill at bedtime can most often control BP.

The physician said that he took BP readings himself.

"But I thought there were many electronic devices that could take blood pressure – some even recording the data directly in the patient’s electronic medical record." I said. "Why not use one of those?"

His response: "One thing I learned in med school was not to trust those electronic BP readings."

Those many years as a quality officer forced me to ask another "Why?"

"But I thought the medical assistant took the blood pressure before you saw the patient?" I asked.

"That is true," he said. "But another thing I learned in med school is not to trust the reading taken by the medical assistant. I have to take it myself."

"How much time does it take for you do obtain your BP reading?"

"I’m pretty quick, maybe 3-5 minutes."

Thus far, we had identified that the machine takes the BP and the doctor doesn’t use the reading. The medical assistant takes the BP and the doctor doesn’t use it. So the doctor has invested 3-5 minutes of his 15 with the patient to take a BP.

What if he changed that? He could spend an hour teaching and role playing with his medical assistant until he was comfortable that the assistant could take a blood pressure reading as well as him. Then he can trust that measurement. Then it becomes 5 minutes of the medical assistant’s time and none of the doctor’s.

If that saves the lower end of the doctor’s estimate – i.e. 3 minutes with 20 patient visits per day - in only one day you have recovered your one hour you invested in training you medical assistant. All future days you have an extra hour to spend dialoguing with your patients.

Or better yet, find an electronic device you trust. I recently tested one for a research study we are conducting with treatment resistant hypertensives. It is critical that we obtain an accurate and reliable BP reading. We are using a device for this, because we think it removes variability from one provider to another and helps with the white coat effect which causes a patient’s blood pressure to elevate when they see the doctor. It also saves time.

The medical assistant made sure I was sitting with my feet on floor and that my arm was supported. She put the cuff on my non-dominant arm, pressed a button on a device the size of a desk phone, and left the room. When she returned, the device had taken 6 BP readings. It discarded the first and averaged the next 5. It automatically recorded the data in my electronic health record using the average, but also remembering the range in case it is needed in the future.

It was painless and only 2 or 3 minutes of the medical assistant’s time. The device itself costs less than $1200 and by my back of the envelope calculations, it would pay for itself in saved time in less than a month.

Granted, this over simplifies what is a much more complex activity than it appears on the surface. Even so, there may be places at the frontlines to find improvements if we are willing to change.

Indeed, my doctor friend asked about the device and said he might just try it.

Current urgent tasks are often the enemy of improvement. Certainly, there are other examples we will have to find and deploy to improve healthcare delivery. As the US system becomes more focused on outcomes and less on activities for reimbursement, the time is ripe to deploy real improvements - prevention and treatment actions that deliver improved outcomes.

As with most quality improvement, a focused effort is important to deployable changes. And those changes must help to tame the time enemy and deliver improved quality of life to patients.

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