Improve Quality, Efficiency, & Communication with Physician Navigators

executive-assistantEmergency physicians spend more time looking for charts, finding lab reports, and checking if treatments are done, than they do caring for patients.  After continual interruptions from allied health providers, patients, and other physicians, doctors have little time left for patients.

Some say scribes help.    But after trying scribes, we found navigation to be our greatest need, not transcription.

Physician navigators (PNs) do 2 things:

Direct physician-patient traffic

Manage information

They do not:

Make clinical decisions

Give clinical advice

Order clinical care

PNs improve:

Patient experience.

Physician efficiency

Team communication, especially between nurses and physicians.

PNs perform non-medical tasks that MDs do when working without a PN.  They do anything doctors do that does not require a medical degree.  

We use Physician Navigators to

  • Keep informed of patients waiting in all areas of the department
  • Find out which patients are waiting to be seen next
  • Accept and photocopy patient handover lists from the physician handing over —
  • Make sure all these patients are reviewed and looked after by the accepting physician
  • Keep track of all the patients the doctor has seen and when patients are ready for reassessment
  • Obtain chart for “next available MD to see”
  • Access electronic charts; print out reports
  • Prepare chart for MD reassessment: blood-work, x-rays…printed and ready to hand to patients at discharge
  • Update MD data in the ED information system (tracking board)
  • Page and receive specialist phone calls
  • Receive and manage other incoming calls
  • Hold non-critical calls for MD when MD is with a patient
  • Assist RNs locating MD for urgent needs
  • Inform patients about wait times and purpose
  • Direct patients in and out of examining stations
  • Update RNs on MD work plan
  • Receive RN requests for patient reassessment
  • Work with the team (e.g., RN and RT) to gather equipment for procedures
  • Handout patient information sheets and referral forms to patients when instructed by MD
  • Assist with paperwork to ensure proper completion
  • Create handover list at the end of a shift

Physicians Navigators do this, and more, with good humour, a positive attitude, and in a polite, semi-invisible way.  After a few shifts with a PN helping out, physicians never go back.

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4 Features of an Outstanding Clinic

joy_at_work_coverHelping in new clinical settings over the past year, I find these core features in great clinics and hospital departments.

Outstanding clinics:

1. Remember Their Core Motivation

Most of us run from task to task without asking why.  At some point, we chose to do what we are doing right now.  Even with years of training, people don’t have to keep providing patient care; they could look elsewhere.

People need help to remember why they do what they do, and why they work in a particular place.

Most people who work in healthcare applied from a desire to help people.  They looked for specific jobs that allowed them to help and serve patients.

Outstanding clinical groups never forget that serving patients comes before anything else.

2. Support Their Core Business

Especially in large groups, staff might think the clinic or hospital pays them.  In a sense, that’s true, but also very wrong.  Every business gets paid for doing something.

Although revenue flows through the clinic before it gets to the staff, employees must know that the clinic stays open if physicians see patients.  Anything that slows, or stops physicians seeing patients results in poor patient service and less revenue.

Great clinics keep physicians working at what physicians do best:  seeing patients.

3. Think About Governance

Governance refers to how organizations are governed and controlled, how decisions get made, and how decision-making units fit together.  A solo physician deals with everything, or delegates to an office manager.

Problems arise as clinics grow.  At some point, groups need to think about a formal, simple governance structure.  Communication, authority, and accountability must flow in a line through the structure.   If structure gets ignored and leaders start talking like customers expecting to be heard like owners, chaos ensues.  (Check out: The Imperfect Board Member)

High performing clinics have an explicit governance structure that everyone follows.

4. Manage Performance

Once everyone remembers why they are there, knows how the clinic earns income, and understands how decisions are made, staff needs support to perform well.  With clear expectations, most staff members excel; some do not.  Even in a small group, staff needs performance reviews, incentives to improve, rewards for excellence, and follow-up on underperformance.

Outstanding clinics measure performance using explicit criteria supported by everyone.  When members do not perform well after attempts to help them change, great clinics help low performers find work elsewhere.

Final Thought

Oppressive workplaces leave you emotionally exhausted at the end of a day, fill you with dread at going to work, and require you to tiptoe around icy colleagues.  Dennis Bakke wrote bestseller Joy at Work suggesting that we embrace human values as ends in themselves, not just means to business ends.

Outstanding clinics foster uplifting, healing work environments.

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Built to Fail: Canadian Healthcare + US Legal System


Canadians take pride in having non-American healthcare.

US healthcare makes millions by driving activity:  patient visits, tests, and procedures.  American lawyers take money back with lawsuits.  Canadians have a very similar legal system, also based on English common law.


If healthcare is a commodity that can be bought and sold, patients should be able to sue for bad product.


But, if healthcare is a public offering paid for with tax dollars, patients should have rigid limits on lawsuits, or not be able to sue at all.


Here’s why:

Threat of suit changes behaviour, but not for patient benefit. Providers change behaviour to protect providers, not patients. Physicians order tests far beyond what’s needed, just in case.

Defensive medicine is expensive.  Providers know that ordering more tests protects them in court.  More testing also fits commercial interests: sell more.  So, commercialized medicine and medio-legal activity benefit each other: more tests and more law suits!

Extra tests put patients at risk. Every test carries some inherent risk: radiation, discomfort, etc. Tests also carry the risk of false positive results that can lead to useless surgeries (with risks) and more useless tests.

Publicly funded healthcare was designed for necessities, not to generate more business. It never existed to create work for itself. Doing more in a system designed to cover only the necessities eventually leaves too little to cover the basics.


We need legislated legal reform.  Our publicly funded system will go bankrupt if it exists with our current, American-style legal system.


Benefits of reform:

  1. Improved quality of care.  While you’d think that keeping all healthcare providers in perpetual fear of punishment and lawsuits would improve care, it doesn’t.  Instead, it creates a culture of covering up, or denying errors at all costs.  Medicine, like life, is full of errors.  Errors present an opportunity to improve quality, not something to hide or run-away from.  Quality improves very slowly in a system that crushes speaking up.
  2. Patient experience. Patients do not want to go through useless tests. Most want what’s necessary medically, not what’s necessary to protect providers in court.
  3. Efficiency.  If providers didn’t have to practice defensive medicine, we would see a drastic change in ordering behaviour. Huge numbers of imaging tests and lab investigations would be dropped in favour of clinical judgement.
  4. Capacity. If providers only performed tasks that directly added value for patients, we could care for more patients; wait lists would disappear.

What do you think?  Does it make sense to have a US-style legal approach to a publicly funded healthcare system?


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