Measuring emergency department patient wait time 2008

DETERMINANTS OF WAITING TIME MANAGEMENT FOR HEALTH SERVICESA POLICY REVIEW AND SYNTHESIS Final Synthesis Report Marie-Pascale Pomey Pierre-Gerlier Forest Claudia Sanmartin Carolyn DeCoster Madeleine Drew R09-01 Février 2009 Legal Deposit – Bibliothèque et Archives nationales du Québec, 2009 Legal Deposit – Library and Archives Canada, 2009 ISBN : 978-2-923544-19-9 (printed version) ISBN : 978-2-923544-20-5 (PDF) DETERMINANTS OF WAITING TIME MANAGEMENT FOR HEALTH SERVICES— A POLICY REVIEW AND SYNTHESIS CIHR Research Synthesis: Priority Health Services and Systems Issues #137064 December 2008 Prepared by: Marie-Pascale Pomey Pierre-Gerlier Forest Claudia Sanmartin Carolyn DeCoster Madeleine Drew Address for correspondence: Dr Marie-Pascale Pomey Department of Health Administration, GRIS, Faculty of Medicine, University of Montreal, CP 6128, Succ Centre Ville, Montreal, Québec, Canada H3C 3J7 Phone Number: 514-343-6111 ext 1-1364 Fax Number: 514-343-2448 Email: marie-pascale.pomey@umontreal.ca CONTENTS ACKNOWLEDGEMENTS EXECUTIVE SUMMARY RÉSUMÉ THE REPORT 13 INTRODUCTION 13 1.1 Aims and objectives .13 1.2 Significance of the problem 14 1.3 Background 14 1.4 Structure of this report 19 2. SYSTEMATIC LITERATURE REVIEW 20 2.1 Methods 20 2.2 Results from the literature review 25 2.3 Models 37 2.4 Key findings of the literature review .38 2.5 Study limitations for the literature review 39 INTERVIEWS OF CANADIAN POLICYMAKERS AND DECISIONMAKERS 41 3.1 Methodology for the interviews 41 3.2 Results of the interviews 44 3.3 Key findings from the interviews 49 3.4 Study limitations for interviews .50 SUMMARY OF THE FACTORS IDENTIFIED 51 INTERPRETATION OF THE RESULTS .53 5.1 Divergent and convergent findings between the literature review and the interviews 53 5.2 Comparison of the findings to the grey literature and to Canadian publications 54 POLICY IMPLICATIONS 56 IMPLICATIONS FOR FUTURE RESEARCH 58 CONCLUSION 59 APPENDICES 64 -3- ACKNOWLEDGEMENTS This work would not have been possible without the support of a Canadian Institutes of Health research grant (# KSY-73928) The authors also thank the following individuals: Diane Lorenzetti for her expertise and assistance in refining the search terms and systematically searching all the databases; Catherine Safianyk, Johanne Preval and Ghislaine Tré for their research assistance; Jennifer Petrela for her editorial contribution; and the healthcare managers and policymakers who participated in the interviews and shared their experience and insight -5- EXECUTIVE SUMMARY Background For over a decade, industrialized countries around the world have struggled to solve the problem of long wait times for scheduled medical care (Siciliani and Hurst 2003) Canada has focussed its search for a solution at the federal and provincial levels, and recent Canadian wait time initiatives have consistently looked to centralized programs as their solution (Health Council of Canada 2007) The role of regional health authorities and hospitals has often been ignored or downplayed, this despite the fact that these institutions are directly responsible for initiating and implementing policies and strategies to improve timely access to care It is our position that the experiences of these institutions can provide valuable learning regarding the key determinants associated with the successful measurement and management of waiting times If resources, financial or otherwise, are an important explanatory factor of health organizations’ action or inaction, it can also be hypothesized that governance structures, practices, organizational culture, data collection, and management patterns also count as among the contributing factors Research Objectives The purpose of this project is to synthesize the existing intelligence regarding the management of waiting times for specialized and diagnostic services in an effort to identify the key local and contextual factors of successful waiting time management This procedure was performed by means of a systematic review of literature that focused on the success and failure factors of wait time management (WTM) for scheduled care and through interviews with key policymakers and decision-makers involved in the management of waiting times in Canada The information thus gathered was then synthesized according to a predetermined conceptual framework in order to identify local and contextual factors associated with the management of waiting times Conceptual Framework To organize the factors to be identified through the literature review and the interviews, we used a conceptual framework inspired by Parsons’ widely recognized and robust fourquadrant model The four dimensions used for this model were governance, culture, resources, and tools Because waiting time management strategies work within a broad context and are therefore influenced by more than local factors, both the local and the contextual levels had to be taken into account This is the reason why the model represents all four dimensions at both levels Literature Review Methods For the literature review, six medical databases and 19 non-medical databases were searched for articles published between 1990 and 2005 that addressed wait time or wait list management for scheduled care Articles focusing on waiting times for transplants, emergency care, long-term care and pharmaceuticals were excluded on the grounds that the dynamics of wait times in these areas are quite different The database search resulted -6- in 5202 abstracts, exclusive of duplicates Each of the four levels of screening was performed by two reviewers using online software (SRS 4.0, TrialStat) The final 31 articles retained for data abstraction had been published in peer-reviewed journals and consisted of either a model or a framework with WTM factors at the organizational level or of an initiative that specifically addressed WTM and stated organizational factors explicitly Interviews Methods We conducted 16 semi-structured interviews and one focus group with individuals involved in WTM strategies in Canada at the federal/provincial or the organizational level The one to two-hour interviews took place between October 2005 and August 2006 and all were taped and transcribed Results Few articles found in the peer reviewed literature explicitly addressed the factors that could enhance or inhibit the implementation of a wait time reduction strategy at the local level and few were empirical studies Instead, most were case descriptions with little rigorous hypothesis generation or testing The studies focussed more on evaluating outcomes than on evaluating the implementation of WTM initiatives Some of the local factors most frequently cited both in the literature review and in the interviews were physicians’ involvement to bring resistant physicians on board (culture), appropriate levels of dedicated staffing to ensure continuity (resources), and information management systems to collect and analyse data (tools) At the contextual level, funding levels and earmarked resources recurred most often in the literature review, but interviewees emphasized financial incentives and the need for them to be aligned between the contextual and the local level Unsurprisingly, leadership emerged as an additional important governance factor at both the local level, where it surfaced as strong clinical leadership, and at the contextual level, where it appeared as the need for vision and direction within a structure that ensured coordination, reporting and monitoring Many other factors were identified under the four dimensions and are further explained in this report Study Limitations Although non-peer reviewed articles and the grey literature may have contributed interesting insights, the literature review was limited to peer-reviewed papers in order to keep the scope of the exercise manageable The final sample of abstracted articles is small and there was no scale of evidence to measure the quality of the evidence The sample size for the interviews was also small, but the consistency of the responses by individuals from different Canadian provinces and different levels of involvement helped counter this limitation Nonetheless, it is important to specify that our findings should be considered exploratory: the primary purpose of this study was to identify a number of factors and test their impact in a later study -7- Implications for Policy Even though the main purpose of this review was to identify factors that impact the implementation of WTM strategies and use those factors to develop a framework, it can also inform policymakers of actions that may be beneficial: • • • • • • • involve physicians from the outset; take organizational culture into account before implementing a given strategy; invest in evaluations and quality improvements at the organizational level; invest in the relationship between managers and physicians; earmark funds to help the local level launch the WTM project; invest in information management and tools; align high-level policies with local strategies In general terms, higher level decision-makers need to take organizational factors into account to maximize the successful implementation of WTM strategies Implications for Future Research We have already suggested the utility of further research on the factors identified in this study in order to evaluate their relevance, pertinence and real impact on the implementation of WTM strategies In addition, it would be interesting to conduct a more thorough investigation of the value of neutral third parties, an idea brought up by several of our interviewees In-depth case studies in healthcare organizations where wait list management strategies have succeeded or failed should also be considered Important to note is that for any study in this field, researchers should take care in defining the waiting time period under consideration Finally, this study focused on scheduled care, but the factors identified here may also be applicable to primary care, long-term care, mental health or other fields of heath care where there are also long wait times For these areas, additional factors may be at play, warranting further research Conclusion The present exploratory study was conducted with a view to understanding the factors that enhance or impede the implementation of wait time management strategies The systematic review of published peer reviewed articles as well as our complementary interviews with key policymakers and decision-makers involved in the management of waiting time in Canada identified a number of key factors The next steps require decision-makers and policymakers to start taking some of these factors into consideration and for researchers to conduct further studies to better understand the impact and interaction of these factors in terms of how their influence on the implementation of WTM strategies -8- LETTRE D’INFORMATIONS POUR LES PERSONNES PARTICIPANTES PROJET DE RECHERCHE SUR LES DÉTERMINANTS DES TEMPS D’ATTENTE POUR LES SERVICES DE SANTÉ – UNE REVUE ET UNE SYNTHÈSE DES POLITIQUES Chercheurs principaux: Marie-Pascale POMEY, Professeure Adjointe École de Gestion Université d’Ottawa 136 rue J-J Lussier, Ottawa, ON, K1N 6N5, Canada Tél: (514) 343-6111 ext 1-1364, Fax: (613) 562-5164 Pierre-Gerlier FOREST, Professeur titulaire Département de science politique Pavillon Charles De Koninck, local 2462 Tél: (613) 941-3003, Fax: (613) 941-3007 Co-chercheuses: Claudia SANMARTIN, Chercheure sénior Statistics Canada, University of Calgary Carolyn DECOSTER, Professeure Adjointe Manitoba Centre for Health Policy, University of Manitoba Coordinatrice Madeleine DREW, Assistante de recherche École de Gestion, Université d’Ottawa Objectif: étoffer et enrichir les connaissances sur les déterminants de la gestion des temps d’attente dans les organizations de santé Méthodes: Grâce au recueil des « histoires de cas », il sera possible de compléter la revue systématique de la littérature préalablement effectuée Tout d’abord, dans un premier temps, des entretiens semi-structurés seront réalisés auprès de décideurs et d’experts canadiens Puis, dans un deuxième temps, une journée de travail permettra de réunir des experts en gestion des temps d’attente travers le pays Ce formulaire de consentement fait référence la première partie de l’étude Participation: Vous êtes invité participer cette étude, ce qui nécessite de votre part que vous en acceptiez les conditions Le chercheur principal ou l’assistante de recherche communiquera avec vous ou votre assistante par téléphone afin de fixer un rendez-vous pour la réalisation d’un entretien qui pourra se faire en personne ou au téléphone Un certain nombre de questions ont été préalablement préparées, mais vous aurez aussi la possibilité d’aborder des points dont vous jugerez importants L’objectif principal de cet entretien est de cerner votre expérience dans la gestion des temps et des listes d’attente, de nous faire part d’études inédites sur le sujet, et enfin, de partager votre connaissance - 115 - d’histoires de cas ayant donné de bons résultats dans la gestion des temps et des listes d’attente au niveau organizationnel L’entretien devrait durer au plus une heure Avec votre accord, l’entretien sera enregistré et retranscrit A votre demande, un résumé de l’entretien pourra vous être envoyé Révision de l’entretien: Il vous est offert la possibilité de revoir le résumé de l’entretien dans un délai raisonnable afin que vous puissiez y apporter des corrections, si nécessaire Sélection des participants: Une pré-sélection sera faite en fonction de personnes reconnues pour leur expertise dans le domaine de la gestion des temps d’attente dans les organizations de santé Ensuite, ces experts, rencontrés en entretien, pourront suggérer d’autres noms Ces derniers seront alors ajoutés la liste et seront contactés afin de conntre leur intérêt participer une telle recherche Risques et inconforts: A part le temps consacré cette étude, il n’existe aucun risque ou inconfort identifié Compensation: il n’existe pas de compensation financière liée la participation cette étude Toutefois, si des documents devaient être envoyés aux chercheurs, les coûts d’envoi seraient couverts Bénéfice concernant la participation cette étude: Votre participation cette étude permettra, tout d’abord, de faire avancer les connaissances dans le domaine des facteurs facilitant ou, au contraire, entravant la bonne gestion des temps d’attente au niveau organizationnel, mais aussi, d’identifier les besoins pour des recherches futures Désistement: Vous pouvez en tout temps vous retirer de l’étude, vous n’avez aucune obligation de vous justifier pour cette décision Si vous étiez tenu de prendre une telle décision, cela n’aurait aucune conséquence sur votre crédibilité dans votre travail Si vous vous désistez, l’enregistrement et la retranscription de votre entretien seront détruits Confidentialité: L’information contenue dans votre entretien peut être traitée de diverses faỗons, en fonction de vos prộfộrences, en: Confidentialitộ stricte, ce qui veut dire que celle-ci sera totalement codée afin qu’aucun nom soit identifié pendant les discussions entre les membres de l’équipe de recherche ou lors de la journée de travail Confidentialité partielle, ce qui veut dire que votre nom ou celui de votre institution pourra être utilisé alors que tous les autres cités seront codés Pas de confidentialité, ce qui veut dire que votre institution sera clairement identifiée au cours de la journée de travail et dans les rapports qui seront publiés par la suite Finalement, votre participation nous permettra de faire une synthèse de différentes expériences mises en place pour gérer les temps d’attente dans tout le pays afin de pouvoir créer une banque des meilleures pratiques dans le domaine Ainsi, dans ce contexte, seriez-vous peut-être intéressé ce que votre institution soit identifiée? - 116 - Les transcriptions seront sauvegardées sur un ordinateur comportant un mot de passe dans un local fermé clé Les enregistrements de l’entretien ainsi que notre banque de données seront détruits avant l’année 2010 Financement: Cette étude est financée par les Instituts de Recherche en Santé du Canada (IRSC) Journée d’étude: Il vous sera peut-être demandé de participer aussi une journée d’étude avec d’autres experts sur les temps d’attente Cette participation sera volontaire et nécessitera votre accord sur un formulaire de consentement différent Copies: le consentement ci-joint pour l’entretien est signer en deux exemplaires : un exemplaire doit être renvoyé par courrier ou fax ou remis en main propre avant la réalisation de l’entretien; l’autre, doit être gardé par la personne vue en entretien Pour plus d’informations: Pour tout renseignement sur vos droits comme participant une recherche, vous pouvez vous adresser au Responsable de la déontologie en recherche de l’université d’Ottawa, 550, rue Cumberland, pièce 159, tél : (613) 562-5841 ou ethics@uottawa.ca Pour tout renseignement complémentaire, vous pouvez communiquer avec la chercheuse principale: Marie-Pascale Pomey par téléphone au (514) 343-6111 ext 1-1364 Si vous souhaitez participer cette recherche, pouvez-vous envoyer dès présent par fax une copie du formulaire de consentement joint l’attention de Marie-Pascale Pomey au (613) 562-5164 ou nous contacter par téléphone ou courriel Dans le cas de l’envoi d’un fax, nous prendrons contact avec vous dans les meilleurs délais * Pour ne pas surcharger le texte, le masculin comprend le féminin - 117 - FORMULAIRE DE CONSENTEMENT POUR UN ENTRETIEN réalisé dans le cadre du projet de recherche intitulé “PROJET DE RECHERCHE SUR LES DÉTERMINANTS DES TEMPS D’ATTENTE POUR LES SERVICES DE SANTÉ – UNE REVUE ET UNE SYNTHÈSE DES POLITIQUES” Je, soussigné (e), (nom du participant en lettres majuscules) déclare avoir pris connaissance de la lettre d’information et d’en avoir discuté avec (nom en lettres majuscules) afin de comprendre l’objet, la nature, les risques et les bénéfices de ma participation cette étude Après avoir réfléchi pendant un temps raisonnable, je donne mon consentement pour participer cette étude Je suis d’accord pour que l’entretien soit enregistré: Oui _ Non Après une période raisonnable de réflexion, j’ai décidé que je souhaitais avoir la possibilité de relire le résumé de l’entretien : Oui _ Non Après une période raisonnable de réflexion, je souhaiterais que l’information partagée au cours de cet entretien soit traitée ainsi (cochez les cases en fonction de vos choix): Confidentialité Stricte Mon nom et celui de mon institution restent anonymes Confidentialité Partielle Mon nom reste anonyme, celui de mon institution peut être cité Mon institution reste anonyme, mais mon nom peut être cité Pas de confidentialité Mon nom et celui de mon institution peuvent, tous les deux, être cités Au cours de la journée de travail Dans le rapport de recherche Dans les articles Note: une seule croix par ligne Signature du Participant: _ Date: _ **** Je, soussigné (e), (nom en lettres majuscules) _ déclare avoir exposé l’objet, la nature, les risques et les bénéfices liés la participation cette étude (nom en lettre capital) _ Signature de la personne qui fait l’entretien: _ Date: _ - 118 - APPENDIX 12: Interview guide (English and French) Semi Directed Interview Guide Interviews with Canadian Experts Decision-Makers and People Working in Regional Health Authorities, Hospitals, and Clinics Personal information What are your title and your functions? In what organization and in what sector are you working? What is your educational and professional background? When did you begin working in the health field? Case stories Can you share with us one or two initiatives with which you have been involved and which had an impact at the organizational level? For each initiative: a Timeframe b Provincial, regional or local initiative c Context of this initiative d Major causes of the problem? (for example, inadequate resources, lack of coordination, lack of governance at the provincial/regional/local level, lack of environmental leadership, type of management tools) e Motivations for the solution taken f People involved (physicians, stakeholders, level of government, clients, etc…) What were some of the cultural factors in the implementation of the initiatives? e.g., professional autonomy, professional norms about ethics the values, the organizational climate, the way the information is shared in the organization, climate of cooperation, tasksharing responsibility communication tools to educate the public and the professionals What were some of the governance factors in the implementation of the initiatives? e.g leadership, board, development, citizen and communication participation, type of organization database management (centralized or not), attraction and retention of experienced and skilled managerial staff, access to the right information, capacity to analyze the data, be able to plan the resources, be able to assess what happened, to be able to analyze what happened What were some of the resource factors? e.g Human, financial, infrastructure resources What were the tools used? e.g Information technology (IT), Information management (IM), verification method, evaluation method, audit, operational research, prioritization tools, looking at the organizational care process, looking at the patient pathway - 119 - Was an evaluation conducted (formal or informal)? • If yes what type of information was used and what was the outcome? • Were the objectives achieved? (Examples: reduce WT, Better prioritization of patient, etc.) 10 From your point of view, is it a successful or an unsuccessful example? Why? Is it a short term or a long term solution? 11 Do you think that this initiative can be a model for policy-making or waiting time management? a If yes, why? b If no, why not? What lessons can be learned from it for the policy decision-makers or the waiting time / waiting list managers? Documents 12 Do you know of any studies, reports or position papers which have not been published and that relate to determinants of waiting time or waiting list management or are related to policy introduction at the organizational level? • If yes, would it be possible for you to provide us a copy? • If not, you have suggestions for how we may be able to obtain one? Other person to contact 13 Is there anyone else you feel we should talk to? Do you know of other people involved in waiting time or waiting list management who may have any relevant documents for this study? 14 Do you know of other people who have been involved in waiting time or waiting list management who can share some case stories with us? Closing 15 Do you have any additional information or comments you would like to share? - 120 - Guide d’entrevue semi-guidé Entrevue avec des experts canadiens et avec des personnes travaillant dans les systèmes de santé régionaux, des hôpitaux ou des cliniques Information personnelle Quel est votre titre professionnel et quelles sont vos fonctions? Dans quel type d’organization et dans quel secteur travaillez-vous? Quelle est votre formation? Décrivez brièvement votre parcours professionnel? Quand avez-vous commencé travailler dans le domaine de la santé? Histoire de cas Pouvez-vous nous parler d’une ou de deux initiatives auxquelles vous avez participé et leur impact au niveau organizationnel? Pour chaque initiative, spécifiez: a Le temps écoulé entre la conception et l’observation de résultats b Si l’initiative est au niveau provincial, régional ou local c Le contexte d Les causes majeures du problème (ex.: ressource inadéquate, manque de coordination, manque de gouvernance au niveau provincial/régional/local, manque de leadership, type d’outils de gestion) e Les motivations pour la solution choisie f Les personnes impliquées (médecins, partenaires, niveau de gouvernement, usagés, etc.…) Quels étaient les facteurs culturels dans la mise en œuvre de l’initiative? Ex autonomie professionnelle, normes professionnelles, éthique, valeurs, climat organizationnel, la dissémination de l’information, climat de coopération, partage des tâches et responsabilités, outils de communication pour les professionnels et le public Quels étaient les facteurs reliés la gouvernance? Ex leadership, conseil d’administration, communication et participation des citoyens, type d’organization, bases de données pour la gestion (centralise ou non), attraction et rétention du personnel de gestion qualifié et avec expérience, accès de l’information pertinente, capacité d’analyse de l’information, capacité de planifier les ressources, capacité d’évaluer et d’analyser les évènements Quels étaient les facteurs reliés aux ressources? Ex Ressources humaines, financières, et d’infrastructure Quels outils ont été utilisés? Ex Technologie informatique, gestion de l’information, méthode de vérification, méthode d’évaluation, audit, recherche opérationnelle, outil de hiérarchisation, processus de soin - 121 - Une évaluation de l’initiative a-t-elle eu lieu? (formelle ou informelle) - Si oui, quel type d’information a été utilisé et quels étaient les résultats? - Les objectifs ont-ils été atteints? (par exemples : diminution du temps d’attente, meilleure hiérarchisation des patients, etc.) 10 D’après vous, les initiatives étaient-elles des réussites ou non? Pourquoi? Est-ce une solution court terme ou long terme? 11 Pensez-vous que ces initiatives seraient des modèles pour la gestion des temps d’attente ou pour la mise en œuvre des politiques contre les temps d’attente? - Si oui, pourquoi? - Si non, pourquoi pas? Quels leỗons peuvent ờtre apprises pour les preneurs de décision ou les gestionnaires de temps d’attente et de liste d’attente? Documents 12 Avez-vous connaissance d’études, de rapports ou de documents inédits et, qui selon vous, seraient pertinents pour mieux saisir les déterminants des temps et des listes d’attente ou bien qui mentionneraient l’introduction de politique concernant ce sujet au niveau organizationnel? - Si oui, pourriez-vous nous procurer une copie? - Si vous n’avez pas accès une copie, que suggéreriez-vous pour en obtenir une? Autres personnes contacter 13 Y a-t-il quelqu’un d’autre qui nous devrions parler pour récolter de l’information au sujet de la gestion des temps d’attente au niveau organizationnels? 14 Connaissez-vous quelqu’un qui aurait d’autres documents qui pourraient être pertinents pour notre étude? Conclusion 15 Avez-vous quelque chose ajouter avant de conclure l’entrevue? - 122 - APPENDIX 13: Case studies CASE STUDY 1: Joint Arthroplasty “Orthopaedic Blitz” – A Local Initiative Queen Elizabeth II Health Science Centre, Halifax, NS Interview with Dr Michael Dunbar As part of a multifaceted initiative to manage waiting list for orthopaedic care at the Queen Elizabeth II Health Science Centre in Halifax, Nova Scotia, the orthopaedic department initiated an “Orthopaedic Blitz” Before the initiative, orthopaedic surgeons typically performed no more than three joint replacements in a 10-hour day Since other hospitals reported performing five joint replacements per day, the department wished to determine how many joint replacements it could complete in a day and identify the barriers to continually accomplishing this number Other orthopaedic surgeons agreed to allow operating room time to be exclusively dedicated to joint arthroplasty for a period of two weeks Hospital staff also agreed to lend beds from other units to orthopaedic patients in case of overflow in the orthopaedic ward The outcome was that for those two weeks, staff completed four joint replacements per day without working overtime The principal barrier to this increase in treatment was identified as limited resources: real resources such as operating room availability, ward beds, and rotating human resource shortages (anesthesiologists and nurses),and resources linked to a “micro perception of cost”: cancelling cases because no overtime salary was available with which to pay nurses The organization’s culture was also such that middle management was not encouraged to take the larger picture into consideration There was a perception that surgeons wished to perform more surgeries in order to earn more money, even though all surgeons at the institution are salaried employees Other initiatives undertaken at this location include the implementation of a centralized waiting list management system for total hip replacements, total knee replacements, and arthroplasty performed by the hospital’s 12 orthopaedic surgeons The centralized list allowed for modeling of a waiting list management system and led to the purchase of web-based data collection software with which staff managed the lists A factor that delayed the implantation of the software consisted of interdepartmental disagreement between physicians and information technology staff on the type of software selected (sub-culture differences) In contrast, many factors enabled the implementation of the initiative, including leadership by a local surgeon with good credibility, buy-in by physicians because the proposed tools were simple and met clinical needs, the relatively small number of surgeons involved, and recognition of the need of data with which to model wait list management scenarios - 123 - CASE STUDY 2: PROVINCIAL SUPPORT FOR ORGANIZATIONAL INITIATIVES Kingston General Hospital, Kingston, Ontario, Interview with Joe de Mora The Kingston General Hospital (KGH) is a 456-bed teaching hospital that serves more than 500,000 people in southeastern Ontario and is the community hospital for the Kingston area KGH provides an array of specialized acute and ambulatory clinical services including traumatic care, cardiac care, stroke treatment, pediatric care, perinatal care, end-stage renal disease care and stem cell transplants It is also the home to the Cancer Centre of Southeastern Ontario As a local operational initiative, KGH started tracking surgical wait lists in the early 2000s It did so by developing software that linked its patient care system to the surgical department, the surgeons’ wait list, and the hospital’s operating room schedule The development phase of this initiative was lengthy and use of the system was made mandatory for all surgeons in 2004 The system is used to allocate all operating room time and to produce information on wait times by discipline and by procedure When Ontario’s wait time strategy came into effect, KGH’s Cancer Centre submitted a project that looked specifically at cancer waitlists Some of the personnel who had been involved in surgical wait times worked with oncology staff to submit the funding application, which was successful The type of tracking system used for surgical care was extended and adapted to cancer treatments, including radiotherapy and ambulatory care In the words of the hospital’s media webpage, “The web-based wait list management and tracking application pulls together data from various existing clinical systems to track and monitor a patient’s journey through the cancer care system, from the detection of an abnormality to treatment - and all points in between.” A key factor that positively influenced this project was the injection of seed money to kick-start the project Clinical leadership and knowledge transfer at the organizational level also enabled the project’s success Other positive factors named by the interviewee included the system’s easy data entry structure, regular content updates, the fact that decisions are made at the clinical level, and the fact that surgeons themselves decided to use the system It proved to be important that the system was both non-punitive and perceived as such Buy-in from physicians resulted partially from the fact that more than three quarters of doctors were on alternate funding plans This meant that doctors were more concerned about the availability of resources and the effective and efficient use of operating rooms than they were concerned about a loss of income But as for any change, an initial investment of time and effort was required to explain to physicians how the initiative could help their clinical practice and their workload - 124 - CASE STUDY 3: Centralizing Referrals for General Surgery - A Local Initiative St Boniface General Hospital, Winnipeg, MB Interview with surgeon Dr Mark Taylor, January 2006 The St Boniface General Hospital is a Catholic tertiary healthcare facility affiliated with the University of Manitoba It is part of the Winnipeg Regional Health Authority At the time of the interview, the hospital had no system with which to organize waiting lists for general surgery Each surgeon simply kept his or her own wait list Family physicians referred patients to the surgeons of their choice, and wait times varied widely depending on surgeon Once surgeons saw a patient, they could either book the first open operating slate or put the patient on a waiting list No prioritization system was in place and there was no accountability system at any level Surgeons were assigned schedules for operating rooms and they booked patients at their discretion The only policy on the part the hospital was that patients have at least one week’s booking notice The hospital monitored the schedule The interviewee had once suggested centralizing the referral system for the seven general surgeons working at the institution The system recommended by the interviewee would have allowed family physicians to choose between referring their patients to the surgeon of their choice or using a centralized system according to which the patient would see the first available surgeon qualified in the treatment necessary to his or her case There had been some enthusiasm for this idea, but two surgeons, interestingly those with the longest waiting lists, refused to participate Without buy-in from all surgeons or the political support to move ahead, the initiative stalled The issue in this organization is not capacity for general surgery but rather the great variability in waiting times between patients awaiting the same surgery While it is undeniably positive that the average waiting time for general surgery is not long, this situation also means that there is little incentive to institute change The Winnipeg Regional Health Authority does not see general surgery as a priority, so there is no political pressure to take action In addition, individual hospitals have little encouragement to treat patients more rapidly since existing globalised budget allocations act as a financial disincentive for treating greater volumes of patients The story of this initiative confirms that to implement a new strategy, one must have surgeons onside To obtain buy-in requires respect and trust Furthermore, change is impossible without the support of the top tier of an organization, which in this case consist of many layers: the CEO of the Winnipeg Regional Health Authority, senior hospital management and the regional department of surgery Without pressure or support from the top, there is no reason for surgeons to take a risk or what they perceive as a risk In this situation, professional autonomy has proved to have negative consequences Furthermore, surgeons’ actual remuneration system, i.e the fee-for-service model, has been a major cultural impediment to moving forward Every action taken on wait lists is seen as possibly diminishing physicians’ income - 125 - CASE STUDY 4: A Regional Initiative for Surgeries Vancouver Coastal Health Authority, Vancouver, BC Focus group with members of the Regional Surgical Executive Council - October 2005 The Vancouver Coastal Health Authority (VCH) serves residents in Vancouver, North Vancouver, West Vancouver, Richmond and the mountain communities of coastal British Columbia It regroups several acute care hospitals and offers a full range of healthcare services along the continuum of care VCH took a regional approach to decreasing waiting times In the summer of 2002, it created the Regional Surgical Executive Council composed of 17 members of varied backgrounds including managers, physicians, and surgeon representatives of different medical specialties The council represented the different hospitals and health services of the region The initiative began as the Regional Surgical Services Planning Project that planned to relocate surgeries to different sites It conducted an environmental scan and Sullivan Consulting, a consulting company, was hired to develop national benchmarks for efficiencies, staffing levels and best practices The project was supported by VCH’s senior executive team This initial phase over, the project has evolved to include 16 specialty working groups and various sub-committees A group of co-chairs for specialty services (34 people in total) meet regularly with the council, after which decisions are reinforced at the local level within specific sites Over the course of its existence, the council has been a means of causing surgeons and committees to work together It has allowed surgeons to recognize their input and due largely to its title ("Regional Council"), has proved to have the influence to move issues forward Surgeons are now more likely to collaborate than before In addition, surgeons perceive a lack of capacity to be the major obstacle to more efficient operations and working as a regional council has helped them approach the ministry for more funding The group is very transparent and very inclusive Support staff were hired specifically for the Regional Surgical Services Planning Project The project team (i.e surgery administrators and leaders) meets every two weeks and makes decisions by consensus Final decisions are made and approved through the hospital structure The project team addresses problems related to access to surgery with respect to both demand and supply To this, VCH first developed its Resource Allocation Methodology (RAM) RAM is based on data and not on historical allocations, which are standardized across the region A decision to increase operating room allocations is based on three criteria: long wait times, a critical mass on a given wait list, and an overall low utilization rate (number of surgeries/capita) Developing a demand model to predict future demand for surgical services was another initiative Millions of dollars were spent on a regional operating room information management system VCH also worked with the province to develop a specialty specific prioritization tool using tools developed by the Western Canada Waiting List Project On the supply side, special Ministry of Health funds targeted wait list reductions for the most urgent needs (treatments for which the gap between the target treatment time and - 126 - the actual wait list time were high) Simpler day surgeries were outsourced to private clinics in order to free operating room space for more complex cases that required intensive care The same surgeons who operate in the private clinics also operate in VCH hospitals and the same administrative structure is in place (the same booking system, the same charts, and the same computer system) In this way, private clinics act as additional operating rooms for the public system Some surgeons were shifted from one site to another in order to maximize capacity (e.g for hip and knee replacements and cataract surgery) In addition, surgeries were sometimes moved out of operating rooms and into procedure rooms The capacity to perform cataract surgeries was increased by doubling the number of rooms where anesthesia could be administered, and one operating room was designated for surgeries not requiring an anesthesiologist Reliable data is of course necessary to all of these initiatives One of the biggest challenges is to ensure that wait lists are accurate, as to allocate operating room time for an inaccurate wait list reduces efficiency In the first round of contacting patients on the wait lists, 30%-50% of those on wait lists for joint replacement surgery were removed due to various factors (the surgery had already been completed, the patient had died, the patient no longer wanted the surgery) VCH now contacts each patient after 26 weeks on the waiting list The next step is an online electronic booking IMIS infrastructure to help the process Project administrators plan to package the prioritization tools within the IMIS system in order to increase surgeon buy-in Surgeons will be responsible for filling out the prioritization form but VCH will ensure that the data is used for operating room allocations The measure currently used consists of the length of time between the moment that the patient consults the surgeon to the time of actual surgery The province also plans to develop a patient registry that precludes the double-booking of patients across the province, and a master provincial procedure list that will allow the ministry of health to determine wait times for specific procedures - 127 - Adresse de correspondance Prière d'adresser toute correspondance concernant le contenu de cette publication ou autres rapports déjà publiés : Groupe de recherche interdisciplinaire en santé Secteur santé publique Faculté de médecine Université de Montréal C.P 6128, Succursale Centre-Ville Montréal (Québec) H3C 3J7, Canada Téléphone : (514) 343-6185 Télécopieur : (514) 343-2207 Adresse de notre site Web http://www.gris.umontreal.ca/