Final Report of the Federal Advisor on Wait Times

Chapter 3: Management and Innovation in Health Care Systems

The development of benchmarks and targets against benchmarks were a necessary short-term goal to meet the commitments made by First Ministers in September 2004. However, the concerted efforts that have been taking place over the last few years to shorten wait times will not be sustained unless the machinery of health care systems is transformed. Without these transformations it is unlikely the system will be able to sustain these wait time reductions without significant financial infusions. Our goal must be to ensure that the recipient of care, the patient, and processes and quality of care, are the priorities of caregivers and care systems.

There are improvements that can be made now within existing health care systems that will have long-term effects. These include:

• adoption of new management, business and industrial practices^[12] by provinces and territories, regional health authorities and health care institutions;
• development of wait time coordination expertise in provincial and territorial health care systems including wait time champions and coordinators who assist both patients and their families to navigate complex health care systems; and
• development of a training program for current clinical leaders, nurse managers and other health care professionals in wait list management practices.

We already know from experience that the maintenance of individual wait lists by individual specialists contributes to lengthy waits for some patients. Opportunities for earlier care, perhaps with another specialist, are often missed. Our system will benefit from:

• use of single common waiting lists;
• an approach that permits patients to be referred to a speciality service that prioritizes the patient by acuity and offers the first available slot for intervention;
• the use of queuing theories to alter current processes;
• innovative case management;
• team based care;
• appropriateness; and
• pre-habilitation programs to ensure fitness for surgery.

Pre-habilitation may allow for improved fitness for surgery and fewer cancellations. Weight loss, blood pressure control and blood sugar control can all be improved through these processes. A patient would only enter a wait list when they were fit to do so and when benefit is minimized.

The attention given to unacceptably long waits over the last several years has given us insight into how wait times can be reduced or eliminated. This chapter explains why waits exist and provides an inventory of necessary system innovations. All decision-makers and health care leaders must be aware of this body of knowledge. These innovations are now being implemented in many sites throughout Canada and show great promise. Finally, there is a growing interest in issues of appropriateness. The first issue of appropriateness pertains to the choice of care the patient will receive; the second issue relates to appropriate and efficient use of available resources.

3.1 Why are there waits for services?

There are a variety of factors that influence wait times:

• the type of care that the patient requires;
• the doctor whose list the patient is on;
• how urgently the patient requires care; and
• other factors related to individual patient needs or conditions.

Capacity is usually not measured ^[13]

Typically the providers of health care services know their activity or utilization level but may not know their capacity or demand. For example, in primary health care settings, there are patients who phone for appointments but are turned away. These individuals may go elsewhere or not seek care at all. This means that appointment books reflect only those individuals who successfully schedule an appointment. In order to accurately measure demand, it is necessary to record calls where an appointment has been requested and refused.

In addition, actual capacity is usually unknown. One example is the practice of routinely scheduling treatment based on thirty-minute intervals when the average procedure may take only 17 minutes.^[14] A study has shown that bookings were done on this basis "because some procedures took 30 minutes". In this instance there was almost 50% more capacity than was being utilized.

Appropriateness of care

Appropriate health care is when the health benefit exceeds the negative consequence of not having treatment by enough of a margin to justify treatment.

The University of British Columbia (UBC) evaluated the indications and outcomes for six elective surgical procedures and reported the findings in 2002 in the Canadian Medical Association Journal. The UBC study found that 94% of elective hip replacement patients were better after surgery, 4% were unchanged in their symptoms and 2% were worse.^[15] On the other hand, only 70% of cataract surgery patients were improved while 26% actually had worse vision after the procedure. It appears that most of the joint replacement patients were getting appropriate care while many cataract patients were not. If one-quarter of Canadian cataract surgery patients should not have surgery at all, wait lists for this procedure could be eliminated or substantially reduced.

Another example of appropriate use of health care services is demonstrated by the use of the Ottawa Ankle Rules.^[16] We know that the Ottawa Ankle Rules can decrease the need for x-rays by up to 40% while not actually missing anyone who has a broken bone.^[17] A study of Canadian emergency physicians showed that less than one-third of these physicians were using the rules correctly. ^[18] The implementation of the Canadian CAT (Computed Axial Tomography) Scan Rule for patients with head injuries^[19]has the same potential to reduce the need for CAT scans in these instances by 40% or more.^[20]

3.2 A perspective on health care waits and delays

Canadians need to be aware that just because there is a wait for care does not mean that the wait is medically unacceptable. However nobody wants to wait, or should wait, months for an artificial joint while suffering pain or disability. There may be other circumstances in which it is convenient for a patient to delay major surgery by a week or two to wrap up loose ends or make arrangements with family or friends to assist with their impending recovery. As well, some patients in consultation with their physicians may prefer to delay surgery for "pre-hab".^[21]

Sometimes it is the unpredictability of a delay rather than the length of the delay that presents the problem. For example, people often have to make special arrangements for care of their home or dependents when they have surgery. Having a specific date for surgery may allow time to mobilize family and friends. Without a specific date or with a cancellation, it can be difficult or impossible to make such arrangements.

3.3 Best practices and efficiencies

Healthcare is sometimes compared to a "cottage industry". Over time each province and territory, region, facility and doctor's office has developed their own best practices designed to meet their individual needs or those of their patients. It is only natural that they would feel the pride of ownership for having created systems or process that have shown success. Difficulty arises from the fact that while there are many innovative ideas that are in practice across Canada these ideas are not shared across jurisdictions. This means that our health care system is really a patchwork of systems often lacking efficiency and resistant to change when new best practices are identified.

Many best practices exist and could be replicated. One example is the Kingston Surgical Booking system, which was developed over eight years, and now provides an overall view of the city's surgical waiting list. It keeps track of the actual time taken for individual surgeons to perform different procedures and to ensure most efficient booking of procedures. The system also provides alerts for pre- and postoperative care. It can warn clinicians about the need for a lung function test prior to surgery or the need for a rehabilitation bed after surgery. Chapter 4 will address the importance of information technology in these activities as it relates to system transformation and the reduction or elimination of wait times.

One of the more recent applications of better business practices is the Alberta Hip and Knee Replacement Project.^[22] Initially the project attempted to have referring doctors complete a referral template to ensure that appropriate investigations had been completed. However, as the project progressed it was found to be easier to place family doctors into the clinics to assist with the initial work up of patients. Patients are assigned to case managers who track them throughout their care.

Specialization

Specialization is another means of achieving efficiencies within health care systems. There are many examples of specialized centres. Toronto's Queensway Surgicentre, a division of the Trillium Health Centre (a public hospital) is the largest not-for-admission surgical centre in North America. Another example in Manitoba is the provincial government purchase of the Pan-Am Clinic from its private sector owners. The Clinic now operates as a unit of the Winnipeg Regional Health Authority (WRHA).

Leadership

There are many examples of leadership that have resulted in innovative ideas. It will serve our systems well to identify individuals who are trained, who have leadership abilities and clear and measurable objectives to bring about change. Too often healthcare organizations have little capacity to take on quality improvement projects. This can be a significant barrier to innovation. In many instances, a barrier to making an innovative improvement is that health care organizations until recently have had little capability for quality improvement projects.

To effectively engage in quality improvement an organization must:

• include quality improvement in its strategic plan;
• provide leadership;
• ensure resources are available to support quality improvement activities;
• develop measures to assess quality and have regular quality monitoring; and
• ensure that feedback is provided with reports to the appropriate unit and up through the organization.

Role Definition

Discussions on health human resources have for many years focused on capacity - the number of training spots available in medical schools, universities and colleges, recruitment, retention and repatriation initiatives. Supply is an important health human resource issue, but so is role definition. Role definition with respect to the current workforce is relevant to wait time management. For example, nurse anaesthetists have the potential to relieve surgical backlogs resulting from a shortage of anaesthesiologists and nurse practitioners, working within their scope of practice, can assume broader clinical functions in primary care settings. Enhancing the role of various health care workers increases capacity and makes more appropriate use of physician time. Chapter 5 will address this issue as well.

3.4 Models for quality improvement

There are models for quality improvement that have shown success and are in use both internationally and nationally. One example is the UK's National Health Service (NHS) Institute for Innovation and Improvement.^[23] The Institute was created to lead a quality improvement activity that applies evidence to practice by encouraging clinical teams within organizations to test changes. The Institute has also used a collaborative model where teams from different organizations work on the same issue over the course of 6 to 12 months and compare the results. This initiative has achieved significant reductions in wait times in the UK over the past six years.^[24]

The Saskatchewan Health Quality Council has developed its own process to improve access. The Council draws upon the experience of organizations that have demonstrated success with a particular initiative.^[25] For example the Saskatoon Community Clinic implemented an "advanced access" system a number of years ago. Staff from the Clinic are presently assisting the Council to implement province-wide, same day access to primary health care by 2010.

While the collaborative model of quality improvement has had some success, it can be expensive to operationalize. A recent review observed that organizations need a commitment to quality improvement to ensure that a collaborative initiative will have an impact on their organizations.^[26]Organizations which successfully ran collaboratives also attempted to create a culture for quality. They focused on process and outcome measurement to drive change.

3.5 Modern methods of queue management

Queuing Theory

Queuing theory is a branch of mathematics that deals with waits and delays. It contributes to the practice of advance access (also called open access).^[27]Queuing theory can be applied to improve flow whenever something or someone arrives from somewhere else, has something done to them and departs. Applications of queuing theory are used routinely for air traffic control, manufacturing processes, amusement parks and many other aspects of day-to-day life, including inventory control in hospitals. Yet in an area as important as acute care, there has been little use of queuing theory to reduce patient waits in the health care system.

Queuing theory uses various techniques or tools. The following are examples of queuing tools that can make service more responsive to patient waits.

Advance Access

One example of managing waits and delays is referred to as "advance access". Many family doctors have wait lists of four weeks or more for routine appointments. Advance access is a method of organizing, scheduling and planning patient flow in office practice with the goal of scheduling appointments on the day of choice, including the same day.

Advance access typically uses this analysis:

• assess whether capacity is sufficient to meet demand;
• if capacity is sufficient to meet demand, temporarily increase resources to clear the backlog; and
• if capacity appears insufficient for demand, then attempt to smooth capacity and reduce demand.

If these attempts are unsuccessful, then a bottleneck exists that must be identified and rectified.

Dealing with bottlenecks

In instances where a bottleneck exists, a root cause analysis may be needed to determine if the cause is a result of a shortage of capital, human or other operating resources. There may be instances where new or additional resources are necessary to eliminate the bottleneck. Analysis should be repeated on a regular basis since over time bottlenecks in the process may move around. The goal is to even the flow by reducing variation as much as possible. This is only possible when the whole pathway of care can be seen and managed.

Smoothing Capacity

Smoothing capacity means eliminating the peaks and valleys of capacity that plague health systems. For example, there are more discharges from hospitals on Friday than other days, especially Sundays. That means, in general, hospital staff rush on Friday to discharge patients often competing for orderlies, pharmacy orders and other services. Patients who arrive home with questions may not be able to reach the family doctor or staff who took care of them in hospital.

Health systems also tend to increase variation by creating multiple lines for services for different priority ratings or doctors, similar to a line up at a bank. As we know, more people can be processed when one line feeds all the tellers. When there are separate lines, some lines move more quickly than others. Sometimes, one line will be free when there are lines for the other tellers. In the example of a bank line, it may take a minute or more to identify the long line and move someone over. Frequently it is a person from the end of the longer line, rather than the front or middle of another line that is moved or moves to the free teller. This action compromises fairness.

When delays for health services get long, the numbers of patients who do not attend for their appointments rises. They might have received care elsewhere or simply forgotten that they had an appointment because of the long wait. In addition, some patients deteriorate and may no longer be appropriate candidates for the scheduled care. Staff may call patients who live nearby and are mobile but ignore those who have greater urgency. If the vacant slot is not filled, the capacity is lost and cannot be regained.

Prioritization can actually make delays worse. It is understandable that when there is not enough capacity, staff will prioritize patients, creating separate categories, which result in multiple queues and more capacity/demand mismatches. In most instances there is enough capacity but it is not used efficiently. Doctors usually administer their own wait lists through their offices and as a result some doctors or some hospitals end up with longer lists than others.

It is also the case that more appropriate analysis at the onset of care can reduce demand. Many Canadians face long waits for specialist visits. Throughout Canada, many specialists routinely schedule referrals as one-hour appointments. In some instances it may be possible to schedule a shorter visit or avoid having the patient visit the specialist at all if the issue is not complex and can be addressed with a 5-minute phone call between the family doctor and the specialist. In other cases, the patient (and family) may require a half-day assessment from a multidisciplinary specialist team due to the complexities of the case. Assessing the need before hand could save valuable time that could be used where it is needed most.

Inappropriate use of resources

Inappropriate use of available resources also contributes to lengthy waits for services. An example of this is in the field of diagnostic imaging. We know that there are instances of repeated exams resulting from x-ray films that are inadvertently lost or inaccessible. We know too that wrong exams may be ordered; an exam might not be required at all; or x-ray exams are ordered in a process of elimination. Inappropriate use of resources is a major contributor to lengthy wait times and increases costs unnecessarily.

A pilot study undertaken by the Canadian Association of Radiologists (CAR) has shown that only 86% of requests for diagnostic testing were appropriate. In 9% of the cases, a more appropriate test should have been ordered, resulting in a duplication of studies. In 4% of cases imaging was not necessary at all. This means that 10% of referrals or close to 4 million exams per year could have been eliminated. This represents the workload of 200 radiologists.^[28]

Multi-step health care

Most health care encounters involve several steps. For example, arthritis patients usually start off being treated by their family doctors. Eventually, if their joint pain or disability increases, the family doctor will refer the patient to a rheumatologist or an orthopaedic surgeon. After the initial specialist visit, the patient will usually be sent for an imaging study (e.g. X-ray, MRI) and then often be referred to a physiotherapist. At some point in follow up, if the patient is still deteriorating, an orthopaedic surgeon will put the patient on his or her surgical list. At each step in the process, the patient may face months of waiting . Multi-step services such as these can be subject to repeated delays.

When dealing with long waits for several linked services, the first step is to map the whole course of care and evaluate the results. Sometimes, this process will immediately suggest re-design possibilities such as eliminating unnecessary steps, streamlining the number of steps or combining multiple steps.

The use of registries

Earlier in this chapter, in the discussion of best practices and efficiencies, I mentioned the importance of information technology in reducing wait times. Technology plays a key role in many of the queue management techniques as well. Registries, as part of electronic information systems, are essential for better queue management. They have the added benefit of providing valuable data that can be used to evaluate outcomes. At present there is little data collected on patients prior to or after medical procedures. The data collected through registries can be a useful tool for analysis. It has been suggested that the following data be included in wait list registries:

• timeline information, including but not limited to original request for consultation with family physician, first appointment with specialist, time of decision about treatment, exit from queue without service, time of service provision, follow up appointments;
• clinical presentation;
• symptom changes over time;
• co-morbidities;
• reason for delays in care;
• reason for leaving queue; and
• outcomes, including mortality, morbidity and quality of life.

3.6 Provincial wait time champions

There is a need to support clinical leaders as they inspire change within our health care systems. In provinces where governments and health departments have placed leadership and accountability squarely with respected clinical leaders, progress has been significant and visible.

I have described in this chapter many elements of the administration of care that require change, each of these contributing to transformation in one domain or another. The responsibility for the planning and management of these changes must be given to a leader who has interest and expertise in this field, management skill, proven clinical knowledge and the confidence of peers. This is no small expectation. It is clear to me that these individuals exist across provincial jurisdictions and that they can be recruited to assume the leadership that this change process requires.

Such leaders can play a role within their own jurisdictions and nationally as well. In all of these areas of innovation and process improvement, leaders rely on other leaders with whom to share best practices, experiments and ideas. We know already that provinces are conducting their own change processes and that from these efforts many outstanding innovations have been put into place. In order to ensure that this process of change continues and that all provinces are able to share in and learn from the best practices of others, I support the creation of a network of provincial wait time leaders. Governments should identify the necessary resources to develop this network and support it with resources sufficient to address provincial needs and interprovincial collaboration. The development of this network will increase the chance that work will be undertaken with experience and vigour and that the knowledge that is acquired in one jurisdiction can be put to good use in another.

3.7 Navigating the health care system

Difficulties encountered by patients and their families while navigating through complex health care systems are well documented by the media and by various health care analysts. There are countless stories of patients who have either been lost "in a black hole" while waiting for treatment or have had difficult experiences due to inefficiencies within the system. These issues range from minor glitches, easily rectified with a phone call, to major inefficiencies that need to be identified and corrected through root cause analysis. A new staff function called wait time coordinator, navigator or advocate has emerged to assist patients in progressing through treatment processes.

Aside from the benefits to patients and families, navigators can also assist health care providers. In Nova Scotia, oncologists rely upon the navigators to coordinate care. Family doctors and health care centres have come to depend upon their clinical knowledge of the structure and function of the cancer treatment system. The navigator keeps in touch with the family physician's office during the diagnostic work to ensure that appropriate referrals are being made for further diagnostic tests and specialists consultations. In addition, navigators coordinate with surgeons' offices to ensure that referrals are being made for radiotherapy and chemotherapy, if required.

Navigators or case managers^[29] are empowered to challenge the system. Navigators can do more than assist individual patients to solve isolated problems. They can be linked to a quality improvement process that ensures their knowledge about system inefficiencies is passed on to others.

Clarifying the Roles

There are a number of different approaches to addressing the navigator, advocate or wait time coordinator roles but a common factor is the focus on patient-centred care. Job functions can be similar but activities may begin or end at various stages in patient care. It is possible for the same individual to function as both a wait time coordinator and navigator/advocate.

A wait time coordinator is typically assigned to a patient upon booking of a treatment and communicates with that patient until the commencement of the service.^[30] The wait time coordinator is a designated position within an organization or care network with functions involving case management for a specific group of individuals during the time they are waiting for care (either surgical or diagnostic such as an MRI/CT scan).

A patient navigator/advocate (system navigator) involves providing assistance to patients once they have already entered the system (i.e. during a hospital stay). The navigator typically will guide the patient through the system or act as an advocate to speak on their behalf when they may be unable to speak for themselves. System navigators tend to be embedded within other types of case management or coordinator models.^[31]

The roles of wait time coordinators, navigators or advocates have the potential to not only provide assistance to the patient (and family) but to include a responsibility to improve patient flow by identifying and reporting on bottlenecks or inefficiencies.

3.8 Training health care professionals

A culture of change is necessary if we are to succeed in transforming the health care systems. It is necessary to train professionals currently working within our health care systems in techniques that will improve flows and shorten wait times. Process improvements are still taking hold in our systems. We need to invest in training to build a community of support and expertise at both individual and organizational levels. The Canadian Health Services Research Foundation (CHSRF) has prepared such an education program known as "Shorter Waits and Improved Flows Training Program" (SWIFT).^[32] The program provides training through a combination of on-site, sequestered training; web based learning; at-home instruction and an annual face-to-face meeting of fellows and graduates. An ongoing network will continue to support graduates. The program would target clinical leaders, managers, nurse executives, administrators and others who play critical roles in time sensitive clinical care and could be offered in both official languages.

3.9 Conclusion

There are many challenges associated with reducing waits and improving access to health care in Canada. Examples from across the country and around the world demonstrate that it is possible to dramatically reduce waits. Canadians could potentially have same day access to primary health care, one or two week access for appointments with medical specialists, and almost no waiting for tests and surgeries.