Shorter Waits and Improved Flows Training Program (SWIFT)

Report 1

A Proposal from the Canadian Health Services Research Foundation

"Governments acknowledge that they cannot reduce wait times on their own"
Statement of Federal-Provincial-Territorial Ministers of Health
Toronto, Ontario - October 22-23, 2005

"A Conservative Government will be open to innovations which would reduce waiting lists, improve the quality of care, and ensure better coordination and information sharing
in the delivery of health"
Conservative Party of Canada; Policy Declaration; March 19, 2005

Shorter Waits and Improved Flows Training Program (SWIFT)/
Réduction de l'attente par des processus intégrés de services (RAPIDS)
A Proposal from the Canadian Health Services Research Foundation (PDF version)

Key Features

• Fully bilingual program to improve wait times and patient flows through executive training for those managing access to the health system
• Post-training network activities including annual meetings to share experiences with peers and continuous learning opportunities via 'desktop technology' that connects graduates to distance education modules and updated research on patient flow and related areas
• Five year, phase one training blitz to graduate at least 400-500 executives, physicians, nurses and other allied health professionals involved with managing patient flows, followed by 60 to 80 graduates per year for five years thereafter in a second consolidation phase
• Applications made by institutions sponsoring their most appropriate candidates; nominal financial and in-house resource contributions from the sponsor that support a rapidly expanding cohort of designated trainees in each institution
• One year duration with three face-to-face weekend training sessions (two regional and one national) and an intervention project conducted at the home institution
• Training sessions distributed across the four regions (West, Ontario, Quebec, Atlantic) in a way that balances regional convenience with opportunities for national peer networking
• Additional web-based modules for further learning available for trainees to select from to complete the program
• Total cost of $29.5 million ($14.4 million for the 'blitz phase' and $12.8 million for the consolidation phase, plus approximately $2.2 million ramp-up and wind-down activities)

Background

Waiting is an important issue in health care, and wait time issues powerfully influence health politics and policy agendas. Governments have made major commitments to decrease wait times, notably in the five clinical areas specified in the 2003 Health Accord and confirmed by the federal government and the provinces in the December 2005 agreements on benchmarks. Progress requires not only commitment and in some cases funding, but also concrete tools and processes to manage a complex system. The quality improvement literature contains stories of major success in reducing wait times on a local and even (in the case of the UK in particular) a national scale. Dramatic improvement is possible if people have the knowledge, tools and support to bring it about.

Program goals and description

This proposal, led by the Canadian Health Services Research Foundation (PDF version), will develop the Shorter Waits and Improved Flows Training (SWIFT) program. The two objectives of the program are:

1. To train clinicians, managers and policy makers in how to reduce unnecessary and harmful waits in the health care system, thereby improving the patient experience and reducing overall wait times for services
2. To create an ongoing national network of evidence-informed decision-makers able to use developing knowledge and access new tools to improve the flow of patients in and their access to healthcare services.

In December 2005 we surveyed 14 of the leading senior managers and clinicians across the country to assess their interest in such a program, and to obtain their advice on how it might be developed and implemented to be effective and responsive to their needs and circumstances. In all but one case there was enthusiastic support for the program and a commitment to sponsor and support trainees.

The following proposal for SWIFT incorporates the findings of this survey and suggests that the detailed form and content of the program should be defined by:

• The deliberations of a curriculum committee to create the precise educational strategy, identify national and international faculty, assess the time required to deliver a successful program, and design the modules that combine core and optional content
• Further consultations with the practice, management, and policy communities to influence curriculum development and overall program design
• Discussions with existing and prospective partners to generate a broad base of support, identify opportunities for complementary programming and experiences for participants, and avoid duplication of effort
• Feedback from initial cohorts of alumni and emergence of new interests and needs from the health care system

The overall design and structure of SWIFT will build on the successes and lessons learned from similar CHSRF capacity development programs for evidence-informed decision-making such as the Executive Training for Research Application (EXTRA) program (PDF version). Rather than rely on a single educational institution for delivery the program will run from a central coordinating office that selects the best faculty from many national and international educational institutions. This coordinated national characteristic also facilitates the fully bilingual nature of the program, the development of national peer-networking (a highly valued product of these programs by participants), and an ability to rapidly adapt the curriculum to changing regional needs using ongoing monitoring and evaluation data.

By moving the 'training' from the traditional university-based environment into a nationally coordinated program it is far more responsive to the needs and contexts of its clients. It is also better able to create a national community of graduates poised to improve patient flows, reduce wait-times, and improve patient satisfaction using the best available evidence. These individuals and the network they form will serve as a vital ongoing resource to assist organizations across the country to improve their performance.

The program, offered in both official languages, will involve a combination of:

• learning and exchange in regionally-based sequestered venues
• self-directed web-based learning
• interventions in trainees home institutions
• at least one annual face to face meeting of all program participants
• the creation of a network to continue to support the evidence needs of graduates beyond the formal training program

Our experience with the EXTRA program has demonstrated that SWIFT will require significant organizational commitment to implementing wait times and patient flow strategies to improve access. With a backlog of skill development needs an initial 'blitz phase' will create 400-500 graduates in the first five years of the program. In the second five-year 'consolidation phase' maintenance and growth will be achieved with 60-80 graduates per year. In addition, the maximum benefit stemming from the gradually expanding network of graduates will take time to manifest. For these reasons, this proposal is constructed as two five year phases on the premise that the full benefits will only be achieved with a minimum 12-year program - the two 5-year offerings with the addition of one year to prepare for the first intake and one year to complete evaluations and reports.

Target Audiences

SWIFT will target people in a position to introduce wait time management techniques and flow processes into important areas of care. The eligibility pool should be inclusive and provide opportunities for all involved in the patient flow management process. Examples include:

• Clinical leaders, such as heads of surgery or diagnostics
• Clinical managers, such as directors of various care portfolios
• Operating room managers
• Professional access leaders such as chief nursing, rehabilitation, laboratory, diagnostic imaging, and other officers
• Senior leaders in organizations who can make policy and resource allocation decisions
• Directors and managers of provincial and regional care networks (e.g., Saskatchewan Surgical Care Network; Cancer Care Ontario)
• Quality improvement officers
• Information system managers
• Wait time coordinators
• The staff of Quality Councils and other organizations with quality improvement mandates

Ramping up

Our experience with EXTRA has taught us that proper planning is critical to the success of this type of program. In the first year of funding, we will consult with partners, leaders in the health system, and potential candidates to ensure that the program is designed to meet the specific needs of the system and its clients. We will design a curriculum that addresses the right issues and competencies, and develop an IT desktop that is configured to the specific needs of trainees. We will assemble and train a world-class faculty, and create the necessary training materials in both official languages. We will ensure that the logistical details are in place for us to deliver a rigorous, high quality and sustainable training experience.

Proposed Intake

Following a ramp-up period, the program will serve 4 regionally-based cohorts of 25 trainees each year for at least the first 5 years - the 'blitz phase'. In the subsequent five years, the 'consolidation' phase, the four cohorts will be reduced in size to between 15 and 20. Participation in the program will be spread out over the course of one year.

Given that managing wait times and patient flows is an organizational and systemic rather than an individual issue, it is not surprising that the survey of health system leaders revealed unanimous agreement that it is more effective to solicit organizations as applicants rather than individuals. Organizations will express their intentions and commitments to improve wait time performance, and will be asked to designate the individual(s) to participate in the program. If demand is sufficiently high, it could be feasible to offer a combination of SWIFT-funded and organization-funded slots (to accommodate large organizations who might wish to have larger numbers trained). In addition, there could be a "train the trainer" approach to build capacity faster in enthusiastic organizations.

The initial focus will be on research-based approaches to managing acute care wait times and related patient flow issues. The initial survey revealed a wide spectrum of other interests that could be offered as optional modules as the program evolves. Among the areas that might be considered are research-based approaches to:

• Change management and communications with the public
• Access to primary care
• Referral patterns to specialists
• Risk management
• Managing information flows from, for example, diagnostics to providers, hospitals to ambulatory care, primary care to community and long term residential care

Program Content

SWIFT will provide on-site, intensive training in wait time and patient flow organization and management. Based on preliminary thinking at CHSRF and the initial survey feedback, and using a variety of pedagogical tools, the core curriculum will provide participants with evidence-based training, tools, and approaches to address areas such as:

• Operations research-processes for optimizing patient flows and reducing wait times
• Information systems for wait times management
• Prioritizing need-whether and how to classify patients
• Identification of the sources of bottlenecks
• Interactions among patient needs and system capacities that can either slow down or speed up the journey through the care process
• Multi-level modelling of needs and capacities
• Management of human, capital, and financial resources to reduce wait times

The program will also incorporate contextual content such as:

• Identifying and incorporating community needs
• Defining and improving appropriateness
• Evaluating performance for improvement-both process and outcomes
• Incorporating the role of incentives-aligning practices with objectives

Program Logistics and Approach

Based on the initial survey and the preliminary overview of content, but subject to further refinement of the curriculum, the program will be shaped around the following form:

• Three core modules of three days each (Fri-Sat-Sun) over a one year period
• The first two modules will each be offered in each region (West, Ontario, Quebec, and Atlantic) for a total of eight module offerings to 25 regional participants each time; the third and final module will be delivered nationally in a central location with all 100 participants in attendance
• Participants will choose up to three additional modules to be offered using web-based delivery mechanisms, on topics of interest to be taken at the discretion of the participants and/or their home organizations; there will be up to one week of this kind of web-based instruction in home organizations
• A core faculty of four will develop and deliver the program (reducing the reliance on one-time guest lecturers given the focused and operational nature of the training)
• Senior organizational officials from the home institution will attend policy-oriented sessions

Organizational Commitments

The experience of CHSRF with existing capacity development programs argues for measures to encourage strong organizational commitments to the program. Thus SWIFT will require that:

1. The organization submits the application and selects the participant(s) to represent it
2. Each trainee or team of trainees will be supported to undertake an intervention project in his or her home organization to put in practice the learnings from the program
3. The organization will contribute a standard configuration laptop computer and $5,000 per trainee toward the accommodation, travel and network connection costs for the program
4. The senior-most executive responsible for wait times management/patient flows in each trainee's organization will attend the annual all-participant session

Core and Potential Partners

The core partners for this program along with CHSRF have already confirmed their enthusiasm and interest: the Royal College of Physicians and Surgeons, the Academy of Canadian Executive Nurses, the Canadian Society of Physician Executives, and the Canadian Council on Health Services Accreditation. It will also be crucial to attract a Quebec core organization such as the AQÉSSS (L'Association québécoise d'établissements de santé et de services sociaux).

In addition to these core partners, the involvement of organizations that can assist with curriculum development and delivery, communications and knowledge translation, and recruitment is highly desirable. Examples of such organizations are:

• Organizations with a quality improvement mandate, particularly those with a mandate to build capacity in service organizations, e.g., the Saskatchewan, Alberta and Ontario Health Quality Councils
• Organizations with specific wait time management mandates, e.g., Coronary Care Network of Ontario, Saskatchewan Surgical Care Network
• Educational programs for administrators, e.g., Masters of Health Administration and Masters of Business Administration courses
• Continuing health education programs or standards-setters
• Organizations with a mandate to provide potentially relevant infrastructure support, e.g., Canada Health Infoway
• Organizations with a monitoring and reporting mandate, e.g., Health Council of Canada
• Organizations with a research mandate, e.g., Canadian Institutes of Health Research

Relationships with Existing Programs

Some jurisdictions have already developed or supported programs to enhance knowledge and strategies to reduce wait times (e.g. Ontario' Health Improvement Teams, Health Quality Council in Saskatchewan). We expect that these activities will continue, and SWIFT/RAPIDS will monitor the initiatives to ensure that our program is both complementary and innovative.

The uniqueness and value-added of our program lies in the following areas:

1. It will examine both technical and policy aspects of wait times and access rather than focusing exclusively on specific tools and processes. Participants will be exposed to the environmental factors that affect system performance and will learn from international experiences. There will be a particular emphasis on change management, and barriers to and facilitators of rapid improvement.
2. While wait times for specific procedures are top of mind in Canada at present and will be addressed in the early phases of SWIFT/RAPIDS, they are a subset of the larger question of the flows of patients, information, human resources, and capital. Bottlenecks occur for many reasons and may vary from sector to sector (e.g. laboratory, primary care, long term residential care and emergency room). The program will continuously scan the environment and will develop new modules to address emerging problems.
3. It will sustain a network of graduates that will create opportunities for continuous learning and exchange across the country.
4. There will be continuous evaluation to ensure relevance, high standards of instruction and materials, and applicability to concrete problems in the system.

Governance and Accountability

In consultation with program partners, an Advisory Committee will be established to oversee the curriculum development and overall design of the program. It will also be charged with recommending ongoing adaptation in response to the results of regular progress monitoring and outcome evaluation.

The CHSRF Board of Trustees will be responsible for the administration of funds and the accountability for its appropriate use in line with the program's stated goals and objectives. An annual report will be produced and submitted to the Government of Canada and other related funding partners in which expected annual performance will be matched against actual outcomes and performance measures.

Budget Overview

The proposed budget that we are requesting has been calculated for four phases: ramp-up (year 1), blitz intake phase (years 2-6), consolidation intake phase (years 7-11) and wind-down (year 12).

The costs for each phase are:

• Year 1:
  $1,144,500
• Years 2-6
  $14,410,750
• Years 7-11
  $12,790,250
• Year 12
  $1,112,750

Detailed calculations for the $29.5M total costs are outlined on the following page.

A Proposal from the Canadian Health Services Research Foundation

	Ramp-up Year 1	Blitz Phase Years 2-6	Consolidation Phase Years 7-11	Wind-down Year 12	Total
Staffing	287,750	2,104,250	1,971,500	443,000	4,806,500
Consultancy	100,000	129,750	79,000		308,750
Curriculum development	150,000	344,000	100,000		594,000
Travel - committee	32,000	-	-		32,000
Communications and promotion	100,000	515,500	412,000		1,027,500
Trainees - travel & residencies		2,846,000	2,395,500		5,241,500
Faculty - travel, residencies and stipends		1,564,500	1,752,250		3,316,750
Senior organizational officials - participation costs		676,000	444,750		1,120,750
Course materials / on-going network costs	250,000	564,250	894,000		1,708,250
IT Platform / Desktop		1,500,000	1,500,000		3,000,000
Site rentals / venues		321,250	293,000		614,250
Candidate review / selection		355,000	203,250		558,250
Translation (documentation and simultaneous)		417,000	169,000		586,000
Program evaluation		625,000	375,000		1,000,000
Miscellaneous	50,000	250,000	250,000	50,000	600,000
Final program evaluation				200,000	200,000
Concluding conference				150,000	150,000
Concluding debrief				50,000	50,000
Final documentation production				50,000	50,000
Subtotal	969,750	12,212,500	10,839,250	943,000	24,964,500
Overhead	174,750	2,198,250	1,951,000	169,750	4,493,750
Total	1,144,500	14,410,750	12,790,250	1,112,750	29,458,250