Success and Sustainability Factors for Wait Time Management Strategies

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Success and Sustainability Factors for Wait Time
Management Strategies

• Presented by
• Marie-Pascale Pomey, Claudia Amar
• and Juan- Carlos Sabogale Olarte
• University of Montreal

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Outline

• Definition and context
• Wait time management strategies (WTMS)
• Examples of WTMS
• Context
• Previous work
• Research synthesis to identify the factors that
  impact the implementation of WTMS
• Ongoing work
• Case studies to elucidate the factors that
  enhance or inhibit the sustainability of
  successful WTMS

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1. Definition and context
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What is a wait time management strategy?

• A wait time management strategy is an initiative
  that targets the reduction of wait time for
  access to healthcare services Kreindler (2010).

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Examples of WTMS

• Increase capacity
• Augment the number of healthcare providers
• Expand the hours of operation
• Invest in medical technology
• Develop coordinated care processes and practical
  guidelines
• Invest in information technology
• Central wait list registries
• Operating room (OR) booking systems
• Information systems to track performance against
  wait time targets

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Examples, cont

• Control demand
• Clinical assessment / prioritization tools
• Clinical appropriateness guidelines
• Maximize existing capacity
• Pooling wait times appears to be another
  potential solution
• Choose an alternative provider
• Pay for increased activity
• Pay to use private facilities

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Examples, cont

• Change funding
• Fee-for-service payment to physicians
• Activity-based payment to hospitals and/or
  bonuses for achieving extra volume
• Maximum wait time guarantees

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Why is it important to study WTMS at the
organisational level?

• Canadian decision-makers appear to agree that the
  answer to the problem of wait lists and wait
  times lies at the federal and provincial levels,
  with centralized programs the solution
• But it is at the level of healthcare
  organizations whose programs dovetail with
  provincial and federal policies, that solutions
  can be found.

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2. Previous work
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Researchers

• Marie-Pascale Pomey, MD, PhD, U of Montreal
• Pierre-Gerlier Forest, PhD, Trudeau Foundation
• Claudia Sanmartin, PhD, Statistics Canada
• Carolyn de Coster, PhD, Alberta Health Region
• Madeleine Drew, MHA, Accreditation Canada
• Catherine Safianyk and Maggy Pierre, masters
  level students

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Research synthesis

• Topic To identify the factors that impact the
  implementation of WTMS for scheduled care
• Three sources of data
• Articles
• published between 1990 and 2009
• 6176 articles, 44 articles abstracted
• 32 published between 1990 and 2005
• 12 published between 2006 and 2009
• Interviews
• 16 individual interviews and one focus group
• Key stakeholders, policy-makers and managers
• Workshop (30 participants)
• Workshop on the Determinants of Wait Time
  Management Strategies Ottawa, ON March 25, 2009

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Research objectives

1. To conduct a systematic review of the literature
   on the success and failure factors of wait time
   management for scheduled care
2. To conduct interviews with key policy and
   decision-makers involved in the management of
   waiting lists to analyze factors that inhibit or
   encourage the implementation of WTS at the
   organizational level
3. To synthesize the information gathered in order
   to identify policy and organizational
   determinants associated with managing waiting
   times
4. To validate the findings with a group of experts,
   key stakeholders, policy-makers, and managers
   (the workshop)

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Conceptual framework
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Research synthesis

• Data-gathering
• Sources 6 medical and 19 non-medical databases
• Excluded Transplants, emergency, LTC,
  pharmaceuticals
• Screening (on SRS 4.0 - Trialstat)
• Four levels of review performed by two reviewers
• Peer-reviewed journals only
• Final inclusion criteria
• A model or framework with WTM factors at the
  organizational level OR
• An initiative specifically addressing WTM and
  explicitly stating organizational factors
• Timeframe
• Articles from 1990-2009

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Data collection (RS) ? 1
Total number of abstracts at The first level of screening 5202 Total number of articles for data abstraction 44
Level of strategies (n44 ) at a higher level 25 57 at a local level 19 43 Level of strategies (n44 ) at a higher level 25 57 at a local level 19 43
Clinical area of initiatives Clinical area of initiatives
Elective surgery (gal) 14 32
Orthopedic surgery 10 23
Eye care 10 23
Cardiac surgery 8 19
Cancer 2 3
Diagnostic imaging 0 0
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Types of strategies?1
Phase Level Strategy Number of articles
Implementation Higher level Booking system Max wait time guarantee Software development Increases in capacity Pooled wait lists Prioritization tools Better data collection and analysis Others (sending patients abroad, GP fund-holding) 5 4 1 1 1 1 1 2
Organizational level Increases in capacity Work reorganisation Pre-operatory clinic Pooled wait lists Prioritization tools Better data collection and analysis Software development 2 4 2 1 1 1 3
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Types of strategies?2
Phase Level Srtategies Number of articles
Sustainability Higher level Prioritization tools 1
Organizational level Work reorganization at the local level Booking system 4 1
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Interviews
Number of Interviews 17 Number of focus groups (5 participants) 1 Number of individual interviews 16
Level of interviews at a higher level 9 at a local level 8
Clinical area of initiatives (may be more than one initiative per interview) Orthopedic surgery 7 Medical imaging 2 Cardiac surgery 2 Other area or broad spectrum initiative 9
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Workshop
Workshop participants care providers, health system managers, policy-makers, the representatives of national associations of healthcare professionals, the representatives of accreditation bodies
Objectives To review the findings of the Determinants of Waiting Time Management for Health Services - A Policy Review and Synthesis project with an expert group of individuals who could apply the research findings To validate the research findings with experts from different domains in order to ensure that the findings were sound and to explore how the identification of the various factors could be developed into best practices To discuss ways to disseminate the research findings with the greatest benefit to policy-makers and managers To solicit suggestions for future research and to secure research settings
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Results (synthesis) ? local level
Governance Leadership (clinical and management) A dDedicated decision-making and management structure Interorganizational partnerships Accountability (local agreement) Culture Physician involvement Trust between managers and clinicians Quality improvement culture Culture of innovation and performance Public awareness and empowerment
Tools Information management systems Training and support (coaching) Resources Dedicated staffing Flexible and adequate capacity Individual/team incentives
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Results (synthesis) ? context
Governance A high-level (i.e. central) coordinating/reporting structure Stakeholder engagement Culture Consultation with frontline actors Public awareness
Tools Standardized guidelines The collection and standardization of data Training in WTM Resources Funding levels Earmarked resources Financial incentives
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Results (INT and WS) specific to the Canadian
context
Governance CG Leadership CG Accountability at a higher level CG Competing health system priorities Lack of shared learning opportunities between organizations and among jurisdictions Culture CC Trust between local and high levels CC Public awareness CC System reactivity LC Lack of participation and engagement among front-line healthcare workers LC Limited information-sharing
Tools CT Public website CT Queuing theory and modeling LT Clinical guidelines and pathways LT Process for resource allocation Resources LR Seed money
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Factors that proved successful in sustaining
reductions in WT

• Accurate analysis, forecasting and planning (T)
• Focus and persistence on the problem throughout
  the organization (G)
• Flexible capacity (R)
• Detailed examination and understanding of the
  whole hospital production process to improve
  efficiency (T)
• Clinical ownership and involvement (individual vs
  HCO) (C)

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Lessons learned

• Few articles explicitly address the factors that
  can enhance or inhibit the implementation of a
  WTMS at the local level
• Two studies have focused on sustainability
• One in the UK Appleby (2003)
• One in ON Trypuc (2006a, b, c 2007 and 2009)
• Need more research on the factors that help
  sustain WTMS

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2. Ongoing work
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Objectives

• To elucidate the factors that enhance or inhibit
  the sustainability of a successful WTMS
• To elucidate potential unintended consequences
  related to the implementation and sustenance of a
  WTMS

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Definition of a successful project

• Project success defined by De Wit (1988)
• The project is considered an overall success if
  the project meets the technical performance
  specification and/or mission to be performed, and
  if there is a high level of satisfaction in
  regard to the project result among important
  people in the parent organization, essential
  people in the project team and essential users or
  clientele of the project endeavour.
• Rosenau, 1998 Saladis Kerzner, 2009
• Successful The project is completed on time and
  on budget, with all features and functions
  originally specified.
• Challenged The project is completed and
  operational, but is over budget, is late, and has
  fewer features and functions than initially
  specified.
• Failed The project is cancelled before
  completion, or is never implemented. 

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A successful WTMS

• At the system level
• The project reaches the target determined by the
  government
• At the organizational level
• The project reaches the target determined by the
  government
• The project reaches the target fixed by the HCO

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Sustainability

• Sustainability yield as the management of a
  resource for maximum continuing production,
  consistent with the maintenance of a constantly
  renewable stock (Tivy and Ohare, 1982)

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Sustainable development

• Development that meets the needs of the present
  without compromising the ability of future
  generation to meet their own needs (The World
  Commission on Environment and Development, 2009)

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Industry
Education
Water
Health
Public Services
Transportation
Food
Electricity
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Sustainable development needs to

• 1) integrate conservation and development
• 2) satisfy basic human needs
• 3) achieve equity and social justice
• 4) allow for social self-determination and
  cultural diversity
• 5) maintain ecological integrity
• Jacobs, Gardner and Munro (1987)

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Sustainability of change

• Sustaining any profound change process requires
  a fundamental shift in thinking. We need to
  understand the nature of growth processes and how
  to catalyze them. But we also need to understand
  the forces and challenges that impede progress,
  and to develop workable strategies for dealing
  with these challenges. (Senge, 1999)

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A sustainable WTMS

• sustains reductions of wait times in the long
  term does not merely reduce them temporarily
• does not produce unintended consequences
  (Bardacha and Cabana, 2009)
• Patients
• Providers behaviour
• The use of ressources

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Literature A successful and sustainable WTMS

• Appleby et al. 2003
• Successful Consistenly low proportion of
  patients waiting longer than six months
• Variable success Some success in reducing the
  proportion of patients waiting longer than six
  months, but reductions not sustained
• Unsuccessful Consistently high proportions of
  patients waiting longer than six months

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Studys objective

• To elucidate the factors that enhance or inhibit
  the sustainability of WTMS for total joint
  replacement (TJR) surgeries in Canadian HCOs in
  order to reduce wait times and respect
  national/provincial and federal benchmarks

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Our projects definition of a sustainable WTMS

• Sustainable A WTMS that has resulted in all
  patients waiting less than 26 weeks for a TJR for
  at least 6 months or one year during the past 18
  months
• Moderately sustainable A WTMS that has
  temporarily reduced waiting for a TJR to less
  than 26 weeks for at least 6 months or one year
  during the past 18 months
• Unlikely to be sustainable A WTMS that has not
  be able to reduce waiting for a TJR to less than
  26 weeks for at least 6 months or one year
  during the past 18 months

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Relationship between the concepts
Successful
Sustainable
Unintended consequences
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Successful Moderate Unsuccessful
AL Moderately successful -Continuum of care -Central clinic -Streamlined referral process
SK Successful -Increase capacity a new provincial clinical pathway for hip and knee replacement patients -Control demand HKR referral scoring tool -Using existing capacity pooled referrals were established
ON Successful Increasing capacity Centralized referral tracking and triage assessment clinic Capitalization of existing resources and expertise APP Control demand Moderately successful Using existing capacity APP Increasing capacity a regional joint assessment centre (RJAC) Unsuccessful Increase capacity Arthroplasty Intake Clinic (AIC)
NS Unsuccessful Increasing capacity and using existing capacity Model-simulating the flow of patients Using a central intake process Controlling demand VAS assessment tool
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Interviews

• The medical director, the director of operations,
  the senior manager responsible for WT targets,
  the orthopedic ward director, the clerk
• One person at the ministry level in charge of WT
  or WL

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Semi-directed interview guide

• Warm-up questions
• Description of the WTMS and validation of the
  WTMS results
• HCO governance (how decision are taken,
  organization of the overall WTMS, management
  measures to improve performance)
• HCO culture (recruitment, managerial and clinical
  leaders, relationships, physicians involvement,
  general attitude about WT reductions)
• HCO resources (finances, capacity, physicians...)
• HCO tools
• Environmental context (policy, resources,
  governance, culture)
• How organizational and environmental factors
  interact
• Unintended consequences within and outside the
  organization
• Wrap-up

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KT

• Tools to help managers in HCOs integrate factors
  that can help to sustain their WTMS into their
  management of the project
• Tools to help managers assess the unintended
  consequences that could follow the introduction
  of a WTMS

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Thank you

• Questions?
• marie-pascale.pomey_at_umontreal.ca