Access to Surgery in British Columbia - Ministry of …...Access to Surgery in BC | The Cutting Edge January 15-16, 2009 Conference Report Page 4 EXECUTIVE SUMMARY On January 15th

ACCESS TO SURGERY IN BRITISH COLUMBIA

The Cutting Edge January 15-16, 2009

Access to Surgery in BC | The Cutting Edge

January 15-16, 2009 Conference Report Page 2

TABLE OF CONTENTS

Executive Summary __________________________________________________________ 4

Objectives ________________________________________________________________ 4

Panel presentations ________________________________________________________ 4

Five key conference themes _________________________________________________ 6

Introduction ________________________________________________________________ 8

Provincial Perspective ________________________________________________________ 10

BC Wait Times Strategy to enhance surgical access ______________________________ 10

Surgical Patient Registry ____________________________________________________ 11

Provincial eHealth initiatives_________________________________________________ 11

Improving surgical access in BC’s Health Authorities _______________________________ 14

Vancouver Coastal Health Authority’s Surgical Access Strategy ____________________ 14

Improving surgical access in the Interior Health Authority ________________________ 14

Canadian Pediatric Surgical Wait Times Project _________________________________ 15

Fraser Health Authority surgical access activities ________________________________ 16

Surgical access initiatives at Vancouver Island Health Authority ____________________ 16

Surgical services planning in the Northern Health Authority_______________________ 17

Learning from other provinces_________________________________________________ 19

Alberta: Addressing surgical challenges________________________________________ 19

New Brunswick: Improving surgical access _____________________________________ 19

Ontario: Improving access at Ottawa Hospital __________________________________20

Saskatchewan: surgical care network _________________________________________ 21

Saskatchewan: regional quality improvement __________________________________22

Advanced access in surgical practice ____________________________________________24

Optimizing referrals and surgical office practice ________________________________24

Implementing advanced access techniques in a surgical office _____________________25

How quality improves access __________________________________________________27

National Surgical Quality Improvement Program (NSQIP) in FHA ___________________27



Improving surgical access in the UK _____________________________________________29

The road to hell is paved with good intentions: the unintended consequences of policy initiatives_________________________________________________________________29

Moving to a “no wait” culture for elective care in England ________________________30

Experience from the UK – Making it happen ____________________________________ 31

Key themes for moving forward in BC ___________________________________________34

Next steps for British Columbia ______________________________________________34

Appendix __________________________________________________________________36

Access to Surgery Conference Planning Committee ______________________________36

Poster presentations _______________________________________________________37

List of conference participants _______________________________________________39



EXECUTIVE SUMMARY On January 15th and 16th, 2009, health care leaders involved in surgical access from across British Columbia took part in Access to Surgery in British Columbia | The Cutting Edge, a conference hosted by the BC Ministry of Health Services, in collaboration with BC health authorities and the British Columbia Medical Association. Conference participants had the opportunity to learn about and discuss innovations, strategies, successes and challenges across BC, Canada and the UK that have improved access to surgical services.

Objectives

The goal for the conference was to solicit feedback through panel and audience participation to:

Identify priorities for the provincial strategy to reduce wait times and improve access

Discuss how to apply learnings to clinical settings

Provide participants with actions to take away from the conference

Foster personal commitment to improving surgical access

Panel presentations

A series of panel presentations and discussions enabled conference participants to learn about initiatives underway in BC, other provinces and abroad to reduce waitlists and improve access to surgery.

The first panel profiled BC’s strategic approach to reducing wait times and improving surgical access with presentations on:

BC’s Provincial Wait Times Strategy to clear backlogs and improve access, which is aligned with priority areas identified in the First Ministers’ Meeting 10-Year Plan to Strengthen Health Care—hip and knee, sight restoration, cardiac, cancer and diagnostic imaging—and best practice nationally and internationally.

BC’s Surgical Patient Registry, a province-wide system that tracks patients waiting for surgery. Patient information, including data from urgency assessment tools and operating room booking systems, is entered into the registry and used by surgeons, health authorities and the Ministry to evaluate and monitor surgical wait times across health authorities.

BC’s eHealth initiatives to support an electronic health record for BC residents, including lab, drug, diagnostic imaging and public health repositories, registry projects, infrastructure to handle electronic messages, ensure security and privacy, and provide audit capability, and the deployment of electronic medical record capability to BC physicians.

In the second panel BC health authority leaders profiled a number of initiatives to improve access to surgery in the context of the broader provincial strategy:



Vancouver Coastal Health Authority’s Surgical Access Strategy, which includes a Regional Surgical Executive Council and systems for allocating operating room time and beds, based on supply and demand.

Improving surgical access in the Interior Health Authority, based on an operational review that resulted in one surgical program led by a regional surgical council.

Canadian Pediatric Surgical Wait Times Project, which has developed pediatric access targets for surgery, based on level of priority. BC Children’s Hospital participates in this national project.

Fraser Health Authority surgical access activities, which include OR scheduling analysis, region-wide expansion of a central intake and referral service for joint replacement, and a rapid surgical recovery model.

Surgical access initiatives at Vancouver Island Health Authority, including a medical and administrative co-management model and island-wide booking guidelines.

Surgical services planning in the Northern Health Authority, focused on an orthopedics expansion at Prince George Regional Hospital and a regional surgical services plan.

The third panel presented some of the challenges and successes other provinces have experienced in their efforts to improve access and reduce wait times for surgery:

Alberta: Addressing surgical challenges using a system-wide, strategic approach to overcome unacceptable wait times for joint replacement surgery.

New Brunswick: Improving surgical access with a provincial surgical care network, standardized definitions and policies, and scheduling based on clinical acuity and time on the waitlist.

Ontario: Improving access at the Ottawa Hospital with more OR, recovery, intensive care and staffing capacity, standardized care maps, and a single queue for orthopedic surgery to meet provincial targets.

Saskatchewan: Surgical Care Network and regional quality improvement, with a provincial surgical registry to track all surgeries and help book patients according to target timeframes, and regional quality improvement projects such as new musculoskeletal and bariatric surgical assessment centres, a hip and knee pathway, increased capacity and a patient safety checklist.

The next two presentations examined the interface between general practitioners and specialists, and introduced the advanced access concept to enhance surgical office practice:

Optimizing referrals and surgical office practice by measuring and forecasting demand and supply for appointments to set an access standard.

Implementing advanced clinic access for surgeons by reducing demand and backlog, planning for contingencies, and redesigning the practice model.



The next presentation showed how the American College of Surgeons National Surgical Quality Improvement Program has been used in the Fraser Health Authority to reduce length of stay by improving quality and increasing capacity.

Three presentations from the UK reviewed their efforts to reduce wait times and ensure timely access to surgery from the perspectives of a business working with government, the National Health Service, and a health care trust:

Unintended consequences of wait time policies adopted in the UK, Australia and Canada found small policy deficiencies can have large, unintended consequences, not all negative, for patients, hospitals and surgeons.

The 18-week initiative: Moving to a no wait culture in the UK, where the referral to treatment pathway was redesigned so no one has to wait longer than six weeks from GP referral to surgeon, and no longer than 12 weeks from surgeon to surgery.

Experience from the UK, where politicians brought health professionals together to produce the National Health Service 10-year plan, which set hard targets for wait times and access to change the system.

Five key conference themes

After the final presentation, a five-member panel of BC health care leaders reflected on the lessons learned at the conference and discussed five key theme areas for moving forward in BC with conference participants:

1. Build strong leadership and governance to provide direction and improve provincial integration and coordination

Establish a provincial surgical council to provide strategic advice and better coordination of surgical issues across health authorities.

Improve communication within and integration among health authorities.

2. Build an open “can do” culture to support change and innovation

Engage patients, physicians, clinicians, managers and staff so they can contribute to planning and implementation.

Use expert panels and local delivery area clinical and management input to help develop informed policies and provide advice.

Examine funding rules to increase flexibility and reward quality improvement and innovation.



3. Take a systems approach to redesign across the continuum, based on the patient journey

Capitalize on existing strengths and address weaknesses in integrating care across the continuum.

Enable consistent learning from other regions and jurisdictions and adopt ideas likely to be beneficial in BC.

Consider the patient’s journey from first referral onward. Improve the interface among GPs specialists and diagnostic services.

4. Focus on quality improvement and safety as mechanisms for improving access

Create collaborative, multidisciplinary teams and partnerships focused on improvement.

Define and meet quality outcomes to free up resources currently spent handling preventable events.

Integrate safety and quality to improve efficiency and access.

5. Develop tools to support improvement

Expand and advance the capacity of SPR to support change.

Create a mechanism to heighten awareness of and share information on innovation efforts across surgical sites.

Provide surgeons with quality SPR data and follow up on outliers.



INTRODUCTION On January 15th and 16th, 2009, health professionals—including surgeons, anesthesiologists, family physicians, nurses and managers—joined health care leaders from British Columbia, Canada and the UK to participate in Access to Surgery in British Columbia | The Cutting Edge, a conference hosted by the BC Ministry of Health Services, in collaboration with BC health authorities and the British Columbia Medical Association (BCMA).

The purpose of the conference was to discuss progress and obtain stakeholder feedback on BC’s strategy to decrease wait times and improve access to elective or scheduled surgical services. Conference participants heard about innovations, successes and challenges from across BC, Canada and the UK.

This event builds on a similar meeting hosted by the Interior Health Authority in June 2006. With province-wide participation, it was hoped this latest conference would be a catalyst to advance the provincial strategy for improving surgical access across BC.

Objectives

Conference Chair Dr. Andy Hamilton noted that the goal for the conference was to solicit input through panel discussion and audience participation to:

Identify priorities for the provincial strategy to reduce wait times and improve access

Discuss how to apply lessons to clinical settings

Provide participants with actions to take away from the conference

Foster personal commitment to improving surgical access

Audience response system

A key goal of the conference was to solicit participant feedback and make the event as interactive as possible. To achieve this goal, an audience response system (ARS) was used by the conference chair to pose a series of questions and generate discussion. The ARS enabled participants to provide immediate feedback on questions related to the conference presentations. It can highlight the audience’s diversity of opinion, elicit underlying beliefs, quantify opinion on taking action, test knowledge on a particular conference subject, and demonstrate the impact the conference had on participants.

Opening remarks

The Honourable George Abbott, Minister of Health Services

Minister Abbott acknowledged BC health authorities and the BCMA, partners in developing the conference, and welcomed national and international guests to the event. He noted that health care professionals and leaders face the challenge of matching rising public expectations for the health system with the resources available to pay for procedures. Consequently, the central question for the conference was: how can we change the way we do things now to improve access?



A shift has taken place in health care in recent years toward a growing culture of innovation. Surgical innovation and best practice from other jurisdictions can be trialed in BC, and successful practices should be implemented. BC has already achieved notable successes, such as the Richmond hip and knee project and the Centre for Surgical Innovation at University of British Columbia Hospital.

As a consequence of work done in recent years to address wait times, BC has seen improvements in many areas—hips, knees, cataracts and cancer procedures. The Surgical Patient Registry, while still in the early stages, holds enormous promise for improving efficiency and helping patients understand their process of care.

Minister Abbott noted that when progress is achieved in some areas, people will ask what the next steps are, and that much work remains to be done. Additional long term changes may be achieved as a result of discussions at the conference, leading to greater success for the health care delivery system in BC.

Dr. William Mackie, President, BCMA

Dr. Mackie noted that the conference brought together health care professionals concerned with addressing the surgical waits that patients face. From the patient’s perspective, the uncertainty of not knowing when their surgery will take place, their diminishing quality of life, and the possibility of having procedures cancelled and rescheduled can be a source of frustration.

Physicians and other health care leaders have a collective responsibility to do better. Dr. Mackie explained that the BCMA has been at the forefront of this challenge for some time, advocating for increased access to health care services through system capacity, comprehensiveness of services, and timeliness. The BCMA has worked with the Ministry of Health Services and the health authorities on initiatives to decongest emergency departments, address physician shortages, and advance multidisciplinary care. BCMA has issued two policy papers containing recommendations for improving capacity, benchmarks, management tools, accountability, funding, and access to acute care services.

The BCMA has also advocated for comprehensive care to include medical, hospital, pharmaceutical, home care, long term care and inpatient rehabilitative services, which can sometimes prevent patients from requiring surgery or speed their recovery. Dr. Mackie suggested that timeliness can be improved with maximum allowable wait times and patient care guarantees.

Collaboration among the BCMA, Ministry of Health Services and health authorities has led to the success of the Practice Support Program, which supports family physicians to adopt best practices, including advanced access, group medical visits and improved chronic disease management.

Despite system improvements, a central question remains: how can we collectively do better to address the needs of the surgical patient and improve timely access along the care continuum, from the general practitioner to surgeon to diagnostic services to the operating room and recovery? Dr. Mackie concluded by noting that this conference has the right ingredients—wisdom and experience from BC, Canada and abroad, the full spectrum of players, and the goodwill and commitment—to make a real difference for patients in BC.



PROVINCIAL PERSPECTIVE The first panel of the conference included three presentations that profiled BC’s current approach to reducing wait times and improving access to surgery.

BC Wait Times Strategy to enhance surgical access

Rebecca Harvey, Executive Director, Acute Care and Performance Accountability, Ministry of Health Services

Ms. Harvey described the Provincial Wait Times Strategy, which is a key priority for government. The strategy is aligned with the priority areas identified in the First Ministers’ Meeting (FMM) 10-Year Plan to Strengthen Health Care—hip and knee, sight restoration, cardiac, cancer and diagnostic imaging—and best practice nationally and internationally. The strategy focuses on clearing backlogs, optimizing existing capacity and expanding capacity across the province in key areas.

The population of BC and the number of surgical procedures performed in the province increased significantly between 2000 and 2008. Improvements in reducing wait times were also achieved in key surgical areas during this time. BC has taken a systems approach towards improving surgical access. The provincial strategy focuses on:

Organization and service structure – BC is incorporating evidence-based innovations into systems management and clinical practice such as the multidisciplinary OsteoArthritis Service Integration System (OASIS) and the Centre for Surgical Innovation at UBC Hospital. In addition, the Ministry of Health Services has used an expert panel process, similar to that used in Alberta and Ontario, to obtain strategic guidance from health care leaders on improving access to care for musculoskeletal patients. Initial dialogue sessions for the Surgeon Practice Support Program have been held in each health authority.

Surgical patient management - BC has developed a provincial surgical registry to improve the quality of wait time data and enable more active management of waitlists. The registry is a collaborative project involving the Ministry of Health Services, health authorities and the BCMA.

Health system accountability – The wait times strategy has been aligned with health authority performance expectations through the Government Letter of Expectations. The Ministry of Health Services has been working with Simon Fraser University to establish mathematical waitlist models, forecasting need in key surgical areas, used to develop appropriate wait time and volume targets.

Strengthening governance – BC has targeted policy and funding to support innovation, such as activity-based funding for hip and knee joint replacement in 2008/09, the $100 million Health Innovation Fund in 2007/08, and the $75 million Lower Mainland Innovation and Integration Fund in 2008/09 to help Vancouver Coastal Health and Fraser Health Authorities integrate services and programs for the Lower Mainland population.

Next steps include expanding improvements in FMM areas to other surgical specialties, examining the wait from GP to specialist, establishing new expert panels on cataract surgery and emergency room decongestion, and enhancing the public wait times website.



Surgical Patient Registry

Mr. Brian Schmidt, Senior Vice President, Provincial Services, Population and Public Health, Provincial Health Services Authority

The Surgical Patient Registry (SPR) is managed by the Provincial Health Services Authority on behalf of the Ministry of Health Services and health authorities. With more than 70 hospitals in BC using multiple booking systems and surgical procedure definitions, the registry took several years to implement. Now the registry has its first full year of data.

Operating room (OR) booking data is automatically uploaded from all hospitals for new and completed adult surgical cases, and pediatric data could be included in future. Standardized patient urgency assessment tools are completed as part of the OR booking package. SPR provides daily updates of waitlist data, and standardized waitlist reports on provincial procedure codes and data definitions. The data shows:

Who is waiting (patient demographics)

What patients are waiting for (procedure)

Where patients are waiting (hospital, health authority)

How long patients are waiting (time in weeks)

Which surgeries are postponed or cancelled and reasons why

Urgency of the patient (from the assessment tool)

SPR coordinators in each health authority have access to their registry data and summary, comparative provincial data. Currently, surgeons can access the SPR through their SPR coordinators. SPR data is used for provincial surgical waitlist reporting on the Ministry of Health Services website.

The SPR will be evaluated to ensure data is available is useful forms. The next steps include:

Producing comprehensive waitlist reports for surgeons, health authorities and the Ministry of Health Services

Enhancing the SPR database structure and logic to increase system utility and flexibility

Connecting the SPR to health authority OR booking systems on a real time basis

Provincial eHealth initiatives

Ms. Elaine McKnight, Assistant Deputy Minister, Health System Information Management and Information Technology Division, Ministry of Health Services

Ms. McKnight provided an overview of provincial eHealth initiatives that will standardize health information technology across BC and support a longitudinal electronic health record (EHR) for BC residents. These initiatives include:



“The Surgical Patient Registry is designed to support the integration of administration, planning

and decision making for surgical booking in BC.” Elaine McKnight, Ministry of Health Services

Lab, drug, diagnostic imaging and public health repositories

Registry projects to integrate client and provider demographic repositories

Infrastructure to handle electronic messages, ensure data security and privacy, and provide audit capability

The Physician Information Technology Office (PITO) project to deploy EHR capability to over 4,200 BC physicians’ offices by 2012

The first EHR release is scheduled to be deployed in March 2009, with PHSA participating in a pilot. PharmaNet, lab and public health data will begin to be integrated later in 2009. So far, 1,000 physicians have registered with PITO for EHR installation, with another 1,000 to be registered in the coming year.

The goal is to integrate the SPR with other eHealth projects so, for example, the physician’s office is connected to electronic OR booking allowing e-referrals. Significant business and technical changes are required. The process will take time and must be done in stages. Broader EHR deployment is needed to provide the foundation for integrating the SPR with surgical practices.

The SPR’s current role is primarily waitlist tracking and reporting. The intent is for this role to expand in the future to provide summary assessment feedback and, in the longer term, to include administrative and decision support for surgical booking processes. Over the next two years, the SPR will be integrated with eHealth client and provider registry services, and SPR referral and consult notes could be integrated with the EHR.

Provincial Perspective – Key discussion points

After the presentations, panel members and conference participants engaged in a dialogue on the issues raised, and the following points were discussed:

The SPR:

o Recognizing its great potential, health authorities are using the SPR and are engaged in developing reports that will be useful for physicians and managers.

o At present, the SPR does not track the wait between primary care and specialist assessment; this would be a valuable enhancement.

o The usefulness of the SPR would be improved if it could be linked to the surgical patient’s lab, diagnostic and other relevant clinical information.

o Expanding the SPR to include pediatric elective surgery cases should be considered.

Electronic health records:

o Integrating the varied and incompatible electronic platforms used by the heath authorities to create a patient record that spans the continuum of care is a challenge that the Ministry, in collaboration with others, will take up over the next few years.



Focus on wait times for hip and knee replacement:

o Health authorities and the Ministry need to closely monitor whether the emphasis on hip and knee procedures – or any other single procedure – has increased waits or otherwise affected other elective procedures.

Audience Response System results

Before the Provincial Perspective Panel, conference chair Dr. Hamilton asked participants two questions about access to surgery in BC. First: what is the current median wait time for all surgery in BC, and second: what will happen to the median wait time for surgery by 2012?

Chart #1 illustrates that the majority identified current median wait time as being between 12 and 24 weeks; SPR data as at January 15, 2009, suggests that 4.4 weeks is the correct answer.

Chart #1

What do you think the median wait across all categories included in the BC Surgical Patient Registry is?

A. Less than 3 weeks B. Between 3 to 6 weeks C. Between 6 to 12 weeks D. Between 12 weeks and 6 months E. More than 6 months

Chart #2 illustrates that the most frequent response was that there will be an improvement in wait time of 10% to 25% by 2012.

Chart #2

What do you think will happen to elective surgical wait times in BC by 2012?

A. After being booked, no one will wait more than 18 weeks

B. There will be 25% to 50% improvement C. There will be 10% to 25% improvement D. There will be no improvement E. Things will be worse



IMPROVING SURGICAL ACCESS IN BC’S HEALTH AUTHORITIES BC health authority leaders profiled a number of projects that improve access to surgery in the next panel. These efforts are part of the broader health authority surgical access strategies.

Vancouver Coastal Health Authority’s Surgical Access Strategy

Ms. Cheryl Bishop, Director, Maternity and Surgical Programs, Providence Health Care, Vancouver Coastal Health Authority

Vancouver Coastal Health Authority (VCHA) established a Regional Surgical Executive Council in 2002 and has numerous strategies underway to improve surgical access. Ms. Bishop’s presentation focused on three:

Resource Allocation Methodology (RAM) – The RAM system calculates OR allocation by surgeon, specialty and site. RAM looks at all measurable demand for OR time, including emergency, urgent, elective and specially funded, and does a gap analysis of supply and demand. RAM factors in surgical utilization during a six-month period. Unscheduled OR allocation is based on actual utilization, while the OR allocation for scheduled cases is calculated half on waitlist growth and half on wait time performance. A spreadsheet calculates OR time for each surgeon, which is converted into an OR schedule by service and site.

Bed Allocation Methodology (BAM) – BAM is used to develop daily bed quotas for each surgical specialty based on a template with average lengths of stay and history of utilization to ensure bed capacity is appropriately used. The quotas are then negotiated with surgeons, matched to the OR Master Schedule, and a slate is published for the next few months. However, this approach does not take into account daily fluctuations, such as the impact of a busy weekend or emergencies.

Dynamic Smoothing of surgical inpatient beds – The objective of this pilot at St. Paul’s Hospital is to project upcoming surgical slates to proactively adjust cases, identify discharge opportunities and plan for additional staffing or bed needs. The system looks at data on all OR cases and average lengths of stay in the coming two weeks, enabling staff to book according to bed availability and avoid cancelling patients.

VCHA has wait time targets for 90% of all surgical cases, based on either the procedure (e.g., orthopedics, plastics, ear, nose, throat (ENT), ophthalmology) or the diagnosis (e.g., general surgery, gynecology, vascular). VCHA is currently investigating an Ontario framework to establish diagnosis-based targets for all scheduled surgery, since the same procedure may be required more quickly for some diagnoses than others.

Improving surgical access in the Interior Health Authority

Dr. Mike Carter, Urologist, Kelowna General Hospital, and Co-chair, Interior Health Authority Surgical Council

Following the advice of an operational review, the IHA integrated 18 geographically dispersed surgical delivery sites into one regional program. IHA created a Surgical Review Committee to identify priority areas for integrating all sites into the regional program; three aspects of the regional program are described below:



Governance – IHA set up a 16 member surgical council with surgeons, anaesthetists, administrators, business support staff, nursing staff, information support staff, and the Senior Medical Director as executive sponsor. A core project team takes issues identified by sites forward to the council.

Pre-surgical screening – Since practice varied across IHA, a standardized evidence-based program was developed which took the responsibility away from surgeons for screening. Increased funding was added to address staffing shortages in key areas.

Information management – Dr. Carter explained how IHA had inconsistent OR booking procedures with no waitlist management. A working team implemented a standard peri-operative system, a regional booking form, regional OR booking guidelines and use of the surgical assessment tools linked to the SPR to standardize booking processes across the region.

The council achieved its goals by the end of 2006 and new priorities were developed to continue improving surgical services access. Dr. Carter noted that waitlist audits are now undertaken to identify patients waiting more than a year and assess whether these patients ought to be on a waiting list for surgery.

Canadian Pediatric Surgical Wait Times Project

Dr. Geoff Blair, Surgeon-in-Chief, BC Children’s Hospital, Provincial Health Services Authority

Dr. Blair described how paediatric surgical chiefs from across Canada met in 2004, launched the Canadian Paediatric Surgical Wait Times (CPSWT) project, and identified wait times for access to surgery as a major problem for children. In 2006, Ontario Child Health Network paediatric surgical access targets were adopted by the CPSWT as the national standard.

In 2007, a $2.6 million pilot project on wait times for children and youth was announced, funded by the federal government. Stage one of the project focused on developing a database to record paediatric wait times in six priority areas: cardiac surgery, cancer surgery, neurosurgery, strabismus surgery, scoliosis surgery, and dental surgery. The goals were to apply access targets across all 16 academic paediatric health centres in Canada, determine how many patients were waiting within and beyond the target window, share knowledge to enhance network connections, and develop a clinical pathway guideline for cancer surgery. Clinicians from across Canada met to revise access targets, now known as the Paediatric Canadian Access Targets for Surgery (P-CATS). Dr. Blair noted the potential to merge the P-CATS system with BC’s SPR.

Dr. Blair also noted that translating these ideas into action required leadership from CEOs and chief surgeons, governance structure, alignment with provincial health ministries, information technology tools, site coordinators and weekly conferences. Developing standardized data was also important.

In 2008, stage two of the CPSWT project received $9.2 million in funding from the federal government. Data collection will expand from six to eleven surgical areas and will include select community hospitals. The project will look at surgical indications and OR performance.



Data for BC’s Children’s Hospital (BCCH) shows wait times for spine and cardiac surgeries exceed the targets. BCCH uses a dynamic block scheduling tool which can do simulations to assess performance changes, and has developed a priority wait list tool that allows the medical office assistant to automatically book patients and populate the waitlist.

Fraser Health Authority surgical access activities

Mr. Steven Kabanuk, Surgical Services Project Director, Fraser Health Authority

Typical measures of access include wait times relative to targets, surgical volumes, case rates, cancellations, postponements and length of stay. However, Mr. Kabanuk suggested that, by focusing on quality of care and patient outcomes, access and system efficiency can be improved.

Mr. Kabanuk explained that in Fraser Health Authority (FHA), each hospital is managed independently, and a fully integrated program management model has yet to be implemented. Current improvement initiatives in FHA include:

Analysis – FHA has been analyzing OR scheduling to reduce cancellations and postponements, assessing urgent OR capacity requirements, piloting bed forecasting software, allocating new cataract cases based on case rates, and jointly analyzing FHA/VCHA “long waiters.”

Interdisciplinary service redesign – A central intake and referral service for total joint replacements is being implemented at Chilliwack General Hospital and will be expanded FHA-wide.

Capacity – Between 2007 and January 2009, hip and knee surgeries completed within the provincial 26 week target increased, from less than 50% to 77% for hips and to 68% for knees. While cataract surgery capacity increased 40 % over three years, improvement in meeting wait time targets has been elusive.

Quality and safety – A rapid surgical recovery model for cardiac surgery was modified for general surgery at Royal Columbian Hospital. A Surgical Safety Collaborative has reduced surgical infections from 4-8% to less than 1% in two years. FHA has participated in the National Surgical Quality Improvement Program; this has helped reduce length of stay and increase access, and will be expanded across the authority, subject to funding.

Surgical access initiatives at Vancouver Island Health Authority

Ms. Eileen Goudy, Director, Anaesthesia and Surgical Services, Vancouver Island Health Authority

Vancouver Island Health Authority (VIHA) has used a co-management model with medical and administrative leaders from across the health authority working together to address surgical access issues. Ms. Goudy described a number of projects currently underway in VIHA:

“Surgical access: patients’ ability to access the resources to obtain surgery when and where needed.”

Steve Kabanuk, Fraser Health



Improving waitlist management – VIHA created a Manager of Booking and Waitlist Management. Eight sites work with surgeons’ offices to ensure patients are ready to accept a surgical date. Island-wide booking guidelines were developed with surgeons, and waitlists are updated and monitored in collaboration with physicians’ offices.

Surgical informatics – VIHA created a Manager of Surgical Informatics to ensure the SPR was implemented island-wide; standardized electronic booking for all ORs allows the reporting of comparable waitlist data.

Standardized order sets – The surgical program developed standardized order sets for pre- and post-operative care to improve patient safety and clinical outcomes.

Pre-admission review – VIHA reviewed cases, staffing roles and functions, and pre-admission clinic processes. Standardized roles and functions are being trialed in one site and lessons learned will be applied to others.

Surgical quality councils – A surgical executive quality council sets quality priorities and reviews local surgical council minutes.

OR practice group – This group has examined best practices and policies related to surgical access.

Site visits – The surgical executive team implemented regular visits with surgical leadership at every site to review data, quality councils, capital equipment projects and surgical informatics, and to set targets.

Surgical services planning in the Northern Health Authority

Mr. Sean Hardiman, Chief Liaison Officer, Health Authority Manager, Northern Health Authority

Mr. Hardiman explained that the Northern Health Authority (NHA) plans to expand orthopedics at Prince George Regional Hospital (PGRH) and develop a surgical services plan. A change in arthroplasty funding and a growing orthopedic waitlist were the drivers for change. NHA reviewed current services and capacity at PGRH, and initiated planning to expand arthroplasty cases. One challenge the community faces is recruiting surgeons, anaesthetists and rehabilitation therapists.

The first phase of the expansion adopted the Richmond model, with two orthopedic surgeons and a dedicated OR and recovery unit. The model uses a four-day care plan and early discharge. Optimization clinics were launched as well.

Care North is the primary health care strategy in NHA to create Integrated Health Networks with providers working as a team. Phase two of the arthroplasty expansion will improve the link between primary care and surgeons, using the OASIS model, with a single referral resource for GPs and an arthroplasty and osteoarthritis clinic.

The expansion has highlighted the need for a more comprehensive approach to surgical services planning. To achieve accreditation as a regional trauma system necessitates a coordinated approach to surgical services.



As a result, NHA has begun examining current surgical practices, population needs, and human resources in each health service deliver area to improve the region-wide surgical program. A plan should be in place by the end of March 2009.

Improving Surgical Access in BC – Key discussion points

After the presentations on behalf of BC’s health authorities, panel members and conference participants engaged in a dialogue on the issues raised, and the following points were discussed:

Coordination across health authorities:

o Although a tremendous amount of good work is occurring in BC’s health authorities to improve access, activities do not appear to be well coordinated across the province; some seem to be going in differing directions and not aligned with the government’s strategy.

o Employing a consistent approach to improving access across all health authorities is an important objective. Ideally, this Access to Surgery conference will serve as a positive step toward communicating differences and aligning efforts.


Before the presentations from BC’s health authorities, conference chair Dr. Andy Hamilton asked participants about their perceptions on variations in wait times across the province. As outlined in chart #3, the majority agreed or agreed strongly that there is a significant difference in wait times across BC’s hospitals.

Chart #3

To what extent do you agree with the statement: I think there is significant difference in wait times among different health authorities and hospitals?

A. Strongly agree B. Agree C. Disagree D. Strongly disagree E. Don’t know

Following the health authorities’ presentations, Dr. Hamilton asked if conference participants had a better understanding of progress on wait time improvement across BC’s health authorities and most said they did, as illustrated in chart #4.

Chart #4

To what extent do you agree with the statement: I now understand better the progress across all health authorities on surgical wait times?




LEARNING FROM OTHER PROVINCES The third panel presented some of the challenges and successes other provinces have experienced in their efforts to improve access to surgical services.

Alberta: Addressing surgical challenges

Dr. Chris de Gara, Professor of Surgery and Associate Dean, Continuous Professional Learning, University of Alberta

Access to surgery problems are resource-based; however, occasionally it is the surgeons themselves that are part of the problem, rather than the solution.

Dr. de Gara outlined some of the access issues, highlighting bariatric, joint and prostate cancer surgery in Alberta as examples:

The province has 50,000 to 75,000 morbidly obese residents. Gastric bypass surgery is a cure and 2,500 patients are waiting, but only five surgeons perform the procedure and can handle about 200 cases a year. Laparoscopic gastroplasty would be a less expensive but effective option, with fewer complications. General surgeons could handle some of the cases. Dr. de Gara highlighted how sound infrastructure—regional weight-wise clinics, trained technicians, a business plan, and buy-in from surgeons and government—would be required to get general surgeons involved.

Prior to 2005, many patients were experiencing unacceptable wait times for joint replacement surgery. The Alberta Hip and Knee Project was developed as a pilot to test a redesigned care path for total hip and knee replacement patients, by streamlining the orthopedic surgeon role across the continuum of care. Patient evaluation is done by GPs and physiotherapists, triage is done by nurse practitioners, and peri-operative care is done by hospitalists and GPs, freeing surgeons to focus on the surgery. The referral-to-seen wait went from 21 weeks to 21 days, seen-to-surgery from 58 to 7.5 weeks, and length of stay from 6 to 4.7 days.

Almost 2,000 people in Alberta develop prostate cancer each year. There are a number of treatment options—open, laparoscopic or robotic surgery; radiotherapy, which is probably equivalent to surgery; and taking a wait and see approach. With a lower case fatality for this cancer, a lot of men are likely receiving treatment they may not benefit from. Robotic surgery is more expensive, slower and lacks evidence to show it achieves better outcomes.

Dr. de Gara noted that waitlist reduction should be addressed using a system-wide, strategic approach, balancing health care and surgeons’ needs.

New Brunswick: Improving surgical access

Ms. Kathy Bell, Health Care Consultant, New Brunswick Department of Health

New Brunswick has two regional health authorities, 16 surgical centres and about 240 surgeons. Ms. Bell outlined how the province focused on three areas to improve access to surgery:

Process improvement – New Brunswick set up a surgical care network and invited surgeons to participate. The philosophy was to be inclusive for all committees, and the participation of surgeons has been very good. A clinical acuity model and standard definitions for wait times, case times, delay codes and procedure names were developed.



OR governance committees developed standardized policies that may vary operationally at each site. Surgery scheduling is based on clinical acuity and length of time waiting for surgery, with OR time specifically booked for long waiters. A review of flash sterilization and the required number of instruments was carried out to promote best practice. It is hoped that costs can be reduced by establishing appropriate stock levels and savings redirected toward performing more procedures. A provincial pre-operative screening initiative was put in place to ensure that 100% of scheduled patients would be screened for surgery. This initiative ensures that patients receive the clinical testing and patient teaching that they need in order to prepare them for surgery.

Capacity enhancement – More nurses, technicians, materiel management coordinators, clerical staff, business and access managers and IT staff were hired across the province and additional equipment was purchased.

Technology development – A new provincial surgical access registry was developed, based on consultation with BC and Saskatchewan. The registry provides real time data, has live interfaces with various systems and requires no duplicate entries. Standardized and ad hoc reports facilitate a data driven approach. The data in the registry is used for scheduling patients and for allocating OR time.

Registry reports are also used for the New Brunswick public website, www.surgerynewbrunswick.ca. Since the registry went live in January 2008, the median wait time for all surgery went down 24%, the median wait for cancer surgery went down 50%, and the number of patients waiting 12-18 months and longer than 18 months both decreased 27%.

Ontario: Improving access at Ottawa Hospital

Dr. Jeff Turnbull, Chief of Staff, The Ottawa Hospital

Ontario has a population of 12 million, six academic health sciences centres and 14 recently established Local Health Integration Networks (LHIN). The Ottawa Hospital is the health science centre for the Champlain LHIN with its three campuses, 964 beds, 42 operating rooms (OR) and it performs 101 elective surgeries per day. It is one of the largest hospitals in Canada and is recognized as one of most efficient in Ontario.

Dr. Turnbull described how a key challenge has been the efficient use of community hospitals. Many patients in the area go to The Ottawa Hospital, when the community facility 20 minutes away may have unused capacity. He noted that efforts among all regional hospitals need to be better coordinated to address occupancy issues at The Ottawa Hospital, which consistently experiences occupancy rates exceeding 100%. Dr. Turnbull believes that the current utilization of Alternate Level of Care beds will have to be reduced to address this issue. Further, with specific programs targeted to reduce wait times, there was not a significant reduction in surgical cancellations and other wait times did not decline, highlighting the complexity of the access issue. Some unintended consequences of increased occupancy may be higher infection rates associated with high occupancy, less than stellar patient satisfaction, stressed staff, higher readmission rates, and less time for educational programs.

“It doesn’t matter how many people are on the waitlist. What matters is how long people

are waiting and what they’re waiting for.” Kathy Bell, New Brunswick Department of Health



The Ontario strategy to address wait times stresses access to MRI and CT scans, emergency, cataracts, general surgery, orthopedics (knees/hips) and cancer surgery. To meet provincial targets, the Champlain LHIN has focused on system redesign. Dr. Turnbull described how The Ottawa Hospital has focused on two areas:

Capacity – The hospital has 10 more ORs now than a decade earlier, increased Post-Anaesthetic Care Unit and Intensive Care Unit (PACU/ICU) capacity and observation units, increased staff, developed an anaesthetic assistants program, added more surgeons, and created overnight stay units to take more patients.

Efficiency – The hospital has been the most efficient in many areas in the province. Volumes were variable, so OR time was redistributed to reduce rapid increases and drops, resulting in fewer cancellations. A surgical information management system showed when procedures were running late and why. Other initiatives included standardizing over 50 care maps; same day admit/early discharge units; a patient flow monitor to move people across silos; a single queue for orthopedic surgery procedures, although patients can wait longer for a specific surgeon if they choose; emergency surgery slots during the day; four joint rooms; common governance for surgery, ICU, PACU and diagnostic facilities; aggressive daycare activity; and investments in technology.

Saskatchewan: surgical care network

Mr Ron Epp, Surgical Registry Manager, Government of Saskatchewan

The Saskatchewan Surgical Care Network (SSCN) was created in 2002 to advise the Minister on how to provide timely, coordinated and appropriate surgical care for all Saskatchewan residents.

The committee is comprised of representatives from general practice, surgery, regional and Ministry administration and regulatory bodies; patient representation will be added. Its Surgical Services Subcommittee, comprised of a surgeon from each service, plays a clinical advisory role. The Regional Operations Advisory Subcommittee, made up of OR managers and directors, oversees the ongoing operation and development of the registry.

The SSCN’s surgical registry tracks all surgeries, produces detailed reports to help manage daily patient flow, and provides real-time information to administrators at all levels of the system. The registry uses clinical priority scoring tools to assess each patient’s relative need for surgery. The urgency score, used in conjunction with target time frame, allows the systematic booking of patients based on their relative need.

Data quality policies and IT solutions have been established to ensure the data stays clean, by identifying duplicate bookings, patients with missing data and patients that have died.

“Improving access requires organizational commitment, data to support decisions, physician

engagement, leadership, a focus on quality, regional partners and systems thinking.”

Dr. Jeff Turnbull, Chief of Staff, Ottawa Hospital



Current SSCN initiatives include designing clinical pathways for hip and knee, spine care and urology education; developing a Physician Referral Guide Website to assist physicians refer their patients to an appropriate specialist; the inclusion of confirmed and suspected cancer surgery data; planning surgical centres that focus on less complicated, high-demand procedures. The SSCN hopes to use registry data to assist with demographic forecasting to guide program development and resource allocation.

The SSCN publicly reports surgical wait times, as well as Saskatchewan’s progress meeting both pan-Canadian wait time benchmarks for surgery and provincial target time frames for surgery.

Saskatchewan: regional quality improvement

Mr. Trent Truscott, Executive Director of Surgery, Regina Qu’Appelle Health Region

Mr. Truscott talked about improving access to surgery from a regional perspective. He described how the Regina Qu’Appelle Health Region set a goal to shift from a culture focused on maximum throughput with acceptable outcomes to maximum capacity with exceptional outcomes, by implementing several projects:

Multidisciplinary musculoskeletal centre – Patients are seen in a clinic setting and assessed by a multidisciplinary team. Of the 200-plus patients who participated in the pilot project, only 19 were referred to a surgeon. The remaining patients received other treatment, such as physiotherapy. A survey found 97% of patients rated the service as good to excellent.

Hip and knee pathway – A business case for the pathway was developed with orthopedic surgeons in the region. All orthopaedic surgeons in the region supported the development of a pathway, including the implementation of a multidisciplinary musculoskeletal assessment centre. A pilot project using the pathway showed length of stay dropped by a half day at one hospital and 3.3 days at another. Another goal was to increase pre-operative education attendance from 30% to between 80% and 90%. An 85% attendance rate was achieved in a trial, and length of stay for educated patients was one day shorter.

Bariatric surgical assessment centre –The business case for this multidisciplinary centre was developed with a bariatric surgeon, and a pilot project is underway. Patients participate for six months to determine if they meet the criteria for surgery.

Increasing surgical system capacity – This project has three components to expand surgical capacity in the region: an ambulatory surgical centre, increasing overall capacity, and renewing business processes. Surgeons and anaesthesiologists have participated on the steering committee, program planning committee, surgical working group and change management committee.

Patient safety initiative - A Surgical Program Quality Improvement and Patient Safety Committee was developed, made up of frontline staff and physicians. The committee reports to the Surgical Program Executive (which does not take direction from the committee), and is currently implementing the World Health Organization (WHO) patient safety checklist.



Learning from Other Provincial Strategies – Key discussion points

After the presentations by speakers from other Canadian jurisdictions, panel members and conference participants engaged in dialogue on the issues raised, and the following points were discussed:

Focus on access targets for FMM identified procedures:

o Because of their special status, FMM procedures like hip and knee replacement are not usually among the surgeries affected when cancellations are required in any given hospital.

Collection of standardized data:

o All Local Health Integration Networks (LHINs) in Ontario collect and report the same wait time data despite the fact that different surgical management information systems are used in the hospitals. Can this be accomplished in BC?

Use of scoring tools to assess patient urgency:

o Standardized assessment tools are used in several Canadian jurisdictions; they take into account the urgency of a patient’s condition as well as the impact of that condition on a patient’s quality of life and the ability to live independently.

o The Saskatchewan Surgical Care Network combines a target wait time with patient urgency and factors in procedure urgency profiles. The system is designed to give the sicker patients access first. There is consistent use of the tools across the province and all patients are scored in the same way.


Having heard speakers from Alberta, Saskatchewan, Ontario and New Brunswick, Dr. Hamilton asked conference participants about the transferability of some of these ideas and approaches for improving access to surgery. Chart #5 shows that virtually all participants agreed that BC could learn from other jurisdictions.

Chart #5

To what extent do you agree with the statement: Many elements of these approaches can be successfully adapted in BC to achieve similar results?




ADVANCED ACCESS IN SURGICAL PRACTICE These presentations examined the interface between GPs and specialists, and introduced the advanced access concept to enhance surgical office practice.

Optimizing referrals and surgical office practice

Dr. Alexandra Tcheremenska-Greenhill, Associate CEO, BCMA

The SPR currently captures wait time data between the surgeon and OR. Dr. Tcheremenska-Greenhill noted that, in the future, capturing data between the GP and surgeon could better inform planning and decision making.

At the Institute for Healthcare Improvement (IHI), Mark Murray, MD, and Catherine Tantau, RN conducted research into the etiology of wait times. They demonstrated that wait times result from a complex combination of variation and mismatch. Based on their insights, a model for rapidly improving access was developed called “open “or “advanced” access. Their method for success, which has been demonstrated to work in many settings, starts with setting an access standard, most often to offer an appointment with a surgeon from the practice on the same day, and a surgical date within five days of recommending a surgical intervention.

Dr. Tcheremenska-Greenhill explained that, 99% of the time, the number of available appointments is greater than the number of calls. When a surgical practice is asked to track data, a lot of mismatch is discovered. For example, one patient showing up late for an appointment can disrupt the entire day. When the available slots are calculated, a 20% gain can be achieved in most cases, with the potential to transform the practice overnight.

Most schedules are full, so people miss lunch or postpone work when extra demands arise. Dr. Tcheremenska-Greenhill suggested calculating how many unplanned events happen in 15-minute increments during a weeklong schedule, and averaging it out per day. Scheduling this average time each day to deal with the unexpected creates catch up time and prevents backlogs.

Surgical offices need to measure and forecast delay, demand and supply for appointments and procedures over a year to identify patterns, and then work on diminishing demand. Call the GPs and ask them to do tests before sending referrals. Develop a referral protocol and practice support team. Educate the medical office assistant on how to schedule appointments so complex patients are not booked one after the other. With this approach, one orthopedic practice had the average referral wait time drop from 70 days to seven days in less than a year.



Implementing advanced access techniques in a surgical office

Dr. Mark Ogrady, Otolaryngologist and Chief of Surgery, Regina Qu'Appelle Health Region, Saskatchewan

The length of a waitlist is a function of several factors which can be managed. Dr. Ogrady noted that measures to change his mix of patients, as well as becoming more efficient, were needed to reduce a backlog. He described his personal journey to reducing his office wait time and the challenges of getting back on track when circumstances change.

There are two types of demand: external demand results from GP referrals, while internal demand builds when a specialist sees a patient and arranges a follow up appointment. Extending the period for a follow up appointment is one method of reducing internal demand. Another is to have patients call two weeks prior to book their next appointment, opening hours of un-scheduled time to see patients. These measures all help reduce new patient queues. Health care providers routinely put some patients in more quickly, deferring the care of someone else. In some situations, this type of priority must occur, but queue jumping must be kept to a minimum. Strategies to deal with patients who wish to get in sooner, but whose clinical condition does not warrant this, include the use of an accurate cancellation list.

Dr. Ogrady suggested it is important to plan for contingencies by tracking how schedules are disrupted, and then redesigning the approach to proactively deal with issues. Accurate data is vital to support informed decisions. Change management is crucial, and patient satisfaction surveys can provide valuable feedback on service quality.

Advanced Access in Surgical Practice – Key discussion points

After the presentations from the speakers, panel members and conference participants engaged in dialogue on the issues raised, and the following issues were discussed:

Need for improvement across continuum of care:

o One challenge to improving office efficiency is the mismatch between the amount of OR time a surgeon has and the number of cases waiting.

o In addition to the surgeon’s office, increasing efficiency has to be done in the OR as well. There is room for improvement in most surgical settings, across the whole continuum.

Professional satisfaction in the surgeon’s office:

o When a practice works through its backlog of cases, professional satisfaction increases, staff feel happier, and working can become more enjoyable.

“A waitlist is not a demand problem, it’s a

backlog problem.” Dr. Mark Ogrady, Regina Qu'Appelle Health Region




The next two charts show how participants’ responses differed before (#6) and after (#7) the presentations by Drs. Ogrady and Tcheremenska-Greenhill on the application of advanced access techniques in the surgeon’s office. Conference chair Dr. Hamilton asked for a response to the statement: a surgeon can use advanced access to reduce office wait time for a referral from primary care, from over one year to just over one week.

Chart #6

To what extent do you agree with the statement: A surgeon can use advanced access to reduce office wait time for a referral from primary care, from over one year to just over one week?


Comparing Chart #6 to #7, it appears that many became convinced of the potential value of advanced access in a surgical office setting.

Chart #7

Now, having heard the presentations, to what extent do you agree with the statement: A surgeon can use advanced access to reduce office wait time for a referral from primary care, from over one year to just over one week?




HOW QUALITY IMPROVES ACCESS This presentation examined the link between quality improvement and increasing access to surgery.

National Surgical Quality Improvement Program (NSQIP) in FHA

Dr. Peter Doris, General Surgeon, Surrey Memorial Hospital

Over 200 hospitals have participated in the National Surgical Quality Improvement Program, two from Fraser Health and the rest in the United States. The program focuses on quality improvement outcomes. The benefits included identifying quality improvement targets, improving patient care and outcomes and decreasing costs. The data showed that post-operative complications increased length of stay and costs. Dr. Doris presented the outcomes of a June 2008 NSQIP report which showed general/vascular surgery outcomes at Surrey Memorial (SMH) relative to other participating hospitals in the program:

The mortality rate was comparable, with most hospitals close to a 2% rate

30-day post-operative morbidity was the worst of all the hospitals

SMH was fourth worst for post-operative pneumonia and urinary tract infections (UTI)

SMH was third worst for surgical site infections (SSI)

The results were used to identify opportunities for improvement, develop solutions and monitor the impact. The Six Sigma quality improvement model has been used to improve performance. SMH formed teams to address three problem areas: pneumonia, UTIs and surgical site infections. SMH has been learning about improving safety systems from the airline industry, where team resource management is used to flatten hierarchy. To achieve this goal, SMH puts team members’ first names on a white board in the OR and articulates safety and quality as goals. In addition, the NSQIP involves contacting patients 30 days after surgery for feedback.

SSIs have been found to dramatically increase length of stay by 10 to 20 days. Since reducing SSIs could open these days for another patient, SMH developed SSI evidence-based best practices. SMH has also begun to examine the impact of emergency delays on post-operative complications and length of stay.

A study in the New England Journal of Medicine reported that hospitals were able to reduce SSIs 3.4% just by using the WHO surgical safety checklist. So SMH posted the checklist on laminated cards in each OR, and the team goes through the list of questions and debriefs each procedure. The goal is quality surgery which reduces complications, length of stay and readmission rate, enhancing access for other patients as a result.

The latest semi annual report from NSQIP for SMH indicates that such programs have resulted in decreases in mortality (33%), morbidity (24%), SSI (22%), UTI (33%) and pneumonia (46%). Access was improved as there was an associated decrease in average surgical LOS.

“Measuring surgical outcomes enhances access.”

Dr. Peter Doris, SMH




Dr. Hamilton invited response to a question about the relationship between quality assurance and improved surgical access. Graph #8 shows that the majority of participants agreed or strongly agreed that addressing quality can improve access to surgery.

Chart #8

To what extent do you agree with the statement: Addressing quality on its own can improve access?




IMPROVING SURGICAL ACCESS IN THE UK This panel reviewed initiatives in the UK to reduce wait times and ensure timely access to surgery from three perspectives: an international consultant who has worked with a number of governments, the National Health Service (NHS) executive, and the CEO of a foundation trust.

The road to hell is paved with good intentions: the unintended consequences of policy initiatives

Mr. Anthony Thompson, CEO, the Checklist Partnership, Shropshire, United Kingdom

Mr. Thompson provided a short overview of approaches adopted in England, Scotland, Australia and Canada. His survey found small policy deficiencies can sometimes have large consequences for patients, hospitals and surgeons, both positive and negative. Mr. Thompson outlined a number of policy options to address wait times and their consequences:

Having no policy – Pressure was building on the health service in England during the 1980s to address poor outcomes for some long waiters, so having no policy was not a viable option. In these circumstances, funding went to the least well managed services, with well managed ones losing out.

Funding initiatives – Money can be targeted to treating long waiters, but this approach can create an incentive to have long lists to get extra money, and intentionally reward hospitals with long waiters. In 1997, the Labour government came into power pledging to take 100,000 people off the waiting list and reduce the maximum wait for admitted patients, originally from 18 to 12 months, then to six months and 13 weeks for outpatients. A plan was then developed to have referral to the initiation of treatment take no more than 18 weeks.

Reducing the list size – In the UK, hospitals felt forced to reduce lists by fiscal year end, so many electives were performed by March 31 each year. By April and May, the list of heavy cases ballooned out. In Glasgow, just 25 of 200 orthopedic patients were put on the list each month to avoid negative publicity, which meant OR and bed capacity were not being properly planned.

Maximum wait time targets – Maximum wait time targets are simple and fair, but do not focus on clinical quality or patient experience. Targets can also create a climate of fear, with some CEOs fired for having long waiters and some cheating (like the deferred list in Glasgow). Nevertheless, hospitals were pressured to examine systems, manage patient pathways and processes, and plan professionally. A number of approaches can be used:

- An overarching target for all patients to be treated within a specified time frame.

- Proportional targets such as treating 90% of hip and knee patients in six months. This approach is the same as a policy not to treat 10%, yet these patients have the same clinical priority as most of the 90%.



- Procedure targets such as hips, knees and cataracts. The impact on other procedures should be quantified. Ontario statistics show wait times up 24% for non-cataract and 6% for non-hip/knee procedures.

- Patient categorization, Australia’s system, puts patients in categories 1, 2 or 3 for 30 days, 90 days or 12 months, based on clinical priority. But this system was subjective and actual cases treated did not coincide with the categories. As a result, patients now have to be treated in chronological order in each category. Individual exceptions are allowed, but must be explained.

Policies should be simple and based on clinical priorities and strong numerical analysis. For Mr. Thompson, three principles are important: protect resources for clinical priorities, higher priority patients should have shorter waits, and similar priority patients should be treated in chronological order.

Moving to a “no wait” culture for elective care in England

Ms. Philippa Robinson, National Implementation Director, 18 Weeks, Department of Health, London, UK

The Department of Health has implemented an 18 Week policy for the National Health Service (NHS). Within the NHS, 10 health authorities provide strategic leadership and local health communities, which include hospitals and trusts, commission and deliver health services. Ms. Robinson’s presentation provided an overview the 18 Week initiative and how it was implemented.

Patient surveys in 2004 showed one in four people felt they should have been treated sooner. Stories of patients waiting for treatment moved the issue up the political agenda, and waitlist initiatives were thought to be the answer. However, planning on averages and historic activity, not capacity, demand and variation, led to queues, and hidden waits like diagnostics undermined progress. Access targets were not perceived as connected to quality and safety.

The approach changed to focus on the overall referral to treatment (RTT) pathway. 18 Week pathways are measured from referral to first treatment, and include all the stages leading up to treatment: outpatient appointments, diagnostic tests (which were not previously measured) and inpatient procedures.

Ms. Robinson noted that some misconceptions were encountered during implementation. It was originally thought that the 18 week pathways could be achieved by reducing waits at each stage of treatment, through simple process improvements at each stage, or by solving diagnostic waits alone. However, the NHS realized the entire pathway had to be redesigned; implementing the 18 Week program needed to involve system transformation. The NHS had to implement IT infrastructure to electronically track patients across the entire pathway, and four pillars were created to support redesign:

Engage clinicians, managers, staff and patients in solving the challenges to create a no delay culture

Enable service transformation by providing clear responsibilities, aligned incentives and proven solutions

Develop robust performance measurement and management systems to assure and sustain delivery

Offer intensive support by sharing good practice guides and introducing a delivery support program



NHS developed 43 multi-professional pathways, new and expanded workforce roles, IT advances, and tools designed to reduce delays.

Previous initiatives to tackle long orthopedic wait times produced short term results, so the NHS published good practice guides to bridge the gap between knowledge and implementation. Intensive team support was provided to help groups sustain 18 Weeks. In terms of results, Ms. Robinson reported that by March 2007, most orthopedic patients were treated in 25-40 weeks; by October 2008, the wait changed to 11-16 weeks. Overall, 90.6% of admitted patient pathways and 96.3% of non-admitted patient pathways are now under 18 weeks. Very few patients wait over six weeks for diagnostics.

Experience from the UK – Making it happen

Dr. Mark Goldman, CEO, Heart of England Trust, Birmingham, UK

Dr. Goldman’s presentation provided an overview of UK initiatives to address wait times from the Trust perspective. He explained that the public clamour for improvement in the NHS became overwhelming in the early 1990s. The political response was to increase spending and address waitlists. The Conservative government of the day introduced the Patient's Charter, which guaranteed admission to treatment in two years, and was extended in 1995 to guarantee a maximum wait time of 18 months.

In 1997, the Labour party promised to reduce waitlists by 100,000 and implement maximum inpatient waits. Cataracts and cardiac surgery would be priorities. Politicians brought health professionals together to produce the NHS 10-year plan, which set targets for wait times and access. The government announced an extra £1 billion for the NHS in England in 1998/99, and a commitment to bring UK funding up to European funding standards by 2010/11.

Systems reform included the introduction of tariff payments, which are fixed prices for NHS procedures and follow the patient. As a result, patients could choose to go to their local hospital or anywhere else in the country. The government offered the private sector “tariff-plus” payments and contract commitments over several years to add capacity, encourage diversity of provision and support patient choice.

Between 2000 and 2004, the number of outpatients waiting over 13 weeks dropped significantly; so did inpatients waiting over six months. The diagnostic pathway was also redesigned to cut long waits. By 2007, the average wait for inpatient treatment was about seven weeks, with 75% of inpatients waiting less than 13 weeks.

Some changes in the UK include generic referrals coming into groups of surgeons, standardization in theatres and on wards, same day admissions, an increased proportion of day surgery and pre-op assessments done by nurses.

Dr. Goldman noted that physicians agreed to participate as clinical team leaders responsible for achieving targets; this resulted in better outcomes and reduced waiting times for patients.

The NHS has now shifted to focus on quality and safety, learning from Jönköping, Sweden, which has achieved exceptional quality and resource efficiency in the country and is sharing its business plan.

“Access is no longer a problem. The NHS transformed the system by working with

clinical teams to transform clinical pathways and align demand and capacity.”

Dr. Mark Goldman, Heart of England Trust



Improving Surgical Access in the UK – Key discussion points

After the presentations by speakers from the UK, panel members and conference participants engaged in dialogue on some of the points raised, and the following issues were discussed:

The use of procedures versus diagnoses to categorize patients:

o Surgical procedures are applicable to a variety of clinical situations of varying urgency, from cancer to a more benign condition; ideally, patient prioritization systems should take the diagnosis and the required procedure into account.

Resources to support system change and wait time reduction:

o Part of the very impressive improvements to access in the NHS is attributable to gains in productivity and not to additional funding. A central issue becomes how to better use existing resources.

Comprehensive approach

o There is merit in looking at health care reform from the pathway perspective, as opposed to focusing on individual components of the patient journey.

Quality, access and safety:

o Productivity improvements are based on the belief that doing the right thing at the right time increases quality and safety and results in improved access.

Human resources:

o Systemic change at the NHS was a lot of work for a lot of people, requiring incredible flexibility in the workforce. There was no great difficulty with the non-physician unions. Communication with the medical community is very important.

Leadership:

o Committed and consistent leadership from the highest levels was responsible for the sustained effort and ultimate success of the 18 Weeks initiative.




In advance of the presentations by Mr. Thompson, Ms. Robinson and Dr. Goldman, conference chair Dr. Hamilton asked participants about their familiarity with the 18 Week referral to treatment pathway. Chart #9 shows that the majority disagreed with the statement: I am very familiar with the 18 week initiative.

Chart #9 To what extent do you agree with the statement: I am very familiar with the NHS 18 week initiative? A. Strongly agree B. Agree C. Disagree D. Strongly disagree E. Don’t know

After the three talks on reforming access to surgery in the UK and general discussion, Dr. Hamilton asked participants about the extent to which NHS-style reforms are applicable in BC. Chart #10 shows that most participants agreed that elements of the NHS approach could be successful here in BC.


Chart #10 To what extent do you agree with the statement: Many elements of the NHS approach can be successfully adapted in BC to achieve similar results? A. Strongly agree B. Agree C. Disagree D. Strongly disagree E. Don’t know



KEY THEMES FOR MOVING FORWARD IN BC

Next steps for British Columbia

Panel members: Dr. Jeff Coleman, Chief Operating Officer, VCH; Ms. Wendy Hill, Assistant Deputy Minister, Health Authorities Division, Ministry of Health Services; Dr. Mike Stanger, BCMA Representative to the Provincial Surgical Services Steering Committee, and Council Chair, Society of Specialist Physicians and Surgeons; Dr. Alexandra Tcheremenska-Greenhill, Associate CEO, BCMA; and Dr. Les Vertesi, Department of Emergency Medicine, Royal Columbian Hospital

Conference chair Dr. Andy Hamilton asked panel members to reflect on the conference proceedings and, drawing on their own professional experience, identify key themes or focus areas for improving surgical access in BC. Panel members identified five key themes, with suggested actions to support moving forward:

1. Build strong leadership and governance to provide direction and improve provincial integration and coordination

Establish a provincial surgical council to provide strategic advice and better coordination of surgical issues across health authorities.

Improve communication within and integration among health authorities.

2. Build an open “can do” culture to support change and innovation

Engage patients, physicians, clinicians, managers and staff so they can contribute to planning and implementation.

Use expert panels and local delivery area clinical and management input to help develop informed policies and provide advice.

Examine funding rules to increase flexibility and reward quality improvement and innovation.

3. Take a systems approach to redesign across the continuum, based on the patient journey

Capitalize on existing strengths and address weaknesses in integrating care across the continuum.

Support learning from other regions and jurisdictions and adopt ideas likely to be beneficial in BC.

Consider the patient’s journey from first referral onward. Improve the interface among GPs, specialists and diagnostic services.

4. Focus on quality improvement and safety as mechanisms for improving access

Create collaborative, multidisciplinary teams and partnerships focused on improvement.

Define and meet quality outcomes to free up resources currently spent handling preventable events.

Integrate safety and quality to improving efficiency and access.



5. Develop tools to support improvement

Expand and advance the capacity of the SPR to support change.

Create a mechanism to heighten awareness of and share information on innovation efforts across surgical sites.

Provide surgeons with quality SPR data and follow up on outliers.


After the final panel presentations and discussion, Dr. Hamilton posed concluding questions to the conference participants. First, he repeated the question asked at the beginning of the conference about the outlook for surgical wait times in 2012, and then he asked about mechanisms to drive change in BC.

Chart #11 shows a shift in opinion. At the beginning of the conference, most thought there would be an improvement of 10-25%; at the end of the conference, an improvement of 25-50% by 2012 was the most frequent response.

Chart #11 Now what do you think will happen to elective surgical wait times in BC by 2012? A. There will be no one waiting more than 18 weeks B. There will be 25-50% improvement C. There will be 10-25% improvement D. There will be no improvement E. Things will be worse

Finally, Dr. Hamilton asked participants to pick the most important mechanism for change from a list of five options. Chart #12 highlights the responses: strong leadership from the top received the greatest support, followed by a clear provincial strategy, greater clinical involvement, ambitious targets along with clear accountability, and increased funding and resources.

Chart #12 From what we’ve heard over the last two days, what is the MOST IMPORTANT mechanism to achieve meaningful reductions in waitlists? A. Strong leadership at the top to lead the changes necessary B. A clear provincial strategy outlining how BC will move

forward C. Greater clinical involvement to support and lead the changes D. Ambitious targets and clear accountability for reaching the

targets E. Increased funding and resources



APPENDIX

Access to Surgery Conference Planning Committee

Dr. Andy Hamilton, Interior Health Surgical Council Co-chair; Conference Chair, Access to Surgery in British Columbia | The Cutting Edge

Dr. Alexandra Tcheremenska-Greenhill, Associate Chief Executive Officer, BCMA

Ms. Alison Millar, Director, Priority Projects (Surgical Access/Wait Times), Health Authorities Division, Ministry of Health Services

Mr. John McGurran, Wait Times Advisor to the Ministry of Health Services; President, Cordova Bay Research Ltd.

The planning committee would like to acknowledge the services of Lisa May, Principal, May Communications, in preparing this report.



Poster presentations Title Authors OsteoArthritis Service Integration Systems (OASIS) Program

Cindy Roberts, Program Director Margarite Paul, RN Educator

Rapid Surgical Recovery: an Innovative Approach to Improving Access to Surgical Care

Jocelyn Reimer-Kent, RN, MN, RCH Clinical Nurse Specialist & Clinical Adjunct Professor, UBC School of Nursing Dr. Richard Merchant, MD, FRCPC - RCH Department of Anaesthesia and Peri-operative Medicine & Clinical Professor of Anaesthesia, UBC Faculty of Medicine Dr. Laurence Turner, MA, MB,BS, FRCSC - RCH General Surgeon & Clinical Associate Professor, UBC Faculty of Medicine

Predicting Operating Room Resource Needs Using Discrete Event Simulation for a Vascular Surgery Service

Dr. Jim Dooner

Interior Health Authority Surgical Wait List Audit

Lisa Himmelman, IHA Darcy Doberstein, IHA

Suspended Category Analysis Lisa Himmelman, IHA Regional Pre-Surgical Screening Program

Dr. Andy Hamilton, IHA Denise Dunton, IHA

National Surgical Quality Improvement Program (NSQIP)Yields Remarkable Positive Outcomes

Angela Tecson, RN, BSN, SCNR, Surrey Memorial Hospital, FHA

Bone and Joint Canada – Improving Access to Hip and Knee Surgery

Hazel Wood, BSc OT, MBA Rhona McGlasson, BSc. PT., MBA

Impact of Additional Daytime “Sweeper” Operating Room on Delivery of Emergency Surgical Care in Teaching Hospital

A.K. Buczkowski, A. Bolton, A. Csapo, G. Warnock Departments of Surgery, Anaesthesia and Senior Management Peri-operative Services, Vancouver General Hospital, VCHA

Shifts of Time Allocation Will Not Resolve Waiting Times Issue for All

A.K. Buczkowski, C.H. Scudamore, S.W. Chung Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, UBC Hepatobiliary and Pancreatic Surgery Service, Vancouver General Hospital, VCHA

Development of Integrated OR Access System

O.N. Panton, M. Hameed, A.K. Buczkowski Division of General Surgery, Department of Surgery Urgent Surgery Care Service, VGH

Surgical Pre-Admission Clinic (Pac) Lean Redesign

Jeanette Kuper and Anastasia Elworthy St. Paul's Hospital, Providence Health Care



Title Authors Advanced Access Scheduling in Physician Office Practices in British Columbia

Dr. Alexandra Tcheremenska, Associate CEO, BCMA Dr. Dan MacCarthy, Director, Professional Relations, BCMA Liza Kallstrom, Lead, Change Management and Practice Support, BCMA Rosemary Gray, Lead, Change Management and Practice Support, BC Ministry of Health Services

Improving Urgency Profiling and Waitlist Reporting in the Interior Health Authority

Michael Carter, Andrew Hamilton, Janine Johns, Lisa Himmelman, Darcy Doberstein Surgical Council, IHA

Use of LEAN Design Elements to Improve Access to Cataract Surgery

H Khan, C Service, E Imber, A Boardman, M Orr, D Gramigna, M Hinz, VIHA

A New Model for the Provision of Peripheral Nerve Block Anaesthesia at St Paul’s Hospital: Improving Hospital Resource Use and Enhancing Patient Care

Dr. Stephen Head, MD, FRCPC, Staff Anaesthesiologist Dr. Scott Bell, MD, FRCPC, Staff Anaesthesiologist St Paul’s Hospital

Computer Modelling of Surgical Waitlists

Dr. Les Vertesi, Complex Systems Modelling Group at IRMACS, Simon Fraser University

Public Private Partnership on the Provision of Scheduled Surgical Procedures Poster

Leanne Appleton, Vancouver Coastal Health Susan Wannamaker, VCH Lenore Van Oene, ASC Vancouver Surgical Centre

Scope of Practice of 12 GP-Surgery Hospitals in British Columbia

Nancy Humber, MD, Associate Clinical Professor, UBC, Community Researcher, Vancouver Foundation

Rural Patience Experiences Accessing Surgical Services in British Columbia


Models of Rural Surgical Service Delivery in British Columbia


The Practice and Training Experiences of Rural GP Surgeons

Dr. Jude Kornelsen, Assistant Professor, UBC Department of Family Practice and Co-Director of the Centre for Rural Health Research (UBC/VCHRI) Dr. Stefan Grzybowski, MD, CCFP, MClSc, FCFP, Professor UBC Department of Family Practice and Co-Director of the Centre for Rural Health Research

The Right Wait-Establishing Wait Time Targets for All Scheduled Surgery

Susan Scrivens, VCHA



List of conference participants Name Organization Hon. George Abbott Government of British Columbia Courtney Addis Vancouver Island Health Authority Leanne Appleton Vancouver Coastal Health Authority Deljit Bains Fraser Health Authority Afsaneh Bakhtiani Sur Baycroft Vancouver Coastal Health Authority Morris Barer University of British Columbia Scott Bell Vancouver Coastal Health Authority/Providence Health Care Katherine Bell Access Management Health Loraine Best Fraser Health Authority Indu Bhalla Vancouver Coastal Health Authority Andrea Bisaillon Vancouver Coastal Health Authority Geoffrey Blair British Columbia Children's Hospital Tricia Braidwood-Looney Ministry of Health Services Dave Brar Ministry of Health Services Pat Breakey Interior Health Authority Kelsey Breault Northern Health Authority Don Briscoe Canadian Medical Association Anthony Britto Fraser Health Authority Erica Britto Fraser Health Authority Anne Marie Broemeling Ministry of Health Services Margaret Brown Interior Health Authority Jeff Brown Regina QuAppelle Health Region Erin Brown Vancouver Coastal Health Authority Margaret Brown Vancouver Island Health Authority Janine Bryant Laura Bryn- Jones Fraser Health Authority Stephanie Buckingham Vancouver Island University Andrzej Buczkowski Diamond Health Centre Sam Bugis Vancouver Coastal Health Authority / Providence Health Care David Butcher Northern Health Authority Bill Campbell Fraser Health Authority Lia Carter Fraser Health Authority Mike Carter Interior Health Authority Will Chambers Vancouver Island Health Authority Julie Chan Hospital of Sick Children Debbie Chin Vancouver Coastal Health Authority John Chritchley Phyllis Chuly Vancouver Island Health Authority Bob Clark Vancouver Island Health Authority Jeff Coleman Vancouver Coastal Health Authority Teri Collins Ministry of Health Services Will Collishaw Ministry of Health Services Kelli Connelly Vancouver Island Health Authority Mike Conroy Vancouver Island Health Authority Sharon Cook Interior Health Authority Geoff Cundiff Vancouver Coastal Health Authority/Providence Health Care Chris deGara University of Alberta Sheila Dentoom Vancouver Coastal Health Authority Mariana Diacu Ministry of Health Services



Name Organization Laura Dickinson Vancouver Island Health Authority Darcy Doberstein Interior Health Authority Jim Dooner Vancouver Island Health Authority Peter Doris Fraser Health Authority Jennifer Duff Vancouver Coastal Health Authority/Providence Health Care Denise Dunton Interior Health Authority Anastasia Elworthy Vancouver Coastal Health Authority/Providence Health Care Kyleen Ennis Health Care Service Corporation Angela Enright Vancouver Island Health Authority Ron Epp Government of Saskatchewan Lisa Evans New Brunswick Department of Health Robert Evans UBC Centre for Health Services & Policy Research Mary Falconer Ministry of Attorney General Fatima Fazal Surgical Centres Inc. Patricia Fawas College of Physician and Surgion of BC Ronda Field Vancouver Coastal Health Authority Laura Fitzgerald Johnson and Johnson Medical Products Barb Fitzsimmons Provincial Health Services Authority Donald Fockler Vancouver Island Health Authority Andy French Deloitte & Touche Jennifer Frood Canadian Institute for Health Information Donnie Fullerton Interior Health Authority Kim Gadsden Vancouver Island Health Authority Eduardo Garza Fraser Health Authority Nancy Gault Canadian Institute for Health Information Lorraine Gillespie Fraser Health Authority Andre Goetze Northern Health Authority Mark Goldman Heart of England Trust Brian Goldman Mount Sinai Hospital Bradley Gollason Northern Health Authority Linda Goranko Fraser Health Authority Jason Goto Analysis Works Inc Eileen Goudy Vancouver Island Health Authority Raymer Grant Vancouver Coastal Health Authority Kari Grant Interior Health Authority Joyce Gray Fraser Health Authority Rosemary Gray Ministry of Health Services Sandra Grimwood Vancouver Coastal Health Authority / Providence Health Care Anton Grunfeld Fraser Health Authority Martha Grypm Fraser Health Authority Stefan Grzybowski UBC Department of Family Practice Vit Gunka Judy Hagen Fraser Health Authority Andy Hamilton Interior Health Authority Sean Hardiman Northern Health Authority Rebecca Harvey Ministry of Health Services Steve Head Vancouver Coastal Health Authority/St. Paul's Hospital Wendy Hill Ministry of Health Services Matt Himmelman Interior Health Authority Lisa Himmelman Interior Health Authority Nora Huber Ministry of Health Services Lori Hughes Fraser Health Authority



Name Organization Nancy Humber Interior Health Authority Avis Husel Alberta Health & Wellness Chris Ingram Ministry of Health Services Tabea Jaeger Fraser Health Authority David James Vancouver Island Heath Authority Loraine Jenkins Fraser Health Authority Deborah Jeske Vancouver Coastal Health Authority Shahzeed Jiwa Fraser Health Authority Janine Johns Interior Health Authority Liza Kallstrom British Columbia Medical Association Patrick Kelly Fraser Health Authority Carla Kerr Provincial Health Services Authority Hamza Khan Vancouver Island Health Authority James Kim British Columbia Anaesthesiologist Society Nicholas Kimberley Vancouver Island Health Authority Rhonda Kremko Fraser Health Authority Arden Krystal Fraser Health Authority Jeanette Kuper Vancouver Coastal Health Authority / Providence Health Care Carol Laberge Fraser Health Authority Bonnie Lantz Blaylock Surgical Centre Ralph Lapp Vancouver Island Health Authority Crystal Large Vancouver Island Health Authority Bertrand Lau Fraser Health Authority Cindy Laukkanen Fraser Health Authority Melanie Leckovic Fraser Health Authority Laurie Leith Vancouver Coastal Health Authority Shelagh Levangie Denise Lowe Interior Health Authority Julie Lucas Blaylock Surgical Centre Valerie MacDonald Fraser Health Authority Bill Mackie British Columbia Medical Association Laurel Magri Vancouver Coastal Health Authority Elaine Mah Fraser Health Authority Marnie Matthews Northern Health Authority Nikki McCallum Ministry of Health Services Peter McClung British Columbia Medical Association David McCoy Vancouver Island Health Authority Janis McGladrey Provincial Health Services Authority John McGurran Cordova Bay Research Debra McKitrick Fraser Health Authority Elaine McKnight Ministry of Health Services Michael McMillan Northern Health Authority Richard Merchant Fraser Health Authority Alison Millar Ministry of Health Services Allan Miller Northern Health Authority Corey Ming Lun Vancouver Coastal Health Authority Jemal Mohamed Ministry of Health Services Rocky Moise Vancouver Island Health Authority Irene Moncrieff Interior Health Authority Randell Moore Vancouver Coastal Health Authority/Providence Health Care Maureen Morris Fraser Health Authority Michele Neal Vancouver Island Health Authority



Name Organization Scott Neilson Vancouver Island Health Authority Karen Nichvaldoff Fraser Health Authority Alastair Nicoll BC Dental Association Gary O'Connor Interior Health Authority Patrick O'Connor Vancouver Coastal Health Authority Mark O'Grady Regina Qu'Appelle Health Region Karin Olson Vancouver Coastal Health Authority Roland Orfaly Fraser Health Authority William Orrom Vancouver Island Health Authority Eric Paetkau Vancouver Coastal Health Authority Wendy Panton Vancouver Coastal Health Authority Sharon Parent Fraser Health Authority Ryan Paterson Vancouver Coastal Health Authority Margarite Paul Vancouver Coastal Health Authority Monica Pfenniger Fraser Health Authority Wayne Pisesky Interior Health Authority Derek Plausinis Interior Health Authority Jennifer Anne Power Ministry of Health Services Daniela Radu Provincial Health Services Authority Jeff Rains Fraser Health Authority Ghalib Rajan Fraser Health Authority Bojan Ramadanovic The IRMACS Centre Sue Rasmussen Northern Health Authority Melanie Rathgeber Saskatchewan Health Quality Council John Reid Vancouver Coastal Health Authority / Providence Health Care Jocelyn Reimer-Kent Fraser Health Authority Linda Revell Fraser Health Authority Joanna Richards Ministry of Health Services Philippa Robinson UK Department of Health Meilan Robson Vancouver Coastal Health Authority Ian Rongve Ministry of Health Services Con Rusnak Vancouver Island Health Authority Alexander Rutherford The IRMACS Centre Marius Saayman Interior Health Authority Maryam Saeri Provincial Health Services Authority Ramesh Sahjpaul Vancouver Coastal Health Authority Stephanie Sainas Provincial Health Services Authority Manik Saini Ministry of Health Services Marilee Saunders Fraser Health Authority Geoff Schierbeck Interior Health Authority Brian Schmidt Provincial Health Services Authority Nicholas Schnee Vancouver Coastal Health Authority / Providence Health Care Lynda Schock Vancouver Island Health Authority Susan Scrivens Vancouver Coastal Health Authority Carla Service Vancouver Island Health Authority Richele Shorter Ministry of Health Services Richard Simpson Ministry of Health Services Heather Speirs Vancouver Coastal Health Authority Michael Stanger Vancouver Island Health Authority Dawn Stangl Vancouver Coastal Health Authority Michelle Stanton Vancouver Coastal Health Authority Nicola Stephens Provincial Health Services Authority



Name Organization Miriam Stewart Fraser Health Authority Prudence Taylor Alberta Health & Wellness Cam Taylor Interior Health Authority Alexandra Tcheremenska-Greenhill British Columbia Medical Association Angela Tecson Fraser Health Authority Leanne Thain Fraser Health Authority Will Thomas Ministry of Health Services Nancy Thomas Interior Health Authority Anthony Thompson The Checklist Partnership Maureen Thomson Interior Health Authority Monica Todesco Vancouver Coastal Health Authority Kamiko Toriyama Vancouver Island Health Authority Robyn Tremblay Interior Health Authority Jan Trippel Northern Health Authority Trent Truscott Regina QuAppelle Health Region Jeff Turnbull The Ottawa Hospital David Twist Fraser Health Authority Rudi Valerio Provincial Health Services Authority Alexa Van Der Waall The IRMACS Centre Rardi Van Heest Fraser Health Authority Leslie Vertesi Fraser Health Autohrity Diana Villalba Fraser Health Authority Elisabeth Wagner Ministry of Health Services Jean Walters BC Ministry of Attorney General Yanchae Wang The IRMACS Centre Susan Wannamaker Vancouver Coastal Health Authority Robert Weiler Saskatoon Health Region Martin Weirich Christy Westropp Yukon Ministry of Health & Social Services Malcolm Williamson Ministry of Health Services Debra Wilson Fraser Health Authority Bernd Wittmann Interior Health Authority Hazel Wood Bone & Joint Canada Peggy Yakimov Interior Health Authority Erdem Yazganoglu Provincial Health Services Authority Sheri Yager Vancouver Island Health Authority Christine Young Ministry of Health Services Janice Yurchuk Vancouver Coastal Health Authority Jaycille Zart Vancouver Island Health Authority

Documents

Access to Surgery in British Columbia - Ministry of …...Access to Surgery in BC | The Cutting Edge January 15-16, 2009 Conference Report Page 4 EXECUTIVE SUMMARY On January 15th