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Ken FyieUniversity of Calgary and Alberta Bone and Joint Health Institute
Waiting Time Management Strategies for Scheduled Health Care ServicesOttawa, Ontario – March 28, 2012
Motivation and research question
Methodology
Results
Discussion and next steps
Involuntary WaitsA system-related wait, caused by inability to meet demand
Voluntary WaitsPatient-related factors directly impacting the system’s ability to deliver care in a specified timeframe
Source: Marshall et al. (2012) – under submission
Referral DateReferral
Received DateMSK Consult
DateActual Surgeon
Consult Date
T Surgeon T Referral T Received T MSK
Involuntary Waits
Voluntary Waits
Involuntary Waits
Source: Marshall et al. (2012) – under submission
Inconsistent and incomplete measurement of waiting times From referral made to musculoskeletal (MSK)
assessment to surgical consultation
Little analysis about the context of delays
Few published analyses of referral processing inside clinics – a “black box” from the outside
Can the hip and knee referral process from primary care providers to orthopaedic specialists in Alberta be positively impacted by the introduction of an electronic referral tool?
We: Qualitatively evaluate current referral practices Quantitatively evaluate three system measures
reflecting current quality of care
Data collected in three stages: Initial clinic visits, with semi-structured
interviews Retrospective patient chart sampling Time and motion study of clinical staff
Patients are consulting for hip and knee osteoarthritis for first time Primarily referred to clinics by GPs
Three volunteer hip and knee clinics in Alberta
Settin
g
Number of
surgeons
MSK screeni
ng option availab
le
Integration
between surgeon
s and clinics
Complexity of
patients
Degree of
Electronic Usage
Clinic 1~4000-5000
referrals per year
UrbanMulti-
surgeon (10-20)
YesHighly
integrated
Handle all complexiti
es
Very advanced
Clinic 2~200-300 referrals per year
RuralSingle-
surgeonNo
Moderate integrati
on
Low complexiti
es
Moderately
advanced
Clinic 3~400-500 referrals per year
Midsized city
Multi-surgeon (2-9)
YesModerate integrati
on
Handle all complexiti
es
Moderately
advanced
Alberta total: ~15,000 referrals across 9 hip and knee clinics
• Accessibility:– 1) Waiting times (business days) –
• Time referral made to time referral deemed complete• Time referral deemed complete to time of first surgical consult
– 2) % of patients seeking next available surgical consult– 3) Estimate of involuntary and voluntary waiting times
• Referral Appropriateness:– 4) % of referrals initially arriving complete and
correctly directed– 5) Clinical rules for accepting referrals– 6) MSK screening usage
• Efficiency:– 7) Time spent by clinic staff evaluating each referral
11-15% of the referral made to surgical consultation waiting time is involuntary
Scheduling rules vary across clinics
From:Referral
made
Referral deemed
complete
Referral made
To:Referral deemed
complete
Surgical consultation
Surgical consultation
Clinic 1Mean
Median
90th %
235
60
8176
129
9786
178
Clinic 2Mean
Median
90th %
74
29
413251
5135
104
Clinic 3Mean
Median
90th %
231346
131134182
139145212
05
01
00
05
01
00
05
01
00
0 100 200 300 0 100 200 300
0 100 200 300
Clinic 1 Clinic 2
Clinic 3Pe
rcen
t
Work days between referral date and date accepted/complete referralGraphs by Site
Red line: 90th percentile timeTan line: Mean waiting timeGreen line: Median waiting time
Note: few patients with long waiting time drive results
Red line: 90th percentile timeTan line: Mean waiting timeGreen line: Median waiting time
Note: few patients with long waiting time drive results
This is much higher than in literature (only 40%-70% in previous studies)
% of referrals with next available
surgeon option chosen
% of referrals with specific surgeon
selected
% less waiting time: when next available
is chosen
Clinic 1 71% 21% 36% (20 days)
Clinic 2 Only one surgeon
Clinic 3 80% 20% 14% (21 days)
Why are referrals rejected? Incomplete: referral
variables not filled out▪ Rules vary depending on
clinic▪ Most rejected referrals
are due to incompleteness
Incorrectly directed: cannot be treated at specific clinic▪ Longest delays
associated with this
% of initially rejected referrals
Primary Reason
Clinic 1 13%Missing x-
rays
Clinic 2 49%Missing BMI (height/weig
ht)
Clinic 3 No information
MSK screening results in fewer “currently non-surgical” patients seeing a surgeon
Clinic 1 Clinic 3% of
patients referred to
MSK asssessment
87% (105 of
121)
38% (19 of
50)
% of MSK patients assessed surgical
67% (70 of 105)
32% (6 of 19)
% of MSK patients assessed nonsurgical
33% (35 of 105)
68% (13 of
19)
These assessments resulted in:- 29% of referred patients at clinic 1 - 26% of referred patients at clinic 3
not seeing a surgeon for a surgical consultation
Clinic staff Most referrals take ~9-14 minutes Referrals with missing information take
longer Most staff have other work areas in
addition to referral processing Technology could increase efficiency
(duplicate data entry, scanning information)
Clinical time tracking is consistent Bone and Joint Clinical Network defined
waiting times Clinical processing rules vary
What is necessary on a referral form How patients are prioritized Whether triaging (MSK assessment) is
available Requirements prior to consult or surgery Feedback to GPs
Reduced waiting times: cut initial involuntary times by up to 20 days
All Alberta patients can choose next available surgeon
Consistent referral forms to minimize missing information: eliminate the 10-50% not initially accepted
Urgency scoring: get care to worse-off patients quicker
Reductions in certain tasks by clinic staff: save 8 minutes in scanning time
Electronic referral should be evaluated to determine how system outcomes change Must account for multiple changes occurring at
once
Voluntary waiting times should be separated
Basic standardization of the referral process should occur Differing clinic processing rules need to be
considered Reduces variation, creates one consistent queue
for patients
Current referral practices show some inefficiencies and gaps in knowledge, producing worse system outcomes
Electronic referral and central intake can potentially improve referral processing and system outcomes
Future analysis needed when electronic referral is implemented
Alberta Bone and Joint Health Institute: Tanya Christiansen Karen Phillips Stephen Weiss Christopher Smith Cy Frank Betty Smith
University of Calgary: Deborah Marshall Tom Noseworthy Aish Sundaram
Staff at three volunteer hip and knee clinics in Alberta
Funding provided in part from hSITE/NSERC and Alberta Health Services, and the
Alberta Osteoarthritis AIHS Team Grant