What to do with the Queue: Improving Wait Times Flashcards
What to do with the Queue?
“people with cancer may be treated with various combinations of surgery, radiation therapy, and chemotherapy. Radiotherapy cannot be administered in every hospital; it requires equipment and skilled technical staff. One such specialized hospital, the Princess Margaret Hospital (PMH) in Toronto, found itself faced with a growing waitlist problem in its radiotherapy department. What should it do?
Policy Issues Addressed
- queuing theory
- wait lists and how to manage them
- human resources planning
- payment mechanisms and incentives
- ethics of rationing
Summary of the Issue
- PMH had huge backlogs in both 1991 and 1999, so bad patients had to be referred elsewhere
- shortages of radiation therapists, oncologists and physicists (only 20% of patients were being treated within the 4-week period recommended by CARO
- almost half were waiting longer than 8 weeks
- cancer care Ontario, established at this time to coordinate wait times management for cancer treatment
Framing (Problem Identification)
- Distribution; send patients to other centres where demand is not so great
- HHR Issues: address shortages, improve pay, extend length of time imaging machines were running
- Management and Oversight: Establish oversight body to address wait times
Key ideas in the CCO Approach to Wait Times Management
- Queue: A line or sequence of patients waiting to be treated
- identifying appropriate wait times
- measuring wait times appropriately (e.g. two intervals established)
Key Ideas in Queue Theory
- Customers
- Input source
- Queue discipline
- service mechanism
- ethics
Policy Theory and Ethics and Queuing
- consensus policy - costs/benefits, technical issues
- virtue ethics
- utilitarian (happy: unhappy)
- ethics of care as a goal, sometimes hard to achieve
- personality (access, common good, performance)
- principlism
Queue Theory
p = A / (s*u)
p: proportion of available resources
A: the rate at which patients arrive
s: the number of health care professionals in the system
u: rate at which patients are treated
- consider queue discipline (How do people line up)
- behaviour in the line up
- people leave queue (end up coming back needing more advanced care)
- baulking (take a long time)
- blocking (limits on how many ppl they’ll see)
5 Mechanisms to Reduce a Wait List
- Decrease patient arrival rate (A) - more population health prevention, disperse places to go, cap on # of procedures
- increase the treatment rate (u) - increase hours of operation
- Increase the number of health care providers in the system (s) - accept international doctors, increase # of med school students
- limit number of patients in the queue
- Modify the queue discipline
ECFAA (Excellent Care For All Act)
the legislation applies to hospitals as identified in the Public Hospitals Act
Hospitals must:
- establish quality committees
- put annual quality improvement plans in place and make these available to the public
- link executive compensation to the achievement of targets set out in the quality improvement plan
- put patient/care provider satisfaction surveys in place
- conduct staff surveys
- develop a declaration of values following public consultation, if such a document is not currently in place
- establish a patient relations process to address and improve the patient experience
Why an Understanding of Wait Times is Important for Consumers:
- control; estimating when the service you need will happen means you don’t have to put your life on hold
- Awareness; seeing how the wait time at your hospital compares to other Ontario hospitals means you can have a better-informed conversation with your family doctor about your options
- Peace of Mind; Understanding why you may need to wait can help put you at ease because your wait time will be appropriate for your condition
What is Wait Time?
- wait time is the amount of time you have to wait for a surgery/exam
- wait is measured from the time your surgery/exam is booked until the time it is received
- if several surgeries or exams are required, each one may have its own wait time
Wait Times Information System
- a key part of the Ontario Wait Time Strategy
- collects wait time data in 94 adult surgery and DI hospitals and in 78 pediatric surgery hospitals
- the system tracks all surgical procedures in Ontario
- Hels us to assess patient urgency using a defined wait times standard
- measures and reports wait times and data on the utilization of procedures
- assists by providing near-real-time data for monitoring and managing waitlists
- reports wait time information to the public
Goals and Strategic Objectives
- person-centred
- safe
- equitable
- efficient
- effective
- timely
Surgical Wait Time: Wait 1
Date referral for new consultation is received to the date the patient had their first surgical consultation minus any Dates Affecting Readiness to Consult (DARCs) which are patient-related delay reasons
Retrospectively collected
Surgical Wait Time: Wait 2
Number of days from decision to treat to OR date, minus any Dates Affecting Readiness to Treat (DARTs)
Required Date Entries for Wait 1 and 2
- Referral date
- consult date
- the decision to treat date
- surgery date
Wait 1 Calculation - DARCs
Dates Affecting Readiness to CONSULT
referral received date - patient unavailable (days) - date of first consultation
periods of time between the referral and consult date when the PATIENT is unavailable for a first consultation due to patient-related reasons. The time will be subtracted from the overall Wait 1
Wait 2 Calculation - DARTs
Decision to Treat Date (DTT) - wait time (days) - date surgery performed
- decision to treat: the date when both the surgeon and the patient mutually agreed to proceed with surgery
- Priority: the level of priority for the procedure used to identify similar patients in need of care
DART - Dates Affecting Readiness to Treat
decision to treat date (DTT) - patient unavailable (days) - date surgery performed
Periods of time between the decision to treat date and the actual procedure date when the patient is unavailable for the procedure due to patient-related reasons. The period of time will be subtracted from the overall Wait 2
DARC - Developmentally Appropriate Wait
Consultation cannot occur until pediatric patient has reached a certain stage in development (PEDIATRIC CASES ONLY)
DARC - Inability to contact Patient
Office has made a reasonable effort to contact patient to schedule consultation, but has not been able to do so
DARC - Change in Medical Status
Patient’s medical status has changed and first consultation cannot be performed until the patient’s condition stabilizes
DARC - Missed Consultation
the patient does not show up for the first consultation and does not inform the office that they won’t be able to attend the appointment.
DARC - Patient Chooses to Defer
The patient is unavailable for the first consultation due to personal reasons (such as a vacation), personal preferences for the date/time of consultation, or weather reasons
DARC - Pre-defined Follow-up Interval
The clinician determines that the first consultation is required at a clinically defined point in the future. This includes waiting for medical clearance or coordination of multiple services
DART - developmentally appropriate wait
Procedure cannot occur until pediatric patient has reached a certain stage in development (PEDIATRIC CASES ONLY)
DART - Inability to Contact the Patient
The office has made a reasonable effort to contact the patient in order to schedule or confirm the date and time for the procedure
DART - Change in Medical Status
The patient’s medical status has changed such that the procedure cannot be performed
DART - Missed Surgery
The patient does not show up for the procedure. The patient does not contact the office that they won’t be attending the appointment
DART - patient chooses to defer
The patient is unavailable for the procedure due to personal reasons (such as vacation), personal preferences for the date/time of procedure, or weather reasons
DART - Pre-defined follow-up Interval
The clinician has made the decision to treat, but the procedure is required at a clinically defined point in the future. ie: follow-up scan in 3 months, cancer re-check in 1 year
DART - Neo-Adjuvant CHemotherapy
The patient requires chemotherapy before the procedure
DART - Other Surgical Procedure
The clinician has made the decision to treat but the patient must undergo a surgical procedure prior to this procedure
How Should Wait 1 Priority Level be Defined?
- Priority levels, description, and prioritization guidance were created by an expert panel of clinicians to help guide the professional decision-making of clinicians in Ontario
- access targets are recommended maximum wait times for each priority level
- clinicians exercise their own judgment to determine the priority level for the consultation
- priority level allows clinicians and hospital administrators to access if patients are being consulted within the access target and will provide a basis for discussions between and among clinicians and administrators regarding access to care issues
Wait 1 Access Target Ranges for Surgical Oncology
Priority 1 - 1 day
Priority 2 - 10 days
Priority 3 - 21 days
Priority 4 - 35 days
look at slides for assessment tools and stats
Throughput
- represents the ratio of closed cases to new cases added to the waitlists for a given time period
- priority level 1 cases are excluded
- queue statistics, including the throughput ratio, can be used to assess the impact on wait times of adding and/or completing additional surgeries
- a throughput ratio greater than 1.0 indicates that more cases were removed from the wait list than were added during the period
- normal fluctuations in throughput ratio should be expected and may balance out over time, with some quarters less than 1.0 and other quarters greater than 1.0
- a consistent trend in queue statistics over several quarters is more likely to affect wait times, particularly if the actual volume is large
