Measuring emergency department patient wait time 2008

This procedure was performed by means of a systematic review of literature that focused on the success and failure factors of wait time management WTM for scheduled care and through inte

OF WAITING TIME MANAGEMENT FOR HEALTH SERVICES-

A POLICY REVIEW AND SYNTHESIS

Final Synthesis Report

Marie-Pascale Pomey

Pierre-Gerlier Forest

Claudia Sanmartin Carolyn DeCoster Madeleine Drew

R09-01

Février 2009

Legal Deposit – Bibliothèque et Archives nationales du Québec, 2009 Legal Deposit – Library and Archives Canada, 2009

D ETERMINANTS OF W AITING T IME M ANAGEMENT

FOR H EALTH S ERVICES —

A P OLICY R EVIEW AND S YNTHESIS

CIHR Research Synthesis:

Priority Health Services and Systems Issues #137064

December 2008

Marie-Pascale Pomey Pierre-Gerlier Forest Claudia Sanmartin Carolyn DeCoster Madeleine Drew

Address for correspondence:

Dr Marie-Pascale Pomey

Department of Health Administration, GRIS, Faculty of Medicine, University of Montreal,

CP 6128, Succ Centre Ville, Montreal, Québec, Canada H3C 3J7

Phone Number: 514-343-6111 ext 1-1364

Fax Number: 514-343-2448

Email: marie-pascale.pomey@umontreal.ca

CONTENTS

ACKNOWLEDGEMENTS 5

EXECUTIVE SUMMARY 6

RÉSUMÉ 9

THE REPORT 13

1 INTRODUCTION 13

1.1 Aims and objectives 13

1.2 Significance of the problem 14

1.3 Background 14

1.4 Structure of this report 19

2. SYSTEMATIC LITERATURE REVIEW 20

2.1 Methods 20

2.2 Results from the literature review 25

2.3 Models 37

2.4 Key findings of the literature review 38

2.5 Study limitations for the literature review 39

3 INTERVIEWS OF CANADIAN POLICYMAKERS AND DECISIONMAKERS 41

3.1 Methodology for the interviews 41

3.2 Results of the interviews 44

3.3 Key findings from the interviews 49

3.4 Study limitations for interviews 50

4 SUMMARY OF THE FACTORS IDENTIFIED 51

5 INTERPRETATION OF THE RESULTS 53

5.1 Divergent and convergent findings between the literature review and the interviews 53

5.2 Comparison of the findings to the grey literature and to Canadian publications 54

6 POLICY IMPLICATIONS 56

7 IMPLICATIONS FOR FUTURE RESEARCH 58

8 CONCLUSION 59

APPENDICES 64

ACKNOWLEDGEMENTS

This work would not have been possible without the support of a Canadian Institutes of Health research grant (# KSY-73928) The authors also thank the following individuals: Diane Lorenzetti for her expertise and assistance in refining the search terms and systematically searching all the databases; Catherine Safianyk, Johanne Preval and Ghislaine Tré for their research assistance; Jennifer Petrela for her editorial contribution; and the healthcare managers and policymakers who participated in the interviews and shared their experience and insight

EXECUTIVE SUMMARY

Background

For over a decade, industrialized countries around the world have struggled to solve the problem of long wait times for scheduled medical care (Siciliani and Hurst 2003) Canada has focussed its search for a solution at the federal and provincial levels, and recent Canadian wait time initiatives have consistently looked to centralized programs as their solution (Health Council of Canada 2007) The role of regional health authorities and hospitals has often been ignored or downplayed, this despite the fact that these institutions are directly responsible for initiating and implementing policies and strategies

to improve timely access to care It is our position that the experiences of these institutions can provide valuable learning regarding the key determinants associated with the successful measurement and management of waiting times If resources, financial or otherwise, are an important explanatory factor of health organizations’ action or inaction,

it can also be hypothesized that governance structures, practices, organizational culture, data collection, and management patterns also count as among the contributing factors

Research Objectives

The purpose of this project is to synthesize the existing intelligence regarding the management of waiting times for specialized and diagnostic services in an effort to identify the key local and contextual factors of successful waiting time management This procedure was performed by means of a systematic review of literature that focused

on the success and failure factors of wait time management (WTM) for scheduled care and through interviews with key policymakers and decision-makers involved in the management of waiting times in Canada The information thus gathered was then synthesized according to a predetermined conceptual framework in order to identify local and contextual factors associated with the management of waiting times

Conceptual Framework

To organize the factors to be identified through the literature review and the interviews,

we used a conceptual framework inspired by Parsons’ widely recognized and robust

four-quadrant model The four dimensions used for this model were governance, culture,

resources, and tools Because waiting time management strategies work within a broad

context and are therefore influenced by more than local factors, both the local and the contextual levels had to be taken into account This is the reason why the model represents all four dimensions at both levels

Literature Review Methods

For the literature review, six medical databases and 19 non-medical databases were searched for articles published between 1990 and 2005 that addressed wait time or wait list management for scheduled care Articles focusing on waiting times for transplants, emergency care, long-term care and pharmaceuticals were excluded on the grounds that the dynamics of wait times in these areas are quite different The database search resulted

in 5202 abstracts, exclusive of duplicates Each of the four levels of screening was performed by two reviewers using online software (SRS 4.0, TrialStat) The final 31 articles retained for data abstraction had been published in peer-reviewed journals and consisted of either a model or a framework with WTM factors at the organizational level

or of an initiative that specifically addressed WTM and stated organizational factors explicitly

Interviews Methods

We conducted 16 semi-structured interviews and one focus group with individuals involved in WTM strategies in Canada at the federal/provincial or the organizational level The one to two-hour interviews took place between October 2005 and August 2006 and all were taped and transcribed

Results

Few articles found in the peer reviewed literature explicitly addressed the factors that could enhance or inhibit the implementation of a wait time reduction strategy at the local level and few were empirical studies Instead, most were case descriptions with little rigorous hypothesis generation or testing The studies focussed more on evaluating outcomes than on evaluating the implementation of WTM initiatives

Some of the local factors most frequently cited both in the literature review and in the interviews were physicians’ involvement to bring resistant physicians on board (culture), appropriate levels of dedicated staffing to ensure continuity (resources), and information management systems to collect and analyse data (tools) At the contextual level, funding levels and earmarked resources recurred most often in the literature review, but interviewees emphasized financial incentives and the need for them to be aligned between the contextual and the local level Unsurprisingly, leadership emerged as an additional important governance factor at both the local level, where it surfaced as strong clinical leadership, and at the contextual level, where it appeared as the need for vision and direction within a structure that ensured coordination, reporting and monitoring Many other factors were identified under the four dimensions and are further explained in this report

Study Limitations

Although non-peer reviewed articles and the grey literature may have contributed interesting insights, the literature review was limited to peer-reviewed papers in order to keep the scope of the exercise manageable The final sample of abstracted articles is small and there was no scale of evidence to measure the quality of the evidence The sample size for the interviews was also small, but the consistency of the responses by individuals from different Canadian provinces and different levels of involvement helped counter this limitation Nonetheless, it is important to specify that our findings should be considered exploratory: the primary purpose of this study was to identify a number of factors and test their impact in a later study

Implications for Policy

Even though the main purpose of this review was to identify factors that impact the implementation of WTM strategies and use those factors to develop a framework, it can also inform policymakers of actions that may be beneficial:

• involve physicians from the outset;

• take organizational culture into account before implementing a given strategy;

• invest in evaluations and quality improvements at the organizational level;

• invest in the relationship between managers and physicians;

• earmark funds to help the local level launch the WTM project;

• invest in information management and tools;

• align high-level policies with local strategies

In general terms, higher level decision-makers need to take organizational factors into account to maximize the successful implementation of WTM strategies

Implications for Future Research

We have already suggested the utility of further research on the factors identified in this study in order to evaluate their relevance, pertinence and real impact on the implementation of WTM strategies In addition, it would be interesting to conduct a more thorough investigation of the value of neutral third parties, an idea brought up by several of our interviewees In-depth case studies in healthcare organizations where wait list management strategies have succeeded or failed should also be considered Important

to note is that for any study in this field, researchers should take care in defining the waiting time period under consideration Finally, this study focused on scheduled care, but the factors identified here may also be applicable to primary care, long-term care, mental health or other fields of heath care where there are also long wait times For these areas, additional factors may be at play, warranting further research

Conclusion

The present exploratory study was conducted with a view to understanding the factors that enhance or impede the implementation of wait time management strategies The systematic review of published peer reviewed articles as well as our complementary interviews with key policymakers and decision-makers involved in the management of waiting time in Canada identified a number of key factors

The next steps require decision-makers and policymakers to start taking some of these factors into consideration and for researchers to conduct further studies to better understand the impact and interaction of these factors in terms of how their influence on the implementation of WTM strategies

RÉSUMÉ

Contexte

Depuis plus d'une décennie, les pays industrialisés dans le monde entier cherchent des solutions afin de résoudre le problème des temps d'attente pour les soins médicaux planifiés (Siciliani and Hurst 2003)

Le Canada a axé sa recherche de solutions aux niveaux fédéral et provincial, et les récentes initiatives canadiennes portant sur les temps d'attente considèrent les programmes centralisés comme une réponse au problème des temps d’attente (Health Council of Canada 2007)

Le place des autorités régionales de la santé et des hôpitaux a souvent été ignorée ou minimisé, et ce, malgré le fait que ces institutions sont directement responsables d’initier

et mettre en œuvre des politiques et des stratégies visant l’amélioration de l'accès aux soins de santé Or, les expériences de ces institutions dans ce domaine nous fournissent des éléments précieux pour identifier les principaux déterminants associés à la réussite de

la mesure et de la gestion des temps d’attente

Si les ressources, financières ou autres, sont des facteurs importants explicatifs de l'action

ou de l'inaction des organismes de la santé, on peut aussi avancer l'hypothèse que les structures de gouvernance, les pratiques, la culture organisationnelle, les systèmes d’information, et les modes de gestion également peuvent compter parmi les facteurs contributifs

Objectifs de la recherche

Le but de ce projet est de synthétiser les renseignements existants sur les stratégies mises

en place pour la gestion des temps d'attente (GTA) associés aux services spécialisés et diagnostiques afin d’identifier les principaux facteurs locaux et contextuels favorisant leur implantation

Pour ce faire, un examen systématique des écrits portant sur les facteurs de réussite et d'échec de la GTA eu égard aux soins planifiés ainsi que des entretiens réalisés avec les principaux décideurs politiques et les décideurs impliqués dans la gestion des temps d'attente au Canada ont été réalisés

Les données ainsi recueillies ont ensuite été synthétisées selon un cadre conceptuel en vue d'identifier les facteurs locaux et contextuels associés à la gestion des temps d'attente

Cadre conceptuel

Pour organiser les éléments qui devaient être identifiés par la recension des écrits et les entrevues, nous avons utilisé un cadre conceptuel inspiré par le modèle des quatre quadrants de Parsons, largement reconnu et robuste

Les quatre dimensions utilisées pour ce modèle étaient : la gouvernance, la culture, les ressources et les outils

Vu que les stratégies de la GTA prennent place dans un contexte plus vaste et sont donc influencées par d’autres facteurs que ceux locaux, non seulement les facteurs ont été pris

en compte mais aussi ceux se situant au contextuel

C'est pourquoi le modèle représente les quatre dimensions à la fois au niveau local et contextuel

Méthodologie de la revue de la littérature

Pour construire notre revue de la littérature, nous avons consulté six bases de données médicales et 19 non-médicales Nous avons sélectionné les articles publiés entre 1990 et

2005 portant sur les temps d'attente ou sur la gestion des listes d'attente pour les soins programmés

Les articles traitant des temps d'attente pour les greffes, les soins d'urgence, les soins de longue durée et les médicaments ont été exclus, compte tenu que la dynamique des temps d'attente dans ces domaines est très différente

La recherche effectuée sur la base de données a abouti à 5202 résumés, à l'exclusion des doublons Chacun des quatre niveaux de sélection a été réalisé par deux examinateurs en utilisant un logiciel en ligne (SRS 4.0, TrialStat)

Les 31 derniers articles retenus sont tous issus de revues avec comité de pairs Il s’agissait d’un modèle ou d’un cadre conceptuel construit avec des facteurs organisationnels de la GTA ou bien des initiatives qui traitaient spécifiquement de la GTA ó les facteurs organisationnels étaient énoncés explicitement

Méthodologie des entretiens

En complément nous avons réalisé 16 entretiens semi-structurés et un groupe de discussion avec les personnes impliquées dans les stratégies de la GTA aux niveaux fédéral/provinciaux ou des organisations de santé au Canada Des entretiens d’une durée approximative de 2 heures ont eu lieu entre octobre 2005 et aỏt 2006, lesquels ont tous été enregistrés et transcrits

Résultats

Parmi les articles recensés peu d’entre eux étaient des études empiriques et abordaient explicitement les facteurs qui favorisaient ou défavorisaient la mise en œuvre d'une stratégie de réduction des temps d'attente au niveau local La plupart était des descriptions de cas avec des hypothèses peu rigoureuses ou des tests Les études se penchaient plus sur l'évaluation des résultats que sur l'évaluation de la mise en œuvre des initiatives de GTA

Parmi les facteurs locaux les plus fréquemment cités, aussi bien dans la revue de la littérature que dans les entretiens, on retrouve la participation des médecins en vue de faire adhérer les médecins résistants (culture), l’adéquation du nombre d’effectifs dédiés

à assurer la continuité (ressources), les systèmes de gestion d’information pour colliger et analyser les données (outils)

Au niveau contextuel, dans la revue de la littérature, les niveaux de financement et les ressources affectées revenaient le plus souvent alors que dans les entretiens, les personnes interviewées soulignaient les incitatifs financiers et la nécessité pour eux d'être alignées entre les niveaux contextuel et local

Sans surprise, le leadership est apparu comme un élément additionnel faisant partie des facteurs importants à considérer dans la gouvernance tant au niveau local, ó il refait surface en tant qu’un leadership clinique solide, qu’au niveau contextuel, ó la nécessité d’avoir une direction et une vision au sein d'une structure qui assure la coordination, la récolte de données et le suivi s’avèrent essentielles

Limites de l’étude

Bien que les articles sans comité de pairs et la littérature grise auraient pu contribuer à donner un aperçu intéressant, nous avons limité la revue de la littérature aux articles publiés dans des revues avec comité de pairs L'échantillon final des articles retenus était relativement petit et ne comportait pas une échelle de preuve optimale De plus, la taille

de l'échantillon pour les entretiens était également relativement petit, mais la cohérence des réponses des personnes issues de différentes provinces canadiennes et de différents niveaux de participation a aidé à contrer cette limitation Néanmoins, il est important de préciser que nos conclusions doivent être considérées comme exploratoires: le but principal de cette étude était d'identifier un certain nombre de facteurs et de tester leur impact dans une étude ultérieure

Implications pour les politiques de santé

Même si le principal but de cette étude était d'identifier les facteurs qui ont une incidence sur la mise en œuvre de stratégies de GTA et l'utilisation de ces éléments pour élaborer

un cadre d’analyse, il peut aussi informer les décideurs dans leur prise de décision au niveau des politiques qui pourraient être bénéfiques, comme :

• impliquer les médecins, dès le départ;

• tenir compte de la culture organisationnelle avant de mettre en œuvre une stratégie donnée;

• investir dans les évaluations et l'amélioration de la qualité au niveau de l'organisation;

• investir dans les relations entre les gestionnaires et les médecins;

• affecter des fonds à l'échelon local pour aider le lancement d’un projet sur la GTA;

• investir dans la gestion de l'information et des outils;

• aligner les politiques de haut niveau avec les stratégies locales

En termes généraux, les décideurs de haut niveau doivent prendre en considération les facteurs organisationnels afin de maximiser le succès de la mise en œuvre de stratégies de GTA

Implications pour des recherches futures

A la suite de ce travail, il serait intéressant de mener une enquête plus approfondie sur la valeur d’organismes tiers et neutres, une idée évoquée par plusieurs de nos interviewés comme étant favorable à la GTA Des études de cas approfondies menées dans les organisations de santé, ó des stratégies de gestion des listes d'attente ont réussi ou échoué, devraient également être considérées

Il est important de souligner que quelle que soit l’étude menée dans ce domaine, les chercheurs devraient être vigilants dans la définition du temps d’attente Enfin, cette étude a porté sur les soins programmés, mais les facteurs identifiés ici peuvent être également applicables aux soins de santé primaires, aux soins de longue durée, à la santé mentale ou à d'autres domaines des soins de santé ó ils existent des longues files d'attente Pour ces domaines, d’autres facteurs additionnels pourraient être identifiés, ce qui justifie la nécessité de faire des recherches plus approfondies

Conclusion

La présente étude exploratoire a été menée en vue de comprendre les facteurs qui favorisent ou entravent la mise en œuvre des stratégies de gestion des temps d'attente L'examen systématique d'articles publiés dans des revus avec comité de pairs ainsi que nos entretiens complémentaires avec les principaux décideurs politiques et les décideurs impliqués dans la gestion des temps d'attente au Canada ont permis d’identifier un certain nombre de facteurs clés

Les prochaines étapes exigent des décideurs et des responsables politiques de prendre en considération certains de ces facteurs, et pour les chercheurs de mener d'autres études pour mieux comprendre l'impact et l'interaction de ces facteurs en fonction de leur influence sur la mise en œuvre de stratégies de GTA

THE REPORT

“Often forgotten in policy discourse, but necessary for a successful outcome, is the

approval of the implementers.”

Hanning M., and Spånberg, U., 2003

1 INTRODUCTION

For the past two decades, access to healthcare services has been a critical issue both in Canada and abroad1 Long waits for core specialized health care services have been consistently identified as a key barrier to care,2,3 and governments and organizations at all levels have responded by adopting a range of strategies to better manage waiting lists

In September 2004, Canada’s First Ministers committed $5.5 billion to timely access in five healthcare areas over a ten-year period4 In June 2005, the Supreme Court of Canada struck down Quebec’s ban on private insurance for Medicare-covered services (the

“Chaoulli decision”) in a bid to reduce wait times in the province And in April 2007, the federal government announced that it would provide $612 million to provinces that would commit to respecting maximum wait times for at least one medical procedure performed in their jurisdiction5 These initiatives show that over the past three years, Canadian decision-makers have consistently seen the centralization of programs at the federal and provincial levels as the means to solve problems of waiting lists and waiting times6

While these initiatives are promising, it is our opinion that insufficient attention has been paid to the ways that healthcare organizations themselves have implemented strategies to reduce waiting lists and wait times While the literature has analyzed a variety of strategies7,8,9 seldom does it discuss the ways that that those strategies were implemented10 or the key factors associated with their failure or success

Accordingly, we conducted an exploratory study with a view to understanding the factors that enhance or impede the implementation of national, provincial, regional or organizational wait time management (WTM) strategies at the organizational level Our research was funded by CIHR as a “Research Synthesis: Priority Health Services and Systems Issues” under the topic “Timely Access to Health Care for All” This report describes all components of the study

1.1 Aims and objectives

The purpose of this project is to synthesize the existing intelligence regarding the measurement and the management of waiting times for specialized and diagnostic services in an effort to identify key contextual and organizational determinants of successful waiting time management

The specific objectives of the project were to:

1) Conduct a systematic review of the international scholarly literature that focuses on policy and organizational determinants of waiting time management at the organizational level;

2) Supplement gaps in the literature with interviews with key policy and makers involved in the management of waiting times in Canada and build a library of case stories;

decision-3) Synthesize the information thus gathered in order to identify the policy and organizational factors associated with the management of waiting times and develop a model;

4) Identify gaps in learning for future research

1.2 Significance of the problem

Access to health care services has been and continues to be an important issue in Canada While the Canadian Health Act guarantees Canadians reasonable access to medically necessary health care services, concerns have been raised regarding the timeliness of that access11 and long waits for key specialized health care services have been consistently identified as a key barrier to care12,13 Significant attention has therefore been directed toward the better measurement and management of waiting lists in principal problematic areas

Over the last decade, governments and organizations within Canada and abroad have adopted a range of strategies to better measure and manage waiting times But much of the work on waiting times in Canada has focused on the systematic level (provincial and federal-level structures) The role of regional health authorities and hospitals has often been ignored or downplayed, despite the fact that these institutions are directly responsible for initiating and implementing policies and strategies to improve timely access to care It is our position that the experience of these institutions can provide valuable lessons about the key determinants associated with successful measurement and management of waiting times If resources, financial or otherwise, are an important explanatory factor of health organizations’ action or inaction, it can also be hypothesized that governance structures, practices, organizational culture, data collection, and management patterns also count among the contributing factors

1.3 Background

1.3.1 What is a “waiting list”?

In their report to Health Canada, McDonald and colleagues (1998) defined a “wait list”, a

“waiting list” and “wait time” as a roster of patients awaiting a particular service Most such lists refer to elective (scheduled) services, although some exist for urgent and emergency services as well The lists are made when demand for a service exceeds the

available supply The term “waiting time” refers to the length of time between the moment that a patient is enrolled on a waiting list and the moment that s/he receives that service To define wait lists, therefore, is to define how and when patients are put on a given list and how and when he services are delivered With rare exceptions, waiting lists

in Canada, as in most countries, are non-standardized, capriciously organized, poorly monitored, and in grave need of retooling14 As a result, evidence suggests that waiting lists may be inflated by 20% to 30% by the presence of patients who have died, who have already received the procedure, who have declined the procedure, or who do not have know they have been scheduled During the last ten years, initiatives have sought to have waiting list data more carefully and accurately compiled and more routinely monitored

1.3.2 Measurement of waiting lists and waiting times

Standard and universally accepted methods to define and measure waiting lists and waiting times for a broad range of healthcare services do not currently exist15, 16.. One of the key recommendations of the literature has been the development of reliable and comparable waiting time data for a broad range of medical procedures so that patients, healthcare providers and governments can have a more accurate understanding of the extent and nature of waiting times15

Healthcare organizations seeking to provide better information about waiting lists and waiting times face a range of challenges Perhaps the first and most fundamental challenge is defining the waiting period, that is, the precise points at which the clock starts and stops To date, the primary focus has been on waiting times for hospital-based services such as elective surgery and certain diagnostic tests17 In some jurisdictions, a distinction has been drawn between Wait Time 1: the general practitioner’s referral to the specialist and Wait Time 2: the time between the visit to the specialist and the surgery itself In 2007, CIHI still reported that provinces varied in the definitions of waiting time segments they used to collect wait list data18

1.3.3 What do we know about factors relating to waiting lists and

waiting times?

Several hypotheses about the causes of waiting lists exist19,20 A first causative factor may be the data collection system used by a given institution It appears that decentralized responsibility for list generation, whereby lists are almost exclusively created in the offices of individual physicians or in hospital diagnostic departments, actually fosters the growth of waiting lists when compared to centralized lists generated

by a regional authority, for example21

A second cause implicated in waiting list growth is a reduction in resources But while it

is often assumed that resource reductions will lead to longer waiting lists, this phenomenon is far more complex than one might think In the United Kingdom, a study using data from a general hospital surgical department showed that a modest reduction in beds can lead to clear cost savings – but at the expense of a dramatic increase in waiting times22

Experts also debate the role of the healthcare funding system as a cause of increased waiting times In healthcare systems that are predominantly funded by the public sector, such as the systems of the United Kingdom, Canada, New Zealand and Australia, waiting lists are thought to be endemic Some experts explain this phenomenon as the product of non-market financing, that is, the divorce between the payment and the receipt of services23,24 In contrast, under the entrepreneurial American system, waiting is generally thought to be less common Countering these examples, however, is the French healthcare system, which although publically funded does not have this degree of concern

Another factor is technology The impact of developments in medical technology, though often cited as contributing to increased waiting, is not certain Some forms of technology clearly inspire the formation of lists In the early 1980s, for example, the introduction of the anti-rejection drug cyclosporine occasioned the rapid increase of heart transplantations25 At the same time, other technical developments in cardiac pharmacology created drugs that allowed some patients to be removed from transplant waiting lists26 The sudden appearance and wide dissemination of a serious new disorder can also contribute to the generation of waiting lists

Three other factors have also been suggested: physician behaviour, patient behaviour and

an aging population It is clear that physician behaviour has the potential to contribute to the development of waiting lists in several significant ways For example, it has been argued in the United Kingdom that the costs of efficiently managing waiting lists—administrators’ goal—in terms of updating, prioritizing, rescheduling cancellations, computerizing and so on, are chiefly born by physicians, who must contribute the time and effort required It has also been argued that a lengthy individual waiting list may actually be viewed as a testament to the special skills of a physician in comparison to his

or her colleagues27 The manner in which physicians organize their practices may also influence list formation It has been shown in the United States that patients wait longer for an appointment at a prepaid health maintenance organization that with a fee-for-service physician28 The patterns of physicians’ clinical behaviour may also contribute Referrals by general practitioners can be directed away from consultants with long lists

by informing the referring doctors of consultants with shorter lists29.Close monitoring of waiting lists within individual institutions or regions may reveal physicians with significantly different thresholds for placing similar patients on waiting lists30.Finally, when British physicians deliberately employed well-defined objective criteria for admission to a urology waiting list, the length of the list shrunk substantially31, 32

In some cases, patient behaviour may also be responsible for the lengths of lists and the time that individual patients spend on those lists Patients may choose to remain on lists

in order to see a specific physician33 or to secure admission to a preferred long-term care facility34 They may also fail to cancel scheduled outpatient appointments or booked surgery,35 which would have shortened waits for remaining patients In the United Kingdom, the auditing of waiting lists frequently uncovers patients who are found to have

already received care elsewhere without having removed their names from the original list36

Finally, with respect to the ageing of the population, many of the services for which there

is contemporary concern about growing lists, such as cataract surgery or joint placement, are services that are predominantly associated with older patients The growth of the elderly population has for that reason caused concern that the associated demand for constrained resources has also contributed to the growth of waiting lists

1.3.4 What is a waiting time management initiative?

A waiting time management initiative is an initiative that targets the reduction of wait time for access to healthcare services In this study, we look more specifically at initiatives that target access to scheduled care In Canada, investments have been made to increase capacity and improve information technology37 Examples of initiatives to increase capacity at the local level include increasing the number of healthcare providers, expanding their hours of operation, investing in medical technology and developing coordinated care processes and practice guidelines to increase patient throughput Information technology investments have targeted the better measurement, reporting, monitoring, and managing of waiting list and waiting times and the evaluation of program performance Examples of these kinds of investments include the implementation of central wait list registries, operating room booking systems and information systems to track performance against wait time targets Other types of initiatives to control demand include the implementation of clinical assessment (prioritization) tools and clinical appropriateness guidelines

1.3.5 Determinants of the success of WTM strategies

Change is a notion that evolves over time to reflect different current approaches, models and theories Generally speaking, the notion of change conjures up the idea of modification, limited in time and space, with one or more parameters

The volume of literature related to the determinants of organizational change is extensive and the conceptualization of the parameters that an organization can change varies by author38 Guilhon39 speaks of transforming structures and competencies Miller, Breenwood and Hinings40 view change as a redirection of strategy, structure or culture Mintzberg, Ahlstrand and Lamel41 suggest that change may focus on strategy, i.e vision and staff In the literature on innovation, we also see change as the introduction of an idea

or behaviour that is new to an organization42,43,44,45 It can take the form of a product, a service, a technology, a program, a policy or a process

For this study, we considered the implementation of waiting time reduction strategies as both a type of change introduced at the organizational level and a health policy We aimed to identify the type of determinants or factors that influence the success of implementation

To organize these factors, we used Parson’s social system action theory to evaluate how different factors interact and affect outcomes at both the local and the contextual level Accordingly, we created a conceptual framework based on Parsons’ widely recognized four quadrant model46 The Parsonian perspective corresponds to a structuro-functionalist view of organizations and focuses on the four functions required by organizations to survive: goal attainment, environmental adaptation, production and culture For presentation purposes, we have modified the sequence of the dimensions in Parsons’ paradigm

The four dimensions used for this model are as follows:

- Governance factors (goal attainment and environmental adaptation), defined as

“the conduct of collective action from a position of authority”47;

- Cultural factors (culture), defined as “underlying beliefs, values, norms and

“Local level” refers to the service delivery level that coordinates patient care Examples

include hospitals or similar institutions and for some provinces, health authorities In this report, the terms “local factors” and “organizational factors” are used interchangeably Local or organizational level factors refer to factors that can be mobilized by the governance body, the management team or clinician teams

But the success of waiting time management strategies are influenced by more than just local factors such as an organization’s culture, governance, resources and tools

Organizations work within a context and factors at the national and regional levels also

need to be taken into account Examples of contextual-level factors include wider

economic conditions, national or provincial legislation and policies, and national human resource shortages

Combining the two levels of analysis (contextual and local) with the four dimensions of determinants at each level produced the following model (Chart 1):

Chart 1: Conceptual Framework

1.4 Structure of this report

We have divided this report into five sections The first section focuses on the literature

review It states the questions addressed by the review, outlines the methods developed

for our search strategy, explains the selection criteria, the data extraction and the data synthesis processes, and presents the findings and key results The second section reports

on the interviews conducted with healthcare policymakers and decision-makers, describing methods, findings, and key findings The third section on the interpretation of

the results presents a synthesis in the final framework, a summary of all the factors

identified within each dimension at both the local and the contextual level, and discusses the points of convergence and divergence between the data collected in the literature and

the data from the interviews The fourth section looks at the policy implications of the findings and the fifth and final section suggests future research that would further our

understanding of organizational determinants of the success or failure of WTM strategies

2. SYSTEMATIC LITERATURE REVIEW 

2.1 Methods

2.1.1 Establishing the search protocol

The specific objectives of the systematic literature review were as follows:

¾ To identify the factors that impact WTM at the local level

¾ To understand how local / regional / national factors that impact WTM intersect with policies and strategies at higher levels of the healthcare system

To meet these objectives, we asked the following two questions:

1 What factors impact WTM at the local level?

2 What policies and strategies at different levels of the healthcare system intersect with the factors that impact WTM at the local level?

We began by establishing a list of databases based on previous literature reviews and on the suggestions of experts in the field This list comprised six medical databases and 19 non-medical databases (refer to Appendix 1) Our search criteria targeted articles published between 1990 and 2005 1990 may seem an early parameter but we wished to capture some of the earlier work done on waiting times, especially in the United Kingdom

The key words for the search strategy were developed in accordance with the research questions and the framework’s four categories of determinants A librarian specialized in literature reviews and in the field of waiting times helped the research team select search terms and develop search strategies for each electronic database

Checking the reference lists of key studies retrieved complemented the databases searches and helped to ensure that no important studies were missed

The results for each search were downloaded to a reference manager and then uploaded into SRS (TrialStat), the web-based systematic reviewing platform used for this study

2.1.2 The search strategy

2.1.2.1 Searching medical databases

Six medical databases were searched: CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, Healthstar, Medline (including Medline in process)

Lists of keywords relevant to waiting times management were developed in consultation with the research team and through an initial pre-search for relevant articles Keywords including waiting lists, wait times, queus were combined, using the Boolean operator AND, with terms reflecting relevant management issues such as policies, information

systems, budgets, health priorities, patient referral, health care delivery and personnel management

These keywords were used to create a search strategy in MEDLINE This strategy then underwent repeated testing, using both a set of key articles previously identified in our grant application and sample abstract scanning by the research team, until we were satisfied that the search strategy was well balanced in terms of both sensitivity and specificity

As waiting time management in transplantation, emergency department and psychiatric care differ significantly from waiting time management for scheduled care, we decided to exclude articles that focused on these three domains

Additional search strategies to complement the search outlined above were also developed for the medical databases to ensure that we captured all relevant articles on waiting time management in Canada and all studies that dealt specifically with elective surgery and diagnostic imaging Diagnostic imaging and elective surgery were selected for additional searches as they are specific fields of interest for this study These search strategies differed from the one outlined above in that we were less concerned with specificity and more concerned with the sensitivity of the search With these searches,

we were willing to accept a lesser degree of precision if it resulted in a comprehensive capture of all relevant studies

A record of each search strategy is provided in Appendix 2

A total of 4682 articles were generated by the main search Of these, 2766 articles were duplicates, yielding a final count of 1916

The three additional searches yielded 3517 articles Of these, 918 were duplicates The final count was 2599 articles See Appendix 4 for a summary of the results retrieved with each database searched

2.1.2.2 Searching non-medical databases

An initial exploratory search of non-medical databases revealed that relevant references could be found in the databases selected

The 19 non-medical databases searched included Canadian math, engineering, economics, sociological and multidisciplinary databases See Appendix 1

Using the MEDLINE searches outlined above, a variety of search strategies were developed to take advantage of each database’s unique searching functions A record of each search is provided in Appendix 3

2.1.2.3 Searching French databases

To search the Repère database, we translated the general terms associated with “wait

times” and “wait list” into French To do this, we used the dictionary and the key terms

of the French database After narrowing our search to health, we found two references

2.1.3 De-duplication

The results from each database searched were downloaded into Reference Manager and then uploaded into SRS (TrialStat) SRS (TrialStat) was used to identify and eliminate duplicate references

Table 1: Number of articles by database and search types

before and after de-duplication Type of Search

Total number of references before de- duplication

Total number

of references after de- duplication

Number of duplicate references removed

Percentage of duplicate references*

* Note: Percentage of duplicate references = Total number of duplicate references removed / total number

of references before duplication (e.g.: 1758/4682=0.375)

2.1.4 Screening

The research team developed screening tools through discussion and testing Screening for articles was then systematically performed by two reviewers who used the web-based systematic reviewing platform SRS (TrialStat)

Basing themselves on the objectives of the research synthesis and on the research questions, the research team developed inclusion and exclusion criteria through an iterative process at each level of screening Criteria were refined according to the results

of the testing of the criteria against sets of articles reviewed by all five members of the team This process allowed the reviewers to develop a common interpretation of the criteria Some considerations for the efficient use of the software were taken into account

in terms of how the questions were prioritized and laid out In the end, the team conducted four levels of screening (see Appendix 5)

LEVEL 1

Objective: To exclude all articles that were obviously irrelevant

The research team established a list of inclusion criteria (see Table 2) Two sets of 20 articles were reviewed by all team members to validate this first set of criteria To ensure the consistency of interpretation at the first level of screening and to calculate initial KAPPA scores between reviewers, another 200 references from Embase were screened

by combining different pairs of reviewers (100 articles reviewed by each reviewer) Out

of 5205 references, 1044 were passed (20%) and 4158 were excluded (80%)

Table 2: Initial Inclusion Criteria Criteria Inclusion

Coverage Any article that referred to waiting time management for scheduled

care (non-emergency acute care facility-based procedures)

Publication types Peer-reviewed and non-peer-reviewed journals

Language Any language with an abstract in English or in French

Study period 1990 to 2005

Study design Any study design (qualitative and quantitative/survey)

LEVEL 2

Because of the unexpectedly high number of references that remained after the first level

of screening (1044 references), we elected to exclude articles in non-peer reviewed journals, articles written in languages other than French and English, articles identified as comments, newspapers articles and reports Peer reviewed journals were identified by using a pre-established list of peer reviewed journals from the School of Management at

the University of Ottawa and by searching the Ulrich Periodical Directory™, a bibliographic database that provides detailed, comprehensive, and authoritative information on serials published throughout the world Some journals that had published

numerous relevant papers were not peer reviewed, so we contacted the editors of Nursing

Standard, Nursing Times, and Health Services Journal directly We also contacted

Longwoods Publishing for Healthcare Quarterly and Healthcare Papers The list of all

the journals identified in our systematic review and their peer-reviewed or reviewed status is provided in Appendix 6 Of the 1044 references identified in the first level of screening, 619 (60%) were from peer reviewed journals

non-peer-LEVEL 3

With 619 references still remaining, the research team again reviewed the titles and abstracts against the same criteria as was used in the first level screening, this time excluding all articles that were not directly linked to wait time management The number

of references was thus reduced to 206 (67% articles were excluded)

LEVEL 4

Two hundred and six full articles were thus retrieved and screened by two reviewers Those articles not excluded were divided into various categories that corresponded to whether they presented a model or described a strategy, whether the strategy was started

at the organizational level, the regional level or a higher level; and whether the articles presented organizational factors that had influenced WTM strategies either explicitly or implicitly (See Appendix 5 for the screening form that outlines inclusion and exclusion criteria) Once this screen was completed, we selected the articles that explicitly stated organizational factors The inclusion criteria according to which these articles were selected are presented in Table 3

Table 3: Final inclusion criteria

Criteria Inclusion

Coverage o A model or a framework with WTM factors at the organizational level

o An organizational or regional initiative that specifically addressed wait times or wait lists; the article explicitly states organizational and possibly contextual factors that impacted WTM

o Higher level (national or provincial) strategies or policies that addressed WTM as described; an article that explicitly identifies how organizational-level factors impacted the implementation of a

strategy/policy

Publication types Peer-reviewed publication only

Language French or English

Study period 1990 to 2005

Study design Any study design (qualitative and quantitative/survey)

To summarize the above, we began with 5202 abstracts and after three levels of screening, produced 206 full articles to review (Table 4) Of these 206 articles, we conducted a fourth level of screening and retained 31 articles to be abstracted (see Appendix 8 for the full list of abstracted articles, together withtheir reference numbers as used in the text)

Table 4: Number of records for each screening level

articles before screening

Number of articles passed

Number of articles excluded

Level 2 – Peer reviewed journals 1044 619 (60%) 425 (40%) Level 3 – Refining selection 619 206 (33%) 413 (67%)

Level 4 – Full article review 206 31 (15%) 175 (85%)

2.1.5 Data abstraction

Data abstraction was qualitative and was performed by four members of the research

team using SRS (TrialStat) The principal investigator reviewed all abstracted data The

abstraction form was a custom-designed template that had been tested on a sample of

articles Whenever possible, reviewers used quotes to describe initiatives, and for all

factors identified in the articles, added page and paragraph references (see Appendix 7 for

the data abstraction form)

2.2 Results from the literature review

2.2.1 Overview of the selected articles

As previously explained, a total of 31 articles met the inclusion criteria Although all the

papers retained for abstraction explicitly included implementation factors at the local

level, the wait time strategies described in the articles had been initiated at any level

(local, provincial or national)

All studies had been published in peer reviewed journals Twenty nine articles out of 31

had been found in medical databases, and two had been found in non-medical databases

(Table 5)

Table 5: Number of abstracted articles retrieved from each database

Name of database and (search

strategy)

Article Number Number of

articles found

Percentage share of all 31 articles found

EMBASE (broad search limited

Over three quarters of the articles selected had been published after 1996 (see Table 6)

Close to half of the articles (45%) had been published in the United Kingdom Four

papers describe initiatives in Sweden; three of these were from the same authors Only

one of the articles described a Canadian initiative (Table 7)

Table 6: Number of articles abstracted by year of publication

Year of publication Article number Number of

articles found

Percentage share

of all 31 articles found

1996-2000 1, 6, 7, 8, 9, 11, 12, 13, 14,

16, 18, 28

12 39% 2001-2005 2, 3, 4, 5, 10, 15,

17, 19, 20, 25, 26,

27, 29, 30

14 45%

Table 7: Number of articles by jurisdiction

articles found

Percentage share

of all 31 articles found

Strategies were initiated either at the local level, i.e in healthcare organizations, or at a

higher level, i.e the national or the provincial level (Table 8) At the local level,

strategies included work reorganizations, increases in capacity and the development of

software for data collection or the simulation of waiting lists At the national level,

strategies included the implementation of a booking system and maximum waiting time

guarantees (see Table 9) These strategies covered a broad range of clinical areas, such as

orthopedics, eye care and cardiac care, and many covered general surgery or spanned

many domains We noted that none of the studies covered medical imaging, where a

waiting time problem has been identified and which area was specifically included in our

research question (Table 10)

Table 8: Number of articles per level at which the strategy was initiated

articles found

Percentage share

of all 31 articles found

Higher level strategies

Table 9: Number of articles per strategy described

articles found

Booking systems (the United Kingdom and New Zealand) UK: 10, 20,

Work reorganizations at the local level 1, 15, 19, 24, 27 5

Software development for WTM (includes simulation) 7, 8, 26, 31 4

Table 10: Number of articles per clinical area affected by the initiative

Clinical area of the initiative Number of articles

2.2.3 Methodology used by the selected articles

Most articles used a case study methodology (19), a few were multiple case studies (4), and some combined a case study with a survey (2) There were also a few pre-

strategy/post-strategy comparisons (6) and a few time series (2) (Table 11) Only eight studies articulated a theoretical framework (Table 12) and only six defined the waiting time period they used (Table 13) Definitions of waiting times as found in the articles are detailed in Appendix 9

Table 11: Number of articles by methodological approach

Methodological approach Article number

Number of articles found

Percentage share of all

31 articles found Case study – single,

descriptive/ qualitative studies

1, 2, 3, 5, 6, 7, 12, 14, 15,

16, 18, 19, 21, 22, 23, 26,

27, 28, 31

Percentage share of all

31 articles found

Table 13: Number of articles that defined the waiting period

Definition of the waiting time Article number

Number of articles found

Percentage share of all

31 articles found

Table 14: Factors identified by each article according to dimension and level

Article

Level of

Local Contextual Local Contextual Local Contextual Local Contextual

Article

Level of

Local Contextual Local Contextual Local Contextual Local Contextual

Percentage of articles with at least

one factor identified the

dimension and level indicated

(%):

UK = The United Kingdom

2.2.5 Local-level factors

As previously mentioned, the local level refers to service delivery level entities such as hospitals, other care-delivering institutions, or for some provinces in Canada, health authorities that coordinate patient care The local level is different from the contextual level, which refers to national and regional-level factors such as wider economic conditions, national or provincial legislation and policies, and human resource shortages

The local-level factors are presented here are organized according to the four dimensions

of our conceptual framework

2.2.5.1 LOCAL-LEVEL GOVERNANCE

Leadership was the most frequently cited factor This factor is related to governance and

was found in five articles (10, 19, 20, 26, 31) “A good example was one of the pilots

chosen as a case study (pilot 16) whose leadership by the chief executive of a health authority over a number of years in making the services accessible and responsive, was instrumental in enabling booking to be introduced across a wide scope of activities” (10, p.431)

In one article published in the United Kingdom, leadership was actually said to be

essential: “Effective local leadership by trusted chief executives, senior clinicians, and

project managers is essential to support change” (20, p.5)

Four articles stressed that a dedicated project

group (19), pilot team (26) or project manager

(10, 20) were key factors for success All stated

that these factors had had a positive impact on

moving the strategy forward Four other factors

were mentioned positively: support from the CEO

(10), liaison between primary and secondary care

(14), effective organizational design (26), and

accountability of clinicians (24)

Other factors were identified as having had a

negative impact on the implementation of a WTM

strategy These included mergers within

organizations (20) and, in New Zealand, the

complexity of the contract process, which splits

the purchase and the provision of services (9)

“Improved liaison between primary and secondary care is

a key factor in booking systems implementation” (14, p.72)

“The pilot team oversaw the transition from a paper-based system to a real time intranet network” (26, p.35)

“These clinicians are invested with the responsibility and accountability for ensuring that predetermined outcomes, developed by the

multidisciplinary team, are achieved” (24, p.97)

It is interesting to note that no references to the role of the governance body were made in any of the articles retrieved

2.2.5.2 LOCAL-LEVEL CULTURE

As Ham et al (2003) point out, “the fact that some of the pilots in our study made more

progress than others, even though all had to overcome the conservatism built into professional practices, suggests that organizational cultures do have an impact on the implementation of quality improvement initiatives like the booked admissions program”

(10, p 432) Definitely the most recurrent cultural factors found in our study related to physicians’ involvement and attitudes towards WTM strategies Eleven articles, approximately one third of those analyzed, mentioned this phenomenon in one way or another (2, 7, 9, 10, 11, 13, 14, 17, 18, 19, 20, 25) For example, some doctors were reported to be skeptical of the strategy proposed (9) while others showed little interest in shortening the lists (9, 11) One study on the implementation of generic waiting lists for cataract surgery mentioned that “most of the consultants had reservations” (17) One study even reported resistance, albeit not necessarily wide-spread resistance, to the WTM

initiative on the part of some hospital physicians: “The Patient Bridge revealed

significant, but unevenly distributed, resistance among hospital physicians” (2, p.324) In

another article, a survey on pooled waiting list for cataracts revealed that 67% of the ophthalmologists surveyed were against the list, while most GPs were in favour (25)

Also, “Consultants’ reluctance to change established ways of working and to give up

their freedom to determine relative priority was also widely reported to have slowed the implementation of booking” (20, p.4) And in a different article that commented on the

same study, we read, “It is especially important to engage physicians in quality

improvement and, as in the booked admissions program, to support the innovators in demonstrating that change is possible” (10, p 437) Yet another study emphasized the

need for physicians’ support to avoid resistance: “because doctors (as professionals)

work with considerable independence, the implementation of any policy requires their support” (7, p.174)

Among cultural factors that facilitate the implementation of WTM strategies, we found factors such as focusing on a culture of quality improvement (24) and embracing

innovations: “Without a management team prepared to learn and adopt production

management theory the quick resolution of the critical situation would not have been possible”(15, p.245) Other determinants included a patient-centered culture (24); a

system that was flexible enough to accommodate clinicians’ preferences (20, p 4-5); good organizational memory within a learning organization that built on past achievements (24); and the presence of unified organizational values, norms and beliefs shared by all employees and professionals, with few differing and competing sub-cultures Implementation of new strategies was made easier when staff members

embraced the innovation: “Staff in the clinical units led the change process but were

supported by others willing to run with the vision” (24, p.98) In another study, the

“collective realization that innovation was needed to correct the problem” contributed to

the success of the implementation (26, p.35) A culture that emphasized staff participation, as exemplified in the implementation of a unit assessment tool to optimize patient flow (26, p 34), was also shown to have facilitated change

Trust was another important factor The lack of trust between managers and clinicians when they are not involved in changes affecting clinical decisions was shown to be sometimes detrimental to the implementation of an initiative (5) In the same study,

distrust between managers and physicians was also highlighted as resulting in feelings

that physicians “have been disenfranchised and have no influence in policy or strategic

decision making” (5, p 68) However in a different study, management expressed its trust

that nurses would maximize the use of beds in order to help implement a new tool for

patient flow (26):“Staff affected by quality improvement programs must be able to see

that they, as well as the patients, will benefit from the changes” (10, p 435)

Finally, one of the articles also emphasized that one should not underestimate “the

importance of allowing time for change to occur and of building up the capacity for change and reform within hospitals and other health care organizations” (10, p.437)

2.2.5.3 LOCAL-LEVEL RESOURCES

The most commonly found local-level factors found in the literature consisted of factors related to infrastructural, human or financial resources (see Table 14) Flexible and adequate capacity was key to the successful implementation of WTM strategies More

specifically, insufficient infrastructural resources were mentioned in several articles (7,

20, 26, 30) as a limiting factor Capacity constraints, both in the operating room and for post-surgery beds (10, 29), were highlighted as hindering the implementation of WTM strategies One study reported that surgical capacity was increased to meet wait time

guarantees (18) Decreasing bed blocking also enabled more operations (11, 13): “It is

likely that the extra capacity from fewer bed blockers has contributed substantially to the increased number of operations Hospital beds are no longer regarded as a bottleneck as was earlier the case in some hospitals” (11, p.31) In the United Kingdom, “the availability of extra funds helped establish booking by investing in […] equipment.”(10, p.429) These measures helped organizations create flexible and adequate capacity

“Interviews with participants testified to the

importance of these arrangements, particularly

full-time project managers dedicated to

introducing booking and sustaining it beyond

the end of the pilot period” (10, p.427)

“A field coordinator played a critical role in

instructing and coaching surgeons on how to

get immediate real-time feedback on data they

submitted” (3, p.200)

On the human resources side, one

third of articles underlined the importance of appropriate levels of dedicated staffing to the WTM initiative (3, 4, 7, 10, 15, 16, 19, 22, 21,

26, 29) Some mentioned the key role

of a dedicated project manager or coordinator (see quotes, left) An

appropriate staff level prior to the

initiative also contributed favorably to

one initiative: “Our [department] must be considered to be well-staffed and resourced

[…] by UK standards In such circumstances, one would expect such an outcome from a well-run initiative, but one could not necessarily expect the same in a department with less initial resources” (21, p.406)

A few articles pointed out that the contrary is also true: “This was due to the limited

opportunities the sites had to find the resources the model suggested would be required.”

(7, p177) Both being short of professional staff (15) and only being able to recruit for a

short time (9) limited institutions’ ability to implement new strategies: “If the contract

system had a longer-term focus and hospitals could offer staff contracts for 3 years instead of 6 months or 1 year, then opportunities to perform additional procedures would

be enhanced in the context of booking system initiatives”, which initiatives involves

much planning ahead (9, p.268) “This is compounded by a shortfall in the number of

surgeons and operating list space, compared with the demand for this service” (29,

p.281)

On the financial resources side, incentives at the individual or the unit/team level were

also cited as contributing to the success of the outcome One example was the purchase

of computers that allowed doctors to schedule patients directly (10, p.429) Disincentives can also be powerful, as in Sweden where hospitals ran the risk of being forced to send patients elsewhere at the hospital’s expense if the hospital did not meet waiting time guarantees (11,12) It is also true however that what may be attractive to providers may

be unattractive to those who purchase the services (23)

2.2.5.4 LOCAL-LEVEL TOOLS

Organizational tools are instruments or procedures used at the organizational level Examples are intranet systems (26), websites that post tools for GPs and allow doctors to

communicate (19), and CQI tools that help implement initiatives (24) “With the

integration of continuous quality improvement and a customer focus into service delivery, quality patient outcomes are the impetus for change” (24, p.15)

The most commonly cited tool was an information management system set up to meet high information demands around the WTM initiative Examples are databases for recording information (2, 19, 7, 20, 16) and scheduling software (14, 9) Interestingly, it was noted that overly complex systems constituted barriers to the implementation of

WTM strategies (20) “Pilot sites [with] complex information and communications

technology […] were at a disadvantage.” Simple, easy to use, user-friendly, and effective

solutions for information presentation were lauded, as was system flexibility in the case

of information systems implemented over a region or country (6, 7) It was also important that those concerned be able to access relevant data (7) and that the data be “clean” (11)

Training and support was the most cited important tool The increased use of quantitative information made it important to train staff to analyze basic statistics and time series data and to obtain a basic understanding of spreadsheets (6, 7) Training in the redesigning of services, undertaken by a national team, also took place (10)

Some tools that were useful, especially for GPs, included pro-forma referral guidelines and referral letters for GPs to use (19) More clinical instruments were also mentioned, namely the Harris Hip Score and the American Knee Society Score These were used as scoring instruments for hip and knee joints arthroplasty (16) or as criteria for determining which patients were appropriate for placement on a pooled waiting list (17)

2.2.5.5 LOCAL-LEVEL FACTORS SUMMARY

Below is a summary table of some of the more prominent local-level factors for each of the dimensions in the framework, as identified in the literature review

Table 15: Local-level factors that promote or inhibit the implementation

of wait time management strategies in healthcare organizations

(summarized from the literature review)

2.2.6.1 CONTEXTUAL-LEVEL GOVERNANCE

The first contextual-level governance factor highlighted by the literature review was the need for high level (i.e central) coordinating, reporting, and monitoring structures (9,10,14,18,31) Project groups or committees at a high level such as England’s National Patients’ Access Team (NPAT) (10) positively affected outcomes at the organizational level Reporting was part of all agreements between regional health authorities in Sweden (18) and dedicated monitoring policy structures, which highlighted regional differences, as also effective (9) Political support for these structures was also a factor (31), and the absence of political support was seen to discourage players from sustaining the effort to implement a new WTM initiative (13)

Another positive contextual-level government factor identified in the literature was stakeholder engagement, whether the involvement of professional associations such as a provincial orthopaedic association or the involvement of other partners such as patients

(23) or Ontario’s Ministry of Health and Long Term Care (3) Stakeholders were solicited for information on data (18), for advice on existing processes, for their ideas for improvements (9) and for ensuring reporting (18)

2.2.6.2 CONTEXTUAL-LEVEL CULTURE

Although the literature identified few factors in this category, consultations with line actors nonetheless surfaced as having contributed to the implementation of WTM initiatives (9,10,13,17,18) At this level, physicians’ involvement and consultation with doctors was shown to be a positive factor Physicians’ perception of an initiative and its

front-relevancy to themselves was likely to have contributed as well: “In the early discussions

about [a national] register, the participating surgeons stated that if the compiled data proved to be valuable to participants after the first year, the registration should continue” (18, p.140)

Public awareness was also identified One article mentioned that “we have found it

important to convey clear information about the change to booking systems to the public

As good understanding develops, most people quickly recognize the advantages offered to patients” (14, p.71)

2.2.6.3 CONTEXTUAL-LEVEL RESOURCES

Found in over a third of the papers abstracted (2,3,5,9,10,12,13,14,18,19,20,21,22), funding was by far the most recurrent contextual resource factor Higher level funding was sometimes specific to an initiative (for example, to address backlog: 2, 5, 9, 22) and sometimes earmarked for a specific purchase, for example the purchase of information system equipment for data collection (3) An economic recession (11) or budget cuts (7) limited the financial resources available and by reducing funding levels, had a negative impact on the implementation of new WTM strategies In New Zealand, limited resources led to the increase of priority criteria thresholds for eye care, complicating the process of booking patients for treatment This affected the implementation of the WTM initiative

nation-wide (9, p.266)

At Sweden’s local level, counties received extra resources in the form of special grants earmarked to fund the guaranteed reform (13, p.21-22) These national-level incentives

were perceived as an important part of the program’s implementation (11, 12, 13) (''The

incentives that were introduced in the maximum waiting time guarantee mainly intended

to change the behavior of the hospital departments'': 12, p 183) However, “the increase

in the number of operations alone is insufficient to solve problems with long and varying waiting lists for elective surgery Applying similar indications and priority setting are equally important” (12, p.192); and so is providing adequate incentives to motivate all

units to implement the recommend priorities (12)

2.2.6.4 CONTEXTUAL-LEVEL TOOLS

At the contextual level, tools include instruments or procedures that affect more than one organization, such as the development and the implementation of standards and guidelines (5, 11, 12, 13, 14) The implementation of a central registry was identified as a

positive factor that allowed for the collection and standardization of data (11,13,14,18) Training is also considered a tool in this model, because it helps to implement a WTM strategy Training can be in specific professional skills or in management skills, for example in service redesign to enable a booking system (10, 20)

2.2.6.5 CONTEXTUAL-LEVEL FACTORS SUMMARY

Below is a summary table of the more prominent factors at the contextual level for each

of the framework dimensions, as identified in the literature review

Table 16: Contextual-level factors that promote or inhibit the implementation of

wait time strategies in healthcare organizations (summarized from the literature review)

Governance

ƒ Coordinating/reporting structure

ƒ Stakeholder engagement

Culture

ƒ Consultation with front-line actors

ƒ Public awareness

Tools

ƒ Collection and standardization of data

be met for the successful implementation of quality improvement initiatives in health care This model grouped the factors under six categories Two of the categories,

“national context” and “local context”, acknowledged the need to look at the system on more than one level This is also acknowledged in our model The authors also identified the dimension “culture and capacity”, which we have labeled “culture” and “resources” One of their other categories is “roles of physicians”, which like our study emphasizes doctors’ key role Lastly, their category “mechanisms of change” covers a collection of factors all of which have been classified in various dimensions in our own model (see Appendix 10)

2.4 Key findings of the literature review

Our key findings can be summarized in the following points:

1 Few articles explicitly addressed the factors that can enhance or inhibit the implementation of a wait time reduction strategy at the local level and no factors were identified for the field of medical imaging

2 Few studies were empirical: the majority was case descriptions with little rigorous generation or testing of hypotheses Nonetheless, two articles (10, 20), both of which were written by the same British authors and both of which were based on the same study, offered a comparative analysis between different sites that implemented a new booking system One of the articles (10) presented a model

of factors that influenced the implementation of the strategy

3 The studies focused more on evaluating the outcomes of WTM initiatives than on evaluating their implementation

4 Of the 31 articles that identified organizational factors that had influenced implementation, only 20 acknowledged contextual factors

5 An analysis of the factors that were most frequently cited in each dimension shows leadership to be key at the local level and present, but not key, at the contextual level Another highly recurrent local factor, this one identified within the culture dimension, was physician involvement in WTM initiatives Respect for physicians’ values and culture was also highlighted at the broader contextual level In the resource dimension, dedicated staffing is often mentioned at the local level but has no equivalent at the contextual level, where factors are concentrated around financial resources and funding Finally, and perhaps unsurprisingly, information management systems are found both at the local level and at the contextual level This can be explained by the fact that all levels require better data in order to better manage the wait times

6 Not all the same factors were identified at the local and contextual levels Some local factors not found at the contextual level were a decision-making and management structure dedicated to wait time management; trust between managers and clinicians; a quality improvement culture within the organization; and adequate infrastructure capacity supported by higher-level funding

7 The only theoretical framework identified in the literature referred to booking systems The elements of this framework are reflected in the elements of our model but were not organized according to different decision-making levels (local and contextual)