Winnipeg, Manitoba
December 7, 2005
Co-chairs: Morris Barer, CIHR Institute of Health Services and Policy Research (IHSPR); Brian Postl, Federal Advisor on Wait Times.
Participants: Alan Bernstein, President, CIHR (opening remarks); Arlene Wilgosh, Deputy Minister, Manitoba Health and Manitoba Healthy Living (morning only); Peter Glynn, co-Chair, Saskatchewan Surgical Care Network and Senior Advisor, Ontario Wait Time Strategy; Charlotte Johnson, Health Canada; William Mackillop, Queen's University Cancer Research Institute; Dwight Nelson, CEO, Regina-Qu'Appelle Health Region (by phone); Geoff Porter, Cancer Care Nova Scotia; Vivian Sandberg, Health Canada; Mark Taylor, Department of Surgery, University of Manitoba; Jack Tu, Institute for Clinical Evaluative Sciences; Diane Watson, IHSPR.
Presenters: Tom Noseworthy, Director, Western Canada Waiting List Project; Claudia Sanmartin, Statistics Canada; Ben Chan, CEO, Health Quality Council (by phone); Michael Rachlis, Health Policy Consultant, Toronto.
Facilitator/Rapporteur: Steven Lewis, Access Consulting Ltd., Saskatoon.
Timely access to quality care for all has emerged as a priority theme for health services and policy research. The purpose of this invitational workshop was to discuss and begin to provide more specificity to the strategic research and knowledge translation agenda for this topic over the next five years. This is one of a number of inputs into the development of a long-term research agenda on this topic, and is intended to become a source of recommendations on investment priorities.
The First Ministers' commitment in the 2004 Ten Year Plan to developing benchmarks for wait times in five key clinical areas is recognized as a starting point for improving timely access for all appropriate health care services. While the First Ministers will act in the short term to reduce excessive wait times in critical areas, there is a need for research to refine understanding of both the root causes of wait times, and the most cost-effective techniques for streamlining health care delivery.
Recently, the Federal/ Provincial/Territorial Ministers of Health agreed to "undertake a joint research program to develop a body of clinical evidence that demonstrates how wait times affect patients' health. This program would build on the work that has already been undertaken by CIHR. With the benefit of this research, federal, provincial and territorial governments can develop better approaches to review and assess clinical evidence in support of wait time benchmarks."1
The participants and presenters represented clinicians, managers, researchers and policy makers. They agreed on a number of key elements of a strategic research agenda, including:
Continue to inform the development of benchmarks
While it is crucial to act immediately to reduce wait times-particularly the "long tail" of the distribution curve, where people are waiting too long by any measure of acceptability-it is also important to refine our understanding of how waiting affects quality of life and clinical status before an intervention, and outcomes after, and to broaden the range and rigour of inputs that inform the development of benchmarks. For example, it is important to achieve a deeper understanding of public and patient perceptions and expectations with respect to timeliness and the consequences of waiting. Existing evidence may be used to identify areas or services deserving of future benchmarks. We should also be aiming for the use of common, compatible approaches and metrics in the development of future benchmarks.
There may also be a need to prospectively validate across Canadian contexts, and possibly refine, the recent national wait time benchmarks. To determine whether they are clinically valid when used for management and decision-making in real-world settings, the clinical consequences for patients who receive care within the benchmarks, compared to those who don't, must be studied.
Address appropriateness
Timely access to unnecessary or poor quality care is no achievement. If benchmarks and targets are to be reasonable, meaningful, equitable and health-improving, there will have to be standards and common approaches to determining where an intervention is, all things considered, warranted, and identifying when a patient truly needs to be on a wait list. Factors that inform appropriateness include age, acuity, estimated duration/extent of benefit, and additional risk factors: it will be important to understand the generic aspects of appropriateness for a particular intervention and the effect this might have on prioritization of cases on a wait list. The research should investigate the issue of risk tolerance and risk management, particularly in areas such as diagnostic imaging where the indications for tests are often inconclusive until after the fact, and the benefit ranges from reassurance for the anxious to more efficient and effective interventions. Failure to address appropriateness greatly reduces the likelihood of reaching durable and sustainable solutions to access issues.
Identify the nature and mix of causes of wait time problems
Waiting results from a combination of shortages of physical capacity; shortages of health human resources; unrealized opportunities to improve the "process flow" efficiency of service delivery (i.e. to reduce permanent or smooth temporary supply-demand mismatches); and spatial-geographical, personal/family and/or financial barriers to seeking or receiving care. We know, increasingly, where wait time problems are most prominent and how long waits are for various services. Yet the root causes of waits are likely to vary by geography, by clinical condition and by delivery site; thus solutions will need to vary accordingly.
Health care systems are complex and some patient processes involve many steps through community and institutional services of different types in different locations. The greater the complexity, the greater the likelihood of bottlenecks, redundancies, miscommunications and vulnerabilities to long waits. While the causes of waiting will be somewhat different in local contexts and for different conditions/procedures, comprehensive research programs should be able to identify some general features and lessons that will be widely applicable. Without these investigations into root causes, and the translation of such knowledge to inform system-, region- and institution-level management of wait times, we run the risk of continued patchwork solutions that may be ineffective or, worse, exacerbate existing problems.
Identify the processes and flows that contribute to wait times
Health care involves the movement of people and information, and the use of physical space and other forms of capital. Our understanding of wait times can be improved by examination through the "lens" of these traffic flows. A strategic research agenda should incorporate the insights and expertise of operations research, which has helped many other industries to improve productivity and quality.
This research may be evaluative, by examining the impact of applying operations research and modeling to health care or more fundamental, by understanding how to adapt these techniques to the health care sector. For example, an analysis of jurisdictions that have implemented successful queue management techniques in specific clinical areas could identify barriers to and facilitating factors for change for similar programs in Canada.
Examine how organizational design, policies and incentives affect wait times
Organizational design, policies, payment methods, reward systems and other incentives affect health provider behaviour and performance. As elsewhere in the health care system, some incentives are aligned with goals for wait list reduction in target areas while others work against them. Focusing exclusively on the mechanical aspects of waiting omits a critical aspect of the root cause analysis. Regionalization and other approaches to service integration have transformed the Canadian health care landscape in the past decade, and it is important to understand how these new patterns of governance and management affect processes, flows, productivity and efficiency. Much of this research is a subset of change management.
Examine the public and media roles
Waiting is also a political issue, and the politics are often mediated through the media. Whatever solutions are developed must ultimately resonate with the public. Media reporting of wait time issues and performance needs to be accurate, balanced and nuanced; the public needs accessible information that is accurately and clearly distilled from often complex realities and choices. The sociology and mass communications aspects of wait time perceptions and expectations are worthy of serious study.
Use innovative approaches to funding the research agenda
It is important to ensure that the research agenda is as timely and responsive as possible to the changing realities of the health care system. Moreover it is essential to address all of the factors that affect waiting; studies of isolated phenomena that do not take into account the complex environment in which both problems and solutions emerge will be of limited use. Among the proposed strategies for ensuring the agenda is relevant, agile and productive are:
1Annual Conference of Federal, Provincial, Territorial Ministers of Health. News Release. Toronto, Ontario. October 22-23, 2005.
