The challenges in providing timely access to health care are becoming increasingly common and cross many disciplines. Whether the conversation is around delays for elective surgery, emergency department overcrowding or long waits for specialist appointments, the frustration is felt by patients, practitioners and healthcare administrators alike. The recent Preferential Access Inquiry in Alberta highlighted that long wait times lead to inappropriate attempts to expedite access, and suggested that Alberta implement waiting list management strategies. However, such strategies are expensive and have not only been largely unsuccessful, but they represent an acceptance of long wait times rather than a proactive approach to reducing them.
Simply put, waiting lists occur when the demand for a service exceeds the system’s ability to provide that service. The natural conclusion is that there is an inadequate supply of resources (e.g. providers, testing facilities, hospital beds) to meet patient demand. While some systems truly do not have sufficient resources, in reality wait times can be reduced by making more effective use of available resources. In essence, to improve access we need to find ways to work smarter not harder.
As part of a systems approach to the problem of timely access, it is important to understand the relationship between supply and demand. One such relationship, utilization (defined as demand divided by supply), can give us a clearer sense of why delays are occurring.
For example, if we have the ability to perform four CT scans per day, but have a daily average of five patients requiring a scan, our expected utilization level is 5/4 = 1.25. This system will not be able to meet demand, and we expect wait times to increase over time. If we have 20 CT scanners for those five patients, the expected utilization is 0.25, and we expect little or no wait.
Where the problem becomes more challenging is when the expected utilization is approximately one; when demand levels approach resource supply, the formation of waiting lists depends on other factors such as variation. There are two categories for the cause of variation. Natural variation occurs for reasons that are out of our control, such as the clinical case mix or the arrival frequency of patients. Artificial variation is due to system design factors, such as appointment scheduling rules and staff availability.
For example, if elective surgical patients are admitted on Mondays to undergo surgery during the week, there will be fewer beds early in the week and possibly many beds later in the week as these elective patients are discharged. The impact on the hospital of this type of artificial variation is that patients arriving through the emergency department will experience avoidable delays early in the week.
The approach to long wait times in health care has historically been to argue for more resources or to develop complex policies to manage wait times. Both of these approaches may be relevant, but each represents additional cost to the system. Rather, we need to give more thought to the impact of variation; specifically, we should aim to eliminate artificial variation (by smoothing elective surgical admissions through the week, for example) and manage natural variation (perhaps by trying to schedule the existing resource supply around expected demand patterns).
With increasing pressures to meet patient demand, constrained budgets may limit the ability to increase resources to eliminate waiting lists. Instead, an analysis of demand, supply, utilization and variation can provide a clearer picture of why delays might be occurring and how best to mitigate them. Currently, this approach is being used by operations researchers, in partnership with Canadian health care organizations, to improve the efficiency of health services delivery. Examples from Alberta include the reduction in wait times for elective joint replacement surgery and the improvement of response times for ambulance services. However, these are isolated examples, of which there are far too few given that the lack of timely access is such a widespread problem in health care. It is time for other health care systems to follow suit.
The comments section is closed.
I have worked on several wait time strategies and I agree with the Dr. Pendharkar’s conclusion. “Choosing the right thing to do” is a first step in any change process, but more importantly “doing the right thing about it” is the challenge. I always wonder how do we best encourage and support the clinician’s uptake of best practices for best patient care. There are so many “best practice” guidelines out there. Specific monitoring and incentive based strategies often show good results, but I would suggest that can sometimes equate to lesser effectiveness/ productivity in an area not being monitered. There is lots of money going into the healthcare system…where does accountability lie with knowing that the right thing is being done with it? We live in a land of much opportunity…. with access to many good but also “not so good” opportunities. I bet you if we had a whole lot less money to work with, we probably would quickly figure out how to do a lot more with a lot less.
Dr. Fullerton’s comments are bang on. As the “inverted pyramid” demographics of the baby boomers begins to move through the health care system, and will continue to do so over the next 3 decades, the current degree of “overcrowding” of the health care system is likely to triple, for as she points out: “hundreds of thousands more elderly patients with chronic and acute disease are just around the corner. Falls, pneumonia, cancer, diabetes, dementia are poised to surge despite programs for prevention.” Preventive programs are admirable, but there is also the reality of real and serious disease. Prevention will delay the onset of health care woes, but inevitably, every Canadian will eventually eventually die, and the vast majority of us will acquire health care needs prior to our death.
The governments – federal and provincial – have a grave responsibility to pay attention to the facts and take urgent and proactive measures to increase the capacity in all areas of the health care system to address the tsunami of very real and unavoidable health care problems that is inevitable in every area of the health care system. Measures must include the urgent need to increase the capacity for chronic care. This demographic reality simply can’t be solved by increasing “efficiency”.
Emergency Departments must be freed of “boarded” patients, so that emergency department care spaces can be used for the purpose for which they were intended: for the diagnosis and treatment of undifferentiated incoming emergency patients. There must be a Canada-wide policy instituted, so that patients are “admitted” to inpatient units within a given threshold of time after the decision to admit has been made. Hospitals must be made accountable for meeting this goal. Many emergency departments across the country have been at or beyond the breaking point for years due to lack of such a policy and appropriate action to increase capacity in other areas of the health care system. Until such capacity is made, overcrowding must be “equally shared” throughout the health care system. The overcrowding situation in many emergency departments continues to worsen, despite the diligent focus suggested by Dr. Pendarkar by hospitals to increase efficiencies in emergency departments and throughout the institutions, and despite the initiation of “pay for performance” measures in some cases. Tightening efficiencies is wise and commendable, but there is only so much that can be done when efficiencies are strangulated by the ever increasing volume of patients whose flow through the health care system is blocked due to inadequate upstream capacity. Condoning the boarding of admitted patients in emergency departments is a deplorable practice, and the proverbial “canary in the coal mine”.
Even Dr. Pendharkar will likely agree with the reality is that triple the demand for a service will require a vigorous increase in the supply of resources despite maximizing innovative measures such as artificial variation – maybe not triple the resources, with impeccable efficiencies, but at least double. We can’t argue with math. So let’s encourage our governments to get on with vigorous capacity building and implementing accountability for timely admission of patients, before the wait to get into an emergency department is 2 blocks long.
The emergency department has operated as the health system ‘buffer’ for holding, triaging and handling those patients that others in the system are not able to handle for whatever reason… after hours and vacation relief for doctors practices, long term care and retirement home support, family caregiver first line of response when they are overwhelmed, uninsured who get into medical difficulties, … in addition to people who are require immediate healthcare for traumatic accidents, heart attacks, psychotic breakdowns, drug overdose, gunshot wounds …
Emergency overwhelmed status in a clear indication of overall health care systems performance and availability of alternate health care services of all types. Given the 24 hours per day, 365 day per year operation and highly trained health care professionals working in emergencies it is not surprising others have migrated to this service as a fall-back to help them cope with their workloads or lack of alternatives to serve the specific needs of patients.
Maybe the emergency room status could be more specifically identified as a global indicator of total health systems performance by regional and provincial health authorities.
Rigorous analysis of the patients coming into and out of the emergency departments provides a good starting point for identifying areas for improving the local health care delivery practices … so long as people work together in good faith and use these analyses to focus on improving overall patient centred health care delivery.
Quote: “we need to find ways to work smarter not harder”
The public provincial health care systems are treading water now. “Working smarter not harder” is something akin to “doing more with less” that I have heard throughout my 28 years of practice. One could say that that approach has worked to date to keep improving access. However, the efforts have still not resulted in significant improvements in wait times and these efforts occurred during both economic and demographic “good times”.
Ontario, the most populated province is just beginning to age with an expected tripling of over 90 year olds between now and 2036. Hundreds of thousands more elderly patients with chronic and acute disease are just around the corner. Falls, pneumonia, cancer, diabetes, dementia are poised to surge despite programs for prevention.
If we take a snap shot in time it might appear that efficiency strategies will work. Looking only at the current situation does not take into account what is coming longer term. Some remote monitoring here and there, some fall prevention programs, flu shots and streamlining hospital beds and surgeries will not be enough. There are huge challenges ahead that cannot be met with “working smarter not harder”. We can try, but we had better have a back-up plan.
Thank you for your comments.
I agree completely that we need to look to the future as we address the wait time issue. In my mind, “demand” has two components: actual current demand and ‘latent demand.’ The latter refers to demand that we don’t see because the waiting lists are too long, and potential demand growth due to changing population demographics. The concepts I discussed can certainly be applied to projections; we can look at what future capacity and demand issues will be and how variation will affect the formation of waiting lists.
The value of this approach is not lost on me even if demand explodes due to an aging population. Many health care systems function inefficiently because there isn’t enough attention paid to the role of variation; the management of this variation is even more important when resources are further stretched due to burgeoning demand.
Like you, I think that isolated improvement projects are not going to be the transformative change that is needed, but they are a start, and have resulted in significant local improvements in access. I think an operational approach to care delivery has a clear role to play going forward. True, we will likely face capacity constraints, but we can still find ways to use that capacity more effectively rather than blindly increasing resources. We also need to think about managing demand, especially that which occurs due to improvements in access. There is a whole other conversation here about the appropriateness of care.