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