Table 3 Case 1 (Atlantic Canada) - Factors affecting WTMS sustainability and unintended consequences
Organizational factors | |
|---|---|
Governance | - Lack of incentives to encourage staff engagement (including nurses): “To make things work…. There have to be incentives; so the incentives could be either paid time –…scheduled into their regular time. It’s usually not above their normal time… If we can find some people that see the benefit of reducing the wait time so that the patients come in healthier, then that information will then spread. But it’s a lot of education with the nurses to get them to buy into processes. And the administrative culture is slowly changing,… it’s very difficult to get change.” (I.1.3) - Lack of upper management involvement and of support for WTMS within the hospital |
Culture | - Physicians not all engaged and cultural gap between senior and junior surgeons: “We have some people that have been doing surgery here for a very long time – twenty-five plus years – and they like it the way it was, and it’s very difficult to change. Our new surgeons are sold on technology, transparency… using people to their maximum potential;… employing a physiotherapist to do some assessments,… using the nurses to do that kind of thing, and have the surgeon do surgery. So we have two different camps right now… it’s a culture thing, it’s a generational gap; we do meet resistance from… the old boys’ club” (I.1.2). |
Methods and tools | - Public website informing patients and families about TJR wait times (within hospitals in the region) - Computerized Pathway Healthcare Scheduling (PHS) system used for booking and registration - Discharge abstract database containing retrospective data on patients - Lack of standardization of the referral process resulting in delays in the referral process: “We didn’t catch that it would have been necessary to have a standardized process for our referral process from the beginning”. (I.1.5) |
Resources | - Increased resources allocated for renovation of assessment clinic, booking and registration system, clinical staff, patient information website, increased OR time - Nursing shortages due to budget constraints - Physicians competing with other specialties for OR time and access |
Main contextual factors | |
- Insufficient funding considering large proportion of population with arthritis in the province: “I’m always trying to meet the target... We’ve met the target, but there’s more coming in through the door, and... we have a very high arthritis population... So it’s not a surprise that as we become older there’s going to be more people waiting. So…if the expectation is to get down to that 180 days or 182 days – whatever people dispute that it is – then there’s got to be some capacity”. (I.1.3) | |
Unintended consequences | |
Serendipities | - Development of new educational programs for others patients: - Model for improvement in other areas of specialization: So this strategy has helped us evaluate other programs; because spine has a huge wait time, and 95% of people that refer for spine surgery don’t require spine surgery…. There’s been positive spin-offs from the strategy for other surgeries. (I.1.2) |
Negative consequences | - Increased wait times resulting from public awareness and patient’s preferences (times and surgeons): “Now people are going to start reporting their wait time by province, by district, or by area –you could end up getting more referrals because your waits are lower…. if it’s out on the public website, all the family docs can look at it…. So it starts becoming referring to a hospital versus referring to a surgeon…. So you get a dump with a lot of referrals pretty quick, and if you get a huge amount coming in, … you’re probably not going to be meeting your benchmark anymore”. (I.1.4) |