Table 4 Case 2 (Central Canada) - Factors affecting WTMS sustainability and unintended consequences
Organizational factors | |
|---|---|
Governance | - Good support from middle managers in helping physicians find solutions and implement them - Leadership by a non-clinical director of surgical services: “I’m not a nurse or a surgeon, I came in and said, ‘Well, this doesn’t really make sense, we need to work together,’ so...over the years we’ve really improved that” (I.2.1). - Shared leadership between APPs and surgeons |
Culture | - Tension between different types of physicians and between physicians and OR nurses/anesthesiologists - Lack of culture of collaboration among nurses and surgeons Physicians are independent practitioners, they’re not employees of the hospital, so unless you’re partners with them and doing some of these creative collaborative things and getting them on your side, you can maybe get some traction but...otherwise...there’s no incentive. (I.2.1) |
Methods and tools | - Province-wide wait time system software (iPort) that provides self-service reporting of wait times, as previously existing system was inadequate: “They’re not really big fans of the wait times system or the requirements under them, so the quality of the data reporting was poor, and there were some accuracy issues” (I.2.9). - Provincial metric: The provincial metric will remain, as far as I know, the 90th percentile. That’s the direction they’re going on all of the indicators, because the political reason for it is that the longest-waiting person is waiting for service and that’s what really needs to be measured. (I.2.3) |
Resources | - Inefficient utilization of OR rooms, - Insufficient staffing (nurses and anesthesiologists) - Inefficient bed management and utilization |
Main contextual factors | |
- Health region support for professionals to improve data collection and interpretation. - Latitude in HCO activities to meet health region target: “We don’t micromanage the providers and tell them specifically what activities to undertake. They’re basically required to meet the accountabilities in their agreements so... there is an accountability agreement there that specifies that …182 days is the number for wait times, and basically whatever reasonable activities they need to undertake to do, that is up to them.” (I.2.2) - Negotiation between HCO and health region authority on indicators used to justify funding: “In an ideal steady-state environment, if there was an increase in volumes, you would see wait times drop, but in many cases there’s actually an inverse relationship because… the wait time isn’t measured until the procedure is done. So I often say on a lot of these indicators that it’s going to get worse before it gets better.” (I.2.6) | |
Unintended consequences | |
Serendipities | - Model for other programs to improve referral processes and dialogue with GPs: “This is a good model, because it helps to ensure that there is a good distribution of who is receiving the referrals… Now the lessons learned out of ortho are certainly being applied across the board to many areas.” (I.2.4) |
Negative consequences | - Increases in wait time due to double referrals - Increase in wait list due to patients preferences: “Dr. Y… is an excellent surgeon, but Dr. X has a better reputation, for whatever reason, in the community. So his [Dr. Y’s] wait time is usually around 160–170 days, whereas Dr. X’s real wait time is usually…closer to 230 days. So they say, ‘Well, for another two months,… I’ll just wait for Dr. X, it’s not a big deal.’ But to the Ministry… it’s hard for us to capture that.” (I.2.3). - Increase in nosocomial infections |