Table 5 Case 3 (Western Canada) - Factors affecting WTMS sustainability and unintended consequences
Organizational factors | |
|---|---|
Governance | - High support and governance from RHA level - Hospital mainly dedicated to elective orthopedic surgery and implementation of a two-room model - Development of a centralized intake process and adjustment of referrals distribution: “We’ve been going through call distribution strategy because [Hospital X] has gotten to a point where they’re actually refusing referrals because there’s no way they can see those patients in a timely manner…So we spend a lot of time focused on redistribution and centralized intake…We were calling patients and literally offering patients another surgeon or another date and another time.” (I.3.2) |
Culture | - Physician engagement, leadership and innovative culture within the Hip and Knee Institute - Lack of common goals and values related to WTM among surgeons across all sites: “There always seems to be a dollar for any kind of improvement and sustaining that; … making the money the reason you make change,… to influence people’s participation, but it shouldn’t be the reason why we’re making that change, and getting people aligned on the why we need to make a change has been very challenging. I don’t think people have embodied the values, and to me that’s one of the challenges on why we can’t sustain this, because we don’t have people aligned on the goal.” (I.3.1) |
Methods and tools | - RHA developed Patient Access Registry Tool (PART) to reconcile and monitor patient wait lists - Standardized common referral form for surgeons: “So this is the flow chart for the common intake process. So it starts with the standardized referral form –either paper… There’s actually an online version called bridging generalist to specialist care: BGSC” (I.3.4) |
Resources | - Increased human resource staffing: clinical assistants for OR, staff for pre-habilitation clinic - Resources not allocated specifically to HR: “There were not clearly specific resources allocated to staffing, but a global envelope dedicated to increase case volumes, so those have not been sidelined directed resources. For instance, they’ve used the pre-hab clinics, which were established, and the resources associated with them, to support some of the activity as well. The people doing the work have been the same people who existed prior and post, they’re not tied to the funding.” (I.3.1) |
Unintended consequences | |
Main contextual factors | |
- RHA funding to increase volumes of TJR - Strong leadership at both provincial and RHA level | |
Serendipities | - Model for other programs and specialties |
Negative consequences | - Increases in wait time due to patient and GP misunderstanding of the referral process and patient’s preferences (times and surgeons): “Basically, given the validation reference we’ve made, when repeated in many other areas, we see a range of between 20% up to 50 and 60% of inappropriate referrals being made and inappropriate patients sitting on wait lists.” (I.3.4) - Increases in wait time due to the high reputation of the Institute: “Then once you start decreasing that wait, you find all these undiscovered bottlenecks. … it seemed like the whole city thought that the only place you could have your hip or knee done was here at [Hospital X], so… we got backlogged again…, started actively redirecting uncomplicated consults to surgeons with the shortest waitlist in town.” (I.4.2) - Changes to strategy impacted patient satisfaction (positively and negatively, depending on timing) and led to staff exhaustion |