Table 6 Case 4 (Central Canada) - Factors affecting WTMS sustainability and unintended consequences
Organizational factors | |
|---|---|
Governance | - Strong leadership from hospital CEO and upper management - Surgeons, staff, and middle and top managers aligned toward the same goal: to treat people in as excellent a way as possible - Progressive implementation of an APP (advanced practice physiotherapist) model: “It’s like you’ve done your homework up front, you have a plan, you [do] exactly what you say, small steps, and ... we definitely used plenty of study methodology. So we would do small cycles of change, and what did work, we built on bigger, but if it didn’t, you hadn’t invested so much that you couldn’t change and do something different and tweak it differently.” (I.4.6) - Committees to coordinate strategy and to sustain ongoing work |
Culture | - Hospital mainly dedicated to elective orthopedic surgeries - Culture of innovation shared by all the professionals, staff and managers (middle and top) - Culture of quality improvement and interdisciplinary teams, stability, cohesiveness and unified culture: “There are a lot of old-timers, as we call each other…. We have a great team here and that, I really believe, has been another… critical success factor, because it’s a very cohesive team. There’s input from everybody, everyone takes part in [the] initiative…. So I think that the team works very well. [When] we have a solid team like that, you’re at an excellent starting point, right?” (I.2.8) |
Methods and tools | - Central intake clinic and referral tracking system (provincial wait time information system) - Development of a standardized request form for consultation - Patient orientation program designed to assess patient’s overall health prior to surgery - Methods to improve workflow - Quality tools used to establish the critical pathway for developing the APP role |
Resources | - Increased staffing allocated; more nurses assigned to the OR to support higher volume of TJR - Good distribution of TJR between all surgeons |
Main contextual factors | |
- Government funding to increase the volume of TJR - Need for clear objectives at start of fiscal year: “Cancelling and then rebooking, and ... the hours that must have gone into the scheduling, you know? .... I think it’s important that the thing is clear, or as clear as it can be, at the start of the fiscal year, so that it gets planned out, and then if there need to be adjustments, the sooner we know the better.” (I.4.2) | |
Unintended consequences | |
Serendipities | - Greater trust between surgeons and APPs: “We did some early research looking at level of agreement just to build the confidence. So we really hadn’t had that, it was like a brand new role; but we had all of the tools to show why it would be a good fit, and to gain their confidence. There’s a clear line of communication, everybody knows their roles, we developed algorithms so that the advanced practice physios are integrated into the process.” (I.4.7) - Improved OR efficiency: “But you can’t maintain that kind of throughput unless there’s space dedicated, and equipment dedicated, and personnel dedicated to the anesthesia part.” (I.4.2) - High patient satisfaction (due to better communication from APP) - Better communication with family physicians: “It’s been great because we’re actually even fostering better inter-professional education with family physician residents.... We just recently had a family practice resident who spent six weeks with us because they deal a lot with arthritis issues, so they were learning from us – it was one of the rheumatology residents [who] spent time with us – because there’s a lot of interaction possible because of the way we’ve aligned our clinics.” (I.4.6) |
Negative consequences | - Work overload for nurses - Increased waiting times and cancellations due to patient preferences - Increased waiting times due to GP resistance or lack of comprehension of the referral system: I’m not sure that the family doctors understand that what we’re trying to do is get all of the referral information into a central area, there’s a checkbox, a minimal amount of information is required for you to go through that, and if you provide that information, we’ll do our best to get your patients assessed either quicker, or by whom you request in a timely fashion; but it won’t be quickly (I.4.2) |