Wait Times on Longwoods.com

How busy are private MRI centres in Canada?

Mon, 17 Nov 2008 13:05:07 -0500

Background: Long waits for publicly funded magnetic resonance imaging (MRI) services have spurred the opening of private MRI centres in Canada. Little is known about the number and utilization of these facilities.

Methods: The authors surveyed all 17 private and 69 of 73 public English-speaking MRI centres in Canada in 2006, using hours of operation and waits for an elective MRI as surrogate measures of procedure volume and facility capacity.

Results: Public MRIs had more hours of operation on weekdays (14.7 vs. 9.7, p < 0.001) and weekends (11.8 vs. 8.2, p < 0.001). Waits were longer in public vs. private MRI centres (13.6 vs. 0.5 weeks, p < 0.001).

Conclusions: Private MRIs provided fewer hours of operation but shorter wait times compared to public centres. This finding suggests that private centres have unused capacity and relatively small procedure volumes, and provide a minority of studies.

From Diagnosis to Cure: A Process Improvement Journey

Tue, 23 Sep 2008 13:00:15 -0400

There has been much excitement in the Canadian healthcare industry about possible benefits of adopting Lean methodologies to improve efficiency and effectiveness. Increasing pressures from financial deficits, wait times and access-to-care issues, along with capacity and resource constraints, have accentuated this excitement. This article shares the story of how University Health Network, a major healthcare organization in Toronto, Ontario, embarked upon clinical process improvement projects using Lean methodologies and principles. Focusing on improving patient flow and access to care and reducing wait times, efforts included the areas of medical imaging, palliative care, general internal medicine, the operating room department and the emergency department.

Canadians with Health Problems: Their Use of Specialized Services and Their Waiting Experiences

Fri, 15 Aug 2008 10:31:02 -0400

Improving access to healthcare has been a consistent priority for Canadians. In particular, reducing patient waiting times for health services has been a prominent policy issue. Across the country, governments are using a range of strategies to reduce patient waiting times for care, with a particular focus on reducing waits for specialized services. Although information is emerging on waits for selected procedures, there is limited information on whether the utilization of services or waiting experiences of Canadians with health problems are different from those of the general population. Data from the Health Services Access Survey (2001-2005) were used to compare waiting experiences for specialized services between adults with health problems and healthier adults. The specialized services included specialist visits for a new illness or condition, non-emergency surgery and diagnostic tests. National-level estimates revealed that adults with health problems were more likely to self-report that they required specialized services. However, the median waiting times for these services were comparable to those of healthier adults.

Evaluation of booking systems for elective surgery using simulation experiments

Fri, 20 Jun 2008 10:00:46 -0400

Objective: This study compared two methods of booking elective surgery - booking from wait lists and pre-booking surgery dates at the time of decision to operate - in terms of cancellations of elective procedures and time to surgery.

Parallel Lines Do Intersect: Interactions between the Workers' Compensation and Provincial Publicly Financed Healthcare Systems in Canada

Fri, 20 Jun 2008 09:59:58 -0400

The authors of this paper use a case study approach to document and analyze the interactions that arise between two healthcare payers in Canada: the provincial public healthcare insurance plans and the provincial workers' compensation boards. Through a documentary review and semi-structured key-respondent interviews, the study identified a set of policy events and decisions undertaken by each payer that had consequences for the other. These events, which included changes to governance, funding and service delivery within each system, generated interactions transmitted through the political, institutional and economic environments (primarily through competition for the same resources) and cross-system learning. The two payers currently lack a formalized process by which to consider such spillover effects and to coordinate policy between them. These interactions, and their associated consequences for both payers, raise important policy challenges and, more generally, provide insight into the dynamics of parallel systems of healthcare financing.

Analysis of international migration patterns affecting physician supply in Canada

Fri, 20 Jun 2008 09:59:25 -0400

This paper analyzes the migration patterns of both Canadian medical school graduates and international medical graduates (IMGs), and the impact of these patterns on physician supply in Canada. Immigration patterns of IMGs have changed over time, with fewer physicians from the United Kingdom and more from South Africa. A large portion of IMGs who leave Canada (43%) return "home." Recently, the average duration of practice in Canada for these doctors has been three years, a finding that suggests many came for educational purposes or to acquire skills. The heterogeneity and complexity of international migration are highlighted in this paper.

Reducing Wait Times Through Operations Research: Optimizing the Use of Surge Capacity

Wed, 27 Feb 2008 10:18:45 -0500

Applying operations research methods, the authors show that when base capacity is sufficient to meet average demand wait time targets can be met by the judicious use of overtime.

A General Method for Identifying Excess Revisit Rates: The Case of Hypertension

Wed, 27 Feb 2008 10:18:19 -0500

The authors describe a method for comparing actual to expected visit rates at the physician level that controls for patient characteristics, providing a potentially useful measure for performance monitoring, feedback and quality improvement.

Patient and Surgeon Views on Maximum Acceptable Waiting Times for Joint Replacement

Mon, 19 Nov 2007 11:00:08 -0500

Objective: To assess patient and surgeon views on maximum acceptable waiting times (MAWT) for hip and knee replacement, their determinants and their relationship to levels of urgency based on the Western Canada Waiting List Priority Criteria Score (PCS). Methods: At the decision date for surgery, orthopaedic surgeons assessed consecutive patients with the PCS and MAWT. Patients were surveyed 3-12 months post-surgery for MAWT and potential determinants. Results: The patient sample of 208 was 56% female, mean age 69 years (SD 11). Mean MAWT for patients was 18 weeks (SD 11) and for surgeons, 17 weeks (SD 11). Median MAWT for three levels of urgency (PCS) ranged from 13-17 weeks (patients) and 9-26 weeks (surgeons). Patient MAWT was unrelated to the surgeon-rated measures: MAWT (r=.05) and the PCS (r=-.10). Multiple regression analysis showed that males, knee vs. hip replacement, a longer waiting time and a perception of fairness in regard to waiting time were significant predictors of longer patient MAWT. Knee replacement, a better ability to walk without significant pain and less potential for progression of the disease were significant predictors of longer surgeon MAWT. Conclusions: Patient and surgeon perspectives on MAWT are important to the development of waiting time benchmarks. Benchmarks based on levels of urgency ensure a more transparent and fair process for waiting time management. Knowledge of determinants of MAWT should inform better management of waiting time and access, by understanding the basis of patient and physician views on acceptable waiting times.

Performance Measurement in Healthcare: Part II - State of the Science Findings by Stage of the Performance Measurement Process

Tue, 15 Aug 2006 14:14:09 -0400

This paper summarizes findings of a comprehensive, systematic review of the peer-reviewed and grey literature on performance measurement according to each stage of the performance measurement process - conceptualization, selection and development, data collection, and reporting and use. It also outlines implications for practice.

A Survey of Oncology Advanced Practice Nurses in Ontario: Profile and Predictors of Job Satisfaction

Tue, 15 May 2007 14:13:44 -0400

The purpose of this study was to examine role structures and processes and their impact on job satisfaction for oncology advanced practice nurses (APNs) in Ontario. APNs caring for adult, paediatric or palliative patients in integrated regional cancer programs, tertiary care hospitals or community hospitals and agencies were invited to complete a mailed self-report questionnaire. A total of 73 of 77 APNs participated in the study. Most APNs (55%) were acute care nurse practitioners employed by regional cancer programs or tertiary care hospitals. Adult patients with breast or haematological cancers and those receiving initial treatment or palliative care were the primary focus of APN roles. APN education needs related to specialization in oncology, leadership and research were identified. Overall, APNs were minimally satisfied with their roles. Role confidence ( b =.404, p =.001) and the number of overtime hours ( b =-.313, p =.008) were respective positive and negative predictors of APN job satisfaction. Progress in role development is described, and recommendations for improving role development and expanding the delivery of oncology APN services are provided.

Reconstructing Cancer Services in Ontario

Thu, 15 Jul 2004 14:13:11 -0400

This paper draws upon experience gained in the recent restructuring of cancer services in Ontario that can provide insights for broader regionalization efforts. Although Ontario is the only province in Canada not to regionalize its healthcare system, the Ontario cancer services system, like most others in Canada, is based on a regionalized system. However, the growing burden of cancer and predictable crises in cancer services in Ontario necessitated a rethinking of how the cancer system should be structured and how services should be delivered. Based on recommendations by the Cancer Services Implementation Committee in 2001, Ontario's cancer services system has recently gone through major restructuring, which has established new institutional arrangements for the Ministry of Health and Long-Term Care, Cancer Care Ontario (CCO) (the provincial cancer agency), a new Quality Council and 11 new regionally based Integrated Cancer Programs (ICPs). This restructuring has created several levers for promoting regional change and motivating performance improvement, including (1) public reporting on performance with a new quality mandate, (2) fiscal and performance-based agreements between CCO and the ICPs, (3) leading and coordinating communities of practice and (4) direct ministerial access. While institutional relationships are still developing, these experiences may provide important insights for regionalization efforts in other jurisdictions and sectors in Canada.

Quality Councils as Health System Performance and Accountability Mechanisms: The Cancer Quality Council of Ontario Experience

Wed, 15 Mar 2006 14:12:42 -0400

Recent national and provincial reviews on the status of healthcare in Canada have recommended the establishment of quality councils to guide quality improvement efforts. The emergence of quality councils, such as the Health Quality Council of Alberta, the Saskatchewan Health Quality Council, the Cancer Quality Council of Ontario and the Health Council of Canada, reflect new but largely unscrutinized models for improving quality of care. We discuss the varying mandates of these new quality councils, their fit with evolving governance and accountability structures and the credibility and legitimacy of their role as perceived by other health system organizations. To further illustrate these issues, we present insiders' perspectives on the Cancer Quality Council of Ontario's activities over its first three years, including the initial agenda, critical success factors and the nature of evolving relationships with other organizations in Ontario's healthcare system. While current Canadian quality councils represent an eclectic mix of methods for achieving improvements in quality of care, it is not entirely clear how quality councils will stimulate sustained and significant improvements in quality of care where other models have failed. However, these new Canadian quality councils represent natural experiments in motion from which much needs to be learned.

The Evolution of a Health Information Brokering Service in the Province of British Columbia

Thu, 15 May 2003 14:12:07 -0400

The Provincial Health Services Authority (PHSA) is implementing a health information brokering service in the province of British Columbia. This brokering service (called the Clinical Broker) is based upon the experienced gained by the B.C. Cancer Agency (BCCA) in the creation of its Electronic Health Record (EHR) for cancer care. The brokering service will initially focus on an operational need for information exchange between healthcare providers. Over time, it will be extended to include more complex healthcare services, such as results query, appointment booking and clinical decision support.

Integration of Cancer Services in Ontario: The Story of Getting It Done

Tue, 15 Jun 2004 14:11:30 -0400

Leaders in healthcare have known for years that integrating service delivery makes sense, yet paradoxically across Canada, despite major system restructuring, cancer care has remained the exception. In Ontario it was recognized that this was an area both ripe for and in need of change. The economic impact associated with the growing burden of cancer in Ontario has been well documented (Sullivan et al. 2003). Also well documented are the potential solutions for how cancer services could be better integrated and organized to improve efficiency and quality of care (Hudson 2001). Until recently, however, little action was taken. Traditional biases, turf protection, political minefields and perhaps even restructuring fatigue have been excuses to stand still.

Enhancing Quality Improvement

Wed, 15 Mar 2006 14:10:58 -0400

The healthcare systems of most developed nations face a common challenge: a substantial gap exists between the best possible care and the care routinely delivered. Numerous studies in the literature and reports from authoritative bodies, such as the Institute of Medicine (IOM) in the United States, have provided compelling and persuasive evidence that care is not consistently safe, timely, effective, equitable, efficient or patient-centred. A landmark study published in 2003 reported that Americans receive recommended care 54.9% of the time (McGlynn et al. 2003). The recent survey conducted by the Commonwealth Fund of sicker adults in six countries - Australia, Canada, Germany, New Zealand, the United Kingdom and the United States - underscores the pervasive challenges of providing high-quality care. The differences between the six countries pale in contrast to the common theme of significant opportunities for improvement in all nations (Schoen et al. 2005).

The Health Council of Canada: A Speculation on a Constructive Agenda

Sun, 15 Jun 2003 14:10:28 -0400

Mr. Romanow and Senator Kirby each devoted several years and intense effort to studying the Canadian healthcare system. They both came to the view that a national health council is a good idea. Their shared hope was that a health council could bring evidence and reason to bear on health problems that are often buried in the rhetorical avalanche of intergovernmental combat. One suspects that most Canadians also prefer light to heat in health matters.

Gary Mar, Alberta Minister of Health and Wellness

Sat, 15 Mar 2003 14:09:15 -0400

The Hon. Gary G. Mar QC (PC), MLA for Calgary Nose Creek, is Alberta's Minister of Health and Wellness. He was elected to his third term as Member of the Legislative Assembly in 2001, and was subsequently reappointed Minister of Health and Wellness. Since he was first elected to the Alberta Legislature in 1993, Mr. Mar has served as Minister of Community Development, Minister of Education and Minister of Environment. Mr. Mar is a member of the Agenda and Priorities Committee and the Standing Policy Committee on Health and Community Living.

Adoption of Information Technology in Primary Care Physician Offices in Alberta and Denmark, Part 2: A Novel Comparison Methodology

Tue, 15 May 2007 14:08:46 -0400

This article follows on from part 1 on the history of medical computing in Alberta and Denmark (Protti et al. 2007). It provides background to the driving forces for automation in primary care physician offices in Denmark and Alberta. It also summarizes the functionality of electronic medical records (EMRs) in both jurisdictions and compares the status of primary care physician office computing in Alberta to that of Denmark. The scoring system used is based on data gathered from publicly available sources on the Internet, databases held by the respective jurisdictional programs (MedCom and Physician Office System Program [POSP]) and interviews with individuals involved in the deployment of systems. The article offers a novel method of scoring the adoption of computerized advances in the office setting that may be applicable to other health jurisdictions, at country, state or provincial levels.

The Challenge of Effective Workplace Change in the Health Sector

Mon, 15 Jan 2007 14:08:17 -0400

There is significant personal injury risk associated with the provision of high-quality healthcare. The magnitude of this risk, combined with the possibility that it can often go underappreciated by caregivers and the organizations they work for, might help explain why the health sector has largely missed out on the benefits of an overall declining trend in injury rates. Despite covering two very different topics in their lead papers, Shamian and El-Jardali and Clements, Dault and Priest present a surprising degree of overlap in relation to what might help enable effective workplace change. Leadership, role clarity, trust, respect, values and workplace culture are all viewed as key enablers of effective teamwork by Clements, Dault and Priest. They could also be considered required ingredients of successful workplace health initiatives, as discussed by Shamian and El-Jardali. A lot of background and positional work regarding teamwork and healthy workplaces exists, but this has not necessarily translated into front-line change. These authors have done an excellent job of pointing out the potential benefits of workplace changes. What is needed now is for someone to take the lead in developing, implementing and evaluating these changes.

Evaluating Organizational Readiness for Change: A Preliminary Mixed-Model Assessment of an Interprofessional Rehabilitation Hospital

Fri, 15 Sep 2006 14:07:44 -0400

We conducted a Functional Organizational Readiness for Change Evaluation (FORCE) to assess the characteristics of readiness for change across two programs (N=216 employees) in an interprofessional rehabilitation hospital that was about to undergo strategic changes as part of a planned physical merger within the next two years. The study used a mixed-method approach: a quantitative survey, previously validated in a drug rehabilitation setting, followed by key informant interviews to further enlighten survey findings. Statistical analyses identified correlations between demographic variables (age, education and experience) and readiness for change, as well as the prevalence of specific organizational characteristics (motivation for change, access to resources, staff attributes, organizational climate, and exposure/use of training opportunities) that facilitate or impede change. Findings were intended to better inform the tactics for successful implementation of upcoming initiatives. Much like assessing a patient prior to initiating a treatment, FORCE can serve as a management tool to direct the planning and implementation of changes intended to improve hospital performance.

Better for Ourselves and Better for Our Patients: Chronic Disease Management in Primary Care Networks

Tue, 15 May 2007 14:07:11 -0400

Capital Health in Edmonton, Alberta, implemented a system-wide chronic disease management model to support people with chronic disease and their primary care physicians. Groups of family physicians, in partnership with the health region, developed primary care networks to provide services that are customized to meet the priorities of the local community. Management of chronic disease is a cornerstone service, and diabetes management is the most fully developed program. Key to its success are standardized protocols, consistent follow-up and patient education by trained primary care nurses. This model will be used as a template for the management of other chronic diseases.

Reflections on Conversations with Robert Bell and Michael Guerriere: What Is Relevant Research?

Sun, 15 Jan 2006 14:06:42 -0400

Two decision-makers from the acute-care sector weigh in on the issue of relevant research. Between the two of them they look for patient-defined research, evidence to support the conclusions, information that can lead to interventions designed to improve quality and outcomes and defined control mechanisms to properly identify the practices that improved the system. Three examples are cited and discussed. The context is set by comments from one of Canada's leading researchers and the use of research from one of this decade's most lauded system turnarounds.

The VHA's Commitment to Accountability: A "Third Way" for Medicare?

Sun, 15 May 2005 14:06:09 -0400

Albertans are seeking a "Third Way" for Medicare; Canadians generally are struggling with the issue of "sustainability."The transformation of the Veterans Health Administration suggests that the key to sustainability is not levels of spending per se but public confidence that a system delivers value for money. The VHA regained confidence by defining its value ("Quality") and being accountable for delivering it. The US health system is no model for Canada, but Quality and Accountability should be part of a Third Way, incorporating the best ideas from the US into a renewed public system.

How Effective Leaders Achieve Success in Critical Change Initiatives, Part 3: Command and Let Go of Control

Tue, 15 May 2007 14:05:38 -0400

Leadership is cited as a critical success factor in virtually every publication on complex change. What is not as frequently described are the perspectives, strategies and behaviours that are required to effectively lead initiatives involving multiple independent entities in complex systems. A recent study by Starfield Consulting was designed to determine exactly that. The goal was to pinpoint common characteristics and behaviours of leaders who had successfully implemented complex change in public service and healthcare systems. Research interviews were conducted with 40 leaders who each had successfully led a change initiative involving multiple organizations, jurisdictions or highly siloed functions within an organization.

Evidence, Interests and Knowledge Translation: Reflections of an Unrepentant Zombie Chaser

Sat, 15 Jan 2005 14:05:03 -0400

Justice Emmett Hall's landmark 1964 Royal Commission report is remarkable as, among other things, a very early Canadian example of successful knowledge brokering. It predates by about three decades even the earliest discourse in Canadian health research circles about knowledge translation (KT), knowledge transfer, knowledge exchange, knowledge brokers and the like. And yet the tomes contain some wonderful examples of bringing research evidence to the attention of policy-makers, and of translating that evidence into a form easily digestible by them and by the public (surely the sign of a successful knowledge broker). Not everything he recommended ended up as policy, but some important things did.

Issues in the Governance of Canadian Hospitals IV: Quality of Hospital Care

Sun, 15 Jun 2003 14:04:34 -0400

This is the fourth and final article in a series examining governance in Canadian hospitals. These articles draw upon experiences gained from operational reviews of hospitals across Canada to suggest approaches to building more effective hospital governance.

Back to Basics on Report Cards

Tue, 15 Nov 2005 14:03:52 -0400

Making Performance Reports Work is a valuable and timely contribution to the literature, particularly at the macro level when First Ministers have made commitments in 2000, 2003 and 2004 to report to their respective populations on a series of indicators, including wait times.

Pay-for-Performance - Can It Work in Canada?

Mon, 15 May 2006 14:03:14 -0400

Physician reimbursement in Canada has been dominated by pay-for-volume which leads to high utilization. The concern is that this does not promote attention to quality issues that are known to affect health services. However, the evidence that pay-for-quality works is weak, despite the logic of the approach. Also, pay-for-quality methods that seem to work in primary care may not be appropriate in specialties such as surgery. Canada offers opportunities to assess the effect of pay-for-performance in several areas. Developing primary care networks are attractive locations to study the effect of pay-for-quality, perhaps even in a randomized trial. Specialized high-volume surgical programs, such as the Alberta arthroplasty pilot project, might be study of pay-for-participation, in a partnership of providers and sponsors.

The Nurse Practitioner Role: Into the Future

Sun, 15 May 2005 14:02:39 -0400

Advanced practice nursing in Canada is receiving attention locally and nationally as gaps in our healthcare system persist, specifically as they relate to access to care and wait times. Nationally, nurse practitioners (NPs) and nursing leaders have developed documents that begin to define the foundation required for the successful introduction, evolution, evaluation and sustainability of the NP role (Bryant-Lukosius and DiCenso 2004). Much work has been done to promote the role of the nurse practitioner across Canada as provinces and territories learn from one another and overcome barriers to furthering this advanced practice nursing role (CNA 2006).

Actions to Preserve and Enhance Canada's Healthcare System: Some Ideas for Actions by All Governments.

Sat, 15 Feb 2003 14:01:26 -0400

This paper sets forth a set of necessary actions by federal, provincial and territorial governments that are required in order to preserve and enhance Canada's healthcare services. They are offered in support of the Report of the Commission on the Future of Health Care in Canada (the Romanow report) and the Report of the Standing Senate Committee on Social Affairs, Science and Technology (the Kirby report). The actions are listed under three themes...

Healthcare Reform: Do You Have What It Takes? A Leadership Checklist

Tue, 15 Dec 1998 14:00:34 -0400

The Scenario: You have just become the Chief Operating Officer of a hospital site where you were the former CEO. The senior team met for the first time last week and includes former leaders and several new faces. A new CEO was selected by a steering committee of the new board and hails from the private sector. The hospital has become one of six sites consolidated into a regional health system, which also includes home care, long-term care, public-health, ambulance and other services. There is only one governance, management and medical staff structure where there had been eight (including non-institutional providers) previously. A seventh site, owned and operated by a religious order, has made a contractual arrangement for its continued autonomy and funding. Several of the sites had deficits in the preceding fiscal year and a financial recovery plan has been requested within 90 days. Three years ago, a consultant's report noted numerous efficiency opportunities but the focus of its implementation became the new regional model.

Building a Quality Improvement Coalition: A Cancer Information Management Strategy for Ontario

Thu, 15 May 2003 13:59:29 -0400

Information management plans should support the organization's overall business objectives rather than being crafted in isolation from overall organizational strategies. The cancer system is undergoing significant transformation, including integration of service delivery at the regional level and a revamped role for Cancer Care Ontario. The Cancer Information Management plan for Ontario outlines an approach to linking and coordinating various information management systems and projects to support the new directions. Through a coalition of partners working together and by building on the success of earlier initiatives - including the widespread adoption of CPOE within a large part of the cancer system - the plan will improve the quality of care for Ontario cancer patients.

Accelerating the E-health Connectivity Imperative: Implementing Short-term Value against Long-term Goals when Building Private-sector Relationships

Tue, 15 May 2001 13:57:30 -0400

The role of the private sector in the e-health equation, whether it be a pure business transaction (e-commerce), information transaction (e-health) or a patient care transaction (e-care), is to encourage, build and foster connectivity. The key to building successful connectivity projects that link groups together electronically is to demonstrate value to all parties. Framing this is an over-arching understanding by all participants in the system of the necessity to implement projects with short-term value, while keeping in mind the long-term goals of sustainability and increased care in the Canadian healthcare system.

Building on Values. The Future of Health Care in Canada: Executive Summary

Sat, 15 Feb 2003 13:56:15 -0400

Taken together, the 47 recommendations contained in this report serve as a roadmap for a collective journey by Canadians to reform and renew their health care system. They outline actions that must be taken in 10 critical areas, starting by renewing the foundations of medicare and moving beyond our borders to consider Canada's role in improving health around the world.

The Sustainability of Canada's Healthcare System: A Framework for Advancing the Debate

Sun, 15 Apr 2007 13:55:44 -0400

The debate of whether Canada's healthcare system is sustainable is mired in ideology. This paper offers a framework that takes us beyond the ideological standoff with a process to deal ethically with the issue of the sustainability of publicly funded healthcare.

Diagnostic Imaging in Canada

Sat, 15 Oct 2005 12:30:32 -0400

In Ontario, between 1993 and 2003, the annual number of MRI scans performed increased by more than 600 per cent (Iron et al. 2003), and the number of CT scans increased threefold (Tu et al. 2005). Despite these massive increases, the Fraser Institute reported a median wait of five weeks for CT and thirteen weeks for MRI scanning in 2004 (Esmail and Walker 2004), and Canadians are increasingly concerned about the length of time they wait for diagnostic imaging. Because of this, politicians have made decreasing wait times for diagnostic imaging one of their top priorities (Health Canada 2004).

Waiting Lists: Management, Legalities and Ethics

Wed, 22 Aug 2007 12:30:04 -0400

A recent report by the Fraser Institute suggests that wait times have increased slightly in 2004. The survey of almost 2,900 physicians in 12 specialties found the average elapsed time was 17.9 weeks between patients getting a referral from a GP to see a specialist and receiving treatment. This broke down into 8.4 weeks for the referral portion and 9.5 weeks for the treatment portion. The overall wait time was calculated to be 17.7 weeks in 2003. The problem of waiting lists presents a challenge for all Canadian surgeons, and the predicted demographic factors of the Canadian population indicate that the problem will increase. A symposium was held at the Canadian Surgery Forum in London, Ontario, on September 20, 2002, to present state-of-the-art thinking about waiting lists and to stimulate discussion among Canadian surgeons. The three invited speakers are prominent in their respective fields of expertise. In this issue of Law & Governance we present a commentary of their oral presentations.

Medical Imaging in Canada: Bringing the Picture into Focus

Sat, 15 Nov 2003 12:29:30 -0400

Recent public opinion polls, the 2003 First Ministers' Accord on Health Renewal, regional and hospital plans and election campaign platforms confirm that timely access to diagnostic services is a major priority across the country. Underlying the access challenge is a tangle of questions about the right number and mix of imaging machines; the types of services provided; how imaging influences patients' care and outcomes; how long patients wait for tests, results and follow-up care; and who provides imaging services. Until now, we have had little systematic knowledge of the imaging landscape in Canada. An overview of recent trends and emerging issues is essential to sound decision-making at all levels.

The Transformation Experience of the Veterans Health Administration and Its Relevance to Canada

Sun, 15 May 2005 12:28:58 -0400

Over the past few years, there has been a steady stream of visitors to Canada from the US Veterans Health Administration (VA). Led by the former Under Secretary for Health in the Department of Veterans Affairs, Dr. Ken Kizer, they come to tell the remarkable story of how the VA transformed itself from a hospital-based bureaucracy described as "dangerous, dirty and scandal- ridden" to a healthcare system for veterans recognized for its high-quality, patient-centred care. It is a fascinating story of how a publicly funded healthcare service changed its entire approach to patient care with a quality improvement lens at its core. Fifteen years ago, critics of the VA called for its complete privatization as the only solution to fixing its problems. A team of quality champions set out to prove otherwise. Canada has some lessons to learn. The VA is a compelling role model for Canadian reformers, in large measure, due to its public sector character.

Determinants of Unacceptable Waiting Times for Specialized Services in Canada

Thu, 15 Feb 2007 12:28:29 -0400

Much of the current evidence regarding timely access to healthcare services focuses on the duration of the waiting time as the principal determinant of wait time acceptability. We conducted the first national-level analysis of wait time acceptability in Canada to identify the determinants of unacceptable waits for specialized healthcare services, including selected demographic and socio-economic variables.

The Pivotal Role of Critical Care and Surgical Efficiencies in Supporting Ontario's Wait Time Strategy: Part 3

Fri, 15 Sep 2006 12:27:41 -0400

Ontario's Wait Time Strategy (Strategy) - launched in November 2004 - is designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006: cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements, and MRI and CT scans (Trypuc et al. 2006a). Since the Strategy began, the Ministry of Health and Long-Term Care (Ministry) has provided significant additional funding to perform more cases with the full understanding that improving access by reducing wait times is not simply a matter of providing more money to do more volumes.2 Rather, fundamental system and practice changes are needed to sustain improvements over the long term.

Public Reporting Makes Accountability Possible

Tue, 15 Nov 2005 12:26:47 -0400

This paper reviews the meta-analysis of Brown, Bhimani and MacLeod and finds it an important contribution to the literature on performance reporting (PR) in healthcare. Of 1,053 papers identified in their search, only 62 met their criteria for inclusion in the review. The authors used a Knowledge, Attitudes and Behaviour (KAB) model for their analysis. Of the 63 papers reviewed, most related to individual consumers and groups of providers, fewer related to groups of consumers and individual providers.

Healthcare Organizations and Patient Transfers: A Transportation Industry Perspective

Sat, 15 Jun 2002 12:26:00 -0400

A major restructuring is underway in Ontario in the delivery of a wide range of public services, including healthcare, public transit and ambulance services. The resulting trends in these three industries have converged in a number of models for the delivery of non-emergency patient transfers. Hospitals find themselves involved in the business of transportation: engaged in new partnerships, and making new choices, to manage the movement of stable patients between sites, to medical procedures and to return home. This article offers insights and lessons from some of the transportation professionals who have been advising and assisting healthcare professionals on this new responsibility.

Board Accountability Is the Key to Ensuring Timely Access

Sun, 15 May 2005 12:25:21 -0400

Baker and Schwartz have done an excellent job of clearly laying out the challenges confronting Canadian healthcare providers in ensuring timely access to care. Baker and Schwartz identify three approaches that various jurisdictions have used to improve access to care...

Strangulation or Rationalization? Costs and Access in Canadian Hospitals

Sat, 15 Nov 2003 12:24:43 -0400

Beginning a little over a decade ago, Canadian hospitals began experiencing the most severe fiscal restraint of the past half-century. Between 1992 and 1996, hospital expenditure per capita fell sharply, from $939 to $858. These cuts fuelled professional declarations and a swarm of anecdotes about the dire consequences for the health of Canadians, whose confidence in the healthcare system dropped precipitously. Yet, a series of provincial royal commissions or similar inquiries during the previous decade had concluded that there was substantial scope for rationalization and cost containment within the provincial hospital systems. This paper examines the statistical record, looking at hospital capacity, access and utilization, prior to, during and after the 1990s reductions, and the impact of provincial finances on hospital funding decisions. While hospital bed capacity and inpatient utilization declined significantly, day surgery and other hospital-based ambulatory services have increased dramatically. There seems to be little or no evidence of "dire consequences" from the cuts themselves. But having succeeded once in implementing major program cuts in response to looming or actual deficits, right wing governments may, in the future, be tempted to create deficits deliberately through tax cuts. A "privatization" agenda for healthcare, designed to benefit the wealthy and private provider groups, could then be supported by claims that the public system is fiscally "unsustainable."

Now's the Time to Stand Up for Medicare

Wed, 22 Aug 2007 12:02:15 -0400

A National Perspective from The Hon. Roy Romanow.

Primary Healthcare: The All-Too-Quiet Revolution in Waiting

Sat, 15 Jan 2005 12:01:42 -0400

Remodelling the kitchen won't help the house with a weak foundation. The same holds truth in healthcare. We cannot solve quality and access problems or deal effectively with wait times unless primary healthcare - the foundation of the system - is solid. That is why the First Ministers' 2003 Healthcare Renewal Accord identifies it as the cornerstone of tomorrow's healthcare system. But progress is slow, and the foundation is creaking under the strain of even greater pressures.

New Health Professionals Network: The Future Face of Medicine

Thu, 15 Dec 2005 12:00:58 -0400

Just over a year ago a group of students, interns and residents in nursing, medicine and pharmacy launched the New Health Professionals Network (NHPN) to advocate for the strengthening of medicare and to highlight the need for interdisciplinary, team-based healthcare. Since that time, NHPN has been active in the public policy debate over the future of our healthcare system.

Project Profile: Canadian Healthcare Excellence in Quality Award (CHEQA)

Sun, 15 Jan 2006 12:00:20 -0400

The Quality Healthcare Network (QHN) in collaboration with rL Solutions, awarded the inaugural Canadian Healthcare Excellence in Quality Award (CHEQA) at a cocktail reception, closing September's QHN Fall Leading Forum.

Opinions: Patient Satisfaction Surveys: Another View

Tue, 15 May 2007 11:55:40 -0400

Exploring "patient satisfaction" is intuitively appealing as one way to understand the patient experience and to help guide healthcare providers to improve healthcare. The cover article by McKim et al., entitled "Emergency Department Patient Satisfaction Survey in Alberta's Capital Health Region" published in your recent issue (Vol.10, No.1), does little to advance our understanding of how to use patient satisfaction metrics in this regard. Unfortunately, McKim and his colleagues are not alone - the healthcare literature is replete with other articles that leave us hungering for a better way to conduct similar research and to turn the research results into actionable improvement strategies.

The Burgeoning Disorder of Technophilia

Sat, 15 Oct 2005 11:54:52 -0400

Andreas Laupacis and William Evans have deftly accomplished the difficult task of synthesizing the major issues at hand. Their comments are timely, reflecting society's increasing preoccupation with rapid access to diagnostic imaging. Paradoxically, the recent CIHI report on medical imaging records a steady increase in scanners, without the expected reduction in wait times. The role of private facilities is unclear, and the value of screening asymptomatic patients is unproven. There are few clear guidelines for ordering images. New intraoperative, functional and molecular imaging technologies will further strain the system. This array of challenges should be urgently tackled by a decisive panel of national experts, who would in turn supervise consultants working full-time on guideline development.

Facts and Opinions: Hospital Wait List Lessons From the UK

Tue, 15 Mar 2005 11:54:04 -0400

The issue of reducing waiting for health services in the UK has been a political initiative for the Blair government for several years. Interestingly, "reducing waiting for healthcare" was the key communication in Britain rather than reducing waiting times for "key procedures," which signalled that initiatives were to be put in place to reduce waits in the health system generally. As a result, this included, for example, waits to obtain service from general practitioners, as well as waits for hospital-based services.

Transforming Cancer Services in Ontario: A Work in Progress

Sun, 15 May 2005 11:53:25 -0400

Cancer Care Ontario (CCO) is the largest provincial cancer agency in Canada, with a long and rich history as a specialized service entity within a generic delivery system in Ontario. CCO's evolution has been well characterized by Hayter (1998), and described by us previously (Sullivan et al. 2003, 2004). Once criticized as a very inward-looking body with a mixed record in solving a series of radiation waiting-time crises, CCO has reinvented itself over the past three years in ways that are very similar to the transformation of the Veterans Health Administration.

Waiting Time for Radiation Therapy in Breast Cancer Patients in Quebec from 1992 to 1998

Sun, 15 Jan 2006 11:52:32 -0400

This study was conducted among surgically treated breast cancer patients in Quebec to determine waiting time between surgery and post-operative radiation therapy and factors influencing it.

Reflections on a Conversation with Brian Postl: Can Healthcare Research Make a Difference to Policy and Practice?

Thu, 15 Sep 2005 11:51:19 -0400

"Research is key in the Process of Change." That's how Dr. Brian Postl begins a conversation on strategies to ensure a stable and reliable bridge between researchers and policy makers in healthcare. He suggests "evidence" as one of four themes that the journal Healthcare Policy should consider as it looks at knowledge and its impact on policy and practice. And he is quick to agree that we need to reach audiences that influence the policy and decision-makers; the direct approach won't be enough. He believes there are untapped ways and means to share the collected evidence and change behaviour. Finally, he underscores the importance of real cases - using evidence - as valuable translation tools.

The Pivotal Role of Critical Care and Surgical Efficiencies in Supporting Ontario's Wait Time Strategy: Part 3

Fri, 15 Sep 2006 11:50:36 -0400

Emergency Department Patient Satisfaction Survey in Alberta's Capital Health Region

Mon, 15 Jan 2007 11:48:41 -0400

In 2005, a large Canadian health region conducted an emergency department patient feedback survey to obtain information on patient perceptions of satisfaction with emergency services received. The Capital Health region is one of nine Alberta Health Authorities, located in the central portion of the province, serving a population of 1.6 million people in metropolitan Edmonton and the surrounding area. Analysis reveals significant demographic and acuity differences in perceptions of care and suggests the need to consider patient mix in future satisfaction surveys and to examine improvement strategies targeted at these specific patient groups.

Reinventing Veterans Health Administration: Focus on Primary Care

Wed, 15 Mar 2006 11:47:30 -0400

Can we improve access in primary care without compromising the quality of care? The purpose of this article is to demonstrate how timely access to primary care can be achieved without compromising the quality of the care being delivered. The Veterans Health Administration (VHA) is an integrated healthcare system that has implemented change to improve primary care access to the veterans it serves, while not only maintaining but also actually improving the quality of care.

The Saskatchewan Surgical Care Network - Toward Timely and Appropriate Access

Sat, 15 Nov 2003 11:46:43 -0400

Peter Glynn's article, "Creating a Surgical Wait List Management Strategy for Saskatchewan," published in a recent issue of Hospital Quarterly (6(3), Spring 2002) described the development of a surgical wait list strategy for Saskatchewan. The initial strategy development process uncovered several issues that needed to be addressed.

Chronic Disease Prevention and Management: Some Uncomfortable Questions

Fri, 15 Jun 2007 11:45:18 -0400

Morgan, Zamora and Hindmarsh make a compelling case for a national strategy on chronic disease prevention and management. The truths raised in the lead paper are not particularly inconvenient, but they do raise a number of uncomfortable questions: (1) Why are physicians not taking a more responsible and active role to prevent and manage chronic diseases on behalf of their patients? (Physicians must recognize that it is their professional responsibility and their job to provide their patients with the appropriate level of care for chronic conditions.) (2) Why are non-physician healthcare providers not playing a larger role to prevent and manage chronic diseases? (3) Why is there a greater focus on managing chronic diseases than on preventing or delaying them from happening? (4) Have we forgotten the profound impact of the social determinants of health on illness, life expectancy and death?

Ontario Creates a Centralized RFP Process from Which all Participants Emerge as Winners

Wed, 22 Aug 2007 11:44:56 -0400

In late November 2004, Ontario's Ministry of Health and Long-Term Care launched an inaugural bulk-purchase initiative for the replacement of 28 computed tomography (CT) scanners and eight magnetic resonance imaging (MRI) machines across the province. The original intent was to leverage volumes to achieve cost-savings on equipment pricing for participating hospitals. The success of the venture has led to the consideration of using the process as a model for many future ministry-funded healthcare procurement initiatives. In fact, this model sparked the interest of other provinces, and dialogue has begun on adapting the process nationally.

Evaluating Outcomes in Ontario's Wait Time Strategy: Part 4

Sun, 15 Apr 2007 11:44:09 -0400

The goal of Ontario's Wait Time Strategy - launched in November 2004 - was to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006: cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements and magnetic resonance imaging (MRI) and computed tomography (CT) scans. The Ministry of Health and Long-Term Care set out to shift a system where no one really knew how long the majority of people waited for most healthcare procedures to one where people waited less time from the decision to receive a procedure to actually receiving the procedure. Systems, structures and processes had to be established within two years to measure and monitor what appeared to be fairly simple wait times in five well-defined areas (Trypuc et al. 2006b). In addition, accountability structures, incentive systems and a public forum to communicate wait times needed to be developed, and - most importantly - surgeons, radiologists and supporting clinicians had to perform more procedures.

Under the Radar: Stealth Development of Two-Tier Healthcare in Canada

Tue, 15 Aug 2006 11:43:32 -0400

The shocked reaction of commentators to the recent Canadian Supreme Court decision (Chaoulli v. Quebec) overturning Quebec's ban on private healthcare insurance is difficult to square with the facts and policy options realistically open to provincial governments. The problem is that rhetoric has centred on preserving a single-tier universal system that has never existed in the form its supporters imagine. Meanwhile, quasi-private agencies and healthcare entrepreneurs have been improvising private care options, either ignored or abetted by governments. Consequently, policy and practice have become increasingly divergent. Supporters of Canadian-style medicare can only hope that the Chaoulli decision will force clearer-headed policy re-appraisal. Towards that end, this paper argues that provincial governments ought to focus more on robust regulation of already existing, privately financed healthcare, including the commissioning of care by Workers' Compensation Boards.

How Do Patients and Physicians Rate Urgency of Care? A Comparison of Urgency Ratings for General Surgery

Fri, 15 Mar 2002 11:42:10 -0400

Recent discussion concerning the Canadian healthcare system has focused on how well the system provides access to patients awaiting care. Accessibility is one of the guiding principles of the Canada Health Act. This principle stipulates that "provinces and territories must provide reasonable access to insured health care services on uniform terms and conditions ... unimpeded ... by charges or other means [such as] age, health status or financial circumstances." The notion of uniform terms and conditions speaks to equity of access - that fair rules apply in obtaining medically necessary services. However, when demand for medical services outweighs the supply of these services, the issue of "fair rules" concerning who comes first or who is most in need is a hotly debated subject. This debate has focused not just on how long patients may have to wait for access, but also on the question of how caregivers decide the priority of providing care. Central to this discussion is the need to develop a transparent methodology that fairly prioritizes patients based on urgency, timely access to services and acceptability to all stakeholders.

Determinants of Waiting Time for a Routine Family Physician Consultation in Southwestern Ontario

Thu, 15 Feb 2007 11:39:25 -0400

Waiting times are a reality in Canada's publicly financed single-payer healthcare system. While there are ample data about waiting times for specialized investigations and procedures, few data exist about waiting times to see family physicians, and determinants of this wait. We analyzed data from a survey of 731 family physicians in southwestern Ontario to understand physician- and practice-level determinants of waiting time. Physician gender, usual number of patients seen per week, involvement in teaching and population served were the key determinants of physician-reported waiting time.

National Quality Council: Healthcare Renewal in Canada: Accelerating Change

Tue, 15 Mar 2005 11:38:35 -0400

Recent Canadian history has been marked by an increasing anxiety about the state of our healthcare system. As our population ages and new demands and demographic pressures are placed on the healthcare system, the Canadian public has been understandably preoccupied with the long-term viability of the system: Will the care I need be accessible in the future?

Insight: In Conversation with Will Falk, Partner, Accenture Health and Life Sciences

Tue, 15 May 2007 11:37:43 -0400

William Falk has walked the back halls of power and has managed projects and teams that have set directions, shifted public policy and made headlines. No stranger to the complexities of the healthcare system, academic medicine and the drivers of change, Will has formed strong ideas and possible solutions from his observations in Canada and the US. Armed with these experiences, a passion to improve system performance, the promise of information technology and Canada's recent emphasis on wait times and chronic disease management, Will Falk, now with Accenture's Health and Life Sciences practice, has become a proponent of the enabled patient - participants who can better navigate the system and its providers. Ken Tremblay spoke with him at his Toronto office.

Timely and Appropriate Access to Healthcare: The Way Forward - The Roles of the Players

Fri, 15 Sep 2006 11:24:26 -0400

Timely and appropriate access to needed care continues to challenge the healthcare system in every province and territory in Canada. Indeed, the Romanow report (Romanow 2002) stated that "long waiting times are the main, and in many cases, only reason some Canadians say they would be willing to pay for treatments outside the public health system." A recent report from the Canadian Institute for Health Information (CIHI), "Waiting for Healthcare in Canada: What We Know and What We Don't Know" (CIHI 2006), helps outline the current situation. Through the leadership of a number of Canadian healthcare organizations and the Canadian Policy Research Networks, three invitational conferences (Taming of the Queue (TQ) I, II and III) have been held in Ottawa over the past three years. These conferences were to facilitate discussion among participants from all jurisdictions and organizations in order to understand the "wait time problem" and seek solutions. The first conference in 2004 (TQI), I would characterize as "we think we have a problem," the second (TQII) as "we definitely have a problem," while the latest (TQIII) as "there may be solutions." This paper, utilizing both the views and information presented at TQIII and the author's own experience and views, seeks to outline directions that could help us achieve timely and appropriate access to care in Canada.

Physicians: It's in Your Court Now

Thu, 15 Sep 2005 11:21:58 -0400

The Supreme Court decision of June 9, 2005 clarifies the political choice facing organized medicine in Canada. Many of Canada's doctors are strong and eloquent supporters of single-tier health care. Many are not, and never have been. A mere decade ago, at the CMA's annual General Council meeting, a motion declaring that citizens "must have the right to choose regulated private insurance for all medical services" fell on a vote of 88 to 68. Focus groups conducted by the CMA in 1996 revealed a wide chasm between the strong public support for public health care and the then 78% of physicians who believed stronger private-sector participation in health care was either very or somewhat acceptable. And, of course, organized medicine was heatedly opposed to the introduction of medicare in Saskatchewan in 1962. More often than not, doctors' organizations have strongly opposed measures that they have subsequently embraced. In this they are no different from any other privileged group - whatever their virtues, attunement to the will of the demos is not among them.

From the Editor-in-Chief: Waiting Lists? What Waiting Lists? Not Nursing's Problem.

Thu, 15 Sep 2005 11:21:07 -0400

Canada is experiencing problems with wait times for specific healthcare services. This is not uncommon in countries that have a socialized healthcare system. In Canada, the most egregious problems involve wait times for diagnostic tests, particularly MRIs and surgeries for cataracts, hip or knee replacements and cancer. Recently (June 12, 2005), the Supreme Court found in favour of a patient from Quebec and his physician (Chaoulli v. Quebec) who challenged the system because the patient had to wait more than a year to get a hip replaced. Technically, the decision pertains only to the province of Quebec and its healthcare system, but it is seen to have implications for all provinces.

Making the Best Use of Radiological Resources in Canada

Sat, 15 Oct 2005 11:20:32 -0400

Diagnostic imaging plays a crucial frontline role in healthcare, providing the information some physicians need to make a diagnosis and determine a course of treatment for their patients. However, wait times for access to diagnostic imaging examinations continue to be long. This is due to a number of factors, including the expanding indications for CT and MRI and growing reliance on imaging studies, Canada's lag in purchasing new equipment, an American influence on the Canadian healthcare system and clinicians' requests for inappropriate examinations. A number of strategies need to be implemented to maximize radiology's efficiency and ensure that services are being used appropriately. The author advocates the use of appropriateness guidelines for referring physicians, delisting tests that are completely inappropriate, implementing the use of radiology information systems, enhancing radiologist efficiency and using physician extenders to perform less complex medical work.

Waiting for Care in Canada: Findings from the Health Services Access Survey

Wed, 15 Nov 2006 11:17:43 -0400

Waiting for care has been and continues to be a major issue for the healthcare sector in Canada. While considerable gains have been made regarding valid and reliable information on waiting times, gaps remain. Statistics Canada continues to provide information regarding patients' experiences in accessing care at the national and provincial levels, including how long individuals waited for specialized services, through the Health Services Access Survey. The survey offers several advantages, including waiting time information that is comparable across time and space, enhanced patient information and information regarding patients' experiences in waiting for care. The results for 2005 indicate that median waiting time for all specialized services was between 3 and 4 weeks and remained relatively stable between 2003 and 2005. Waiting times for specialist visits did not vary by income. In addition to being asked how long they waited, individuals were asked about their experiences in waiting for care. While the majority of individuals waiting for care indicated that their waiting time was acceptable, there continues to be a proportion of Canadians who feel they are waiting an unacceptably long time for care. Between 11% and 18% of individuals waiting for care indicated that their life was affected by waiting.

Medical Services for Ontarians Outside of Canada

Wed, 22 Aug 2007 11:16:40 -0400

In the last year, the Health Services Appeal and Review Board of Ontario (the "Board") rendered two noteworthy decisions that considered the circumstances under which a person may seek medical treatment outside of Canada and have such treatment covered under the Ontario Health Insurance Plan ("OHIP"). The Board granted Ontario residents David King and Sandra Posluns their requests for reimbursement of expenses incurred for hip replacement surgery obtained in the United States of America (the "U.S."). Both patients were able to satisfy the requirements for reimbursement by demonstrating that the delay in obtaining surgery in Canada would result in medically significant irreversible tissue damage, and that it was necessary to travel outside of Canada to avoid such delay.

Creating a Surgical Wait List Management Strategy for Saskatchewan

Fri, 15 Mar 2002 11:15:32 -0400

In the summer of 2001, Saskatchewan Health asked Dr. Peter Glynn, healthcare consultant, Dr. Mark Taylor, the Deputy Head of General Surgery at St. Boniface General Hospital in Winnipeg, and Dr. Alan Hudson, a Toronto-based neurosurgeon and former CEO of the University Health Network, to advise on the creation of a provincial surgical wait list management strategy to address growing concerns about waiting times for many non-emergent surgical procedures. Although the work was focused on Saskatchewan, this is a common issue across the country.

Wait Times for Paediatric Rehabilitation

Thu, 15 Feb 2007 11:12:58 -0400

Children with physical disabilities experience long waiting times for PT and OT rehabilitation services. Strategies to improve timely service delivery are needed.

Chronic Disease Prevention and Management: Some Uncomfortable Questions

Fri, 15 Jun 2007 11:12:27 -0400

Shopping for High-Technology Treatment in Another Province

Tue, 15 May 2007 11:11:35 -0400

In order to address long healthcare waits, political and professional groups have recommended sending patients to other provinces for diagnostic procedures or treatment. We investigated the feasibility of such recommendations, specifically, whether residence in one province can impede access to MRIs in another province. We contacted all public MRI facilities in Canada and found no difference in wait times between prospective in- and out-of-province patients, although wait times were highly variable from province to province. Over one-fifth (19/86=22%) of centres imposed barriers for out-of-province patients to access care. We discuss several jurisdictional, financial and logistic considerations regarding the feasibility and appropriateness of implementing a national strategy of interprovincial patient transfer for healthcare.

After the Sensible Reforms, What? The Next Big Issue in Wait-Time Management

Sun, 15 May 2005 11:10:47 -0400

Baker and Schwartz have provided an excellent overview of the theories and practices of wait time reduction, complemented by a summary of Ontario's plans to reduce excess waits for cancer care. In this commentary, I pursue a number of issues implicit in their analysis and prescriptions, and revisit the logic of the origins of and solutions to wait times.

Waits for Surgery Following Hip Fracture

Tue, 15 Aug 2006 11:09:44 -0400

Almost all hip fracture patients undergo surgery to repair the fracture. Recent research suggests that timely repair is important for good outcomes following surgery. Patients who had surgical repair of a hip fracture in 2003-2004 were identified using hospitalization data collected by the Canadian Institute for Health Information. Time to surgery was calculated from day of admission to day of surgery. The associations of both patient and system characteristics with waits for surgery were considered. While the majority of patients had surgery on the day of or the day following admission, 29% waited two days or longer for surgery. Wait times were related to patients' age, hospital size, day of admission and whether patients were transferred.

What Pay for What Performance?

Mon, 15 May 2006 11:08:56 -0400

The paper by Pink et al. is extraordinarily timely and useful for those managing the Ontario Wait Time Strategy. Pay-for-performance (PFP) has been a central tenet of this successful, publicly financed initiative, introduced 18 months ago. Governments around the world focus on wait time reduction, and this measurement is fashionably utilized as a popular indicator of how well a healthcare system is performing. Because wait time reduction is so high on the political agenda, governments are prepared to spend public money raising the question of how that money can be best spent to achieve that goal.

Guaranteeing Accountability for Quality Care

Fri, 15 Jun 2007 11:08:21 -0400

The quality gap in the management of chronic disease is an issue which must be addressed if we are to achieve sustainability of our health system and optimal health outcomes for Canadians. The delivery of quality care needs to be a fundamental expectation of providers, professional regulators, institutional leaders and senior government leaders. Success in the arena of quality improvement comes from clarity of accountability, "obsessive" tracking and action on key performance indicators, and results-based teamwork. Strong leadership, identification of shared priorities across the country, full transparency, and an engaged public are all key to moving ahead in this critical area of Canadian healthcare.

Waiting Lists and Nursing

Thu, 15 Dec 2005 11:07:20 -0400

The recent editorial, "Waiting Lists? What Waiting Lists? Not Nursing's Problem" (Pringle 2005), challenges nurses to "step up to the plate" with a pithy and solid analysis of the waiting list issue from a nursing perspective and with recommendations for ameliorating it. Although we are not nurses, and are thereby disqualified from stepping up to the plate, we believe that our experience of working for over a year to implement Ontario's Wait Time Strategy qualifies us to comment on the game.

Reducing Hip and Knee Replacement Wait Times: An Expanded Role for Physiotherapists in Orthopedic Surgical Clinics

Sun, 15 Apr 2007 11:06:56 -0400

The Ministry of Health and Long-Term Care officially announced Ontario's Wait Time Strategy on November 17, 2004, to address timely healthcare access to five key areas: cancer surgery, cataract surgery, hip and knee joint replacement surgery, cardiac procedures and magnetic resonance imaging (MRI) and computed tomography scans (Trypuc et al. 2006). The goal of the Wait Time Strategy was to reduce the time patients wait for these five identified services by December 2006 by funding new innovative evidence-based strategies to help transform the current healthcare system into a more efficient and accountable model with an increasing degree of transparency (Hudson 2006).

Health Services Research after Chaoulli v. Quebec (Attorney General): New Inspiration, New Challenges

Wed, 22 Aug 2007 11:06:34 -0400

As a result of Chaoulli, wait-times research of this kind and health policy research generally in Canada will now take on heightened legal significance. The Court has signaled that future litigants may rely on established benchmarks, targets and care guarantees to establish the appropriateness of legal claims that allege unacceptable waits. More broadly, comparative health-systems research will now provide an evidentiary basis upon which judges may make their determination of the constitutionality of provincial insurance plans.

Ontario's Wait Time Strategy: Part 1

Wed, 15 Mar 2006 11:05:56 -0400

This article is the first in a series of articles examining Ontario's Wait Time Strategy. The series begins with the Strategy's key elements, assesses progress made after one year, and identifies the lessons learned thus far.

A Prescription for Ontario's Wait Time Strategy

Mon, 15 Jan 2007 11:05:26 -0400

After a late start, Ontario is well on its way to implementing an ambitious Wait Time Strategy that has already begun to show some tangible improvements in access to the five priority areas. This commentary argues that in addition to the supporting tools identified in the lead essay, a sustainable wait time strategy must encompass prevention and demand management, address shortages in health human resources, provide patients with recourse to a safety valve and promote interprovincial standards and cooperation. Care will also be needed to ensure ongoing support and engagement of organized medicine, realigning incentives to support patient care and extending the reach of health information systems into the community.

Wait Time Benchmarks, Research Evidence and the Knowledge Translation Process

Thu, 15 Feb 2007 11:04:46 -0400

The first set of evidence-based benchmarks for medically acceptable wait times, announced in December 2005, were developed, in part, through a novel partnership between the Provincial and Territorial Ministries of Health, the Canadian Institutes of Health Research (CIHR) and Canada's health services research community. Responding to a direct request for assistance and demanding timelines from the Provincial and Territorial Ministries of Health, CIHR mounted a rapid-response funding process and supported eight Canadian teams to synthesize evidence to inform the development of the first set of benchmarks. This experience demonstrated that both the research funding process and research syntheses themselves can rapidly inform policy making in even the most heated of environments.

Wading through Wait Times: What Do Meaningful Reductions and Guarantees Mean?

Fri, 15 Jun 2007 11:04:06 -0400

This report is a look at one of the key public concerns about health care, set in the context of the national commitment to achieve meaningful reductions in wait times in five priority areas - cancer, heart, diagnostic imaging, joint replacements and sight restoration - by March 31, 2007.

Patient Wait Times: A Benchmark Issue in Healthcare

Wed, 22 Aug 2007 11:03:10 -0400

A commentary on: Health Services Research after Chaoulli v. Quebec (Attorney General): New Inspiration, New Challenges

Some Ethical Reflections on Accountability

Sat, 15 Jul 2006 11:01:26 -0400

Wait times have come to dominate the health reform agenda and have captured the public imagination. Waiting for any service - from fast food to e-mail - is difficult for contemporary Canadians; this is especially true for healthcare. Addressing wait times is part of a much larger initiative essential for the health system and dependent on a culture shift from the "blame game" to a sustained, meaningful accountability. Achieving this goal in such a value-laden endeavour as healthcare will be no small task. Accountability for the fair provision of access to and quality of services in healthcare is complex and demanding, in large part because of the nature of health need and the social meaning of healthcare. Failure of progress on this issue is related to a lack of clarity about the locus, meaning and scope of accountability. Without such clarity the term runs the risk of becoming useless or dangerous. Ethically, the key lies in understanding the profoundly value-laden nature of both healthcare and public policy.

Accountability Agenda Must Include Home and Community Based Care

Sat, 15 Jul 2006 11:01:03 -0400

Wait times and the wait times agenda are on the Canadian schedule. Although most Canadians support our healthcare system, they are concerned about access. Resolving the wait times agenda might help increase Canadian confidence in the system's ability to provide timely access to care. While the paper by Trypuc, MacLeod and Hudson demonstrates well how quickly governments can mobilize tools and resources to address pressing policy needs, it also reveals the limited and narrow approach taken by governments to the wait times agenda. The Ontario government should recognize that a more integrated and comprehensive approach can significantly advance the wait times agenda and make the system more accountable. Only a broad-based approach will ultimately succeed in reducing wait times and building a sustainable system. A shift in values needs to take place away from the current emphasis on acute care and toward an inclusive vision of home- and community-based care that puts more emphasis on disease management, chronic care and independent living, if there is ever to be any real progress in the battle. Governments will ultimately be held accountable by Canadian healthcare consumers if they fail to make this important shift.

Sustaining Change: The Imperative for Patient Access Strategies

Sat, 15 Jul 2006 11:00:42 -0400

The paper by Trypuc, MacLeod and Hudson provides a timely and important overview of methods to sustain provincial wait time strategies. The emphasis on accountability for patient access to timely care throughout the healthcare system comes through strongly - as it should. These accountabilities are made "real" through purchase service agreements. Physician-hospital relationships are a fundamental aspect of this accountability. This commentary suggests the inclusion of two additional supporting tools in addition to those cited by the authors of the lead paper - quality monitoring and the use of industrial engineering techniques for queue management and patient flow analysis. Strong and persistent leadership of patient access strategies will ensure sustainable change.

Sustaining the Wait Time Strategy

Sat, 15 Jul 2006 10:59:45 -0400

Significant early positive cultural changes have been made in the Ontario healthcare system to address the province's Wait Time Strategy. Improving efficiency in parallel with the introduction of accountability agreements will provide early successes. However, there are fundamental system weaknesses that must be addressed in the long term to sustain the program. These include a wait list information system that addresses all patients waiting for care, additional healthcare providers with wider scopes of practice, improving hospital capacity, accountability agreements with agreed-upon performance indicators, new payment systems for physicians and a fundamental change in referral and care processes. Innovative approaches such as gain-sharing should be considered. Though resources are scarce, there is a need for significant early additional investments to achieve long-term success.

A Prescription for Ontario's Wait Time Strategy

Sat, 15 Jul 2006 10:59:21 -0400

Improving Healthcare - One Slice at a Time

Sat, 15 Jul 2006 10:59:00 -0400

The Ontario Wait Time Strategy is a focused initiative to reduce wait times in five key areas. The plan includes key components of successful change management including targets, funding and driving a culture of accountability. Successfully "redesigning" this slice of the healthcare system will, it is anticipated, act as a catalyst for sustainable change throughout the system. In the mind of this observer "from the trenches," the Wait Time Strategy must quickly be followed by a framework that addresses demand pressures from other parts of the system, but more importantly must be clearly aligned with the overall goals of the system - to improve health outcomes and support healthy lives - across the entire continuum of health services, including prevention, primary, community, long-term and acute care. Accountability for appropriateness and evidence-based care must be as significant as accountability for efficiency and volumes.

The Alberta Bone and Joint Health Institute: Creating Sustainable Accountability through Collaboration, Relevant Measurement and Timely Feedback

Sat, 15 Jul 2006 10:58:08 -0400

A robust accountability strategy is at the core of creating a safe, efficient, effective and sustainable system of healthcare. The commitment to be accountable must extend far beyond the providers of care to include every person involved in the funding, administration, delivery and support of patient care (both directly and indirectly). The Alberta Bone and Joint Health Institute has fostered a new system that will measure, analyze and give valuable feedback to all stakeholders in all three essential domains of system accountability: access, quality and cost. The Institute has employed four key strategies to create system accountability in a hip and knee pilot project: collaboration between stakeholders in defining goals and measures that matter to them; the use of "world's best evidence" to drive decisions and to establish goals and benchmarks to measure against; collection of useful data and its analysis to inform improvement decisions; and timely feedback of relevant data in domains of interest to stakeholders on system outputs in the key domains. While these strategies have not yet been proven to be effective in creating the desired "culture of accountability," they are having a significant clinical impact and do have potential to lead to that outcome.

Knowledge and Behaviour for a Sustainable Improvement Culture

Sat, 15 Jul 2006 10:57:32 -0400

Wait limits have improved UK healthcare access, and Ontario's Wait Time Strategy bears a remarkable resemblance. There appears to be an implicit assumption that capacity and efficiency factors are the main causes of waits. The improvement mechanism is driven by performance measurement that reports wait time outcomes. Our experience makes us conclude that Ontario's plans contain risks.

Developing a Culture to Sustain Ontario's Wait Time Strategy

Sat, 15 Jul 2006 10:44:27 -0400

Ontario's Wait Time Strategy - a significant change management initiative - is designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006 (cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements, and MRI and CT scans). These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services beyond 2006.