Abstract

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. Across Canada, provinces, regional health authorities and hospitals are engaged in developing strategies to facilitate timely patient access to needed healthcare. Trypuc, MacLeod and Hudson have provided an important overview of methods to sustain these strategies - using the Ontario Strategy as an example. Indeed, the authors point out that "Ontario's Strategy is a significant change management initiative." In my opinion, it is much more than that. It is, in large part, fundamental reform of healthcare in Ontario.

The authors identify a set of key elements:

  • empowering patients by democratizing knowledge about wait times
  • increasing system capacity with more and better use of resources
  • making hospital boards and management accountable for managing access through purchase service agreements
  • creating a single province-wide wait time information system with standardized data
  • setting standardized clinical priority levels and wait time targets

The paper's presentation of the progress to date through the implementation of the above elements is impressive. Clearly, strategic purchasing of service through agreements with hospitals that include a set of defined conditions (in other words "pay-for-performance") is paying off. But can this momentum be maintained, along with the changes in thinking about the provision of service that it has engendered?

The authors correctly identify that the key to sustaining these changes is through the explicit accountabilities of all parties. Fundamental to this, I would suggest, is the recognition that confusion is created when we speak of "healthcare providers" rather than clearly signalling that there is really only one "provider": the organizational entity responsible for the provision of services. Certainly, for surgical services and complex diagnostics, physicians, nurses and other professionals do not work in isolation, but under the aegis of a healthcare organization - in Ontario's case "the hospital." The authors allude to the need to be specific in regard to accountability for patient access. It is logical to conclude that the accountability must reside with the organization that holds the resources - not just in the sense of accepting responsibility but also actively measuring and managing. The most important enabler of such accountability, as the authors point out, is data, information and knowledge. Historically, Ontario hospitals have not known the names of the patients waiting for procedures, their clinical priority or even what procedure they were waiting for! The authors clearly intend the implementation of the Wait Time Information System (WTIS) to provide the hospitals with such information on a real-time basis so that they can actively manage patient access.

To achieve active management of timely access for patients, Ontario hospitals must now ensure that physicians see themselves (and are seen) as active participants in access management strategies. Too often, physicians feel disenfranchised from the decision- making structures of the hospitals. The authors rightly point out the pivotal role of physicians in ensuring timely access. The notion, introduced in the paper, of mutual accountabilities between physicians and hospitals should be further explored, as this may be a key component of the sustainability of the strategy. With the "democratization" of knowledge about wait times, we can no longer tolerate vast differences between hospitals in wait time for the same procedure. Active management of patient access, in partnership with physicians, can alleviate that problem.

The authors provide an important list of supporting tools: develop leaders, align incentives and develop information systems. However, two other supporting tools should also be mentioned as having potential to help sustain the strategy. The first is quality and safety measures, processes and monitoring. Just doing more work is neither sufficient nor appropriate. The care must be safe and of appropriate quality in terms of patient outcomes. It must be "state of the art" care, not care that is clearly "out of date." The competence of all participants must be routinely measured to ensure this is the case.

The second supporting tool I would add is the use of industrial (process) engineering techniques to model both queue management and patient flow processes. These technologies have been widely applied in all process industries over the past half-century with great success. Their use might quickly improve the timeliness, efficiency and effectiveness of care processes.

In conclusion, the bottom line in sustaining a strategy of timely and appropriate access is leadership - from boards, management, healthcare professionals and government, supported by an informed public. Without leadership at the local, regional and provincial level, no strategy is sustainable. Such leadership will not be easy, as it will entail confronting the status quo in roles, processes and relationships. It will mean new ways of thinking and working. It will, in some cases, mean deep personal change. It will mean confronting those who don't wish to cooperate. It will mean that there are consequences to not fulfilling accountabilities. It will mean that no one can operate independently and that everyone in healthcare is connected. It will mean trying new ideas and learning from experience. It will mean taking charge. It will mean learning from and coaching each other.

But it will also mean that patients receive timely, appropriate and quality care. They deserve no less, being "the owners" of the Canadian healthcare system. Our ability to deal with the wait time issue will determine our ability to sustain this system. In other words, sustaining the patient access strategy is about sustainable healthcare in Canada.

Estragon: … Let's go.
Vladimir: We can't.
Estragon: Why not?
Vladimir: We're waiting for Godot.

- Samuel Beckett, Waiting for Godot

We can no longer afford to wait. The lead paper sets out a viable strategy for "doing something" about achieving timely care and sustaining wait time reduction. It is time to embrace it.

About the Author

Peter A. R. Glynn, PhD
Health Care Consultant,
Kingston, Ontario