Waiting Time Waiting Time Management Management

StrategiesStrategiesfor Scheduled for Scheduled

Services Services OttawaOttawa

March 28, 2012March 28, 2012

Minimizing the Cost of Waiting

Ray Naden, New Zealand

Scheduled Services

Goals:

•To maximize the value of available capacity

•To minimize the cost of waiting

Decision Service

Decision Service

Waiting

X

Decisions

Decision 1

Decision 2

Decision 3

Is the service worth having?

Is the service available?

How urgently should the service be provided?

macro / meso / micro = for whom?

CARDIOLOGY Monitoring & Care

Assessment? Surgery

D 1? Cardiac Surgery

best

D 2? Within Capacity

D 3? Urgency

Scheduling

Active Review

SURGERY

YY

N N

OtherExits

WAITING LIST

CardiacSurgery

CARDIOLOGY Monitoring & Care

Assessment? Surgery

D 1? Cardiac Surgery

best

D 2? Within Capacity

D 3? Urgency

Scheduling

Urgent

Semi-Urgent

Very Urgent

Acute

Active Review

SURGERY

YY

N N

OtherExits

WAITING LISTCardiacSurgery

Decision 1 - Is the service worth having?

•Joint decision of the patient and specialist

•Patient autonomy and informed choice- good quality information especially on outcomes- assistance in making difficult choices

•Options: “Yes” / “No” / “Maybe later”

•Can lead to fewer procedures being performed

Decision 2 - Is the service available?

•Demand vs Supply

•“Available” ?

•Waiting List - ? list / pool / queue / schedule

•Does “to list” = “to guarantee” (by when?)

? Covert avoidance of Decision 2?

Decision 3 - How urgently should the service be provided?

•Benefits foregone

•Additional avoidable harm due to progression- reversible- irreversible

•Harm due to uncertainty

•Harm to others

The cost of waiting

Provision of Services

•Real capacity- right service at the right time in the right place

•Adequate resilience

•Scheduling and patient management

•Cancellations and deferments

•Reducing uncertainty

•Optimizing preparedness

•Post-op care

Before Decision 1

•Patient awareness and information

•Seeking and accessing specialist assessment- choosing which specialist

•Waiting for specialist assessment- including waiting for diagnostics

•Patient expectations

Cost of Waiting- issues for patients

•Prolonging avoidable loss of quality of life

•Potential harm secondary to treatment

• Autonomy – control of what happens to us

•Uncertainty

•Fairness

Cost of Waiting- issues for health service providers

•Balancing conflicting duties of care / responsibilities

•Managing multiple pressures

•Managing complex systems

•Re-work

•The cost of managing uncertainty

Cost of Waiting- issues for managing whole of system

•Waiting and uncertainty inflates demand- focus on Decision 3 (urgency) takes focus away from Decision 1(value)

•Prioritisation is challenging- macro / meso / micro

•Uncertainty leads to politicization of decision-making

•Reacting to inquiries / media / legal issues / political

Strategies

•Explicitly acknowledge need to prioritize

•Explicit policy on clarity, timeliness and fairness

•Simple patient-related measures of performance

•Align incentives to policy

•Engage physicians in improving decision-making

•Focus on allocative efficiency (what we choose to do) - macro / meso / micro

•Reduce uncertainty, especially for individual patients

•Focus on the cost of waiting (to patients)

0

5

10

15

20

25

30

A B C D E F G H I J K L M N O P Q R S T U V W X Y

Option 1

Option 2

Option 3

Modeling Waiting Time Strategies

Random(225)

Equal(225)

Need(175)

Cost of Waiting(per person)

Patients

Conclusions

•Multiple parts of the process where there is avoidable cost of waiting

•Need to address the whole of the system

•Increasing technical efficiency is useful but will have limited impact, and potentially decrease overall value

•Improving allocative efficiency (what we choose to do) has considerable potential

- macro / meso / micro

Reflections

•Why do we make people wait?

•Is it really necessary or desirable?

•Does it do more harm than good?

•What can we do to minimize the harm of waiting?