Public Sector solutions to Health Care Queues Michael M. Rachlis MD MSc FRCPC ( New Brunswick Ministry of Health and Social Services May 5, 2009

Outline Canada, like many countries has long waits for care In Canada, up until recently, there has been little application of formal queue management methods for healthcare queues Queuing problems are just one aspect of poor quality How to reduce health care wait lists For profit patient care tends to be more expensive and of poorer quality Re-engineering for quality

Germany, CAN, US

Queuing problems are just one aspect of poor quality care

Canada Has Big Quality Problems – Most are similar to those of other countries Misuse – Canadian Adverse Events Study 9000 to 24,000 preventable hosp deaths/yr (GR Baker et al. CMAJ 2004;170: ) 5-10 % of all deaths in developed countries are deaths in hospital caused by the health care system Overuse – Medication and the elderly Under use – Chronic disease management and prevention

Do one-fifth of older Canadian women need to take Benzodiazepines? Do we care what we’re paying for?

Six values for Quality Improvement (US IOM Crossing the Quality Chasm Safety 2.Effectiveness 3.Patient-centredness 4.Timeliness 5.Efficiency 6.Equity

Attributes of High Performing Health Systems Ontario Health Quality Council. April ( 1.Safe 2.Effective 3.Patient-Centred 4.Accessible 5.Efficient 6.Equitable 7.Integrated 8.Appropriately resourced 9.Focused on Population Health

How to reduce health care wait lists

What causes queues? Usually there is enough overall capacity Queues usually develop because of temporary capacity demand mismatches

Temporary capacity/demand mismatch in a system with only 10% variation twice a week Monday, Wednesday, Friday: 10 patient demand, 10 units of capacity, no waiting list Tuesday: 9 patient demand, 11 units of capacity, no waiting list, 2 wasted units of capacity – lost forever Thursday: 11 patient demand, 9 units of capacity, 2 patients put on the waiting list After one year 104 people are waiting and there’s moral panic. BUT average capacity equals average demand

Endoscopy Queues in Birmingham What’s going on here? Why is there still a backlog after 2 wait list initiatives?

Capacity and demand for Endoscopy in Birmingham – Average Capacity is almost always greater than average demand!

Matching variation in demand and capacity (Dr. Martin Lee’s breast clinic) Total number of Patients referred Number of clinic slots available 2 clinics per week with 54 appt Slots. This should have been enough Capacity. But temporary mismatches Meant Dr. Lee struggled to see all patients in the 2 wk standard The Solution? Reduce capacity 10% to 48 appts But spread them out over 3 clinics. Now All patients Are seen in 5 days

Variation in clinical systems 15 Staff skills illness holiday motivation training shifts Patients Resources Process Rooms supplies machines age sex race education motivation disease unclear guidelines differ complications anaesthetics We control 80% of variation! GP Discharged! Information transcription transport applications All Different

Variation kills quality

van Walraven, C. et al. CMAJ 2002;166: Risk for bad outcome after discharge from hospital and % of all discharges, by day of hospital discharge (Ontario data) Why are there 2 ½ times more discharges on Friday than Sunday? And, why are Friday discharges 15% more likely to suffer a bad outcome?

Six Steps to reduced waiting 1.Map the process 2.Eyeball the map 3.Eliminate redundant stages 4.At each stage measure demand and Capacity 5.If Capacity is greater than demand… 6.If Capacity less than demand…

1.Map the process Follow the patients through the process using their eyes Don’t miss the informal stages Measure time at each stage

2.Eyeball the map Use a patient-centred view Are there redundant stages? This is the time for creativity It’s a complex system – Small changes may have big consequences AND vice versa

“I have a good doctor and we’re good friends. And we both laugh when we look at the system. He sends me off to see somebody to get some tests at the other end of town. I go over there and then come back, and they send the reports to him and he looks at them and sends me off some place else for some tests and they come back. Then he says that I had better see a specialist. And before I’m finished I’ve spent within a month, six days going to six different people and another six days going to have six different kinds of tests, all of which I could have had in a single clinic.” Tommy Douglas

3.Eliminate redundant stages Capital Health Edmonton decreased delays for diabetic education by > 90% by not insisting patients see a diabetologist on the first visit to the centre Sault Ste. Marie decreased delays from mammogram to definitive diagnosis by 75% collapsing visits for mammogram, ultrasound, and biopsy

4.At each stage measure demand and capacity Demand should be measured prospectively with regard for appropriateness Capacity should be identified with regard to the actual length of time to provide services Measure variation

We want to meet the demand for appropriate care. Too much healthcare is inappropriate Wright et al CMAJ 2002 – 25% of cataract operations were questionable CAT and MRI scan overuse?

5.If Capacity is greater than demand… Work down backlog Identify temporary capacity/demand mismatches Reduce variation to eliminate or decrease capacity/demand mismatches – Re-shape demand – Smooth capacity

Reducing and reshaping demand

Re-shaping demand Can you do anything to prevent illness and reduce demand for your service Can you deal with your service demand in a more efficient fashion? – What are the alternative courses – What are their advantages and disadvantages What are the barriers to reshaping demand for your service

Smoothing capacity Do you have the data? Can you match your capacity to your demand? What are the barriers to flexibly using your capacity?

6.If Capacity is less than demand… Identify temporary capacity/demand mismatches Reduce variation to eliminate or decrease capacity/demand mismatches – Shape demand – Smooth capacity

6A. If your Capacity is now greater than demand… Go to Step 5

6B. If your Capacity is still less than demand… Which resources are the constraint – Capital – Human – Other operating resources Add appropriate new resources Find the new bottleneck – There will always be one part of the process which runs slower than others Continue to “chase the bottleneck”

Good News! We could solve almost all our problems with innovation and quality!

Good News! We could access primary health care within 24 hrs “Even if we did nothing else, and we should implement other reforms, if every family physician implemented Advanced Access, every Canadian could have a family doctor.” Penticton British Columbia’s Dr. Jeff Harries to the CMA meeting, “ Taming the Queue”. Ottawa. March 31, 2006

Good News! We could have elective specialty consultations within one week – The Hamilton Family Medicine Mental Health Program increased access for mental health patients by 1100% while decreasing psychiatry outpatients’ clinic referrals by 70%. – The program staff includes 150 family doctors, 80 mental health counsellors, and 17 psychiatrists and provides care to 300,000 patients

Good News! We could have elective surgery within two months – In Toronto, Barrie, and other parts of Ontario arthritis patients are assessed within two weeks for joint replacements and have their surgery within two months

And, limited understanding of queueing “They (wait lists) are the inevitable result of a public system that can consequently offer universal access to health services within the limits of sustainable public spending.” “The expert witnesses at trial agreed that waiting lists are inevitable. The only alternative is to have a substantially overbuilt health care system with idle capacity.” Canadian Supreme Court Minority Chaoulli 2005

For profit patient care tends to be more expensive and of poorer quality

For profit delivery: In general -- higher costs, worse outcomes PJ Devereaux et al (CMAJ. 2002;166: 1399–1406. CMAJ 2004;170:1817–1824) – For profit hospitals had 2% higher death rates and 20% higher costs

For profit delivery: In general -- higher costs, worse outcomes PJ Devereaux et al (JAMA. 2002;288: 2449– 2457.) – For profit dialysis clinics had 8% more deaths – For-profit clinics had fewer and less trained staff – For profit clinics dialyzed patients for less time and used lower doses of erythropoietin – In the US, 2,000 premature deaths occur every year among dialysis patients using for-profit clinics.

Contracting out clinical services isn’t nearly as easy as the advocates claim (Deber 2002) low contestability high complexity low measurability susceptibility to cream skimming externalities

“Before the buy-out, I could have taken the money and gone on vacation. Now the surpluses are used to treat more patients.” Dr. Wayne Hildahl, Executive Director, Winnipeg Regional Authority Pan Am Clinic (and former private owner)

Externalities -- Non Profits are more likely to: Expend resources on linking different organizations together to plan community networks Engage their communities and enlist volunteers Provide benefits, continuing education, and training to their staff

Some public private partnerships do work!

To quote Tony Soprano, “Fuhgetaboutit!” There are public sector solutions to all of Medicare’s problems.

See M Rachlis “Private Health Care won’t Deliver” ( /pubs/2007%20Rachlis%20privat e%20public.pdf) /pubs/2007%20Rachlis%20privat e%20public.pdf

Re-engineering for quality Saskatchewan Health Quality Council ( Ontario wait list management ( Ontario Health Quality Council ( Winnipeg’s Pan Am Clinic ( Toronto’s Trillium Health Centre Surgicentre ( ical_services/queensway/surgicentre.html) ical_services/queensway/surgicentre.html

Re-engineering for quality Why Wait? Public Solutions to Cure Surgical Wait lists ( lists%20paper%20final.pdf ) lists%20paper%20final.pdf Public Solutions to Health Care Wait Lists ( /Health_Care_Waitlists.pdf) /Health_Care_Waitlists.pdf Institute for Healthcare Improvement ( Improving Patient Flow (

Summary: Canada, like many countries has long waits for care In Canada, up until recently, there has been little application of formal queue management methods for healthcare queues Queuing problems are just one aspect of poor quality There are public sector strategies to eliminate waits and delays and deal with other quality problems For profit care tends to cost more and deliver less Let’s re-engineer for quality

“Courage my Friends, ‘Tis Not Too Late to Make a Better World!” Tommy Douglas (per Alfred Lord Tennyson)