1. Waiting Time Management Strategies for Scheduled Services Ottawa March 28, 2012 Minimizing the Cost of Waiting Ray Naden, New Zealand

2. Scheduled Services Goals: To maximize the value of available capacity To minimize the cost of waiting

3. DecisionService

4. DecisionService Waiting X

5. 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?

6. CARDIOLOGY Monitoring & Care Assessment ? Surgery D 1 ? Cardiac Surgery best D 2 ? Within Capacity D 3 ? Urgency Scheduling Active Review SURGERY YY N N Other Exits WAITING LIST Cardiac Surgery

7. 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 Other Exits WAITING LIST Cardiac Surgery

8. 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

9. 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?

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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)

17. Modeling Waiting Time Strategies Random (225) Equal (225) Need (175) Cost of Waiting (per person) Patients

18. 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

19. 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?