Waiting Time Management
Strategies
for Scheduled Services
Ottawa
March 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
X
Waiting
Service
Decisions
Decision 1
Is the service worth having?
Decision 2
Is the service available?
Decision 3
How urgently should
the service be provided?
macro / meso / micro = for whom?
Other
Exits
Cardiac
Surgery
WAITING LIST
D1
? Cardiac
Surgery
best
N
Y
D2
? Within
Capacity
Y
D3
? Urgency
Scheduling
N
SURGERY
Assessment
? Surgery
Active
Review
CARDIOLOGY Monitoring & Care
Other
Exits
Cardiac
Surgery
D1
Y
? Cardiac
Surgery
best
Y
D2
? Within
Capacity
D3
WAITING LIST
Acute
Very Urgent
Scheduling
? Urgency
Urgent
N
Assessment
? Surgery
N
Semi-Urgent
Active
Review
CARDIOLOGY Monitoring & Care
SURGERY
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?
The cost of waiting
•Benefits foregone
•Additional avoidable harm due to progression
- reversible
- irreversible
•Harm due to uncertainty
•Harm to others
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)
30
Modeling Waiting Time Strategies
25
Random
Cost of Waiting
(per person)
(225)
20
Option 1
15
Equal
(225)
10
Need
5
(175)
Patients
0
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 2
Option 3
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?