Monday, September 5, 2011

Long wait times for surgery? Never again!

There is absolutely no inevitability as long as there is a willingness to contemplate what is happening.

- Marshall McLuhan


When someone decides they want to have surgery performed, they usually want to know details: What will happen? Will it be painful? What are the complications?  But, even if they don't have a lot of questions about How and What, they almost always ask about When.

And that is often an awkward question to answer.

Our surgical booking system divides patients into 4 categories: emergency,cancer, urgent and elective.  While the first 3 categories denote pressing need for surgery, "elective" surgery indicates that the procedure can be delayed without significantly compromising the person's health or chance for a good outcome.  It's an arbitrary definition, and varies from surgeon to surgeon.  The perception of what should be considered "elective" certainly varies between surgeon and patient.

The Saskatchewan Surgical Initiative's (SkSI) goal is that, by 2014, all patients will have the option to have their surgery within 3 months.  ("Option", because some people may choose to delay their surgery until a more convenient time).  By the end of 2011-2012, the goal is to reduce all surgical wait times to less than 12 months.

A 12 month wait for surgery is shocking, and some people wait 18 months or longer!  The amazing thing about that is that we (patients, surgeons, administrators) have accepted this as inevitable.

But, we won't accept these waits for much longer.  Take a look at this trend: 



This is the number of people waiting longer than 12 months (top line) and 18 months (bottom line).  Over the last year, the numbers in each group have been halved!  While this trend had started (due to other provincial initiatives) even prior to SkSI's formal start in 2010, it has been bolstered by SkSI.  Additional OR time, as well as more effective use of that time, are helping to clear the "long wait" backlog.

This success isn't without a cost.  In our practice, we've been assigned additional OR time to provide service for our patients who have been waiting for over 12 months.  This means that the urologist will not be available to provide other important services, such as office consultation or cystoscopy clinics.  As such, wait times in those areas have increased.

There's nothing magical about how this wait time success is being achieved.  Health system leaders decided that this would be a strategic priority, and put attention and resources toward fixing it.  Leaders and managers are accountable for achieving targets.  With this approach, SkSI will meet its goals - whether by 2014 or not is just a quibble.  Then, once the SkSI goals are met, our healthcare system can focus on another strategic priority.

And that's when all SkSI's work will be in danger.

We can only concentrate on a few major initiatives at a time.  A fairly small number of people are involved in moving these projects ahead, and only have so much time and attention to go around.  Once we declare "Mission Accomplished" on surgical wait times, and move on to, say, Primary Care Reform, surgical wait times may creep back up.

In addition to reducing the surgical backlog, we need to build in sustainability, such as ongoing surveillance and transparent reporting of wait times.  More important is a critique of current practices - keeping the effective parts and redesigning the rest.  We need to create processes (e.g. pooled referrals, assessment and treatment pathways) that will survive the inevitable dimming of the spotlight currently illuminating the surgical system.  We can't rely on the hyper-vigilance associated with being the provincial priority du jour.

I look forward to the day when, as I hold forth in front of a group of medical students, they shake their heads and smile wryly at the old-timer's tall-tales of surgical wait lists longer than 3 months.

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