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Now or Never
the political will exists to reduce wait times
Doug Thomson
CEO, Canadian Orthopaedic Association
When the First Ministers reached their $41-billion accord on long-term health care funding last September, the federal government specifically pledged $4.5 billion for a Wait Times Reduction Fund. These new monies would be dedicated to training and hiring human resources, clearing backlogs, building capacity, expanding community care and developing tools to manage wait times. All this activity would be directed at five clinical areas deemed to be priorities: cancer, heart, diagnostic imaging, sight restoration and joint replacement.
In return for its largesse, the federal government finally got what it had sought for so long. For the first time ever, the provinces and territories committed themselves to performance evaluations on wait-time reduction. And lest anybody develop cold feet, a very tight timeline was imposed on the whole process. By December 2005, all provinces and territories must have developed “comparable indicators of access to health care” and “evidence based benchmarks for medically acceptable wait times.” By December 2007, each jurisdiction must establish target dates to achieve priority benchmarks.
What are the implications of all this for Canada’s orthopaedic surgeons? Well, for one thing, once benchmarks are developed, target dates established, and an earnest effort to reduce wait times underway — that is, in three years from now — no level of government will ever want to discuss the issue again. There will be no appeal. The dragon of wait times will be considered slain.
So if it’s now or never to make positive changes in working conditions, then other important considerations emerge for the orthopaedic profession: How to reach a lasting consensus on comparable indicators and evidence based benchmarks for joint arthroplasty? Also, with the spotlight so much on hips and knees, how do we guard against progress in this one clinical area at the expense of less common, but no less important, procedures — robbing Peter to pay Paul, so to speak? And how does one get heard amid all the competing voices of the other specialist societies involved in the process?
So far, efforts by the Performance Indicator Reporting Committee (PIRC), a federal/provincial/territorial working group formed in 2002, has come to very little, since its consultation process was deeply flawed. In order to meet the commitments in the 2004 accord, PIRC is widely expected to be further mandated to find consensus on a broad range of indicators by December 2005. The COA will want to have its perspectives on indicators of access to orthopaedics presented in compelling fashion.
To make sure that it does have that opportunity, the COA has entered into an informal alliance under the aegis of the Canadian Medical Association (CMA), which is acting as a secretariat. In addition to the COA, the alliance comprises the Canadian Association of Medical Oncologists, the Canadian Association of Nuclear Medicine, the Canadian Association of Radiologists, the Canadian Cardiovascular Society and the Canadian Ophthalmological Society. In mid-October a letter to the deputy minister of health from the CMA on behalf of the alliance requested “immediate and ongoing input” into the process of developing indicators.
The letter also outlined a number of “first principles” identified by the alliance:
• medically appropriate benchmarks for wait times should be pan-Canadian, evidence based rather than geographically bound;
• wait time benchmarks should be continuously evaluated, refined and updated;
• the practicing community should be consulted early and often if development and implementation of benchmarks are to succeed;
• reduction of wait times in the five priority areas should be patient-centred and encompass the full spectrum of care;
• benchmarks and the associated provincial targets to reduce wait times must be sustained through the Wait Time Reduction Fund, so that success is not achieved at the expense of other health services.
As a means for proceeding, the alliance strongly urges in its letter that the federal/provincial/territorial ministers of health create a Steering Committee on Wait Time Strategy. Representation from the relevant clinical specialties would be on five Expert Tables, each of which reflects one of the areas of clinical priority. Furthermore, any physicians selected to represent the physician community should be drawn from a slate of candidates supplied by the alliance.
While there is strength in presenting a united front, each national specialty society will have its work cut out for it. The COA sees its role as a facilitator or honest broker, making sure that provincial associations are informed about benchmark efforts by their sister organizations. To that end, the COA’s Board of Directors has instructed the National Standards Committee to focus exclusively on evidence based benchmarks. Since June, the Committee Co-Chairs, who are both in Toronto, have been meeting every two weeks with a paid researcher and are making good progress.
Although Canada has an established track record in developing clinically based benchmarks, the literature is sparse when it comes to hip and knee arthroplasty. One the best known models is the Cardiac Care Network of Ontario (CCNO), which has developed an urgency rating score through clinical consensus for cardiac procedures. Based on these scores, the CCNO has developed maximum recommended wait times for cardiac catheterization and surgery, against which performance is publicly measured.
Since 1998, members of the Western Canada Wait List (WCWL) have been working to develop effective tools to manage wait times in five clinical areas: hip and knee arthroplasty, general surgery, cataract removal, children’s mental health and MRI scans. The WCWL process for determining benchmarks is elaborate, including clinical, patient and public consultations. The current phase of work, scheduled to be completed in December 2004, is developing a referral instrument for primary-care physicians and benchmark wait times for hip and knee procedures.
The Saskatchewan Surgical Care Network (SSCN) takes another approach, overseeing a province-wide centralized registry that tracks all patients waiting for surgery. Registry data fuels development of clinical standards and tools for prioritizing patients, and allows the SSCN to monitor system performance. Recently, work has begun on achieving two priority goals: performing 95% of cancer and suspected cancer surgeries within three weeks of assessment, and completing surgical procedures for patients who’ve been on the waiting list for more than 18 months. Although some critics feel this centralized model only works in provinces with populations of less than a million, it’s worth noting that at least seven other provinces are debating the merits of wait-time strategies that use central registries for real-time management of patient triage, benchmarks and performance evaluation.
It’s anticipated that the alliance of specialties will need to deliver a preliminary report to the health ministers for review by the summer of 2005. That leaves a scant six months to meet the commitment of developing pan-Canadian wait times. To help focus the debate, here’s a list of questions that each provincial association should try to resolve:
• How do we assure that orthopaedic surgeons and the COA are deeply involved in the process to develop wait-time benchmarks, and that the process, itself, is at arm’s length from government control?
• How do we develop wait-time benchmarks that are scientifically rigorous and that are practical to implement?
• How do we ensure enough flexibility in a system of pan-Canadian benchmarks so that existing provincial initiatives are accommodated?
• Which specific procedures are subject to wait-time benchmarks, just hip and knee arthroplasty?
• How best to consult and incorporate the views of patients, public and health care providers into the process of developing wait-time benchmarks?
• How to ensure that reduction in wait times for hip and knee arthroplasty doesn’t come at the expense of stagnant or increased wait times for other orthopaedic procedures?
• How do pan-Canadian wait-time benchmarks fit into the broader effort of reducing wait times that addresses capacity and infrastructure issues?
Having worked our way through the above list, there’s a final question that we might want to add: How do we benchmark the benchmarks? In other words, is there a litmus test that can help us assess whether we have benchmarks we can live and work with? As might be expected, the CMA has gone down that road before us. We can borrow a page from its 1999 policy statement on operational principles for managing and measuring wait times. Herewith, then, adapted for our current circumstances, are some operational principles that might serve as a litmus test:
Pan-Canadian Application: wait-time benchmarks should not vary from one jurisdiction to another.
Integration with Provincial Approaches: wait-time benchmarks should build on existing wait-time management initiatives, accommodating diversity, avoiding duplication and promoting innovation at the provincial/territorial level.
Provider-Friendly: wait-time benchmarks should be seamlessly integrated into the care continuum and avoid placing an onerous burden on providers.
Patient-Oriented: wait-time benchmarks should be easily accessible and understandable by patients who want to know about medically appropriate wait times.
Focused on Health Outcomes: wait-time benchmarks should be designed to promote the best possible outcomes with regard to the patients’ quality of life and longevity.
Evidence based: wait-time benchmarks should be the product of clinical consensus on the best evidence available, and should reflect the views of patients, particularly when quality of life is at issue.
Arm’s Length from Government: wait-time benchmarks should be developed independent of government control to ensure the highest degree of credibility.
Ongoing Evaluation: wait-time benchmarks should be routinely evaluated and adjusted as new evidence emerges.
Accountability and Transparency: reports of performance relative to wait-time benchmarks should be regularly made public.
COA members have much to debate and agree upon, and little time to do so. Realistically, we have two to three months in early 2005 to reach consensus on the fundamental questions raised earlier in this article and develop benchmarks that meet the above litmus test of operating principles. If you have strongly held views on indicators and benchmarks, make them known to your provincial association. Your views will be captured by the National Standards Committee, which for the moment has morphed into the COA’s task force on these issues.
This is a fast-moving train that’s left the station — certainly faster than the publication cycle of the COA Bulletin. In response, we soon hope to have in place an e-mail vehicle that will keep better pace with developments and let you know what’s happening at the national and provincial levels, as well as in the other specialties. We’ll be in touch soon.
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