public sector solutions to health care queues michael m. rachlis md msc frcpc () new brunswick...
TRANSCRIPT
Public Sector solutions to Health Care Queues
Michael M. Rachlis MD MSc FRCPC(www.michaelrachlis.com)
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
% Long Waiting Times(CAN, USA, Germany)
0% 10% 20% 30% 40% 50% 60%
> 5 d for GPappointment
ER wait > 2 hr
Specialist waittimes > 4 weeks
Elective surgerywait > 4 months
K Davis. Commonwealth Fund April 2006
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;170:1678-1686)
• 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 2001. www.iom.edu)
1. Safety2. Effectiveness3. Patient-centredness4. Timeliness5. Efficiency6. Equity
Attributes of High Performing Health Systems Ontario Health Quality Council. April 2006. (www.ohqc.ca)
1. Safe2. Effective3. Patient-Centred4. Accessible5. Efficient6. Equitable7. Integrated8. Appropriately resourced9. 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
Capacity (Max) Actual capacity Demand
Activity Waiting list
0
20000
40000
Week
Minutes
WL Initiative
Backlog !
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!
0500
100015002000
25003000
3500
40004500
Theatre time(minutes)
Cidex leak
Capacity (Max)
Actual capacityendoscopists
Demand
Activity
0500
100015002000
25003000
3500
40004500
Theatre time(minutes)
Cidex leak 0
500
100015002000
25003000
3500
40004500
Theatre time(minutes)
Cidex leak
Capacity (Max)
Actual capacityendoscopists
Demand
Activity
Matching variation in demand and capacity (Dr. Martin Lee’s breast clinic)
Total number ofPatients referred
Number of clinicslots available
Week
0
10
20
30
40
50
60
3-Ja
n-0031
-Jan-
00
28-F
eb-0
0
27-M
ar-0
0
24-A
pr-0
0
22-M
ay-0
0
19-Ju
n-00
17-Ju
l-00
14-A
ug-0
0
11-S
ep-0
0
9-Oct
-00
6-Nov
-00
4-Dec
-00
1-Ja
n-01
29-Ja
n-01
26-F
eb-0
1
26-M
ar-0
1
23-A
pr-0
1
21-M
ay-0
1
18-Ju
n-01
16-Ju
l-01
13-A
ug-0
1
10-S
ep-0
1
15-O
ct-0
1
Number
2 clinics per week with 54 apptSlots. This should have been enough Capacity. But temporary mismatches Meant Dr. Lee struggled to see all
patients in the 2 wk standard
The Solution? Reducecapacity 10% to 48 appts But spread them out over 3clinics. Now All patientsAre seen in 5 days
Variation in clinical systems
15
Staffskills
illness holiday
motivation
trainingshifts
Patients
Resources
Process
Rooms
suppliesmachines
age
sex
race education
motivation
diseaseunclear
guidelines differ
complications anaesthetics
We control 80% of variation!
GP Discharged!
Information
transcription
transport
applicationsAll Different
Variation kills quality
van Walraven, C. et al. CMAJ 2002;166:1672-1673
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 process2. Eyeball the map3. Eliminate redundant stages4. At each stage measure demand and
Capacity5. 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 measuredemand 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 problemswith 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 MinorityChaoulli 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” (
http://www.michaelrachlis.com/pubs/2007%20Rachlis%20private%20public.pdf
)
Re-engineering for quality
• Saskatchewan Health Quality Council (www.hqc.sk.ca)
• Ontario wait list management (http://www.health.gov.on.ca/transformation/wait_times/wait_mn.html)
• Ontario Health Quality Council (www.ohqc.ca)
• Winnipeg’s Pan Am Clinic (http://www.panamclinic.org/)
• Toronto’s Trillium Health Centre Surgicentre (http://www.trilliumhealthcentre.org/programs_services/surgical_services/queensway/surgicentre.html)
Re-engineering for quality
• Why Wait? Public Solutions to Cure Surgical Wait lists (http://www.michaelrachlis.com/pubs/070508%20BC%20waitlists%20paper%20final.pdf )
• Public Solutions to Health Care Wait Lists (http://www.policyalternatives.ca/documents/National_Office_Pubs/2005/Health_Care_Waitlists.pdf)
• Institute for Healthcare Improvement (www.ihi.org)
• Improving Patient Flow (http://www.steyn.org.uk/)
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)
