Healthcare Management Forum Gestion des soins de santé 49

imely access to healthcare services has become a primary concernfor most Canadians. One of the key issues is lengthy waits forspecialized services such as elective surgeries and diagnostic tests.1

A recent survey conducted by Statistics Canada on access tohealthcare services revealed that approximately 20 percent of thosewho required specialized services over a 12-month period reportedthat they had difficulties accessing care. Most indicated that waitingfor care was the problem. Approximately one in four of those whodid wait for care indicated that their waiting time was unacceptable,and one in five reported that they experienced adverse effects suchas stress, anxiety and pain.2 It is evident that waiting for care is anissue for some patients. There is little accurate, reliable information

to determine precisely how many patients wait for care and for how long.3

Governments at all levels have been called upon during the past several yearsto reduce lengthy waits and improve overall access to healthcare services.There have been numerous debates, however, regarding the actual extent ofthe problem and the best way to address it. In 1989, Health Canada releasedthe first national report on the state of waiting times in Canada. One of thereport’s most important recommendations pertained to the development ofreliable and comparable waiting time data for a broad range of medicalprocedures so that patients, healthcare providers and governments couldhave a better and more accurate understanding of the extent and nature ofwaiting times. Furthermore, the development of these data systems mustbegin with standard definitions for waiting times (i.e., when the waiting forcare begins and ends).4,5

The need for reliable information has never been greater. In September 2000,on a set of 14 indicators, the First Ministers agreed to provide comparableinformation across all provincial and territorial jurisdictions and improveoverall accountability within the system. One of the three areas of reportingis quality of healthcare services. Waiting times for selected diagnostic andsurgical procedures was selected as one of the indicators to provide

ORIGINAL ARTICLE

T

Toward Standard Definitions forWaiting Times

by Claudia A. Sanmartin and the Steering Committee of the Western Canada Waiting List Project

AbstractThere are no standard or universally accepted definitions of waiting times for abroad range of health services and procedures. The Western Canada WaitingList Project, like other similar projects, has recognized the need to establish suchstandard definitions to improve the accuracy and comparability of waiting timeinformation across procedures and jurisdictions and of information provided topatients. This article proposes standard definitions of waiting times for surgeryand magnetic resonance imaging.

Claudia A. Sanmartin,MSc, PhD, SeniorAnalyst, StatisticsCanada, was a researchassociate with theWCWL Project.

Members of the Steering Committee: (Chair) Dr. Tom Noseworthy, Professor, Department ofCommunity Health Sciences, University of Calgary,Alberta; Dr. Morris L. Barer, Director, Centre forHealth Services and Policy Research, and Professor,Department of Healthcare and Epidemiology,University of British Columbia, Vancouver, BritishColumbia; Dr. Charlyn Black, Co-Director, ManitobaCentre for Health Policy and Evaluation, andAssociate Head and Associate Professor, Departmentof Community Health Sciences, University ofManitoba, Winnipeg; Ms. Lauren Donnelly, ActingExecutive Director, Acute and Emergency ServicesBranch, Saskatchewan Health, Regina; Dr. DavidHadorn, Research Director, Western CanadaWaiting List Project; Dr. Isra Levy, Director, HealthPrograms, Canadian Medical Association, Ottawa;Mr. Steven Lewis, Partner, Access Consulting,Saskatoon, Saskatchewan; Mr. John McGurran,Director, Western Canada Waiting List Project, and Research Associate, Department of Public Health Sciences, University of Alberta, Edmonton; Dr. Sam Sheps, Head, Department of Healthcareand Epidemiology, University of British Columbia,Vancouver, British Columbia; Dr. Mark C. Taylor,Assistant Professor, Department of Surgery, Universityof Manitoba, Winnipeg; Mr. Laurie Thompson, ChiefExecutive Officer, Health Services Utilization andResearch Commission, Saskatoon, Saskatchewan;Mr. Darrell Thomson, Director, Economics and PolicyAnalysis, British Columbia Medical Association,Vancouver, British Columbia; Ms. Barbara Young,Regional Utilization Consultant, Clinical EvaluationServices, Calgary Regional Health Authority,Calgary, Alberta.

50 Healthcare Management Forum Gestion des soins de santé

information on accessibility of services.Reporting began in September 2002 andthe next report is due in November 2004.6

Over the past several years, provincialministries of health across the countryhave been working toward thedevelopment of waiting list strategiesand management systems. Waiting listinformation and management for cardiacservices has existed for more than adecade in Ontario through the CardiacCare Network. Patients awaiting selectedcardiac services are placed on theprovincial-wide registry and followedthroughout the course of their wait andeventual surgery (see www.ccn.on.cafor more info). British Columbia hasmade waiting time information byhospital and physician available to thepublic for several years through theMinistry of Health Web site(www.healthservices.gov.bc.ca/waitlist).In Manitoba, the Cataract Waiting ListProgram was developed to track andprioritize patients waiting for cataractsurgery.7 In Saskatchewan, plans have beenproposed for a province-wide surgicalwait list management strategy.8 This isjust to name a few.

Despite these efforts, no standard oruniversally accepted definitions of waitingtimes exist for a broad range of servicesand procedures. Such standards areneeded to improve the accuracy andcomparability of waiting time informationprovided to patients, healthcare providersand policy makers. Standard definitionswill also serve to improve the comparabilityof data across procedures and jurisdictions.The establishment of standard definitionsrepresents the first step in determiningwhether patients are gaining access tocare within a reasonable and acceptableperiod of time.

The Western Canada Waiting List Project(WCWL) is a federally funded partnershipof 19 organizations that was created todevelop priority tools to assist in themanagement of waiting lists.9 In additionto the development of the tools, theWCWL Project also focused its efforts onthe development of standard definitionsof waiting times for general surgery, hipand knee replacement surgery, cataract

surgery and magnetic resonance imaging(MRI). A comprehensive list of waitingperiods potentially facing patients seekingthese services is identified and definedbased on an examination of the standardpaths to care for these procedures. Themajor issues and challenges facing theimplementation and operationalizationof standard definitions for waiting timesare discussed and recommendations areproposed regarding future efforts in this area.

Definitions Currently UsedWaiting times have been studied, bothwithin Canada and internationally, usingvarious definitions. Most studiesconducted to date have focused on threedistinct waiting periods: waits to see thespecialist, waits to receive hospital-based services and total waiting time.The differences lie primarily in how thesewaiting periods are defined (i.e.,precisely when the waiting period beginsand ends).

The waiting time for a specialist consul-tation has been defined as the timebetween the referral from the primarycare practitioner to the consultation.10-13

In the early 1990s, this definition wasintroduced in the National HealthService in the United Kingdom to ensurethe comparability of national waiting timestatistics for specialist consultations.11

Specialist waiting times have also beendefined as the time between the visit tothe primary care physician and thespecialist consultation.12

The majority of studies conducted todate have focused on waiting times forhospital-based services such as surgery.In most cases, waiting times weredefined as beginning when the patientwas booked for surgery and placed on thehospital waiting list.5, 6, 13-16 Alternatively,surgical waiting times were also definedas the time between when the patientand physician decided that treatmentwas necessary and desirable (oftenreferred to as the “decision to treat”), andthe date of treatment.14 The decision totreat is often assumed to take placeduring the last presurgical consultationwith the specialist or surgeon. This

definition is commonly used in studieswhere, in the absence of waiting list data,waiting times were estimated retrospec-tively using health administrative data(i.e., hospital and physician paymentdata), and the date of the last presurgicalconsultation was used as a proxy date forthe day of the treatment decision.1, 15-16

Finally, some argue that the only truemeaningful measure of waiting is the“total waiting” time to care. One of theearliest definitions emerged from theUnited Kingdom where researchersdefined total waiting time as beginningwhen the patient seeks care, oftenmarked by the first visit to the primarycare practitioner, and ends when thetreatment has been provided.16 A similardefinition has been proposed in Canadaby the British Columbia MedicalAssociation.6

There are clearly various definitions usedto report waiting times for medicalservices in Canada and abroad. Whilemany of these definitions may beappropriate for specific procedures, theirvariability represents a problem whenthere is a need to aggregate or comparewaiting time information acrossjurisdictions, procedures and specialtygroups. Standard definitions for waitsrepresent the first step to improving themanagement and reporting of waitingtime information.

Defining Waiting Times: A Path-to-Care ApproachA comprehensive understanding of the“standard” paths to care can provideinformation regarding the potentialwaiting periods faced by patients duringthe course of care and highlight the keyprocesses that may serve to define thestart and end of each waiting period.Paths to care were developed inconsultation with WCWL panel membersfor surgery (i.e., general surgery, hipreplacement and knee replacement) andMRIs using a Delphi approach in whichmembers were presented with an initialpath and asked to revise or change asnecessary. Several iterations wereconducted until a model was agreed on.The work of the WCWL Project was

Healthcare Management Forum Gestion des soins de santé 51

conducted by clinical panels establishedfor each procedure area. The panelscomprised 12 members includingspecialists (in the relevant field),referring physicians, academics andrepresentatives of the regional healthauthorities. They were chaired by anexperienced and respected leader in therelevant clinical area selected by the hostregion. Selected members from the kneeand hip replacement panel, generalsurgery panel, cataract panel and MRIpanel participated in the development ofthe standard definitions.

Waits for SurgeryGiven the similarities in the paths to carefor general surgery, knee and hipreplacement and cataract surgery, asingle path to care was developed torepresent waiting times for surgery(figure 1).

Waiting time for primary care (wait #1): Thefirst waiting period likely experienced bypatients is the waiting time for a primarycare consultation with either a general orfamily practitioner. This waiting period isdefined as the time between the date of requestfor a consultation to the date of the primarycare consultation.

Waiting time for initial specialist/surgicalconsultation (wait #2): Once the initialprimary care consultation has beenconducted, the physician may recommenda visit to a specialist or surgeon. In thecase of cataract surgery, however, patientsmay be referred directly to an ophthal-mologist by an optometrist. The secondwaiting period, therefore, is defined asthe time between the date of referral and thedate of the specialist/surgical consultation.

Waiting time for the decision to treat (wait #3):Following the initial specialist/surgicalconsultation, patients may take differentpaths leading to the treatment decision.The waiting times experienced bypatients will vary depending on thecourse of treatment. The decision to treatmay be made at the initial specialist/surgical consultation or a subsequentpresurgical consultation if the patientrequires more than one consultation toreach a treatment decision. In the firstcase, patients will not experience any

waiting. In the latter case, the timelapsed between the first consultationand the decision to treat cannot beconsidered a waiting period (in thetraditional sense), since prior to adecision to treat, there is no treatmentfor which the patient is waiting. In somecases, patients may be placed on awaiting list in anticipation of thepotential need for treatment, assumingthey will need care once they reach thetop of the queue. The waiting times forthese patients, however, will appearexceedingly long compared with thewaits of those placed on the list followingthe treatment decision. This may occur insituations where waiting lists are “gamed”to improve access for selected patients.

Waiting time for major diagnostic tests (wait#3a): Alternatively, diagnostic tests maybe required to make or confirmdiagnoses and treatment decisions. Insome cases, only specialists may makerequests for diagnostic tests, while inother jurisdictions, the request may bemade directly by a primary carepractitioner. The waiting time fordiagnostic tests (wait #3a), therefore, isgenerally defined as the time between thedate of the request for a test and the date ofexamination.

Waiting time for subsequent specialist/surgicalconsultation (wait #3b): Patients with morecomplex diagnoses may be referred to asecond specialist or surgeon for furtherconsultation before a decision to treat

Surgery

Wait #4b

Placement on HospitalWaiting List(Booking)

Decision to TreatReferral to Other

Specialist(s)

Specialist/SurgicalConsultation

Primary CareConsultation

OptometristConsultation

First Contact withPrimary CarePractitioner

Wait #4a

Wait #3

Wait #3bWait #3a

Wait #2

Wait #1

Diagnostic Test

Figure 1: Waiting Times for Surgery

52 Healthcare Management Forum Gestion des soins de santé

can be made. For example, patientsrequiring surgical treatment may bereferred to the surgeon following aninitial specialist consultation. In suchcases, patients may be facing a sub-sequent specialist consultation waitingtime (wait #3b) defined as the time betweenthe referral date from the first specialist to thedate of the subsequent specialist/surgicalconsultation.

Waiting time for surgery (wait #4): Oncethe decision to treat has been made,patients will likely face a final waitingtime for surgery. As noted in theliterature and in the path to care, thiswaiting time may begin at one of twopoints in time: at the time of thetreatment decision, or at the time ofhospital “booking.” In the case of the firststarting point, the last presurgicalconsultation with the specialist orsurgeon is commonly assumed to bewhen the decision to treat is made. Thesurgical waiting time, therefore, may bedefined as the time between the date of thedecision to treat and the date of surgery (wait#4a).

Alternatively, the surgical waiting timemay begin when the patient is booked forsurgery or placed on the hospital waitinglist. The surgical waiting time, therefore,may alternatively be defined as the timebetween the date of booking or placement onthe hospital waiting list and the date ofsurgery (wait #4b).

This definition, however, does notcapture the elapsed time between thedecision to treat and the date of bookingor placement on the hospital waiting list.In most cases, this waiting time is likelyto be negligible when physicians requestbookings immediately following thetreatment decision. However, they maychoose to delay this request for variousreasons (e.g., confirmation of operatingroom time). Although the patient hasbeen waiting for surgery since the initialdecision to treat was made, their“official” waiting time, as calculatedusing the booking date or date ofplacement on the waiting list, will besignificantly shorter. The validity of thisdefinition, therefore, is dependent in parton the processes and strategies used to

book patients or place patients onhospital waiting lists.

Waits for MRI The route to MRI examinations, like otherdiagnostic tests, will depend in part onthe jurisdictional policies that determineaccess to these services. In many cases,patients referred for MRI examinationsmay experience waits similar to thosediscussed above for surgery, namelywaits for a primary care consultation(wait #1) and for an initial specialistconsultation (wait #2) (figure 2). Thesame definitions are applied to thesewaits and therefore do not require furtherdiscussion. There are several options fordefining waits for MRIs.

Waiting time for receipt of request for MRI(wait #3a1): In some areas, MRIs can only

be requested by a specialist; in otherareas, they can be requested by a primarycare practitioner. The first waiting period,therefore, is defined as the time between therequest for an MRI and when the request isaccepted by the radiologist. This waitingperiod is likely negligible if requests aremade in a timely manner. However, giventhe lack of standard processes within andacross jurisdictions, it is difficult toestimate whether, or to what extent, thisis the case in all areas.

Waiting time for MRI (wait #3a2): Themore significant waiting period for MRIsbegins after the request has beenreceived and reviewed by the radiologist.This waiting period is defined as the timebetween when the request for an MRI has beenaccepted by the radiology department or MRIclinic and the date of the MRI examination.

MRI Examination

Wait #3a(2)

Request received andreviewed by the

radiologist

Request for MRI

Referral to SurgeonSpecialist Consultation(incl. Hospital inpatients)

Primary CareConsultation

First Contact withPrimary CarePractitioner

Wait #3a(1)

Wait #2

Wait #1

Note: In somejurisdictions

GPs arepermitted torequest MRIs

Figure 2: Waiting Times for MRI Examinations

Healthcare Management Forum Gestion des soins de santé 53

Alternatively, the two waiting periods canbe combined in the following definitionfor MRI waits: the time between the date ofrequest for an MRI examination and the dateof the examination (wait 3a). This definitionmay be appropriate in jurisdictionswhere standard request forms or lettersare used that provide a referral date.Since the waiting period for patientsbegins when they and their physiciandecide that an MRI is necessary, thisdefinition more accurately reflects thewaiting time experienced by patients.

DiscussionBuilding on the existing informationregarding definitions for waiting timesand the expertise of the WCWL clinicalpanels, waiting times for surgery andMRIs were identified and defined.Standard definitions can be appliedacross a range of services and procedureswith similar waiting periods.

The implementation and operationali-zation of such standards will likely meetvarious challenges. The degree to whichprocesses and procedures used to delivercare are standardized across proceduresand jurisdictions will affect the ability tooperationalize standard measures of waits.Measuring waits for specialist/surgicalconsultations or MRIs, for example, isdependent on the availability of accurateinformation regarding the referralprocesses for these services. Currently,various methods are used to referpatients including phone, mail, fax or, insome cases, e-mail. Valid informationregarding referral dates is critical tomeasure waits that begin with this date.

The availability of existing waiting timedata and the use of standard proceduresin the delivery of care will also affect theability to implement national standardsfor waiting times. In some provinces suchas Ontario and British Columbia,information systems are in place tocapture waiting time data for a range ofprocedures. This, however, is not the casein all jurisdictions nor for all specialtygroups. The implementation processmay involve the establishment of infor-mation systems to collect data based onstandard definitions of waiting times.

Perhaps the immediate challenge lies inthe next steps toward the establishmentof standard definitions for waiting timesin Canada. To achieve this goal, anational initiative must be mobilized toseek consensus regarding standarddefinitions among key stakeholdergroups including physicians, healthcaremanagers, policy makers, patients andacademics as well as relevant nationalgroups charged with reporting the stateof the healthcare system. Whereverpossible, standard definitions should beidentified and adopted for similarwaiting experiences within and acrossspecialty and procedure groups. Thisprocess should be supported by astructure, newly established or currentlyexisting, with the ability and capacity towork at the national level and across abroad range of healthcare services.

Efforts to establish standard definitionsfor waiting times represent one of severalstrategies being developed to addressthe issue of waiting lists and waitingtimes in Canada. Together, theseapproaches clearly mark a shift towardthe development of strategies to providevalid and accurate information onwaiting times better to inform patients,healthcare providers and policy makers.

AcknowledgmentThe Western Canada Waiting List Project was supported by afinancial contribution from the Health Transition Fund (HealthCanada) as Project NA489. The views expressed herein do notnecessarily represent the official policy of federal, provincial orterritorial governments.

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5. Sanmartin C, Shortt SED, Barer ML, Sheps S, Lewis S,McDonald P. Waiting for medical services in Canada: lots ofheat, but little light. Canadian Medical Association Journal2000;162(9):1302–1310.

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