DETERMINANTS OF WAITING TIME MANAGEMENT FOR HEALTH SERVICES- A POLICY REVIEW AND SYNTHESIS

DETERMINANTS OF WAITING TIME MANAGEMENT FOR HEALTH SERVICES- A POLICY REVIEW AND SYNTHESIS Final Synthesis Report Marie-Pascale Pomey Pierre-Gerlier Forest Claudia Sanmartin Carolyn DeCoster Madeleine Drew R09-01 Février 2009

Legal Deposit Bibliothèque et Archives nationales du Québec, 2009 Legal Deposit Library and Archives Canada, 2009 ISBN : 978-2-923544-19-9 (printed version) ISBN : 978-2-923544-20-5 (PDF)

DETERMINANTS OF WAITING TIME MANAGEMENT FOR HEALTH SERVICES A POLICY REVIEW AND SYNTHESIS CIHR Research Synthesis: Priority Health Services and Systems Issues #137064 December 2008 Prepared by: Marie-Pascale Pomey Pierre-Gerlier Forest Claudia Sanmartin Carolyn DeCoster Madeleine Drew Address for correspondence: Dr. Marie-Pascale Pomey Department of Health Administration, GRIS, Faculty of Medicine, University of Montreal, CP 6128, Succ. Centre Ville, Montreal, Québec, Canada H3C 3J7 Phone Number: 514-343-6111 ext 1-1364 Fax Number: 514-343-2448 Email: marie-pascale.pomey@umontreal.ca

CONTENTS ACKNOWLEDGEMENTS...5 EECUTIVE SUMMARY...6 RÉSUMÉ...9 THE REPORT...13 1. INTRODUCTION...13 1.1 Aims and objectives...13 1.2 Significance of the problem...14 1.3 Background...14 1.4 Structure of this report...19 2. SYSTEMATIC LITERATURE REVIEW...20 2.1 Methods...20 2.2 Results from the literature review...25 2.3 Models...37 2.4 Key findings of the literature review...38 2.5 Study limitations for the literature review...39 3. INTERVIEWS OF CANADIAN POLICYMAKERS AND DECISIONMAKERS...41 3.1 Methodology for the interviews...41 3.2 Results of the interviews...44 3.3 Key findings from the interviews...49 3.4 Study limitations for interviews...50 4. SUMMARY OF THE FACTORS IDENTIFIED...51 5. INTERPRETATION OF THE RESULTS...53 5.1 Divergent and convergent findings between the literature review and the interviews...53 5.2 Comparison of the findings to the grey literature and to Canadian publications...54 6. POLICY IMPLICATIONS...56 7. IMPLICATIONS FOR FUTURE RESEARCH...58 8. CONCLUSION...59 APPENDICES...64-3 -

ACKNOWLEDGEMENTS This work would not have been possible without the support of a Canadian Institutes of Health research grant (# KSY-73928). The authors also thank the following individuals: Diane Lorenzetti for her expertise and assistance in refining the search terms and systematically searching all the databases; Catherine Safianyk, Johanne Preval and Ghislaine Tré for their research assistance; Jennifer Petrela for her editorial contribution; and the healthcare managers and policymakers who participated in the interviews and shared their experience and insight. - 5 -

EECUTIVE SUMMARY Background For over a decade, industrialized countries around the world have struggled to solve the problem of long wait times for scheduled medical care (Siciliani and Hurst 2003). Canada has focussed its search for a solution at the federal and provincial levels, and recent Canadian wait time initiatives have consistently looked to centralized programs as their solution (Health Council of Canada 2007). The role of regional health authorities and hospitals has often been ignored or downplayed, this despite the fact that these institutions are directly responsible for initiating and implementing policies and strategies to improve timely access to care. It is our position that the experiences of these institutions can provide valuable learning regarding the key determinants associated with the successful measurement and management of waiting times. If resources, financial or otherwise, are an important explanatory factor of health organizations action or inaction, it can also be hypothesized that governance structures, practices, organizational culture, data collection, and management patterns also count as among the contributing factors. Research Objectives The purpose of this project is to synthesize the existing intelligence regarding the management of waiting times for specialized and diagnostic services in an effort to identify the key local and contextual factors of successful waiting time management. This procedure was performed by means of a systematic review of literature that focused on the success and failure factors of wait time management (WTM) for scheduled care and through interviews with key policymakers and decision-makers involved in the management of waiting times in Canada. The information thus gathered was then synthesized according to a predetermined conceptual framework in order to identify local and contextual factors associated with the management of waiting times. Conceptual Framework To organize the factors to be identified through the literature review and the interviews, we used a conceptual framework inspired by Parsons widely recognized and robust fourquadrant model. The four dimensions used for this model were governance, culture, resources, and tools. Because waiting time management strategies work within a broad context and are therefore influenced by more than local factors, both the local and the contextual levels had to be taken into account. This is the reason why the model represents all four dimensions at both levels. Literature Review Methods For the literature review, six medical databases and 19 non-medical databases were searched for articles published between 1990 and 2005 that addressed wait time or wait list management for scheduled care. Articles focusing on waiting times for transplants, emergency care, long-term care and pharmaceuticals were excluded on the grounds that the dynamics of wait times in these areas are quite different. The database search resulted - 6 -

in 5202 abstracts, exclusive of duplicates. Each of the four levels of screening was performed by two reviewers using online software (SRS 4.0, TrialStat). The final 31 articles retained for data abstraction had been published in peer-reviewed journals and consisted of either a model or a framework with WTM factors at the organizational level or of an initiative that specifically addressed WTM and stated organizational factors explicitly. Interviews Methods We conducted 16 semi-structured interviews and one focus group with individuals involved in WTM strategies in Canada at the federal/provincial or the organizational level. The one to two-hour interviews took place between October 2005 and August 2006 and all were taped and transcribed. Results Few articles found in the peer reviewed literature explicitly addressed the factors that could enhance or inhibit the implementation of a wait time reduction strategy at the local level and few were empirical studies. Instead, most were case descriptions with little rigorous hypothesis generation or testing. The studies focussed more on evaluating outcomes than on evaluating the implementation of WTM initiatives. Some of the local factors most frequently cited both in the literature review and in the interviews were physicians involvement to bring resistant physicians on board (culture), appropriate levels of dedicated staffing to ensure continuity (resources), and information management systems to collect and analyse data (tools). At the contextual level, funding levels and earmarked resources recurred most often in the literature review, but interviewees emphasized financial incentives and the need for them to be aligned between the contextual and the local level. Unsurprisingly, leadership emerged as an additional important governance factor at both the local level, where it surfaced as strong clinical leadership, and at the contextual level, where it appeared as the need for vision and direction within a structure that ensured coordination, reporting and monitoring. Many other factors were identified under the four dimensions and are further explained in this report. Study Limitations Although non-peer reviewed articles and the grey literature may have contributed interesting insights, the literature review was limited to peer-reviewed papers in order to keep the scope of the exercise manageable. The final sample of abstracted articles is small and there was no scale of evidence to measure the quality of the evidence. The sample size for the interviews was also small, but the consistency of the responses by individuals from different Canadian provinces and different levels of involvement helped counter this limitation. Nonetheless, it is important to specify that our findings should be considered exploratory: the primary purpose of this study was to identify a number of factors and test their impact in a later study. - 7 -

Implications for Policy Even though the main purpose of this review was to identify factors that impact the implementation of WTM strategies and use those factors to develop a framework, it can also inform policymakers of actions that may be beneficial: involve physicians from the outset; take organizational culture into account before implementing a given strategy; invest in evaluations and quality improvements at the organizational level; invest in the relationship between managers and physicians; earmark funds to help the local level launch the WTM project; invest in information management and tools; align high-level policies with local strategies. In general terms, higher level decision-makers need to take organizational factors into account to maximize the successful implementation of WTM strategies. Implications for Future Research We have already suggested the utility of further research on the factors identified in this study in order to evaluate their relevance, pertinence and real impact on the implementation of WTM strategies. In addition, it would be interesting to conduct a more thorough investigation of the value of neutral third parties, an idea brought up by several of our interviewees. In-depth case studies in healthcare organizations where wait list management strategies have succeeded or failed should also be considered. Important to note is that for any study in this field, researchers should take care in defining the waiting time period under consideration. Finally, this study focused on scheduled care, but the factors identified here may also be applicable to primary care, long-term care, mental health or other fields of heath care where there are also long wait times. For these areas, additional factors may be at play, warranting further research. Conclusion The present exploratory study was conducted with a view to understanding the factors that enhance or impede the implementation of wait time management strategies. The systematic review of published peer reviewed articles as well as our complementary interviews with key policymakers and decision-makers involved in the management of waiting time in Canada identified a number of key factors. The next steps require decision-makers and policymakers to start taking some of these factors into consideration and for researchers to conduct further studies to better understand the impact and interaction of these factors in terms of how their influence on the implementation of WTM strategies. - 8 -

RÉSUMÉ Contexte Depuis plus d'une décennie, les pays industrialisés dans le monde entier cherchent des solutions afin de résoudre le problème des temps d'attente pour les soins médicaux planifiés (Siciliani and Hurst 2003). Le Canada a axé sa recherche de solutions aux niveaux fédéral et provincial, et les récentes initiatives canadiennes portant sur les temps d'attente considèrent les programmes centralisés comme une réponse au problème des temps d attente (Health Council of Canada 2007). Le place des autorités régionales de la santé et des hôpitaux a souvent été ignorée ou minimisé, et ce, malgré le fait que ces institutions sont directement responsables d initier et mettre en œuvre des politiques et des stratégies visant l amélioration de l'accès aux soins de santé. Or, les expériences de ces institutions dans ce domaine nous fournissent des éléments précieux pour identifier les principaux déterminants associés à la réussite de la mesure et de la gestion des temps d attente. Si les ressources, financières ou autres, sont des facteurs importants explicatifs de l'action ou de l'inaction des organismes de la santé, on peut aussi avancer l'hypothèse que les structures de gouvernance, les pratiques, la culture organisationnelle, les systèmes d information, et les modes de gestion également peuvent compter parmi les facteurs contributifs. Objectifs de la recherche Le but de ce projet est de synthétiser les renseignements existants sur les stratégies mises en place pour la gestion des temps d'attente (GTA) associés aux services spécialisés et diagnostiques afin d identifier les principaux facteurs locaux et contextuels favorisant leur implantation. Pour ce faire, un examen systématique des écrits portant sur les facteurs de réussite et d'échec de la GTA eu égard aux soins planifiés ainsi que des entretiens réalisés avec les principaux décideurs politiques et les décideurs impliqués dans la gestion des temps d'attente au Canada ont été réalisés. Les données ainsi recueillies ont ensuite été synthétisées selon un cadre conceptuel en vue d'identifier les facteurs locaux et contextuels associés à la gestion des temps d'attente. - 9 -

Cadre conceptuel Pour organiser les éléments qui devaient être identifiés par la recension des écrits et les entrevues, nous avons utilisé un cadre conceptuel inspiré par le modèle des quatre quadrants de Parsons, largement reconnu et robuste. Les quatre dimensions utilisées pour ce modèle étaient : la gouvernance, la culture, les ressources et les outils. Vu que les stratégies de la GTA prennent place dans un contexte plus vaste et sont donc influencées par d autres facteurs que ceux locaux, non seulement les facteurs ont été pris en compte mais aussi ceux se situant au contextuel. C'est pourquoi le modèle représente les quatre dimensions à la fois au niveau local et contextuel. Méthodologie de la revue de la littérature Pour construire notre revue de la littérature, nous avons consulté six bases de données médicales et 19 non-médicales. Nous avons sélectionné les articles publiés entre 1990 et 2005 portant sur les temps d'attente ou sur la gestion des listes d'attente pour les soins programmés. Les articles traitant des temps d'attente pour les greffes, les soins d'urgence, les soins de longue durée et les médicaments ont été exclus, compte tenu que la dynamique des temps d'attente dans ces domaines est très différente. La recherche effectuée sur la base de données a abouti à 5202 résumés, à l'exclusion des doublons. Chacun des quatre niveaux de sélection a été réalisé par deux examinateurs en utilisant un logiciel en ligne (SRS 4.0, TrialStat). Les 31 derniers articles retenus sont tous issus de revues avec comité de pairs. Il s agissait d un modèle ou d un cadre conceptuel construit avec des facteurs organisationnels de la GTA ou bien des initiatives qui traitaient spécifiquement de la GTA où les facteurs organisationnels étaient énoncés explicitement. Méthodologie des entretiens En complément nous avons réalisé 16 entretiens semi-structurés et un groupe de discussion avec les personnes impliquées dans les stratégies de la GTA aux niveaux fédéral/provinciaux ou des organisations de santé au Canada. Des entretiens d une durée approximative de 2 heures ont eu lieu entre octobre 2005 et août 2006, lesquels ont tous été enregistrés et transcrits. - 10 -

Résultats Parmi les articles recensés peu d entre eux étaient des études empiriques et abordaient explicitement les facteurs qui favorisaient ou défavorisaient la mise en œuvre d'une stratégie de réduction des temps d'attente au niveau local. La plupart était des descriptions de cas avec des hypothèses peu rigoureuses ou des tests. Les études se penchaient plus sur l'évaluation des résultats que sur l'évaluation de la mise en œuvre des initiatives de GTA. Parmi les facteurs locaux les plus fréquemment cités, aussi bien dans la revue de la littérature que dans les entretiens, on retrouve la participation des médecins en vue de faire adhérer les médecins résistants (culture), l adéquation du nombre d effectifs dédiés à assurer la continuité (ressources), les systèmes de gestion d information pour colliger et analyser les données (outils). Au niveau contextuel, dans la revue de la littérature, les niveaux de financement et les ressources affectées revenaient le plus souvent alors que dans les entretiens, les personnes interviewées soulignaient les incitatifs financiers et la nécessité pour eux d'être alignées entre les niveaux contextuel et local. Sans surprise, le leadership est apparu comme un élément additionnel faisant partie des facteurs importants à considérer dans la gouvernance tant au niveau local, où il refait surface en tant qu un leadership clinique solide, qu au niveau contextuel, où la nécessité d avoir une direction et une vision au sein d'une structure qui assure la coordination, la récolte de données et le suivi s avèrent essentielles. Limites de l étude Bien que les articles sans comité de pairs et la littérature grise auraient pu contribuer à donner un aperçu intéressant, nous avons limité la revue de la littérature aux articles publiés dans des revues avec comité de pairs. L'échantillon final des articles retenus était relativement petit et ne comportait pas une échelle de preuve optimale. De plus, la taille de l'échantillon pour les entretiens était également relativement petit, mais la cohérence des réponses des personnes issues de différentes provinces canadiennes et de différents niveaux de participation a aidé à contrer cette limitation. Néanmoins, il est important de préciser que nos conclusions doivent être considérées comme exploratoires: le but principal de cette étude était d'identifier un certain nombre de facteurs et de tester leur impact dans une étude ultérieure. Implications pour les politiques de santé Même si le principal but de cette étude était d'identifier les facteurs qui ont une incidence sur la mise en œuvre de stratégies de GTA et l'utilisation de ces éléments pour élaborer un cadre d analyse, il peut aussi informer les décideurs dans leur prise de décision au niveau des politiques qui pourraient être bénéfiques, comme : impliquer les médecins, dès le départ; tenir compte de la culture organisationnelle avant de mettre en œuvre une stratégie donnée; - 11 -

investir dans les évaluations et l'amélioration de la qualité au niveau de l'organisation; investir dans les relations entre les gestionnaires et les médecins; affecter des fonds à l'échelon local pour aider le lancement d un projet sur la GTA; investir dans la gestion de l'information et des outils; aligner les politiques de haut niveau avec les stratégies locales En termes généraux, les décideurs de haut niveau doivent prendre en considération les facteurs organisationnels afin de maximiser le succès de la mise en œuvre de stratégies de GTA. Implications pour des recherches futures A la suite de ce travail, il serait intéressant de mener une enquête plus approfondie sur la valeur d organismes tiers et neutres, une idée évoquée par plusieurs de nos interviewés comme étant favorable à la GTA. Des études de cas approfondies menées dans les organisations de santé, où des stratégies de gestion des listes d'attente ont réussi ou échoué, devraient également être considérées. Il est important de souligner que quelle que soit l étude menée dans ce domaine, les chercheurs devraient être vigilants dans la définition du temps d attente. Enfin, cette étude a porté sur les soins programmés, mais les facteurs identifiés ici peuvent être également applicables aux soins de santé primaires, aux soins de longue durée, à la santé mentale ou à d'autres domaines des soins de santé où ils existent des longues files d'attente. Pour ces domaines, d autres facteurs additionnels pourraient être identifiés, ce qui justifie la nécessité de faire des recherches plus approfondies. Conclusion La présente étude exploratoire a été menée en vue de comprendre les facteurs qui favorisent ou entravent la mise en œuvre des stratégies de gestion des temps d'attente. L'examen systématique d'articles publiés dans des revus avec comité de pairs ainsi que nos entretiens complémentaires avec les principaux décideurs politiques et les décideurs impliqués dans la gestion des temps d'attente au Canada ont permis d identifier un certain nombre de facteurs clés. Les prochaines étapes exigent des décideurs et des responsables politiques de prendre en considération certains de ces facteurs, et pour les chercheurs de mener d'autres études pour mieux comprendre l'impact et l'interaction de ces facteurs en fonction de leur influence sur la mise en œuvre de stratégies de GTA. - 12 -

THE REPORT Often forgotten in policy discourse, but necessary for a successful outcome, is the approval of the implementers. Hanning M., and Spånberg, U., 2003 1. INTRODUCTION For the past two decades, access to healthcare services has been a critical issue both in Canada and abroad 1. Long waits for core specialized health care services have been consistently identified as a key barrier to care, 2,3 and governments and organizations at all levels have responded by adopting a range of strategies to better manage waiting lists. In September 2004, Canada s First Ministers committed $5.5 billion to timely access in five healthcare areas over a ten-year period 4. In June 2005, the Supreme Court of Canada struck down Quebec s ban on private insurance for Medicare-covered services (the Chaoulli decision ) in a bid to reduce wait times in the province. And in April 2007, the federal government announced that it would provide $612 million to provinces that would commit to respecting maximum wait times for at least one medical procedure performed in their jurisdiction 5. These initiatives show that over the past three years, Canadian decision-makers have consistently seen the centralization of programs at the federal and provincial levels as the means to solve problems of waiting lists and waiting times 6. While these initiatives are promising, it is our opinion that insufficient attention has been paid to the ways that healthcare organizations themselves have implemented strategies to reduce waiting lists and wait times. While the literature has analyzed a variety of strategies 7,8,9 seldom does it discuss the ways that that those strategies were implemented 10 or the key factors associated with their failure or success. Accordingly, we conducted an exploratory study with a view to understanding the factors that enhance or impede the implementation of national, provincial, regional or organizational wait time management (WTM) strategies at the organizational level. Our research was funded by CIHR as a Research Synthesis: Priority Health Services and Systems Issues under the topic Timely Access to Health Care for All. This report describes all components of the study. 1.1 Aims and objectives The purpose of this project is to synthesize the existing intelligence regarding the measurement and the management of waiting times for specialized and diagnostic services in an effort to identify key contextual and organizational determinants of successful waiting time management. - 13 -

The specific objectives of the project were to: 1) Conduct a systematic review of the international scholarly literature that focuses on policy and organizational determinants of waiting time management at the organizational level; 2) Supplement gaps in the literature with interviews with key policy and decisionmakers involved in the management of waiting times in Canada and build a library of case stories; 3) Synthesize the information thus gathered in order to identify the policy and organizational factors associated with the management of waiting times and develop a model; 4) Identify gaps in learning for future research. 1.2 Significance of the problem Access to health care services has been and continues to be an important issue in Canada. While the Canadian Health Act guarantees Canadians reasonable access to medically necessary health care services, concerns have been raised regarding the timeliness of that access 11 and long waits for key specialized health care services have been consistently identified as a key barrier to care 12,13. Significant attention has therefore been directed toward the better measurement and management of waiting lists in principal problematic areas. Over the last decade, governments and organizations within Canada and abroad have adopted a range of strategies to better measure and manage waiting times. But much of the work on waiting times in Canada has focused on the systematic level (provincial and federal-level structures). The role of regional health authorities and hospitals has often been ignored or downplayed, despite the fact that these institutions are directly responsible for initiating and implementing policies and strategies to improve timely access to care. It is our position that the experience of these institutions can provide valuable lessons about the key determinants associated with successful measurement and management of waiting times. If resources, financial or otherwise, are an important explanatory factor of health organizations action or inaction, it can also be hypothesized that governance structures, practices, organizational culture, data collection, and management patterns also count among the contributing factors. 1.3 Background 1.3.1 What is a waiting list? In their report to Health Canada, McDonald and colleagues (1998) defined a wait list, a waiting list and wait time as a roster of patients awaiting a particular service. Most such lists refer to elective (scheduled) services, although some exist for urgent and emergency services as well. The lists are made when demand for a service exceeds the - 14 -

available supply. The term waiting time refers to the length of time between the moment that a patient is enrolled on a waiting list and the moment that s/he receives that service. To define wait lists, therefore, is to define how and when patients are put on a given list and how and when he services are delivered. With rare exceptions, waiting lists in Canada, as in most countries, are non-standardized, capriciously organized, poorly monitored, and in grave need of retooling 14. As a result, evidence suggests that waiting lists may be inflated by 20% to 30% by the presence of patients who have died, who have already received the procedure, who have declined the procedure, or who do not have know they have been scheduled. During the last ten years, initiatives have sought to have waiting list data more carefully and accurately compiled and more routinely monitored. 1.3.2 Measurement of waiting lists and waiting times Standard and universally accepted methods to define and measure waiting lists and waiting times for a broad range of healthcare services do not currently exist 15, 16.. One of the key recommendations of the literature has been the development of reliable and comparable waiting time data for a broad range of medical procedures so that patients, healthcare providers and governments can have a more accurate understanding of the extent and nature of waiting times 15. Healthcare organizations seeking to provide better information about waiting lists and waiting times face a range of challenges. Perhaps the first and most fundamental challenge is defining the waiting period, that is, the precise points at which the clock starts and stops. To date, the primary focus has been on waiting times for hospital-based services such as elective surgery and certain diagnostic tests 17. In some jurisdictions, a distinction has been drawn between Wait Time 1: the general practitioner s referral to the specialist and Wait Time 2: the time between the visit to the specialist and the surgery itself. In 2007, CIHI still reported that provinces varied in the definitions of waiting time segments they used to collect wait list data 18. 1.3.3 What do we know about factors relating to waiting lists and waiting times? Several hypotheses about the causes of waiting lists exist 19,20. A first causative factor may be the data collection system used by a given institution. It appears that decentralized responsibility for list generation, whereby lists are almost exclusively created in the offices of individual physicians or in hospital diagnostic departments, actually fosters the growth of waiting lists when compared to centralized lists generated by a regional authority, for example 21. A second cause implicated in waiting list growth is a reduction in resources. But while it is often assumed that resource reductions will lead to longer waiting lists, this phenomenon is far more complex than one might think. In the United Kingdom, a study using data from a general hospital surgical department showed that a modest reduction in beds can lead to clear cost savings but at the expense of a dramatic increase in waiting times 22. - 15 -

Experts also debate the role of the healthcare funding system as a cause of increased waiting times. In healthcare systems that are predominantly funded by the public sector, such as the systems of the United Kingdom, Canada, New Zealand and Australia, waiting lists are thought to be endemic. Some experts explain this phenomenon as the product of non-market financing, that is, the divorce between the payment and the receipt of services 23,24. In contrast, under the entrepreneurial American system, waiting is generally thought to be less common. Countering these examples, however, is the French healthcare system, which although publically funded does not have this degree of concern. Another factor is technology. The impact of developments in medical technology, though often cited as contributing to increased waiting, is not certain. Some forms of technology clearly inspire the formation of lists. In the early 1980s, for example, the introduction of the anti-rejection drug cyclosporine occasioned the rapid increase of heart transplantations 25. At the same time, other technical developments in cardiac pharmacology created drugs that allowed some patients to be removed from transplant waiting lists 26. The sudden appearance and wide dissemination of a serious new disorder can also contribute to the generation of waiting lists. Three other factors have also been suggested: physician behaviour, patient behaviour and an aging population. It is clear that physician behaviour has the potential to contribute to the development of waiting lists in several significant ways. For example, it has been argued in the United Kingdom that the costs of efficiently managing waiting lists administrators goal in terms of updating, prioritizing, rescheduling cancellations, computerizing and so on, are chiefly born by physicians, who must contribute the time and effort required. It has also been argued that a lengthy individual waiting list may actually be viewed as a testament to the special skills of a physician in comparison to his or her colleagues 27. The manner in which physicians organize their practices may also influence list formation. It has been shown in the United States that patients wait longer for an appointment at a prepaid health maintenance organization that with a fee-forservice physician 28. The patterns of physicians clinical behaviour may also contribute. Referrals by general practitioners can be directed away from consultants with long lists by informing the referring doctors of consultants with shorter lists 29. Close monitoring of waiting lists within individual institutions or regions may reveal physicians with significantly different thresholds for placing similar patients on waiting lists 30. Finally, when British physicians deliberately employed well-defined objective criteria for admission to a urology waiting list, the length of the list shrunk substantially 31, 32. In some cases, patient behaviour may also be responsible for the lengths of lists and the time that individual patients spend on those lists. Patients may choose to remain on lists in order to see a specific physician 33 or to secure admission to a preferred long-term care facility 34. They may also fail to cancel scheduled outpatient appointments or booked surgery, 35 which would have shortened waits for remaining patients. In the United Kingdom, the auditing of waiting lists frequently uncovers patients who are found to have - 16 -

already received care elsewhere without having removed their names from the original list 36. Finally, with respect to the ageing of the population, many of the services for which there is contemporary concern about growing lists, such as cataract surgery or joint placement, are services that are predominantly associated with older patients. The growth of the elderly population has for that reason caused concern that the associated demand for constrained resources has also contributed to the growth of waiting lists. 1.3.4 What is a waiting time management initiative? A waiting time management initiative is an initiative that targets the reduction of wait time for access to healthcare services. In this study, we look more specifically at initiatives that target access to scheduled care. In Canada, investments have been made to increase capacity and improve information technology 37. Examples of initiatives to increase capacity at the local level include increasing the number of healthcare providers, expanding their hours of operation, investing in medical technology and developing coordinated care processes and practice guidelines to increase patient throughput. Information technology investments have targeted the better measurement, reporting, monitoring, and managing of waiting list and waiting times and the evaluation of program performance. Examples of these kinds of investments include the implementation of central wait list registries, operating room booking systems and information systems to track performance against wait time targets. Other types of initiatives to control demand include the implementation of clinical assessment (prioritization) tools and clinical appropriateness guidelines. 1.3.5 Determinants of the success of WTM strategies Change is a notion that evolves over time to reflect different current approaches, models and theories. Generally speaking, the notion of change conjures up the idea of modification, limited in time and space, with one or more parameters. The volume of literature related to the determinants of organizational change is extensive and the conceptualization of the parameters that an organization can change varies by author 38. Guilhon 39 speaks of transforming structures and competencies. Miller, Breenwood and Hinings 40 view change as a redirection of strategy, structure or culture. Mintzberg, Ahlstrand and Lamel 41 suggest that change may focus on strategy, i.e. vision and staff. In the literature on innovation, we also see change as the introduction of an idea or behaviour that is new to an organization 42,43,44,45. It can take the form of a product, a service, a technology, a program, a policy or a process. For this study, we considered the implementation of waiting time reduction strategies as both a type of change introduced at the organizational level and a health policy. We aimed to identify the type of determinants or factors that influence the success of implementation. - 17 -

To organize these factors, we used Parson s social system action theory to evaluate how different factors interact and affect outcomes at both the local and the contextual level. Accordingly, we created a conceptual framework based on Parsons widely recognized four quadrant model 46. The Parsonian perspective corresponds to a structuro-functionalist view of organizations and focuses on the four functions required by organizations to survive: goal attainment, environmental adaptation, production and culture. For presentation purposes, we have modified the sequence of the dimensions in Parsons paradigm. The four dimensions used for this model are as follows: - Governance factors (goal attainment and environmental adaptation), defined as the conduct of collective action from a position of authority 47 ; - Cultural factors (culture), defined as underlying beliefs, values, norms and behaviors 48 ; - Resource factors (production), whether human, financial, infrastructural or informational; - Tools (production), the instruments or procedures seen as helpful for implementing a strategy. We chose this framework for a number of reasons, primary among which was the framework s robust nature. Over the course of the past 50 years, the framework has been used in disciplines as different as sociology, administration, and management. It has also been used in organizational contexts of all kinds: industry, health, and more. In our case, the framework allowed us to consider not only factors like resources and tools that are commonly taken into account but also political and cultural factors that are often overlooked. This framework met our needs for a structure that ensured that we would not neglect dimensions that might have played a role in the implementation of WTM strategies within healthcare organizations. Local level refers to the service delivery level that coordinates patient care. Examples include hospitals or similar institutions and for some provinces, health authorities. In this report, the terms local factors and organizational factors are used interchangeably. Local or organizational level factors refer to factors that can be mobilized by the governance body, the management team or clinician teams. But the success of waiting time management strategies are influenced by more than just local factors such as an organization s culture, governance, resources and tools. Organizations work within a context and factors at the national and regional levels also need to be taken into account. Examples of contextual-level factors include wider - 18 -