Eastern Health (NL)

  • Elaine Warren, Program Director, Surgery, Eastern Health, St. John's, Newfoundland and Labrador

An Evidence-based Approach to Improving Orthopedic Patient Flow and Wait Times

Throughout the last two decades the Canadian healthcare system has struggled with prolonged wait times and delays in care. Access challenges have contributed to dissatisfaction in patients, physicians, and healthcare providers; increased healthcare costs and poor patient outcomes. In particular the interface of primary and secondary care is a concern for Canadians. Very little attention has been devoted to initiatives focused on improving this interface. With this in mind, the goal of this intervention project was to redesign the referral process from primary to specialized care to improve access (Wait Time 1). A secondary purpose was to integrate best practices regarding the implementation of wait time management strategies into the project. The interventions identified for this project included: the development of a standardized referral tool for the Orthopedic Service, establishment of a centralized intake process for all non-urgent orthopedic referrals; implementation of  a process to track and measure Wait Time 1 and the development of a check-list of factors that support the implementation of wait time management strategies. It was hypothesized that through the implementation of process improvements and wait time management strategies, significant improvements in access would be achieved.

In April 2011 a standardized referral tool and a Centralized Intake and Triage Model were introduced for the full orthopedic service in Eastern Health.  This model supported both the collection and sharing of a comprehensive data set around the demand for orthopedic services that was not previously available within the organization. Strategies were then developed and implemented to better match the supply and demand for the service. Six months post-implementation median wait times were reduced by 72% for high priority patients and 45% for the remainder. Additionally, wait times for individual physicians have equalized and duplicate referrals have been virtually eliminated.

Key to the success of this project were its evidenced-based framework, the high levels of physician and team engagement, the establishment of a strong evaluation methodology, and the extensive organizational support received. The robust evidenced-based framework for this project included: the incorporation of best practices in Orthopaedic care as outlined in the Bone and Joint Canada Toolkit, the use of the IHI Physician Engagement Framework, Kotter’s Change Model and Pomey’s framework for implementing wait time management strategies. Adoption of the centralized intake model by all clinics providing Orthopedic services in Eastern Health was an important first step in the delivery of a truly centralized access model that will ensure all patients have access to the first available specialist across the system. While this model was adapted from similar models utilized in several other orthopedic programs in Canada for hip and knee patients, it is unique in that all (non-emergent) referrals for patients requiring assessment by an Orthopedic specialist are managed in one system.