Wait time from a patient’s perspective, involves the time from when they are initially assessed as needing a procedure to when the procedure is carried out. Within the health system – wait time is tracked from the time a patient is initially assessed (usually by a primary care provider – or in the case of eye care, an optometrist), to when they are seen by a specialist (Wait One) and then from when a decision is made to treat the patient with surgery to when the surgery is performed (Wait Two).
48 Currently Wait Two data is collected and publically reported through the MOHLTC wait time web site12. This reported data compares Wait Two times for each hospital in Ontario that offers surgical services. The Ministry has also set targets as to how long a patients should wait from decision to treat to their surgery. In the case of
cataract surgeries that are classified as priority four (elective), the target wait time is 182 days (or six months).
The expectation is that no one should have to wait longer than this time for the procedure.
The Wait Time Information System (WTIS) allows wait times to be adjusted for specific reasons related to the patient’s situation. For example if a person goes away on vacation and is not available, then the time they are unavailable is subtracted from their overall wait time. In this way as a system performance measure the system is not penalized for something over which they had no control.
For people on a Wait 1 list these patient-rated reasons are called DARCs [Dates Affecting Readiness to CONSULT].
For people on a Wait 2 list, these same patient-rated reasons are called DARTs [Dates Affecting Readiness to TREAT]. In addition, there are system related reasons for delays that are documented but are not subtracted from the wait time calculations. These system related delays apply to both Wait 1 and Wait 2. One of the current system-related delays is described as follows:
Patient Preference
Procedure delayed due to patient’s choice to remain on waitlist of a particular clinician or at a particular location despite being offered another option.
It is proposed that Patient Preference as described is not a delay caused by the system of care but is patient-driven and therefore it should therefore be repositioned as being both a DARC and a DART and as being a reason to subtract the time involved from the patient’s overall wait time.
Future State Recommendation 25.0
The Ministry of Health and Long-Term Care should review Patient Preference as a system-related wait time delay and move it into being both a DARC and DART as defined by the Wait Time Information System.
Target of Recommendation:
Ministry of Health and Long-Term Care
Financial and Resource Impact
Time and resources required to review the current state, develop and implement changes
Intended Outcome:
Wait time data will more accurately reflect system issues that need to be addressed by hospitals and ophthalmologists
Current evidence (Table 10) shows five of the seven centres providing cataract surgery in the South West LHIN are completing cases well below the provincial Wait Two target of 182 days or six months. Evidence presented in Table 11 shows the same general pattern for completed cases from April through October 2014. Wait Two data collected on a month by month basis by hospital shows that wait times can vary depending on a number of factors, the primary one being the number of procedures completed in a given month.
Beginning in the fiscal year 2014-15 the MOHLTC, through its wait time system, began collecting Wait One information. This information has not yet been made public and when it is, it is expected to be reported at the hospital level .
12 http://www.health.gov.on.ca/en/public/programs/waittimes/
49 Table 10.0
Profile of Cataract Surgery by Hospital – 2012-13 to 2014-15 (April-October) Wait 2 - Closed Cases
* Priority 4 cases can be considered to be elective surgery procedures.
Table 11.0
Profile of Wait Two times for Cataract Surgery by Hospital, (April 2014 -October 2014) – Closed cases
LHIN 3 yr. average:
135 days
Provincial target:
182 days
Source: Ontario Wait Times Information System
50 More recent data collected shows that Wait Two wait times have improved. In December 2014 for example, the Wait Time for open cases (yet to be done) was 127 days on average across the LHIN and 134 days at St. Joseph’s with only the Clinton site of HPHA still above the provincial benchmark at 198 days for open cases.
In The Current State of Vision Care report the following comments were made about access to care and wait times:
In the South West LHIN at the present time, all referrals for cataract surgery are made directly to a specific ophthalmologist and each physician creates and maintains their own wait list. Wait lists are not pooled and referrals are not made to a service with the allocation of cases being managed internally. For this reason wait lists can vary significantly between hospitals and between/among ophthalmologists working in the same location.
The ability of a hospital to improve (i.e. reduce) wait times (Wait 2 only) is a function of two variables. One is its ability to achieve improvements in productivity by reducing the time and resources used to carry out the procedures or by adding resources. The second is more challenging as it involves not the internal capacity of the hospital to do the work but the number of people on the wait list. As soon as a decision to treat is made the “clock starts ticking” and continues until the procedure is completed13. The more people on the list the greater the possibility that more people will not be able to get the procedure within the predefined target time.
Overall productivity can improve or stay the same if the wait list does not grow significantly, but if it does then it becomes more challenging to use productivity measures alone to achieve the intended target (cases done within the predefined time).
It is clear that if the volume of services is controlled but the demand for the service is not, the wait times for the service will go up. Under current circumstances hospitals are not able to control either the supply or demand for cataract services.
There is an argument to be made in favour of leveling the wait list among physicians within a specific hospital as it reduces the time a patient may need to wait for the procedure. There are certainly a number of cases where this has been done while reserving the option for a patient to stay on a longer wait list of they have a preference for a specific surgeon or need to be treated by a specific surgeon for medical reasons.
There is no external impediment to doing this as volume allocations are assigned to a hospital, not to specific physicians. It also does not change the total number of cases done, just who would do them and when patients would get the procedure. There is also a case for this to be done on a LHIN-wide basis for the same reasons.
Again, it would not change the overall volumes, just when and by whom the procedure would be done.
There are three components of wait times that hospitals and ophthalmologists can address directly. They can:
• Ensure they provide cataract services within QBP funded parameters as outlined by the MOHLTC
• Address both cost and productivity issues
• Balance wait lists so individual patients have relatively equitable access to cataract services
Each of these factors will be addressed in this discussion paper. Wait list management will be addressed here.
13 The WTIS does allow a person to be taken off the list – in other words to “stop the clock” if they are not available – go on vacation for example or a medical condition prevents them from having the procedure.
51 Wait list management is not a new concept but its application has been more limited than it could be. Hospitals continually triage patients in their emergency department and manage wait times according to patient acuity. The Cardiac Care Network manages wait times for cardiac patients referred to them based on acuity and this has been operational on a province-wide basis for many years.
It’s less common for people on a wait list for an elective procedure to be managed; although the MOHLTC, as part of its wait time initiative has set wait time targets for specific elective surgical procedures, including a number of ophthalmic procedures. The MOHLTC publically publishes wait times for surgical procedures by hospital on their website. People can then choose to go to a hospital with a short wait time if they want to. In practice people tend to go where their physician refers them or in the case of vision care, their optometrist.
The opportunity to change the referral to a specific ophthalmologist for a specific procedure is based on the opportunity to create greater equity for patients in terms of how long they are waiting. By pooling or sharing referrals it’s possible, all things being equal, to balance wait times among the physicians involved14. As a first step it’s proposed this type of wait list management begin with a focus on cataract surgery be explored by the two hospitals who have three or more ophthalmologists, namely Grey Bruce Health Services and St. Joseph’s Health Care London.
Future State Recommendation 26.1
Grey Bruce Health Services and St. Joseph’s, if there is significant variability in individual physician wait times for cataract surgery and/or wait time targets are not being met, should each take steps to investigate the merits and if warranted, plan and implement an internal cataract surgery referral wait list management process among the ophthalmologists who perform cataract surgery.
Target of Recommendation:
Grey Bruce Health Services and affiliated ophthalmologists
St. Joseph’s Ivey Eye Institute and all ophthalmologists who do cataract surgery
Finance and Resource Impact:
Administrative support to manage the intake and triage of referrals
The following recommendation is predicated on their being a significant difference in wait times among these physicians and organization. If this is not the case, the rationale for pooling referrals does not exist.
Future State Recommendation 26.2
Each of the five hospitals in the LHIN with one and two ophthalmologists per site in the central and southern part of the LHIN, if there is significant variability in individual physician wait times for cataract surgery and/or wait time targets are not being met, should explore the merits and feasibility of developing an internal wait list management process or as appropriate a wait list management process between sites.
Target of Recommendation:
Huron Perth Healthcare Alliance and affiliated ophthalmologists Woodstock Hospital and affiliated ophthalmologists
Alexandra Hospital and affiliated ophthalmologists
Middlesex Hospital Alliance and affiliated ophthalmologist St. Thomas Elgin General Hospital and affiliated ophthalmologist
14 An excellent example of an outline of how this can be done comes from Saskatchewan where pooling of referrals to specialists has been actively promoted. For details see the publication, “Pooled Referrals: Implementation Guide for
Specialists”, February 2013, Ministry of Health, Government of Saskatchewan. http://www.health.gov.sk.ca/pooled-referrals
52 Finance and Resource Impact:
Time and resources needed to undertake a review and feasibility study and implement a solution Time and resources needed to meet to discuss issues and develop action plans
Future State Recommendation 27.0
The hospitals and the ophthalmologists who do cataract surgery should take responsibility for tracking Wait One and Wait Two wait times as well as completed and open cataract surgery cases on a physician specific level on an on-going basis, and then develop strategies and action plans to ensure there is equitable access to cataract surgery throughout the South West LHIN.
Target of Recommendation:
Huron Perth Healthcare Alliance and affiliated ophthalmologists Woodstock Hospital and affiliated ophthalmologists
Alexandra Hospital and affiliated ophthalmologists
Middlesex Hospital Alliance and affiliated ophthalmologist St. Thomas Elgin General Hospital and affiliated ophthalmologist St. Joseph’s and affiliated ophthalmologists
Grey Bruce Health Services and affiliated ophthalmologists
Finance and Resource Impact:
Time and resources needed to track and analyze utilization and wait times and implement a solution Time and resources needed to meet to discuss issues and develop action plans
Intended Outcome of Recommendations 26.1, 26.2 and 27.0:
Patients needing cataract surgery will have equitable access to the procedure regardless of where they live or who does the surgery.
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