Insights from the design and implementation of a single-entry model of referral for total joint replacement surgery: Critical success factors and unanticipated consequences.

BACKGROUND: Single-entry models (SEMs) in healthcare allow patients to see the next-available provider and have been shown to improve waiting times, access and patient flow for preference-sensitive, scheduled services. The Winnipeg Central Intake Service (WCIS) for hip and knee replacement surgery was implemented to improve access in the Winnipeg Regional Health Authority. This paper describes the system's design/implementation; successes, challenges, and unanticipated consequences. METHODS: On two occasions, during and following implementation, we interviewed all members of the WCIS project team, including processing engineers, waiting list coordinators, administrators and policy-makers regarding their experiences. We used semi-structured telephone interviews to collect data and qualitative thematic analysis to analyze and interpret the findings. RESULTS: Respondents indicated that the overarching objectives of the WCIS were being met. Benefits included streamlined processes, greater patient access, improved measurement and monitoring of outcomes. Challenges included low awareness, change readiness, and initial participation among stakeholders. Unanticipated consequences included workload increases, confusion around stakeholder expectations and under-reporting of data by surgeons' offices. Critical success factors for implementation included a requirement for clear communication, robust data collection, physician leadership and patience by all, especially implementation teams. CONCLUSIONS: Although successfully implemented, key lessons and critical success factors were learned related to change management, which if considered and applied, can reduce unanticipated consequences, improve uptake and benefit new models of care.

The use of a policy dialogue to facilitate evidence-informed policy development for improved access to care: the case of the Winnipeg Central Intake Service (WCIS).

BACKGROUND: Policy dialogues are critical for developing responsive, effective, sustainable, evidence-informed policy. Our multidisciplinary team, including researchers, physicians and senior decision-makers, comprehensively evaluated The Winnipeg Central Intake Service, a single-entry model in Winnipeg, Manitoba, to improve patient access to hip/knee replacement surgery. We used the evaluation findings to develop five evidence-informed policy directions to help improve access to scheduled clinical services across Manitoba. Using guiding principles of public participation processes, we hosted a policy roundtable meeting to engage stakeholders and use their input to refine the policy directions. Here, we report on the use and input of a policy roundtable meeting and its role in contributing to the development of evidence-informed policy. METHODS: Our evidence-informed policy directions focused on formal measurement/monitoring of quality, central intake as a preferred model for service delivery, provincial scope, transparent processes/performance indicators, and patient choice of provider. We held a policy roundtable meeting and used outcomes of facilitated discussions to refine these directions. Individuals from our team and six stakeholder groups across Manitoba participated (n = 44), including patients, family physicians, orthopaedic surgeons, surgical office assistants, Winnipeg Central Intake team, and administrators/managers. We developed evaluation forms to assess the meeting process, and collected decision-maker partners' perspectives on the value of the policy roundtable meeting and use of policy directions to improve access to scheduled clinical services after the meeting, and again 15 months later. We analyzed roundtable and evaluation data using thematic analysis to identify key themes. RESULTS: Four key findings emerged. First, participants supported all policy directions, with revisions and key implementation considerations identified. Second, participants felt the policy roundtable meeting achieved its purpose (to engage stakeholders, elicit feedback, refine policy directions). Third, our decision-maker partners' expectations of the policy roundtable meeting were exceeded; they re-affirmed its value and described the refined policy directions as foundational to establishing the vocabulary, vision and framework for improving access to scheduled clinical services in Manitoba. Finally, our adaptation of key design elements was conducive to discussion of issues surrounding access to care. CONCLUSIONS: Our policy roundtable process was an effective tool for acquiring broad input from stakeholders, refining policy directions and forming the necessary consensus starting points to move towards evidence-informed policy.

Impact of a regional acute care surgery model on patient access and outcomes.

BACKGROUND: The consolidation of acute care surgery (ACS) services at 3 of 6 hospitals in a Canadian health region sought to alleviate a relative shortage of surgeons able to take emergency call. We examined how this affected patient access and outcomes. METHODS: Using the generalized linear model and statistical process control, we analyzed ACS-related episodes that occurred between 39 months prior to and 17 months after the model's implementation (n = 14,713). RESULTS: Time to surgery increased after the consolidation. Wait times increased primarily for patients presenting at nonreferral hospitals who were likely to require transfer to a referral hospital. Although ACS teams enabled referral hospitals to handle a much higher volume of patients without increasing within-hospital wait times, overall system wait times were lengthened by the growing frequency of patient transfers. Wait times for inpatient admission were difficult to interpret because there was a trend toward admitting patients directly to the ACS service, bypassing the emergency department (ED). For patients who did go through the ED, wait times for inpatient admission increased after the consolidation; however, this trend was cancelled out by the apparently zero waits of patients who bypassed the ED. Regionalization showed no impact on length of stay, readmissions, mortality or complications. CONCLUSION: Consolidation enabled the region to ensure adequate surgical coverage without harming patients. The need to transfer patients who presented at nonreferral hospitals led to longer waits.

CONTEXTE: Le regroupement des services chirurgicaux d'urgence (SCU) dans 3 hôpitaux sur 6 d'une région sanitaire canadienne visait à contrer une relative pénurie de chirurgiens capables d'effectuer les interventions d'urgence. Nous en avons analysé l'impact sur l'accessibilité des services et sur les résultats chez les patients. MÉTHODES: À l'aide du modèle linéaire généralisé et d'un contrôle statistique des procédés, nous avons analysé les cas adressés aux SCU entre 39 mois précédant et 17 mois suivant l'entrée en vigueur du regroupement des services (n = 14 713). RÉSULTANTS: L'intervalle avant l'intervention chirurgicale s'est allongé après le regroupement des services. Les temps d'attente ont principalement augmenté pour les patients qui consultaient dans un hôpital de premier recours d'où ils étaient susceptibles d'être réorientés vers un hôpital de référence. Même si les équipes des SCU ont permis aux hôpitaux de référence de gérer un volume beaucoup plus important de patients sans augmentation du temps d'attente à l'hôpital même, le temps d'attente dans son ensemble s'est prolongé à l'échelle du système en raison de l'accroissement du nombre de transferts. Les temps d'attente pour les hospitalisations ont été difficiles à interpréter parce qu'on avait tendance à admettre les patients directement aux SCU, en contournant les services d'urgences. Pour les patients qui passaient par les urgences, les temps d'attente pour une hospitalisation ont augmenté après le regroupement; toutefois, cette tendance a été compensée par l'attente pour ainsi dire nulle des patients qui contournaient les services d'urgence. La régionalisation n'a exercé aucun impact sur la durée du séjour, les réadmissions, la mortalité ou les complications. CONCLUSIONS: Le regroupement a permis à la région d'assurer une couverture chirurgicale adéquate sans nuire aux patients. La nécessité de réorienter des patients vers les hôpitaux de référence a contribué à prolonger les temps d'attente.