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Curing lengthy wait times in the public health system

How incentives, engagement with frontline health professionals and a centralized health care agency saved thousands of hospital bed-days a year

A version of this commentary appeared in the Hill Times, Halifax Chronicle Herald, Edmonton Journal and Calgary Herald

Sometimes public health care is like the human body. When you have an ailment in one area, you need to look somewhere else in the anatomy for the cause or the contributor.

Long wait times for hip and knee replacements are a good example. Cause: not enough surgeries to keep up with demand from an aging population. Well, that’s part of the problem.

We also know that many patients stay in hospital longer than the recommended four-day provincial benchmark for hip and knee surgeries. Evidence suggests that most often it’s because the patient, who is medically ready to go home, has not arranged for someone to help with recovery at home or feels more secure surrounded by professional hospital staff.

But every hour an acute care bed remains occupied by a recovering patient who doesn’t really need to be there is an hour the same bed cannot be occupied by another patient who needs a new hip or knee.

And for every patient, getting access to that bed means eliminating the stress of an unnecessary, very unpleasant and long wait for surgery.

At the Alberta Bone and Joint Health Institute, having developed the four-day length-of-stay standard using international evidence, we crunched the provincial hospital stay numbers for the  Bone and Joint Clinical Network (BJCN) of Alberta Health Services (AHS).  We found that in 2009-10, patients who had elective or planned hip replacement spent on average an extra 1.2 days in hospital, while knee replacement patients stayed an extra three quarters of a day, beyond what the guidelines recommend.

While this may not seem excessive, this means that approximately 16,000 bed-days would have been freed up had the average stay in acute care followed the recommended standard.

If these beds had been available for hip and knee replacement patients, this would have opened up bed capacity for another 4,000 surgeries. More surgeries mean shorter wait lists and wait times without incurring incremental costs.

The answer seems obvious: apply the four-day standard.

Unfortunately, health care decision-making is decentralized. Frontline staff in every orthopaedic unit across the province make local decisions, such as keeping a patient in acute care for an extra day, often without being aware or informed of the broader “system” impact.

So Alberta Health Services devised an experiment in 2010-11 using non-financial incentives to get frontline staff across the province engaged in applying the four-day benchmark. The BJCN was given the task of coordinating the clinical, operational and strategic aspects.

Multidisciplinary teams — surgeons, nurses, therapists and managers — were formed at 12 hospitals in the province where hip and knee surgery is performed.  Each team set out to reduce patient stay to the benchmark while also striving for other creative ways to improve performance.

Teams tracked their progress on a scorecard, met monthly for review, and shared results with other teams, creating an undercurrent of competition. Patients were managed more closely to ensure that they had a plan for coping at home after surgery. Those not medically ready to leave hospital, but not at risk, were moved into sub-acute care.

The experiment produced an impressive annualized savings of almost 11,000 acute care bed-days and was quickly adopted by AHS as a permanent program.

The final numbers aren’t in yet for 2011-12, but preliminary results suggest more than 13,500 bed-days have been saved, opening up bed capacity to potentially perform an extra 3,375 hip and knee replacements.

The teams’ incentive: a portion of the savings in resources were pumped back into hip and knee replacement services where the teams could see the impact of their success first-hand.

Partly on the strength of this success together with much more accurate measures of population needs, AHS added 1,080 hip and knee replacements to its planned volumes in 2011-12.  Importantly, the cost of these surgeries was partly offset by the efficiencies from the reduced acute care stay.

Today, AHS is seeing its wait times for hip and knee surgery decline steadily. Part of the success is rooted in giving frontline health care professionals the means and incentives to participate directly in meeting the four-day benchmark. And part of the success comes from having moved  to a single health care agency, which makes it possible to implement provincial programs like this one.

Over the next few years, incremental surgery volumes together with the additional surgical capacity produced by freeing up beds should enable AHS to meet its ultimate target of a maximum 14-week wait in 2014-15 for an elective hip or knee replacement.

Public health care suffers from many ailments but, as Canada’s premiers recognized when they formed their Health Care Innovation Working Group in January, it also brims with opportunities if you look in the right places.

Cy Frank is an expert advisor with EvidenceNetwork.ca and the Executive Director of Alberta Bone and Joint Health Institute.  He is also an orthopaedic surgeon practicing in Calgary, professor of surgery in the Division of Orthopaedics, University of Calgary, and the McCaig Professor of Joint Injury and Arthritis Research.

April 2012

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