Academic journal article Australian Health Review

Achieving Waiting List Reform: A Pilot Program Integrating Waiting Time, Category and Patient Factors

Academic journal article Australian Health Review

Achieving Waiting List Reform: A Pilot Program Integrating Waiting Time, Category and Patient Factors

Article excerpt


Responding to a patient's concern, an insightful ministerial enquiry in 2006 asked 'Can you assure my constituent that there is no patient of lower priority ahead of them on the waiting list?' Those familiar with the challenge of delivering elective surgery would recognise the difficulty of reply.

Management of public hospital waiting lists is one of the most vexing issues in the delivery of surgical services. Patients awaiting surgery are assigned to one of three priority-related categories. These are designated Category 1 (Urgent), Category 2 (Semi-Urgent) and Category 3 (Non-Urgent). Categories are defined by the time within which treatment should be provided - that is, 30, 90 and 365 days, respectively. They are intended to guide clinicians in the appropriate selection of patients for surgery. In theory, patients in higher categories of priority are treated ahead of those assigned lower degrees of urgency.

In practice, administration of the waiting list is more complex. Clinicians must balance time waiting against the pri- ority that has been assigned. For example, a semi-urgent patient who has been waiting for a long time might reasonably be treated before an urgent patient who has just been added to the waiting list.

The existence of waiting lists reflects resource limitations that are inherent in public health. Waiting list statistics have become a surrogate indicator of the adequacy of resource allo- cation. Because of a focus on these figures, hospitals strive to minimise overdue patients. Unfortunately, this reasonable intent can have unintended clinical implications.1 Direct linkage of waiting list performance with funding incentives has previously resulted in deliberate and systematic waiting list manipulation.2 Although these inducements have been dismantled, it remains difficult for healthcare regulators to oversee waiting list manage- ment. At a local hospital level, pressure to meet waiting list criteria may risk patients being assigned lower categories of urgency.

As might be expected, no systematic review of these issues has been undertaken. Nevertheless, there is evidence of ongoing concern regarding bias in waiting list management. In early 2011, the ACT Auditor General reported the reclassification of 259 Category 1 waiting list patients. Of these, 97% were reclassified without any documented clinical reason. The report also described a consistent practice of downgrading patients' category of urgency close to the time when they would become overdue - often following a request for review by the hospital.3

The critical issue underpinning all of these tensions relates to the lack of effective management tools. The most fundamental requirement of waiting list administration is that it appropriately orders patients awaiting surgery. Presently, hospitals lack a mechanism to prioritise patients in a manner that is defensible, equitable and safe. In an era that has undergone transformational change in consumer IT, it is perplexing that there has been no similar reform in the technology supporting this important aspect of clinical care.

In 2008, a hospital unit in SA implemented a program to assist waiting list management. This integrates patients across all categories of urgency. Priority is assigned on the basis of primary category, wait time and the specific characteristics defined for each individual patient. The program has proved simple, robust and effective in supporting patient management. It is time saving in use, and provides management capacities that have not been available previously.

Uniquely, the current approach is based on weightings applied to criteria that are specifically defined for every procedure. As a result, it is applicable to waiting lists comprising patients with very diverse conditions and clinical priorities. We believe the nature of this program offers an insight into directions that are necessary in the evolution of waiting list management. …

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