Appendix 3 - Université de Montréal

177 Pages·2012·1.25 MB·French

by  Claudia Amar

Université de Montréal

Factors that impact the sustainability of wait time management strategies for total
joint replacement surgeries in canadian provinces

Par
CLAUDIA AMAR

Département d’administration de la santé
Faculté de Médecine

Mémoire présenté à la Faculté de Médecine
en vue de l’obtention du grade de Maîtrise
en Administration des services de santé
Option Analyse et Évaluation du système de santé

Avril, 2012

© Claudia Amar, 2012
Université de Montréal
Faculté de Médecine

Ce mémoire intitulé:
Factors that impact the sustainability of wait time management strategies for total
joint replacement surgeries in canadian provinces

présenté par :
Claudia Amar

a été évalué par un jury composé des personnes suivantes:
Claude Sicotte
président
Marie-Pascale Pomey
directeur de recherche
Nicole Dedobbeleer
membre du jury
i

Résumé

Pour répondre aux exigences du gouvernement fédéral quant aux temps
d’attente pour les chirurgies de remplacement du genou et de la hanche, les
établissements canadiens ont adopté des stratégies de gestion des listes d’attentes
avec des niveaux de succès variables. Notre question de recherche visait à
comprendre Quels facteurs ont permis de maintenir dans le temps un temps d’attente
répondant aux exigences du gouvernement fédéral pendant au moins 6-12 mois?
Nous avons développé un modèle possédant quatre facteurs, inspiré du
modèle de Parsons (1977), afin d’analyser les facteurs comprenant la gouvernance, la
culture, les ressources, et les outils.
Trois études de cas ont été menées. En somme, le 1er cas a été capable
d’obtenir les exigences pendant six mois mais incapable de les maintenir, le 2e cas a
été capable de maintenir les exigences > 18 mois et le 3e cas a été incapable
d’atteindre les objectifs. Des documents furent recueillis et des entrevues furent
réalisées auprès des personnes impliquées dans la stratégie.
Les résultats indiquent que l’hôpital qui a été en mesure de maintenir le temps
d’attente possède certaines caractéristiques: réalisation exclusive de chirurgie de
remplacement de la hanche et du genou, présence d’un personnel motivé, non distrait
par d’autres préoccupations et un esprit d’équipe fort. Les deux autres cas ont eu à
faire face à une culture médicale moins homogène et moins axés sur l’atteinte des
cibles; des ressources dispersées et une politique intra-établissement imprécise.
Le modèle d’hôpital factory est intéressant dans le cadre d’une chirurgie
surspécialisée. Toutefois, les patients sont sélectionnés pour des chirurgies simples et
dont le risque de complication est faible. Il ne peut donc pas être retenu comme le
modèle durable par excellence.

Mots clés: stratégies, attente, maintien dans le temps, Canada, hanche, genou,
chirurgies
ii

Summary

In response to federal government requirements regarding wait times for
elective hip and knee surgery, hospitals have adopted wait list management
strategies, with variable success. This research examined organizational and systemic
factors that made it possible to keep wait times within federally established limits of
6-12 months.
We used a model based on Parsons’ model. Four dimensions were used to
analyze the following factors: governance, culture, resources, and tools. Three cases
studies were done: Case 1 was able to meet the requirements for six months but
unable to sustain this level; Case 2 was able to maintain compliance with
requirements for > 18 months; and Case 3 was never able to meet the requirements.
Documents were collected and interviews conducted with people involved in the
strategies.
In all, eight interviews were conducted at each site and all documents related
to each strategy were collected. The results indicated that the one hospital that was
able to maintain compliance with the wait time requirements had specific
characteristics: an exclusive mandate to do only hip and knee replacement surgery;
motivated staff who were not distracted by other concerns; and a strong team spirit.
The two other cases had to contend with a medical culture that was less
homogeneous and they were less focused on meeting targets and had resources that
were dispersed as well as unclear inter-organizational policies.
In the end, the hospital factory model is appealing in the context of super-
specialized surgery. However, because patients are selected for simple surgeries, with
little risk of complications, it cannot be promoted as a sustainable model of
excellence.

Keywords: strategies, wait times, sustainability, factors, Canada, hip, knee, surgeries
iii

Table of Contents

Résumé ...................................................................................................................i

Summary ..................................................................................................................ii

Table of Contents ............................................................................................................... iii

List of Tables .................................................................................................................vi

List of Abbreviations .......................................................................................................... vii

Acknowledgements ............................................................................................................ ix

CHAPTER 1 -
 INTRODUCTION ................................................................................. 1

CHAPTER 2 -
 RESEARCH PROBLEM ....................................................................... 3

2.1
  Background ............................................................................... 3

2.2
  Objectives and Research Questions ........................................... 4

2.2.1
  General Objective ......................................................................................... 4

2.2.2
  Specific Objectives ........................................................................................ 4

2.2.3
  Main Research Question .............................................................................. 4

2.2.4
  Secondary Research Questions ................................................................... 5

2.3
  Defining Key Concepts .............................................................. 5

2.3.1
  What constitutes a wait list? .......................................................................... 5

2.3.2
  How do we measure wait lists and wait times? ............................................. 6

2.3.3
  What is known about factors that affect wait lists and wait times? ............... 6

2.3.4
  What is a Wait Time Management Strategy? ............................................... 7

2.3.5
  The Concept of Organizational Change ........................................................ 8

2.3.6
  The Concept of Innovation .......................................................................... 10

2.3.7
  First Phase of Change: The Concept of Implementation ............................ 11

2.3.8
  Second Phase of Change: The Concept of Sustainability .......................... 12

2.3.9
  The Concept of Success ............................................................................. 13

CHAPTER 3 -
 CONCEPTUAL FRAMEWORK ............................................................ 15

CHAPTER 4 -
 LITERATURE REVIEW ON THE DETERMINANTS OF THE SUCCESS
OF WTMS ........................................................................................ 17

4.1
  Organizational-Level Factors ................................................... 17

4.1.1
  Organizational-Level Governance .............................................................. 18

4.1.2
  Organizational-Level Culture ...................................................................... 18

4.1.3
  Organizational-Level Resources ................................................................. 20

4.1.4
  Organizational-Level Tools ......................................................................... 21

4.2
  Contextual-Level Factors ......................................................... 22

4.2.1
  Contextual-Level Governance .................................................................... 22

4.2.2
  Contextual-Level Culture ............................................................................ 23

4.2.3
  Contextual-Level Resources ....................................................................... 24

4.2.4
  Contextual-Level Tools ............................................................................... 25

CHAPTER 5 -
 CANADIAN POLICY PUT IN PLACE TO BETTER MANAGE HIP AND
KNEE REPLACEMENT SURGERIES ................................................... 26

CHAPTER 6 -
 THE METHODOLOGY ....................................................................... 30

6.1
  The Research Team ................................................................. 30

6.2
  Research Design ..................................................................... 30

6.3
  Recruitment Method and Sample .............................................. 32

6.3.1
  Sampling ..................................................................................................... 32

6.3.2
  Classification of WTMS ............................................................................... 32

6.3.3
  Recruitment of health care organizations and key informants .................... 32

6.3.4
  Ethical consideration ................................................................................... 33

6.4
  Data Collection and Materials .................................................. 34

6.4.1
  Interviews .................................................................................................... 34
iv

6.4.2
  Timeframe for Data Collection ..................................................................... 36

6.5
  Data Collection and Analysis ................................................... 36

6.5.1
  Data Collection ............................................................................................. 36

6.5.2
  Data Analysis ............................................................................................... 36

CHAPTER 7 -
 RESULTS ........................................................................................ 38

CHAPTER 8 -
 CASE 1 ........................................................................................... 39

8.1
  Description of the case ............................................................ 39

8.1.1
  Type of health care organization .................................................................. 39

8.1.2
  Classification of the case ............................................................................. 39

8.1.3
  The Provincial Wait Time Management Strategy ......................................... 40

8.1.4
  The Hospital’s Wait Time Management Strategy ......................................... 40

8.2
  Factors that influence the WTMS’s success and sustainability .. 41

8.2.1
  Contextual Governance ............................................................................... 41

8.2.2
  Contextual Resources .................................................................................. 43

8.2.3
  Contextual Culture ....................................................................................... 45

8.2.4
  Contextual Tools .......................................................................................... 46

8.2.5
  Organizational Governance ......................................................................... 47

8.2.6
  Organizational Resources ............................................................................ 48

8.2.7
  Organizational Culture ................................................................................. 50

8.2.8
  Organizational Tools .................................................................................... 52

CHAPTER 9 -
 CASE 2 ........................................................................................... 58

9.1
  Description of the case ............................................................ 58

9.1.1
  Type of health care organization .................................................................. 58

9.1.2
  Classification of the case ............................................................................. 58

9.1.3
  The Provincial Wait Time Management Strategy ......................................... 58

9.1.4
  The Hospital’s Wait Time Management Strategy ......................................... 58

9.2
  Factors that influence the WTMS’s success and sustainability .. 60

9.2.1
  Contextual Governance ............................................................................... 60

9.2.2
  Contextual Resources .................................................................................. 62

9.2.3
  Contextual Culture ....................................................................................... 64

9.2.4
  Contextual Tools .......................................................................................... 65

9.2.5
  Organizational Governance ......................................................................... 66

9.2.6
  Organizational Resources ............................................................................ 68

9.2.7
  Organizational Culture ................................................................................. 72

9.2.8
  Organizational Tools .................................................................................... 76

CHAPTER 10 -
  CASE 3 ..................................................................................... 84

10.1
 Description of the case ............................................................ 84

10.1.1
  Type of health care organization .................................................................. 84

10.1.2
  Classification of the case ............................................................................. 84

10.1.3
  The Provincial Wait Time Management Strategy ......................................... 84

10.1.4
  The Hospital’s Wait Time Management Strategy ......................................... 85

10.2
 Factors that influence the WTMS’s success and sustainability .. 86

10.2.1
  Contextual Governance ............................................................................... 86

10.2.2
  Contextual Resources .................................................................................. 87

10.2.3
  Contextual Culture ....................................................................................... 88

10.2.4
  Contextual Tools .......................................................................................... 90

10.2.5
  Organizational Governance ......................................................................... 91

10.2.6
  Organizational Resources ............................................................................ 92

10.2.7
  Organizational Culture ................................................................................. 95

10.2.8
  Organizational Tools .................................................................................... 98

CHAPTER 11 -
  DISCUSSION AND RECOMMENDATIONS FOR PRACTICE AND
POLICY-MAKING ............................................................................ 105

11.1
 Discussion ............................................................................. 105
v

11.1.1
  Factors that differentiate the three cases from one another ..................... 105

11.1.2
  Factors that ensure WTMS sustainability ................................................. 108

11.1.3
  Factors necessary for WTMS implementation versus those necessary
for its sustainability .................................................................................... 111

11.2
 Recommendations .................................................................. 113

11.2.1
  Decision-Makers’ Level: ............................................................................ 113

11.2.2
  Managers at the Contextual Level: ........................................................... 114

11.2.3
  Organizational Level: ................................................................................ 114

CHAPTER 12 -
  CASE STUDY LIMITATIONS AND FUTURE RESEARCH ................ 116

12.1
 Common Limitations ............................................................... 116

12.1.1
  Reliability ................................................................................................... 116

12.1.2
  Construct Validity ...................................................................................... 117

12.1.3
  Internal Validity ......................................................................................... 117

12.1.4
  External Validity ........................................................................................ 118

12.1.5
  Qualitative Data Limitations ...................................................................... 118

12.2
 Suggestions for Future Research ............................................ 118

CHAPTER 13 -
  CONCLUSION ........................................................................... 120

References ..............................................................................................................122

Appendix 1:
  Theoretical Framework ............................................................................. x

Appendix 2:
  Semi-directed interview guide: Interviews with people involved in wait
time management for HKR in Regional Health Authorities and Hospitals
or Clinics .................................................................................................. xi

Appendix 3:
  Provincial wait time management strategies .......................................... xvi

Appendix 4:
  Case 1 Wait Times for Hip and Knee Replacements and Surgical
Volumes, April 2009-September 2010 .................................................. xxiii

Appendix 5:
  Case 2 Wait Times for Hip and Knee Surgeries and Surgical Volumes,
April 2009-September 2010 .................................................................. xxvi

Appendix 6:
  Case 3 Wait Times for Hip and Knee Replacements and Surgical
Volumes, February 2010-September 2010 .......................................... xxvii

Appendix 7:
  Cross-analysis of the three case studies ............................................ xxviii
vi

List of Tables

Table 1. Organizational factors that impact WTMS success and sustainability ..................... 56

Table 2. Contextual factors that impact WTMS success and sustainability ........................... 56

Table 3. Organizational factors that impact WTMS success and sustainability ..................... 80

Table 4. Contextual factors that impact WTMS success and sustainability ........................... 82

Table 5. Organizational factors that impact WTMS success and sustainability ................... 103

Table 6. Contextual factors that impact WTMS success and sustainability ......................... 103

Table 7. Cross-analysis of the three case studies: organizational governance ................... xxix

Table 8. Cross-analysis of the three case studies: contextual governance .......................... xxx

Table 9. Cross-analysis of the three case studies: organizational culture ........................... xxxi

Table 10. Cross-analysis of the three case studies: contextual culture .............................. xxxii

Table 11. Cross-analysis of the three case studies: organizational resources .................. xxxiii

Table 12. Cross-analysis of the three case studies: contextual resources ......................... xxxv

Table 13. Cross-analysis of the three case studies: organizational tools .......................... xxxvi

Table 14. Cross-analysis of the three case studies: contextual tools ...................................... xl
vii

List of Abbreviations

ABJHI: Alberta Bone and Joint Health Institute
APP: Advanced Practice Physiotherapist
BJC: Bone and Joint Canada
CEO: Chief Executive Officer
CIHI: Canadian Institute of Health Information
CIHR: Canadian Institutes of Health Research
CJAG: Concordia Joint Assessment Group
CJRR: Canadian Joint Replacement Registry
COA: Canadian Orthopaedic Association
CPO: College of Physiotherapists of Ontario
F/P/T: Federal/Provincial/Territorial benchmark
GP: General Practitioner
HCC: Health Council of Canada
HCO: Health Care Organization
HKR: Hip and Knee Replacement Surgeries
IT: Information Technology
JHDMP: Joint Health and Disease Management Program
LHIN: Local Health Integration Network
LOS: Length of Stay
MDC: Multi-Disciplinary Clinic
MHA: Medical Health Administration
MPAN: Manitoba Patient Access Network
NPAT: National Patients’ Access Team
OAC: Orthopaedic Assessment Clinic
OAS: Ontario Arthritis Society
OMA: Ontario Medical Association
OR: Operating Room
PA: Physician Assistant