Article Figures & Tables
Figures
- Figure 1:
Suggested steps to successful single-entry model (SEM) implementation. Relationship between domains. Equity and patient factors were described as an overarching theme that influences how the backlog is perceived and might be managed. Described facilitators and barriers inform how SEMs can be operationalized.
- Figure 2:
Steps suggested by participants for successful implementation of a single-entry model.
Tables
Participant Primary role(s) Professional setting (Toronto, other or both) No. of years of experience (> 30, 20–30, < 20 yr) Working or retired Previous, current or no experience with SEMs Academic or nonacademic hospital affiliation (for those affiliated with a hospital) P1 Surgeon, administrator Toronto 20–30 Working Current Nonacademic P2 Surgeon, administrator Both > 30 Retired Previous Academic P3 Policy Both < 20 Working Current NA P4 Hospital executive Other < 20 Working None Nonacademic P5 Surgeon Other > 30 Retired Previous Academic P6 Policy Both 20–30 Working Current NA P7 Policy Both < 20 Working Current NA P8 Surgeon, policy-maker Toronto > 30 Working None Academic P9 Hospital executive Toronto 20–30 Working Previous, current Academic P10 Surgeon, administrator Toronto > 30 Retired None Academic Note: NA = not applicable, SEM = single-entry model.
Domain Subdomains Representative quotations Perceptions of the problem – “… in our Canadian health care system, there is no cushion. So there is never, you know when something bad happens, there was never a way to sort of make up for things and really what happened was, the cushion for the ICUs became the nursing care, really, and I think really that what’s been most short of in this. You know, we have the surgeons, we have the anesthetist, we don’t have the nurses, and we don’t have the porters and things. So, you know, when we got short of staff in the ICU, they needed more nurses to go up and work in the ICU…. Then they had to take nurses from, from the OR to work up on medical floors” (P1) Barriers to implementing SEM Concerns about standardization “I would pick a type of surgery that, you know, is, as I was saying before is quite standardized, and that everybody performing it would have a good experience. You know a good amount of experiences, because you, you know, it’s, it’s not going to work if say, for example, you know one surgeon, hardly does that operation when people are concerned about sending their, their patients to that person that they’re competent so I think it needs to be something that everybody feels that there’s a sort of a relatively equal amount of competence in” (P1)
“So I like the idea, but it’s a tiny piece of the whole story. I mean, you can’t do surgery, big surgery, if there’s no ICU bed available or if you can’t do the case. So you’re gonna have a single entry, but can’t do the case so it won’t end up making a difference. There’s a lot to this and I don’t want to discourage you, but the concept of everybody waiting for one doctor, unless it is a very specialized process. You don’t want any old Joe doing an aortic arch replacement, you want someone who really knows what they’re doing. There are procedures where you want one or two people” (P2)
“Having a standardized framework across the board will be helpful. One, one barrier to that will be every hospital has totally different … Given the independence of individual hospitals in the province, compared to other jurisdictions, every hospital might have their own policies that they’re empowered to make on their own … So having a central policy when it comes to surgeries, and SEM will likely be challenging given how the hospital system currently operates. So there would be need for some type of change management involved” (P3)Managing personalities “Well, I don’t think people see, like, the average surgeon, understands the benefits. So we would actually really have to craft the messaging clearly around how does this benefit patients, how does this benefit you and how does it benefit [our organization], and really understand the downsides of those SEMs. And to really tackle those barriers head on, whatever they may be, I think many surgeons have this misconception that it will, they’ll lose income, or lose patients out of it” (P7) Facilitators to implementing SEM Benefits of SEM “So we have what are called rapid access clinics in each LHIN, where family physicians refer to one place, and then assess the patient. I think it’s regarding lower back pain they’re first assessed by advanced practice physio, and then if they are deemed eligible for surgery then they’re referred to the first available surgeon. So that’s, that’s kind of a good example of a successful SEM because, not only is it triaging folks to the most available surgeon, but it’s also identifying before they get to the surgeon, whether they actually need surgery or not. Because surgeons get a lot of inappropriate referrals, and a lot of people don’t need surgery and you settle down into an alternative pathway of conservative management” (P6) Getting a win-win-win “I think if you really want something to work well, it’s great to have a win-win-win. Right, so, you know, if the win can be, say, for patients, they get their surgery faster, for family physicians it’s easy, very easy to make that referral so that for their offices there’s less hassle that way and their patients are happier. There’s a win for them. And then for surgeons. If the win can be, you know, that it will kind of make your life easier, because you’re not struggling to find, find OR time for somebody who’s a little bit more urgent or something like that — you see what I mean. So, like, I think you can make an argument that for a single entry that there, there is an argument that there is a win-win-win there. And I think if that happens then it’ll be successful. If it’s not a win-win-win — like, if it’s a lose for somebody — it’s probably gonna fall apart” (P1) Impact on wait times “So will it flatten the disparity of wait-list from surgeon to surgeon? Absolutely. From hospital to hospital? Possibly. From region to region? Somewhat. But will it be the panacea for wait-lists? Absolutely not” (P8)
“It has helped the patients dramatically, there’s no question about it. You know, people don’t wait nearly as long as they used to. And there’s much better data around how long you’re waiting, depending on where you live, so on. And we have things like the first available surgeon program so that if there’s two of us working in the hospital, my waiting list is a year and the guy next door’s waiting list is three months, the patient’s given the option of seeing the three-month guy” (P5)Operationalizing and financing a SEM Improving capacity “Another initiative that we’ve been working on is surgical smoothing to increase efficiency and throughput for operating rooms, so we’re enabling better scheduling systems for individual hospitals in order to maximize all scheduled surgeries to ensure there’s no time that’s lost. We’re also leveraging public hospital and private clinic partnerships, or community clinic partnerships. And a number of hospitals have essentially put together their own independent partnerships with clinics in their regions. So I know, for instance, one hospital has a partnership with a cataract clinic, and that hospital now oversees all operations of that clinic and it’s essentially extra OR time, extra labour, and they have that partnership that the ministry doesn’t oversee” (P3) Performance management “Obviously, you really want to know about qualitative data like patient acceptance and quality of care in the eyes of the patient and in the eyes of the caregivers. You know, those are pretty straightforward things that you could measure and would be pretty profound in their ability to set the stage for the future. That’s the sort of thing that’s going to change attitudes if it could be shown for the government that yes, we can do more and more efficiently for hospitals, that yes, we can do these on an outpatient basis and we can still look after our patients with COVID-19 and the other disasters that come in. For the surgeon, that yes, I’m still busy and I’m still getting paid. And for the patients, that yep, I’m still happy about this” (P10) Resource availability “So there was a fair amount of resistance to this initially because it was an additional administrative burden for their secretaries. So we worked fairly hard to try and streamline this, to make it less onerous for them… and I didn’t have anything to do with this, obviously, I don’t know anything about computers. But my colleague had hired a computer genius who set up this whole program. And so what we did was we set up a program so that there was a single-entry for the surgeon’s secretary … And we had to get hospitals to buy in to this to say to the attendings, ‘If you don’t have patient entered into the data system, you can’t book the surgery’” (P5)
“… Also leveraging hospital partnerships and incentivizing for more hospital-to-hospital transfers and transfers of volumes. The hospital system has historically been very siloed… Hospitals are independent corporations, they manage their own surgeries and the system has historically been very siloed” (P3)Surgical type considerations “I think you want to prioritize things for single-entry that are high volume, low acuity” (P6)
“But for commodity surgeries like cataracts, knee replacements, hip replacements, coronary artery surgery, the ones you crank out, then I agree with you it would be great and we’d push hard for that in [our field]” (P2)Ways to motivate stakeholders “I think you need physician leaders to champion it. It would be great to have patients as well, but I think you need physician leadership with physician leaders … I think if you had some, you know, people that would, you know, say that this is a good model, I think you could also talk about it in negotiations, I know that the government’s in negotiations with the OMA right now — wouldn’t that be an interesting thing to put forward from a policy perspective?” (P4) Patient factors and equity “The second thing was that they realize that there was a lot of patients being seen in doctors offices that didn’t have to be seen, because they didn’t really need a hip or knee placement. Okay. So the family doctor would send somebody to me, and they’d say, well, maybe you need your knee operated on, I’ll send you to see the orthopedic surgeon. So months later, they would see the orthopedic surgeon, right, because he had this huge waiting list. The ortho would spend five minutes with the guy and say, ‘Oh, you don’t need a knee replacement. Okay, you don’t need a knee operation’” (P5)
“But you wouldn’t know where that person sits socioeconomically ... So I actually think it provides a degree of level set, that it’s not cherry picking, you’re wealthy, I like you, you’re white, you’re going to be problem free, and I’ll take you. And in this case, you gotta take everyone. An eye is an eye is an eye. And I mean, that’s the truth of it. I’m not suggesting surgeons do that now or are malicious or deliberate about doing it. But as we know, through this pandemic, with all the other social issues that have come into play, there is a, there’s a bias. There’s a bias and this allows individuals from marginalized communities to get world-class eye care. Why should they be denied or cherry-picked? They shouldn’t. They should be given equal access … [The focus is] on the eye and the individual, not the colour of their skin, their background and how much money they have or don’t have. That’s irrelevant when it comes to cataract surgery. It may become relevant when there are specialty lenses that are required, medically necessary, that are not covered by OHIP, that patients do not have to pay. I am quite proud of what we’ve done” (P9)Note: ICU = intensive care unit, LHIN = Local Health Integration Network, OHIP = Ontario Health Insurance Plan, OMA = Ontario Medical Association, OR = operating room, SEM = single-entry model.
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