Snakes and ladders: the barriers and facilitators of elective hip- and knee-replacement surgery in Australian public hospitals
Authors: Walters Julie L. , Mackintosh Shylie F. , Sheppard Lorraine 
Published: March 2013

Objectives.
Waiting lists for elective surgery are a persistent problem faced by health systems. The progression through elective surgery waiting lists can be likened to a game of snakes and ladders where barriers (snakes) delay access to surgery and facilitators (ladders) expedite access. The aim of the present study was to describe the barriers and facilitators to delivery of total hip- and total knee-replacement surgery in South Australian public-funded hospitals.

Methods.
Semistructured interviews with staff, direct observation of administrative processes and documentation analysis were combined under a systems theory framework.

Results.
System barriers (snakes) were grouped into five categories: resources, workload, hospital engagement, community engagement and system processes. Inadequate resources was the most prominent barrier, patient cancellations resulted in one-third of administrative tasks being repeated and there was a perceived lack of engagement to maximising efficiency. Interestingly, despite a lack of resources being perceived to be the biggest problem, additional resources without system change was not considered an effective long-term strategy.

Conclusions.
Given the complexity of the elective surgery system, it is not surprising that single-item reforms have not created lasting reductions in waiting times. Multifaceted, whole-system reforms may be more successful.

What is known about the topic?
Waiting lists and waiting times for surgery are controversial, associated with frequent reforms and negative emotive headlines. We know from existing literature and anecdotal reports that individuals frequently experience lengthy delays before receiving elective surgery. Anecdotal reports also suggest that there are inefficiencies within elective surgery systems that contribute to these delays and result in cancellations, patient deterioration and poor overall satisfaction with the public health system in Australia. What isn’t clear is whether this perception is accurate and what inefficiencies do exist that could be specifically targeted for reform.

What does this paper add?
This paper adds weight to the argument that some inefficiencies exist within elective surgery systems, and identifies specific barriers to the delivery of total hip- and total knee-replacement surgery in South Australian public hospitals. It also identifies several strategies that could improve system function, some of which have already been implemented at a local level in response to stress on the system, and some of which require broad region- or state-wide change. In contrast to existing research, the level of detail provided in the present paper should allow for targeted reforms with the potential to improve system function and the efficiency with which joint-replacement surgery can be delivered.

What are the implications for practitioners?
All clinicians aim to provide the best intervention for their patients. Should the findings of this study be used to inform elective surgery system changes, patients and clinicians should experience a more streamlined approach to referral for and receipt of elective surgery in public hospitals. The consistency with which barriers and facilitators were identified across the four hospitals involved in this research supports the generalisability of the results. This further suggests that although specific to hip and knee replacement, many of the same barriers and facilitators could be in place across numerous surgical and non-surgical disciplines.