A Comprehensive Case Study of an Orthopaedic Surgery Central Intake Service in the Winnipeg Regional Health Authority: A Single-Entry Model to Manage Waiting Times for Total Joint Replacement Surgery of the Hip and Knee
Creators: name: Damani, Zaheed
Publisher: name: Cumming School of Medicine
Year: 2018
Subjects: subject: Health Services Research
subject: Quality of care
subject: Surgery
subject: arthroplasty
subject: waiting times
subject: waiting list
subject: waiting time management
subject: single-entry models
subject: centralized intake
subject: pooled lists
subject: Health Sciences
subject: Health Care Management

description: Background: Single-entry is an increasingly prominent waiting time management strategy in healthcare but its impact on quality of care is poorly understood. We evaluated the Winnipeg Central Intake Service (WCIS) for total joint replacement (TJR) surgery of the hip or knee, a single-entry model (SEM) to manage patients referred for TJR surgery of the hip or knee. Methods: A pre/post mixed-methods case study approach was used to measure the WCIS' influence on six dimensions of quality of care: acceptability, accessibility, appropriateness, effectiveness, efficiency, safety. Qualitative interviews were used to assess experiences of patients, family physicians, orthopaedic surgeons, surgical office assistants and WCIS project team members. A pre/post intervention cross-sectional design was used to quantitatively assess changes in the six dimensions by comparing historical and prospective cohorts. Results: Our qualitative inquiry revealed that benefits of the WCIS included streamlined processes, greater patient access, improved measurement and monitoring of outcomes. Challenges included low awareness, change readiness, and initial participation among stakeholders. Unanticipated consequences included workload increases, confusion around stakeholder expectations, and under-reporting of data by surgeons' offices. Stakeholder acceptability was conditional, not universal. Assessment of capacity and readiness to change, and efforts to increase awareness, preparedness and uptake are critical. Factors for successful implementation include clear communication, robust data collection, physician leadership, and patience by all (especially implementation teams) allowing for an effective top-down, and bottom up approach. Our quantitative analysis revealed that the WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality. Waiting time was significantly improved (WT) for consult for TJR of the hip (WT1) and all WTs for TJR of the knee. Total knee replacement surgeries performed within the nationally-recommended 26-week benchmark increased by 5.9% post-WCIS. Post-surgical complication rates (safety) were lower post-WCIS. Accessibility and safety were the only quality dimensions that changed (post-WCIS for TJR of the hip and knee). Conclusion: Overall, WCIS implementation contributed to improvement in some, but not all dimensions of quality of care. This is the first study to comprehensively assess the influence of SEMs on the delivery of TJRs across all dimensions of quality. Findings of this research are generally consistent with existing literature related to SEMs and change management in healthcare. SEMs show an ability to improve accessibility without adversely affecting other dimensions of quality, albeit with conditional, not universal stakeholder acceptability. Limitations of this study include non-longitudinal cohorts, and availability and quality of data. Findings from this research can help strengthen existing SEMs and inform development of new ones for improved patient experience and outcomes and system performance.