Achieving waiting list reform: a pilot program integrating waiting time, category and patient factors

Abstract

Equity in resource allocation is central to the tenet of social justice in health care. The management of surgical waiting lists is of critical importance to clinicians, patients and regulators. In most hospital environments, the basic process has remained unchanged for decades. Patients are assigned to one of three urgency-related categories. Clinicians consequently administer three competing patient pools. The basis by which patients are selected for treatment may be difficult to define. The specific clinical circumstances of each patient are often unreported and may be unknown to those administering the list. Waiting list bias is also recognised. This may reflect clinician advocacy, pressure to meet category timeframe restrictions or perceived training requirements. In this environment, it is difficult to demonstrate propriety in care. We report the implementation of a pilot program to redesign waiting list management within a South Australian public hospital unit. This allows assemblage of patients into a single list. Overall priority is determined by balancing clinical acuity and waiting time. The determination of acuity takes into account both the primary category and the specific characteristics of each patient that are relevant to their intended procedure. Uniquely, the process is applicable to lists containing patients with dissimilar conditions. This paper reviews the limitations of current approaches in meeting reasonable community expectations. The principles and social justification underpinning this reform are introduced. Finally, the benefits offered by the program are discussed and interim results are reported. What is known about this topic? Current models for the management of hospital waiting lists have remained largely unchanged for several decades. Typically patients are allocated to urgent, semi-urgent and non-urgent categories of care. No methodology exists to systematically integrate these groups, or to account for specific patient factors. In this void, propriety in management is difficult to establish or defend. What does this paper add? A program is reported that unifies all categories of patients into a single prioritised waiting list. The order of patients is dynamic, and transparently reflects waiting time, category assignment and relevant individual patient factors. Uniquely, the program is applicable to lists containing patients with diverse clinical conditions. What are the implications for clinicians? Adoption of new technology is essential if reasonable community expectations in waiting list management are to be met. The current program provides unambiguous, defensible prioritisation of all patients awaiting care. The present reliance on individual managers is reduced, and the unique circumstances of each patient are recognised. We believe this approach affords significant benefit to patients, practitioners and regulators.