Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation

ObjectivesWe assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety.DesignPreimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts.SettingRegional, provincial health authority.ParticipantsPatients awaiting total joint replacement of the hip or knee.InterventionsThe WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood.Primary and secondary outcome measuresPrimary outcomes related to ‘accessibility’: waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression.ResultsVariability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee).ConclusionsThe 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.

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Insights from the design and implementation of a single-entry model of referral for total joint replacement surgery: Critical success factors and unanticipated consequences

Health Policy ◽

10.1016/j.healthpol.2017.10.006 ◽

2018 ◽

Vol 122 (2) ◽

pp. 165-174 ◽

Cited By ~ 1

Author(s):

Zaheed Damani ◽

Gail MacKean ◽

Eric Bohm ◽

Tom Noseworthy ◽

Jenney Meng Han Wang ◽

...

Keyword(s):

Joint Replacement ◽

Success Factors ◽

Total Joint Replacement ◽

Joint Replacement Surgery ◽

Replacement Surgery ◽

Design And Implementation ◽

Critical Success ◽

Entry Model ◽

Single Entry ◽

Unanticipated Consequences

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The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement

Current Reviews in Musculoskeletal Medicine ◽

10.1007/s12178-017-9418-3 ◽

2017 ◽

Vol 10 (3) ◽

pp. 365-369 ◽

Cited By ~ 6

Author(s):

George F. Chimento ◽

Leslie C. Thomas

Keyword(s):

Quality Of Care ◽

Joint Replacement ◽

Total Joint Replacement ◽

Perioperative Surgical Home

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Prevalence and determinants of self-directed referrals amongst patients at hospitals in eThekwini District, KwaZulu-Natal 2015

South African Family Practice ◽

10.4102/safp.v61i2.5007 ◽

2019 ◽

Vol 61 (2) ◽

pp. 52

Author(s):

A. Rajman ◽

O. H. Mahomed

Keyword(s):

Quality Of Care ◽

Waiting Time ◽

Protective Factor ◽

Waiting Times ◽

Referral Letter ◽

Significant Positive Association ◽

Cross Sectional ◽

Patient Awareness ◽

District Hospitals

Background: Non-compliance with designated referral pathways has ramifications such as increased patient waiting time, overburdening of higher levels of care and increasing healthcare costs on patients and the healthcare system. The purpose of this study was to assess the determinants of self-directed referrals amongst patients attending hospitals in the eThekwini district of KwaZulu-Natal.Methods: An analytic, cross-sectional study was conducted at the Medical Outpatient Departments across five district hospitals in eThekwini using interviewer-administered questionnaires. Descriptive statistics were used to determine the proportion and the most frequent factors contributing towards patient self-referral. The likelihood of patients to self-refer was tested using chisquare (X2) and a multivariate regression model.Results: There were 315 patients interviewed with 35% (n = 109/315) having self-referred. The majority (51%; 55/107) of selfreferrals were male and were of African race (74%; n = 80/107). Five institutional factors, namely: availability of medication at the pharmacy (98%); quality of care at the facility (93%); waiting time at facility (92%); services provided (90%); and attitude of healthcare workers (87%), were ranked as the main drivers of self-referral. Multivariate logistic regression established a significant positive association between patient self-referral and male gender (OR 1.73; CI 1.04–2.87, p 0.05). Age 39 years (OR 0.96; CI 0.94–0.99, p 0.05); and patient awareness of a referral letter (OR 0.28; CI 0.09–0.86, p 0.05) emerged as protective factor against self-referrals.Conclusion: Males patients tend to bypass the referral pathway whilst younger patients and patients who were aware of a referral letter were less likely to bypass the referral system. In addition to addressing the systemic challenges of waiting times, quality of care and availability of medication, a patient-oriented approach that comprises education, encouragement and increased patient awareness is an important strategy to improve referral pathway compliance.

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Waiting time in public hospitals: case study of total joint replacement in Hong Kong

Public Administration and Policy ◽

10.1108/pap-10-2018-009 ◽

2018 ◽

Vol 21 (2) ◽

pp. 120-133 ◽

Cited By ~ 1

Author(s):

Yee-man Tsui ◽

Ben Y.F. Fong

Keyword(s):

Hong Kong ◽

Waiting Time ◽

Joint Replacement ◽

Process Management ◽

Emergency Services ◽

Total Joint Replacement ◽

Care Quality ◽

Public Hospitals ◽

Content Type

Purpose The purpose of this paper is to review the causes of long waiting time in Hong Kong public hospitals and to suggest solutions in the service, organisational, systems, financial and policy perspectives. Design/methodology/approach The paper is a review of waiting time of public hospital services. Total joint replacement, which is one of the elective surgeries in public hospitals, is presented as a case study. Findings The average waiting time of semi-urgent and non-urgent patients in the accident and emergency departments of public hospitals is two hours, and that of specialist outpatient (SOP) clinics is from 1 to 144 weeks. For total joint replacement, it is from 36 to 110 months. Measures like Government subsidisation programme for the replacement surgery and employing adequate physiotherapists, Chinese medicine practitioners, clinical psychologists and nurses to reduce the waiting time are suggested. Issues concerning the healthcare system of Hong Kong, such as structural reform, service delivery model, primary care, quality and process management, and policy reviews, are also discussed. Originality/value The ‬over-reliance of public services has resulted in long waiting time in public hospitals in Hong Kong, particularly in the emergency services and SOP clinics. However, the consequences of long waiting period for surgical operations, though much less discussed by the media and public, can be potentially detrimental to the patients and families, and may result in more burdens to the already stretched public hospitals‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬.

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Improving the waiting times within a hospice breathlessness service

BMJ Open Quality ◽

10.1136/bmjoq-2018-000582 ◽

2019 ◽

Vol 8 (2) ◽

pp. e000582

Author(s):

Caroline Sime ◽

Stuart Milligan ◽

Kevin Donal Rooney

Keyword(s):

Palliative Care ◽

Quality Improvement ◽

Waiting Time ◽

Current System ◽

Waiting Times ◽

Well Being ◽

Common Symptom ◽

Specialist Palliative Care ◽

Published Evidence

BackgroundBreathlessness, a common symptom in advanced disease, is a distressing, complex symptom that can profoundly affect the quality of one’s life. Evidence suggests that specialist palliative care breathlessness intervention services can improve physical well-being, personal coping strategies and quality of life. In the UK, the use of quality improvement methods is well documented in the National Health Service. However, within the independent hospice sector there is a lack of published evidence of using such methods to improve service provision.AimThe aim of this project was to reduce the waiting time from referral to service commencement for a hospice breathlessness service by 40%—from a median of 19.5 to 11.5 working days.MethodsUsing a quality planning and systems thinking approach staff identified barriers and blockages in the current system and undertook plan-do-study-act cycles to test change ideas. The ideas tested included offering home visits to patients on long-term oxygen, using weekly team ‘huddles’, streamlining the internal referral process and reallocating staff resources.ResultsUsing quality improvement methods enabled staff to proactively engage in positive changes to improve the service provided to people living with chronic breathlessness. Offering alternatives to morning appointments; using staff time more efficiently and introducing accurate data collection enabled staff to monitor waiting times in real time. The reduction achieved in the median waiting time from referral to service commencement exceeded the project aim.ConclusionsThis project demonstrates that quality improvement methodologies can be successfully used in a hospice setting to improve waiting times and meet the specific needs of people receiving specialist palliative care.

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Measuring and Analyzing Waiting Time Indicators of Patients’ Admitted in Emergency Department: A Case Study

Global Journal of Health Science ◽

10.5539/gjhs.v8n1p143 ◽

2015 ◽

Vol 8 (1) ◽

pp. 143 ◽

Cited By ~ 6

Author(s):

Saeed Amina ◽

Ahmad Barrati ◽

Jamil Sadeghifar ◽

Marzeyh Sharifi ◽

Zahra Toulideh ◽

...

Keyword(s):

Emergency Department ◽

Waiting Time ◽

Waiting Times ◽

Hospital Data ◽

Governance System ◽

Cross Sectional ◽

Average Waiting Time ◽

Study Population

BACKGROUND & AIMS: Measuring and analyzing of provided services times in Emergency Department is the way to improves quality of hospital services. The present study was conducted with aim measuring and analyzing patients waiting time indicators in Emergency Department in a general hospital in Iran. MATERIAL & METHODS: This cross-sectional, observational study was conducted during April to September 2012. The study population consisted of 72 patients admitted to the Emergency Department at Baharlo hospital. Data collection was carried out by workflow forms. Data were analyzed by t. test and ANOVA. RESULTS: The average waiting time for patients from admission to enter the triage 5 minutes, the average time from triage to physician visit 6 minute and the average time between examinations to leave ED was estimated 180 minutes. The total waiting time in the emergency department was estimated at about 210 minutes. The significant correlation between marital status of patients (P=0.03), way of arrive to ED (P=0.02) and type of shift work (P=0.01) with studied time indicators were observed. CONCLUSION: According to results and comparing with similar studies, the average waiting time of patients admitted to the studied hospital is appropriate. Factors such as: Utilizing clinical governance system and attendance of resident Emergency Medicine Specialist have performed an important role in reducing of waiting times in ED.

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