Toward systematic reviews to understand the determinants of wait time management success to help decision-makers and managers better manage wait times

For the past two decades, access to healthcare services has been a critical issue in most Organisation for Economic Co-operation and Development (OECD) countries [1]. Long waits for core specialized healthcare services have consistently been identified as a key barrier to access to care [2, 3], and governments and organizations have responded with a range of strategies to better manage wait times. For example, in September 2004, Canada’s First Ministers committed $5.5 billion to timely access in five healthcare areas over a 10-year period [4]. In June 2005, the Supreme Court of Canada (in the Chaoulli Decision) struck down Quebec’s ban on private insurance for Medicare-covered services in a bid to reduce wait times in that province. In April 2007, Canada’s federal government announced it would provide $612 billion to provinces that would commit to respecting maximum wait times for at least one medical procedure in their jurisdiction [5]. From these initiatives, it is clear that over the past decade Canadian decision-makers have consistently seen the centralization of programs at the federal and provincial levels as the means to solve problems regarding wait lists and wait times [6]. While these initiatives are promising [7‐9], we believe insufficient attention has been paid to how healthcare organizations themselves have implemented strategies to reduce wait lists and wait times [10]. We therefore conducted a systematic review, supplemented by a workshop with experts, to better understand the key organizational and contextual level factors that influence the success or failure of wait time management strategies (WTMS) undertaken by organizations, not only in their implementation but also in their sustainability over the longer term. Given that WTMS implementation and sustainability have not been defined in the literature as such, we borrowed from the change theory literature on the life cycle of typical change initiatives [11], where the implementation phase is defined as the period when a new intervention is introduced and the sustainability phase as the period during which it is consolidated. In the systematic review and expert workshop, we focused on factors that were considered to influence the success of WTMS implementation and sustainability; we did not focus directly on the impact of these factors on reducing wait times. Our systematic review explored five questions:

The systematic review was limited to published articles. Six electronic medical databases were searched: CINAHL, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Embase, Healthstar, and MEDLINE (including MEDLINE In-Process). We consulted 19 electronic non-medical databases, which included general Canadian databases (Canadian Business & Current Affairs; Canadian Newsstand; Canadian Periodical Index; Canadian Research Index; Repères), math and engineering databases (Compendex; IEEE Xplore; Inspec; MathSciNet), economics databases (EconLit & ERIC [CBSCO Host]), and sociological (Communications Abstracts; ERIC; PAIS; Social Sciences Abstracts; Sociological Abstracts) and multidisciplinary (ABI Inform; ProQuest Dissertations & Theses; Scopus) databases. We used the search terms ‘waiting lists’ [or] ‘wait time’ [or] ‘queues’, combined using the Boolean operator and with terms reflecting management issues, such as ‘policies’, ‘information systems’, ‘budgets’, ‘health priorities’, ‘patient referral’, ‘health care delivery’, and ‘personnel management’. Additional search strategies to complement the search outlined above were developed for both medical and non-medical databases to ensure that we captured all relevant articles on WTMS. One example of the search strategies used is given in Table 1. This search strategy was developed and used for the Cochrane Central Registry of Controlled Trials, Healthstar, and MEDLINE medical databases.

The systematic review was carried out over two periods of time. The first search, conducted in 2005, covered articles published between 1990 and 2005, and the second search, conducted in 2011, covered those published between 2006 and 2011. We conducted a workshop in March 2009 with healthcare experts to validate the first findings of the systematic literature review and to ensure they were robust. We conducted our review in two steps because most of the articles retrieved in the first period were related to WTMS implementation, but workshop participants felt it would be important also to include articles related to WTMS sustainability. Consequently, we extended our research until 2011 to capture such articles. We also explored together how the factors identified could be developed into best practices to create a tool for managers in healthcare organizations responsible for WTMS. Participants were selected because they had responsibility for healthcare provision, health system leadership, and wait time management, were in a position to provide experience-based critiques, and could potentially apply the research findings in their context.

The data from the systematic review are presented here in narrative form because of the heterogeneity of study designs in the articles examined for our systematic review. The articles reviewed used a wide variety of study designs and approaches, including case studies, pre-post comparisons studies, prospective studies, simulation/modeling studies, and time series studies. We combined the findings of the two periods, specifically identifying factors that emerged in relation to WTMS implementation or sustainability. We adapted Parson’s social system action theory to classify the factors [12]. This framework, which we used in previous work to identify contextual and organizational factors [13], was also useful to identify a priori coding categories [14], which is helpful when conducting reviews of qualitative studies. This framework (Figure 1) is composed of different factors that can be present at the contextual and organizational levels: ‘governance and leadership’, defined as ‘the conduct of collective action from a position of authority’ [15]; ‘culture’, which consists of ‘underlying beliefs, values, norms and behaviours’ [13, 16]; ‘resources’, which may be human, financial, infrastructural, or informational; and ‘tools’, referring to instruments or procedures. The organizational level corresponds to the specific context of WTMS initiatives within healthcare organizations, whereas the contextual level refers to the broader context of WTMS initiatives, such as policies, laws, or regulations from provincial, regional, or other health authorities.

From this systematic review of 47 articles, we were able to identify key factors influencing WTMS, especially for implementation. Few studies explored the determinants of WTMS sustainability [22‐26, 57‐63]. With regard to evidence-based healthcare programs and practices, two recent systematic reviews looked at factors that influence the sustainability of such initiatives [64, 65]. Most of the studies reviewed there did not define the notion of sustainability in clear terms, and most did not use a rigorous research design to evaluate research findings on factors impacting sustainability [65]. Although that review found the same main determinants of sustainability as emerged in our review, the factors identified were less accurate than those we were able to show. For example, that review did not identify subcategories for factors related to the cultural dimension, such as performance culture, quality improvement, or public awareness and empowerment. Furthermore, the studies reviewed did not always link the determinants of healthcare innovations’ sustainability to their impacts on particular goals or on benefits for patients.

Despite the lack of evidence in the literature on the notion of sustainability and its determinants, the discussions in the workshop helped to shed light on this notion. Indeed, the workshop allowed us to identify additional constraints and barriers related to WTMS sustainability (see Table 4). Moreover, the workshop participants’ notions concerning implementation differed from those identified in reviewed articles in two ways. First, the participants identified factors that negatively impacted WTMS implementation, in contrast to the success factors found in articles. They also identified factors, again negative, that were especially related to sustainability and were not in the literature. Most of those were related to governance at the local level, such as limited information sharing between professionals and managers, lack of time allocated to WTMS, and lack of partnership between professionals, especially physicians, and managers (see Table 4). Despite these differences, many of the factors identified in the literature and the workshop were similar, including those relating to implementation (see Table 4). As such, this process highlighted the importance of taking into account the potential limitations of using a theoretical framework for data extraction [14].

Because the workshop experts were healthcare managers and decision-makers directly involved in wait time reduction strategies in Canada, their input helped validate the findings and robustness of our systematic review, in addition to complementing our findings with sustainability factors that were rarely addressed in the literature.

We should also point out that an article published by our team in 2010 on a study of success factors in WTMS implementation showed the same main findings as did our systematic review [13]. That study used data from interviews with key physicians, managers, policy-makers, and researchers from across Canada who had worked on initiatives to reduce wait times. The same governance factors were noted in that article, as were cultural factors related to physician involvement in WTMS and the need for a quality improvement culture. That study also highlighted the importance of aligning contextual-level and local policies. Funding levels and financial incentives were addressed both in that article and in our systematic review. As well, subsequent to that 2010 article and inspired by it, a very interesting tool was developed to assess the success of WTMS implementation, which was applied in an orthopedic program [66] (see Table 6).

Some of the factors identified in our study have been mentioned in other Canadian and international studies published in the grey literature. For example, the Canadian Centre for Policy Alternatives (CCPA) report in December 2005 [67] mentioned coordination, dedicated evaluation tools, commitment and cooperation by all stakeholders, and an innovative culture of performance as the main factors that can enhance the success of a WTMS. The March 2006 report of the Association of Canadian Academic Healthcare Organizations [68] and the June 2006 Final Report of the Federal Advisor on Wait Times [69] also mentioned some of the factors identified in our study, such as those related to physicians’ involvement in WTMS. Another publication, by the Health Council of Canada [6], reported that interviews with leaders of initiatives to reduce wait times in Canada had revealed a number of key success factors. Unsurprisingly, these are similar to the factors identified in our study and include: support from governments leaders; strong program leadership that brings together administrative and clinical champions; full-time staff who are dedicated to making the program work; information systems that enable programs to centralize wait lists, to track wait times in local areas and province-wide, and to share this information publicly; adequate funding for the introduction of information systems and effective program leadership; and a broad, comprehensive approach to the many large and small changes required to reduce wait times for care [6].

At the international level, a study conducted by the King’s Fund in the UK [70] examined organizational characteristics that sustained WTMS improvements. Once again, some factors identified in our study were also in the King’s Fund report, such as the need for reliable information, strong leadership, and incentives, although our findings were more extensive.

This is the first published review on factors that can influence success in implementing or sustaining WTMS in healthcare organizations. The conceptual framework used in this study is one that we previously used for a published study on success factors of WTMS implementation, which was based on interviews with physicians, healthcare managers, and policy-makers [13]. Our framework, inspired by Parson’s widely recognized and robust four-quadrant model [12], was useful for organizing and analyzing the factors identified in the literature as influencing the implementation and sustainability of WTMS at both the systemic and local levels.

The paucity of articles with evidence on sustainability points strongly to the need for more research in that area related to impact on WTMS. Since our systematic review did not explore how these individual factors influenced reduction of wait times, future research should focus on success factors that help to both implement and sustain WTMS and that ensure reduction of wait times.

Nevertheless, our results can be useful to healthcare decision-makers and managers seeking to develop best practices based on success factors for WTMS implementation and sustainability. One example of such use is the tool presented in Table 5, which is a checklist of factors developed to support managers at the organizational level implementing a WTMS in one of the main orthopedic services of Ontario’s Eastern Regional Health Authority. This tool was shown, in a study, to have been a successful method of knowledge translation that contributed to the sustainability of that initiative [66].

Marie-Pascale Pomey, MD, MSc, PhD, is an associate professor in the Department of Health Administration, Public Health Research Institute, Faculty of Medicine, University of Montreal. Pierre-Gerlier Forest, PhD, is president of the Pierre Elliott Trudeau Foundation. Claudia Sanmartin, PhD, is a senior researcher in the Health Analysis Division, Statistics Canada. Carolyn DeCoster, PhD, RN, MBA, is executive director for Clinical & Zone Analytics, Data Integration, Measurement & Reporting, Alberta Health Services. Nathalie Clavel, MHA, is a research assistant, IRSPUM. Elaine Warren, RN, MSc, is regional director of Surgical Services, Eastern Health, and program director of Critical Care, Eastern Health. Madeleine Drew, MHA, is a research assistant, IRSPUM. Tom Noseworthy, MD, PhD, is an associate chief medical officer for Strategic Clinical Networks and Clinical Care Pathways, Alberta Health Services.