Wait-Time Strategy

Rocco Rossi, CEO, Heart and Stroke Foundation of Ontario, and Director, The Empire Club of Canada; Ena Vukatana, Senior Student, North Toronto Collegiate Institute; Reverend Canon Philip Hobson, Incumbent, St. Martin in-the-Fields Anglican Church, Toronto; Hilary Short, President and CEO, Ontario Hospital Association; Dr. Terry Sullivan, President and CEO, Cancer Care Ontario; Dr. Robert Conn, President and CEO, Smartrisk; Sylvia Morawetz, Principal, S.A.M. Solutions, and Director, The Empire Club of Canada; Michael Decter, Founding Chair, Health Council of Canada; Janice Skot, President and CEO, Royal Victoria Hospital, Barrie; and George L. Cooke, President and CEO, The Dominion of Canada General Insurance Company, and Past President, The Empire Club of Canada.

Introduction by John Niles

Past Presidents, Directors, honoured guests, and members of the Empire Club of Canada:

It was Rex Murphy, who, when speaking at the Empire Club in December of 2001, said, "Health care in this country is a doctrine before it is a policy. It is not the third rail of Canadian politics. It is the back-up generator of Canadian self-understanding. Health care is the surrogate or default mechanism of Canadian patriotism."

And it was Chief Justice Beverly McLachlin, who will be speaking in a few weeks at the Empire Club, who said, "Access to a waiting list is not access to health care."

Without a doubt, health care has been and will continue to be an important topic and wait times a hot button issue in our country.

So who better to deal with this than Dr. Alan Hudson? Besides the enviable success as a health-care leader, primarily as President and CEO for 10 years at the University Health Network (UHN) in Toronto, Dr. Alan R. Hudson is a neurosurgeon whose many awards and professional activities have helped to establish him as a world-class researcher and authority on the peripheral nerve. He has authored definitive books on the subject and has more than 130 publications. He has made numerous presentations, including keynote addresses for major professional associations and universities. He has held key appointments, such as President of the Society of University Neurosurgeons, President of the Canadian Neurological Society and Honorary President of the World Neurosurgical Federation.

Between 1979 and 1989, Dr. Hudson chaired the Division of Neurosurgery, Department of Surgery at the University of Toronto, prior to which he was Professor and Associate Chair, Department of Surgery, and Head, Neurosurgical Division, at St. Michael's Hospital.

During this time, he and his colleagues performed the world's first sciatic nerve transplant in September 1988. With a degree from the University of Cape Town, Dr. Hudson also holds many honorary degrees and fellowships. He completed a research year at Oxford University as a McLaughlin Fellow, an AMP from the Harvard Business School and has served on many boards. Born in Cape Town, South Africa, Dr. Hudson was made an Officer of the Order of Canada in 2000 for service to health and medicine.

Please greet with me Dr. Alan Hudson.

Alan Hudson

Well thank you very much. I accepted this invitation with some enthusiasm until I read the list of distinguished individuals who had addressed this club over the past many years and all I can say is that I'm extremely honoured to be included in that company.

So, where does this lightening rod of wait times come from in the Ontario context? It started in September of 2004 at a federal-provincial meeting in Ottawa where all the premiers got up, regardless of political stripe, and said, "Wait times, wait times, wait times." They all nominated the big five--cancer, cataract, cardiac, hips and knees, MRS CT--which you all recognize as the things that baby boomers want fixed. So that's where it started for us and in December of the following year George Smitherman announced targets for Ontario for wait times. These targets are as good as or better than those agreed upon across this nation. So that's basically how we started.

What was the international and the national situation when Ontario started? Well most countries and some provinces were way ahead of us. We've had help from Scandinavia, the U.K., Australia and New Zealand. In this province, the only data we had of any worth was from the Cardiac Care Network. Saskatchewan had borrowed that methodology and expanded it to a wait-times strategy and we borrowed it back. So that's how we got started.

I was appointed advisor to the Premier and the Minister of Health of this province, but I want to stress that today I am speaking on behalf of thousands of individuals. These are the nurses, anaesthetists, surgeons, administrators, bureaucrats and politicians, who have all been involved in this mammoth change process. There's been a little bit of confusion in the last few weeks--challenges to the integrity of the data; people don't understand the data flow. There's even been a suggestion, a laughable suggestion, that we have not made any progress at all. So I think the theme today is truth, truth through facts. Wait times are a symptom of complex structures. If they work well, wait times come down; if they don't, wait times go up. The first flash was that this was not about wait times; this was about health-care systems and it was about even more than that.

We looked around Ontario and found that we were in a pre-industrial revolution situation. In this province when we started, there were 150-odd craft shops, independent, you know them as hospitals, way, way behind the times, with regard to any significant activity with IT. What about cost generation? If you're a patient, say with mild hypertension, your physician may ask you to come back once a month in a fee-for-service situation, or may ask you to come back once a year. I'm not too sure many of your companies would allow a 12-fold variation in cost generation but that's what was going on. What about quality? Well if you have to have your lung out, at one hospital in Ontario the death rate is about 14 per cent; at another hospital it's 3 per cent. I wonder how long Toyota would stay afloat if they allowed that range of quality and safety outcome and we're dealing with human beings. What about efficiency? Well we looked around and were amazed to find that even in some famous hospitals quite close to here, for the first case of the day time was not measured. The reason that's so important is that if that first case is delayed, you end up cancelling the last case and hence your efficiency deteriorates.

I think the best summary statement I can make, to my absolute amazement, is that we discovered that 50 per cent of the surgeons in this province could not launch Internet explorer. I have 12 grandkids, they all have Web access, so the truth of this initial scan was plain; we had a huge problem of significant dimensions and the government decided that we were going to fix it. So what do we do? On the accountability issue we asked where this health company spent about $35 billion a year. Very few of you in this room are in companies spending that much money. Who was in charge of wait times? That was easy--no one.

I would go to a hospital board meeting and say to the board chair, "Tell me about the wait times in your hospital for the big five?" They didn't know. Then I'd say, "Why don't you know? This is fairly fundamental information." I was a little frightened because virtually none of them knew. When I was a neurosurgeon the only person who knew my wait times was my secretary. My partners didn't know, let alone the hospital, let alone the province. So the first manoeuvre was to place accountability with the boards of the hospitals, which meant the CEO had to be able to answer the question I just posed. They got that information from the surgeons. This has worked extremely well. It's at a point at which the contracts are now signed and of course accountability determined.

The next piece we had to put in place was the question of specific financing. Many of you will not know that the way hospitals in Ontario are funded is with a global budget. You're given a sack of gold and you're told to run the hospital for the year. You appreciate your incentives to treat just one patient. If you feed two, you'll simply double your cost. There's no profit; there's no margin. Now working in that hospital, for someone like myself on fee for service, my incentive is to do as many cases as I can. I don't know how many of you work in companies where the fundamental incentives are diametrically opposed to one another, but that was what we found.

This is the way we modified it. Just think of cataracts for example, from that global budget. At the hospital, a certain number of cataracts were done. I have no idea how that number was derived because there's no system. Well we froze that number and that became the base. We said, "Overpaying 750 dollars a cataract case, full price, how many additional cataracts do you wish to do? This is a voluntary contract." This system has worked extraordinary well.

The next piece was introducing expert panels because we had to have answers. What was the appropriate target for a cataract patient? How long should he wait? Did it really matter if he waited three more months? Would he get a worse outcome? These expert panels were extraordinarily helpful in advising. They were not bargaining. They consist of numerous experts, mainly physicians and nurses, and this has been a huge success. In addition, we have coaching teams, which go from hospital to hospital, essentially helping hospitals improve their through-put. In the narrow sense, these expert panels are doing what I describe. In a broader sense we have created hundreds of leaders, particularly physician leaders around this province, to help produce big changes. In the very broad sense, we've linked hundreds, in fact, now thousands in this province to the bureaucrats and to the politicians in a rather interesting form of government. It's worked extremely well.

With regard to the focus dollars, these are new cases, these are add-on cases, these are not substitute cases, so obviously we need new dollars, particularly when paying full price. In less than two years we have $614 million devoted to this cause and if you add in bulk purchases of MRI CT, we have in fact received about a billion dollars in two years. This is a huge contribution. This is your tax dollars. You are waiting to see what your ROI is and I'm going to show you what happened to the wait times in a few minutes.

The key part to this of course is IT--data collection, analysis and reporting. We thought this would probably be easy because every one of the separate hospitals said we must have a single IT arrangement in this province. When we started, we were working off data two years old. When you look on the Web site now, with the new intermediate system in play, you're looking at data two months old and we are actually going live as we speak, with the main electronic system, which will give us data two days old--a huge step forward for this province.

The data goes from the surgeons to the analytical office, which happens to be at Cancer Care Ontario, and is then transmitted to the public Web site. If a single politician or a single bureaucrat puts a single finger on one digit of the reams of material on that Web site, I would resign. No one is manipulating any data. The data is what it is. From the start, we've always said the good, the bad and the ugly goes up and that's exactly what happens. So you'll see wait times getting worse in some hospitals, obviously not the majority, but there is no manipulation of that data.

Let me move on to show you what you want to see. What is a wait time? For the patient there's only one wait time--from the first symptom until the last treatment. Within that there are about seven or eight wait times which we have to measure to see where the choke points are. Every country in the world has started by measuring from the decision to treat. Someone looks in your eyes and says, "You have a cataract," and you say, "Yes I'll have it fixed." When you have it fixed is the end of where we're measuring. When I say wait times, that's the interval to which I'm referring. Now we've already backed up from that one. We've backed up to measuring waiting to see the specialist and then of course further back, waiting to see the primary care person.

Let me now show you what your tax dollars have done. On the right side is a star, which is the announced target. You can see where we started; you can see where we are now; you can see the trend line. We will hit the target when we report in April and my guess is we'll probably go under it. That is a fantastic accomplishment. All you have to do is to ask these patients, and there are thousands of them, who are now getting treatment in a much more reasonable time. This is a tremendous tribute to all those involved in delivering these services.

If you were a patient at a hospital with a very long wait time, you don't care what's happened to the provincial average. You care about yourself. We now have data by LHIN (Local Health Integration Network) and by hospitals. We now need to smooth these out so that patients have equal access regardless of where they live in Ontario.

Here's the same data; just a different format. On the vertical axis you can see the number of people treated and across the bottom, weeks waited. The blue line is the original curve and the magenta line is what's happening today. You can see a big shift to the left. In other words, a lot of patients have been treated in a relatively short time. You can also see we are moving towards the target I showed you previously, and we will get there very soon.

Here's the story on hips. When we started we thought this was impossible. The anecdotal evidence was that there was an enormous backlog. However through an enormous effort and enormous stress, there has been almost a 50-per-cent increase in volume. New cases, add-on cases, not substitute cases. You'll see that we're missing the target on that projection but the Premier recently announced additional funding, additional cases, and we're hoping to bend that line down so that when we report in April, we will have got to the target and that is just a fantastic result of the incredible amount of work of thousands of people in this province.

Now here's the cancer story. First you look where the star is. You'll see that cancer has primarily been below the target all along because hospitals naturally have been prioritizing cancer. You'll also see a little bit of a drift up there. Yes, in some hospitals cancer waiting times are going up. Isn't it marvellous we can actually measure it now and do something about it because in the tenure of the previous government there was no measurement system and hence you wouldn't even have known this. Now we have the ability to analyze the data in the 10 areas of surgical oncology. We know which three are causing the trouble--neurological, thoracic and gynaecological. We can look at this data, by hospital, by LHIN, so we know in which hospitals we have a problem. The government can now institute a remedy and as this goes on over time that's exactly what will happen. So this again is a big step forward. We can actually measure this as we move along.

Here's a summary. The intent is to get the blue out to the periphery and you can see with cancer surgery and bypass surgery, we are there. We will be in April on target for cataracts. To my amazement we will be on target for hips. We will not hit the target for knee replacement in April; we'll hit it a bit later. We've now discovered that you'd have to do about three knees for every one hip, which we didn't know going in. We've made very significant improvements in MRI CT with an enormous number of extra examinations being done but you can see that is where the challenge remains. This is such a challenge for many countries and for many provinces, that they don't even measure it, but we are making good progress in this regard as well.

Now let me move away from the results and say how well this has worked in the short term, to get through the backlog. We have now moved to the real change, which of course is the introduction of systems. We have to produce systems, if we're going to get any of the efficiencies and hence be able to afford our future. I only have time for one so I'll mention the hip and knee program in this LHIN, in which we're sitting, where six hospital CEOs and 26 orthopedic surgeons have signed onto a program. Two years ago, they would not agree on the day of the week. They're all now moving in a combined effort to try and produce better care for our patients. So the way this works is you phone 1-800-HIPS and you're assigned by protocol to a work-up team, which does not consist of orthopedic surgeons. This consists of nurse practitioners, occupational therapists, physical therapists and so on. By protocol your tests, your studies are done. You don't have to go around looking for them yourself. If you get enough points, you're seen by an orthopedic surgeon with a view that hopefully they will operate on 80 per cent of the patients they see. You want to leave that top piece because that's a judgment piece. That is better than operating on approximately 20 per cent of the patients they see now--a huge jump in efficiency. In the United States, orthopedic surgeons are in the operating room about 66 per cent of the week; in Canada, about 30, a huge opportunity for improvement. The patient is looked after throughout the process and of course, very importantly, returned to the community on the rehabilitation side. We are looking to very significant improvements in wait time.

To institute the systems I've described the key is that we must recognize the truth. We have a shortage of non-MD health-care professionals--nurse practitioners, occupational therapists, MRI techs, and so on. Much of our problem will be solved if we pay attention to this component of the human relations challenge. Now are there any challenges in this? Well of course there are. This is a huge challenge to medical hierarchies, to power structures, to the way medicine is being practiced. Let me just mention two categories. There are many, many more. I mentioned some of the challenges for physicians and some for patients. For physicians, there's a very big governance issue. If your company's board passed a strategy and a few weeks later you got a letter from some of the employees saying they didn't feel like doing it, I wonder what would happen to them. You know what would happen to them. You have to realize physicians do not work for hospitals. They do not work for LHINs. This issue of governance has to be debated. There are many solutions but the status quo is obviously completely unacceptable.

Another challenge for the physician is the tradition of personal referral. Many of you may think you've researched your surgeon. You don't know his results. You don't know his complication rates. You don't know her infection rates. You don't know all the key things that you would normally use to make a rational decision. You wouldn't possibly buy a house with that lack of information. The public is now demanding that information. This again is a challenge. When I flew back from London the other day, I didn't know the name of the pilot, but I did know that he'd been very well trained and retrained on the ground and the air, particularly when he changed equipment. I was tested once and I introduced a lot of technology I was never tested on. Once again, very significant changes need to come very quickly. The present system means you only fly on an airplane if you know the pilot's name. Guess what? You can't organize an airline that way. Guess what? You can't organize medicine that way.

What about the challenges for the patients? We've been talking about supply and capacity. There's a very big part to this, which of course is demand. Demand and control. Self care of patients will become more and more important to reduce demand, obesity being a very obvious example and underlying much of what I've been talking about. The expectations and demands of patients driving so much of this really have to become more realistic and instead of demanding more money and more doctors, the public should demand more data and more information. Some of this is counter-intuitive. If you look at expenditures in the States by state for public patients and look at the quality of results and output, you'll find that the states that spend the most have the worst outcomes. This is an inverse relationship. How is that possible? Well there are a lot of studies that show that in fact most of this is related to idiosyncratic behaviour of physicians ordering more consultations, more tests, more expense resulting eventually in poorer quality. Does the public of Ontario know that? The answer is no.

Finally, patients, the public, will have to avail themselves of screening techniques that were introduced into this province, most recently colon screening techniques this week. That is one of the four big cancers. It is a preventable cancer and so we hope that patients will do their part in reducing this wait time effort by helping us reduce demand for surgery.

So what's next? What do we do once these projects are now completed? Obviously we have to expand and we have to diversify what we are measuring. Firstly we have to get equality of access for all patients and all LHINs. Some LHINs are getting better, others worse. That's inappropriate for this province. The government has announced that it is moving to all surgeries. That process is underway.

We will now measure wait times for gall bladder, shoulders and so on. We have proposals, which the government is considering, and they will look at the introduction of these programs beyond the big five, in accordance with the public purse.

Let me conclude. I'm non-political and non-partisan. Therefore I will conclude with a few political remarks. You have to ask why previous governments have not done this. I mean it is so obvious. Could you imagine banks, airlines, retailers, working at the level we've been working at, from an IT point of view? Why haven't they done this? Were they afraid that they couldn't actually get a single IT program through this province? It has now been accomplished. Were they afraid of what they might find, because of course once you have found it, you have to do something about it? Which groups, interest groups, self interest groups, have not pushed this along? Who's worried about this data coming out and being part of a public transparent process so that patients are empowered to look after themselves and to make choices. Interesting questions. Let me say this in a non-partisan way and I mean it. This could have been a financial disaster. We all know of IT programs and programs of this dimension that have failed, whether it's in banks, or in public service. It has of course been a big success. This was a huge political risk. That risk was taken by Dalton McGuinty and by George Smitherman and on a values-based determination. We measure things and report transparently. They deserve a huge amount of credit. On this file, these two gentlemen have done more than the previous governments put together. The outgoing president of the Canadian Medical Association stated Ontario was a laggard. We are now the leader. We are now the leaders in this country. Let me also tell you that a colleague of mine, the surgeon chief in Ottawa, last week told me that for the first time he now knows each of his patient's waiting list, how many are waiting. He can now actually run the department for which he's responsible. He told me this was the greatest thing since sliced bread. Interesting concept for a surgeon. So I hope, by giving you some of the facts and keeping away from the political rhetoric, you can see that your tax dollars have resulted in a very, very substantial improvement.

We have a huge way to go yet. We are obviously not perfect. We are happy to receive criticism. But this has been one of the most exciting changes in this province. It is a foundation now on which you can add module after module and I really give tribute to the thousands in this province who have joined together to make this happen. Thank you very much.

The appreciation of the meeting was expressed by George L. Cooke, President and CEO, The Dominion of Canada General Insurance Company, and Past President, The Empire Club of Canada.