Snakes and ladders: the barriers and facilitators of elective hip- and knee-replacement surgery in Australian public hospitals

Abstract

Objectives. Waiting lists for elective surgery are a persistent problem faced by health systems. The progression through elective surgery waiting lists can be likened to a game of snakes and ladders where barriers (snakes) delay access to surgery and facilitators (ladders) expedite access. The aim of the present study was to describe the barriers and facilitators to delivery of total hip-and total knee-replacement surgery in South Australian public-funded hospitals.Methods. Semistructured interviews with staff, direct observation of administrative processes and documentation analysis were combined under a systems theory framework.Results. System barriers (snakes) were grouped into five categories: resources, workload, hospital engagement, community engagement and system processes. Inadequate resources was the most prominent barrier, patient cancellations resulted in one-third of administrative tasks being repeated and there was a perceived lack of engagement to maximising efficiency. Interestingly, despite a lack of resources being perceived to be the biggest problem, additional resources without system change was not considered an effective long-term strategy.Conclusions. Given the complexity of the elective surgery system, it is not surprising that single-item reforms have not created lasting reductions in waiting times. Multifaceted, whole-system reforms may be more successful.What is known about the topic? Waiting lists and waiting times for surgery are controversial, associated with frequent reforms and negative emotive headlines. We know from existing literature and anecdotal reports that individuals frequently experience lengthy delays before receiving elective surgery. Anecdotal reports also suggest that there are inefficiencies within elective surgery systems that contribute to these delays and result in cancellations, patient deterioration and poor overall satisfaction with the public health system in Australia. What isn't clear is whether this perception is accurate and what inefficiencies do exist that could be specifically targeted for reform. What does this paper add? This paper adds weight to the argument that some inefficiencies exist within elective surgery systems, and identifies specific barriers to the delivery of total hip-and total knee-replacement surgery in South Australian public hospitals. It also identifies several strategies that could improve system function, some of which have already been implemented at a local level in response to stress on the system, and some of which require broad region-or state-wide change. In contrast to existing research, the level of detail provided in the present paper should allow for targeted reforms with the potential to improve system function and the efficiency with which joint-replacement surgery can be delivered. What are the implications for practitioners? All clinicians aim to provide the best intervention for their patients. Should the findings of this study be used to inform elective surgery system changes, patients and clinicians shoul...

Barriers and enablers to the implementation and sustainability of short‐stay arthroplasty programs for elective primary total hip and knee replacement: A systematic review with qualitative evidence synthesis

“…A TDF domain common to both patient and health professional themes was environmental context and resources. Consistent with previous literature (Walters et al., 2013), we found that staff shortages were perceived to be a major barrier to the successful implementation of short‐stay programs by health professionals. This barrier was described by patients as well and is supported in existing qualitative literature where patients describe difficulty arranging physiotherapy after hospital discharge following traditional care pathways for THR or total KR surgery (Webster et al., 2014).…”

Standardising the cataract referral process for public hospitals: perspectives of optometrists in New South Wales, Australia

“…In contrast, private hospitals will usually charge additional out‐of‐pocket costs for these services, some of which can be reimbursed if the patient has private health insurance. The public system offers the major benefit of little or no out‐of‐pocket expenses, but the waiting time is much longer due to resource limitations (including surgeon availability), and competition from emergency surgery and other elective specialties for operating theatre time …”

“…The public system offers the major benefit of little or no outof-pocket expenses, but the waiting time is much longer due to resource limitations (including surgeon availability), and competition from emergency surgery and other elective specialties for operating theatre time. 5,6 Faced with similar challenges, cataract prioritisation tools have been developed to improve transparency and equity of access to high-demand publicly funded services in other health system settings, such as the UK's Action on Cataracts' Referral Guidelines 7 and the Western Canada Waiting List cataract prioritisation tool. 8 Although application of the prioritisation tools increase the time to complete a referral from the optometrist, it may help them to better understand the referral pathway in a public system.…”

Measuring waiting times for elective surgery in public hospitals

“…The article by Walters et al 1 raised some very important points related to the problem of long elective surgery waiting lists in Australian public hospitals, including those related to the reporting of waiting lists being a poor indicator of quality for a health service. The number of people on a waiting list does not actually give any indication as to whether patients are being seen within clinically appropriate times, and only represents part of the patient's journey.…”

“…The paper by Walters et al 1 outlined several barriers to the delivery of timely elective surgery and called for targeted 'wholesystem' reforms to improve the efficiency in the delivery of this service. However, the true effect of these reforms on the quality of the service being provided cannot be adequately measured unless consistent and transparent capturing of clinically relevant waiting list data is introduced.…”