Wednesday, April 01, 2009

Waiting Lists? What Waiting Lists?

Waiting in Line at the Eiffel Tower - gadl @ Flickr

It is hard to ignore the news in Victoria about waiting list manipulation. Ho hum. This is old news. If you want to know how to manipulate a waiting list, refer to my previous blog entry. Every few months a politician rants on about how waiting lists are down and everything is just dandy. Shortly after the opposition carries on about how waiting lists are going up and the sky is falling down. Then an election happens, and sometimes they swap sides... and guess what, the newly-elected government politician says waiting lists are down and the newly-ousted opposition says waiting lists are up and the cycle goes on.

At the bottom of all of this political to-ing and fro-ing is an army of doctors, nurses, and paramedical staff who try their level best to treat as many patients as possible with the money that they have been allocated. It's not a lot of money, and there are an unending stream of patients, but we do what we can.

And then in between this sandwich is a layer of bureaucrats who fiddle the numbers. The Department of Healthiness, or Human Servicing, or Ageing Gracefully, or whatever (let's call them The Department) look after the politics, and dole out the money. The Hospital Administrators hold out their hands and grab as much cash as they can. The line between The Department and The Hospital Administrators can be very grey and muddy. Some people work both sides of the fence.

It is an area of pragmatism and compromise. The Department asks for good media release material - reduced waiting lists, greater throughput, briefer ED waits. The Hospitals deliver. No-one asks how they deliver... they just do. If you ask for Key Performance Indicators (KPIs) then you will get KPIs. If this means fiddling the books, then you fiddle the books. What does it matter as long as patients are still treated exactly the same as they were before? The media release is just meaningless drivel. At the end of the day youse goes to the hospital and youse gets your operation (after a variable waiting period which is dependent on so many factors that understanding it all would take a PhD or a Masters Degree).

I admit that I have worked in Victorian Hospitals. At the request of Booking Office Managers I have signed off on forms making patients "Not Ready For Care". I have kept waiting list forms in my bag for two or three weeks before handing them in to the data-entry clerks. I have seen waiting list forms sit in a pile for several weeks waiting to be entered. Never has this process made any difference to how long a patient has physically waited for their operation - only the accounting. This is not isolated to a single hospital in Victoria - this happens in every hospital in Australia, and most likely around the world. The same thing happens in every large organisation or company world-wide. Don't be a hypocrite - if you are a manager you are probably doing exactly the same thing to your KPIs.

I once worked in a hospital where my manager would deliberately lose my overtime claim sheet for several pay periods in a row. After a few months she would find them all and pay my overtime, along with all of my colleagues in the same department. We thought she was incompetent until we realised that she got a monthly bonus if the salaries came in under budget. Once a quarter she would pay us out and forgo her bonus - but the other three months made up for it.

Where patients wait a long time for their operation there are generally only a limited number of reasons:
  1. Rate-Limiting Steps. There are only so many resources to do a particular operation, and everyone has to wait. This may mean waiting for investigation results, theatre allocations, specialty staff availability for complex operations, ICU beds, or special equipment for a particular operation. Basically all operations need critical planning and preparation steps to be performed first. If one of these steps cannot proceed, then it becomes a rate-limiting step.

  2. Administrative foot-dragging. This is where clinical or financial approval for a particular procedure takes a long time, or is difficult to organise. There is no excuse for this except lazy, procrastinating administrators who don't think anything needs to be done any earlier than the next committee meeting in 3 months time.

  3. Patient indecision. Some patients just cannot make up their mind. They want to go on the waiting list but they don't want their operation when you ring them up. "It's not convenient." "I'd rather wait until school holidays." "Let me do it when I come back from New Zealand." "I can't get time off work." These patients inevitably get upset that they have been waiting 5 years despite ringing them 20 times and they complain interminably, often to their local MP.

  4. Genuine stuff up. Sometimes forms get lost. Sometimes some poor data entry clerk spells a name wrong, or accidentally presses delete. Sometimes the doctor's handwriting is illegible. We don't like it when this happens, but it happens.
Waiting lists are a fact of life. Political maneuvering is a fact of life. Management data fiddling is a fact of life. Media beat-ups are a fact of life. Like Dr Simon Leslie of Shellharbour Hospital, I'd rather just get on with the job of fixing people.

We have an unhealthy obsession with statistics and numbers. Collecting data on every scrap of activity is the reason why hospitals have half the numbers of beds they had 20 years ago - they have all been converted to offices for data-collectors, administrators and managers. The administrators need administrators, and then they need auditors to oversee the administrators, and directors to supervise the auditors.

Why can't doctors and nurses just be given the money and the trust that they can go about their job treating as many patients as possible. So what if the waiting list is a bit longer this year, or a bit shorter? No amount of number juggling can hide a 5 or 10-year trend. Stop focusing on short term goals, stop using health statistics for political gain, and you will get accurate figures and more importantly the trust of your staff.

  • Hospital data fiddling raises national concerns - ABC Radio PM (Click to See)

  • Nothing but the truth - AMA Vic President Doug Travis (Click to See)

  • Minister orders hospital audits after dud figures - The Age (Click to See)

  • Audit slams phantom wards scam - The Age (Click to See)

  • Bullying, bottlenecks and death by a thousand paper cuts - SMH (Click to See)


Anonymous said...

I disagree with the assumption that waiting list manipulation doesn't change how long patients wait for operations.

If we use a lie (using stats) to say there is no waiting list problem then additional resources will not be allocated and ignore attempts at increasing real efficiency. This means that real waiting times may increase along with losses in quality of life, patient productivity, increased complications and increased cost of care. It’s not just the usual cost of the operation but all the related costs before and after that don’t show up in the hospital stats.

Differences in the delay of processing of forms will change the order when patients are seen.

Sheepish said...

Dear Anonymous (why are there so many people called Anonymous???),

I would agree wholeheartedly with you if the statistics were actually used for resource planning - unfortunately as far as I can tell they are only used as a political football. I am not saying that sitting on waiting list forms is a great thing to do, just that we live and work in a pragmatic world and have to get on with things.

I remember clearly in a chat with a friend who was government department lackey a few years ago why we don't look at more useful KPIs - the response was that there was no interest in measuring a KPI unless it was a number that could be improved upon and promoted in a media release.

Efficiency is squeezed to its limit already - there is no efficiency gain to be realised. The only thing to be gained is more capacity by capital investment - and this will never happen because placing a chokehold on capacity is the only way to limit ongoing costs!

Just like the logic that if we have fewer doctors the health budget will be smaller. Bugger the patients.

As for differences in delay of processing forms... all the forms for our specialty went through me. It didn't matter how long I sat on them, or when I put them on the list, or when I received them. I filled out the forms, I handled the forms, I reviewed the waiting list, and I booked and scheduled patients into theatre where I then operated on them.

Patients were prioritised by me on the basis of clinical need, resource availability, and waiting time came a very distant third. They were more frustrated by delays and cancellations non the day of operation than an extra week after 2 years of waiting. This is what happens every day in every hospital I have worked at. How about yours?