Still Waiting After All These Years

Canadians understand that when they require non-urgent health care, they will usually have to wait. They wait in emergency departments, they wait for diagnostic tests, they wait to see specialists, and they wait for surgery and procedures. When waits are appropriately brief, they feel confident and satisfied. When waits are too long, however, patients and their families experience anxiety, economic hardship, needless pain and suffering, and perhaps even more serious adverse events, including death.

A tremendous amount of effort and resources have been poured into the wait time dilemma over the past few years. While governments have contributed targeted funding, medical professional groups have developed evidence-based wait time benchmarks. The Wait Time Alliance (WTA), a federation of 14 national specialty societies and the CMA, has been particularly active in shedding light on these waits through the annual publication of a national report card. (You can check out these report cards at

While progress has undoubtedly been made, patients, providers and payers remain underwhelmed. Why are so many Canadians still so dissatisfied with their health care experience? Why does Canada still perform so poorly compared to other Western nations on important measures like ER wait times, access to primary care, access to surgical procedures, and access to long term care? After so many years of attention, we’re still waiting to see real, sustained improvement.

Part of the problem has been, and remains, the inability of our health care structures and organizations to function as a true system. Patients undergo health care experiences, or journeys, and these journeys are typically made up of many individual components spanning several settings. For example, one typical scenario might look like this:

A patient waits to see a family physician. She then waits for diagnostic tests, waits for a referral to another specialist, waits for more tests that the specialist ordered, waits for the results to come back, waits for a procedure or surgery, and then waits for rehab.

We often refer to a patient’s progression through this journey as patient flow.

As depersonalized as the term is, patient flow does reflect the dynamics of the process; it allows us to conceptualize the experience as one that is characterized by several different events occurring in series. The transition points between each component are often where the bottlenecks in flow are; it is at these bottlenecks where negative perceptions, inequities, and suboptimal outcomes are born. It is also where inefficiency and waste are generated. The Canadian Medical Association has estimated that waits exceeding medically acceptable benchmarks for just four key procedures cost the Canadian economy $14.8 billion dollars in 2007.

Despite the fact that patients are the customers (it’s about them, not us), and that it is the sum total of all of these events that comprise the whole health care experience, our institutions and organizations continue to function in silos. Our reporting structures and accountabilities are to these institutions, not to the patients. We are working vertically rather than horizontally.

How can we help our processes, structures, institutions, and organizations to do things differently?

We can start by acknowledging and measuring the patient journey in its totality. The process needs to be geared to navigate and coordinate patients through a real ‘system’, with full transparency about what constitutes reasonable and safe waits for each component. Patients would have the confidence that they are being “managed” through a continuum rather than being awkwardly shuffled from one silo to the next. This process would allow for real-time monitoring of the entire experience so that pressure points could be attended to in a timely way and so that proper comparisons can be made between political jurisdictions – those who are performing below benchmarks would be compelled to improve.

Shorter waits and better coordination between the care experiences that comprise the patient’s journey – that is how we can transform from a system that merely delivers excellence in episodic care to one that is truly accountable to the longitudinal patient experience.

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