unintended consequences and wtms workshop on waiting time management strategies for scheduled health...

Unintended Consequences and WTMS

Workshop on Waiting Time Management Strategies for

Scheduled Health care

OttawaMarch 28, 2012

Marie-Pascale Pomey, MD, PhDJuan Carlos Sabogal, MD, MHA (c)

OUTLINE OF THE SESSION

1.Research project

2.Concept of Unintended Consequences

3.Individual task

4.Audience discussion

Unintended ConsequencesUnintended Consequences

Project 4: What Seems to Be Working (or not)?

• Objective: What are the determinants that can explain why a waiting time management strategies (WTMS) for total joint replacement (TJR) surgeries to respect federal benchmark in Canada is sustainable or not?

• Sub-objective: What are the potential Unintended Consequences of implementing those WTMS?


DEFINITION

“Unintended consequence refers to a particular effect of purposive action

which is different from what was wanted at the moment of carrying out the act, and the want of which was a reason for carrying it out”.

(Baert, 1991)


INTENDED vs. UNINTENDED CONSEQUENCES

INTENDED: Purpose and intention of actionGoals of any event (positive consequences)• Improved WT• Increase patients’ satisfaction

UNINTENDED: Lack of intention and purposefulness(positive and negative consequences)• Select non complex cases• Increase team innovation culture


DESIRABLE vs. UNDESIRABLE

CONSEQUENCESDESIRABLE CONSEQUENCES (Positive)* Improved WT• Work team• No increase in nosocomial infections

UNDESIRABLE CONSEQUENCES (Negative)* Increase in other WTs (neurosurgery, general

surgery)* Increase in medical complications


DIRECT vs. INDIRECTCONSEQUENCES

DIRECT: Changes that occur in immediate response to an event ( Rogers, 1995)

• Improved OR time for hip and knee surgeries.

INDIRECT: Consequence caused by a chain of events (Bloomrosen, 2011) “Consequences of consequences” (Rogers, 1995)

• Increase in OR time in other specialitiesUnintended ConsequencesUnintended Consequences

ANTICIPATED vs. UNANTICIPATED CONSEQUENCES

ANTICIPATED: Ability to forecast (positive or negative)

• Stress on staff• Tension among surgeons

UNANTICIPATED: Inability to forecast (positive or negative)

• Increase OR time for other surgeries• Role model of the program


ATTRIBUTES OF UNINTENDED CONSEQUENCES (Rogers, 1995; Bloomrosen et al. 2011)


DEFINITIONS

• Anticipated and desirable consequences: “Goals”: Objectives of a WTMS – Reduction in WT / WL

• Anticipated and undesirable consequences: “Trade-offs”: We accept that there are some likelihood effects in exchange for a greater good - Stress on staff.

• Unanticipated and desirable consequences: “Serendipities”: Happy surprises - Team cohesion.

• Unanticipated and undesirable consequences: Negative consequences that are not anticipated or expected (negative side effects) - Increase in WT for a surgeon consultation


THREE DIFFERENT LEVELS OF CONSEQUENCES


CONSEQUENCES AT THE FEDERAL/PROVINCIAL HEALTH CARE

SYSTEM LEVELExamples:

Budget: * Less budget for other areas (-) * No funding to sustain WT strategies in

the long term (-)

Waiting time: * Increased WTs in other specialities (-)

Health policies: * Less attention to other WTs, for example, neurosurgery,

general surgery, paediatric surgery (-)

* Used the same policy as a role model for different subjects (+

or -) Unintended ConsequencesUnintended Consequences

ORGANIZATIONAL LEVEL

REHABILITATIONSURGERYREFERRAL PROCESS


CONSEQUENCES AT THE ORGANIZATIONAL LEVEL

Examples:Pre-hospital: * Lack of knowledge of the

referral process by GPs (-) * Patients better informed

(+)

Hospital: * Team work in OR (+) * Decrease in OR time for

other specialties (-)

Post-hospital: * Lack of follow-up in the rehabilitation process (-)

* Patients' satisfaction (-/+)


CONSEQUENCES AT THE INDIVIDUAL LEVEL

Examples:Managers: * Increase personal and

professional Motivation (+)

Health Professionals: * Tension among surgeons (-)

* Stress on staff (-)

Patients: * Decrease in patients’ satisfaction (-)


WORKSHOP: Task

From your own experience, and based on the framework presented, can you share with us some examples of UCs in terms of:Could you fill in the worksheet

with some examples of…Trade-offs

SerendipitiesNegative UC


TIME CONSTRAINTS

Individual brainstorming : 10 min.

Audience discussion: 15 min.


WORKSHEET

ANTICIPATED AND DESIRABLE

“INTENDED or Goals”

ANTICIPATED AND UNDESIRABLE

“Trade-offs”

UNANTICIPATED AND DESIRABLE =

“Serendipities”

UNANTICIPATED AND UNDESIRABLE“UNINTENDEDor Negative”


THANK THANK YOUYOU

THANK THANK YOUYOUUnintended ConsequencesUnintended Consequences

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