Blog Post Eight

Written By John J. Maddigan

Our Uniquely Qualified Premier Is The Right Man For the Job!

 Newfoundland and Labrador are Uniquely Capable and Qualified to Succeed: From NL's Premier to Its Dedicated Healthcare Professionals

On August 17, 2023, the Government of Newfoundland and Labrador announced it was taking action to reduce surgical wait times based on the report from the Provincial Surgical Backlog Task Force. Minister Tom Osborne announced that the government would enact all 32 task force recommendations.

While announcements like these are standard for provincial governments across Canada this one is different. This Task Force's report focuses on surgical backlogs, and NL's Premier is a surgeon himself and knows better than any Premier in Canada HOW to enact this report.  

In addition, NL has a uniquely dedicated group of healthcare professionals to implement these 32 recommendations successfully. How do I know this? On more than one occasion, my sister's family physician called her after 8 pm to discuss her care. One time is a fluke, but repeatedly, and always after 8 pm tells me that her family physician works all day and then starts making her calls to patients - after she has put in a FULL DAY OF WORK. Yea, that's dedication! 

NL has a golden opportunity precisely because of our Premier's background as an accomplished surgeon. He is uniquely qualified to put NL at the forefront of fixing one of our healthcare system's most vexing problems, large and growing surgical backlogs. I'm confident he is up to the challenge and has the skill set to make this report a reality. Let's hope the financial resources are there to make this a seminal moment in NL's history.

Introduction

The Task Force's work is a well-written and thankfully brief report that gets right to the point. For those of you that haven't read the report, I'll give you a very brief summary of the highlights:

• Much of the reduced capacity to complete surgeries is due to severe shortages in nursing, allied health, and support staff.

• More than any other province NL has a large outward migration of young adults. Leaving the province with a disproportionate and escalating elderly population.

• In addition, NL is one of the provinces with the most significant burden of chronic diseases.

• Delays in surgery not only lead to lower patient satisfaction but creates an escalatory cost to the healthcare system.

• Surgical throughput occurs in three phases: pre-op evaluation, surgery, and post-op care/patient disposition and all phases must function harmoniously to avoid bottlenecks.

• The report also points out the need for better information gathering in a standardized format to make more informed decisions.

• Inadequate staffing of Long-Term Care homes has resulted in 20 percent of acute care beds (beds in hospitals) being occupied by patients that should be discharged to other facilities (see surgical throughput above).

The Task Force was asked to provide short- and long-term solutions to address the surgical backlog and new and innovative solutions to manage surgical wait times. Another critical mandate was to devise ways to target one-time funding from the Government of Canada to address surgical backlogs. 

The Report Itself

I won't get into all 32 recommendations, but if they take the Bill Gates approach to solving problems, the Ministry of Health will have a much easier time implementing the Task Force's recommendations. When Bill Gates tackled a significant new problem, he started with two questions: Who has dealt with this problem well? And what can we learn from them?

• All seven of the Task Force's Measuring and Monitoring recommendations should use the Bill Gates method for problem resolution. Someone has already dealt with these issues; let's not reinvent the wheel. These were the first seven recommendations, which should and can be addressed immediately. 

• Minister Osborne needs to gather a group of retired nurses and doctors that, with the aid of one administrative person, can track down solutions from around the world and put together recommendations within 60 days. Hell, I'd volunteer to help.

• The Operational Improvements will be more difficult and should be separated into at least two groups. One group must be handled by the government and the other by doctors and hospital administrators. Here's how I'd break down the recommendations so we know who should be held responsible and accountable.

• Recommendations 9, 15, 16, 17, 20, 24, and 25 should be dealt with by doctors and hospital administration.

• Recommendations 19, 21, 27 and 28 must be dealt with by both doctors/hospital administration and the government because funding is involved. 

• Recommendations 8, 10,11, 12, 13, 14, 15, 18, 22, 23, 26 likely should be handled by the provincial government.

• The Maximizing the Workforce recommendations should be split as follows: 29 and 31 government, 30 doctors/hospital administration and 32 both bodies.

But What Can Be Done Now?

Admittedly, 32 recommendations are a lot to deal with, so breaking them up in the way suggested above or in some manner is essential and must be done in parallel processes, not serially, as that would take too long.

As mentioned above, NL should see how other provinces deal with the same issues. One does not have to look far to see that Saskatchewan was in a similar position in 2009. Based on a review of the Saskatchewan Surgical Initiative (SSI), it looks like the Task Force did look at the SSI. Saskatchewan introduced the Saskatchewan Surgical Initiative to address its surgical backlog in March 2010. According to government reports, wait times dropped significantly over the next four years. For more details, click here to link to the government-issued report.  

One of the most controversial components of the SSI was the government's use of private clinics to deal with the backlog. Surprisingly the use of those private clinics saved the government money.  

With a reported backlog of 2330 ophthalmology surgeries, I recommend that virtually all these procedures be handled by private clinics as the vast majority of these procedures are likely cataract surgeries. This change would eliminate at least 25 percent of the overall backlog and free up surgical procedures with no private clinic option(i.e. hip replacement). These are usually same-day procedures where the patients go home the same day without any need to enter alternative care facilities. According to Dr. Ashley Behrens of Johns Hopkins Medicine, a routine cataract surgery takes 10-20 minutes to complete. Given this benchmark, NL’s backlog could be eliminated in five weeks with three surgeons working 10-hour days five days a week. Completely doable! Frankly, I don’t know how many ophthalmologists there are in St. John’s, my point is that if a true focus on surgeries was made the existing backlog could be cleared up in a reasonable time frame. The reality is that with better utilization of surgical time using the same assumptions, two doctors working 10 hours days performing surgery two days a week could eliminate the entire backlog in 20 weeks.

Some may argue with this, but difficult decisions must be made, and this is one of them. The other glaring statistic is the backlog of vasectomies, almost 1000. Here another difficult decision must be made. While these are completely elective procedures they can be performed quickly and without any need for much post-operative care. In addition, these surgeries are likely all same-day procedures that do not require alternative care post-surgery. While it may seem counterintuitive to prioritize completely elective procedures, many goals can be accomplished simultaneously:

1. A large proportion (10-12%) of the surgical backlog can be dealt with in as little as two weeks if six surgical suites are utilized at the Health Sciences facility, and a six-day surgical schedule is followed. This initiative would require only three urologists. The same assumptions as cataract surgeries were made for vasectomies.

2. Because a high percentage of the patients are young and healthy, they will require little post-op care and likely no beds required in ALC facilities as patients are discharged the same day as surgery and recover at home on the couch.

3. With no pressure on acute care beds for a two-week period from these 1000 surgeries, this will likely free up a number of acute care beds that will be required for the more invasive surgical procedures that will follow.

Let's do some math. If we could focus on performing only one type of surgery all day, every day for a two-week period all of the province’s backlog of vasectomies could be cleared up in just two weeks. If the same focus was applied to cataract surgeries three ophthalmologists working 10-hour days, five days a week could clear up that backlog in five weeks. NL could eliminate approximately 35 percent of its surgical backlog and be well-placed to take on procedures that put more stress on NL's healthcare system. This acceleration of surgeries will cost the taxpayers more in the short term but likely save even more in the long run. Logistically this would be very challenging but some version of this type of focus illustrates what can be accomplished..

I know surgical suites cannot be dedicated solely to one type of surgery for a protracted period of time at the expense of putting off all other procedures, the point is that with laser-like focus more can be achieved than is being accomplished currently. Based on current backlogs we need this type of focus.

The next recommendation the government should look at is number 18 – the use of ambulatory surgery centers (see ophthalmology surgeries mentioned above). Saskatchewan did this, and it helped significantly. In addition, the government may think of setting up one of these facilities exclusively for hip and knee replacements. A friend used a facility like this in Montreal and was extremely happy with the outcome. The Shouldice Hospital is another example of this type of facility.

Recommendation number 21 is an innovative solution to a significant potential bottleneck: establish anesthesia block rooms for procedures to maximize OR room utilization. I don't know if there is a shortage of anesthesiologists in NL, but this is an excellent way of eliminating this bottleneck.

Recommendation 26 amazed me. There is an UNOPENED surgical suite in the Janeway Hospital. I don't care how short of nurses NL is; we have to open this suite and let our young, energetic surgical nurses figure out how to make this work. With the proper support and data, I'm confident they can.

My Take

Let's give our government credit for seating this Task Force and the Task Force for their outstanding work. But now, the tough work begins. It begins by making some hard decisions that should start being made as early as Monday, August 22, 2023. But still, more work must be done.

The Task Force acknowledged the severe shortage of nurses but other than Recommendation Number 30, they have not suggested ways of dealing with the nursing shortage in the short term. The only answer is better utilization of the existing facilities and human resources ( Recommendation 19 addressing this in part).  The best opportunity for better utilization exists between the Janeway and Health Sciences facilities because of their close proximity.

I'm confident I don't have all the answers to NL's surgical backlogs. However, other institutions have looked at the problem of surgical backlogs extensively. Kaiser Permanente of California studied how to reduce the turnover time between surgical procedures. The study, Decreasing Operation Room Turnover Time: A Resource Neutral Initiative, showed that turnover time was reduced by 35% by focusing on parallel processing (assuming appropriate staffing levels) and enhanced communication.  

Another study in NYC, Improving Operating Room Turnover Time in A New York City Academic Hospital via Lean, reported similar results.

Recommendation 28 discusses the need for a Lean Team, so I hope this is what the Task Force had in mind. This revelation brings up a question. Why doesn't the Janeway always have a "standing" Lean Team in place to review every process? But that's another matter.

Other ways to increase surgical room and human resources utilization could be to look at the various surgical scheduling methods like Block Scheduling and combine those with Recommendations 3, and 4 of the Task Force.  

There also needs to be a much better use and collection of data to ensure that goals are being met, and analytics are being used to improve the system every day.

Clearly, many steps can be taken immediately to reduce the surgical backlog in NL, and Premier Furey is the perfect person to make this happen.

If the Premier can make this happen, it can be a model that could be emulated across Canada and likely worldwide. The next step the Health Minister MUST TAKE immediately is to put someone in place to implement the Task Force recommendations – a recently retired surgeon would be my pick!

 Transforming Canada’s Healthcare System one day at a time.