Critical Intelligence Unit

Approaches to reduce surgical waiting time and waitlist: Living evidence

Living evidence tables provide high level summaries of key studies and evidence on a particular topic. They include links to sources and insights into ‘best bets’ for improvement. They are reviewed regularly and updated as new evidence and information is published.

Background

Surgery waiting time refers to the time between a patient’s addition to the surgery waiting list on to their admission to the hospital for surgery.1 In Australia, the measurement of waiting time excludes the time between general practitioners' referral to a specialist outpatient appointment and assessment; and any time spent not ready for surgery, i.e. pending improvement of clinical condition, awaiting a follow-up surgery (staged) which is planned for a certain time after or deferred for personal reasons.2, 3 Surgery waiting list refers to the number of people registered on the list to be admitted for a surgical procedure.*

This living table lists strategies identified in the peer-reviewed and grey-literature with evidence of feasibility and an association with a reduction in waiting times and hospital procedure waiting lists. Literature on surgery waiting time management comprises mostly observational or descriptive studies and lacks robust randomised controlled trials or rigorous comparative studies. However, within the context of health policy research, observational studies are often considered to provide acceptable evidence of effectiveness.

Strategies to reduce waiting time are often introduced as a package and can be influenced by interrelated cultural, environmental, operational and practical factors, such as leadership, engagement, treatment pathways and processes for waitlists or operating rooms.4 Therefore, it can be difficult to quantify the effect of a single measure from others.

Evidence to date points to a system-wide, multi-component and targeted, i.e. by identifying root causes, where actions are needed or bottlenecks, approach to achieving a sustainable and long-term reduction in waiting times and attaining an optimal balance between supply and demand for surgical services.4, 5

Notes on methods

Defining policy and intervention effectiveness: an association with an improvement (either as a standalone or bundled intervention) in direct indicators of waiting time and waitlist, i.e. time to surgery and size of the waiting list; or indirect indicators such as referral rates, cancellation rates, no-show rates, operating room efficiency, bed occupancy, length of hospital stay and early discharge. Policy effectiveness can also be defined as “the extent to which a policy is able to give affect to its stated goals”.6

Strength of evidence is rated as follows:

  • Consistent positive evidence of effectiveness
  • Limited but promising evidence of effectiveness
  • Mixed evidence on effectiveness
  • Not possible to determine—no information on impact found
  • Consistent negative evidence on effectiveness

* Because waiting list generally do not include waits for specialist outpatient appointments, they cannot be used as a measure of community surgical demand or community waiting time for treatments.

Regular checks are conducted for new content and any updates are highlighted.

StrategiesEvidence on effectLevers for and influencing factors on effectiveness

Increasing supply

Expanding capacity through human and material resources to increase surgical activities

Additional funding – additional funding, particularly in the short-term, has been used to:

  • purchase additional elective procedures from the private sector
  • increase staffing levels –  particularly for surgical sessions
  • invest in facilities, information technology and beds
  • expand diagnostic capacity.4, 7

Across jurisdictions including Canada, UK and Ireland where additional and targeted funding has been allocated to increase surgical activity, varying degrees of success in reducing wait times and waitlists have been reported.8-11

  • Targeted funding, i.e. identifying areas where additional funding is most needed, is more likely to result in immediate and sustainable gains in reducing waitlists.4, 7
  • Funding can be in two forms:
    • Conditional funding – funding or incentives based on performance or on condition that certain targets are met.12
    • Unconditional funding – incremental funding without any conditions or restrictions.5
  • Conditional funding has been shown to be more effective than unconditional funding.5
  • Funding schemes that incentivise lower waiting times, waitlist, hospital length of stay, readmission rates and mortality, without risk adjustment for patient characteristics, can risk inadvertently introducing patient selection bias or patient composition effect.13-16
  • Both immediate and short-term funding to reduce the size of waiting lists and long-term funding for sustained reduction and system resilience are being implemented across many jurisdictions with promising results.5, 10, 17

Publicly funded, privately delivered services – there is consistent positive evidence of effectiveness for select procedures, e.g., surgeries and services identified as being low-complexity high volume, as well as imaging and diagnostic testing.7, 8, 18

  • Studies from Canada and England suggest that publicly funded, privately delivered services can be associated with increased socioeconomic disparity in access and geographical inequalities without heightened oversight.20, 21

Encourage the take-up of private health insurance – there is weak and mixed evidence on its effectiveness.

  • Studies from Australia and Canada suggest a positive association with reduced waiting times for privately insured patients; however, the impact on waiting time for public patients is mixed or even negative if privately insured patients are prioritised in the public system.5, 7, 22, 23
  • A 2023 report from Australia suggests that raising private health coverage to reduce the waiting times in public hospitals is ineffective and impractical.24

Multiple evidence reports identify key lessons for leveraging private sector capacity to reduce the surgical waitlists.

  • Transparent and open procurement and regulatory frameworks for outsourcing from private services, as well as specific targets to cut waitlists, can help to ensure greater accountability.18, 25
  • Agreements to ensure adequate patient care or full cycle of care in the private sector can help to avoid patients returning to the public sector for incomplete care or follow-up.17, 26
  • In some countries such as France and Ireland, specific measures such as incentives to work exclusively in public sectors were offered to clinicians to prevent staff from shifting to the private sector due to increased publicly funded privately delivered services.17
  • Standardised prioritisation systems based on evidence-based criteria, i.e. clinical need, can be used across sectors or disciplines to ensure equitable access to care regardless of patient socio-economic or insurance status.27, 28

Expanding workforce – there is consistent positive evidence of its effectiveness. Specific strategies being implemented across multiple countries include:

  • increasing training positions for roles that are experiencing a shortfall
  • accelerating career progression of junior doctors
  • delaying retirement
  • improving staff retention.4, 17, 29

Insufficient numbers of qualified workforce and those in the pipeline can be a limiting factor for system's capacity to address the surgical backlog. Short- and long-term workforce actions have been adopted in many jurisdictions with:

  • A prognostic assessment of future staffing demands at the national, regional and local levels can help to develop informed and coordinated workforce strategies and improve uptake and implementation.
  • Improvement of the working conditions of staff helps to avoid burnout and absenteeism.17, 29
  • Team reconfiguration and skill mix within workforces can help to redistribute tasks across the team and systems to increase efficiency.
  • Technology such as artificial intelligence can help to improve workforce productivity, reduce the workforce demand for repetitive administrative tasks and provide decision support.30-32

Expanding roles for non-physicians – consistent positive evidence of effectiveness, particularly when tasks related to preadmission services are shifted to nurses.7, 33 Emerging positive evidence on task shifting from specialist surgeons to primary care providers and allied health professionals for minor low complexity surgeries, including:

  • nurses performing minor or low complexity procedures such as biopsies, hysteroscopy, and carpal tunnel syndrome procedures7, 34
  • general practitioners performing minor surgeries - associated with minimal referrals and reduced waiting list35
  • specialist sonographers performing head and neck ultrasound fine-needle aspiration cytology instead of an oncologist – associated with shortened waiting list.36

There is evidence and expert consensus that effective implementation of expanding roles for non-physicians requires:

  • linkage and integration with the educational system with updated curricula or additional workforce-based training
  • regulatory adjustments and review of respective scope-of-practice laws
  • consideration of appropriate payment mechanisms
  • clinical guidelines and structured protocols to standardise clinical practices30, 37, 38
  • technology to enable remote consultation between different providers.39

Managing demand

Reducing and managing the need for surgical services

Value-based care – there is limited yet promising evidence of effectiveness, particularly for strategies including:

  • de-funding – associated with a reduction in publicly funded care for procedures that were categorised as low value40
  • targeted education for clinicians and patients.41

An online tool predicting improvement in quality of life did not have a significant effect on patients’ willingness for surgery, their treatment preference, or the decision quality.42

There is evidence that the effective implementation of value-based care and reduction of surgical procedures identified as potentially low-value will require:

  • evidence-based clinical guidelines to guide implementation and monitoring of clinical variations across both the public and private service providers
  • payment mechanisms that discourage the surgical procedures identified as potentially low-value and incentivise guideline adherence and provision of high-value care
  • transparent, informed and shared decision-making for the cohort of patients where there is an indication for a procedure being of potentially low value.28, 43

Review and standardisation of referral criteria – there is limited yet promising evidence of effectiveness in reducing inappropriate referrals, the number of patients being added to the waitlist, and the waiting times, especially at the primary to specialist care interface.19 This strategy has been associated with an estimated 10% reduction in volume capacity.10

  • Regular evaluation of the referral criteria and threshold for onward addition to the waiting list with clinician engagement can help to identify patients who could be better managed in the primary care or other alternative settings.
  • Collaborative learning system with primary care and community service providers can ensure that relevant providers are up to date with current evidence and thresholds for referral.4, 28

Active waiting – there is limited yet promising evidence of success in reducing the demand for surgeries.

  • Ongoing engagement and encouragement of primary care management while waiting – patients who improved to be removed from the waitlist; and patients waiting for surgical procedures identified as potentially low-value to be referred to alternative models of care.
  • Promoting self-management.
  • Remote monitoring.4, 27, 44
 

Waitlist management

Processes for adding and managing patients who are currently on the waitlist

Referral process – there is consistent positive evidence of effectiveness, particularly for the electronic referral systems that support the attachment of documents, i.e. photography, images, test results.4

Triage and prioritisation – consistent positive evidence of effectiveness in reducing waiting times especially when done at the referral stage.43, 45, 46 It has also been associated with better benchmarking and improved practices.7 Commonly used strategies include those based on:

  • clinical parameters, need and/or urgency
  • urgency and ability to benefit
  • urgency and social and economic considerations
  • patient choice for a provider or geographical mobility.
  • other criteria such as certain high-priority conditions or length of time spent on the waiting list.4, 7, 8, 25, 27, 47
  • Standardised triage, prioritisation tools and methods across the system can help to ensure transparency and equity in waitlist management.4, 27, 43, 47-51
  • Recent developments have explored using dynamic modelling or augmented intelligence to assist patient prioritisation based on risk prediction:52-55
    • A recent Australian study explored the use of a dynamic priority scoring system to prioritise patients on the waiting list based on both the time waited and clinical factors. This system demonstrated the potential to reduce subjectivity in previous systems and increase transparency and efficiency.53
  • Universal prioritisation tools with vertical (across multiple disciplines) and horizontal (within the individual discipline) equity could potentially help reorder patients on waiting lists.43

Centralised queue waiting list – there is consistent positive evidence of effectiveness in reducing waitlist and promoting utility and equity.27, 56 This approach matches the patient to the next available provider following prioritisation.27 Strategies include:

  • single entry models
  • pooled waiting lists
  • equalisation of waiting lists between providers for the same procedure in the same facility and then expanding to between facilities for reasons of equity.4, 27, 57

This approach has been shown to reduce waitlist mortality, increase the number of procedures performed and improve one-year post-surgery survival for heart transplantations.58

Decentralised surgical care – there is limited yet promising evidence of effectiveness. This involves tertiary hospitals partnering with community hospitals with pre-existing relevant surgical programs. This approach transfers select low-acuity patients, primarily targeting the longest-waiting cases, from the tertiary hospital waitlists to partner hospitals closer to the patients' home.59

This strategy has been implemented in multiple jurisdictions with the following factors being identified as key facilitators of success:

  • information technology infrastructure27
  • guidelines and regulations.
  • physician, community and patient engagement and promotion of  acceptability.56
  • team-based, cooperative, and shared surgical care among a group of providers.27
  • encouragement of private providers to join the centralised waitlist management.27

Critical success factors for this strategy include:

  • interprofessional team commitment and engagement
  • investment in resources and infrastructure for sustainability
  • ongoing evaluation and continuous program improvement
  • collaborative partnerships59

Regular validation of waiting lists – there is limited yet promising evidence of effectiveness. This involves regular assessment of patient conditions, auditing waitlist, keeping patient information up to date and progressing patients along the list accordingly. Strategies include:

  • administrative validation – improving data accuracy and reducing non-attendance10
  • clinical validation – assessing patient conditions, need for change in prioritisation category or need for additional tests10
  • removing patients that no longer need or are eligible for the surgery4
  • identifying patients who are ready to proceed with procedures.10

There is evidence and expert consensus that the following actions will likely increase the effectiveness and efficiency of waitlist validation process:

  • targeting surgeries identified as potentially low-value, high-cost for reassessment27
  • regular reassessment of patients on the waiting list with long waits to ensure that the procedure is still required, and priority has not changed10
  • regular review of the waitlist of individual surgeons so that other strategies such as pooling or collaborative care can be considered.27

Monitoring – there is a lack of evidence specifically addressing the impact on waiting times and waitlists, however, it is often used for benchmarking, comparison and quality improvement.7, 43 Strategies include:

  • Collection and analysis of waiting list data
  • Reporting and feedback.4

Auditing, performance monitoring and reporting of facilities, units and/or providers for waitlist data accuracy and reasons for cancellations can help to:60-63

  • develop targeted strategies to reduce inefficiencies.
  • prevent avoidable cancellations.

Preoperative management

Optimising patient's clinical conditions, and preparing patients for what to expect before, during and after the surgery

Proactive clinical assessment – there is consistent positive evidence of effectiveness in reducing cancellations, no-show and subsequently improving efficiency and reducing waitlist.7, 43

  • Preadmission clinics or preanaesthetic assessment clinics have been associated with a reduction in cancellation rates and discharge delays in clinically appropriate patients.64, 65
  • Nurse-led preoperative clinics or nurse-led assessments in low-risk and appropriate patients were associated with a reduction in cancellations.59, 66
  • Virtual preadmission services such as virtual assessment, web-based questionnaires or virtual support lines had limited yet promising evidence for reducing waiting time and waitlist.7, 67

Effective preoperative management requires the following:

  • workforce and administrative support
  • education and training for nurses
  • streamlined preadmission processes and pathways
  • clinical guidelines and protocols to ensure patients are appropriately reviewed and unnecessary tests are avoided.7, 60, 67, 68

Patient education – there is limited yet promising evidence for effectiveness, particularly for optimising patient conditions prior to scheduled procedures, reducing cancellation and delay rates and improving patient-reported outcomes. Strategies include:

  • support line – telephone or online live support
  • online information – web information, online virtual classes
  • digital apps – personalised information, navigation tools, virtual reality-based apps and reminders67, 69, 70
  • patient reminders– telephone, text or app reminder.4, 71
 

Treatment space management

Arrangement and management of physical infrastructure where the care is delivered

Elective surgical hubs – there is consistent positive evidence ofeffectiveness. These hubs have been implemented in multiple countries as a key strategy to reduce the waiting list, with varying degree of success.10, 17, 67, 72-74 The hubs separate elective care from emergency care and mainly focus on high volume low complexity procedures. Models include:

  • located within the hospital – ring-fenced space, beds4 and capacity73
  • stand-alone hub – on a separate site to the hospital
  • specialist hospitals or hubs – stand-alone locations focusing on one specialist surgery and often treating high-complexity and high-priority cases72
  • day surgery centre – dedicated site for day case surgeries.75, 76

A 2024 NHS-commissioned evaluation estimates that surgical hubs could significantly increase treatment volumes by around 11%, and were having systemwide effects on elective care that supported their continued expansion.73

One-stop centres – there is limited yet promising evidence of effectiveness in reducing patient visits, referrals and increasing efficiency.67, 77 Key features include consultation, diagnosis, care plan and sometimes treatment in almost a single visit.78, 79

Evidence from the UK suggests that surgical hubs require:

  • truly protected, ring-fenced resources
  • adequate workforce planning and staffing
  • adequate pre-operative and discharge planning and information provided to patients
  • appropriate location, considering equity access, convenience and travel time for patients
  • shared learning across surgical hubs
  • robust governance and performance measurement
  • regular monitoring and evaluation of benefits and unintended consequences.72, 75

Operating theatre efficiency

Optimising operating theatre room capacity to process an optimum number of procedures without compromising safety and quality

Operating room scheduling and time allocation – there is consistent positive evidence of effectiveness for the following strategies:

  • separation of emergent and unscheduled surgery from planned surgery17, 72, 80
  • high volume low complexity programme – dedicated list for straightforward cases67
  • specialised high-throughput lists67
  • high intensity theatre (HIT) lists11, 81
  • block schedule – service-specific or surgeon specific
  • split blocks
  • open blocks for add-on surgical cases
  • golden patient approach, i.e. the most medically fit patient is placed first on the list82
  • schedule patients requiring inpatient beds postoperatively as late in the block as possible
  • post anaesthesia care unit flow83, 84

The Getting It Right First Time (GIRFT) in England recommends the following actions to increase theatre capacity and utilisation to reduce the waiting times for children and young people. These actions are backed by best practice case studies.

  • Running dedicated paediatrics lists or operating days.
  • Adding extra sessions or ‘super-days’ for children’s surgery, especially those with high volumes.
  • Sharing capacity across systems including elective surgery hubs.
  • Booking the recommended number of cases per session.
  • Increasing efficiency of flow with safe expedited discharge protocols.
  • Staggering children’s admission times for surgery.85

Technology-enabled theatre scheduling systems – there is emerging evidence of effectiveness in improving operating theatre efficiency.86

There is evidence and expert consensus that the following contextual and cultural factors can help to improve the operating theatre efficiency:

  • performance monitoring
  • staff feedback and education
  • team briefings and morning huddles
  • changes to the surgeon's traditional model of placing major cases first on the list
  • quality improvement initiatives – including but not limited to plan-do-check-act and plan-do-study-act cycles, continuous quality improvement, statistical process control, total quality management, Six Sigma, Lean and Lean Six Sigma87
  • standard operating procedures (SOPs)82, 88
  • checklists to improve team cooperation88
  • data-driven emergency versus planned surgery caseload prediction to inform staffing and strategic planning80, 89
  • artificial intelligence – machine and deep learning models82-84, 90-92
  • careful planning at multidisciplinary meetings to select suitable staff and patients for high-intensity theatre (HIT) lists11, 93, 94

Postoperative management

Supporting patient’s early recovery and early discharge home

Bed management – there islimited but promising evidence for effectiveness in improving patient flow. Strategies being piloted include:

  • electronic bed management95
  • Just-In-Time bed-assignment strategy – assigning ready-beds to ready-to-move patients instead of preassigning beds.96
  • Enhanced digital infrastructure for real-time bed vacancy prediction and management within the hospitals can help to increase postoperative recovery capacity.67

Early discharge home, same-day surgery and enhanced recovery after surgery (ERAS) –there isconsistent positive evidence of effectivenessinimproving patient flow, reducing hospital length of stay, readmissions and costs.97-100 Key elements include:

  • improved anaesthesia and surgical practices
  • criteria led discharge
  • early mobilisation
  • early discharge
  • remote consultation
  • care coordination.4, 27, 100, 101

Key enablers for implementation of early supported discharge include:

  • clinical guidelines, standardised models of care and protocols102
  • adaptation of models to fit local contexts98, 103
  • primary care provider, patient and carer engagement and education101
  • facility monitoring for quality outcomes.101

Virtual wards or hospital-at-home – there is limited yet promising evidence of effectiveness, particularly for:

  • postoperative recovery at home with virtual support or hybrid support67, 104
  • preoperative virtual monitoring of patient vital signs before admission for surgery for select conditions, i.e. acute cholecystitis, freeing up bed occupancy.105

Key enablers of success include:

  • providing patient information, addressing acceptance and inequality to access
  • clinical pathways for virtual ward discharge.67, 104

Performance management

Improving efficiency and productivity by increasing accountability and using financial incentives

Setting targets –thereis consistent positive evidence of effectiveness and this approach has been implemented across multiple countries.5, 17 Strategies include:

  • maximum waiting time guarantee for patients – can be conditional or unconditional, stronger evidence for conditional targets
  • explicit targets for waiting time and waitlist reduction for systems and providers.8, 10

The enablers for implementation include:

  • monitoring of performance against key waiting time metrics
  • centralised oversight and performance management
  • setting ambitious yet achievable targets for direct indicators such as waiting times and waitlist as well as other indirect indicators such as same day surgery rates and length of stay ensuring long-term sustainability with recurrent
  • funding and enforcement.4, 5, 17, 43

Performance linked to payment and/or incentives – there is consistent positive evidence of effectiveness, especially for reducing waiting time to surgery, increasing day surgery rates and improving other quality and safety outcomes.106, 107

  • Pay-for-performance mechanisms – a payment mechanism in which healthcare facilities, units or individual providers receive conditional funding based on specific predetermined criteria or targets.108 Pay-for-performance strategies include:
    • payment withheld
    • reward or bonus
    • penalty
    • a combination of above.108
  • Broad outcome-based payment models (a combination of global budgets, risk sharing, and financial incentives based on quality indicators) – more likely to result in favourable quality improvement outcomes than narrow outcome-based payment models (financial incentives only).109
  • A combination of non-financial and financial policy measures, such as permission of providers to perform and bill defined services as day cases, introducing target shares, and financial incentives, are found to have an overall positive effect in increasing the day surgery rate in multiple countries.110

A 2016 systematic review on pay-for-performance implementation found that the following factors are likely to support the effective implementation of such programs:

  • emphasising measures that target process-of-care or clinical outcomes
  • transparent and evidence-based target setting and payment mechanisms
  • careful consideration for incentive size, frequency and target – schemes that reward lower mortality, readmissions rates, length of stay and/or waiting times without risk adjustment for patient characteristics risk inadvertently introducing patient selection bias or patient composition effect
  • targeting areas of poor performance
  • flexibility and adaptability to change over time.16

References

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Notes

* Preliminary data, not fully established, in some cases small numbers or short follow up; interpret with caution

^ Commentary, grey literature, pre peer review or news

The "last updated" date refers to the date when the evidence was last reviewed.

Living evidence tables are based on a simplified review method and may not be entirely exhaustive but aim to provide a balanced assessment of what is already known about a specific problem or issue. They include some links to low quality sources and an assessment of the original source has not been undertaken. Sources are monitored regularly but due to rapidly emerging information, tables may not always reflect the most current evidence. The tables are not peer reviewed, and inclusion does not imply official recommendation nor endorsement of NSW Health.

Last updated on 7 Jan 2026

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