Approaches to reduce surgical waiting time and waitlist

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.

Strategies	Evidence on effect	Levers for and influencing factors on effectiveness
Increasing supply Expanding capacity in the form of 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 – in particular 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 degree of success in reducing wait times and waitlists has been reported.^{8, 9}¹⁰	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 met¹¹ Unconditional funding – incremental funding without any conditions or restrictions⁵ 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.^12-15 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, 16}
	Publicly funded, privately delivered services – there is consistent positive evidence of effectiveness for select procedures, e.g., surgeries and services identified as high volume low complexity, and imaging and diagnostic testing.^{7, 8, 17} Encourage the take-up of private health insurance – weak and mixed evidence on effectiveness. Studies from Australia and Canada suggest a positive association with reduced waiting times for privately insured patients; however, the impact on waiting times for public patients is mixed or even negative if privately insured patients are prioritised in the public system.^{5, 7, 18, 19} A 2023 report from Australia suggests that raising private health coverage to reduce the waiting times in public hospitals is ineffective and not practical.²⁰	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.^{17, 21} 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.^{16, 22} In some countries such as France and Ireland, specific measures such as incentives to work exclusively in public sectors were offered to clinicians to avoid staff being shifted out to the private sector as a result of increased publicly funded privately delivered services.¹⁶ 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.^{23, 24}
	Expanding workforce – consistent positive evidence of 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, 16, 25}	Insufficient numbers of qualified workforce and those in the pipeline can be a limiting factor for system capacity to address the surgical backlog. Short- and long-term workforce actions have been adopted in many jurisdictions. 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.^{16, 25} 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.^26-28
	Expanding roles for non-physicians - consistent positive evidence of effectiveness, particularly when tasks related to preadmission services are shifted to nurses.^{7, 29} 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 procedures^{7, 30} general practitioners performing minor surgeries - associated with minimal referrals and reduced waiting list³¹ specialist sonographers performing head and neck ultrasound fine-needle aspiration cytology instead of an oncologist – associated with shortened waiting list.³²	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 practices^{26, 33, 34} technology to enable remote consultation between different providers.³⁵
Managing demand Reducing and managing the need for surgical services	Value-based care – 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 value³⁶ targeted education for clinicians and patients.³⁷ 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.³⁸	There is evidence and expert consensus that effective implementation of value-based care and reduction of surgeries 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 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 a clinical indication for a procedure being potentially low value.^{24, 39}
	Review and standardisation of referral criteria – limited yet promising evidence of effectiveness in reducing inappropriate referrals, and subsequently the number of patients being added to the waitlist. 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 can be better managed in the primary care or other alternative settings. Collaborative learning system with primary care and community service providers can ensure relevant providers are up to date with current evidence and thresholds for referral.^{4, 24}
	Active waiting – 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 surgery identified as potentially low-value to be referred to alternative models of care Promoting self-management Remote monitoring^{4, 24}
Waitlist management Processes for adding and managing patients who are currently on the waitlist	Referral process – consistent positive evidence of effectiveness, in particular for the electronic referral systems which 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.⁴⁰ It has also been associated with better benchmarking and improved practices.⁷ Commonly used strategies include: based on clinical parameters, need and/or urgency based on urgency and ability to benefit based on urgency and social and economic considerations based on patient choice for a provider or geographical mobility.^{4, 7, 22, 24, 41} based on other criteria such as certain high-priority conditions or length of time spent on the waiting list⁸	Standardised triage, prioritisation tools and methods across the system can help to ensure transparency and equity in waitlist management. ^{4, 24, 41, 42} There have been recent developments in using dynamic modelling or augmented intelligence to assist patient prioritisation based on risk prediction:^{43, 44} 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 a potential to reduce subjectivity in prior systems and increase transparency and efficiency.⁴⁴
	Centralised queue waiting list – consistent positive evidence of effectiveness in reducing waitlist and promoting utility and equity.^{24, 45} This approach matches the patient to the next available provider following prioritisation.²⁴ 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, 24, 46}	This strategy has been implemented in multiple jurisdictions with the following factors being identified as key facilitators of success: Information technology infrastructure²⁴ Guidelines and regulations Physician, community and patient engagement and promotion of acceptability⁴⁵ Team-based, cooperative, and shared surgical care among a group of providers²⁴ Encouragement of private providers to join the centralised waitlist management²⁴
	Regular validation of wait lists – limited yet promising evidence of effectiveness. 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 procedures¹⁰	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 reassessment²⁴ Regular reassessment of patients on the waiting list with long waits to ensure that 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 considered²⁴
	Monitoring – lack of evidence specifically addressing the impact on waiting times and waitlist, however, often used for benchmarking, comparison and quality improvement.⁷ Strategies include: Collection and analysis of waiting list data Reporting and feedback⁴	Auditing, performance monitoring and reporting of facilities, units and/or providers for waitlist data accuracy and reasons for cancellations can help to:^47-50 develop targeted strategies to reduce inefficiencies prevent avoidable cancellations.
Preoperative management Optimising patient clinical conditions, preparing patients for what to expect before, during and after the surgery	Proactive clinical assessment – consistent positive evidence of effectiveness in reducing cancellations, and no-show and subsequently improving efficiency and reducing waitlist.⁷ Strategies include: Preadmission clinics or preanaesthetic assessment clinics have been associated with a reduction in cancellation rates and discharge delays in clinically appropriate patients.^{51, 52} Nurse-led preoperative clinics or nurse-led assessments in low-risk and appropriate patients were associated with a reduction in cancellations^{47, 53} 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, 54}	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, 47, 54, 55}
	Patient education – 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 reminders^{54, 56, 57} Patient reminders– telephone, text or app reminder^{4, 58}
Treatment space management Arrangement and management of physical infrastructure where the care is delivered	Elective surgical hubs – consistent positive evidence ofeffectiveness. Implemented in multiple countries as a key strategy to reduce the waiting list, with varying degree of success.^{10, 16, 54, 59} 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 and beds⁴ 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 cases⁵⁹ Day surgery centre – dedicated site for day case surgeries⁶⁰ One-stop centres – limited yet promising evidence of effectiveness in reducing patient visits, referrals and increasing efficiency.^{54, 61} Key features include consultation, diagnosis, care plan and sometimes treatment in almost a single visit.^{62, 63}	Evidence from UK suggests that surgical hubs require: truly protected, ring-fenced resource adequate workforce planning and staffing adequate pre-operative and discharge planning and information provided to patients appropriate location, taking into account 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.^{59, 60}
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 –consistent positive evidence of effectiveness for the following strategies: Separation of emergent and unscheduled surgery from planned surgery^{16, 59} High volume low complexity programme – dedicated list for straightforward cases⁵⁴ Specialised high-throughput lists⁵⁴ High intensity theatre (HIT) lists⁶⁴ Block schedule – service-specific or surgeon specific Split blocks Open blocks for add-on surgical cases Golden patient approach, i.e. most medically fit patient to be the first on the list⁶⁵ Schedule patients requiring inpatient beds postoperatively as late in the block as possible Post anaesthesia care unit flow^{66, 67} The Getting It Right First Time (GIRFT) in England, UK 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 surgery⁶⁸ Technology-enabled theatre scheduling systems – emerging evidence of effectiveness in improving operating theatre efficiency.⁶⁹	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 major case 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 Sigma⁷⁰ Standard operating procedures (SOPs)^{65, 71} Checklists to improve team cooperation⁷¹ Data-driven emergency versus planned surgery caseload prediction to inform staffing and strategic planning⁷² Artificial intelligence – machine and deep learning models^{65-67, 73}
Postoperative management Supporting patient’s early recovery and early discharge home	Bed management – limited but promising evidence for effectiveness in improving patient. Strategies being piloted include: electronic bed management⁷⁴ Just-In-Time bed-assignment strategy – assigning ready-beds to ready-to-move patients instead of preassigning beds.⁷⁵	Enhanced digital infrastructure for real-time bed vacancy prediction and management within the hospitals can help to increase postoperative recovery capacity.⁵⁴
	Early discharge home, same-day surgery and enhanced recovery after surgery (ERAS) – consistent positive evidence of effectivenessinimproving patient flow, reducing hospital length of stay, readmissions and costs.^76-78 Key elements include: criteria led discharge early mobilisation early discharge remote consultation care coordination.^{4, 24, 79}	Key enablers for implementation of early supported discharge include: clinical guidelines, standardised models of care and protocols ⁸⁰ adaptation of models to fit local contexts^{77, 81} primary care provider, patient and carer engagement and education⁷⁹ facility monitoring for quality outcomes.⁷⁹
	Virtual wards or hospital-at-home – limited yet promising evidence of effectiveness, particularly for: postoperative recovery at home with virtual support or hybrid support^{54, 82} preoperative virtual monitoring of patient vital signs before being admitted for surgery for select conditions, i.e. acute cholecystitis, freeing up bed occupancy.⁸³	Key enablers of success include: providing patient information, addressing acceptance and inequality to access clinical pathways for virtual ward discharge.^{54, 82}
Performance management Improving efficiency and productivity by increasing accountability and using financial incentives	Setting targets –consistent positive evidence of effectiveness and implemented across multiple countries.^{5, 16} 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.^{4, 5, 16}
	Performance linked to payment and/or incentives – consistent positive evidence of effectiveness, especially for reducing waiting time to surgery, increasing day surgery rates and improving other quality and safety outcomes.^{^{84, 85}} Strategies include: 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.⁸⁶ Pay-for-performance strategies include: payment withheld reward or bonus penalty a combination of above.⁸⁶ 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).⁸⁷ 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.⁸⁸	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.¹⁵

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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 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 10 Apr 2024