In this issue of the Canadian Journal of Surgery, a publication by Conner-Spady and coauthors1 provides surgeons with a validated tool for prioritizing access to hip and knee arthroplasty. This stratagem and others recently published by the Steering Committee of the Western Canada Wait List Project2,3 have greatly advanced our ability to bring order out of chaos in prioritizing fair and transparent access to surgical care. Although clinical prioritization bears further refinement, it is nevertheless essential for surgeons to take up the challenge to utilize these tools as part of a system to allocate surgical resources such as operating room time, perioperative support, surgical beds and ancillary services. During the 2003 Canadian Surgical Forum held in Vancouver, the Canadian Association of University Surgeons reviewed the principles of resource allocation, discussed methodological options and addressed management strategies to ensure sound allocation.
Several principles should guide allocation of surgical resources. First, resources must be considered in light of the needs of the patient. In our publicly funded system the patient “owns” the resources. Operationally, this translates to allocation based on standardized analysis of waiting times consistent with recognized benchmarks and national standards. Second, services must be provided in compliance with funding and interregional agreements. Third, in health regions that deliver research and teaching there must be a commitment to renew resources that support the academic and research mandate. Fourth is the principle of integrity, where allocating resources is an open process shared with patients, providers and provincial partners. Fifth, allocation must meet the principle of sustainability. Priority must be given to procedures for which there are evidence-based indicators that demonstrate appropriateness. Finally, surgical resource allocations impacting on the general health care system must incorporate “systems thinking” that identifies a responsible transfer of resources to support the programs.
Accompanying these principles is a need for clear understanding of the accountability for decision-making. Three levels of accountability rest with regional surgical councils, directors of individual surgical programs and senior executive teams; it is essential that surgeons be represented at each of these levels.
Methodology to adjust allocation of resources needs to be developed. It is key that time needed for urgent surgical access should be allocated first. The remaining time, identified as an elective component, is allocated on the basis of prioritization and carefully managed data on waiting.
Two options are available. The first is a prospective protocol based on booked cases waiting. (This should not be based on case counts alone, since the complexity of individual surgical procedures necessitates consideration of surgical times and effects on resources.) Another option is to use a retrospective approach based on average wait for performed procedures: historical data of average waits, collated by surgeon, service and site, is used to re-allocate time and other resources in proportion to the overall average.
Whichever option is used, key consideration must be given to some allocation issues. One of these is to identify a minimum allocation per surgeon, irrespective of wait, in consideration of new surgical recruits, subspecialty surgeons and surgeons who have administrative or research activities. A maximum allocation should also be established. In sites that have teaching at the core of their mission, teaching surgeons require time to instruct. Recent unpublished national benchmark data (collected in June of 2003 for the Vancouver Coastal Health Authority by Johnson and Johnson Consultants) show that the average operating time across a wide variety of surgical specialties in community hospitals is 12%–25% shorter than in teaching hospitals. Finally, there must be acknowledgement of services that provide a heavy commitment to emergency calls.
Inevitably, despite the formulation and adjustment of these methodologies, there will be periods of resource shortfalls because of personnel absences, nondelivery or under-ordering of supplies, epidemics such as SARS, and other, even less predictable variables. In such situations, patients with higher acuity must be offered prioritized access.
A process for review of operating-room allocation methodology is essential. A handful of core factors will underlie success. Internal checks must be incorporated that sustain the observance of the principles of resource allocation already identified. The system must be responsive to ever-shifting demands: making changes in allocation must be easy and inexpensive. The process must be consistent and transparent to all members of the surgical department. Inevitable data audits should feature ease and low cost. Most importantly, a patient-centred approach should always benefit the flow of patients through the surgical system.
In summary, significant challenges lie ahead for surgeons to make use of up-to-date tools developed to prioritize patient care in a sophisticated system of resource allocation. This process should reflect organization, problem-solving, quality of care and renewal of academic commitments. Stewardship of precious resources, with key leadership from surgeons, will give citizens access to standardized surgical care in a timely fashion.