healthstatistics

Waiting

Page history last edited by mohammed al-jadaa 2 yrs ago

Waiting

One cannot fully understand a health system if one does not understand how patients flow through it.

There are many different ways of doing this. One way is to look at the waiting times between different steps of healthcare delivery.

As many steps are involved, many different waiting times and waiting time metrics could be used.

We should use a common language for transparency

Waiting times measure the time difference between a start point and an end point. For instance, one can measure the waiting time from entering a healthcare facility [= start point] to seeing a doctor [end point]. Any definable point in time can be considered either a start or an end point.
Waiting lists measure the number of people in the healthcare system that are currently between a defined start point and end point. For instance, the number of people who have entered a healthcare facility [start point] but have not yet seen a doctor [end point]
Many different statistics can be calculated using waiting times and waiting lists. Statistics need to be tailored to the decision that needs to be supported. For instance, one can use the top-quartile waiting time or the number of people waiting for longer than x minutes in a given time period. All of these will be appropriate in different circumstances.

To enable apples-to-apples comparisons, all organisations should use standard definitions of start and end points, a draft of which is shown below.

Date and time	Definition
Arrival	when patient arrives at primary intended facility (PHC, Outpatient department or inpatient department -- could also be OT), for A&E: when the patient arrives at A&E reception (walking) or is brought into Accident & Emergency Department (ambulance)
Registration	when registration process begins
Appointment	date and time of scheduled appointment
Assessment	when clinical assessment of patient begins that results in positive progress of the patient through the department. For Accident & Emergency this excludes triage or standard observations
Decision to treat	When a decision to treat is made by a doctor or nurse. Excludes triage or standard observations
Decision to refer	When a decision to refer a patient is made by a qualified clinician
Decision to admit	When the healthcare professional responsible for a patient's care decides to enter the patients name onto a waiting list
Completion of care	when the clinician informs the patient that care is complete in that setting (e.g., A&E), and they are ready for discharge, admission or transfer
Discharge	When the patient leaves the department and /or the department is no longer responsible for their care.
Admission	When an inpatient or day case admission occurs.
Transfer	When a patient transfers from another ward or department
Referral made	When a referral is made to / communicated to a healthcare professional, team, service or organisations by the referral source/referrer
Referral received	When a referral is received by a healthcare professional, team, service or organisation
Follow-up appointment	Date and time of next planned appointment is scheduled

Once different points in time are standardised, different waiting times can be defined. Some examples for waiting times are shown below.

It is important for everyone to use the same terminology for waiting times to share practices and understand comparative performance. As a principle, Wait times, when calculated in days do not include the start day, but do include the end day and weekends

Waiting times can easily be redefined, if everyone collects the same start and end point information -- adjusting waiting time definitions is then simply a matter of changing a calculation.

Waiting time	Starts	Ends	Excludes
Waiting time for Accident & Emergency consultation	Arrival at A&E	Assessment at A&E
Waiting time for inpatient admission from Accident & Emergency	Decision to Admit	Arrival in Inpatient facility
Length of stay in Accident & Emergency	Arrival at A&E	Discharge from A&E
Wait time for Outpatient consultation	Referral made	Appointment for Outpatient
Waiting time for Outpatient consultation	Arrival or Registration, whichever is later	Assessment by clinic session clinican	Patients who are late or too late; Time ends if patient declines available doctor (DAD)
Hospital inpatient case	Admission	Discharge from A&E
Wait time for elective care	Decision to Admit	Admission as planned	Emergency admissions

When characterising waiting times or waiting lists, it is important to be clear about whether certain types of patients are included or excluded. These choices can have a significant impact on reported waiting times. A few key proposed definitions to gain clarity on exclusions are shown below

Patient types	Definitions
Declined available Doctor (DAD)	A patient with a scheduled appointment in a specific clinic declines offer of consultation with appropriate clinician e.g. when appointments are dealt with by any clinician available e.g. in order of appointment.
Late	Patient who arrives more than 10 minutes late from the start time of their scheduled appointment but before the clinic session end time
Too late	Arrived for OPD appointment after clinic session end time or when clinic session clinician is no longer available
Did not attend (DNA)	The patient Did Not Attend (DNA) and did not notify the hospital in advance that they were unavailable to attend on the scheduled admission date or appointment
Could Not Attend (CNA)	The patient could not attend (CNA) and notify the hospital in advance that they are unavailable to attend on the offered admission date or scheduled appointment.
Refuses reasonable appointment (RRA)	Patient who refuses a reasonable offer of an appointment / admission date. A reasonable offer is when the patient is offered :- An appointment or admission date with a minimum of three weeks notice. - With at least two different admission dates. Outpatient appointment. An appointment on at least two different dates.