1. Unintended Consequences and WTMS Workshop on Waiting Time Management Strategies for Scheduled Health care Ottawa March 28, 2012 Marie-Pascale Pomey, MD, PhD Juan Carlos Sabogal, MD, MHA (c)

2. OUTLINE OF THE SESSION 1.Research project 2.Concept of Unintended Consequences 3.Individual task 4.Audience discussion Unintended Consequences

3. Project 4: What Seems to Be Working (or not)? Objective: What are the determinants that can explain why a waiting time management strategies (WTMS) for total joint replacement (TJR) surgeries to respect federal benchmark in Canada is sustainable or not? Sub-objective: What are the potential Unintended Consequences of implementing those WTMS? Unintended Consequences

4. DEFINITION “Unintended consequence refers to a particular effect of purposive action which is different from what was wanted at the moment of carrying out the act, and the want of which was a reason for carrying it out”. ( Baert, 1991 ) Unintended Consequences

5. INTENDED vs. UNINTENDED CONSEQUENCES INTENDED: Purpose and intention of action Goals of any event (positive consequences) Improved WT Increase patients’ satisfaction UNINTENDED: Lack of intention and purposefulness (positive and negative consequences) Select non complex cases Increase team innovation culture Unintended Consequences

6. DESIRABLE vs. UNDESIRABLE CONSEQUENCES DESIRABLE CONSEQUENCES (Positive) * Improved WT Work team No increase in nosocomial infections UNDESIRABLE CONSEQUENCES (Negative) * Increase in other WTs (neurosurgery, general surgery) * Increase in medical complications Unintended Consequences

7. DIRECT vs. INDIRECT CONSEQUENCES DIRECT: Changes that occur in immediate response to an event ( Rogers, 1995) Improved OR time for hip and knee surgeries. INDIRECT: Consequence caused by a chain of events (Bloomrosen, 2011) “Consequences of consequences” (Rogers, 1995) Increase in OR time in other specialities Unintended Consequences

8. ANTICIPATED vs. UNANTICIPATED CONSEQUENCES ANTICIPATED: Ability to forecast (positive or negative) Stress on staff Tension among surgeons UNANTICIPATED: Inability to forecast (positive or negative) Increase OR time for other surgeries Role model of the program Unintended Consequences

9. ATTRIBUTES OF UNINTENDED CONSEQUENCES (Rogers, 1995; Bloomrosen et al. 2011) Unintended Consequences

10. DEFINITIONS Anticipated and desirable consequences: “Goals”: Objectives of a WTMS – Reduction in WT / WL Anticipated and undesirable consequences: “Trade- offs”: We accept that there are some likelihood effects in exchange for a greater good - Stress on staff. Unanticipated and desirable consequences: “Serendipities”: Happy surprises - Team cohesion. Unanticipated and undesirable consequences: Negative consequences that are not anticipated or expected (negative side effects) - Increase in WT for a surgeon consultation Unintended Consequences

11. THREE DIFFERENT LEVELS OF CONSEQUENCES Potential Consequences Federal / Provincial Organizational Individual Unintended Consequences

12. CONSEQUENCES AT THE FEDERAL/PROVINCIAL HEALTH CARE SYSTEM LEVEL Examples: Budget: * Less budget for other areas (-) * No funding to sustain WT strategies in the long term (-) Waiting time: * Increased WTs in other specialities (-) Health policies: * Less attention to other WTs, for example, neurosurgery, general surgery, paediatric surgery (-) * Used the same policy as a role model for different subjects (+ or -) Unintended Consequences

13. ORGANIZATIONAL LEVEL REHABILITATIONSURGERY REFERRAL PROCESS Unintended Consequences

14. CONSEQUENCES AT THE ORGANIZATIONAL LEVEL Examples: Pre-hospital: * Lack of knowledge of the referral process by GPs (-) * Patients better informed (+) Hospital: * Team work in OR (+) * Decrease in OR time for other specialties (-) Post-hospital: * Lack of follow-up in the rehabilitation process (-) * Patients' satisfaction (-/+) Unintended Consequences

15. CONSEQUENCES AT THE INDIVIDUAL LEVEL Examples: Managers: * Increase personal and professional Motivation (+) Health Professionals: * Tension among surgeons (-) * Stress on staff (-) Patients: * Decrease in patients’ satisfaction (-) Unintended Consequences

16. WORKSHOP: Task From your own experience, and based on the framework presented, can you share with us some examples of UCs in terms of: Could you fill in the worksheet with some examples of… Trade-offs Serendipities Negative UC Unintended Consequences

17. TIME CONSTRAINTS Individual brainstorming : 10 min. Audience discussion: 15 min. Unintended Consequences

18. WORKSHEET ANTICIPATED AND DESIRABLE “INTENDED or Goals” ANTICIPATED AND UNDESIRABLE “Trade-offs” UNANTICIPATED AND DESIRABLE = “Serendipities” UNANTICIPATED AND UNDESIRABLE “UNINTENDED or Negative” Unintended Consequences

19. THANK YOU Unintended Consequences