The Soft Incompetence of Low Expectations


NSW Hospital wait times Liberal promo Mar 2014The NSW Government is making a bit of a fuss over elective surgery waiting times. On the face of it, percentages attained within target times have increased. Two cheers.

But like every public sector measure, what really matters is what is measured, and how it can be gamed.

Sadly, gaming isn’t easy to see if you’re outside the relevant organisation. But when you look at what is measured, the grand trumpeting of performance is more like a child’s raspberry.

Do we really think that waiting a year for non-urgent surgery is acceptable? I wouldn’t put up with it. I’d pay private, because I can, and because I have private health insurance.

Meeting a target that is ridiculously lax is meaningless.

Low expectations of public hospital performance – expectations represented by these Urgent, Semi-Urgent and Non-Urgent targets – simply hide managerial incompetence under almost ‘perfect’ scores.

What the Priority Categories Mean

After seeing this image I wanted to check the definitions of Clinical Priority Categories so I could truly understand what was going on. Check the difficulty of getting that information and sloppiness of the Health Dept website here.

  • Category 1 Urgent: Admission within 30 days desirable for a condition that has the potential to deteriorate quickly to the point that it may become an emergency.
  • Category 2 Semi-Urgent: Admission within 90 days desirable for a condition which is not likely to deteriorate quickly or become an emergency
  • Category 3 Non-Urgent: Admission within 365 days acceptable for a condition which is unlikely to deteriorate quickly and which has little potential to become an emergency.

1 Year for Non-Urgent

It’s quite instructive to find that in neither the Waiting Time and Elective Surgery Policy, nor the Advice for Referring and Treating Doctors  is the word pain mentioned once. Pain seems to play no role in determining urgency. Nor does childhood language development – a key predictor for broader success in life.

Let’s look at some of the procedures the NSW Health Department, and Commonwealth, consider non-urgent enough for our poorest citizens to put up with for 12 months.

  • Cochlear implant – hey, just stay deaf for a year
  • Fix a tongue tie – hey kid, just don’t speak properly for a year
  • Inserting a grommet – hey, get infections and lose your balance for a year
  • Colonoscopy if you have a family history of bowel cancer
  • Fixing a cleft palate
  • Removing an intervertebral disc causing pain, or laminectomy (removal of back of disc)
  • Fixing hernias
  • Hip, knee or shoulder replacements
  • Tonsillectomy for chronic infections
  • Fixing your rotator cuff (shoulder)
  • Fixing a broken cheekbone or eye socket
  • Shoulder and knee reconstructions
  • Almost all non-cancerous cyst, lipoma and other removals; eye, sinus, nose and mouth surgery; hysterectomies and ovary removal; vasectomy and urinary surgery.

And note: don’t expect to get your ingrown toenail fixed for 12 months.

30 days for Urgent

Let’s think about 30 days as a target for Urgency. Delivery within 30 days is deemed adequate for things like:

  • all malignancies (cancer)
    • you gotta be kidding. You have an identified malignant tumour and required surgical action within 30 days is adequate?
  • Gall bladder removal for acute pain
  • Colonoscopy for Gastrointestinal Bleeding
    • ridiculous. Overt gastro/lower bowel bleeding is a major sign. And waiting 30 days till a colonoscopy is OK? That’s what these targets say.
  • Coronary artery bypass graft.

The Process Incompetence of Recommendation For Admission Forms

A few observations on the process for getting public patients onto the Elective Surgery Waiting List. These are based on the two key documents I ferreted out above.  There will be a more detailed look, but right now I don’t have the time.

  • Doctors must submit Recommendation for Admission Forms on paper within 3 days. Faxes are only accepted in exceptional circumstances and must be followed by originals
  • Forms have to be stamped with receipt date. This is a key step as it sets the date for the waiting list.
  • The RFAs get re-entered/keyed in by hospital staff within 3 days of receipt. They aren’t on the waiting list till that happens.
  • Notifications to patients are by mail
  • No information is entered until the RFA is exactly complete.
  • Only doctors contracted with the Local Health District/Network can recommend admission.

Key takeaway 1: According to policy targets, if a recommended procedure is Category 1 Urgent, it is acceptable for 6 of the 30 days to be taken up with getting the form onto the system.

Key takeaway 2: If RFA submission was put on the web, there would be no need for secondary data entry, no issues of legibility, incomplete data could be captured and alerted before submission, exceptional cases (>12 months, staged patients status review, new procedures and so on ) automatically flagged for review, waiting list dates automatically set and reviewed, and….I give up.

Putting RFA on the web is basic. It’s a form with a database behind it. A bit of validation, warning coding, interface to hospital system and away you go. And, goodbye multiple paper-pushers.

Why isn’t this happening already?

Politicians: From Critics to Defenders

In Opposition it’s all about holding the health system to account for failure to deliver, or delivering so slowly to our most disadvantaged that it’s an embarrassment to our Developed World status.

In Government? The crusaders for reform and transparency become the defenders of the bureaucratic status quo. Because of their fear of political embarrassment, they’re happy with gaming statistics, because it makes them look good. They become partisan promoters, defenders and obscurantisers for their departments, when in Opposition they acted as independent auditors.

In short, they become part of the problem.

The truth is, Ministers and their offices should be an accountability mechanism, representing the voters and driving their departments to meet their needs. Westminster approaches don’t quite get that right.

Time to change the Ministerial Handbooks.

The Ordeal of Finding Out

The process to get this information?

Perhaps you think it might be easier to find what to do for Referring and Treating Doctors. You’d hope the service for the professionals would be up to scratch:

By the way, a deeply dispiriting list. Return to top.

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