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NATIONAL MAXIMUM WAIT TIME ACCESS TARGETS FOR MEDICAL IMAGING (MRI AND CT)

January 2013

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Table of ConTenTsExecutive Summary ............................................................................................................................................................ 2

Background ........................................................................................................................................................................... 6

Methods ................................................................................................................................................................................... 7

Results and Recommendations ...................................................................................................................................... 9

Inclusion/Exclusion populations ............................................................................................................... 9

DefiningtheMedicalImagingWaitTime ............................................................................................... 9

DefiningHowWaitTimesareMeasured ..............................................................................................10

DefiningHowWaitTimesareReported ................................................................................................10

DefiningtheMRIandCTWaitTimesPrioritizationClassificationSystem ............................11

DefiningMaximumTimeIntervalTargets ............................................................................................12

DefiningDatesAffectingReadinesstoTreat/Examine(DARTs) ................................................13

DefiningClinicalScenarioswithinthePriorityCategories ...........................................................14

DefiningtheReferralFormandProcess ...............................................................................................14

DefiningDataQuality ....................................................................................................................................14

Conclusion .............................................................................................................................................................................15

AppendixA–2005WTABenchmarks ......................................................................................................................16

AppendixB-Glossary ......................................................................................................................................................17

AppendixC-CARExpertPanelandConsensusGroup ......................................................................................18

AppendixD–MEDLINESearch ...................................................................................................................................19

AppendixE-Bibliography .............................................................................................................................................20

AppendixF-ConsensusGroupSurvey .....................................................................................................................22

AppendixG-StakeholderOutreach ...........................................................................................................................29

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TheCanadianAssociationofRadiologists(CAR)isamemberoftheWaitTimeAlliance(WTA)1. Since 2005, theWTAhasproducedannualreportsontheprogressofaddressingwaittimesinthefivepriorityareasidentifiedforfocusinthe2004FirstMinisters’HealthAccord.One ofthosefivepriorityareaswasdiagnosticimaging,particularlyaroundMRIandCT.Clinicalspecialtiesestablishedthenationaltargetsforwaittimesinthesepriorityareas.Recognizingthatanyguidancethathasbeenproducedshouldundergoperiodicreviewforcontinuingrelevanceinlightofanynewevidenceorliterature,theCARdeterminedthatthemedicalimagingbenchmarksforMRIandCTestablishedin2005shouldbeupdated(the2005benchmarksaresharedinAppendixA).

TheCARundertookanextensiveprocesstoaccomplishthisupdate.Inthisreport,theCARputsforward recommendationsondefinitionstobeusedinthe collection,trackingandreportingofmedicalimaging waittimedata.Aglossaryofdefinitionscanbefound inAppendixB.Thenewupdatedguidanceissimilar tothe2005benchmarksintheemergentandurgent categories,withsomefurtherclarificationon definitionsandexpansionofprioritycategories.

AsystematicliteraturesearchfailedtoidentifyanyarticlesrelevanttopatientoutcomesandaccesstoMRIorCT.The CAR,therefore,acknowledgesthattheevidencebehindtherecommendationsarethebestrecommendationsof apanelofparticipatingexperts,basedonunsystematicandundocumentedexperience,reviewedandvettedthroughawider,pan-Canadianconsultationprocess.

exeCuTive summary

1 http://www.waittimealliance.ca

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Car Pan-Canadian mri and CT WaiT Time benChmarks

Priority Category Definitions Maximum Time Interval Target

Priority 1 (P1) Emergent: an examination necessary to diagnose and/or treat disease or injury that is immediately threateningtolifeorlimb.

P1:Sameday–maximum24hours*

*Foremergent/life-threateningconditions,somepatientsrequire imaginginevenlessthananhourandthesedecisionsarebased ontheclinicalteam’sjudgment.

Priority 2 (P2) Urgent: an examination necessary to diagnose and/or treat disease or injury and/or alter treatment plan that isnotimmediatelythreateningtolifeorlimb.Basedonprovidedclinicalinformation,nonegativeoutcomerelatedtodelayintreatmentisexpectedforthepatientiftheexaminationiscompletedwithinthebenchmarkperiod.

P2:maximum7calendardays**

**Thereisaspectrumof“urgency”withintheurgentcategory.Inmostinstances,theexamshouldbecompletedassoonaspossibleafterthereferralisreceived.However,insomecases(depending onmedicalneedasdeterminedbytheclinicalteam’sjudgment),whiletheneedisstillurgent,amaximumwaittimeofsevendaysmaybemedicallyacceptable.

Priority 3 (P3) Semi-urgent:anexaminationnecessarytodiagnose and/or treat disease or injury and/or alter treatment plan,whereprovidedclinicalinformationrequires thattheexaminationbeperformedsoonerthanthe P4benchmarkperiod.

P3: maximum 30 calendar days

Priority 4 (P4) Non-urgent:anexaminationnecessarytodiagnose and/ortreatdiseaseorinjury,where,basedon providedclinicalinformation,nonegativelong-termmedical outcome related to delay in treatment is expectedforthepatientiftheexaminationis completedwithinthebenchmarkperiod.

P4: maximum 60 calendar days

Specified Procedure Date TheMRIorCTScanappointmentdaterequestedbytheorderingphysicianforthepurposeofdiseasesurveillance.

Itisrecommendedtotrackperformanceagainstspecifieddates,aspoorperformanceinP1-P4categoriesmayalterperformanceinthiscategory,creatingaseriousconcerninpatientcareforwhichstrategiesshouldbedeveloped.

reCommendaTion 1:

TheCARrecommendsafive-pointpriorityclassificationsystemwithprioritydefinitionsandmaximumbenchmark timeintervaltargetsassharedinthefollowingtable:

Theprioritydefinitionsandmaximumtimeintervaltargetsaresummarizedinthistable.

NOTE:Itisimportanttoemphasizethatthepatientsineachcategoryareheterogeneousintheirclinicalacuity.Clinicaljudgment,therefore,mustdeterminewhenthepatient’sexaminationshouldbeperformed.

NOTE: Itisimportanttoemphasizethatpatientsonthewaitlistrequireclinicalmonitoring.If,duringthecourseofthewaittime,thepatient’sclinicalconditionchanges,thewaitpriorityneedstobereconsidered.

NOTE: MRI = magnetic resonance imaging; CT=computedtomography

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Radiologist Maximum Report Turn-Around Time

Maximum Time Interval Target

Emergent(P1)reports Immediatereportingistheexpectation,withamaximumtimeof1hourforfinalizedreportcompletion.Additionally,directverbalorimmediatewrittencommunicationisconsideredthestandardofpractice.

Urgent(P2)reports Maximumreportingtimeof12hours.Dependingon theclinicalsituationandbasedonmedicalneed,directverbalorimmediatewrittencommunicationmaybenecessary to expedite patient care in this category.

Allotherexamination(P3andP4)reports Maximumfourcalendardays.

reCommendaTion 3:

Thatthecollectionofdataisforallpatientswaiting,including inpatients and emergency patients; excluded aretobeonlythosewhohaveaSpecifiedProcedureDateorDatesAffectingReadinesstoTreat/Examine(DARTs)associatedwiththem–bothasdefinedinthisreport –asthesecanskewperformancemeasures.

reCommendaTion 4:

Thattheradiologyinformationsystems(RIS)havethecapacitytocaptureDARTstofacilitatedataassessment foraccuratedeterminationofwaittimesperformance.

reCommendaTion 5:

ThattrackingperformanceforachievingSpecifiedProcedureDatetargetsbeperformed,recognizingthatover-capacityvolumesordelaysinachievingtheP1-P4categories may impact patient care. Mitigation strategies needtobedevelopedinthissetting.

reCommendaTion 6:

ThattheMRIorCTScanOrderReceivedDatealsobetracked,inadditiontotheMRIorCTScanOrderCompletedOrderReceivedDate–bothasdefinedinthisreport–tocaptureanywaittimethatoccurstoobtainacompletedreferral,whichisapartoftheentirepatientwait;trackingthiswaitwillallowjurisdictionstodetermineifstrategiesarerequiredtoaddressdelaysinthisarea.

reCommendaTion 2:

TheCARrecognizesthatreportturn-aroundtimeisapartofthepatientwait,andrecommendsthefollowingmaximumtimeintervalsforproductionofradiologistreports:

NOTE:Communicationoftheexaminationresultsisthemostimportantpartoftheinterpretiveprocess.Anyunexpectedorcriticalfindingsmust becommunicatedimmediatelyanddirectlytothereferringphysician.

NOTE:Reportturn-aroundtimemaybeaffectednegativelybylackofvoicerecognitiontechnologyand,inacademicdepartments,reportingbyResidentsandFellows.

TheCARalsomakesthefollowingrecommendationsonthereferral,collection,trackingandreportingofMRIand CTwaittimes:

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reCommendaTion 7:

That,inadditiontotrackingtheWaitTimeforReport– asdefinedinthisreport-institutionsthatdonothave newtechnologiesthatallowreportstobeaccessedby thereferringphysicianassoonassignedbytheradiologist,trackandreportthistime,asthisadditionalwaitisapartoftheentirepatientwait;trackingthiswaitwillallowjurisdictionstodetermineifstrategiesarerequired to address delays in this area.

reCommendaTion 8:

Thatthe90thPercentile,MedianandAveragewait timecalculationsbeusedasvaluableassessmentsofretrospectivedataforMRIandCTwaittimetargets, withthe90thpercentilebeingthepreferredretrospectivemeasurement.Forprospectivedataassessment,theN3(thirdnextavailableappointment)timeisencouraged foradditionalperspective–asdefinedinthisreport.

reCommendaTion 9:

ThatallreferralsforMRIandCTscansshouldcomply withnationalguidelines,suchastheCanadianAssociation ofRadiologists’referralguidelines.

reCommendaTion 10:

Thatitisthereferringphysician’sresponsibilitytofollowthepatientclinicallywhiletheyareonawaitinglistandtocommunicate to the radiology department any changes in thepatient’sclinicalconditionthatwouldmeritchanging the examination priority category.

reCommendaTion 11:

Thatthepatientandthereferringphysicianbegiventheappointmentdateassoonasitisestablished,sothatbothpartiesareawareofthelengthofthewait.

reCommendaTion 12:

That,toensuredataaccuracyandreportingcompliance,nationalstandardsfordatacollectionandauditingbeestablishedandimplemented.

reCommendaTion 13:

Thatthedefinitionandprioritizationforwaittimes forMRIandCTbefurthersub-categorizedtoallow morerefinedprioritization.Thiscanbedoneasafuturesteptocapturethecomplexitiesofdecision-makingformedicalimaging(e.g.bybodyareaand/orspecific conditionslikeoncology).

Finally,movingforward,theCARplanstoundertakefurtherworkinthefollowingareasofmedicalimaging benchmarksandaccess,ifappropriate:

• Expansionofwaittimeguidanceintosub-categoryareasforMRIandCTforprioritizationclassification.

• ExpansionofCARwaittimeguidanceintoothermodalities,suchasUltrasoundandFluoroscopy,amongst others.

• CollectionandreviewofexistingmedicalimagingaccesstocarestrategiesandbestpracticesusedinCanadatofacilitatethesharingofthesestrategiesandbestpracticestrategiesthatmaybenefit other jurisdictions.

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TheCanadianAssociationofRadiologists(CAR)isthenationalvoiceofradiologistsinCanada,advocatingforpatientsafetyandqualityinmedicalimaging.TheCAR isamemberoftheWaitTimeAlliance(WTA)2whichwasformedfollowingthe2004FirstMinisters’HealthAccord.TheAccordidentifiedwaittimesasapriorityareaforCanadianhealthcare.Specifically,theFirstMinistersacknowledgedtheimportanceofwaittimesintheir10-Year Plan to Strengthen Health Care3 and committed todevelopingbenchmarksformedicallyacceptablewaittimesinfivepriorityareas—cancer,cardiaccare, diagnosticimaging(DI),jointreplacement,andsightrestoration.Fordiagnosticimaging,waittimesfor MRI(magneticresonanceimaging)andCT(computedtomography)werepinpointedastheareasoffocus.

In2012,theStandingSenateCommitteeonSocialAffairs,ScienceandTechnologyundertookareviewofthe2004HealthAccordandreportedontheprogressofthe10-yearplan to strengthen health care. In its report, Time for Transformative Change4,theCommitteerecommendedthat“provincesandterritoriescontinuetodevelopstrategiestoaddresswaittimesinallareasofspecialtycare…”andthat“thefederalgovernmentworkwithprovinces,territoriesandrelevanthealthcareandresearchorganizationstodevelopevidence-basedpan-Canadianwaittimebench-marksforallareasofspecialtycarethatstartwhenthepatientfirstseeksmedicalhelp.”

Since2005,theWTAhasproducedannualreportsontheprogressofaddressingwaittimesinthefivepriorityareas.Clinicalspecialtiesestablishedthenationaltargetsfor

waittimesinthesepriorityareas.Morerecently,the WTA,throughtheworkofparticipatingclinicalspecialtyorganizations,hasexpandeditslistofareastobetracked (foracompletelistseethemostrecent2012 WTA report card)5.The2012WTAreportcardalsoclearlyhighlightsthattherehasbeenalmostnoprogressinmedicalimagingwaittimesforMRIandCT,inspiteofthewaittimefocus ofthe2004HealthAccord.Recognizinganyguidancethathasbeenproducedshouldundergoperiodicreviewforcontinuingrelevanceinlightofanynewevidenceorliterature,theCARhasdeterminedthatthemedicalimagingbenchmarksforMRIandCT,whichwere establishedin2005,shouldbeupdated.

Pan-Canadianmedicalimagingwaittimebenchmarksareneededtoprovideastandardizednationalmeasurement toolandmethodologywhichcansupportprogress.

Thereiswidevariationincurrentnationalpracticewithrespecttocollectionandassessmentofmedicalimagingwaittimes.Provincialactivitiesrangefromminimaltofullimplementationofprovincialbenchmarks.Informationobtainedfrompan-Canadianmedicalimagingwaittimebenchmarkscanprovideanobjectiveassessmentofaccess.Thisinformationcanbeusedtosupportandpromoteequitableaccesstoimagingbasedonmedicalneed,regardlessofgeographicchallenges.TheCARreporthopestobringbenefittoprovincialprocessesbycreatingstandardizeddefinitionsandmethodologyforwaittimesandmeasurementsthatwillenableconsistentcollection,trackingandreportingofmedicalimagingwaittimedataacrossCanada.ThereportoutlinestheprocesstheCARunder-tookforthatreviewanditsrecommendations.

baCkground

Pan-Canadian medical imaging wait time benchmarks are needed to provide a standardized national measurement tool and methodology which can support progress.

2http://www.waittimealliance.ca 3http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php 4http://www.parl.gc.ca/Content/SEN/Committee/411/soci/rep/rep07mar12-e.pdf 5http://www.waittimealliance.ca/media/2012reportcard/WTA2012-reportcard_e.pdf

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TheprojectwasledbyanExpertPanelandaugmented byaConsensusGroupoftheCanadianAssociationofRadiologists(CAR).

TheExpertPanelandConsensusGroupwerecomprisedofapan-CanadiangroupofradiologistsaslistedinAppendixC. TheExpertPanelandConsensusGroupundertooktwoprocesses,asystematicliteraturereviewandaconsensus-buildingprocessinthecreationofitsrecommendations.

TheExpertPanelundertookalandscapereviewto identifycurrentactivitiesinallprovincesregardingmedicalimagingbenchmarks.Itundertookareview ofexistingprioritygradingsystems,aswellascurrentindicators related to medical imaging access tracking and reporting.

liTeraTure searCh

TheExpertPanelalsoundertookatargetedliteraturereviewofDiagnosticImagingwaittimes,accessdelays andpatientoutcomes.ThesearchstrategywasperformedinMEDLINE.ThestrategyforMEDLINEissummarized inAppendixD.

sTudy seleCTion CriTeria

Allsystematicreviewsandprimarystudiesthat addressthequestionofinterestwereincluded.

Theinclusioncriteriaforsystematicreviewswere:

• Containedevidencerelatedtochangein patient management, clinical outcomes;

• Dedicatedtowaittimesfordiagnosticimaging.Theinclusioncriteriaforclinicaltrialswere:

• Prospectiveclinicalstudiesrelatedto waittimesfordiagnosticimaging;

• Studypublishedinapeer-reviewedjournal; • Studyreportedevidencerelatedtochange

in patient management, clinical outcomes.Thecitationsandabstractsfromtheliteraturesearch werereviewedbyanexpertpanelmemberandmarked as relevant or not relevant, according to the inclusion criteria.

Abibliographyofdocumentsreviewedbythegroup islistedinAppendixE.

Fromthesystematicreview,69articleswereidentified. Anexpertpanelmemberreviewedtheabstractsforeachofthesearticles.Nosystematicrevieworclinicaltrialwasidentifiedthroughthesearchthatmetthesystematicsearch inclusion criteria.

meThods

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Consensus-building ProCess

Aconsensusapproachwasusedindevelopingthisreport.Twomethodsarecommonlyusedforconsensus-basedguidelines:nominalgrouporDelphi.Thenominaltechniqueinvolvesrepeateddiscussionsinaround-tablesetting,withamediatorfacilitatingtheprocessbysolicitingdifferingperspectivesandreducingmisunderstandings. IntheDelphimethod,twoormoreroundsofpostalsurveysareused,withfeedbackofresultstoparticipantsaftereachround.Bothmethodswereusedinthedevelopmentoftherecommendationsinthisreport.

TheExpertPanelwasexpandedtocreateaConsensusGroupandtheconsensusapproachincludedseveralteleconferencesandanonlinesurveyofquestionsrelatedtoallsectionsofthisreportascontainedinAppendixF.SurveyresponseswereconsideredbytheConsensusGrouptoreachconsensusonthereportcontent.

AprocessofexternalreviewofthedraftreportwasalsoundertakentoallowinputbythefullCARmembershipandvariousstakeholderorganizationsaslistedinAppendixG.

Responsestotheexternalreviewwerethenconsidered bytheConsensusGroup,followingwhichthisfinal reportwasprepared.

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inClusion/exClusion PoPulaTions

Currently,somejurisdictionsacrossCanadaonlycapturedataforwaittimesforoutpatientsanddonotcapturedata forotherareassuchasinpatients,emergencyandpediatrics.

TheCAR,inconsideringwhotoincludeinthetracking andreportingofMRIandCTwaittimes,recommends thefollowing:

Inclusion: All patients waiting for an MRI or CT scan

Exclusion: Defined by Dates Affecting Readiness to Treat/Examine (DARTs) on page 13 of this report

TheCanadianAssociationofRadiologistssupports thecollectionofdataforallpatientswaiting,withtheexceptionofthosewhohaveDatesAffectingReadiness toTreat/Examine(DARTs)associatedwiththem.

defining The mediCal imaging WaiT Time

TheCARrecommendsthatthefollowingdefinitions beusedincollecting,trackingandreportingMRI andCTwaittimes.

MRI or CT Scan Referral Date:Thedateonwhich arequestforconsultationforanMRIorCTScanis completedandsignedbythereferringclinician.

MRI or CT Scan Order Received Date: ThedateonwhichtherequisitionforanMRIorCTScanisreceivedattheMedicalImagingBooking(clerical)office.

MRI or CT Scan Completed Order Received Date: Thedateonwhichthecompletedrequisitionforan MRIorCTScanisreceivedattheMedicalImaging Booking(clerical)office.

MRI or CT Scan Completed Order:Anorderthathasallrequiredpatient,physician,clinical,andMRIandCTsafetyinformationandhasbeenprotocolledbytheradiologist.

MRI or CT Scan Finished Date:Thedateonwhich theMRIorCTScanissuccessfullyfinished,asper the expected protocol.

Priority Coding Date: Thedateonwhicharadiologist hasofficiallyassignedtheprioritycodeforanMRI orCTexamination.

Note:PriorityCodingDateisanotherdatethatisencouragedtobemonitoredlocally,asthismaycontributetotheentirewaittimeifradiologists are not completing this promptly.

Report Signed Date: Thedateonwhicharadiologist hasofficiallysignedoffonthewrittenreportforanMRI orCTexamination.Thisincludeselectronicsignature.

Cancellation List:Alistofpatientsandtheircontactinformation,whoserequisitionshavebeenreviewed andprotocolled,whoareavailabletoattendanMRI orCTScanappointmentatshortnotice,duetoa last-minuteavailabilityintheMRIorCTschedule.

resulTs and reCommendaTions

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defining hoW WaiT Times are measured

TheCARrecommendsthatthefollowingdefinitions beusedinmeasuringMRIandCTwaittimes.

Measurement:Waittimesaremeasuredincalendardays.

Wait Time: MRIorCTScanCompletedOrder ReceivedDatetoMRIorCTScanFinishedDate. Thewaittimefromthedateacompletedreferral foramedicalexaminationisreceiveduntilthe datetheexaminationisfinished.

AlthoughforthepurposeoftrackingwaittimeperformanceagainstMRIandCTmaximumtimeintervaltargets,the‘waittime’isdefinedasthewaitfromCompletedOrderReceivedDatetoMRIorCTScanFinishedDate,theCARalsorecommendsthattheMRIorCTScanOrderReceivedDatealsoberecordedandtracked.Thiswillallowcapturinganywaittimethatoccurstoobtainacompletedreferralforamedicalexamination,wherethereferralmustbereturnedtothereferringphysicianformoreinformation.Thisisanimportantpartoftheentirewaitforthepatient,andtrackingitwillallowjurisdictionstodetermineifstrategiesarerequiredtoaddressdelaysinthisarea.

Wait Time for Report:ThetimeintervalfromtheMRIorCTScanFinishedDatetoReportSignedDate.

Withrespecttothe‘waittimetoreport,’withnew technologies,thereportscanbereviewedbythereferringphysician as soon as they are signed. In institutions withoutthesetechnologies,theremaybeanadditionalwaitfromthetimethereportissignedtothetimethat thereferringphysicianhasaccesstothereport.TheCARrecommendsthatfortheseinstitutions,thistimeintervalshouldalsobetrackedandreported.

defining hoW WaiT Times are rePorTed

TheCARrecommendsthatthefollowingdefinitions beusedinreportingMRIandCTwaittimes.These arebasedonretrospectivedata.

Thepatientsineachprioritycategoryhavediversemedicalconditions.The90thpercentileisthepreferred measurementformultimodaldistributions.

90th Percentile Wait Time:90%ofpatients waitedlessthanorequaltothisnumberofdaysbetweentheMRIorCTCompletedOrderReceived DateandtheMRIorCTScanFinishedDate.

Median Wait Time: Thepointatwhichhalf the patients have had their medical imaging examinationandtheotherhalfarestillwaiting, withthewaittimedefinedasthewaitbetween theMRIorCTCompletedOrderReceivedDate andtheMRIorCTScanFinishedDate.

Average Wait Time:Theaverage(ormean)length oftimeapatientwaitedtohavetheirmedicalimagingexamination,withthewaittimedefinedasthewaitbetweentheMRIorCTCompletedOrderReceivedDateandtheMRIorCTScanFinishedDate.

TheCARalsoencouragesreportingonprospective data forMRIandCTwaittimeswiththefollowingdefinition:

N3 Time: Thetimeincalendardaysuntil thethirdnextavailableappointmentin theappropriatepriority(P)category.

Althoughnotcritical,thisN3dataprovidesanadditionalperspectiveonthewaittime.

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defining The mri and CT WaiT Times PrioriTizaTion ClassifiCaTion sysTem

TheCARrecommendsusingafive-pointclassificationsysteminthecollection,trackingandreportingofMRIandCTwaittimes.

Five-point classification system

1.Priority1(P1)2.Priority2(P2)3.Priority3(P3)4.Priority4(P4)5.SpecifiedProcedureDate

TheCARrecommendsthatthefollowingprioritydefinitionsbeusedintheprioritization,trackingandreporting ofMRIandCTwaittimes.

NOTE:Itisimportanttoemphasizethatpatientsonthewaitlistrequireclinicalmonitoring.If,duringthecourseofthewaittimethe patient’sclinicalconditionchanges,thewaitpriorityneedstobereconsidered.

Priority 1

P1: Emergent: an examination necessary to diagnose and/or treat disease or injury that is immediately threateningtolifeorlimb.

Priority 2

P2:Urgent–anexaminationnecessarytodiagnose and/or treat disease or injury and/or alter treatment planthatisnotimmediatelythreateningtolifeorlimb.Basedonprovidedclinicalinformation,nonegative outcome related to delay in treatment is expectedforthepatientiftheexaminationiscom-pletedwithinthebenchmarkperiod.

Priority 3

P3:Semi-urgent–anexaminationnecessarytodiagnose and/or treat disease or injury and/or alter treatmentplan,whereprovidedclinicalinformationrequiresthattheexaminationbeperformedsoonerthantheP4benchmarkperiod.

Priority 4

P4:Non-urgent–anexaminationnecessarytodiagnoseand/ortreatdiseaseorinjury,where,basedonprovidedclinicalinformation,no negativelong-termmedicaloutcomerelatedto delayintreatmentisexpectedforthepatient iftheexaminationiscompletedwithinthe benchmarkperiod.

ForpatientsintheP4category,itisimportanttoacknowledgethatalthoughtheywouldnotbeexpectedtohaveanylong-termnegativemedicaloutcomewhenwaitingformedicalimaging,thepatient’squalityoflifeisimpactedduringthiswaitperiod.TheCAR,therefore,highlights the need to attend to these imaging needs as expeditiouslyaspossible.

Specified Procedure Date

Specified Procedure Date:TheMRIorCTScanappointmentdaterequestedbytheorderingphysicianforthepurposeofdiseasesurveillance.

TheCARrecommendsthatwhenassessingdataforwaittimeperformance,patientsfallingintothiscategorynotbeusedinthedataanalysis(asisalsosuggestedforpatientswithDARTsassociatedwiththem-seepage13foralistofDARTs),asthiscanleadtoaninaccurateassessmentofwaittimeperformanceingeneral.However,itisimportanttotrackwhetherpatientsdo,infact,receivetheirimagingontheSpecifiedProcedureDateand,ifnot,whentheyreceiveit.Itisrecommendedtotrackperformanceagainstspecifieddates,aspoorperformanceinP1-P4categoriesmayalterperformanceinthiscategory,creatingaseriousconcerninpatientcareforwhichstrategiesshouldbedeveloped.

It is important to emphasize that patients on the wait list require clinical monitoring. If, during the course of the wait time the patient’s clinical condition changes, the wait priority needs to be reconsidered.

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defining maximum Time inTerval TargeTs

TheCARrecommendsthatthefollowingmaximumtimeintervaltargetsbeusedinthetrackingandreporting ofMRIandCTwaittimes.

P1 Maximum Time Interval Target for MRI and CT

P1:Sameday-24hours*

*Foremergent/life-threateningconditions,somepatientsrequireimaginginevenlessthananhourandthesedecisionsarebasedontheclinicalteam’sjudgment.


P2: 7calendardays*

*Thereisaspectrumof“urgency”withintheurgentcategory.Inmostinstancestheexamshouldbecompletedassoonaspossibleafterthereferralisreceived.However,insomecases(dependingonmedicalneedasdeterminedbytheclinicalteam’sjudgment),whiletheneedisstillurgent,amaximumwaittimeofsevendaysmaybemedicallyacceptable.


P3: 30 calendar days



Radiologist Maximum Report Turn-Around Time

• Emergent(P1)reports–Immediatereportingistheexpectation,withamaximumtimeof1hourforfinalizedreportcompletion.Additionally,direct verbalorimmediatewrittencommunicationis consideredthestandardofpractice.

• Urgent(P2)reports–Maximumreportingtimeof12hours.Dependingontheclinicalsituationandbased onmedicalneed,directverbalorimmediatewrittencommunicationmaybenecessarytoexpeditepatientcare in this category.

• Allotherexaminations(P3andP4)reports –Maximumfourcalendardays.

TheCARmaximumintervaltimetargetsareatoolthat canbeusedtoobtainmeasurementsnationallythatdefinethecurrentwaittimeandaccessenvironmentformedicalimagingcare.Thesetargetscanbeusedasastandardagainstwhichfuturemeasurementscanbereferencedforbenchmarkingmedicalimagingcareaccessintothefuture.

These targets can be used as a standard against which future measurements can be referenced for benchmarking medical imaging care access.

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defining daTes affeCTing readiness To TreaT/examine (darTs)

ThemethodandtermofDatesAffectingReadinesstoTreat/Examine(DARTs)iswhatiscommonlyusedinOntarioforDI(andsurgery)toidentifypatient-relatedandsystems-relateddelaysforMRIandCTScans.We have chosen to use this term in this report, although other jurisdictionsmayuseotherequallyacceptableterminology.

ExamplesofDARTsinclude:

• Patientchoosestodefer • Patientisano-showforappointment • Patientpreference • Patientisclaustrophobic • Patientdoesnotfollowrequiredpreparation

leading up to scan • Newdisclosureofcontrastallergybypatient • Patientcannotbecontacted • Patientisnowaninpatientatanother

healthcarefacility • IncompleteMRIorCTScanrequisition █ Undisclosedbodyhabitus █Undisclosedrenalfunction • Additionalfollow-uprequiredforMRIsafetyreasons • Patientrequiredorbitx-rays,pre-MRI • Patientrequiringgeneralanesthetic • Patientrequiringinfusionforimaging • Patientnotproperlynotifiedbydoctor’s

officeofappointment • Patientcannotfindscannerlocationor

appearedatwronglocationAsDARTsskewperformancemeasures,theCARrecommendsthatradiologyinformationsystems(RIS)havethecapacitytocaptureDARTsandthatcaseswithDARTsnotbeincludedinthedatatoassesswaittimeperformance.

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defining CliniCal sCenarios WiThin The PrioriTy CaTegories

Recognizingthecomplexitiesofdecision-makingformedical imaging care, including the impact medical imaginghasondeterminingmanagementofpatient care,theCARrecommendsthefuturedefinitionandprioritizationofwaittimesforMRIandCTinsub-categoryareas.Appropriatesub-categoriestobeusedwithintheprioritycategoriesarestilltobedeterminedbutmayinclude,amongothers,thefollowing:

Neuro Pediatrics Cardiac MSK BreastMRI Thoracic Body Oncology ObstetricalMRI

Followingfurtherconsultation,theCanadianAssociation ofRadiologistswillundertakethisbodyofworkin 2013–2014,ifappropriate.

defining The referral form and ProCess

TheCanadianAssociationofRadiologistspromotes thefollowingapproachtoreferralformsformedicalimagingrequests:

• AllreferralsforMRIandCTscansshouldcomplywithnationalguidelines,suchastheCanadian AssociationofRadiologists’referralguidelines.

Concerningthereferralprocess,theCanadianAssociationofRadiologistsrecommends:

• Thatitisthereferringphysician’sresponsibility tofollowthepatientclinicallywhiletheyareon awaitinglistandtocommunicatetotheradiologydepartmentanychangesinthepatient’sclinicalconditionthatwouldmeritchangingthe examination priority category.

• Thatthepatientandthereferringphysician begiventheappointmentdateassoonasitis established,sothatbothpartiesareaware ofthelengthofthewait.

defining daTa QualiTyTheCanadianAssociationofRadiologistspromotes thefollowingapproachtodataqualityintracking andreportingwaittimes:

• Toensuredataaccuracyandreportingcompliance,nationalstandardsfordatacollectionandauditing shouldbeestablishedandimplemented.

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Therecommendationsinthisreportaregearedtowardssupporting clear and consistent collecting, tracking and reportingonwaittimesforMRIandCTmedicalimagingexaminationsthroughoutCanada.

Movingforward,theCARplanstoundertakefurtherworkinthefollowingareasofmedicalimagingbenchmarksandaccess,ifappropriate:

• Expansionofwaittimeguidanceintosub-categoryareasforMRIandCTforprioritizationclassification.

• ExpansionofCARwaittimeguidanceintoothermodalities,suchasUltrasoundandFluoroscopy,amongst others.

• Collectionandreviewofexistingmedicalimagingaccesstocarestrategiesandbestpracticesused inCanadatofacilitatethesharingofthese strategiesandbestpracticestrategiesthat maybenefitotherjurisdictions.

ConClusion

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The 2005 Benchmarks established by the CAR for the Wait Time Alliance (WTA) were as follows: • Emergencycases-Immediateto24h • Urgentcases-Within7days • Scheduledcases-Within30days

Priorityorurgencylevelsaredefinedasfollows: • Emergency=Immediatedangertolife,limbororgan • Urgent=Situationthatisunstableandhasthe

potentialtodeterioratequicklyandresultin an emergency admission

• Scheduled=Situationinvolvingminimal pain,dysfunctionordisability (alsocalled“routine”or“elective”).

aPPendix a – 2005 WTa benChmarks

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MRI or CT Scan Referral Date:ThedateonwhicharequestforconsultationforanMRIorCTScaniscompleted andsignedbythereferringclinician.

MRI or CT Scan Order Received Date: ThedateonwhichtherequisitionforanMRIorCTScanisreceivedat theMedicalImagingBooking(clerical)office.

MRI or CT Scan Completed Order Received Date: ThedateonwhichthecompletedrequisitionforanMRI orCTScanisreceivedattheMedicalImagingBooking(clerical)office.

MRI or CT Scan Completed Order:Anorderthathasallrequiredpatient,physician,clinical,andMRIand CTsafetyinformationandhasbeenprotocolledbytheradiologist.

MRI or CT Scan Finished Date: ThedateonwhichtheMRIorCTScanissuccessfullyfinished,aspertheexpectedprotocol.

Priority Coding Date:ThedateonwhicharadiologisthasofficiallyassignedtheprioritycodeforanMRIorCTexamination.

Report Signed Date: ThedateonwhicharadiologisthasofficiallysignedoffonthewrittenreportforanMRIor CTexamination.Thisincludeselectronicsignature.

Cancellation List:Alistofpatientsandtheircontactinformation,whoserequisitionshavebeenreviewedand protocolled,whoareavailabletoattendanMRIorCTScanappointmentatshortnotice,duetoalast-minute availabilityintheMRIorCTschedule.

Measurement: Waittimesaremeasuredincalendardays.

Wait Time:MRIorCTScanCompletedOrderReceivedDatetoMRIorCTScanFinishedDate.Thewaittimefrom thedateacompletedreferralforamedicalexaminationisreceiveduntilthedatetheexaminationisfinished.

Wait Time for Report:ThetimeintervalfromtheMRIorCTScanFinishedDatetoReportSignedDate.

90th Percentile Wait Time:90%ofpatientswaitedlessthanorequaltothisnumberofdaysbetweenthe MRIorCTScanCompletedOrderReceivedDateandtheMRIorCTScanFinishedDate.

Median Wait Time:Thepointatwhichhalfthepatientshavehadtheirmedicalimagingexaminationandtheother halfarestillwaiting,withthewaittimedefinedasthewaitbetweentheMRIorCTScanCompletedOrderReceived DateandtheMRIorCTScanFinishedDate.

Average Wait Time:Theaverage(ormean)lengthoftimeapatientwaitedtohavetheirmedicalimaging examination,withthewaittimedefinedasthewaitbetweentheMRIorCTScanCompletedOrderReceived DateandtheMRIorCTScanFinishedDate.

Specified Procedure Date:TheMRIorCTScanappointmentdaterequestedbytheorderingphysician forthepurposeofdiseasesurveillance.

N3 Time: Thetimeincalendardaysuntilthethirdnextavailableappointmentintheappropriatepriority(P)category.

aPPendix b – glossary

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TheExpertPanelwhichundertooktheinitialworkcomprised:

• Dr.JulianDobranowski,ON,Chair • Dr.PaulBabyn,SK • Dr.RickBhatia,NL • Dr.BruceForster,BC • Dr.WalterKucharczyk,ON • Dr.BlakeMcClarty,MB • Dr.ChristineMolnar,AB • Dr.MarkSchweitzer,ON

Thegroupwasfurtherexpandedasbelowtoundertakeanadditionalconsensusprocess. TheCARConsensusGroupcomprised:

• Dr.JulianDobranowski,ON,Chair • Dr.JohnAllan,NB • Dr.PaulBabyn,SK • Dr.RickBhatia,NL • Dr.AlanBrydie,NS • Dr.BruceForster,BC • Dr.WalterKucharczyk,ON • Dr.BlakeMcClarty,MB • Dr.ChristineMolnar,AB • Dr.VivianeNicolet,QC • Dr.MarkSchweitzer,ON

aPPendix C – Car exPerT Panel and Consensus grouP

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MEDLINESearchstrategy–SystematicreviewonMRI/CTwaittimes/AccessandclinicaloutcomesSearchrunDecember5,2012Retrievalperiodfrom1946toDecember2012Ovid MEDLINE®

1 expMorbidity/(333436)2 expmortality/(259647)3 1or2(569775)4 expWaitingLists/(7828)5 (waitadjtime:).ti,ab.(829)6 (delay:orwait:ortimingortime).ti.(191013)7 4or5or6(196757)8 expRandomizedControlledTrial/(342532)9 expControlledClinicalTrial/(85711)10 randomallocation/(76622)11 doubleblindmethod/(118555)12 expSingle-BlindMethod/(17105)13 (clin:adjtrial:).ti,ab.(179063)14 ((singl:ordoubl:ortripl:ortrebl:)adj(mask:orblind:)).ti,ab.(116159)15 random:.ti,ab.(587100)16 researchdesign/(68723)17 expcohortstudies/(1235060)18 ((control:adj3(group:orcondition:))or(control:adj2(trial:orstudyorstudies))).tw.(513172)19 (cohortadj(studyorstudiesortrialortrials)).tw.(66080)20 prospectivestudies/(334412)21 interventionstudies/(5705)22 expcasecontrolstudies/(586769)23 expMeta-Analysis/(37995)24 expPracticeGuideline/(17497)25 exp*DiagnosticImaging/(589328)26 exp*MagneticResonanceImaging/(114121)27 exp*Tomography,X-RayComputed/(87297)28 25or26or27(589328)29 or/8-24(2426104)30 3and7and28and29(69)

aPPendix d – medline searCh

20

1. AmericanCollegeofRadiology.NewHarveyL.NeimanHealthPolicyInstitutetoExamineImpactof MedicalImagingonHealthCareQuality,DeliveryandCost[internet].2012Aug6.Availablefrom: http://www.acr.org/About-Us/Media-Center/Press-Releases/2012-Press-Releases/20120803New-Harvey-L-Neiman- Health-Policy-Institute#fontsize-1

2. BaruaB,RovereM,SkinnerBJ.StudiesinHealthPolicy-WaitingYourTurn-WaitTimesforHealthCare inCanada-2011report.Vancouver(BC):FraserInstitute;2011Dec.91p.Availablefrom: http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2011.pdf

3. CanadianMedicalAssociation.It’sabouttime!Achievingbenchmarksandbestpracticesinwaittimemanagement-FinalReportby theWaitTimeAllianceforTimelyAccesstoHealthCare.Ottawa(ON):CanadianMedicalAssociation;2005Aug.98p.Availablefrom: http://www.waittimealliance.ca/images/wta_final_Aug05.pdf

4. CooperRA,StrausDJ.ClinicalGuidelines,thePoliticsofValue,andthePracticeofMedicine: PhysiciansattheCrossroads.JOnctolPract.2012Jul;8(4):233-235.Availablefrom: http://jop.ascopubs.org/content/8/4/233.full.pdf+html?sid=d166e990-bd42-4aa4-87ae-c3e9cf55af6e

5. EasternHealth.AdultMRIPriorityClassification-ReferenceListsforProtocolingMRIRequests–DiagnosticImagingProgram[pamphlet].2012.

6. EmeryDJ,ForsterAJ,ShojaniaKG,MagnanS,TubmanM,FeasbyT.ManagementofMRIWaitListsinCanada. HealthcPolicy.2009Feb:4(3)76-86.Availablefrom: http://www.longwoods.com/content/20537

7. FretheimA,SchünemannHJ,OxmanAD.Improvingtheuseofresearchevidenceinguidelinedevelopment:3.Groupcompositionand consultationprocess.HealthResPolicyandSyst.2006Nov29;4(15).Availablefrom: http://www.health-policy-systems.com/content/pdf/1478-4505-4-15.pdf

8. FretheimA,SchünemannHJ,OxmanAD.Improvingtheuseofresearchevidenceinguidelinedevelopment:5.Groupprocesses.HealthResPolicyandSyst.2006Dec1;4(17).Availablefrom: http://www.health-policy-systems.com/content/pdf/1478-4505-4-17.pdf

9. HahornDC,SteeringCommitteeoftheWesternCanadaWaitingListProject.Developingprioritycriteriaformagneticresonanceimaging:resultsfromtheWesternCanadaWaitingListProject.CanAssocRadiolJ.2002Oct;53(4):210-218.Availablefrom: http://www.wcwl.ca/media/pdf/library/published_papers.4.pdf

10.HealthCanada.HealthyCanadians–AFederalReportonComparableHealthIndicators2010.Ottawa(ON):HealthCanada;2011.220p.ReportNo.:H21-206/2010E-pdf.Availablefrom: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/pdf/pubs/system-regime/2010-fed-comp-indicat/index-eng.pdf

11.HealthCouncilofCanada.Decisions,Decisions:FamilyDoctorsasGatekeeperstoPrescriptionDrugsand DiagnosticImaginginCanada.Toronto(ON):HealthCouncilofCanada;2010Sep.50p.Availablefrom: http://www.healthcouncilcanada.ca/tree/2.33-DecisionsHSU_Sept2010.pdf

12. HealthCouncilofCanada.ProgressReport2011:HealthcarerenewalinCanada.Toronto(ON):HealthCouncilofCanada;2011May.32p.Availablefrom: http://www.healthcouncilcanada.ca/tree/2.45-2011Progress_ENG.pdf

13.HurstJ,SicilianiL.TacklingExcessiveWaitingTimesforElectiveSurgery:AComparisonofPoliciesinTwelveOECDCountries. OECDHealthWorkingPapers.Paris(France):OECDPublishing;2003Jul.54p.Availablefrom: http://dx.doi.org/10.1787/108471127058

14.HurstJ,SicilianiL.TacklingExcessiveWaitingTimesforElectiveSurgery:AComparisonofPoliciesinTwelveOECDCountries-Annex3: DetailedCountryReviews:Figures.OECDHealthWorkingPapers.Paris(France):OECDPublishing;2003Jul.62p.Availablefrom: http://www.oecd.org/els/healthpoliciesanddata/5163944.pdf

aPPendix e – bibliograPhy

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15.KnudtsonML,BeanlandsR,BrophyJM,HigginsonL,MuntB,RottgerJ,fortheCanadianCardiovascularSocietyAccesstoCareWorkingGroup.Treatingtherightpatientattherighttime:Accesstospecialistconsultationandnoninvasivetesting.CanJCardiol.2006;22(10):819-824.Availablefrom: http://www.onlinecjc.ca/article/S0828-282X(06)70299-9/abstract

16.LaupacisA,EvansW.DiagnosticImaginginCanada.HealthcPap.2005Oct;6(1)8-15.Availablefrom: http://www.longwoods.com/content/17718

17.LehouxP.ThePowerofTechnology:ResistingtheSeductionthroughRationality?HealthcPap.2005Oct;6(1)32-39.Availablefrom: http://www.longwoods.com/content/17722

18.NoseworthyT.FurtherReflectionsonDiagnosticImaginginCanada.HealthcPap.2005Oct;6(1)24-27.Availablefrom: http://www.longwoods.com/content/17720

19.Ontario.MinistryofHealthandLong-TermCare.MRI&CTExpertPanel,KellerA(chair).MRI&CTExpertPanelphaseIreport (withAppendixA).Toronto(ON):MinistryofHealthandLong-TermCare(ON);2005Apr.59p.Availablefrom: http://www.ontla.on.ca/library/repository/mon/12000/256889.pdf

20.Ontario.MinistryofHealthandLong-TermCare.MRI&CTExpertPanel,KellerA(chair).MRI&CTExpertPanelphaseIIreport. Toronto(ON):MinistryofHealthandLong-TermCare(ON);2006Dec4.65p.Availablefrom: http://www.ontla.on.ca/library/repository/mon/17000/272636.pdf

21.Ontario.MinistryofHealthandLong-TermCare.OntarioBestPracticeGuidelinesforManagingtheFlowofPatientsRequiringanMRIorCTExamination,effectiveasofMay28,2009.Toronto(ON):MinistryofHealthandLong-TermCare(ON);2009.43p.Availablefrom: http://www.ontla.on.ca/library/repository/mon/23006/292809.pdf

22.PatersonWG,DepewWT,ParéP,PetruniaD,SwitzerC,VeldhuyzenvanZantenSJ,DanielsS,fortheCanadianAssociationofGastroenterologyWaitTimeConsensusGroup.Canadianconsensusonmedicallyacceptablewaittimesfordigestivehealthcare. CanJGastroenterol.2006;20(6):411-423.Availablefrom: http://www.pulsus.com/journals/abstract.jsp?sCurrPg=abstract&jnlKy=2&atlKy=406&isuKy=269&isArt=t&fromfold=

23.PrinceEdwardIsland.DepartmentofHealth.PrinceEdwardIslandWaitTimeStrategy–ASystemthatProvidesTimelyAccess toHealthServicesinPrinceEdwardIsland2007-2011.DepartmentofHealth(PEI);2008Feb29.14p.Availablefrom: http://www.gov.pe.ca/photos/original/doh_waittimest.pdf

24.RoblingMR,PillRM,HoodK,ButlerCC.Timetotalk?Patientexperiencesofwaitingforclinicalmanagementofkneeinjuries. BMJQualSaf.2009;18(2):141-146.Availablefrom: http://qualitysafety.bmj.com/content/18/2/141.full.pdf

25.SteinLA.MakingtheBestUseofRadiologicalResourcesinCanada.HealthcPap.2005Oct;6(1)18-23.Availablefrom: http://www.longwoods.com/content/17719

26.ValenteR,TestiA,TanfaniE,FatoM,PorroI,SantoM,SantoriG,TorreG,AnsaldoG.Amodeltoprioritizeaccesstoelective surgeryonthebasisofclinicalurgencyandwaitingtime.BMCHealthServRes.2009Jan1;9:1.Availablefrom: http://www.biomedcentral.com/1472-6963/9/1

27.WrightJG,LiK,SeguinC,BoothM,FitzgeraldP,JonesS,LeitchKK,WillisB.Developmentofpediatricwaittimeaccesstargets. CanJSurg.2011Apr;54(2):107-110.Availablefrom: http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/cjs/vol-54/issue-2/pdf/pg107.pdf

28.AlbertaWaitTimesReportingWebsite:http://waittimes.alberta.ca/

29.CapitalHealth(Edmonton)AlbertaWaitListRegistryWebsite: http://www.capitalhealth.ca/NR/exeres/8BB0C6CA-B4CB-4A82-9888-A2797B285541.htm?NRMODE=Unpublished)

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aPPendix f – Consensus grouP survey

ThefollowingisthelistofquestionsaskedontheConsensusGroupsurvey. Eachquestionallowedtheopportunitytorespondasfollows:

Yes ___

No ___

If no, what do you recommend as an alternative? _____________________________________________________________

ParT 1: defining The mediCal imaging WaiT Time

1. Do you agree with the following definition for “MRI or CT Scan Referral Date”? MRI or CT Scan Referral Date: ThedateonwhicharequestforconsultationforanMRI

orCTScaniscompletedandsignedbythereferringclinician.

NOTE: Thisdatacurrentlycannotbecaptured

2. Do you agree with the following definition for “MRI or CT Scan Order Received Date”? MRI or CT Scan Order Received Date:ThedateonwhichtherequisitionforanMRI

orCTScanisreceivedattheMedicalImagingBooking(clerical)office.

NOTE:Question3capturestheissueofreceiptof“completed”request

3. Do you agree with the following definition for “MRI or CT Scan Completed Order Received Date”? MRI or CT Scan Completed Order Received Date: Thedateonwhichthecompletedrequisition

foranMRIorCTScanisreceivedattheMedicalImagingBooking(clerical)office.

NOTE:Sincetheremaybeconsiderabledelayrelatedtocompletionoftherequisition,thistimeperiodmustbecaptured

4. Do you agree with the following definition for “Medical Imaging Scan Completed Date”? Medical Imaging Scan Completed Date:ThedateonwhichtheMRIorCTScan

issuccessfullycompletedaspertheexpectedprotocol.

5. Do you agree with the following definition for “Report Verified Date”? Report Verified Date: Thedateonwhicharadiologisthasofficiallysignedoffonthewritten

reportforanMRIorCTexamination.Thisincludeselectronicsignature.

NOTE: Actualwhitepaperwillincludeastatementregardingacademiccenters,residentsandfellows

NOTE: Significantdelayscanoccurincenterswithoutvoicerecognitionandrelyingontranscription

6. Do you agree with the following definition for “Cancellation List”? Cancellation List:Alistofpatientsandtheircontactinformation,whoserequisitionshavebeenreviewed

andprotocolled,whoareavailabletoattendanMRIorCTScanappointmentatshortnotice,duetoa last-minuteavailabilityintheMRIorCTschedule.

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ParT 2: defining hoW WaiT Times are measured

7. Do you agree with the following approach for wait time “measurement”? Measurement:Waittimesaremeasuredincalendardays.

8. Do you agree with the following definition for “wait time”? Waittime:MRIorCTScanOrderReceivedDatetoMedicalImagingScanCompleteddate.Thewaittime

fromwhenareferralforamedicalexaminationisreceiveduntiltheexaminationiscompleted.

NOTE:Question9hasanalternatedefinition

9. Do you agree with the following definition for “wait time”? Wait time: MRIorCTScanCompletedOrderReceivedDatetoMedicalImagingScanCompleteddate.Thewaittime

fromwhenacompletedreferralforamedicalexaminationisreceiveduntiltheexaminationiscompleted.

NOTE: Question8hasanalternatedefinition

10. Do you agree with the following definition for “wait time for report”? Wait time for report: Thetimeintervalfromwhentheexamhasbeencompletedtowhen

thereportismadeavailabletothereferringphysician.

ParT 3: defining hoW WaiT Times are rePorTed

11. Do you agree that the following approach should be used in reporting on data on wait times? 90th percentile

NOTE:Questionondefinitionfollowsinquestion15

12. Do you agree that the following approach should be used in reporting on data on wait times? Median wait time


13. Do you agree that the following approach should be used in reporting on data on wait times? Average wait time


14. Do you agree that the following approach should be used in reporting on data on wait times? N3 time

NOTE: Questionondefinitionfollowsinquestion18

15. Do you agree with the following definition for “90th percentile” for reporting on wait times? 90th percentile wait time: 90%ofpatientswaitedlessthanorequaltothisnumberofdays

betweenthedatetheirreferralwasreceivedandthedateoftheexamination.

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16. Do you agree with the following definition for “median wait time” for reporting on wait times? Median wait time:Thisisthepointatwhichhalfthepatientshavehadtheirmedicalimaging

examinationandtheotherhalfarestillwaiting.

17. Do you agree with the following definition for “average wait time” for reporting on wait times? Average wait time:Thisistheaverage(ormean)lengthoftimeapatientwaitedto

have their medical imaging examination.

18. Do you agree with the following definition for “N3 time” for reporting on wait times? N3time:Thisistimeincalendardaysuntilthethirdnextavailableappointmentinthe

appropriatepriority(P)category.

ParT 4: The mediCal imaging WaiT Times PrioriTizaTion ClassifiCaTion/CaTegories ThaT aPPly To boTh mri and CT

19. Do you agree with using the following five-point priority classification system for reporting on wait times? P1

P2

P3

P4

SpecifiedProcedureDate

NOTE: Prioritydefinitionsarenotedinquestions20-24

ParT 5: defining The mediCal imaging WaiT Times PrioriTizaTion ClassifiCaTion/CaTegories

20. Do you agree with the following definition for P1 (priority 1) for MRI and CT in a priority system classification? P1: Emergent/Immediate: an examination necessary to diagnose and/or treat disease or injury that is immediately

threateningtolifeorlimb.

21. Do you agree with the following definition for P2 (priority 2) for MRI and CT in a priority system classification? P2: Urgent: an examination necessary to diagnose and/or treat disease or injury and/or alter treatment plan that is

notimmediatelythreateningtolifeorlimb.Basedonprovidedclinicalinformation,nonegativeoutcomerelatedtodelayintreatmentisexpectedforthepatientiftheexaminationiscompletedwithinthebenchmarkperiod.

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22. Do you agree with the following definition for P3 (priority 3) for MRI and CT in a priority system classification? P3:Semi-urgent:anexaminationnecessarytodiagnoseand/ortreatdiseaseorinjuryand/oraltertreatmentplan

whereclinicalsymptomsrequirethattheexaminationbeperformedsoonerthantheP4benchmarkperiod.

23. Do you agree with the following definition for P4 (priority 4) for MRI and CT in a priority system classification? P4:Non-urgent:anexaminationnecessarytodiagnoseand/ortreatdiseaseorinjurywhere,basedonclinical

information,nonegativeoutcomerelatedtodelayintreatmentisexpectedforthepatientiftheexaminationiscompletedwithinthebenchmarkperiod.

24. Do you agree with the following definition for Specified Procedure Date for MRI and CT in a priority system classification?

Specified Procedure Date:TheMRIorCTScanappointmentdaterequestedbytheordering physicianforthepurposeofdiseasesurveillance.

NOTE: SpecifiedProcedureDateisdifferentthanDatesAffectingReadinesstoTreat/Examine(DARTS)

ParT 6: benChmark Times

25. Do you agree with the following for “P1 maximum time interval target” for MRI and CT in a priority system classification?

P1:Sameday-24hours







NOTE: A90-daytargethasalsobeendiscussed

29. Do you agree with the following for the “radiologist report turn-around time” target? Radiologistreportturn-aroundtime:Urgentreports–sameday

Allotherexaminations-twocalendardays

NOTE: Actualwhitepaperwillincludeastatementregardingacademiccenters,residentsandfellows

NOTE:Significantdelayscanoccurincenterswithoutvoicerecognitionandrelyingontranscription

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ParT 7: defining daTes affeCTing readiness To TreaT/examine (darT)

30. Do you agree that DART lists should be compiled and DARTs should be captured and excluded from wait time calculations?

Dates Affecting Readiness to Treat/Examine(DART)-areusedtoidentifypatient-relateddelaysforMRIandCTScans.ExamplesofDARTsinclude:

• Patientchoosestodefer • Patientisano-show • Patientpreference • Patientisclaustrophobic • Patientdoesnotfollowrequiredpreparationleadinguptoscan • Newdisclosureofcontrastallergybypatient • Patientcannotbecontacted • PatientisnowanInpatientatanotherhealthcarefacility • IncompleteMRIorCTScanrequisition █Undisclosedbodyhabitus █Undisclosedrenalfunction • Additionalfollow-uprequiredforMRIsafetyreasons • Patientrequiredorbitx-rays,pre-MRI • Patientrequiringgeneralanesthetic • Patientrequiringinfusionforimaging • Patientnotproperlynotifiedbydoctor’sofficeofappointment • Patientcannotfindscannerlocationorappearedatwronglocation NOTE:SpecifiedProcedureDateisreviewedinquestion24

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ParT 8: defining CliniCal sCenarios falling under The PrioriTy CaTegories

31. Do you agree that it would be valuable for the Canadian Association of Radiologists in future to further define wait times for MRI and CT in the following sub-categories?

Neuro Yes____ No____ Spine Yes____ No____ MSK Yes____ No____ Body Yes____ No____ Oncology Yes____ No____ Pediatrics Yes____ No____ BreastMRI Yes____ No____ ObstetricalMRI Yes____ No____ Cardiac Yes____ No____ Prostate Yes____ No____ NOTE:Infuture,someofthecategoriesmaybegroupedtogether

ParT 9: defining The referral form

32. Do you believe that the Canadian Association of Radiologists should promote the following approach to referral forms for medical imaging requests?

AllreferralsforMRIandCTscansshouldcomplywiththenationalreferralstandards.

ParT 10: defining daTa QualiTy

33. Do you believe that the Canadian Association of Radiologists should promote the following approach to data quality in tracking and reporting wait times?

Toensuredataaccuracyandreportingcompliance,nationalstandards fordatacollectionandauditingshouldbeimplemented.

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ParT 11: inClusion/exClusion PoPulaTions

Inclusion:AllpatientswaitingforanMRIorCTscan

Exclusion:DefinedbyDARTS(question30)

34. Currently, some jurisdictions only capture data for wait times for outpatients and do not capture data for other areas, such as inpatients, emergency, pediatrics, and others. Do you believe that all patients waiting for an MRI or CT scan should be captured in the data?

ParT 12: Working grouP (Wg) ParTiCiPaTion and addiTional inPuT

35. The methods used by the WG to develop the national imaging maximum wait time targets were transparent (circle one).

Stronglyagree Agree Disagree Stronglydisagree1 2 3 4Comments:______________________________________________________________________

36. The methods used by the WG to develop the national imaging maximum wait time targets were appropriate.Stronglyagree Agree Disagree Stronglydisagree1 2 3 4Comments:______________________________________________________________________

37. I am satisfied with my opportunities to develop the national imaging maximum wait time targets.Stronglyagree Agree Disagree Stronglydisagree1 2 3 4Comments:______________________________________________________________________

38. What are possible barriers that you foresee to reaching the targets in your province, other than financial and human resource? ___________________________________________________

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All CAR membersMedical imaging organizations:CanadianInterventionalRadiologyAssociationCanadianAssociationofMedicalRadiationTechnologistsCanadianAssociationofNuclearMedicine(alsoaWaitTimeAlliancemember)CanadianSocietyofDiagnosticMedicalSonographersCanadianOrganizationofMedicalPhysicistsBritishColumbiaRadiologicalSocietyAlbertaSocietyofRadiologistsManitobaAssociationofRadiologistsRadiologicalSocietyofSaskatchewanOntarioAssociationofRadiologistsAssociationdesradiologistesduQuébecNovaScotiaAssociationofRadiologistsPrinceEdwardIslandAssociationofRadiologistsNewBrunswickAssociationofRadiologistsNewfoundland&LabradorAssociationofRadiologistsWait Time Alliance members:CanadianAnesthesiologists’SocietyCanadianAssociationofEmergencyPhysiciansCanadianAssociationofGastroenterologyCanadianAssociationofPaediatricSurgeonsCanadianAssociationofRadiationOncologyCanadianCardiovascularSocietyCanadianMedicalAssociationCanadianOphthalmologicalSocietyCanadianOrthopaedicAssociationCanadianPsychiatricAssociationCanadianSocietyofPlasticSurgeonsSocietyofObstetriciansandGynaecologistsofCanadaWait Time Alliance partners:CanadianAssociationofGeneralSurgeonsCollegeofFamilyPhysiciansofCanadaCanadianGeriatricsSocietyOther:CanadianMedicalAssociationandProvincial/TerritorialMedicalAssociationsProvincial/territorialgovernmentswaittimesrepresentatives

aPPendix g – sTakeholder ouTreaCh

613 860-3111 • [email protected] • WWW.Car.Ca

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