Paediatric Orthopaedic Clinic at the Children's Hospital of Western Ontario Custom Case Solution & Analysis

Evidence Brief: Paediatric Orthopaedic Clinic

1. Financial Metrics

• Funding Model: The hospital operates under a global budget from the Ministry of Health, meaning revenue does not increase directly with patient volume.
• Cost Structure: Surgeon compensation is distinct from hospital operational costs, creating a disconnect between clinical activity and facility resources.
• Resource Allocation: Capital for facility expansion is restricted by provincial health planning mandates.

2. Operational Facts

• Patient Volume: The clinic manages approximately 40 to 50 patients during a single half-day session.
• Wait Times: Patients experience average waiting room times of 3 to 4 hours. Initial appointment lead times for non-urgent cases often exceed 6 months.
• Staffing Ratio: Typically 3 surgeons, 2 residents, and 1 fellow per clinic session.
• Facility Constraints: 8 examination rooms are shared among all attending physicians and trainees.
• Process Flow: Registration occurs at the central desk, followed by potential X-ray imaging, then a multi-stage wait for resident and surgeon review.

3. Stakeholder Positions

• Dr. James Howard: Recognizes the current model is unsustainable and prioritizes patient access over traditional hierarchy.
• Trainees (Residents/Fellows): Require high-volume exposure for educational requirements but are currently bogged down by administrative tasks.
• Nursing Staff: Primarily focused on clinical support; their role in patient flow management is currently reactive rather than proactive.
• Referring Physicians: Frustrated by the lack of feedback and long delays for their patients.

4. Information Gaps

• Specific Referral Data: The case lacks a breakdown of referrals by severity or condition type (e.g., scoliosis versus simple fractures).
• No-show Rates: Data on patient cancellations or failures to appear is not quantified.
• Unit Costs: The specific variable cost per clinic visit is not detailed in the exhibits.

Strategic Analysis

1. Core Strategic Question

• How can the clinic increase throughput and reduce wait times given fixed physical space and a capped physician headcount?
• How can the clinic transition from a surgeon-centric model to a process-centric model without compromising educational outcomes?

2. Structural Analysis

The bottleneck is the surgeon. Current protocols require the attending surgeon to see every patient, regardless of the complexity of the case. This creates a queue where the most highly trained resource is performing tasks that could be managed by specialized nurses or physician assistants. The physical layout of 8 rooms for 6 providers (surgeons and trainees) ensures that providers are frequently waiting for rooms, or patients are waiting for providers in a non-synchronized manner.

3. Strategic Options

• Option 1: Advanced Practice Triage. Introduce a Nurse Practitioner (NP) to manage routine follow-ups and post-operative checks.
  • Rationale: Removes 30 percent of the volume from the surgeon bottleneck.
  • Trade-offs: Requires new funding for the NP salary; surgeons must relinquish direct control over routine cases.
• Option 2: Shift-Based Room Allocation. Implement a staggered start time for surgeons and residents to maximize room utilization throughout the day.
  • Rationale: Reduces the simultaneous demand for 8 rooms.
  • Trade-offs: Extends the total clinic day; requires changes to physician schedules.
• Option 3: Referral Filtering. Implement a mandatory standardized referral form to allow for pre-clinic screening.
  • Rationale: Ensures patients are seen by the right provider the first time and reduces unnecessary visits.
  • Trade-offs: May alienate referring family physicians who find the forms burdensome.

4. Preliminary Recommendation

The clinic should adopt Option 1. The primary constraint is surgeon time. By delegating routine follow-up care to an NP, the surgeons can focus exclusively on new consults and complex surgical planning. This directly addresses the 6-month wait list for new patients while maintaining the quality of care for existing patients.

Implementation Roadmap

1. Critical Path

• Month 1: Define NP scope of practice and secure provincial or hospital funding for the position.
• Month 2: Develop clinical protocols for routine follow-ups (e.g., cast removals, simple fracture checks) that do not require surgeon intervention.
• Month 3: Redesign the scheduling software to categorize appointments into Surgeon Only and NP Managed streams.

2. Key Constraints

• Physical Space: The 8-room limit remains the ultimate ceiling. Even with more staff, room turnover must improve.
• Physician Autonomy: Success depends on surgeons trusting the NP to identify when a case needs to be escalated.

3. Risk-Adjusted Implementation Strategy

Start with a 60-day pilot program where the NP handles only one specific type of follow-up (e.g., clubfoot maintenance). This allows the team to refine the hand-off process before expanding to more complex orthopedic conditions. Contingency: If NP funding is denied, the clinic must reallocate one resident to a dedicated triage role, though this may impact educational credits.

Executive Review and BLUF

1. BLUF

The Paediatric Orthopaedic Clinic must transition to a physician-led team model to address the 6-month wait list and 4-hour transit times. The current surgeon-centric bottleneck is the primary driver of patient dissatisfaction and operational inefficiency. By integrating a Nurse Practitioner to manage 25 to 30 percent of routine follow-up volume, the clinic can increase new patient throughput without expanding the physical footprint. This shift is required to maintain the reputation of the Childrens Hospital as a center of excellence.

2. Dangerous Assumption

The analysis assumes that referring physicians will provide high-quality data in their referrals. If the referral quality remains poor, the triage process will fail, and surgeons will still spend time on inappropriate or incomplete cases.

3. Unaddressed Risks

4. Unconsidered Alternative

The team did not fully evaluate a Virtual Triage model. Implementing a tele-health screening for all new referrals could eliminate 15 percent of unnecessary in-person visits before the patient ever enters the hospital, significantly reducing the pressure on the 8 examination rooms.

5. MECE Verdict

The proposed plan is APPROVED FOR LEADERSHIP REVIEW. The recommendations are mutually exclusive in their operational focus and collectively exhaustive in addressing the primary bottleneck of surgeon time and facility constraints.