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Predictable Surgery Program

Partner Institute: 
Centre for Health, Economics Research and Evaluation (CHERE), University of Technology, Sydney
Survey no: 
Marion Haas
Health Policy Issues: 
Quality Improvement, Access, Responsiveness
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes yes no no no no


The New South Wales Health Department has recently introduced a Predictable Surgery Program which consists of a series of strategies to ensure timely access to surgical services. One strategy to be adopted is 23 hour care units which are based on the premise that the majority of surgical care can be administered within a 24 hour period in a non-ward environment. A number of pilot projects have been undertaken and evaluated in preparation for the roll out of this strategy.

Purpose of health policy or idea

The purpose of the 23 hour care unit is to admit patients, prepare them for surgery, monitor and provide them with pain relief post-surgery before discharge - all within 24 hours. Key characteristics of the operation of a unit are:

  • screening of all admission notifications to identify those suitable for admission to the 23 hour care unit
  • selection of appropriate patients using criteria
  • flexible admission time to stagger patient admission
  • use of clinical protocol to inform and direct the patient's progress
  • availability and use of quarantined beds for planned surgical admissions 

All NSW Area Health Services (AHS) were directed to develop 23 hour care units by June 2005. Targets for additional booked (planned) surgery were agreed with each AHS and funding is delivered on the achievement of the targets; no funding is provided for additional work not undertaken.

Main points

Main objectives

The broad objective of the Predictable Surgery Program is to develop and oversee strategies and programs that ensure the people of NSW have predictable and timely access to appropriate surgical services. The objective of the 23 hour care unit is to admit patients, prepare them for surgery, monitor and provide them with pain relief post-surgery before discharge - all within 24 hours.

Type of incentives

All NSW Area Health Services (AHS) were directed to develop 23 hour care units by June 2005. Targets for additional booked (planned) surgery were agreed with each AHS and funding is delivered on the achievement of the targets; no funding is provided for additional work not undertaken.

There are also indirect financial and non-financial incentives available:

  • higher throughput will result in higher income via DRG payments for public patients and payments from private health insurance companies for private patients.
  • waiting lists for surgery are not popular among politicians or the public. being able to demonstrate a decrease in waiting lists is an important objective for the Minister for Health, the Department of Health and individual hospitals.

Groups affected

Patients awaiting/undergoing planned surgery, health care professionals working in surgical services, Area Health Services planning services

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low very low very high
Transferability strongly system-dependent rather system-neutral system-neutral

In NSW, this is an innovative idea. No similar processes have been reported from other States of Australia, but they may have been implemented both in Australia and in other countries. There is no controversy about the need to implement strategies to manage surgical waiting lists - however, it is not clear if the methods being implemented in NSW are in any way controversal amongst health care professionals. If successfully implemented, they could have fundamental impacts on the way surgical services are delivered and potentially important down-stream effects on admissions from ED. Some aspects of the pilot projects have been reported in the media but knowledge of this policy is not widespread amongst the geneal public. The ideas are easily transferable wherever there are surgical waiting lists and problems with waiting times.

Political and economic background

Waiting lists for surgery have long been a hot political topic in Australia and many election campaigns have had hospital waiting lists as an important issue. The issue is complicated by the presence of public and private facilities and the use of both types of facilities by the same surgeons - many individuals work some time as a provider to the public sector and some time in the private sector. The surgeons' offices generate the waiting lists, providing information about the clinical urgency of each patient's condition. Public hospitals have experienced budget constraints at the same time as demand for admissions has grown. As emergency and urgent admissions are given priorities, longer and larger waiting lists for non-urgent surgery have developed.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes yes no no no no

Origins of health policy idea

In August 2004, the NSW Minister for Health established the Surgical Services Taskforce (SST) to address the major issue of access for elective surgical patients. The response of the SST has been to develop the Predictable Surgery Program. One of the strategies of the Program has been the development of 23 hour care units. The NSW Department of Health has prepared a toolkit for distribution to all AHS and directed AHS to implement a 23 hour care unit by June 2005. The toolkit includes guidance regarding the formation and operation of a 23 hour care unit as well as providing information from a number of case studies - which are, in effect, pilot projects- related to the development and implementation of a 23 hour care unit.

Initiators of idea/main actors

  • Providers

Approach of idea

The approach of the idea is described as:

Innovation or pilot project

Pilot project - Three hospitals in Sydney have implemented projects related to surgical care.

Stakeholder positions

The toolkit released by the NSW Department of Health represents a policy paper. It provides detailed justification for the implementation of a 23 hour care unit in each AHS, information about how the development should proceed and advice in the form of case studies undertaken within the NSW health system. No opposition has been publicly voiced. The SST consists of prominent clinicians within NSW, who can be regarded as opinion leaders.

Actors and positions

Description of actors and their positions
Surgical Services Taskforcevery supportivevery supportive strongly opposed
Individual instigators of pilot projectsvery supportivevery supportive strongly opposed
NSW Department of Healthvery supportivevery supportive strongly opposed
NSW Minister for Healthvery supportivevery supportive strongly opposed

Influences in policy making and legislation

No legislation is required.

Actors and influence

Description of actors and their influence

Surgical Services Taskforcevery strongstrong none
Individual instigators of pilot projectsvery strongvery strong none
NSW Department of Healthvery strongstrong none
NSW Minister for Healthvery strongstrong none
Surgical Services Taskforce, NSW Department of Health, NSW Minister for HealthIndividual instigators of pilot projects

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The NSW Health Department and the surgical services with each of the major hospitals in each of the seven AHS in NSW are the main stakeholders involved in the adoption process. The tools required are those available in the toolkit:

  • the processes of service delivery
  • the patient pathway
  • roles of staff
  • step-by-step guide to implementation
  • availability of protocols

However, it is not clear if there are any further tools available ie financial incentives to implement a new system (ie for new equipment, refurbishment etc) or assistance to trouble-shoot (ie if particular problems or issues arise).

Monitoring and evaluation

No formal process of evaluation is foreshadowed. However, the introduction of the program has coincided with a drop in waiting times. The number of people in NSW waiting more than 12 months for planned surgery fell from 10,514 in January 2005 to 50 in June 2006. The government has claimed that this is the result of the Predictable Surgey Program (NSW Health press releases, June 2006, August 2005).

The guidelines stipulate that the protocols will be reviewed annually. In addition, the step-by-step guide sets out some activities which could be used to evaluate the 23 hour care units. For example:

  • reviewing data on high volume low-complexity procedures to ensure that the right patients are being targeted
  • reviewing patient care processes to ensure quality of care is maintained
  • reviewing staff competencies to ensure that appropriate training is provided
  • reviewing outcomes such as unplanned re-admission within x days, length of stay > 23 hours for unit patients, cancellations on day of admission, surgeon and patient feedback.

In addition, the evaluation of the case studies (pilot projects) indicated other outcomes worth monitoring for evaluation purposes:

  • transfers from ED to wards (should be expedited if fewer ward beds are used by surgical patients)
  • overall length of stay (LOS)
  • staff turnover - expected to reduce turnover of nursing staff

Results of evaluation

The evaluation of the case studies (pilot projects) showed that, in general, they achieved their objectives. They:

  • have demonstrated alternative means of managing waiting lists for non-urgent procedures
  • have increased throughput and reduced waiting lists
  • are acceptable to patients and surgeons
  • have produced no increase in adverse consequences or outcomes for patients
  • have reduced cancellation rates for non-urgent surgery
  • have reduced patient LOS

They also showed the major disadvantages of the 23 hour care units including:

  • procedures requiring equipment or significant post-operative care is not suitable- screening must be rigorous
  • deviations from the protocol (ie waiting for specialist assessment prior to discharge) increases LOS 

Expected outcome

It is likely that, if implemented in the same way as the pilot studies, 23 hour care units will be sucessful in reducing waiting lists and times for selected non-urgent procedures. This could have a knock-on effect on transfers from ED, urgent surgery times and working arrangements for doctors and nurses.

However, there are some lessons from the pilot projects that may need to be factored into the expected outcomes:

  • there is a need for intensive screening of all proposed admissions and coordination regarding surgical bookings, pre-admission procedures, surgeons, anaesthetists and the operating theatres.
  • the procedures to be covered by the unit must be agreed by the surgeons involved
  • orientation for junior medical staff and registrars is essential and ongoing re-education of other staff is vital
  • post-surgery discharge assessment and medication orders must be completed at the same time as post-operative orders to allow nurse-initiated discharge.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low neutral very high

Evaluation of the pilot projects suggests that there is no impact on the quality of care delivered to patients. Better discharge procedures may improve the quality of care from the patient's perspective. The level of equity should be improved if throughput is increased and waiting lists and waiting times reduced. There is no evidence that costs are reduced - they may be increased if throughput increases substantially or if more complex cases are admitted.


Sources of Information

NSW Department of Health (2005). Surgical services - 23 hour care units- Toolkit for implementation in NSW Health facilities. Document number GL2005_076

NSW Department of Health. More improvements in NSW public hospital performance. Print media press release, 21 June 2006. accessed 21/6/06

NSW Department of Health. 2005/06 surgery report card: waiting lists cut as surgery increases. Print media press release, 3 August 2006. accessed 3/8/06

Pollicino C, Hayward P, Hall J (2002). Economic evaluation of the proposed surgical scheme at Auburn hospital. CHERE Project report no. 19. Centre for Health Economics Research and Evaluation, University of Technology, Sydney.

Author/s and/or contributors to this survey

Marion Haas

Suggested citation for this online article

Marion Haas. "Predictable Surgery Program". Health Policy Monitor, October 2006. Available at