Knowledge Brief Health, Nutrition and Population Global Practice Increasing the Number of Major Outpatient Surgeries to Reduce the Waiting List in Costa Rica Ana Lucia Rosado Valenzuela, Ashley Sheffel, Micaela Mussini, Ana Maria Lara Salinas, Laura Di Giorgio August 2023 KEY MESSAGES: • Major outpatient surgeries have been shown to be cost-effective models of care compared to surgeries requiring hospitalization - they reduce hospital costs, make it possible to focus limited resources on more severe cases, help reduce the waiting list, and allow patients to recover at home by eliminating the risk of nosocomial infections. • The Costa Rican Social Security Fund progressively increased the percentage of major outpatient surgeries to more than 43% of the major surgeries performed in the system. • With the increase in outpatient major surgeries, Costa Rica reduced by 60% the waiting time (days) for other major surgeries. • Motivation for waiting list reduction, communication, and collaboration between levels of care and implementing centers, and the identification and utilization of available infrastructure and resources have been key to the increase in major outpatient surgeries. • The implementation of changes in the delivery of health services can present significant challenges due to the standardization of clinical guidelines and the approval of operating manuals. Introduction enabling waiting list reduction, and allowing patients to recover at home by eliminating the risk of nosocomial In just five years, major ambulatory (outpatient) surgeries infections. (3) (MAS) in Costa Rica increased from 18% to more than 43% of all major surgeries performed by the Costa Rican One of the biggest problems faced by the CCSS is the Social Security Fund (CCSS, for its name in Spanish, Caja waiting lists at the third level of care, which, among other Costarricense de Seguro Social), in six selected diagnoses things, has a major impact on the judicialization of (varicectomy, hernia, salpingectomy, bone biopsy, healthcare. However, Costa Rica has made progress in implementing an MAS program to improve the situation removal of bone-synthetic devices and laparoscopic and achieve timely care for its patients. (4) cholecystectomy).(1, 2) MASs have increased in popularity globally as a model of care that offers benefits As in many other countries, Costa Rica has seen an in reducing hospital costs by preventing patients from increase in the popularity of MASs. An evaluation being hospitalized (and thus occupying a hospital bed), conducted in 2018 showed that CCSS historical records helping to focus limited resources for more severe cases, evidenced a progressive increase in these procedures Page 1 HNPGP Knowledge Brief from 2010 to 2018. These surgeries are mainly performed generate an increase in these surgical care processes, the in the 29 second and third level hospitals of the CCSS, and CCSS selected the procedures to be performed on an only six of them concentrate close to 50% of the MASs outpatient basis, the specific rules for their execution, performed in the Institution.(2) On the other hand, of the and the general regulations of the facilities that decided total number of procedures on the CCSS surgical waiting to implement them. One year after these revisions, the list, 70% could be performed by MAS.(5) This makes the institution's first "List of Outpatient Interventions" was MAS an ideal way to reduce the surgical waiting list. published and updated three years later. Subsequently, in 2004, a project was generated to strengthen and MAS enhancement in the CCSS has been catalyzed modernize the health sector, which promoted all through the Program for Results (PforR), a World Bank outpatient solutions. In addition, in 2006, an indicator for financial instrument that incentivizes the achievement of the evaluation of MASs was included in the Management strategic objectives and goals of programs in which Commitments of the CCSS. (2, 7) governments seek to improve the use of general public expenditures or improve their performance using their Until then, the hospitals that performed AMS in Costa own processes and institutions. In Costa Rica, this Rica did so under their own internal manuals and without program ran from 2016-2023 for the Strengthening of institutional guidelines. For this reason, in 2015, the Universal Health Insurance. Its initial objectives included Medical Management generated the Plan for the modernizing and strengthening the primary health care Institutional Strengthening of Ambulatory Surgery. network, improving the quality of services, increasing However, more work is needed to implement it in a population coverage, and making the network more coordinated and comprehensive manner, as the need for capable of prevention, early diagnosis and control of institutionalization of an MAS program still persists. (5) diseases relevant to the local, national and regional epidemiological profile. In addition, the objective was Major Outpatient Surgeries in the face of also to improve the institutional and financial efficiency of the CCSS.(1) the Outcomes Program In addition, the increase in the number of MASs was One of the priorities established in the 2016 PforR possible due to the use of some facilitators that allowed planning was to increase the number of MASs in order to their adequate development and to the effort that reduce the surgical waiting list. The CCSS defines MASs as continues to be made in the CCSS to overcome the procedures with admission and discharge in less than 24 barriers and challenges encountered along the way. This hours.(5) Which, avoids the hospitalization of the patient knowledge report is part of a broader series of knowledge and the occupation of a hospital bed reducing then the reports developed by the World Bank on PforR in Costa waiting list and improving the health care model and Rica. This report aims to describe facilitators, challenges reducing hospital costs.(1) These objectives were linked and main lessons learned during the initiative to increase to Disbursement Linked Indicator #1 (ILD 1) of the PforR: MASs for waiting list reduction, with the objective of "Percentage of major surgeries on the priority list providing important inputs for other countries interested performed on an outpatient basis according to CCSS in implementing similar programs. institutional guidelines". Initially, this indicator would be met if after five years, MASs reached at least 43% of the Background total number of major surgeries performed in the institution. On the other hand, the procedures agreed In 1985, the first MAS procedures began to be upon as priorities to be measured within this indicator implemented in Costa Rica. Their initiation was the result were: of the interest of hospital health personnel in 1. Varisectomy implementing innovative methods that they had learned 2. Hernioplasty during their training abroad. (6) The first hospital to 3. Removal of osteosynthetic material implement them was Hospital Mexico. Following this 4. Bone biopsy pioneer hospital, some other tertiary care hospitals 5. Salpingectomy began to perform MAS. 6. Laparoscopic cholecystectomy Subsequently, in 2001, and with the enthusiasm to Page 2 HNPGP Knowledge Brief • Through the impulse of the PforR, and with the precedent had the guidance and technical support of the Major interest of some hospitals of the CCSS, a new intention to Outpatient Surgery Commission at their disposal, if increase the number of AMS was generated. To achieve requested. this, in July 2017, the Major Ambulatory Surgery Commission was formed to resume what was established At the same time, there was innovative collaboration in the Institutional Strengthening Plan for Ambulatory between different levels of care in some of the seven Surgery published in 2015. Accordingly, the Commission Integrated Health Services Delivery Networks (RIPSS), was responsible for developing strategic and technical which are the networks in which the Institution documents for the advancement of the plan (5): decentralizes the delivery of its services. There are four Comprehensive Health Care Centers (CAIS) throughout - Operational Manual for the Implementation of an the CCSS system. These health units are part of the first Ambulatory Surgery Program. level of care and have specialized services and installed - Work Plan to Strengthen Ambulatory Surgery at the capacity (operating rooms and health personnel) for Institutional Level. outpatient procedures. As a result, the RIPSS that have a - Workshop for the Socialization of the Operating CAIS in their territory generated agreements and Manual. collaborations to transfer outpatient procedures from - Diagnostic Survey of General Conditions for the the hospitals to the CASIs, in order to take advantage of Implementation of Ambulatory Surgery Program. this installed capacity. The Operational Manual was submitted to the CCSS COMPLIANCE WITH THE INTERVENTION Medical Management in November 2018 but has not yet INDICATORS been approved, limiting the standardized implementation of the program at the institutional level. In 2013, the percentage of priority MAS procedures Instead, implementing hospitals and health centers have within the PforR accounted for only 18% of all major progressed with the development of ILD 1, through great surgeries. Just 5 years later, in 2018, it was possible to individual efforts. In turn, with the common goal of increase this percentage above the target of 43% reducing the waiting list, there has also been established as part of the PforR. With this, the CCSS collaboration with the Technical Unit of Waiting Lists achieved compliance with the indicator agreed, in (UTLE), a technical body attached to the Medical conjunction with the World Bank, at the beginning of the Management of the CCSS, which analyzes and monitors program. statistical data on the waiting list throughout the institution (surgeries, procedures and outpatient), in In addition, there is an intermediate indicator that is of addition, it has an allocated budget to implement great interest for this project, the decrease in the waiting resolution modalities that improve them. list for hip and knee replacement surgeries. This indicator allowed the measurement of one of the main objectives Strategic Planning and Implementation of the MASs, to improve efficiency and reduce waiting Technical guidance and follow-up for the increase of times in care. In 2015 the wait for knee or hip surgery was MASs is performed by the Major Ambulatory Surgery 1,032 days. Thanks to increases in the MAS, and other Commission.(5) The implementation of these surgeries hospital efficiency programs implemented by the CCSS was carried out in the 29 hospitals and in some first level (e.g., the evening surgery program, surgeries that are care centers of the system. Hospitals have been key in performed outside of regular working hours to make increasing the proportion of AMS. The main reason for efficient use of installed capacity), this indicator dropped them to achieve this positive change was a call for by 60% by 2018, reducing the wait to 422 days; a goal that institutional action to reduce long waiting lists in far exceeded the original goal set of a 35% reduction.(1, different services and procedures. This call allowed 8) hospitals that had already been implementing MASs for On the other hand, although institutional evaluations decades to find ways to increase them even more, and have not yet been made, some units have conducted hospitals that had low numbers of MASs to gradually satisfaction surveys of their MAS patients and the increase their proportion. To achieve this, all hospitals responses regarding their care have been positive. (6) Page 3 HNPGP Knowledge Brief FACILITATORS Being a PforR objective: The increase in MASs was one of The increase in MASs was achieved in part by the correct the indicators promoted through the PforR, by common conjunction of some specific factors. agreement between the CCSS and the World Bank. This ensured that the actions established are being effective Timely care as an institutional priority for the CCSS: in achieving the projected goals for reducing the waiting There is great institutional interest and commitment in list through MASs. the reduction in the waiting list. As a result, this priority has been integrated into the Institutional Strategic Plans, and action plans (for example, the Timely Care Plan) and departments responsible for implementing projects (such as the UTLE) have been created to reduce waiting times.(4, 9, 10, 11) All this becomes a great catalytic platform for MASs. Creation of a specific commission: The creation of the Major Outpatient Surgery Commission allowed progress to be made in the agreements necessary for the Figure 1. Comprehensive Health Care Center in the town generation of key documents to advance in the of Desamparados. Credits: Soto, Adrián. (12) institutionalization of MASs, communication and follow- up of priority indicators in hospitals, as well as training CHALLENGES ENCOUNTERED and mentoring in the health centers that required it. (6) Institutional progress in increasing the proportion of Networking: The CCSS decentralizes the management of MASs has presented some barriers that continue to be health services to the seven RIPSS that comprise it. In addressed to date. each of them, there has been an active channel of Governance and leadership: Although the CCSS has communication between the Medical Management, the shown great interest in the issue of timely patient care, directors of the RIPSS, the hospitals and health centers, the lack of a technical body responsible for the to encourage the increase in the number of MASs. (9) In standardized implementation of the project in the health addition, this important collaboration has been centers has resulted in unclear roles and responsibilities. generated for the transfer of patients waiting for surgery Actions are divided between the Commission and the in the hospitals to the CAIS, in order to improve the UTLE. (5) waiting list. Bureaucracies and administrative inefficiencies: Taking advantage of installed capacity: CAIS operating Approval times for the Operating Manual have been very rooms were originally created for vaginal or cesarean long due to internal bureaucracies.(13) Process that births, but the demand for their use for these purposes intensified with the disruption from the COVID-19 has been low. Hospitals saw this opportunity to transfer pandemic. This delay has limited the potential and perform their MASs in these centers, taking institutionalization and standardization of the MAS advantage not only of the infrastructure, but also of the program in the CCSS, including the regulatory framework, personnel available in them.(6) the organized structure, surgery scheduling and control mechanisms, among others. (5) Existence of a digital health record: In 2018, the integration of the Single Digital Health Record (EDUS) was Independent implementation: Hospitals implement completed in all CCSS hospitals. One component within their MAS programs independently, in the absence of the EDUS is the EDUS-ARCA system, which allows virtual institutional standardization. Although this allowed follow-up of patients' clinical and surgical history from hospitals to explore innovative approaches from which any health center. This portability of information the Institution could learn, it has also led to differences in between levels of care is vital in ambulatory processes as the proportion of MASs performed by hospitals. One of it allows the clinical record to be traceable throughout the reasons for this difference is the availability of the ambulatory care continuum. resources at each hospital. The institutionalization of an MAS program will be important to level out these Page 4 HNPGP Knowledge Brief • differences between hospitals and ensure the same Rapid advancement in technologies and update of standards and processes, according to the local context. procedures eligible as ASC: Due to the great technological advancement in surgery, the procedures to Regional differences: Although there is a desire to be performed under ASC and the clinical guidelines increase the percentage of MASs in all hospitals, the necessary for their execution change rapidly.(14) Due to contextual reality and the variability of available this, the list of procedures authorized to be performed resources (location in rural areas and lower budgets) under MAS has to be constantly updated. It was last make this difficult. For example, there are centers that do updated in 2004. It is therefore important to have a not have timely access to specialized medical equipment routine updating system. in the event of any post-surgical complication.(14) Therefore, these facilities present more challenges in the COVID-19: The COVID-19 pandemic caused disruption in implementation and a greater fear by the health the delivery of hospital and administrative services.(15) personnel of performing MAS. It is therefore important As a result, pending approvals of the Operational Manual to remember that the implementation of MAS needs to and the accelerated increase in MASs were paused for be adapted to the local context. about two years. Fortunately, the administrative and clinical processes are being reactivated. Limited human resources: The limitation in the number of human resources needed to perform MAS has been THE ROAD AHEAD AND THE GAPS TO BE CLOSED one of the main barriers to reducing the waiting list. In The next steps for the CCSS to advance in MASs in an addition, the distribution is inequitable among the institutional manner include the approval of the different units in the country. In spite of this, programs Operational Manual and the generation of a routine are being established to improve the equitable system for updating the list of procedures. With this, distribution of health personnel in areas with the greatest major outpatient surgeries can be implemented in a backlog and to take advantage of the infrastructure more standardized manner throughout the institution. available in other facilities. This progress would allow the expansion of these Standardization of clinical guidelines: At the beginning, procedures to other first or second level health centers, the process of agreement to structure the clinical as has been achieved in the CAIS. On the other hand, and guidelines for patient selection and the procedures in order to continue improving the provision of services, we intend to evaluate the impact of MASs on hospital selected for MAS was complicated. The main challenge efficiency (e.g., in the reduction of hospital costs) and was the diversity in clinical criteria among health professionals. Fortunately, this was resolved thanks to patient satisfaction. the creation of the MAS Commission, which favored the Box 1 summarizes some of the lessons learned in this discussion and agreement of the guidelines. initiative to increase MAS in the CCSS, so that these can Resistance to change: At the beginning, some physicians serve as a guide for other institutions or systems that showed resistance to the implementation of the wish to implement a similar program. ambulatory care model due to fear and lack of knowledge The CCSS will continue to advance on its path towards about it. This resistance diminished as we noticed improving hospital efficiency by growing its network of successful cases of MAS and patients' requests to be MAS implementation throughout the system. These treated on an outpatient basis. In addition to witnessing future advances will bring further reductions in costs and the positive experience in its implementation and the waiting lists, better utilization of hospital beds, and above benefits of generating more capacity in the Costa Rican all, improved satisfaction of health service users. health system. Page 5 HNPGP Knowledge Brief Box 1. Lessons learned • MASs are one of the models of care that has led to the successful reduction of the surgical waiting list at the Caja Costarricense de Seguro Social (Costa Rican Social Security Fund). • Obtaining the political will and support of the Institution's senior management is important to prioritize actions to increase the number of MASs and to speed up the manual and implementation guide approval processes. • Allowing hospitals to implement different approaches to increase MAS made the Institution aware of various forms of implementation by the main implementers. • In order to guarantee an equitable system, an institutional standardization process that takes into account the contextual difference by region is necessary. • Collaboration between different levels of care in regional contexts made it possible to take advantage of the installed capacity to increase the proportion of MASs. • The model of collaboration and transfer of ambulatory surgeries between levels of care has been so successful that for the future increase in the proportion of MASs, the necessary means will be sought for its implementation at the national level. The World Bank's Health, Nutrition and Population Knowledge Briefs are a quick reference on key aspects of specific HNP-related topics that summarize new findings and information. They can highlight a problem and key interventions that have proven effective in improving health, or disseminate new knowledge and lessons learned from the regions. For more information on the topic, visit: www.worldbank.org/health. Generous funding support for this series of Knowledge Briefs was made possible by The Access Accelerated Trust Fund. Page 6 HNPGP Knowledge Brief • References The World Bank. Program Appraisal Document for a Strengthening Universal Health Insurance in Costa Rica. Program-for-Results. 2016. 2. Bronstein Krausz LD. Verification Report: disbursement-linked indicator #1/Milestone 1: Increase in major surgeries in ambulatory settings Pan American Health Organization; 2018. 3. Recart A. MAJOR AMBULATORY SURGERY. A NEW WAY OF UNDERSTANDING SURGICAL MEDICINE. Clinica Las Condes Medical Journal. 2017;28(5):682-90. Costa Rican Social Security Fund. Plan for the Timely Care of Individuals. 2017. p. 61. 5. Costa Rican Social Security Fund. Internal Audit: SPECIAL STUDY ON AMBULATORY SURGERY AT INSTITUTIONAL LEVEL. 2019. 6. Morera JC. Interview with the CCSS/BM Outcomes Program - Major Outpatient Surgeries. In: Rosado Valenzuela AL, editor. 2023. Costa Rican Social Security Fund. Informe de Evaluación de los Compromisos de Gestión 2008-2009. 2010. CCSS/WB Program for Results. Matrix Report: Comprehensive Progress Report on the CCSS-World Bank Program for Results. 2022. 9. Vega Martínez LC. Major Outpatient Surgery Interview, Programa Por Resultados CCSS/BM. In: Rosado Valenzuela AL, editor. 2023. Costa Rican Social Security Fund. Institutional strategic plan 2015-2018. 2015. Costa Rican Social Security Fund. Institutional strategic plan 2019-2021. 2019. 12. Soto A, Ávalos Á. Sanitary order leaves without emergency surgeries to CAIS of Desamparados. La Nación. 2022. 13. Arroyo LP. Interview Program by Results CCSS/BM. In: Rosado Valenzuela AL, editor. 2023. Cambronero E. Interview Program by Results CCSS/BM. In: Rosado Valenzuela AL, editor. 2023. 15. Prensa Latina. Costa Rican Health System resumes services to the population. 2022. Cover photo credits to Mayela López, La Nación, CCSS wants to increase outpatient surgeries to lower waiting lists , 2017. https://www.nacion.com/el-pais/salud/ccss-quiere-aumentar-cirugias-ambulatorias-para-bajar- listas-de-espera/W57BVAQ7EFCWDH56QAHZM4PFGU/story/ Page 7