Knowledge and behaviour for a sustainable improvement culture.

Wait limits have improved UK healthcare access, and Ontario's Wait Time Strategy bears a remarkable resemblance. There appears to be an implicit assumption that capacity and efficiency factors are the main causes of waits. The improvement mechanism is driven by performance measurement that reports wait time outcomes. Our experience makes us conclude that Ontario's plans contain risks. Superficially, the UK approach has been successful with dramatic wait time reductions but has incurred tremendous financial cost and patients not always benefiting. Reasons for partial success are not understanding the cause of waiting, with inappropriate"improvements"; and often encouraging unintended behaviours, with poor stakeholder management. Those sustaining their approach have significantly better performance and timely service without excess cost, but their approach has not seen a wide enough audience for acceptance and adoption. At the top, there is almost bewilderment about why others struggle with wait time targets. For an effective program it is essential to understand the system and have consistency between the measurement system and engendered behaviour, the root causes of waits and solutions, the management style and improvement culture, the reward system and good clinical practice.