Abstract
Importance
Single-entry models (SEMs) can decrease wait times by placing patients in a common queue to see the first available physician. SEMs may be suitable to manage wait times in pediatric otolaryngology; however, understanding is lacking on stakeholder perceptions, and no previous studies have evaluated SEMs specifically for pediatric otolaryngology patients.
Objective
To evaluate the views of referring physicians and otolaryngologists on the role of SEMs in managing surgical backlogs for high-volume procedures, and to investigate their recommendations for optimal SEM design and implementation.
Design
A qualitative study using semi-structured interviews (according to COREQ and SRQR guidelines).
Setting
Primary care and referral settings across Ontario, Canada.
Participants
Twelve referring physicians who refer to pediatric otolaryngologists and 11 otolaryngologists were recruited through purposive sampling. Eligibility criteria included physicians that work in Ontario.
Intervention or Exposures
This study investigated the perceptions of referring physicians and otolaryngologists on the concept of implementing SEMs for pediatric otolaryngology.
Main Outcome Measures
Referring physicians’ and otolaryngologists’ perceptions of SEMs as a method of managing wait times in pediatric otolaryngology.
Results
Four thematic domains, each with subdomains, were identified: (1) perceived value of SEMs; (2) operational design and digital integration; (3) evidence and resourcing; and (4) adoption, scope, and system pressures.
Conclusions
SEMs are viewed as a viable option to address the surgical backlog in pediatric otolaryngology, from the perspective of referring physicians and otolaryngologists.
Relevance
Implementation of an SEM should consider ease of use, adequate support resources, strong and regular communication with all stakeholders, long-term funding, and transparency.
Keywords
Key Messages
Clinicians see SEMs as a promising solution to optimizing patient flow and reducing wait times in pediatric otolaryngology.
Effective implementation depends on trust, transparency, and strong communication between primary care providers, pediatric otolaryngologists, and system administrators.
Ensuring adequate funding and resources, as well as measuring metrics such as wait times, stakeholder satisfaction, and cost-effectiveness, are key to the long-term success of an SEM.
Background
Prolonged surgical wait times have long been a challenge for the Canadian healthcare system.1 -4 This problem was exacerbated by the reduction in elective surgeries during the COVID-19 pandemic in response to increased healthcare demands.5,6 Irrespective of funding and other initiatives that have been proposed by Canadian provincial governments, this challenge remains.3,4 In pediatric populations, including pediatric otolaryngology patients, wait times can be extensive.7,8 Failure to perform these surgeries in an appropriate period of time may result in lifelong consequences for the patients.7,8 However, pediatric patients are seldom prioritized in suggestions made for decreasing surgical wait times. 7
Single-entry models (SEMs), often referred to as central intake models, are a suggested method for proficient management of surgical backlogs.9 -13 Derived from queuing theory, SEMs have demonstrated successful wait time reductions in multiple industries.10,11 Within the healthcare system, SEMs aim to improve flow by directing patients through a single queue where they wait to see the first available surgeon.11,14
In Canada, SEMs have been increasingly incentivized by governments and regulatory bodies over the past decade. In an effort to reduce wait times and improve referral triage, the Canadian Medical Association endorsed SEMs in 2014. 15 Additionally, in 2021, the Ontario Government allocated $18 million toward the use of centralized surgical waitlist management across various medical and surgical specialties.12,16,17
SEMs show promise in decreasing wait times for patients, in addition to the potential of simplifying the referral process for primary care providers. 18 The implementation of SEMs in otolaryngology has been investigated13,19; however, no research has examined the use of SEMs in pediatric otolaryngology specifically. Stakeholder perceptions have not been well elucidated, and more information is needed to inform procedure scope, geographic coverage, ideal structures, and implementation barriers in this subspecialty. This manuscript is the first of a 2-part series that investigates SEMs as a potential solution for managing pediatric otolaryngology surgical backlogs across Ontario. In this manuscript, the perspectives of referring physicians and otolaryngologists are explored (Part I).
Materials and Methods
Western University’s Research Ethics Board provided ethics approval for this research project (REB # 124261).
Study Design
Qualitative research methodology, more specifically interpretative description, was implemented to conduct this study and explore the perceptions of clinicians on the utility of SEMs in managing surgical backlogs in pediatric care. 20 This qualitative approach provided a flexible framework through which prominent clinician perspectives and priorities could be identified, informing actionable takeaways for future SEM implementation and refinement. 20 Interviews were conducted and transcribed using Microsoft Teams (Version 1.6.00.27547; Microsoft Corp). Transcripts were reviewed and de-identified by a study team member (A.L.).
Data Collection
Purposive sampling was employed by senior author J.E.S. via email to recruit otolaryngologists, and physicians that refer patients to pediatric otolaryngologists for routine procedures. Inclusion criteria for referring physicians included physicians in Ontario that refer patients to pediatric otolaryngology that were fluent in English, and exclusion criteria included those who worked outside of Ontario or did not refer patients to pediatric otolaryngology. Inclusion criteria for otolaryngologists included otolaryngologists in Ontario, fluent in English, who hold/held clinical, managerial, administrative, public service, or scholarly roles. Exclusion criteria consisted of those who worked outside Ontario or did not hold roles described by the inclusion criteria. Clinicians that expressed interest were contacted in English by J.S. via email to schedule interviews.
Interview questions were developed by the research team through consultation with subject matter experts and literature review and based on an existing interview guide used by Shapiro et al 19 Each participant was asked a series of 12, open-ended questions, some of which had additional sub-questions (Appendices A and B). Prompts varied slightly depending on if the participant was a referring physician or otolaryngologist but inquired about the same topics.
Semi-structured interviews were then conducted in English with the consented participants in April and May 2024 by C.P., O.S., S.H., V.G., J.S., L.K., and M.Z. Interview transcripts were reviewed on an ongoing basis by the research team. Recruitment concluded when redundancy was evident in the responses and interviews no longer elicited novel insights. Researchers agreed that thematic saturation was achieved when the aforementioned criteria was met. Participants were emailed a $50 e-gift card for voluntary participation in the study.
Data Analysis
Thematic analysis was employed to analyze interview transcripts, chosen for its flexibility and capacity to identify, describe, and organize themes across a large dataset. 21 An inductive coding approach was implemented, with coding conducted separately for referring physicians and otolaryngologists. Trustworthiness of the analysis was ensured through several strategies. To establish credibility, researcher triangulation was implemented by having 2 researchers independently code each de-identified dataset using NVivo 14 software (Version 14; QSR International Pty Ltd). 21 Researchers O.S. and V.G. coded the referring physician data and researchers O.S. and L.K. coded the otolaryngologist data. Peer debriefing was then completed by V.G., O.S., L.K., and J.S. to provide an external check on the data and support the authenticity of interpretations. Dependability was established by documenting the respective coding frameworks and confirmability was maintained by having researchers reflect on their biases throughout the analysis, when appropriate. 21
Through this process, themes and sub-themes were developed separately for the referring physicians and otolaryngologists using their respective codes. Manuscript writers then reviewed these themes and subthemes to identify points of overlap and redundancy and reorganized the key points in a manner that was succinct and digestible for a manuscript. Transferability was incorporated by including direct quotes and contextual descriptions throughout the results section below. 21
Researcher Reflexivity
The research team consisted of medical trainees, surgeons, and administrative leaders with varying levels of experience in pediatric otolaryngology and qualitative inquiry. The diversity of professional backgrounds facilitated critical discussion during theme development and interpretation. Reflexivity was maintained through iterative peer debriefing and reflection on assumptions, ensuring that analytic decisions remained grounded in participants’ perspectives rather than researchers’ preconceptions.
Results
Twelve referring physicians (RPs) and 11 otolaryngologists (O) participated. Findings were organized into 4 overarching themes with subthemes: (1) perceived value of SEMs; (2) operational design and digital integration; (3) evidence and resourcing; and (4) adoption, scope, and context. The themes build from what participants hoped an SEM would achieve, to how it should work in practice, what proof and inputs are required, and the conditions that would shape uptake.
Theme 1: Perceived Value of SEMs
This theme captures why participants saw SEMs as worthwhile. The subthemes focus on efficiency, patient-centeredness, and clinician equity, which together set expectations for downstream design choices.
Efficiency
Participants anticipated SEMs would streamline pathways to intervention and reduce bottlenecks by decreasing “wait times and administrative burden” (RP5). This emphasis on smoother progression from referral to assessment was repeatedly linked to reduced referral redundancy, more predictable timelines, improved patient redirection during a surgeon’s leave of absence, and enhanced efficiency.
Patient-Centeredness
Participants viewed SEMs as an opportunity to increase patient-centeredness through transparency and shared decision-making. This includes adding a feature for families to select how they proceed with the model, such as “opting in or opting out” (O11), and providing physicians and patients with more information about “what the status of the referral is” (RP5). Clear and frequent status updates and workflow processes were expected to better align with family preferences and to reduce frustration during waiting periods. Furthermore, participants believed SEMs would also improve access to specialized health services by removing geographical barriers, making the referral process “more objective” and “fair, . . . no matter where you are” (RP4). It was also expected that this would allow sooner access to care and improve patient outcomes.
Clinician Equity
Clinician equity emerged as a perceived advantage of more standardized distribution, both conceptually as a fairer system and in practice through more balanced workloads. As 1 participant summarized, a SEM, “if administered correctly, could actually increase equity for clinicians” (RP4). Some also pointed to pooled models in which “there’s a pool of referrals and you can . . . choose if you’re available and. . .can accept whatever the next referral online is” (RP1), reflecting efforts to balance equity with physician autonomy.
Theme 2: Operational Design and Digital Integration
Building on the perceived value, participants described what would make an SEM workable in everyday settings. The subthemes highlight a consistent workflow, interoperable systems, administrative support, and referral process standardization.
Workflow and Usability
Participants emphasized that process reliability depends on a simple, consistent workflow embedded in daily practice. Attempts to coordinate similar processes manually were described as “very hard to accomplish if it relies on back-end communication among [multiple] secretaries” (O1). A workable SEM was described as “user friendly,” “straightforward,” and “works [with] their workflow” (RP6), minimizing extra steps and avoiding parallel paper or email trails. Additionally, participants identified the need for adequate training and support on how to navigate the electronic system, such as “having tutorial videos online” (RP1).
EMR Interoperability
Interoperability was seen as foundational to both initial triage and ongoing communication among stakeholder groups. Participants highlighted the importance of SEM connectivity “to [their] EMR so information comes in and out of [the] EMR like it does with Ocean [MD],” (RP9), an existing electronic referral, communication, and consult platform. They further emphasized the need for systems to “talk to each other” (O2). Integration was framed as a prerequisite for consistent use.
Administrative Support and Oversight
Operational success was tied to basic administrative supports that keep processes moving. Participants noted the need for “administrative staff to monitor the referral process” (O5) and for system-level oversight so “no one waitlist is getting out of control” (O4). These roles were positioned as preventing fragmentation and ensuring timely handoffs between steps.
Referral Process Standardization
Streamlining referral processes was seen as crucial to minimize back-and-forth and avoid re-referrals between referring physicians and otolaryngologists. Participants pointed to a submission flow “where you could write a brief description and easily upload attachments” (RP1). When it came to distributing cases, some endorsed pooled assignment principles such that “whatever surgeon is available, the case would be allocated to” (O5). Together, these features were seen to promote clearer referral pathways and reduce inefficiencies caused by varying specialist requirements, aligning with the workflow and digital expectations described above.
Theme 3: Evidence and Resourcing
Participants then turned to what would sustain an SEM beyond initial rollout. They emphasized the need for credible evaluation, cost visibility, and sufficient clinical and administrative capacity.
Evaluation and Metrics
Trust in SEMs was linked to measurement and reporting that reflect real-world practice. Participants emphasized that “data is helpful in terms of changing people’s minds” (O8). They cited downstream indicators as meaningful, including “how many additional ER visits were avoided by implementing a system that accesses care faster” (RP5). Participants underscored the importance of pilot studies and ongoing reporting to demonstrate impact through measures such as waitlist trends, cost-effectiveness, and patient-centered outcomes in ways that are meaningful to different stakeholders.
Costs
Participants highlighted the importance of ensuring evaluations account for all resource requirements, including “the cost. . . to set up the program [and] the software” (O5). Transparency around these costs was viewed as key to building stakeholder support and ensuring long-term sustainability.
Capacity and Roles
Clinical and administrative capacity were repeatedly mentioned as prerequisites for stability. Respondents cautioned that without adequate resourcing “it’s just [going to] fall apart. Or it’s [going to] become less quality and then people are [going to] stop using it” (RP5). Hospital-level determinants were also emphasized: “we need to open up more operating room time, which is not a physician problem, it’s a hospital structure problem” (RP9). Ideal province capacity was summarized succinctly as “in an ideal world, . . . you have more surgeons, you have more sites, you have more manpower” (RP1). Several also pointed to focused administrative responsibilities, including a “dedicated role to deal with the administrative side” (O2), to improve reliability during early rollout and scaling.
Theme 4: Adoption, Scope, and System Pressures
Finally, respondents discussed how participation choices, service boundaries, and wider pressures would shape real-world uptake.
Participation Model and Choice
Perspectives varied on whether participation should be mandatory or optional for patients and surgeons. Some anticipated standardization where “there’s not really a choice with it” (O7), while others emphasized autonomy, such as “the patient has the choice to enter the model or not” (O5). Views on standardization were also shaped by family preferences and existing referral patterns, with “some parents who are very much attached to certain surgeons” (O1). Referring physicians reflected on the trade-offs between streamlined routing and individualized matching, noting that in a more standardized model “you may have that element of choice taken away from you and that takes away in some ways the ‘art of the referral’” (RP12).
Scope and Rollout
Participants discussed geographic and service scope, emphasizing proximity, clear boundaries between consult streams and operating room lists, and cautious scaling. Early rollout was often framed around local or regional access, with participants noting that “appointments must be somewhere where patients can [reasonably] get to” (RP9). Some cautioned that scaling too broadly could be risky, describing provincial rollout as “begging for disaster” (O2). Views differed on the scope of SEMs, particularly whether they should apply to initial consultations or the operating room waitlist. Participants clarified that SEMs are distinct from operative queues, while the initial clinical encounter remained central to triage: “you’ve got to get the child into the office for that initial consultation. . . I think the surgeon can then prioritize if the surgeries are actually necessary, non-urgent or semi-urgent” (O2). Postoperative pathways were also highlighted, including that “from a postoperative perspective if you had a complication, [the local team would] still see you versus if it comes in at the provincial level” (O9).
System Pressures
Otolaryngologists described an environment of unprecedented demand and constraints, particularly following the COVID-19 pandemic. One summarized the situation as follows: “It has exploded to the point where I’ve never seen it like this. . . three years ago my waitlist was two months, and now it’s well over a year” (O10). Participants also noted that pandemic-related system responses created “restrictions on how many pediatric surgeries we [can] do per day” (O9). Furthermore, some primary care providers were described as uncertain about referral pathways, leaving them “confused” about where to direct patients (O7). Together, these pressures help explain why participants returned to the design, evidence, and resourcing elements outlined earlier.
Discussion
This study explored how referring physicians and otolaryngologists in Ontario view SEMs for pediatric otolaryngology. Participants described why SEMs are valuable, what operational features would make them workable, what evaluation and resources are needed to sustain them, and how participation, scope, and wider system pressures would shape real-world uptake. Together, the themes suggest that a well-designed SEM could shorten waits and improve patient experience, provided it is simple to use, integrated with existing systems, adequately resourced, and implemented with clear communication and shared expectations.
Participants underscored that pediatric otolaryngology faces unprecedented demand, with surgical waitlists exacerbated by the COVID-19 backlog and ongoing limitations on pediatric surgeries.5,6,22 This aligns with broader trends in surgical backlogs across specialties and underscores the need for strategies like SEMs to improve patient access. 10
Participants highlighted themes that align with current policy directions in Ontario toward centralized intake and waitlist management, and with national professional endorsements of SEM principles.15 -17 The literature consistently reports that centralized models can reduce waits across multiple specialties, which supports participants’ expectations that an SEM would improve timeliness of care in the context of pediatric otolaryngology.12,22 -27 At the patient level, prior studies associate SEMs with improved satisfaction, which is created through transparency, status updates, and clearer navigation, as also emphasized by participants in this study.22,28,29
Participants framed SEM success as contingent on everyday usability, EMR integration, and reliable administrative support. This is consistent with prior reports that poor user interfaces and fragmented infrastructure can undermine centralized intake, even when the underlying model is sound. 30 Practical implications for Ontario include building or selecting tools that integrate with common EMRs, minimizing duplicate entry, and standardizing referral processes to reduce back-and-forth. The expected reductions in duplicate referrals and unnecessary visits have additional system implications. Prior studies suggest centralized intake can decrease avoidable travel and visits, which may lower health-system carbon emissions; participants’ descriptions of fewer redundancies are consistent with these effects.22,28
Participants also identified small but reliable administrative supports to monitor queues and ensure handoffs. When these basics are absent, programs encounter user interface problems and fragmented infrastructure, which underscore the need to invest in usability from the outset.22,28 -31 Change management principles highlighted in the literature also mirrored what participants asked for, including visible leadership, champions, and routine communication to explain what is changing, why it matters, and how concerns will be addressed.27,31 -33 Pilot implementations, which many otolaryngologists endorsed, can serve as a starting point to generate baseline data and identify workflow pain points to ensure a successful large-scale rollout.10,11,27
Participants anticipated that SEMs could serve as a method of enhancing patient-centeredness and improving patient equity as it has been posited that they may mitigate geographic barriers, allowing for clearer pathways and more consistent access to care. 12 Furthermore, SEMs have the potential to reduce surgeon selection bias and ensure equitable allocation of patients among physicians. Gender inequity among physicians is well studied, and same-sex referral bias among male physicians has been described. 34 SEMs may mitigate these referral biases based on gender and reputation. They may also alleviate physician stress and burnout by redistributing surgical cases, making SEMs an attractive referral system for many pediatric otolaryngologists.12,34 Moreover, SEMs may reduce healthcare’s carbon footprint by eliminating inappropriate referrals and decreasing unnecessary healthcare visits. Accordingly, less patient travel will result in decreased carbon emissions from transportation use. 35 These secondary effects strengthen the case for SEMs as not only access tools but also sustainable solutions in Ontario’s pediatric otolaryngology.
Trust and communication were repeatedly identified as central to uptake. Referring physicians noted that system-level changes are adopted when frontline stakeholders see transparent processes, accessible support, and predictable benefits in daily practice. Otolaryngologists emphasized visible leadership (“SEM champions”) and coherent regional pilots to align hospitals and community practices and to maintain momentum. Practical education materials and straightforward support that make participation easier for primary care were seen as helpful to early adoption.22,27,31 -33 These strategies mirror established change-management principles as leadership clarity and repeated, transparent communication foster buy-in, reduce uncertainty, and improve SEM stakeholder adherence.27,31 -33
Participants linked SEM credibility to measurement and to matching resources with demand. The evaluation frame they described maps closely to published experience with centralized referral in other medical specialties.9,22,33 Participants named practical indicators that clinicians and families notice, including time to assessment, the frequency of re-referrals or back-and-forth, satisfaction of patients and families, and the costs required to run the program. They also emphasized that improving consult streams alone will not shorten time to definitive care if operating room time and clinic capacity are not addressed. Accordingly, pilot implementations should report consult and operative metrics together and link process improvements to capacity planning, while making the costs of setup and administration visible so stakeholders can follow what is required to maintain performance.9,12,16,17,22,27,30
Although only 11 otolaryngologists and 12 referring physicians were interviewed, the composition of participants spanned pediatric, general, community, and academic otolaryngologists and both family physicians and pediatricians. The sample size also aligns with similar qualitative work and was adequate to achieve thematic saturation.22,27 Of note, all participants practiced in Ontario, which may limit generalizability to other jurisdictions. Interpretation of interview data is inherently subjective; to mitigate this, the study used recognized qualitative methods, including triangulation and peer debriefing, and documented coding frameworks as described in the methods section.19 -21 Additional considerations include transferability beyond pediatric otolaryngology given specialty-specific workflows, and the possibility of selection bias if clinicians with strong views were more likely to participate. Finally, this analysis was not designed to link perceptions to quantitative outcomes; future work should include pilot SEMs with measurement of wait times, outcomes, satisfaction, and costs to validate effects in practice.
In summary, the perspectives of referring physicians and otolaryngologists indicate that a carefully designed SEM could reduce wait times and improve patient experience in pediatric otolaryngology. The near-term steps highlighted by participants are practical: connect the model with common EMRs, keep workflows simple, provide modest administrative support, begin with regional pilots that report clear metrics, and communicate openly about scope, allocation rules, and patient options. Where these elements are in place and capacity is aligned, SEMs are well positioned to deliver the access and satisfaction gains described in the interviews.
Conclusion
Surgical backlogs and prolonged wait times remain a major challenge in pediatric otolaryngology and other specialties across Ontario. SEMs offer a coordinated approach to improve efficiency, equity, and patient-centered care. Interviews with otolaryngologists and referring providers highlighted key benefits, challenges, and implementation considerations. These findings should inform the design of future SEMs to ensure adequate resources, communication, and transparency, ultimately supporting high-quality, equitable, and satisfying care for patients and clinicians alike (Figure 1 and Table 1).
Thematic analysis of physician perceptions on SEMs derived from interview transcripts.
Demographic Information.
Abbreviations: O, otolaryngologists; RP, referring physician.
Footnotes
Appendix A. Semi-Structured Screening Guide: Referring Providers
Appendix B. Semi-Structured Screening Guide
Acknowledgements
None.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Informed Consent Statements
All participants provided written informed consent before participating.
Ethical Considerations
Western University’s Research Ethics Board provided ethics approval for this research project (REB # 124261).
Consent to Participate
Participants provided written informed consent for this study.
Consent for Publication
Not applicable.
ORCID iDs
Data Availability Statement
Data is available upon request from the corresponding author.