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Persistently long waiting times for hip and knee total joint arthroplasty (TJA) specialist consultations have been identified as a problem. This study described referral processes and practices, and their impact on the waiting time from referral to consultation for TJA.A mixed-methods retrospective study incorporating semi-structured interviews, patient chart reviews and observational studies was conducted at three clinic sites in Alberta, Canada. A total of 218 charts were selected for analysis. Standardized definitions were applied to key event dates. Performance measures included waiting times percentage of referrals initially accepted. Voluntary (patient-related) and involuntary (health system-related) waiting times were quantified.All three clinics had defined, but differing, referral processing rules. The mean time from referral to consultation ranged from 51 to 139 business days. Choosing a specific surgeon for consultation rather than a next available surgeon lengthened waits by 10–47 business days. Involuntary waiting times accounted for at least 11% of total waiting time. Approximately 40–80% of the time patients with TJA wait for surgery was in the consultation period. Fifty-four per cent of new referrals were initially rejected, prolonging patient waits by 8–46 business days.Our results suggest that variation in referral processing led to increased waiting times for patients. The large proportion of total wait attributable to waiting for a surgical consultation makes failure to measure and evaluate this period a significant omission. Improving referral processes and decreasing variation between clinics would improve patient access to these specialist referrals in Alberta.