Access Management Policy

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1 Access Management Policy Document Type: Policy Version: 3.1 Date of Issue: April 2014 Review Date: April 2016 Lead Director: Post Responsible for Update: Ratifying Committee: Ratified by them in the minutes of: Distribution to: Chief Operating Officer Deputy Director of Operations & Performance Performance & Finance Committee 26 th March 2014 All Trust staff via the Trust Intranet

2 Contents: Heading Number Page 2 of 58 Access Management Policy Page Number Contents / 2 Risk rating 4 1 Introduction 5 2 National Waiting Times and Guidance 6 3 Access Management Policy 7 4 Referrals Referral to Treatment (RTT) GP Referral letters Choose and Book Advice and Guidance Requests Suspected Cancer Referrals Urgent GP Referrals Transient Ischaemic Attacks (TIA) Routine Referrals Inappropriate GP Referrals Referral Confirmation 12 5 Outpatient Appointments Appointment Offers Patient Cancellations (New Referrals) Patient Cancellations (Follow ups) Hospital Cancellations Patients who Do Not Attend (DNA) Annual and Study Leave Clinic Template Changes Pending File RTT Outpatient Outcomes Outpatient Waiting Time Calculations 17 6 Diagnostic Referrals and Appointments 17 7 Inpatient and Day Cases Active Lists Non Active (Suspended) Waiting Lists & RTT Pauses 7.3 Planned Lists 21 19

3 7.4 Patients Listed for more than one Procedure Selecting Patients For Admission The Patient Administration System (PAS) Patient Information Confirmation of Listing Reasonableness of date for admission Private Patients Patients who DNA their TCI Hospital Cancellations (and 28 day breaches) Booked Admissions Validation and Review RTT Inpatient / Day case Outcomes Maintaining the Waiting List 24 8 Other RTT Activity Clock stops Non Waiting List RTT Activity Active Monitoring Inter-Provider Transfer Administrative 26 Minimum Data Set (IPTAMDS) 9 Definitions Associated Documents Duties and Responsibilities The Board of Directors Divisional General Managers Consultants and Clinical Teams Service Managers and Workload Coordinators Clerical and Administration Staff Consultation and Communication with 28 Stakeholders 13 Implementation Education and training Monitoring and review Action Plan Audit Proforma References / Bibliography Appendices 31 Page 3 of 58

4 Risk Rating Who will be affected by this Procedure? Trust Employees & Patients Have any existing risk assessments related to this procedure been appropriately Yes Details: Risk Rating assessed in compilation of the Nov 2012 version of the Policy updated Is a new risk assessment No required by this procedure? Does this procedure require No Health and Safety training? Does this procedure require specialist equipment? No Name: Deputy Director of Operations & Performance Date: 26-MAR-2014 A Potential Severity (1-5) B Likelihood of Occurrence (1-5) C Risk Rating (A x B = C) Raw Risk Rating Final Risk rating Page 4 of 58

5 1 Introduction This policy is the third version of the Access Management Policy. The policy will be reviewed on a biennial basis and includes reference to guidelines and standards produced locally and nationally by the Department of Health and NHS England. Scope This policy covers all services within Mid Cheshire Hospitals NHS Foundation Trust that patients may be referred into. This Policy is intended to be of interest to and used by all those individuals within the Trust or other partnership organisations, who are responsible for referring patients, managing referrals, adding to and maintaining waiting lists for the purpose of organising patient access to hospital treatment and is not intended to be exclusive to medical waiting list management. Whilst doctor and consultant may have been used throughout, this is for the purpose of simplicity. The policy will also made publically available via the Trust s website and circulated to local CCGs and GPs. Purpose The purpose of this policy is: To ensure consistent and equitable access to services by patients referred to the hospital To ensure that patients on elective, outpatient and diagnostic waiting lists are treated in chronological order taking account of their clinical priority To establish a consistent approach in the management of Referral to Treatment (RTT) pathways and service specific waiting lists across the Trust To ensure that patients are only added to the waiting list if there is a real expectation that they will be treated To ensure national and local waiting time standards (see Appendix 1) are met The Board of Directors at Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) are committed to the effective management of Referral to Treatment pathways and all waiting lists and recognises the need to establish and maintain accurate and timely systems of work for all RTT pathways, inpatient, day case, outpatient, diagnostic and other waiting lists. The proactive management of all RTT pathways and waiting lists contributes to an effective operational and procedural system whereby positive actions will affect planning and improving services for patients The purpose of this policy is to outline the systems and standards that will ensure that patients are treated with consistency and equity and this in turn will lead to patients being managed according to clinical priority and available resources This policy is designed to set out clearly the expectations of the Trust and will assist in the achievement of national and local targets The policy covers access for suspected cancer patients to MCHFT services but the cancer pathway management rules are not within the remit of this policy. The Trust will ensure that there are outpatient appointment slots available for patients to book into (ideally this would be within five weeks to support the delivery of the 18 week pathway). It is the policy of the Trust that no one will be discriminated against on grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and Page 5 of 58

6 maternity, race, religion or belief, sex or sexual orientation. The Trust will provide interpretation services or documentation in other mediums as requested and necessary to ensure natural justice and equality of access. Partnerships The local health community will enter into a contract with patients based on delivery of the national waiting time standards and supported by the provision of relevant, clear and concise information. Patients (and parents / carers) will receive clear explanations regarding proposed Inpatient and Day Surgery treatment including benefits and potential risks. Agreement to proceed with treatment will take the form of written consent signed by the patient in accordance with the Trust s policy on informed consent. Patients (and parents / carers) will be made aware of their role in ensuring the Trust s waiting list processes are efficient and are expected to keep the Trust informed of changes to personal circumstances and to keep all appointments. The Trust will ensure that all patients requiring treatment by the Trust will be treated within national waiting time standards. Patient information will be provided, in the appropriate format, to patients explaining the waiting list process, and in particular pointing out the potential consequences of not attending an appointment. This information will be shared when all appointments are agreed with the patient. 2 National Waiting Times and Guidance The Trust is required to achieve the following nationally defined waiting times targets National waiting times targets: 18 week Referral to Treatment (RTT) Cancer Waiting Times Diagnostic 6 week target Consultant-led treatment includes treatments where a consultant retains overall clinical responsibility for the treatment. This could include treatments provided by the service or team led by the consultant. The setting of the consultant-led treatment, whether hospital-based or in a community-based clinic, does not affect the patient s right to start treatment within 18 weeks. The NHS Constitution The NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. The NHS Constitution states that patients have the right to access certain services commissioned by NHS bodies within maximum waiting times. Where this is not possible, the NHS should take all reasonable steps to offer a range of suitable alternative providers. This promise was made a legal right by NHS England and Clinical Commissioning Groups (CCGs) in the responsibilities and standing rules regulations Page 6 of 58

7 It is therefore now a legal right for patients to start their NHS consultant-led treatment within a maximum of 18 weeks from referral; unless they choose to wait longer or it is clinically appropriate that they wait longer. They also have the right to be seen by a specialist within 2 weeks of GP referral for suspected cancer. If the patient cannot be seen within the maximum waiting time, the NHS Constitution states that the patient may contact the commissioner who is funding the treatment (CCGs or NHS England). In these circumstances, the commissioner must investigate and offer the patient a range of suitable alternative hospitals or community clinics that would be able to see or treat the patient more quickly. For more information on the NHS Constitution, please click on the link below: Overview.aspx It is the responsibility of all members of staff to understand the 18 Week principles and definitions. They must be applied to all aspects of individual specialty pathways, and referrals and waiting times will be managed and measured accordingly. No patient should have to wait longer than 18 weeks because of capacity constraints. The following specific national targets apply to RTT waits 90% of pathways where patients are admitted for hospital treatment should be completed within 18 weeks 95% of pathways that do not end in an admission should be completed within 18 weeks 92% of incomplete pathways to be within 18 weeks No patient will wait longer than 52 weeks 3 Access Management Policy RTT pathway waits are the main method the Trust uses to monitor and manage patients access times. However, maximum waiting times are separately used to monitor new outpatient, diagnostic and inpatient day case waiting lists. The RTT and maximum waiting times are monitored on separate clocks and have different rules for how they are calculated. Both RTT clock and maximum waiting time clock rules are covered in this policy. Further guidance on how to manage specific situations with regard to RTT can be found in the RTT scenarios available from the RTT tracker team. GPs in the Trust s catchments area and the relevant Clinical Commissioning Group (CCG) will receive Consultant-specific information relating to waiting times for inpatient and day case procedures and new outpatient appointments. This information is also submitted to the NHS Choices (waiting times) website which is accessible by the general public via the internet. Indicative wait times are automatically calculated and displayed in the Choose and Book System; this means that the information is available to all users and not just those in the local catchment areas. Weekly waiting time performance information (by Specialty) is produced by the Information Department and circulated to all Divisional General Managers for both Outpatient and Inpatient lists. A weekly PTL is produced by the Information Department and forwarded to all Divisions for action to ensure waiting time standards are met. Page 7 of 58

8 The Trust complies with all statutory requirements concerning the submission of statistical information to the Department of Health, NHS England, Monitor or other required entities. In England, under the NHS Constitution, patients have the right to access services within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of alternative providers if this is not possible as per section 2 above. The NHS Constitution handbook currently specifies the maximum waiting time for patients as being 18 Week from Referral To Treatment. If a patient believes they have waited longer than 18 Weeks RTT and wishes to take up their rights under the NHS Constitution then the process detailed in Appendix 3 must be followed. Military veterans should be treated in accordance to the Department of Health guidance. The Guidance can be found by following the link: eterans.aspx 4 Referrals 4.1 Referral to Treatment (RTT) An RTT pathway clock starts when any care professional or service, permitted by an English NHS commissioner to make such referrals, refers to: a) a consultant led service, regardless of setting, with the intention that the patient will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional or general practitioner; b) an interface or referral management or assessment service, which may result in an onward referral to a consultant led service before responsibility is transferred back to the referring health professional or general practitioner. A waiting time clock also starts upon a self-referral by a patient to the above services, where these pathways have been agreed locally by commissioners and providers and once the referral is ratified by a care professional permitted to do so. A new RTT clock is started upon a patient being re-referred in to a consultant-led as a new referral, even if it is for a condition that a patient has been previously discharged for. An RTT pathway will be created at the same time as creating a referral. For Choose and Book referrals the RTT pathway is automatically created. Staff who manage referrals, appointments, clinics and reception areas are responsible for updating the RTT tracking system on ICS as per the RTT Guidance (RTT Outpatient User Guide) (RTT Management Guide). 4.2 GP Referral Letters The Trust and Clinical Commissioning Groups will continue to work together to ensure all referrals are clinically appropriate. GP referral letters will be addressed to either an individual consultant or pooled clinical service as set up in the Directory of Services. Referral to a pooled service should be addressed to Dear Consultant or Specialist. Page 8 of 58

9 Referrals should be sent using the electronic Choose and Book system but referrals will still be accepted by post, fax or . (Any such referrals managed by MCHFT will be done so in accordance with the principles set out in the MCHFT Confidentiality Code of Practice). If the Choose and Book system is unavailable all referrals must be sent electronically to the central MCHFT address: for routine and urgent referrals and to: for urgent cancer referrals. In the event of the unavailability of the system urgent cancer referrals can be sent via secure fax All referrals must include full demographic details, including NHS number, telephone numbers (mobile, daytime, and evening, if possible) and primary language (if not English) to reduce administrative time contacting the patient. All referrals must be date stamped on receipt and logged onto the hospital PAS on the day of receipt. 4.3 Choose and Book Under Choose and Book the patient appointment is already made. The Consultant will review the referral electronically or via paper copy, at the discretion of the Division, and decide whether to accept, reject the referral or change service; the patients GP will be informed of the reason for rejection via the Choose and Book facility. Work lists must be managed on a daily basis by the clinical team or the dedicated representative e.g. PA/APA workload co-ordinator. NHS England has released plans to replace the Choose and Book system with the NHS e-referral System. The latter is expected to be implemented across the NHS by the end of The main proposals for the e-referrals systems are summarised in the below in the extract from the Health & Social Care Information Centre website: When will the new service go live and what will it include? The new NHS e-referral service will go live at the end of Initially, it will offer equivalent functionality to Choose and Book, but with the added benefit of a number of improvements which will be available straight away. A refreshed user interface which will improve the look and feel of the application Comprehensive user help files Management Information and reporting tool, which will make the wealth of information within the service more readily available Additional referrers will be enabled to use the service, a concept known as 'any to any' A simpler integration mechanism for existing integrated supplier systems, such as GP systems and patient administration systems.4.4 Advice and Guidance Requests This service is available both via written requests and, for some clinical services, the electronic Choose and Book system. A clinical response must be sent back to the GP within contract schedule or as defined within individual services and according to CQUINs requirements. Page 9 of 58

10 4.5 Suspected Cancer Referrals The NHS requires that suspected cancer patients or breast symptomatic patients will be seen by a nominated Consultant or relevant member of the clinical team within 14 days of the GP referring the patient. The Trust has a local standard that 2WW patients will be offered an appointment within 7 days. The GP must ensure the referral is received by the Trust within 24 hours of the patient seeing their GP. For Choose and Book urgent referrals for suspected cancer, please see the Standard Framework for Choose and Book (Appendix 4). A notification/confirmation of appointment will be sent to the patient within one working day of the appointment being booked. Secondary care clinical team will review all urgent referrals for suspected cancers, if necessary patients will be reprioritised based on the clinical information provided and an alternative clinical pathway will be followed. The GP will be informed. The appropriateness of suspected cancer referrals will be subject to regular audit and feedback to individual GPs and the relevant Clinical Commissioning Group. 4.6 Urgent GP Referrals Secondary care clinical team will review the referral letter within two working days of receipt. A notification/confirmation of appointment will be sent to the patient within two working days of the appointment being booked. GP referrals graded as urgent by the GP will be entered onto the (PAS) by the Medical Records Department upon receipt, once reviewed and agreed as urgent by the clinical team; patients will be telephoned and offered the first available appointment date within the agreed speciality guidelines. If the patient refuses the appointment, they should be offered alternative appointments. Once the appointment has been made comments will be recorded within the PAS system detailing the reasons why the patient has booked outside of the clinical guidelines. For Choose and Book urgent referrals process, please see the Standard Framework for Choose and Book (Appendix 4). 4.7 Transient Ischaemic Attacks (TIA) TIA referrals should see a stroke specialist within 24 hours. GP referrals for TIA should be sent by secure fax to or ed to tmc-tr.tia- INBOX@nhs.net and then booked into the identified TIA slots on the daily (weekday) clinics of the Stroke Consultants / Registrar. 4.8 Routine Referrals GP referrals will be entered onto the PAS by the Medical Records Department upon receipt and sent to the appropriate Service area for confirmation of the GP s prioritisation. A notification/confirmation of appointment will be sent to the patient within two working days of the appointment booking; for Choose and Book patients who have already made appointments, a Trust confirmation will be sent out as per the Standard Framework for Choose and Book (Appendix 4). Page 10 of 58

11 Secondary care clinical teams will review the referral letter within five working days of receipt. In the absence of the Consultant clinical priority will be assessed by a nominated person within the Division. Each Division will ensure processes are in place to review letters within five working days. Processes will be subject to an audit by the Division on an annual basis On return of the referral letters to the appropriate appointments office, patients will be offered the next available appointment in accordance with their clinical priority. Patients will be given a reasonable offer of an appointment date. For an appointment offer to a patient to be deemed reasonable, the patient must be offered verbally a minimum of two appointments dates on different days, with at least three weeks notice before the first offered appointments. For a written appointment offer to be deemed reasonable, the patient is to be offered an appointment with a minimum of three weeks notice (DSCN 37/2003). Under Choose and Book the Patient Appointment is already made. The nominated person will review the referral and decide whether to accept, reject or change service. For Choose and Book routine referral process, please see the Standard Framework for Choose and Book (Appendix 4). 4.9 Inappropriate GP Referrals If a referral has been made and the special interest of the Consultant does not match the needs of the patient, the Consultant must cross-refer the patient to a colleague where such a service is provided by the Trust and the referral entry AMENDED and duplicate entries NOT created on PAS. In Choose and Book this will be amended via the change service option. If a referral is clinically appropriate but further information is required to process it the GP practice must be contacted to obtain further information. It is the responsibility of the Consultant s PA/APA to access this information. If a referral is made for a specialty or service which the Trust does not provide then the referral will be returned to the GP either via a rejection in Choose and Book which automatically cancels the patients appointment (the patient will receive a cancellation letter), or via letter to the GP with an explanation. It is the GP s responsibility to liaise with the patient. Referrals rejected via Choose and Book must state the reason for rejection and guidance for the GP. If a referral does not meet the referral criteria as set out in the referral pro forma then it will be returned to the referrer outlining the reason for rejection or further management of care. Any referral that is rejected and returned to the referrer will result in a Referral To Treatment pathway clock stop Referral Confirmation Referrals and waiting times should be correctly counted, recorded and monitored. Page 11 of 58

12 For referrals that are not sent via the Choose and Book system, patients will be contacted either by telephone or letter to agree and book their appointment. Patients will be given a Choose and Book written confirmation of their appointment by the referring GP if the appointment has been booked by the practice. Patients who book their appointment with The Appointment Line will have verbal confirmation of their appointment from The Appointment Line call centre staff. 5 Outpatient Appointments 5.1 Appointment Offers Patients are to be kept fully informed and have a single point of contact at the Trust. Only nominated staff will book appointments into the outpatient clinics. Patients will be given two reasonable offers of an appointment date. For an appointment offer to a patient to be deemed reasonable, the patient must be offered verbally a minimum of two appointments dates on different days, with at least three weeks notice before the first offered appointments. For a written appointment offer to be deemed reasonable, the patient is to be offered an appointment with a minimum of three weeks notice (DSCN 37/2003). Staff must abide by the parameters of the clinic structure (template) available; changing new and follow-up slots accordingly to ensure full capacity is maintained this must be agreed with the relevant Service Manager. Patients are seen in the order of clinical priority. Urgent referrals must be given priority. Clinic booking patterns must be reviewed at least monthly to ensure the number of slots reserved for urgent patients reflect the current demand. Other patients must be given appointments in chronological order based on the date the referral was received, to ensure equity of access. A confirmation letter will be sent to the patient, within 2 working days of agreement of referral. This letter will contain appointment details that have been agreed with the patient. Patients must be communicated to in a manner which meets their needs including language and disability. Patients who book their appointment via Choose and Book will be able to print off the appointment confirmation letter via that system. The letter explains clearly the Trust s Policy should the patient cancel the appointment or fails to attend the clinic at the designated time. This includes a warning that if a patient cancels the same appointment twice they will be referred back to their GP. Where short notice (i.e. less than three weeks) is given, the Trust will telephone the patient to agree the appointment. In the event of the patient failing to agree it will be regarded as a hospital cancellation and in these circumstances the waiting time will not be reset. Where short notice offers are made a manual record is created on the PAS system showing the reasons for short notice, the date offered and the date of any verbal exchange. Page 12 of 58

13 5.2 Patient Cancellations (New Referrals) Some patients may not be able to agree a date within the Trust specified target time (e.g. school holidays). For Choose and Book referrals, patients must contact The Appointment Line when they are ready to book their appointment, the RTT pathway will start when they book the first appointment. Under Choose and Book in the event of a patient cancelling their appointment then the patient will be able to rebook via The Appointment Line, Internet or by returning to the GP Practice. The Trust can rebook patients by using the Choose and Book system. Patients that cancel and rebook their appointment on two consecutive occasions will have an RTT clock stop and be referred back to their GP. If a patient refuses a reasonable offer the clock is reset. If the GP refers the patient back again then this starts a new RTT clock. For appointments that are not made via Choose and Book, a patient can cancel their appointment by calling the Trust call centre. If the appointment is no longer required by the patient then the appointment should be cancelled, referral closed, waiting list closed and the reasons entered for each event. The RTT pathway should be closed. Patients that cancel and rebook the same appointment two times will have an RTT clock stop and be referred back to their GP. If a patient refuses a reasonable offer the clock is reset. If the GP refers the patient back again then this starts a new RTT clock. If a Choose and Book patient cancels their appointment and then does not rebook another appointment date then the RTT pathway can be closed after 2 months after the date the patient cancelled their appointment. 5.3 Patient Cancellations (Follow ups) Patients who cancel a follow-up appointment will be offered alternative dates. If the patient cancels their follow up appointment twice consecutively, they should be discharged and removed from the waiting list. These patients will be informed verbally of Trust Policy by the person they contact (Medical Records or consultant s secretary) and given the option to change their mind. If a patient decides to proceed with cancellation then they will be asked to contact their GP for further management. The patient may be re-referred at the GP s discretion. The patient s Consultant may decide to review the decision based on clinical need. If a patient cancels and re-books a follow up appointment appropriately, the 18 Week clock continues. 5.4 Hospital cancellations There are only two reasons for the Trust to cancel clinics or reduce the number of patients attending, namely. The absence of clinical staff on annual leave, study leave, sickness or as a consequence of on-call commitments The failure/breakdown of a critical item of equipment To ensure patient cancellations are kept to a minimum and to comply with DSCN 07/2003, if a patient has their appointment cancelled by the hospital they must be given a minimum three weeks notice and offered two alternative appointment dates if the offers are being made verbally or in writing. The patient must be rebooked within the Trust s specified target time. Page 13 of 58

14 If patients are given less than three weeks notice of a cancellation they must be contacted by telephone and offered two alternative dates. If they accept one of these dates and later change their mind, this must be recorded as a patient cancellation. Where patients refuse the offer of two alternative dates and less than three weeks notice has been given, this must be recorded as a hospital cancellation. In these circumstances the waiting time remains calculated from the date of receipt of the referral or the date the patient booked the appointment in Choose and Book. To reduce the likelihood of cancelled clinics Divisions will implement processes in the following areas. 5.5 Patients who Do Not Attend (DNA) New appointment DNAs Where a patient fails to attend their first new appointment the patient will not be offered another appointment, but will be removed from the waiting list and discharged back to the care of their GP/referrer. The patient and GP/referrer should be informed in writing of the reason for their removal by a letter sent from the Consultant s clinic. The patient may be re-referred at the GP/referrer s discretion. The patient s name is removed from the system, the referral closed and the RTT pathway nullified, provided that the Trust can demonstrate that the appointment was clearly communicated to the patient. An exception to this is referrals for suspected cancer which are sent another appointment within 14 days. Good practice within the Trust is that patients who DNA a 2 nd suspected cancer / 2 week wait appointment then the trust will contact the GP to agree the next steps. When a paediatric patient DNAs, the RTT pathway will be nullified and the parents will be contacted via letter to offer a further date for appointment. Follow up appointment DNAs Patients who fail to attend (DNA) their follow up appointment will not be offered a further appointment unless it is contrary to their best clinical interests this will be the decision of the consultant. If it is decided that the patient will be discharged back to their GP / referrer for subsequent management, a letter will originate fromthe consultant s clinic to the patient and their GP/ referrer and their 18 Week Referral To Treatment clock will stop. For patients who have their appointment re-booked, the 18 week clock continues. The health records of DNA patients must be reviewed by the nominated person at the conclusion of the clinic and any requirement to vary the Trust s policy for individual patients identified. The GP may re-refer DNA patients at their discretion. This will start a new RTT pathway and a new referral. Choose and Book (New patients) DNAs should be managed by primary care using the DNA report functionality. Primary Care administration staff should record the DNA in the Appointments for Booking Work list detailing the outcome of any clinical review. Page 14 of 58

15 5.6 Annual and Study Leave All requests for annual and study leave by consultants and career grade doctors must be completed and submitted at least six weeks before leave is to be taken. At the time leave is requested the appropriate leave form must be completed and approved within the Division in question. Each Division is expected to review the number of consultants able to take leave at any one time to ensure the commitment to ensure that there are outpatient appointment slots available for patients to book into (ideally this would be within five weeks to support the delivery of the 18 week pathway) as per section 1 above. Notification will only be accepted in writing on the appropriate leave form; that clarifies the arrangements to cover duties during absence on leave; available on the Trust s Intranet under Frequently Used Forms - Medical Staff Annual Leave Request Form (Appendix 5); Consultants Annual Leave Request Form (Appendix 6). Where cancellations are initiated due to Annual/Study Leave by the hospital, patients must be booked as close to their original appointment as possible, according to clinical priority, but within the Trust specified target. 5.7 Outpatient Clinic Cancellation / Reduction and Clinic Template Changes Templates must reflect the priority mix of referrals. They identify the number of slots available for new and follow-up appointments, and specify the time each clinic is scheduled to start and finish. All requests for template and temporary clinic rule changes will only be accepted electronically on the specified pro-forma available in the Frequently Used Forms section on the Trust Intranet Procedure for use of Outpatient Clinic Cancellation and Reduction Form (Appendix 7); Outpatient Clinic Cancellation or Reduction Form (Appendix 8); Change to existing OPD Clinic Template or New Service (Appendix 9). A copy of the original form (as per Appendix 8) is to be forwarded to the Service Coordinator/Medical Records Manager as soon as the request is authorised, who will then cancel the clinic as per instructions. The reason for the cancellation will be recorded and form part of the monthly cancellation clinic report. Divisions must review templates on a regular basis to reflect capacity and demand. This must be at least monthly but may need to be sooner where issues arise. Templates may contain Trench clinics that can be used when there is an increase in demand or a need to move a clinic, dependent upon specialty and Division. The Trench clinic should be in the format to include all types of patients, e.g. include new routine, urgent and follow-ups. On all occasions when patient s appointments are cancelled by the hospital at short notice, the referral and where appropriate health records of urgent patients must be reviewed by the nominated person within the clinical team. If a new appointment is not agreed upon within two weeks then the nominated person within the clinical team will determine the next course of action (e.g. new urgent appointment, routine appointment, etc.). Patients with routine appointments which have been cancelled will be offered the next available date for new patients. Discussions will be held with relevant service managers regarding potential breaches.. Wherever possible patients must not be cancelled. Page 15 of 58

16 In cases where changes are requested and six weeks notice of planned leave is not received, the Divisional Clinical Director will be informed changes will not be made until authorisation from the Associate Medical Director are received. It is the responsibility of the all Divisions to ensure systems are in place to guarantee appropriate and timely notification of cancellations, in line with the absence management policy. 5.8 Pending File The pending file consists of details of patients entered onto the outpatient administration system and for whom decisions or appointments are required. Examples include: Patients who have been admitted as inpatients/day cases and discharged following an outpatient appointment, but in respect of whom no follow-up appointments have been made or a decision to discharge conveyed. Patients for whom a follow-up appointment is outstanding. Patients waiting for the results of diagnostic tests. A review/validation of all follow-up patients on the pending file will be conducted on a rolling programme by Medical Records appointments staff. Patients will be contacted and treated within the current DOH and CCG contracted guideline/targets. Each division is required to have in place a local arrangement for validation according to the requirements in each speciality. 5.9 RTT Outpatient Outcomes An RTT Outpatient Outcome form (see Appendix 10) must be made available for every patient who attends as an outpatient. This will be done by the medical records team, in clinic preparation, placing an RTT Outpatient Outcome form in the health records. RTT Outpatient Outcome forms can be adapted to suit the needs/terminology of individual clinical areas provided the use of the different form can be accommodated by the medical records clinic preparation. After each outpatient attendance the RTT outcome must be recorded on the appropriate RTT Outpatient outcome form under instruction from the medical / clinical teams. Outpatient nursing teams should support this process by double checking that the RTT outcome forms are complete and in assisting the medical team to complete the form. These forms are then passed to the medical records main outpatient reception staff or reception staff in other specialty areas of the Trust to be input within 48hrs Outpatient Waiting Time Calculations The maximum waiting time for a first Outpatient Appointment must be calculated from the date when the referral request is received. For electronic referral requests, the Referral Request Received Date is the date the referral request is received electronically by the Trust. For Choose and Book, the referral is received when the patient s unique booking reference number is used to book the first outpatient appointment. Page 16 of 58

17 For written referral requests, letters must be opened and date stamped on the day of receipt. It is this date that must be entered on the PAS, not the date on which the information is fed into the system if this is later than the date of receipt. If the referral request takes the form of a phone call followed by a letter, record the date when the letter arrives. If there is no following letter, the date of the verbal request must be recorded. 6 Diagnostic Referrals and Appointments A Diagnostic test is defined as a test or procedure used to identify a person s disease or condition and which allows a medical diagnosis to be made. A patient s wait for a diagnostic test/procedure begins when the request for the test or procedure is made. The wait ends when the patient receives the test/procedure. Nationally, a 6-week maximum waiting time applies to all diagnostic tests/procedures this includes any subsequent diagnostic appointments, as well as first appointments. The Trust is required to report to the Department of Health any patients waiting 6 weeks or longer for a diagnostic test on the last day of each month. The 6-week maximum waiting time does not include diagnostic tests/procedures where: The patient is waiting for a planned (or surveillance) diagnostic test/procedure, i.e. a procedure or series of procedures as part of a treatment plan which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency, e.g. 6 month check cystoscopy The patient is an expectant mother booked for confinement; The patient is waiting for a procedure as part of a screening programme (e.g. routine repeat smear test etc.) The patient is currently admitted to a hospital bed and is waiting for an emergency or unscheduled diagnostic test/procedure as part of their inpatient treatment. The maximum waiting times for key diagnostics procedures (see appendix 11) are monitored differently to the RTT waiting times. The following section is based on Diagnostic Waiting Times & Activity guidance (v4.1 Updated Oct 2009) and identifies how the diagnostic maximum waiting list should be managed. The principle of reasonable offers will also apply to diagnostic appointments. DSCN 37/2003 indicates that patients must be given a minimum three weeks notice and offered two alternative appointment/admission dates if the offer is being made verbally. If the offer is being made in writing then one appointment / admission offer can be made but again a minimum of three weeks notice must be given. If a patient cancels a diagnostic appointment / admission that is deemed to be reasonable then the diagnostic maximum waiting time is set to zero (DSCN 18/2005 para 2.4.3). The RTT clock remains unaltered. Page 17 of 58

18 If a patient DNA a diagnostic appoinment / admission then the diagnostic waiting time is set to zero (DSCN 18/2005 para 2.4.3). The RTT waiting time is also reset to zero. Medical or social suspensions are not allowed in calculating the diagnostic maximum waiting times nor RTT waiting times. If two diagnostic test/procedures are booked for the same time then two independent diagnostic waiting times need to be monitored. If two diagnostic test/procedures are required and these have to be sequential (e.g. flexible colonoscopy after a barium enema), or if a patient requests tests on two separate visits, then once the first diagnostic test is complete a second diagnostic monitoring period should start for the second diagnostic test / procedure. Endoscopy patients can be booked for their procedure via: Choose and Book - where patients are booked by the GP, or by themselves, into a slot as per C&B rules Manual GP referral - direct to a consultant where the patient is sent a TCI date in the post Electronic referrals (GP referred) - via nhs.net where the referral is received by the diagnostic team, via Medical Records, then the pateint is sent a TCI date in the post Electronic referral (Consultant referred) - to the scheduling team following an outpatient appointment where the patient is provided with a telephone number for the scheduling team and asked to telephone 48 hours post outpatient appointment in order to agree an TCI date Direct access diagnostics, where the results are reported back to the GP, do not start an RTT pathway. 7 Inpatient and Day Cases Patients are admitted in the order of clinical priority. Only nominated people are authorised to add patients to waiting lists. All patients will be kept fully informed from the point of entry onto a waiting list to their admission offer and have a known point of contact at the Trust. Patients must be communicated to in a manner which meets their needs including language and disability. Users will maintain lists on the PAS in a timely manner to ensure that waiting times are correctly calculated as detailed in the Access Management Policy. For a verbal admission offer to a patient to be deemed reasonable, the patient must be offered a minimum of two admission dates on different days, with at least three weeks notice before the first of these admissions. This should be recorded on the PAS. For a written offer to be deemed reasonable a single admission date can be offered with at least three weeks notice. Page 18 of 58

19 7.1 Active Lists The Active Waiting list identifies all patients who are currently waiting to undergo an inpatient or daycase procedure and are fit, ready and able to come into hospital for their procedure Only patients who have elected to undergo the procedure in question and are clinically suitable will be added to lists. Patients who are not fit or willing to be admitted will not be added to the list and their GP advised accordingly. In certain circumstances (e.g. when the patient wishes time to consider the options, the patient is pregnant, the Trust does not offer the treatment, or does not have the required equipment) the nominated person may decide to offer a further outpatient appointment for review. In summary: Only add patients who are able to come in on the date the decision to admit is made; Only add patients if the treatment is ready and available. Paediatric patients must be clearly identified on waiting lists to ensure they are operated upon and admitted to paediatric facilities. The nominated person must decide how they wish to sub-divide their active waiting lists to assist with the clinical management of patients. The clinician listing for surgery will determine a clinical priority for each patient, determined by medical and social factors/circumstances. It is good practice to maintain a separate list for children. The RTT pathway for patients added to an active waiting list will normally continue. If a patient is added to a transplant waiting list then the RTT pathway will stop at the point of listing. If a patient is on a closed RTT pathway, perhaps because treatment has already been given, and is then added to an active waiting list then consideration should be given to opening a new RTT pathway if the consultant feels the treatment being offered is a substantively new or different treatment that does not already form part of that patient s agreed care plan. 7.2 Non Active (Suspended) Waiting Lists & RTT Pauses Non-Active (Suspended) Waiting Lists Patients suspended from the Active Waiting List are patients that for medical or personal reasons are temporarily unable to accept a date to come in for their procedure. Patients can only be suspended in one of two ways: They are medically unfit or their current medication prevents them from having their procedure. The patient s medical unfitness can be assessed by the GP, consultant or the patient themselves. They are socially unavailable for their procedure e.g. holidays, work commitments, and therefore they may request their admission to be delayed. The following rules must also be adhered to regarding the suspension of the patients: The Trust will work to ensure that no patient will be suspended for more than 12 weeks. If the patients total period of suspension will exceed 12 weeks then the Workload Coordinator must bring this patient to the attention of the appropriate Consultant for a decision on whether or not the patient should be Page 19 of 58

20 referred back to primary care with appropriate guidance on re-referral when fit or available for admission. No patient should be suspended immediately when added to the Waiting List. Patients who are not ready or fit for the procedure should not be added to the waiting list. If the suspension period is in excess of 6 weeks, approximately 2 weeks before the patient is due to return to the live waiting list, the patient should be contacted to ascertain if they are ready to return to the active list. In some cases the period of suspension will not allow patients to be contacted within the above timescales. For example a short period of suspension (2 weeks). When staff are informed of a short period of suspension they may well wish to agree a TCI date following the suspension with the patient at the time of notification of the suspension. This should ensure that offers of appointments to patients will adhere to national guidance of reasonableness and the Trust does not breach national waiting time standards. If the patient is not ready to return to the live waiting list and their period of suspension does not exceed 12 weeks the suspension may continue until such time as 12 weeks is exceeded. Care should be taken to ensure that patient s on the suspended list are included in all validation and review processes. Following a period of suspension, there will be no adjustment to the original date on the waiting list when the patient is brought back to the active list, but the suspended days do not count as part of the waiting experience. A patient should not be suspended once an admission date has been agreed, unless the date is later than normal due to the need to resolve other medical problems prior to treatment. Whilst patients remain upon the waiting list for suspended patients they will not count as waiting for statistical purposes. Any periods of suspension will be subtracted from the patient s total time on the list for statistical purposes. For patients who, prior to admission, defer their operation twice (other than for exceptional circumstances or medical reasons), their medical records will be reviewed by the clinical team and a decision to reappoint or remove from the list will be made. The patient and GP will be informed in writing. Patients who have been placed on the list but require further diagnostic testing must not constitute a reason for suspending RTT Pauses An RTT clock may be paused only where a decision to admit for treatment has been made, and the patient has declined at least two reasonable appointment offers for admission. The clock is paused for the duration of the time between the earliest reasonable offer and the date from which the patient makes themselves available again for admission for treatment. If the patient notifies the Trust of any period when they will not be available for admission likely to affect their admission date, for example a two week holiday, this must be recorded as a suspension period for the waiting list entry and a RTT clock pause recorded on the PAS. If the patient is medically unwell for admission but is expected to be fit for surgery in less than 4 weeks e.g. to treat chest infections with antibiotics; the RTT pathway continues. Page 20 of 58

21 If the patient is medically unwell for admission but is expected to be fit for surgery in more than 4 weeks the RTT pathway will stop and restarted when the patient is fit and ready to continue. If a patient is expected to be unwell for more than 12 weeks the patients should be referred back to their GP with written communication. If a patient is unwell (see above) for a diagnostic admission then the RTT clock can be adjusted in line with the procedure above however this does not affect the maximum waiting time clock for key diagnostic procedures (see section 6). 7.3 Planned Lists Patients who are undergoing a course of treatment, surgical intervention or investigation will remain on the lists for recall purposes. These patients are waiting for planned continuation of treatment and are not classified as being on a waiting list for neither RTT nor maximum waiting time clock purposes. Examples include: Check cystoscopies. Check/surveillance endoscopic procedures. Removal of screws/metalwork. Investigation/treatment sequences, e.g. chemotherapy attendances. Where another procedure or test is required before the operation can take place (e.g. Orthodontic work prior to oral and maxillofacial surgery). In this case the first treatment will be undertaken from the active list but subsequent treatment is planned. Only the first treatment should be on the list with the second planned procedure listed after the successful completion of the first procedure. 7.4 Patients Listed for more than one Procedure If more than one procedure is to be performed at the same time, then all procedures must be listed in order of priority as intended procedures on the planned list module. In instances where a patient requires more than one procedure as part of a planned sequence, then the waiting period for the second procedure must be recorded as a planned case (see Planned Lists above). There will be instances where patients are listed for bi-lateral procedures, most commonly cataract and hip surgery, but only one site operated upon during the first admission. The patient must be included on the list from the date that the decision to admit is made for the first site and the patient listed for the second site when clinical review has been undertaken (i.e. the patient is fit for surgery again). The second of a bilateral procedure will start a new RTT clock at the point the consultant decides they are fit and ready for their subsequent procedure. 7.5 Selecting Patients for Admission All patients must be selected for TCI (or offer of TCI) in accordance with their clinical priority. Within that priority they must then be broadly selected for TCI based on length of Referral to Treatment wait (i.e. longest RTT waiter, within clinical priority, first). This ensures fair access to their operation for all patients. However patients who have been waiting a shorter time can be listed if it ensures full utilisation of theatre lists. 7.6 The Patient Administration System (PAS) All inpatient & day case waitlists will be maintained using the PAS in combination with the Choose and Book System and the RTT pathway must be monitored and Page 21 of 58

22 updated according to the RTT Guidance (RTT Outpatient User Guide) (RTT Management Guide). 7.7 Patient Information On every occasion that a patient is added to an inpatient or day case waiting list the following information must be verified before the patient leaves the hospital: Confirmation of the patient s address (including postcode) and telephone numbers (daytime, evening and mobile). Confirmation of the GP s identity and surgery address. The patient s willingness to come in at short notice. Information concerning the patient s non-availability for admission (e.g. holidays, examinations, other social events). A requirement for longer periods of notice for admission in order that the patient may make the arrangements to meet special circumstances (e.g. caring for a disabled or elderly relative). 7.8 Confirmation of Listing All patients must receive written communication confirming that they have been added to a list and in addition, the GP must be notified. 7.9 Reasonableness of date for admission National 18 weeks guidance on Reasonableness for written and verbal offers of admission states that a patient should be offered a minimum of of three weeks notice one offer for written and two for verbal (please see Appendix 13 Glossary) Patients can be offered shorter notice dates but these are only deemed reasonable if the patient accepts the date. If the patient declines a short notice date, they must still be given the opportunity of a minimum of two different admission dates with a minimum of three weeks notice Private Patients Private patients opting to transfer to NHS treatment must be added to the Elective Admission List of the Consultant who will perform the surgery. There is no need for a subsequent NHS Out-Patient Appointment to do this but the referral from the private provider must be in writing. The patient referred in privately must be seen in order of clinical priority and thereafter waiting list chronology. A referral from the private provider must be created on the day the Trust receives notification and the referral and listing date entered onto PAS. The private referral should be filed in the case notes and must contain evidence of the date of the private consultation, the date stamped referral and the date added to list. The RTT clock starts at the point at which the clinical responsibility for the patient's care transfers to the NHS. I.e. the date when the NHS trust accepts the referral for the patient date the private referral is received Patients who DNA their TCI Where a patient fails to attend their TCI date the patient will be removed from the waiting list and discharged back to the care of the GP / referrer unless it is demonstrated by the consultant that doing so will be detrimental to the patient care. If the patient is discharged, a letter should be sent by the consultant s secretary to the patient and their GP / referrer and their 18 Week clock will stop. Page 22 of 58

23 If the patient accepts a further TCI date and goes on to DNA again, they will be removed from the waiting list and discharged back to the care of the GP / referrer. The patient and GP / referrer will be informed by letter and their 18 Week Referral To Treatment clock will stop. Exceptions to this rule are: Patients undergoing cancer treatment; Urgent conditions based upon consultant clinical judgement; Children under the age of 16 years old. In the above cases, patients should be contacted and another appointment made Hospital Cancellations No patient should have their admission cancelled. exceptional circumstances. However this may occur in The Divisional General Manager (DGM) must authorise all on the day cancellations following discussions with the patient s Consultant If the hospital cancels an operation/procedure after admission, or on the day of admission, for non-medical reasons the patient must be given a rearranged date within 28 days of their original date or before their 18 week breach date if this is sooner than 28 days. This must be noted on the list record to ensure that this patient is not cancelled again. A Cancelled Operation Form must be completed, with a detailed explanation of why the cancellation occurred and this reviewed by the Theatre Performance Group. This cancellation information will be reviewed by Performance Management Group on a weekly basis. Commissioners will apply a financial penalty for non-compliance with the 28 day standard (non-payment for procedure episode) A hospital cancellation, for any reason, does not affect the RTT clock - it continues Booked Admissions Full booking The patient is given the opportunity to agree a mutually convenient admission date within one working day of the decision to admit them (i.e. adding them to the waiting list). Patients who could have agreed a date within 1 working day but chose to wait longer than that must still be counted as a fully booked patient. Partial Booking The patient is given the opportunity to agree a mutually convenient appointment date outside of one working day of the decision to admit them. No Choice Given A TCI date is sent to the patient, without any negotiation with the patient. Patients should ideally be either fully or partially booked and recorded as such on the PAS Validation and Review Page 23 of 58

24 All inpatient and day case lists should be validated by PAs and APAs on a weekly basis. Patients waiting on a pathway between 18 and 22 weeks are validated by the RTT Trackers; workload coordinators valid on weekly basis any patients waiting over 22 weeks. This validation relates to the patient s continued requirement for and willingness to undergo the procedure. The patient s details (address, telephone numbers, GP s name and address etc.) will also be validated at that time. The management and monitoring of validation exercises is the responsibility of the relevant Divisional General Manager or nominated representative. Divisional General Managers are responsible for making sure processes are in place to support validation and nominate a relevant Service Manager to monitor/audit validation RTT Inpatient / Day case Outcomes For all inpatients and day cases an RTT outcome must be recorded on ics. For inpatients this will be done automatically by ics when the patient is admitted. It assumes the patient has been treated and so if the patient s operation is subsequently cancelled the RTT pathway would need to be manually updated. For day cases admitted to the Treatment Centre an RTT Outcome form (For example - see Appendix 12) must be made available for every patient who attends. This will be done by the Treatment Centre administration staff, in note preparation, attaching an appropriate RTT Outcome form to the front of the medicals notes. RTT Outcome forms can be adapted to suit the needs/terminology of individual clinical areas provided the use of the different form can be accommodated by the medical records clinic preparation. After each day case the RTT outcome must be recorded on the appropriate RTT Outcome form under instruction from the medical / clinical teams. Theatre nursing teams should support this process by double checking that the RTT outcome forms are complete and in assisting the medical team to complete the form Maintaining the Waiting List The maintenance of the Waiting List for a particular speciality or directorate is the responsibility of the Divisional General Manager of the relevant Division. The DGM (or their representative) must ensure that speciality waiting lists do not contain patients who no longer need their operation. Typically it will be the consultant or their secretary who will first be aware of a patients change in circumstances (e.g. patient treated privately, procedure no longer required). It is vital that this information is immediately relayed to the scheduling staff so an up to date accurate waiting list can be maintained, and that details are amended on ics within 1 working day of receipt of notification of change. 8 Other RTT Activity 8.1 Clock stops A Clock will stop for treatment when: First definitive treatment starts. This could be: Treatment provided by an interface service; (e.g. MSK Service) Page 24 of 58

25 Treatment provided by a consultant-led service Therapy or healthcare science intervention provided in secondary care or at an interface service, if this is what the consultant-led service decides is the best way to manage the patient s disease, condition or injury A clinical decision is made and has been communicated to the patient, and their GP (or other referring practitioner) to add a patient to a transplant waiting list. A Clock will stop for non-treatment when it is communicated to the patient and their GP (or other referring practitioner) that: It is clinically appropriate to return the patient to primary care for non-consultantled treatment in primary care. A clinical decision is made to start a period of active monitoring A patient declines treatment after having been offered it A clinical decision is made not to treat A patient DNAs their first appointment following the initial referral that started their 18 week clock, provided that the provider can demonstrate that the appointment was clearly communicated to the patient. A patient DNAs any other appointment and is subsequently discharged back to the care of their GP, provided that: The provider can demonstrate that the appointment was clearly communicated to the patient Discharging the patient is not contrary to their best clinical interests Discharging the patient is carried out according to local, publicly available policies on DNAs These local policies are clearly defined and specifically protect the clinical interest of vulnerable patients (e.g. children) and are agreed with clinicians, commissioners, patients and other relevant stakeholders. The death of a patient would also end the 18 week pathway. 8.2 Non Waiting List RTT Activity RTT pathway clocks can be affected by non-waiting listing activity, e.g. results from diagnostic tests, which Trust staffs need to be aware of in order to update RTT pathways in a timely manner. 8.3 Active Monitoring An RTT pathway clock may be stopped where it is clinically appropriate to start a period of monitoring in secondary care without clinical intervention or diagnostic procedures at that stage. Diagnostic procedures which are planned procedures as part of a clinically accepted surveillance pathway could allow for a period of active monitoring but equally consideration needs to be given whether a decision not to treat has actually been taken at that time Page 25 of 58

26 8.4 Inter-Provider Transfer Administrative Minimum Data Set (IPTAMDS) If a patient s RTT pathway is being continued at another hospital then a full IPTAMDS needs to be included with the referral letter in order to allow the receiving hospital to continue the patients RTT pathway from the correct administrative point. The clock will continue to run until treatment has taken place. 9 Definitions See Glossary - Appendix Associated Documents Procedures of Limited Clinical Value (CECPCT document) Consultant-to-Consultant including Non GP Referrals Policy (CECPCT document) RTT Validation Scenarios Managing RTT Pathways (ics) User Guide Patient Placement Policy Delivery Same Sex Accommodation Policy & Procedure Cancer Waiting Times (CWTs) a Guide (Version 8.0) Choose and Book User Guides - CaB User Guides Managing the RTT 18 week Pathway RTT Management Guide RTT 18 week Outpatient User Guide - RTT Outpatient User Guide ICS User Guides ics User Guides Choose and Book Website Duties and Responsibilities This document sets out the policy to be followed by all staff when dealing with RTT pathways or managing waiting lists within the Trust. This policy document must be readily available in every Division/Department that deals with RTT pathways and waiting lists and a member of staff in each area must be nominated as the expert in case of RTT and waiting list management queries. A brief version of this policy with the key points for staff can be found in Appendix 2. It is the responsibility of the Divisions to ensure all relevant staff are trained in the correct RTT pathway and waiting list management administration processes. It is the responsibility of all staff involved in waiting lists management to conform to the procedures noted in this policy; failure to do so will be dealt with via the Trust s Capability and Personal & Professional Conduct Policies The Board of Directors The Trust Board of Directors is responsible for the approval of this policy. This responsibility can be delegated. Page 26 of 58

27 11.2 Divisional General Managers Divisional General Managers are responsible for: Ensuring that there is appropriate capacity to meet the demands for the service within the agreed access/waiting times. Additional capacity requirements must be identified to the Executive Team Ensuring that this document is distributed to all staff involved in RTT pathways, waiting list management and access to services Ensuring that local systems and processes comply with the policy Ensuring that systems are in place to audit compliance with this policy Ensuring that appropriate staff are trained in the management of RTT and audit of training is undertaken Maintenance of the Divisional waiting list 11.3 Consultants and Clinical Teams Consultants and clinical teams are responsible for: Ensuring their RTT pathways and waiting lists are managed as effectively as possible through application of the guidelines set out in this policy Ensuring that Patients who are not ready for surgery are not added to the waiting list (i.e. if there was a bed available tomorrow in which to admit the patient they must be fit to come in).for example: Page 27 of 58 Clinically obese patients who require some weight loss prior to a date for surgery being agreed Pregnant patients Patients who require a test to confirm diagnosis Patients who require health education for smoking or alcohol 11.4 Service Managers and Workload Coordinators Service Managers and Workload Coordinators are responsible for: Ensuring that processes are in place to implement and monitor the Access Management Policy Ensuring that outpatient clinic and theatre templates are reviewed on a regular basis to reflect capacity and demand. This must be at least monthly but may need to be sooner where issues arise Ensuring that all RTT pathways waiting lists for their specialty are managed effectively, with the aid of monitoring systems Monitoring with staff the operational management of RTT pathways and waiting lists. Performance review mechanisms will assist in identifying opportunities for improvement; the resources required and agree actions to be taken Ensuring that all patients are booked Developing and redesigning services to sustain booking

28 Ensure action is taken to fulfill identified training needs recorded in Knowledge Skills Framework (KSF) appraisals relating to the management of lists 11.5 Clerical and Administration Staff Clerical and Administration staff are responsible for: Ensuring that they have access to a copy of the Access Management Policy Identifying any training needs relating to the management of RTT pathways and waiting lists Ensuring that they fully understand the Access Management Policy including updates or feedback from the RTT super user forum Ensuring that processes in place to implement and monitor the Access Management Policy are followed Ensuring that all patients are booked 12 Consultation and Communication with Stakeholders Policy version 2 Divisional General Managers Divisional Clinical Directors Service managers Workload coordinators Medical records Governance Lead Information services RTT user group Clinical Commissioning Groups Policy version 3 Divisional General Managers Service managers Workload coordinators Medical records Clinical Commissioning Groups Page 28 of 58

29 13 Implementation This policy will be published on the Trust Intranet under Policies and Procedures. The policy originator will be responsible for ensuring direct distribution to all Associate Medical Directors and Divisional General Managers who will then be responsible for ensuring distribution to all relevant staff. 14 Education and Training To ensure high quality waiting list and RTT administration and continual maintenance of data quality, all staff involved in waiting list management will be trained to a standard level, tailored to the individual s responsibilities. Each year all relevant staff must have their waiting list management and RTT knowledge assessed and recorded as part of their KSF yearly appraisal. Any gaps in skills and knowledge will be addressed through either: - ics refresher training attendance on the Trust s RTT training session individual training from the specialty s RTT core trainer individual training from the medical records supervisors This various training will recognise differences in local administrative arrangements while ensuring consistency in the implementation of the Trust s Access Management Policy. Divisional General Managers are responsible for ensuring their staff comply with the policy and are fully trained by receiving the identified annual training. The divisional performance structures will review to ensure waiting lists are being managed in line with this policy. Indictors that are routinely used in these reviews include: - o Percentage of patients suspended o Number of open pathways o Feedback from RTT trackers when validating the 6 week to breach patients All staff involved in waiting list management will receive identified training at local induction On-going training will be provided by the IT training department for individuals needing a 12 month refresher training for all ics Inpatient and Outpatient Waiting List users Page 29 of 58

30 15 Monitoring and Review Divisional General Managers and Service Managers are responsible for ensuring that processes are in place to implement and monitor compliance with the Access Management Policy. The table below must be completed in the document to demonstrate effective monitoring of all documents. Standard/process/issue required to be monitored Duties Review of compliance: Waiting list management Assessment of RTT knowledge Annual refresher training Review of waiting lists Process for monitoring e.g. audit Policy review KSF Appraisal Data Quality Audit on RTT data Monitoring and Audit Responsible individual /group Deputy Director of Operations and Performance Line Managers Information manager Frequency of monitoring Responsible committee 2 years Performance and Finance Committee (PAF) Annual Annual Divisional Governance committee Data Quality committee 15.1 Action Plan The MCHFT Trust Gap Analysis/Action Plan must be used to demonstrate effective monitoring of all documents. This can be found on the intranet in frequently used forms Audit Proforma The MCHFT Audit proforma must be used to demonstrate effective monitoring and implementation of planned actions. This can be found on the intranet in frequently used forms. 16 References / Bibliography DSC Notice: 37/2003, Measuring and recording of waiting times for KH07, QF01, QM08 and QM08R, Dec 2003 DSC Notice: 18/2005, Introducing the new data collection to monitor diagnostic waiting times and activity, Jan 2006 Diagnostics waiting times and activity, Guidance on Completing the diagnostic waiting times & activity monthly data collection, V4.0, March 2009 Page 30 of 58

31 Diagnostics FAQ, Frequently Asked Questions on completing the diagnostic waiting times & activity monthly data collection Frequently Asked Questions on the Referral to Treatment (RTT) data collection, Department of Health, version 9, January Referral to treatment consultant-led waiting times - Rules Suite, Department of Health, January 2012 The Handbook to The NHS Constitution for England, Dept of Heath March 2013 Everyone Counts Planning for Patients 2014/15 to 2018/19, NHS England, December 2013 Risk Assessment Framework 2013/14, Monitor, August 2013 NHS e-referral Service Vision and Key messages, version 1, NHS England June Appendices 1. Current National & Local Waiting Time Targets 2014/ Access Management Policy Key Notes for Staff 3. NHS Constitution Flowchart 4. Standard Framework for Choose and Book 5. Medical Staff Annual Leave Application 6. Consultants Annual Leave Application 7. Procedure for Use of Outpatient Clinic Cancellation and Reduction Form 8. Outpatient Clinic cancellation or Reduction Form 9. Changes to Existing OPD Clinic Template or New Service 10. RTT Outpatient Outcome Form (Standard) 11. Key Diagnostic Tests & Procedures 12. RTT Inpatient Form 13. Glossary of Terms A B C Version Control Document Communication / Training plan Equality Impact and Assessment Tool Page 31 of 58

32 NATIONAL & LOCAL WAITING TIME STANDARDS 2012/13 APPENDIX 1 Sources: NHS England Everyone Counts 2014/15 and Monitor Risk Assessment Framework 2013/14 Quality Cancer: two week wait from referral to date first seen, comprising either: - all Cancer: 93% - for symptomatic breast patients (cancer not initially suspected): 93% All cancers: 31-day wait from diagnosis to first treatment: 96% All cancers: 31-day wait for second or subsequent treatment, comprising either: - surgery: 94% - anti cancer drug treatments: 98% - radiotherapy: 94% All cancers: 62-day wait for first treatment, comprising either: - from urgent GP referral to treatment: 85% - from consultant screening service referral: 90% Patients identified at high risk of Transient Ischaemic Attacks (TIA) should be reviewed by a stroke specialist within 24 hours of initial contact Patient Experience (Access) Referral to treatment waiting times admitted: 90% - 18 weeks Referral to treatment waiting times non-admitted: 95% - 18 weeks Referral to treatment waiting times incomplete: 92% - 18 weeks Referral to treatment waiting times maximum 52 weeks Referral to treatment waiting times All the above to be achieved by specialty each month Number of diagnostic waits > 6 weeks No more than 1% per month All patients who have operations cancelled for non-clinical reasons to be offered another binding date within 28 days or the patient s treatment will not be subject to PbR payment by commissioners Local Standards Choose & Book Slot Utilisation 2WW cancer referrals to be seen within 7 days. A maximum RTT wait of 52 weeks A maximum waiting time of 13 weeks for an outpatient appointment. A maximum waiting time of 26 weeks for an inpatient admission. A maximum two-week wait standard for Rapid Access Chest Pain Clinics. Page 32 of 58

33 ACCESS MANAGEMENT POLICY APPENDIX 2 Key Notes for Staff: RTT in brief 4.1 Referral to Treatment (RTT) An RTT pathway clock starts when any care professional or service, permitted by an English NHS commissioner to make such referrals, refers to: c) a consultant led service, regardless of setting, with the intention that the patient will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional or general practitioner; d) an interface or referral management or assessment service, which may result in an onward referral to a consultant led service before responsibility is transferred back to the referring health professional or general practitioner. A waiting time clock also starts upon a self-referral by a patient to the above services, where these pathways have been agreed locally by commissioners and providers and once the referral is ratified by a care professional permitted to do so. A new RTT clock is started upon a patient being re-referred in to a consultant-led as a new referral, even if it is for a condition that a patient has been previously discharged for. 4.9 Inappropriate GP Referrals Any referral that is rejected and returned to the referrer will result in a Referral To Treatment pathway clock stop. 5.1 Appointment Offers Patients will be given a reasonable offer of an appointment date. For an appointment offer to a patient to be deemed reasonable, the patient must be offered verbally a minimum of two appointments dates on different days, with at least three weeks notice before the first offered appointments. For a written appointment offer to be deemed reasonable, the patient is to be offered an appointment with a minimum of three weeks notice (DSCN 37/2003). 5.2 Patient Cancellations (New Referrals) Patients that cancel and rebook the same appointment twice will have an RTT clock stop and be referred back to their GP. If a patient refuses a reasonable offer the clock is reset. If the GP refers the patient back again then this starts a new RTT clock. 5.3 Patient Cancellations (Follow ups) If a patient cancels the same follow-up appointment twice, the medical progress will be reviewed by the clinical team and a decision to make a new appointment or discharge will be made. If the patient is being referred back to their GP then the RTT clock will be stopped and the patient s GP will be informed of the outcome in writing. Page 33 of 58

34 5.5 Patients who Do Not Attend (DNA) In the event of a new patient DNA the GP is notified and the patient advised to contact their GP again if necessary. When a paediatric patient DNAs, the RTT pathway will be nullified and the parents must be contacted to agree a subsequent date offered. Patients who fail to attend (DNA) their follow up appointment will not be offered a further appointment unless it is contrary to their best clinical interests this will be the decision of the consultant Non Active (Suspended) Waiting Lists & RTT Pauses An RTT clock may be paused only where a decision to admit for treatment has been made, and the patient has declined at least two reasonable appointment offers for admission. The clock is paused for the duration of the time between the earliest reasonable offer and the date from which the patient makes themselves available again for admission for treatment. If the patient notifies the Trust of any period when they will not be available for admission likely to affect their admission date, for example a two week holiday, this must be recorded as a suspension period for the waiting list entry and a RTT clock pause recorded on the PAS. If the patient is medically unwell for admission but is expected to be fit for surgery in less than 4 weeks e.g. to treat chest infections with antibiotics; the RTT pathway continues. If the patient is medically unwell for admission but is expected to be fit for surgery in more than 4 weeks the RTT pathway will stop and restarted when the patient is fit and ready to continue. If a patient is expected to be unwell for more than 12 weeks the patients should be referred back to their GP with written communication. 8.1 Clock stops The RTT pathway clock stops when first definitive treatment occurs which could be on admission for surgery or in outpatients e.g. through pharmacology treatment or referral to therapists for treatment. The RTT pathway clock stops for non treatment when it is communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay that either: a) It is clinically appropriate to return the patient to primary care for any non consultant-led treatment in primary care; b) A clinical decision is made to start a period of active monitoring; c) A patient declines treatment having been offered it; d) A clinical decision is made not to treat (this is particularly relevant when diagnostic test results return normal and a consultant writes to the GP and patient to inform them rather than wait for an outpatient appointment) 8.3 Active Monitoring An RTT pathway clock may be stopped where it is clinically appropriate to start a period of monitoring in secondary care without clinical intervention or diagnostic procedures at that stage. Page 34 of 58

35 Page 35 of 58 APPENDIX 3

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