Clinical Sub Category Review date February 2016 Distribution Who the policy will be Distributed to senior staff as defined by directors

Transcription

1 Document Details Title Patient Access Policy Incorporating the management of appointments and Did Not Attend (DNA) Trust Ref No Local Ref (optional) Main points the document To ensure the effective management of the 18 week covers pathway, the management of appointment systems and actions to reduce did not access (DNA) rates Who is the document All staff who provide and manage services and those that aimed at? monitor appointment related performance Author Lee Osborne, Programme Manager - Information Services Sara Vale, Head of Child, Family & Preventative Services Approval process Approved by Quality and Safety Committee (Committee/Director) Approval Date 18/02/2014 Initial Equality Impact Yes Screening Full Equality Impact No Assessment Lead Director Steve Gregory Category Clinical Sub Category Review date February 2016 Distribution Who the policy will be Distributed to senior staff as defined by directors distributed to Method Electronically to senior staff and available to all staff via the Trust website Document Links Required by CQC NO Required by NHLSA NO Other NO Amendments History No Date Amendment 1 10 th May 2013 Additional sections added around partial booking, patient cancellations, Patient Access Policy doc Page 1

2 1 Contents 1. Introduction Purpose Definitions Duties Outpatients Outpatient appointment process and clock starts Notification of Outpatient Appointment Date Diagnostics Notification of Diagnostic Appointment Date Audiology Inpatients/ Day case Notification of Admission Date Paediatric and Special Care Dentistry (Oral surgery) Paediatric and Special Care Dentistry (Oral surgery) Pathway Patients requires Dental treatment under General Anaesthetic Patients requires treatment not under General Anaesthetic (GA) Patients require treatment under General Anaesthetic (GA) following Community Dental Practitioners appointment Transfer of Care Patient Choice Delays New Outpatient Appointments Inpatients Admissions clock pause Patient Did Not Attend (DNA s) Patient DNA s New Outpatient Appointments Patient DNA s Follow up Outpatient Appointments Patient DNA s Diagnostics Patient DNA s Inpatients and Day cases Patient DNA Paediatric & Special Care Dentistry (Oral surgery) Cancellation of Appointments Patient Cancellations (CNA) New Outpatient Appointments Patient Cancellations Follow up Outpatient Appointments If a patient cancels an appointment anywhere in an RTT pathway, another appointment should be re-arranged if required Patient Cancellations Diagnostics Patient Access Policy doc Page 2

3 10.4 Patient Cancellations Inpatients and Day cases Patient Cancellations Paediatric & Special Care Dentistry (Oral surgery) Referral Cancellations Advanced Primary Care Services (APCS) Trust Cancellations Outpatient Cancellation Notification of request to reduce/cancel Outpatient Clinic Session Re scheduling of appointments Follow up Patients Inpatients and Day cases cancellations Operations cancelled by hospital on day of admission Consultant to Consultant Referrals Consultant to Consultant Referrals (Same Condition) Consultant to Consultant Referrals (Different Condition) New Pathway with Same Consultant but for a Different Condition Medically Unfit for Treatment Short-term periods of medical unfitness (two weeks or less) Long -term periods of medical unfitness (over two weeks) Hospital Cancellations on the day due to medical unfitness Inter Provider Transfer Forms (IPT) Sending an IPT Receiving an IPT Consultation Monitoring Compliance References Appendix 1- Definition of the Clinical Outcome Coding Outpatients Appendix 2 - Definition of the Clinical Outcome Coding Appendix 3 - APCS Procedure Inter Provider Transfer form (IPT) Appendix 4 - Best practice for managing appointment systems Appendix 5 - Inter-Provider Transfer (IPT) template (printable version) Appendix 6 - Diagnostic classifications Appendix 7 - Paediatric and Special Care Dentistry (Oral Surgery) Pathway Patient Access Policy doc Page 3

4 1. Introduction Every process in the management of patients who are waiting for treatment must be clear and transparent to the patients, staff and partner organisations. These processes must be open to inspection, monitoring and audit. This Policy details the Trusts key principles that govern effective and reliable referral and treatment management throughout the Community Trust and Local Health Community. The overall approach is that the patient s pathway will be monitored and managed in line with national and contractual waiting list guidance and rules. This will also enable the patients to be managed within the national NHS 18 week patient pathway This policy is to be used by all those individuals who are responsible for referring patients and those responsible for managing referrals. It will also be used by all those individuals within the Community Trust including clinicians and administrative staff who have responsibility for the patients progress along the Referral to Treatment pathway (RTT). 2. Purpose The purpose of this policy is to enable a detailed understanding of the systems processes and reference points used by the Trust for management of patients waiting for treatment for all groups of patients. 3. Definitions 4. Duties RTT definitions and Clinical outcome codes are listed in Appendix 1 and Appendix 2 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 speciality pathways, and referrals to ensure wait times are managed and measured accordingly. A patient should never routinely be offered a date that exceeds the national target dates. The Referral to Treatment (RTT) breach date for 18 weeks is the 127th day after the RTT start date. 5. Outpatients The NHS Data Model and Dictionary definition of an Out-Patient Attendance is a Patient seen by a Consultant, a member of the consultant firm/team or locum for such a member. Patient Access Policy doc Page 4

5 5.1 Outpatient appointment process and clock starts For all manual/paper referrals and onward referrals from other providers (for the same condition), the 18 week pathway clock start date will be the date the referral was originally received. For patients who book appointments through the Choose & Book Electronic Booking process, their 18 week pathway clock start will be the date the patient converts their Unique Booking Reference Number (UBRN) into a booked appointment on the Choose and Book System. 5.2 Notification of Outpatient Appointment Date Patients will be given reasonable notice of their outpatient appointment dates. Reasonable notice is defined as 3 weeks notice and this should be given where possible. Patients should be offered a minimum of 2 possible dates within a 5 week period. 6. Diagnostics For the purpose of this policy, a diagnostic test is defined as a circumscribed procedure, which provides objective information to assist the diagnosis and treatment plan for a clinical condition. It does not imply effective intervention or amelioration. The policy describes diagnostic services as a generic term that covers the tests that fall into the categories listed in Appendix 6 A six week diagnostic wait was initially introduced as a milestone towards achieving the standard Referral to Treatment wait of 18 weeks. The NHS Operating Framework, 2012/2013 introduced an expectation that less than 1 per cent of patients should wait six weeks or longer for a diagnostic test. 6.1 Notification of Diagnostic Appointment Date Patients will be given reasonable notice of diagnostic appointment dates. Reasonable notice is defined as 3 weeks notice and this should be given where possible. Patients will be offered a minimum of 2 possible dates within a 2 week period, where possible. NB: The reasonable notice period will not apply to diagnostics appointments which are fully booked on date of request. 6.2 Audiology Referrals to the Community Trusts Audiology service will start the diagnostic six week clock. Patient Access Policy doc Page 5

6 Patients referred to Community Trusts Audiology services will be sent a partial booking invitation letter, inviting the patients/ parents or guardians to telephone within two weeks or receiving the letter to agree a convenient date. The clock will start at on the day the patients/ parents or guardians contacted the Trust to accept a convenient appointment date. The clock stops when the patient receives the diagnostic test/procedure. If a patient cancels or misses an appointment for a diagnostic test/procedure that meets the reasonable notice criteria, then the diagnostic waiting time for that test/procedure is set to zero and the waiting time starts again from the date of the appointment that the patient cancelled/missed. Where this presents a significant technical challenge and doing so does not adversely affect wait times the same clock can continue if there is still an intention to carry out a diagnostic. Similarly, if a patient turns down reasonable appointments, i.e. 2 separate dates and 3 weeks notice, then the diagnostic waiting time for that test/procedure can be set to zero from the first date offered. Where a patient/ parent or guardians do not ring back following their offer to make an appointment then the patients referral would be sent back to the referrer. A covering letter would be sent to the referrer stating that the patient had not booked an appointment and therefore if the patient still requires a referral then a new referral should be made. 7. Inpatients/ Day case Inpatient: A patient admitted with the expectation that they will remain in hospital for at least one night. Daycase: A patient admitted electively (i.e. from a waiting list) during the course of a day with the intention of receiving care without requiring the use of a hospital bed overnight. If the patient treatment then results in an unexpected overnight stay they are counted an Elective Inpatient. 7.1 Notification of Admission Date Patients will be given reasonable notice of admission dates. Reasonable notice is defined as 3 weeks notice and this should be given where possible. Patients will be offered a minimum of 2 possible dates within an 8 week period, where possible. Patient Access Policy doc Page 6

7 7.2 Paediatric and Special Care Dentistry (Oral surgery) Consultations and treatment carried out by General Dental Practitioners, Community Dental Practitioners or by Specialist Practitioners working within the Community is not part of the 18 Weeks Referral to Treatment target. There are, however, two exceptions when community based interventions are part of the 18 Weeks RTT Standard: The planned procedure which is being carried out in the community is undertaken by a secondary care specialist. The procedure requires a General Anaesthetic. In these circumstances the intervention will be included in the 18 Weeks RTT target. 18 Weeks RTT applies to the five secondary care Dental Specialties and General Anaesthetics, namely: Paediatric Dentistry Orthodontics Restorative Oral Surgery Oral Medicine All Dental Procedures (treatment) carried out under General Anaesthetic (this is a service provided by Community Trust using another providers theatre resource) The complex patterns of service delivery in the different care settings require the close co-operation between the Trust and the provider of the Theatre resource (SATH) for the delivery of treatment. This is essential for the management of this group of patients Paediatric and Special Care Dentistry (Oral surgery) Pathway All referrals into the service will be registered onto the Dental Information (IT) system. Referrals will be triaged and treatment will be offered to patients if appropriate. Oral surgery patient pathway flowchart is provided in Appendix Patients requires Dental treatment under General Anaesthetic Patients identified as requiring treatment under GA will be given reasonable notice of admission dates. Reasonable notice is defined as 3 weeks notice and this should be given where possible. Patients will be offered a minimum of 2 possible dates within a 5 week period, where possible. Patient Access Policy doc Page 7

8 The patient pathway will become part of the 18 Weeks RTT standard and the pathway clock start will commence from the date of the original referral received date. Referrals triaged onto the Paediatric and Specialist care Dentistry (Oral Surgery) RTT pathway will be registered onto the Community Trusts PAS (SEMA) Patients requires treatment not under General Anaesthetic (GA) Patients identified as needing treatment that does NOT require a GA will remain on the Community Dental Practitioners (CDP) waiting list and will be offered treatment within the Community Dental service clinics. Patients added to the CDP waiting list will not become part of the 18 Weeks RTT standard Patients require treatment under General Anaesthetic (GA) following Community Dental Practitioners appointment. If following an attendance to a Community Dental Practitioners clinic (CDP) the patient is identified as requiring further treatment under General anaesthetic, the patient s pathway will be converted from CDP to RTT. The patients RTT clock will commence from the date of the last CDP appointment. 7.3 Transfer of Care From time to time patients may be offered admission dates (within the relevant access target) at a hospital other than the Community Hospital. Patients who do not wish to transfer and are prepared to wait longer for an admission date at the Community Hospital, will have their clock paused from the time of the earliest date offered at the alternative provider until the date of admission at the Community Hospital. 8. Patient Choice Delays 8.1 New Outpatient Appointments Patients who choose to delay the start of their pathway beyond 2 reasonable offer dates will have their clock reset from the date of the first reasonable offer. These will be recorded locally and monitored by the service managers responsible for RTT (Referral to Treatment). Patients who choose to delay the start of their pathway 7 weeks beyond reasonable offer dates (i.e. exceeding 12 weeks) will be returned to the care of their GP with advice to re refer for an appointment when the patient becomes available again. 8.2 Inpatients Admissions clock pause A clock may be paused only where a decision to admit has been made, and the patient has declined at least 2 reasonable appointment offers for admission. The clock is paused from the earliest reasonable offer date to the date from which the patient makes themselves available again for admission. Patient Access Policy doc Page 8

9 9. Patient Did Not Attend (DNA s) In order to prevent patient DNA s and meet the required target of 11%, all service areas will work towards the introduction of partial booking systems and electronic reminders, by following the organisations Best practice guidance for appointment management as detailed in Appendix Patient DNA s New Outpatient Appointments All patients who DNA their first appointment will have their 18 week clock nullified. If following re-appointment a second DNA occurs the patient will have their 18 week clock nullified for a second time and will be discharged to the care of their GP/other referral source. A letter will be generated to the GP/referral source informing them the patient has failed to attend 2 scheduled appointments. The letter will advise the GP/referral source that if a further consultation is required the referrer should contact the Community Hospital appointments office within 4 weeks in order to request further consultation. The 18 week clock will restart at the point of the GP s request to rebook a further appointment. (The rule above can only be used if the appointment was made with reasonable notice). NB: A new referral will be required from the GP/referral source for any request for further appointment outside the agreed designated timescale. The patient will also receive a copy of the letter advising of their failure to attend Patient DNA s Follow up Outpatient Appointments Any patient who DNA s a follow up appointment will be offered a further appointment. The 18 week clock will be reset to the DNA date. If following reappointment a second DNA occurs the patient will have their 18 week clock stopped and will be discharged to the care of their GP/other referral source Patient DNA s Diagnostics All patients who DNA their first diagnostic appointment will have their 18 week clock reset to the DNA date. The patient will be offered a rescheduled appointment negotiated up to a maximum of 3 weeks. Patients who DNA a second appointment will not be offered a further date and the clinician who referred the patient for the diagnostic will be notified. This may result in their 18 week clock being stopped, however this decision can only be made by the referring clinician. Patient Access Policy doc Page 9

10 9.1.4 Patient DNA s Inpatients and Day cases Any patient who DNA s an admission date will be offered a further admission date. The 18 week clock will be reset to the DNA date. If following a reoffer a second DNA occurs the patient will have their 18 week clock stopped and will be discharged to the care of their GP/other referral source Patient DNA Paediatric & Special Care Dentistry (Oral surgery) All patients who DNA their first appointment will have their 18 week clock reset to the DNA date. The patient will be offered a rescheduled appointment negotiated up to a maximum of 5 weeks. Patients who DNA a second appointment will be removed from the RTT pathway and reinstated onto the Community Dental Practitioners pathway (see section ) or discharged to care of their General Dental Practitioners The exception to this will be where, in the clinical judgment: The patient needs to be offered another appointment on the grounds of clinical need. The patient could be considered to be vulnerable due to age, reliance on carers, mental capacity etc. 10. Cancellation of Appointments The cancellation of an appointment can be by the patient, GP, referring clinician consultant or clinic if not the Trust Patient Cancellations (CNA) New Outpatient Appointments Patients who cancel their agreed appointments after the date of the clock start will be contacted and a second appointment negotiated up to a maximum of 5 weeks. Subsequent cancellations by the patient will then result in discharge back to the referrer. If the patient is still not able to attend within the 5 weeks they will be discharged back to the referrer and their 18 week clock stopped. The exception to this will be where, in the clinical judgment of the consultant: The patient needs to be offered another appointment on the grounds of clinical need. The patient could be considered to be vulnerable due to age, reliance on carers, mental capacity etc. Patient Access Policy doc Page 10

11 10.2 Patient Cancellations Follow up Outpatient Appointments If a patient cancels an appointment anywhere in an RTT pathway, another appointment should be re-arranged if required. The patient will be offered a second appointment date negotiated up to a maximum of 5 weeks. If the patient can still not attend within this timeframe they will be discharged back to the referrer and their 18 week clock stopped. The exception to this will be where, in the clinical judgment of the consultant: The patient needs to be offered another appointment on the grounds of clinical need. The patient could be considered to be vulnerable due to age, reliance on carers, mental capacity etc Patient Cancellations Diagnostics The patient will be offered a further appointment date for test within a reasonable period. If the Community Services Manager (CSM) feels that 18 Weeks is not achievable the patient may be offered an alternative provider Patient Cancellations Inpatients and Day cases If a patient cancels an admission date anywhere in an RTT pathway, another appointment should be re-arranged if required. The patient will be offered a second appointment date negotiated up to a maximum of 5 weeks. If the patient can still not attend within this timeframe they will be discharged back to the GP/other referral source and their 18 week clock stopped. The exception to this will be where, in the clinical judgment of the consultant: The patient needs to be offered another appointment on the grounds of clinical need. The patient could be considered to be vulnerable due to age, reliance on carers, mental capacity etc Patient Cancellations Paediatric & Special Care Dentistry (Oral surgery) Following the first cancellation a further appointment date for treatment within a reasonable period will be offered. Any subsequent cancellations will result in the patient being removed from the RTT pathway and reinstated onto the Community Dental Practitioners Pathway (see section ) or discharged to care of their General Dental Practitioners The exception to this will be where, in the clinical judgment: The patient needs to be offered another appointment on the grounds of clinical need. Patient Access Policy doc Page 11

12 The patient could be considered to be vulnerable due to age, reliance on carers, mental capacity etc Referral Cancellations Advanced Primary Care Services (APCS) Patients referred to APCS are requested to ring back following their triage time to book their assessment with APCS. Patients are informed of this process. In cases where patients do not ring back within 8 weeks following referral date then the patients referral is removed from the computer system used for monitoring 18 Week RTT. Any referral cancelled is sent back to the GP with a covering letter stating the patient had not booked an appointment and therefore if the patient still required a referral to APCS then a new referral should be made. 11. Trust Cancellations If the Trust or partner organisation cancels a patient s appointment anywhere on an RTT pathway, the clock continues to tick. No clock pause adjustments are allowed for NHS initiated cancellations or rearrangements Outpatient Cancellation Notification of request to reduce/cancel Outpatient Clinic Session Outpatient clinics can only be reduced / cancelled on a Consultant s written confirmation of cancellation and with the knowledge of the manager responsible for Community Hospitals. The Consultant will be required to advise the appointments scheduling office of any changes to clinic schedules. A minimum of six weeks notice is required for annual leave/study leave requests. Any other request for reduced/cancelled clinics giving less than 10 working days notice will not be accepted. If a session is cancelled at short notice, then an extra session needs to be provided by the Consultant at no extra cost. Prior approval must be gained from the appropriate Community Service Manager Re scheduling of appointments Follow up Patients Reschedule standards:- Patients with a wait time on-going treatment status will take priority over routine reviews where the clock has stopped. The Trust and its Consultants will work in partnership to create additional capacity to treat patients from its waiting lists. This may involve working with other NHS Trusts and independent providers. This will help ensure shorter waiting times for treatment. Patient Access Policy doc Page 12

13 If however, during the rescheduling process it is identified that 18 weeks RTT is not achievable patients will be offered a choice of transferring to another consultant or suitable providers. When it is clear where a patient is willing to be treated by a different consultant or different provider, the normal rules of reasonableness will apply and if two or more reasonable offers of treatment with the different consultant/provider chosen by the patient are declined, then the patient s clock can be reset to the. A patient should not be forced to move either to a new consultant or to a different provider 11.2 Inpatients and Day cases cancellations Operations cancelled by hospital on day of admission No patient should have his or her admission cancelled. However this may occur in exceptional circumstances. In the event that the Trust or partner organisation has to cancel a patient s elective procedure on the day of admission or day of surgery for a Non-clinical reason, the patient must be offered another date within 28 days of the cancelled operation date or prior to their 18 week breach date, whichever is sooner. The Trust is monitored on the number of breaches of this national key operating standard. If however during the rescheduling process it is identified that 18weeks RTT is not achievable patients will be offered a choice of transferring to another consultant or suitable providers. When it is clear where a patient is willing to be treated by a different consultant or different provider, the normal rules of reasonableness will apply and if two or more reasonable offers of treatment with the different consultant/provider chosen by the patient are declined, then the patient's clock can be reset. The only exception to this would be if the patient chooses an alternative date to suit their requirements beyond 28 days/18 week breach date. In this instance the clock is paused between the earliest offer date and the patient choice date. Offers given should be clearly documented within waiting list functions. Patients cancelled on the day of admission or operation for medical reasons should have the reason for cancellation clearly documented in order to identify the delay if problems occur with achieving the maximum of 18 weeks. 12. Consultant to Consultant Referrals Consultant to consultant referrals for patients with the same underlying condition are likely to be follow-on referrals after the first outpatient appointment and should Patient Access Policy doc Page 13

14 be included within the 18 week pathway (with the clock starting at the point of the original GP referral). If the patient needs to be referred to a Consultant outside the Trust then the onward referral must be accompanied by an Inter Provider Transfer form (Section 14 Inter Provider Transfer Forms) Consultant to Consultant Referrals (Same Condition) Patients referred on to an alternative Consultant for the same condition as originally referred with. Where possible a Consultant identifies from the contents of the referral letter that the patient requires an appointment with an alternative Consultant. The referral is returned to the appointments office with instructions to forward to appropriate Consultant in next outpatient clinic. If the patient requires an appointment with a Consultant in a different specialty, a decision is made by the clinician to forward to appropriate service or reject back to the GP/other referral source. For patients whereby it is not easily identifiable from the referral letter that they require an appointment with an alternative Consultant the following process will be adopted:- Patient attends OPD consultation with Consultant A Consultant A dictates letter for patient to be seen by Consultant B Patient is advised to book a new appointment with Consultant B at OPD reception desk on exit from clinic Patient is allocated a new appointment slot. If the Community Services Manager (CSM) feels that 18 Weeks is not achievable the patient will be offered an alternative provider. Referral letter forwarded to Consultant B for information Patient attends OPD consultation with Consultant B 12.2 Consultant to Consultant Referrals (Different Condition) Patients referred from one Consultant to another for a different condition. If a Consultant identifies a condition other than that for which the patient was originally referred and makes a referral to another consultant for treatment of that condition, this will start a new patient pathway with a new 18 week pathway clock. NB: The referral date (clock start) for Consultant to Consultant referrals to be recorded on PAS is the date the referral is made to the second consultant. Patient Access Policy doc Page 14

15 New Pathway with Same Consultant but for a Different Condition Patient starts a new pathway with the same consultant but for a different condition. If it is identified during a consultation that a patient requires specialist treatment for a different condition but the consultant is the same, the clinician informs the medical secretary and a new pathway is created using the PAS. This will start a second 18 Week Pathway clock, The first original clock will still be ticking NB: The referral date (clock start) to be recorded on PAS is the date the decision was made to commence a new treatment pathway. 13. Medically Unfit for Treatment Patients who have commenced an 18 week pathway but are found to have a medical problem which prevents commencement of treatment. No patient must be added to the waiting list if they are unfit for their treatment at the time of decision to admit. It is, however, recognised that patients may become unfit or be deemed to be unfit after they have been added to the waiting list. In this event, a clinical assessment must be made to ascertain the likely nature and duration period of unavailability Short-term periods of medical unfitness (two weeks or less) Short-term periods of medical unfitness (two weeks or less) must be absorbed into the overall patient waiting time and will not affect a patient s RTT status or breach date. The patient will be offered a further pre-screening appointment within three weeks of the patient becoming unfit. This will allow patients with minor acute clinical reasons for delay time to recover and the clock will continue to run during this time. If a patient is not fit after that time the patient will normally be discharged and returned to their GP/other referral source for management of the condition that is rendering the patient unfit for the required surgical procedure, or, in relation to dental treatment under GA, to monitor the condition requiring surgery in collaboration with the patient and their medical practitioners. This action will results in their pathway and clock being stopped. A new referral should then be made by the referrer when the patient is fit for surgery, which will initiate a new clock start and pathway. If however the responsible clinician / listing consultant or anaesthetist decide that it would be more appropriate for the patient to remain on the current RTT pathway the Patient Access Policy doc Page 15

16 patient s waiting list clock will continue to tick. The RTT pathway relating to patients with long term period of medical unfitness then applies (13.2) 13.2 Long -term periods of medical unfitness (over two weeks) In the event of a long-term period of the patient being medically unfit (over two weeks) the responsible clinician / listing consultant or anaesthetist can decide to refer the patient back to the care of their GP/other referral source for management of the condition that is rendering the patient unfit for the required surgical procedure, or, in relation to dental treatment under GA, to monitor the condition requiring surgery in collaboration with the patient and their medical practitioners. This action will results in their pathway and clock being stopped. A new referral should then be made by the referrer when the patient is fit for surgery, which will initiate a new clock start and pathway. If the responsible clinician / listing consultant or anaesthetist decide that it would be more appropriate for the patient to remain on the current RTT pathway the patient s waiting list clock will continue to tick. In this event the pathway will subjected to validation at weekly intervals to ensure the patient is offered an appropriate date with the RTT Pathway. If it is likely that the medically unfit duration is to exceed the national RTT target, the patient will be returned to their GP/other referral source until medically fit to proceed. This action will results in their pathway and clock being stopped. A new referral should then be made by the referrer when the patient is fit for surgery, which will initiate a new clock start and pathway Hospital Cancellations on the day due to medical unfitness Where a patients is cancelled medically unfit on the day of admission / surgery (e.g. patient deemed temporarily unfit for surgery due to chest infection) the TCI should be recorded with the outcome Hospital Cancelled Medically Unfit and any relevant information should be recorded on PAS in the notes field. The RTT clock will continue to tick unless a clinical decision is made that the patient is unsuitable for surgery/treatment and they are discharged back to their GP/other referral source care or a decision is made not to treat. 14. Inter Provider Transfer Forms (IPT) The IPT supports the requirement to transfer administrative data to allow the monitoring of a patient s progress along an 18 Week pathway where care has been transferred between providers. Patient Access Policy doc Page 16

17 If the care of a patient on an 18 Weeks pathway transfers between healthcare providers then an IPT should be sent with the referral. An IPT doesn t need to be completed when the patient is being sent for opinion or diagnostics, where the care of the patient remains with the original service provider. The IPT form is included in Appendix Sending an IPT Shropshire Community Health APCS utilise a procedure (Appendix 3) which identifies the criteria by which is followed to identify the criteria for decisions made for the IPT form Receiving an IPT The IPT will provide the clock start date and appropriate information that can be entered on to the PAS. If an IPT form has not been sent with the referral from a provider then you should contact the relevant department at the referring Trust to request it. If the IPT still doesn t arrive the Operational Service manager should be notified. 15. Consultation This policy has been developed in consultation with Heads of Service and service managers. 16. Monitoring Compliance The overall approach is that the patient s pathway will be monitored and managed in line with national and contractual waiting list guidance and rules. These processes must be open to inspection, monitoring and audit. The Trusts Information services team will upload the completed mandated returns in line with national requirements via the Department of Health s (DOH) online data collection tools, the DOH information centre will then publish the provider returns, aggregate the data and produce commissioner returns at CCG level. 17. References Answers to the most frequently asked FAQs for RTT Referral to treatment waiting times Statistics: Consultant-led Referral to Treatment Waiting Times Guidance Direct Access Audiology Data extract service Securing excellence in commissioning NHS dental services Patient Access Policy doc Page 17

18 FAQs pdf Patient Access Policy doc Page 18

19 Appendix 1- Definition of the Clinical Outcome Coding Outpatients Status NOT PART of RTT period Decision that STARTS a new RTT period ALONG the pathway of an RTT Period Decision that ENDS an RTT period Operational procedures to be followed and pathway confirmed for listed scenarios REFERRAL TO TREATMENT OUTCOME Referral to treatment (RTT) PAS code Treatment already started 90 Started at a previous visit or by another consultant. Active monitoring in progress - 91 Started at a previous visit or by another consultant. Active monitoring end - patient has been monitoring their own condition or they have been seen periodically by a 11 clinician. Something about their condition has changed and they now need treating more actively. Consultant refers for separate condition This is a consultant to consultant referral outside speciality. These should not be happening routinely as 12 the PCT will not pay for these episodes. A new referral from the GP should be sort. First activity after referral, treatment in future First attendance in the Trust as there is a condition which 10 requires treatment in the Trust. Subsequent activity after referral, treatment in future a follow up appointment were the patient is progressing 20 towards treatment, e.g. returning for test results. Transferred to another Trust, treatment in future transfer to a tertiary centre where we have not treated 21 the patient but treatment is required. First treatment the treatment which is intended to be 30 definitive for the condition. This is a bit ambiguous. Active monitoring initiated by patient- the patient needs 31 to take responsibility for recognising changes in condition. The patient would like to take some time to consider options beyond a couple of weeks. Active monitoring initiated by consultant the patients 32 general is not correct for the treatment at this time, e.g. clinical monitoring of condition. Patient DNA d appointment first attendance with the 33 Trust only. Decision not to treat, no further contact - the decision 34 has been made with/without the patient that there will be no further treatment by the Trust. Patient declined treatment 35 Patient died 36 Where the patient is referred to the following departments / external provider the pathway will not close until confirmation is received back form external areas. Once first physiotherapy treatment undertaken 30 Once wheelchair is delivered 30 Once artificial limb is fitted 30 Doctor in clinic to Patient Access Policy doc Page 19

20 On ADMISSION the patient s RTT pathway is automatically CLOSED. There are instances where the pathway will need to be RE-OPENED. Reasons for Re-opening RTT pathway Code Tick Treatment not carried out but treatment is still required For any reason the surgery 20 was cancelled, but is still required. Treatment not carried, patient is to be referred to another NHS provider for treatment 21 the Trust is unable to carry out the treatment after further assessment and needs a specialist centre. Treatment is completed but was a diagnostic test only -the admission was never intended to be the definitive treatment, or did not develop into the definitive treatment. Treatment was for a planned an endoscopy, bronchoscopy, colonoscopy. The result was a diagnostic test only and not deemed treatment. If the result was therapeutic treatment the RTT will remain closed. Admission was for a biopsy. Paediatrics admitted for diagnostic tests with sedation. 20 Appendix 2 - Definition of the Clinical Outcome Coding Patient Access Policy doc Page 20

21 Appendix 3 - APCS Procedure Inter Provider Transfer form (IPT) Introduction The IPT form is used to give information on a patient that is transferred from one provider to another in order to ensure that the 18 Week Referral to Treatment Pathway is documented accurately. In Advanced Primary Care Services (APCS) Shropshire Community Health NHS Trust the majority of this form is completed by the administration staff referring the patient on to another provider. One section of the form is regarding referral pathway to the new provider. This section is labelled as follows: A Start of a new pathway (new condition or change of treatment) B Continuation of an active pathway (1st definitive treatment not given) C Continuing treatment for a stopped pathway (1st definitive treatment given) It is important that this section is indicated by the clinician referring on to the next provider. Criteria for the above as follows: A Start of a new pathway (new condition or change of treatment) This will be the option to use when the patient has had an initial intervention from the APCS such as physiotherapy/injections, exercises, other treatments or advice which have been instigated with the intention of managing the patients condition/symptoms which may involve a period of monitoring afterwards to see if this has worked. But when the patient is reviewed e.g. 6 8 weeks later the treatment has only had limited or no lasting effect. In this situation the patient is referred on to secondary FOR A CHANGE OF TREATMENT as the GPwSI is often suggesting that a surgical intervention might be required. (i.e. it s the same condition but likely to be invasive hence change of treatment. B Continuation of an active pathway (1st definitive treatment not given). This will be option to use when the patient has been assessed by APCS by the GPwSI requested diagnostic tests (e.g. MRI/CT scan) etc in order to more fully understand the patient s condition/symptoms. With the result of said investigations the GPwSi decides to refer directly on to secondary care (i.e. does not do any physio / injections / treatment) and therefore no treatment has been commenced pathway started at the initial GP referral into APCS service (i.e. = clock start date on the form) and is still an active clock passed onto secondary care. Patient Access Policy doc Page 21

22 C Continuing treatment for a stopped pathway (1st definitive treatment given) This will be the option when the patient has been commenced on treatment at APCS and the referral to secondary care is for continuation of the same treatment. In the APCS situation this should be a rare occurrence as physiotherapy, injection therapy, podiatry and orthotic onwards referral do not form part of the 18 Week RTT. The 18 Week RTT form is not required in these situations. These patients should be simply discharged from APCS. The clinician should inform the Administration dealing with this transfer by indicating either A, B or C. The mechanism by which this is done (e.g. Dictaphone, documentation etc.) should be discussed with the Co-ordinator for the relevant APCS location. APCS - Process for Returning a Patient s Referral Back to the GP when the patient has not contacted booking in bureau for an appointment Patients referred to APCS activate the booking in number following referral from their GP. These referrals are triaged by APCS and directed to the appropriate care provider through BIB. In some cases patients do not ring back following their triage time to book their assessment with APCS. This may be because the patient no longer required an assessment. In some cases patients do ring back but this can be many weeks following the date of referral. Due to the present system, the 18 Week clock starts ticking at the time of the referral being activated. Therefore, following 8 weeks after referral (allowing a maximum of 2 weeks for triage) if the patient has not contacted the Booking In Bureau to make an appointment for assessment then the patients referral would be removed from the computerised systems used for booking in and monitoring the 18 Week RTT. The referral would be sent back to the GP with a covering letter stating that the patient had not booked an appointment and therefore if the patient still requires a referral to APCS then a new referral should be made. Information regarding this procedure would be documented to all GPs prior to commencing this process. All patient documentation will state that they will be removed from the waiting list if they do not contact within 8 weeks following the activation of their referral. Patient Access Policy doc Page 22

23 Appendix 4 - Best practice for managing appointment systems When patients do not attend (DNA), their appointments this affects waiting times for appointments, the patient s health and wellbeing as well as having a financial impact on the organisation. By reducing the number of DNA s, patients will be seen sooner and resources can be reinvested into improving the quality of patient care. The introduction of a partial booking system has been shown to reduce the number of DNA s. Partial booking of appointments is when upon receipt of a referral the service writes to the patient to ask them to make contact to arrange an appointment at a time and date that is convenient to them. Where services have a waiting list the patient is written to upon receipt of referral to advise them of the waiting time and contacted again when they are near the top of the waiting list asking them to make contact to arrange a convenient appointment. Where a referrer identifies that the patient has poor engagement with services due to their personal circumstances, the appointment arrangements should be made jointly with the referrer s support of the family. Where high rates of DNA occur despite the introduction of partial booking, systems to remind patients of their appointment details by phone, text message or , dependant on patient preference, 48 hours in advance of the appointment will be introduced. In order to consistently roll out this best practice, work will be undertaken to scope the resource implications of partial booking and electronic reminders and to develop appropriate governance for the use of text and communication systems with patients. Patient Access Policy doc Page 23

24 Appendix 5 - Inter-Provider Transfer (IPT) template (printable version) Patient Access Policy doc Page 24

25 Appendix 6 - Diagnostic classifications IMAGING Magnetic Resonance Imaging Computer Tomography Non-obstetric ultrasound Barium Enema DEXA Scan (Dual-energy X-ray absorptiometry) PHYSIOLOGICAL MEASUREMENT Audiology - audiological assessments Cardiology - echocardiography Cardiology - electrophysiology Neurophysiology - peripheral neurophysiology Respiratory physiology - sleep studies Urodynamics - pressures & flows ENDOSCOPY Colonoscopy Flexible sigmoidoscopy Cystoscopy Gastroscopy Patient waiting times for the following groups of tests and procedures should be reported: Imaging - Magnetic Resonance Imaging Imaging - Computed Tomography Imaging - Non-obstetric ultrasound Imaging - Barium Enema Imaging - DEXA Scan Physiological Measurement - Audiology Audiology Assessments Physiological Measurement - Cardiology - echocardiography Physiological Measurement - Cardiology - electrophysiology Physiological Measurement - Neurophysiology - peripheral neurophysiology Physiological Measurement - Respiratory physiology - sleep studies Physiological Measurement - Urodynamics - pressures & flows Endoscopy - Colonoscopy Endoscopy - Flexi sigmoidoscopy Endoscopy - Cystoscopy Endoscopy Gastroscopy Patient Access Policy doc Page 25

26 Appendix 7 - Paediatric and Special Care Dentistry (Oral Surgery) Pathway Community Trust Oral Surgery Patient Pathway Referral into Service GA Pathway Patient Triage GDP Pathway Referral added to GA List (SEMA) RTT start date = Referral received date Treatment under GA RTT start date = Last GDP appt Add to GA list Treatment in clinic GA Treatment Required Referral added to GDP Pathway GDP Appt Further Treatment in clinic Active monitoring Patient attends treatment provided Patient offered TCI date Clock stops Patient Declines TCI Patient DNA Patient Seen in clinic Patient attends treatment provided Patient Offered 2 nd TCI Date Patient DNA Patient Declines TCI Clock Stopped Referral added To GDP Pathway GDP Appt Treatment complete Dicharge GDP FU Appt Part of the 18 Weeks RTT Standard Not Part of the 18 Weeks RTT Standard Patient Access Policy doc Page 26