NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST. PATIENT ACCESS MANAGEMENT POLICY (Previously known as Waiting List Management Policy) Documentation Control

Transcription

1 NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST PATIENT ACCESS MANAGEMENT POLICY (Previously known as Waiting List Management Policy) Documentation Control Reference CL/CGP/026 Approving Body Senior Management Team Date Approved 16 Implementation Date 16 Summary of Changes from Previous Version Substantive changes: - Inserted new section to give patients who DNA a first appointment a further opportunity to attend - Expanded section 6.7 Patient Initiated Delays - Expanded section 6.8 Clinical Delays Supersedes NUH Version 7 March 2016 Consultation Undertaken Patient Access Management Group January 2017 Patient Partnership Group Commissioners Senior Management Team Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications Target Audience 28 February February February 2013 Review Date February 2019 Support the delivery of standards within the NHS Standard Contract for Acute Services and the NHS Operating Framework (Everyone Counts Planning for Patients) Referrers, Patients, Commissioners and NUH Staff 1

2 Lead Executive Author/Lead Manager Chief Operating Officer Rachel Eddie, Deputy Chief Operating Officer Further Guidance/Information Jon Higman Head of Elective Performance CONTENTS Paragraph Title Page 1. Introduction 3 2. Executive Summary 3 3. Policy Statement 4 4. Definitions (including Glossary as needed) 5 5. Roles and Responsibilities 6 6. Policy and/or Procedural Requirements Referrals 6.2 Outpatient Appointments 6.3 Outpatient Cancellations and DNAs 6.4 Diagnostics 6.5 Inpatients and Day Cases 6.6 Inpatient Cancellations and DNAs 6.7 Patient Initiated Delays 6.8 Clinical Delays 6.9 Safeguarding Children and Young People and Vulnerable Adults 6.10 Private Patients 6.11 Overseas Patients 6.12 War Veterans/Armed Forces Training, Implementation and Resources Impact Assessments Monitoring Matrix Relevant Legislation, National Guidance 21 and Associated NUH Documents Appendix 1 National Standards 22 2

3 1.0 Introduction 1.1 Nottingham University Hospitals NHS Trust (NUH) aims to offer patients timely and equitable access to elective services in line with national standards to support the delivery of high quality, effective and efficient patient care and the achievement of the Trusts core business objectives and statutory obligations. 2.0 Executive Summary 2.1 This policy sets out the way in which NUH will approach the management of its elective Outpatient, Diagnostics and Inpatient waiting lists. The policy gives Trust staff clear direction and expectations on all aspects of patient access in line with patient rights as set out in the NHS Constitution and Accessible Information Standard. It is supported by a reference guide (Patient Access Policy Procedural Guidelines) for all staff involved with waiting list management and sets out the mandatory minimum requirements to be adopted by all specialties. The overall purpose of this Policy is to establish a consistent approach to the management of patient waiting lists and times within the Trust. The Trust will use this policy to demonstrate how rules are applied fairly and with equity in the provision of planned care. This policy has been written in line with the national policies regarding Referral to treatment consultant-led waiting times and Diagnostic waiting times and activity and is consistent with the national 18-week Referral to Treatment (RTT) pathway. The best interests of patients are foremost. It ensures that patient waiting times are consistently measured to enable monitoring against compliance with the national waiting time standards. 3

4 3.0 Policy Statement 3.1 The principles of the Policy are as follows: We will offer patients timely, equitable and transparent access to elective care; We will offer patients appointments and admission dates in order of clinical priority and their waiting time guarantee date (RTT or other National or locally agreed target), allowing for the need to use resources effectively; We will communicate effectively with patients and GPs at all stages in a patients pathway; We will offer patients reasonable notice of appointment and admission dates; We recognise the distress caused to patients when appointments or admissions are cancelled or rescheduled and we will put processes in place to ensure that this is avoided wherever possible; We will accurately record all patient details and pathways on Trust systems in a timely manner to support effective management of pathways; We will ensure that all staff involved in the provision or administration of elective care are aware of their responsibilities within the Policy and are appropriately trained; We will ensure that children and vulnerable adults are not disadvantaged by application of the Policy. Patients with a health condition that affects communication with them, such as dementia, learning disability, or deafness will be clearly identified wherever possible and their pathways management appropriately. Equality Act The Trust will work to ensure fair and equal access to services for all patients, and ensure it meets its obligations towards people who have had, or have disabilities under the Equality Act (2010). This places a legal obligation on organisations to make reasonable adjustments to facilitate the care of people with disabilities. Patient safety is our first priority. The Policy is not intended to override clinical judgement and all staff are expected to make decisions in the best interests of patients at all times within the 4

5 context of the Policy and the best use of Trust resources. 4.0 Definitions 4.1 Pathway Management Principles and General Rules National Operating Standards The NHS Constitution clearly sets out a series of pledges and rights for what patients, the public and staff can expect from the NHS. A patient has the right to the following: the choice of hospital and consultant; a maximum waiting time of 18 weeks from GP referral to the start of their consultant-led treatment for elective conditions; to be seen by a cancer specialist within a maximum of two weeks from a GP referral for urgent referrals where cancer is suspected; if this is not possible, the Trust has to take all reasonable steps to offer a range of alternatives. The exception to the right to be seen within the maximum waiting times does not apply: If the patient chooses to wait longer; if delaying the start of the treatment is in the best clinical interests of the patient, for example where stopping smoking or losing weight is likely to improve the outcome of the treatment; if it is clinically appropriate for the patient s condition to be actively monitored in secondary care without clinical intervention or diagnostic procedures at that stage; if the patient fails to attend appointments that they had chosen from a set of reasonable options, or if the treatment is no longer necessary. 4.2 Clock refers to the Referral to Treatment (RTT) clock which measures the time the patient has been waiting from referral. Did Not Attend//Did Not Bring (DNA/DNB) - Patients who have been informed of their date of appointment, admission or preassessment and who without notifying the hospital did not attend. Did Not Bring applies to paediatric patients. Directory of Services (DOS) - The Directory of Service is an 5

6 element of the Choose & Book system which information at service level that describes the services the Trust offers. Elective refers to any planned hospital attendance/treatment. GP General Practitioner (in this document is used to indicate any referrer to secondary care e.g. dentists, optometrists). Guarantee Date date by which the patients diagnostic or treatment must be undertaken in line with relevant national waiting time. NHS e-referrals ERS- A national electronic referral service that gives patients a choice of place, date and time for their first outpatient appointments. Partial Booking the process whereby a patient is held on a waiting list and offered a choice of appointment/admission dates at an appropriate time. Pathway a succession of episodes of care from referral to treatment and beyond which relate to one condition. Patient Administration System (PAS) - Patient Administration System: computerised hospital record keeping system. Planned Waiting List a list of patients who are undergoing review or surveillance procedures at regular intervals or require a procedure when certain clinical criteria are met. Referral To Treatment (RTT) - The part of the patient s care following initial referral, which initiates a clock start, leading up to the start of first definitive treatment or other 18 week clock stop points. 5.0 Roles and Responsibilities 5.1 Committees The Patient Access Management Group (PAMG) is responsible for the implementation of the policy and for ensuring that processes are in place at specialty level to 6

7 monitor and manage adherence to the Policy. The Group will review the Policy at regular intervals to ensure that it reflects local and national guidance Senior Management Team (SMT) is responsible for ratifying revision to the Policy. 5.2 Individual Officers The Chief Executive is ultimately accountable for the delivery of the national access targets The Chief Operating Officer / Deputy COO have delegated responsibility for ensuring that robust systems and processes are in place to support the achievement of the access targets and that there is accurate reporting both internally and externally The Director of ICT / Deputy Director of Information have responsibility for ensuring that there are effective systems in place to enable the Divisions to collect data accurately and to support the accurate monitoring and reporting of waiting lists and performance against access targets Divisional Directors and General Managers are responsible for ensuring that waiting lists are managed appropriately within their Division. It is the responsibility of Divisions to ensure that their patients are managed in accordance with this policy and the procedural guidelines which underpin it Head of Elective Performance / Elective Performance Manager are accountable for: - monitoring performance against locally or nationally agreed targets; - working with Divisions / Specialties to ensure sustainability; - the design and delivery of the comprehensive training programme in relation to elective and diagnostic patient administration; and - working with Divisions to ensure a standardised approach to validation and ensuring data quality. 7

8 5.2.6 Clinical Staff need to be compliant with their responsibilities as set out in the. The clinical management of individual patients on the waiting lists is the responsibility of the Clinician in charge of the patients care Specialty General Manager / Service Managers are responsible for ensuring data is accurate and Elective Access Policy is complied with as well as achieving access targets and supporting waiting list administrators Waiting List Administrators - Whether clinic staff, secretaries, pathway coordinators, validators or booking clerks are responsible to Service/General Managers for: - compliance with all aspects of the Elective Access Policy; - day-to-day management of their lists; and ensuring that information is accurately inputted on patient administration systems at source. 6.0 Policy and/or Procedural Requirements 6.1 Referrals Wherever possible, referrals should be booked using the National NHS e-referral service Each service should have an up to date Directory of Service within NHS e-referral which is reviewed on an annual basis in conjunction with the lead clinician for that service. This will support GPs in referring patients into the appropriate services Each service should offer access to Advice and Guidance to referrers via NHS e-referral system and ensure that arrangements are in place to meet agreed turnaround times Paper referrals will be accepted and processes will be in place to ensure that appointment offers are equitable with those made via NHS e-referral system. 8

9 6.1.5 Inappropriate referrals, including those which do not meet agreed referral criteria, will be rejected and returned to the referrer with an explanation, or forwarded on to the appropriate department Referrals to and from other organisations will be managed via the Inter-Provider Transfer process which ensure that all necessary data is transferred and that the patients RTT pathway transfers with them The need to vet referrals will be locally determined by the specialty and will depend upon the level of urgent and/or inappropriate referrals Consultant annual leave, study leave or sickness should not delay the review of referrals thereby disadvantaging patients. A nominee must be able to review and prioritise in the Consultant s absence The Consultant or nominee will decide if a referral is appropriate. The Consultant can upgrade a routine referral to urgent or suspected cancer, but cannot downgrade an urgent suspected cancer referral unless it is agreed with the referring GP An agreed protocol is in place between NUH and Commissioners which allows Consultant to Consultant referrals only in certain circumstances. If the exclusion criteria in the protocol do not apply, the patient should be referred back to the GP who will make a new referral at the patient s choice of provider. 6.2 Outpatient Appointments All appointment offers will be reasonable Appointments booked via NHS e-referrals will automatically be deemed reasonable due to patient choice Patients referred by letter will be offered a maximum of two 9

10 dates with at least two week s notice All patients referred for suspected cancer will be offered an appointment within 14 days of referral For non NHS e-referrals appointments, the hospital operates a system of partial booking which improves patient choice, reduces DNAs and thereby uses resources more effectively. Patients are contacted via letter to invite them to make an appointment. If the patient does not respond within one week of receipt of the letter, the patient is discharged back to the care of their GP (with the exception of suspected cancer patients who would be contacted by telephone) Patients will be provided with a follow up appointment based on clinical need only Hospital attendances should be avoided where patients can be offered a non-face-to-face consultation, for example, for confirmation of test results Patients requiring long term follow up may be held on review lists until nearer their appointment due date and will then be offered a date through the partial booking process. If a date has not been agreed with the patient by the time of the follow up due date, then a new RTT pathway or relevant diagnostic wait time will be started Where appropriate to the service, open appointments can be offered for a maximum of three months for adults and twelve months for children If a patient is likely to require a diagnostic test during an appointment, every effort will be made to offer the appointment and the diagnostic test on the same day. 6.3 Outpatient Cancellations and DNAs It is the patient s responsibility to keep an agreed appointment and the appointment letter to the patient will clearly state the consequences of not keeping an 10

11 appointment, for example they may be referred back to their GP. NUH commits to make reasonable offers of appointments and to allowing patient to reschedule appointments within reason where notice is given A patient who cancels their first outpatient or follow up appointment will be offered a further appointment. If the patient cancels a second outpatient appointment, with the exception of suspected cancer patients, they will be referred back to the care of their GP A patient who DNAs a new routine appointment will be contacted to be offered the opportunity to make a further appointment. Patients who do not respond to this offer within two weeks will be referred back to their GP A patient who DNAs a follow up appointment will be referred back to the care of their GP unless the clinician reviewing the notes specifies that a further appointment should be offered on clinical grounds. If the patient DNAs a second time, a further appointment will not be given Cancer target patients should not be referred back to the GP after any cancellations or DNAs unless the referral has been reviewed by a clinician and discussed with the patient and/or the GP There is a separate policy for the management of cancellations or DNAs for children see Section Cancellation of appointments by the hospital should be avoided wherever possible. If this is unavoidable due to sickness of key staff or exceptional circumstances, then every effort should be made to offer patients as much notice of cancellation as possible Clinics should not be cancelled due to planned annual/study leave where sufficient notice has not been given. Clinical staff are required to give notice of annual or study leave in line with the Medical Staff - Annual Leave Policy. 11

12 6.4 Diagnostics Patients waiting for a diagnostic outpatient appointment will be offered a maximum of two dates with at least one week s notice and patients waiting for an inpatient diagnostic procedure will be offered a minimum of two admission dates with at least three week s notice for the offer to be considered reasonable The Trust will work to the national standard of six weeks maximum wait for diagnostic tests Reporting turnarounds should not exceed 7 days. 6.5 Inpatients and Day Cases Patients who are added to the active waiting list must be fit, ready and able to come in If the patient is unfit at the time of listing, with the exception of short term, self-limiting illnesses (e.g. cold, flu) to a maximum of four weeks, the patient should not be placed on the waiting list and should be referred back to the GP for management of their condition Patients must not be added to the waiting list for procedures listed in the Policy on Procedures of Limited Clinical Value and East Midlands Commissioning Policy for Cosmetic Procedures unless appropriate criteria are met. Patients not meeting the PLVC criteria should be discharged back to the care of their GP All patients for elective treatment must be placed on the appropriate waiting list on PAS within one working day of the decision to admit For non-contracted activity where prior funding approval is required the patient should not be added to the waiting list until funding has been approved Patients who require a treatment or set of treatments at a 12

13 given interval or require their condition to progress to a certain point e.g. age related, before treatment should be added to the planned list and should have a date by which treatment should commence recorded on PAS. Any patient that has not received their intended procedure by the date the treatment was planned will become active on the RTT pathway Patients should be offered a minimum of two admission dates with at least three weeks notice unless the patient agrees to accept a date at short notice Patients must be dated in order of clinical priority and then in order of their 18 week guarantee date or other relevant standard (e.g. diagnostic) To come in (TCI) dates must be recorded on the relevant hospital systems (PAS and the theatre booking system etc.) at the same time and within 24 hours of agreeing the date with the patient Patients can be removed from the waiting list for a variety of reasons including a clinical decision not to treat, the patient declining treatment or as a result of the cancellation, DNA or suspension rules described in this Policy. If it is felt that a patient should be removed for any other reason, the appropriate manager and/or clinician s advice should be sought and documented before removal If a patient requests time to consider their options for surgery for a reasonable period of time (up to 2 weeks), they should not be removed from the waiting list until a decision is made. If the patient is removed at their request and then decides to proceed to surgery at a later date they will be re-instated on the waiting list when ready It is good practice to contact patients on a waiting list (this includes patients waiting for treatment in an outpatient setting) at regular intervals to confirm that their contact details are up to date and that they still wish to have treatment (validation). Patients should receive a letter asking them to respond within a reasonable timescale, 13

14 which should be no less than three weeks. If they do not respond within this timescale, they can be removed from the list. 6.6 Inpatient Cancellations and DNAs If the patient cancels an agreed admission date, a second reasonable offer will be made, taking into account clinical priority and their relevant guarantee date Patients who cancel an agreed admission date for a second time (with the exception of cancer patients) will be referred back to the care of their GP unless there are exceptional circumstances (such as bereavement) Patients who DNA a routine inpatient/day case procedure will be discharged back to the care of the GP unless the Consultant requests that a further date be offered on clinical grounds Patients who DNA an urgent inpatient/day case procedure (including cancer) will be contacted by letter or telephone to arrange a further date and will only discharged back to the care of their GP if every effort has been made to confirm their contact details and they do not respond to contact The Trust will make every effort not to cancel agreed admission dates for non clinical reasons and recognises the inconvenience and distress caused to the patient. Cancelling admissions causes additional work for staff and can often result in a waste of theatre time and staffing resources Theatre lists should not be cancelled due to planned annual/study leave where sufficient notice has not been given. Clinical staff are required to give notice of annual or study leave in line with the Medical Staff - Annual Leave Policy Last minute (on or after the day of admission) non-clinical 14

15 cancellations must be re-booked in line with the 28 day readmission guarantee and the offer must be reasonable, as defined above Patients cancelled prior to the day of admission should be given a reasonable offer of a date as soon as possible after cancellation and in line with their guarantee date Patients cancelled at the last minute for clinical reasons should be reviewed by a clinician and a decision made to re-instate them or remove them from the waiting list Pre-operative assessment should be used to minimise last minute clinical cancellations by identifying and managing any pre-existing conditions which might lead to cancellation. If the pre-operative assessment cannot be offered at the time of listing the above rules regarding reasonable offers, cancellations and DNAs will apply. 6.7 Patient Initiated Delays Patients who wish to delay their wait for a period longer than 3 months will be reviewed by the clinician to decide if this delay is appropriate. If the clinician is satisfied that the proposed delay is appropriate, a decision will be made to continue the wait If the clinician is not satisfied that the proposed delay is appropriate then the clinical risks should be clearly communicated to the patient and a clinically appropriate TCI date agreed. If the patient refuses to accept the advice of the clinician then the responsible clinician must act in the best interest of the patient. If the clinician feels that it is in the best clinical interest of the patient to discharge the patient back to the care of their GP and inform them that treatment is not progressing then this must be made clear to the patient. This must be a clinical decision, taking the healthcare needs of each individual patient into account. 15

16 6.8 Clinical Delays If a patient becomes unfit after the decision to treat is made and the nature of the condition means that the patient will not be ready for treatment within four weeks the clinician should then determine if it would be appropriate to refer the patient back to the care of their GP or commence a period of consultant initiated active monitoring. 6.9 Safeguarding Children and Young People and Vulnerable Adults NUH recognises its responsibility to ensure the safety and welfare of children and vulnerable adults in its direct care and in its premises There is a separate Access Policy and Safeguarding Policy relating to children and young people This Trust Safeguarding Vulnerable Adults policy supports its discharge of this responsibility to protect the and physical wellbeing of vulnerable adults and to promote their empowerment and welfare, through working practices in NUH, practices in its partnership working, and its assurance framework. Vulnerable adults will enjoy the same rights as other patients in respect of access to care and treatment Private Patients The Trust will manage private patients in line with the Department of Health guidance A Code of Conduct for Private Practice (2004) which states that: The provision of services for private patients should not prejudice the interest of NHS patients Patients who chose to be treated privately are no more or less entitled to NHS services than anyone else and patients are free to change their status from private to NHS and vice versa Where a patient wishes to change from private to NHS 16

17 status, the following principles apply: A patient cannot be both a private and a NHS patient for the treatment of one condition during a single visit to a NHS organisation Any patient seen privately is entitled to subsequently change his or her status and seek treatment as a NHS patient Any patient changing their status after having been provided with private services should not receive an unfair advantage over other patients Patients referred for a NHS service following a private consultation join the NHS waiting list at the same point as if the consultation or treatment were a NHS service. Their priority on the waiting list should be in accordance with clinical priority and in chronological order Patients that are having their procedure carried out privately at Nottingham University Hospitals NHS Trust must be recorded on PAS Overseas Patients The Trust will manage overseas patients in line with the Department of Health guidance Implementing the Overseas Visitors Hospital Charging Regulations (2015) and the Trust Overseas Patients Policy Overseas visitors are defined as those patients presenting to the Trust who have not been lawfully resident in the UK for the preceding 6 months. Please refer to the Trusts Overseas Policy Visitors. The policy applies to adults and also to children /young people whose eligibility for free NHS care is assessed via their parents residency status Where in the course of talking to a patient it becomes clear that the patient is an overseas visitor, staff should always alert the Division lead in order that their eligibility for free NHS care can be clarified, ideally before any non- 17

18 emergency treatment is given War Veterans/Armed Forces Serving Personnel In line with December 2007 guidance from the Department of Health and the Ministry of Defence Armed Forces Covenant (refreshed January 2016) all veterans and war pensioners should receive priority access to NHS care for any conditions which are related to their service, subject to clinical needs of all patients (a veteran is defined as someone who has served at least one day in the UK armed forces). Military veterans should not need first to have applied and become eligible for a war pension before receiving priority treatment. GPs should notify the Trust of the patient s condition and its relation to military service when they refer the patient so that the Trust can ensure that it meets the current guidance for priority service over other patients with the same level of clinical need. In line with clinical policy patients with more urgent clinical needs will continue to receive clinical priority For serving personnel, including Reservists, who are on an NHS Waiting List when referred to NUH due to being posted from somewhere else will have the time already accrued taken into account when agreeing treatment dates. For more information relating to the Armed Forces Covenant click link below: /the_armed_forces_covenant.pdf 7.0 Training and Implementation 7.1 Training Divisions should arrange both induction training (for new starters) and regular refresher training for existing members of staff. Resources in the form of PowerPoint slides are available and may be 18

19 amended as appropriate for local use. 7.2 Implementation This policy will be implemented and monitored by the weekly PTL Meeting, Patient Access Management Group, Operations Group and Trust wide reporting structures. 7.3 Resources No additional resources are required. 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has indicated the need for additional considerations which have been duly incorporated. 19

20 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Adherence to Policy Responsible individual/ group/ committee Individual Managers Process for monitoring e.g. audit Weekly PTL (patient tracking) meeting, monthly validation processes Frequency of monitoring Responsible individual/ group/ committee for review of results Weekly/monthly PTL group/pamg Responsible individual/ group/ committee for development of action plan Divisions/ Corporate Operations Team Responsible individual/ group/ committee for monitoring of action plan Divisions/ Corporate Operations Team 20

21 10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 National Guidance NHS Operating Framework National Contract for Acute Services NHS Constitution Department of Health Referral to Treatment Consultant Led Waiting Times Department of Health Cancelled Operations Guidance A Code of Conduct for Private Practice (2004) Implementing the Overseas Visitors Hospital Charging Regulations (2004) Local NUH Policies, Protocols and Guidelines Medical Staff - Annual Leave Policy Trust Inter Provider Transfer Referral Protocol Overseas Visitors Policy Private Patient Policy Children and Young People Who Do Not Attend Policy Safeguarding Children Policy Safeguarding Vulnerable Adults Policy Patient Access Policy Procedural Guidelines Local Commissioner Protocols Consultant to Consultant Referral Protocol Policy on Procedures of Limited Clinical Value East Midlands Commissioning Policy for Cosmetic Procedures Prior Approval Policy 21

22 National Standards Appendix 1 Section Referral to Treatment Referral to Treatment Referral to Treatment Description 18 Week Non-admitted treated in an outpatient setting 18 Week admitted treated in a daycase or inpatient setting No patients should wait more than 52 weeks from referral to first definitive treatment Cancer Two Week Wait GP referral for urgent suspected cancer to appointment Cancer Two Week Wait for all breast symptoms Cancer 31 day wait (first treatment) 31 Day Second or subsequent treatment (Surgery/Radiotherapy/Drugs) Cancer 62 day wait GP referral to treatment or referral from a screening programme Diagnostic 6 Weeks Cancelled Operations First outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) Diagnosis of cancer to receiving of first treatment, including subsequent Subsequent treatment after receiving first definitive treatment (Surgery) GP referral for urgent suspected cancer, diagnosed and receive first treatment, including up-grades. Patients referred from screening, diagnosed and receive first treatment Patients referred for specific diagnostic tests (list is nationally prescribed) must be seen within a maximum of 6 weeks from when the request is made. Patients cancelled on or after the day of admission should be offered a new binding date within 28 days. Offers are expected to be reasonable as defined in this document. 22