Rapid improvement guide to appointment slot issues

Transcription

1 Rapid improvement guide to appointment slot issues October 2017 This guidance provides information to help providers maintain high standards of clinical care by minimising and managing the number of patients unable to book their first outpatient appointment through the NHS e-referral Service (e-rs), who as a result appear on the chosen provider s appointment slot issue (ASI) worklist. ASIs present a clinical risk because a referral to treatment (RTT) clock does not start on a provider s patient administration system (PAS) while the patient s referral is on an ASI worklist. Patients experience a poor level of service and costly workarounds are. ASIs should be managed with as much priority as any other elective activity, and the aim should be to reduce them to as near zero as possible. Patients on the ASI list must also be included in any demand and capacity planning for services. From 1 October 2018, providers will no longer be paid for activity that results from referrals made other than through the NHS e-referral Service. To support providers in adhering to this requirement, the NHS Paper Switch-off Programme has been set up by NHS England, NHS Improvement and NHS Digital to work with providers to enable them to turn off paper referrals by October It is therefore essential that the issue and consequences of ASIs are effectively understood and tackled. Definition of an appointment slot issue When no clinic appointment is available for patients to book in e-rs the referral can be forwarded (via the Patient Web Application) or deferred (via the professional application) to the patient s chosen provider to enable the provider to book the patient an appointment. When a referral is forwarded or deferred, it will appear on that provider s e-rs appointment ASI worklist. Causes In most cases, ASIs occur because providers have an insufficient number of clinic slots available within the polling range they have set for the service on e-rs. For example, an orthopaedic service may have set a milestone of six weeks for first appointments in order for treatment to take place within the total 18-week RTT timeframe. It is important to ensure that

2 booking ranges for e-rs and manual/paper referrals are aligned, taking into account the pathway milestones and the capacity needed. Consequences of appointment slot issues Clinical risks: Patients on an ASI worklist are not automatically visible on the trust s PTL. This increases the risk of them being missed or having an incorrect clock start recorded when their appointment is made. Poor patient experience: ASIs can cause frustration, confusion, inconvenience and uncertainty for patients. Poor GP/referrer experience: In some cases providers are asking GPs to fax referrals already added to e-rs as part of the initial referral. Costly: The administrative and managerial workarounds to process ASIs are costly and inefficient. They include securing extra slots, removing patients from the ASI list to manually add the referral to PAS and contacting the patient to agree that appointment. NHS Digital, working with providers, has identified that it typically costs providers almost twice as much to process an ASI ( 4.08) as if the patient had been able to book an appointment in the first instance ( 2.21). In addition, it is estimated that it would take about five minutes for a trust s administrative staff to manually update the RTT clock if, which would cost around 0.75 per ASI update. Relationship with RTT clock starts for GP referrals An RTT clock is started automatically when a patient successfully directly books their first outpatient appointment via the national e-referrals Service. The clock start is triggered from the Referral received field on the provider s PAS which is automatically populated with the date on which the patient has made the booking. This is often also referred to as the date the patient converts their unique booking reference number (UBRN) or the date the provider receives notice of the referral. When patients are unsuccessful in directly booking their first outpatient appointment via e-rs, the RTT clock should still be started from the date the patient attempted to book their appointment, ie when the hospital receives the referral on their ASI worklist.

3 Relationship with referral to treatment clock starts for referrals received through referral management, interface and clinical assessment services (intermediary services) For RTT pathways that start within one of the services described above, the RTT clock start date is the date the intermediary service received the original GP referral, not the date the provider receives notice of the onward referral. Minimising appointment slot issues A good practice level of 4% ASIs has been published in 2017/18 CQUIN guidance: 1 The table below is a guide to key interventions that will help to minimise ASIs as far as possible. Who What Why When and commissioners Undertake demand and capacity planning To understand the demand for the service and capacity deficits in depth To ensure sufficient capacity can be agreed / funded to enable all patients to be seen and appointments booked within the agreed milestones (see number 2 below) and commissioners Having done your demand and capacity planning, a first appointment milestone (eg 6 or 10 weeks) within the RTT pathway and set the polling range within e-rs at this timeframe. To ensure patients can be treated within 18 weeks Monitor future slot availability ie the number of slots visible to patients within the polling range To ensure patients referred through e- RS can always directly book their appointment within the agreed milestone To minimise ASIs Weekly 1 RS_CQUIN_Supplementary_Guidance_Feb_17_Final.pdf

4 Who What Why When (specialty managers, clinicians and e-rs lead) Review and update the Directory of Services (DoS) on e-rs. The Directory of Services within e-rs should be regarded as the trust s portfolio of services offered. It is an essential element of e-rs which, when maintained and used to its full potential, can facilitate effective and efficient management of both first outpatient appointments and also the whole RTT pathway. All DoS entries should accurately reflect the service provided and to that end, providers should regularly review and update key areas such as Conditions Treated, Procedures Performed and any Exclusion criteria. Referrals should then be accepted or rejected in line with this (specialty managers, clinicians and e-rs lead) Review services with a view to pooling as far as possible Pooling of services allows for a more equitable spread of slots and evens out waiting times among clinics under the same service (clinicians) Accept, reject or redirect referrals in line with referral criteria on DoS via the establishment of a rota for pooled services. Provide feedback to the referrer To avoid inappropriate future referrals and thus decrease unnecessary demand. A rota for pooled services provides a set frequency for review of referrals, with cover built in as necessary As necessary (specialty managers, clinicians and e-rs lead) Ensure that advice and guidance are made available on all services using e-rs functionality or other local systems To help reduce demand by providing advice to referrers to assist management of their patients care Add as soon as possible if not done so Review in line with DoS review above

5 Best practice management of patients on an appointment slot issue worklist Where ASIs do occur and cannot be avoided, the following should be applied. 1. Patients should be removed from the ASI list as soon as possible, ideally by booking an appointment through e-rs as appropriate, ensuring the RTT clock start rules are adhered to. If this is not possible, the referral should be manually entered onto PAS so that the patient can be tracked via the PTL. For GP referrals: the clock start date should be recorded as the date the patient attempted to directly book their appointment. For onward referrals from intermediary services: the clock start date is the date the intermediary service received the referral or received notice of the referral via e-rs. 2. Following removal of the referral from the ASI worklist, if it is deemed necessary to get the clinical referral information from the referring GP practice, this should be done electronically via a secure generic nhs.net account. Please be aware that this is an extra burden for the GP practice. 3. A choice of two appointment dates for the patient s service/clinic within the agreed first appointment milestone should be secured with the relevant specialty leads. 4. The patient should be contacted by phone (a letter should be sent only to confirm a verbally agreed appointment, or when several reasonable attempts to contact the patient by phone have failed), giving three weeks notice of the choice of two dates.

6 Key performance indicators for effective management of appointment slot issues 1. Number of patients on the ASI list and trend by trust. 2. Number of patients on the ASI list and trend by service. 3. Length of time patients stay on the ASI worklist and the outcome, ie booked through e-rs or cancelled out 4. Time taken to transfer the patient/referral from the ASI worklist to PAS. 5. Difference between RTT clock start on PAS and date the patient attempted book (in days). 6. Difference between RTT clock start on PAS and original clock start date at intermediary service (in days). 7. Length of time on the ASI worklist improvement.nhs.uk NHS Improvement date October 2017 Publication code: IG 42 /17