Referral to Treatment (RTT) Validation and Assurance Standard Operating Procedure (SOP) Contents

Transcription

1 Referral to Treatment (RTT) Validation and Assurance Standard Operating Procedure (SOP) Classification: Standard Operating Procedure Lead Author: Toni Coyle, Senior Manager, Access, Booking & Choice Additional author(s): Stephanie Gibson, Acting Director of Performance and Improvement Authors Division: Clinical Support Services & Tertiary Medicine Unique ID: TWGOP10(16) Issue number: 2 Review : October 2019 Contents Section Page 1.0 Who should read this document Introduction What is in the new version Scope Objectives Procedure References and Supporting Documents Roles and Responsibilities Standards Appendix 5 Appendix 1 Staff Competency Supported by Automated Reports Document control information (Published as separate document) Document Control 8 Policy Implementation Plan 9 Monitoring and Review Endorsement Equality analysis 11 Page 1 of 11

2 1.0 Who should read this document? This procedure is intended to be used by all individuals working in Salford Royal NHS Foundation Trust (SRFT) services who are accountable, manage and undertake validation of patients referral to treatment pathway s, diagnostics wait times and use data quality reports to ensure administrative pathway status are accurate. 2.0 Introduction This procedure is to standardise the RTT validation process for all staff that validate pathways and the steps which need to be undertaken to ensure thorough validation is completed. To ensure that patients are not waiting unnecessarily for assessment or treatment of their condition. To ensure that staff have commenced/amended/closed pathways in line with the Patient Access Policy and Standard Operating Procedure. To ensure that patients who are referred late in their pathway from other organisations are flagged at an early stage. 3.0 What is new in this version? Record of Changes to Document Issue Number: 2.0 Changes approved in this document by MISG October 2017 Section Number Amendm ent (shown Deletion Review the pop on pivot to Addition 5.0 in bold see additions to open pathways italics) each day Reason No used For greater detail, please reference the Patient Access policy, Patient Access Standard Operating Procedure Manual and or the Cancer Services Standard Operating Procedure Manual. 4.0 Scope This policy sets out the overall expectations of SRFT for the management of validation and admissions into and within the organisation and defines the principles upon which the policy is based. 5.0 Objectives To ensure that the PTL reflects the number of patients at the below pathway stages: Out Patient appointments required (OP appt required) Page 2 of 11

3 Out Patient appointments booked outside of breach date (OP Bring Forward) Booked outpatient appointments booked within breach dates (OP Appt OK) Out Patient diagnostics or follow up appointments required/booked (OP Pre Treatment) Admission dates waiting to be booked (TCI Required) Planned admission dates within breach dates (TCI OK) Planned admission dates booked outside of breach dates (TCI Bring Forward) In patient admission dates waiting to be booked (IP Diag Date Required) Planned diagnostic in patient admission dates within breach dates (IP Diag OK) Planned diagnostic inpatient admissions dates booked outside of breach dates (IP Diag Bring Forward) 6.0 Procedure 6.1 Process Check GP/ consultant referral letter /MDS form and cross reference with start date to ensure the pathway has started correctly and within the correct pathway if this is not the start of a new pathway. Liaise with waiting list coordinators for 1 st appointment date to ensure that this is booked within agreed specialty pathway 1 st appointment tolerance. Validate 1 st appointment outcome - check clinic letter with outcome on Patient Centre to ensure correct outcome and code has been applied. Ensure the Patient Access Policy is followed for patient cancellations (2 x pt cancellations pathway to be closed as PC33) with new registration and new pathway commenced if to be rebooked and for DNA s where this is the first activity in a pathway the clock is closed with FA33 with a new and pathway commenced if the appointment is to be rebooked (usually by exception). Liaise with diagnostic services for diagnostic appointments which have been booked outside of agreed specialty pathway tolerances or where pathways are tight and there is a need for diagnostic reports timely*. Establish whether a follow up appointment is required / or if an outcome letter to the patient and GP is required. Where a follow up appointment is required ensure this is booked and within agreed specialty pathway tolerance. Validate follow up attendance check clinic letter with outcome on Patient Centre to ensure correct outcome and code Ensure waiting list episodes or diagnostics with potential to become 1 st definitive treatment are included within the correct pathway. Ensure any onward referrals for the same condition are included within the correct pathway (within same organisation). Validate AT21 pathways to ensure that these are pathways which have been referred out of the organisation for treatment of the condition the patient was originally referred for. Confirm evidence that MDS form has been completed and forwarded to other organisation. Review and validate all not stated pathways to ensure all pathways are appropriately attributed to the correct speciality or deleted Page 3 of 11

4 Validate Data Quality reports 01-16, Open after Elective admissions, Stockport status code ST21 in order to ensure all RTT pathways are appropriate in line with the national guidance and all have a correct status code Complete 2% validation of closed pathways or 50 pathways per 2500 of demonitor. *If following liaison with diagnostic services the respond is inadequate than individuals should escalate to their line manager. The Information Team to circulate weekly reports for validation /assurance that these are genuine positions which are confirmed as correct by the Senior Manager/ designated Manager. 52 week + 36 week + Unknown clock starts 0 wait period closed pathways A response is required within 5 working days in month and to comply with the deadline given at month end. Failure to do so will result in escalation to the Managing Director. In addition the following reports are available: Patient DNA s Use of AT21 s Transaction logs on request Patient deaths 7.0 References Cancer Service Operational policy NHS England Consultant led Referral to Treatment Waiting Time Guidance October Department of Health (2007) Choice at Referral Guidance Framework May. Gateway Reference atistics/publications/publicationspolicyandguidance/dh_ Department of Health (2008) Going Further for on Cancer Waits. Cancer%20Waits%20A%20Guide%20Version%206.8.pdf Department of Health (2010) NHS Constitution for England. Department of Health (2010) Operating framework for the NHS for England 2015/16 Page 4 of 11

5 Department of Health (2017) NHS Planning and Contracting Guidance DSCN Notice 07/2003 Reasonable Notice to Patients DSCN Notice 09/2007 Earliest Reasonable Offer Date nce Overseas Visitor Policy Private Patient Operational policy Roles and Responsibilities All Senior /Operational of Consultant or AHP led services where RTT rules apply, to sign off month end returns for open pathways. All Lead and Support to validate a proportion of admitted, non-admitted and open pathways weekly as outlined in Section 6. All 18 week pathway facilitators/validators to validate pathways within their services on a daily basis within the standards outlined in the Patient Access Policy and Standard Operating Procedure. All Medical to update pathways within the standards of the Patient Access Policy and Standard Operating Procedure. Clinical outcome forms to be completed daily and transcribed into Patient Centre in line with the Trusts cashing up policy. 9.0 Standards All staff involved in validation MUST undertake the weekly validation of: All 18 week breaches Diagnostic patients waiting 3 weeks and above All Data Quality reports Referral to Treatment Wait time Targets Commitment Operational Standard Open 92% Direct Access Audiology 95% Page 5 of 11

6 Diagnostic Target Less than 6 weeks 99% Cancer Wait time Targets Commitment Operational Standard 62-Day (Urgent GP Referral to Treatment) Wait for: All Cancers 85% 62-Day For First Treatment from First Screening Service Referral for: All Cancers 90% 31-Day (Diagnosis To Treatment) Wait for First Treatment: All Cancers 96% 31-Day (Diagnosis To Treatment) Wait for First Treatment: All Cancers 98% 31- Day Wait for Second or Subsequent Treatment: Anti-Cancer Drug 94% 31- Day Wait for Second or Subsequent Treatment: Surgery 94% 31- Day Wait for Second or Subsequent Treatment: Radiotherapy Treatments 94% All Cancer Two Week Wait 93% Two Week Wait for Symptomatic Breast Patients ( Cancer not Suspected initially) 93% 9.0 Explanation of Terms and Definition APPT DNA GP IP MDS OP PTL RTT Appointment Did Not Attend General Practioner In Patient Minimum Data Set Outpatients Patient Tracking List Referral to Treatment Active Waiting List Admitted Pathway Could Not Attend (CNA) Patients awaiting elective admission for treatment and are currently available to be called for admission. A pathway that ends in a clock stop for admission for treatment (day case or inpatient). Patients who notify the hospital that they are unable to attend a previously agreed appointment regardless of notice period. Page 6 of 11

7 Clock Pause Day Cases (DC) Decision to Treat Diagnostic Did Not Attend (DNA) Elective Admissions First definitive Treatment Hospital Initiated Cancellation Inpatient The act of pausing 18 week clock, clocks may only be paused for non-clinical reasons and only where a patient chooses to wait longer for admissions than 2 reasonable offers made by provider. Patients who require admission to the hospital for treatment and will need the use of a bed/trolley/recliner but who are not intended to stay in hospital overnight. Where a clinical decision is taken to treat the patient. This could be treatment as an IP or DC, but can also include treatments performed in other setting e.g. OP Is a procedure or test to identify an individual's to help determine a condition, disease or illness? Patients, who have been informed or agreed their admission date (inpatients/day cases) or appointment date (outpatients) and who, without notifying the hospital, did not attend for admission/op appointment. Where a decision to admit a patient for treatment is made that is not an emergency. The patient will be placed on an elective admission waiting list. An intervention intended to manage patient s disease, condition or injury and avoid further intervention. First definitive treatment is a matter of clinical judgement A cancellation of admission by the hospital Patients who require admission to the hospital for treatment where there is an intention to stay in hospital overnight. Page 7 of 11

8 Minimum Data Set Is the administrative data from the referring provider to the receiving provider, to inform the receiving provider knowing the status of patients pathways. Non Admitted pathway Non Consultant led Outpatients (OP) Primary Targeting List A pathway that ends in treatment that does not require an admission or a clock stop for non treatment. Where a consultant does not take overall clinical responsibility for the patient. Patients referred by a general practitioner or another clinical professional i.e. another Consultant/Dental Practitioner for clinical advice or treatment not requiring admission. A list of all patients whose treatment needs to be planned to meet target wait times. Planned Admissions Pre Treatment Unfit For Surgery TCI Patients who are to be admitted as part of a planned sequence of treatment or investigation. They may or may not have been given a firm date. Patients that had attended the hospital but has not had first definitive treatment A list of patients awaiting elective admission who are currently unsuitable for admission due to some underlying medical reason. To come in, the date of a patient s admission to hospital Page 8 of 11

9 11.0 Appendices Appendix 1 Competence Staff Group Method Automated Report Understand the Principles and comply with Trusts' Access Policy and SOP Demonstrate understanding of process to add patients to Inpatient waiting list ensuring they receive treatment within national/local agreed targets All groups administering RTT Support Induction, Directorate meetings E learning package Induction None Planned In-pt pivot Patients on active monitoring with no clock stop Open pathways after elective admission Demonstrate Dictation of Outpatient Clinic letter including clear instruction as to the status of the patient pathway Clinicians Induction Directorate meetings Patients with 2 or more open pathways with same speciality condition (new) Audit of clinic letters hat com Demonstrate on Patient Centre the process to close a patient pathway using correct RTT code AHP s Validators Induction E learning package Validation process supported by SOP Assurance audit Fully trained on use Patient Centre / EPR/ C&B, ABC,, validators induction Evidence of in house training Staff G&O assurance None Able to demonstrate understanding of Outpatient & RTT pivots Demonstrate application of Patient Access Policy & SOP to multi/sub speciality pathways ABC validators ABC validators induction Induction Adhoc user reports Multiple open pathways Able to describe the information contained within MDS ABC Induction Patients with unknown clock start Page 9 of 11

10 Application of RTT status codes following typing of results letters validators E learning package, local induction Patients with no clock start or stop dates Demonstrate complete/accurate recording of investigations on the departmental investigations log at the point of referral Induction None Maintain an up to date investigation log where investigations are acted upon daily. Liaise with support services to minimise delays in pathways Induction None Identify pressure points or deteriorating position in the system via RTT pivot Demonstrate the validation & updating of RTT pathways Validators managers Induction, E learning package A&P meeting Induction G&Os A&P meetings Klickview reports by directorate Validation SOP Over 36 week report Closed registrations open pathways Patients with unknown clock starts Patients with no clock start or stop date Understand the application of national codes Receptionist w/list co coordinators Induction elearning Audit Page 10 of 11

11 Appendix 2 Page 11 of 11