TRUST POLICY FOR WAITING LIST AND PATIENT ACCESS MANAGEMENT. Version: 6 Status: Final Author: Nick Seed. Version Date Author Reason

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1 TRUST POLICY FOR WAITING LIST AND PATIENT ACCESS MANAGEMENT Reference Number: COR/2013/002 Versin / Amendment Histry Versin: 6 Status: Final Authr: Nick Seed Versin Date Authr Reasn Title: Head f Transfrmatinal Implementatin Dianne Presctt Intrductin f Natinal 18 week rules Dianne Presctt Cmments frm MAC 3 3/ 2011 Dianne Presctt Updated 4 July 2012 Gayle Halliday Cancer Centre Updates 5 August 2012 Helen Sctt-Suth Organisatinal change and Internal Audit Recmmendatins 6 March 2013 Helen Sctt-Suth Revisin fllwing discussin at MAC in Dec 2012 and with Strategy and Partnership (Di Presctt) Training and Disseminatin: All Staff assciated with Waiting List and Patient Access Management must underg training n this plicy, see Sectin 8 f the Trust Prcedures fr Waiting List and Patient Access Management. This will be delivered t all new staff as part f their inductin as applicable and thrugh an essential annual E- learning assessment. General Managers will be respnsible fr ensuring medical staff are cmpliant with their training. Plicy published n hspital Intranet/website T be read in cnjunctin with: Trust Prcedures fr Waiting List and Patient Access Management. Trust Plicies fr Safeguarding Children and Adults, Draft Trust Plicy Children, Yung Peple and Nenates wh DO Nt Attend (DNA) their Appintments, Prcedures f Limited Clinical Value, Access t Health Services fr Military Veterans: pririty treatment Gateway 13406, A Cde f Cnduct fr Private Patients, The Natinal Cancer Actin Team Cancer Waiting Times guide versin 8.0, Overarching Leave Plicy (Trust Leave Plicy fr Cnsultant & SAS Dctrs) versin 3.4 In cnsultatin with and date: Management Executive (ME) April 2013 Medical Advisry Cmmittee (MAC) December 2012 Cancer Centre Manager June 2012

2 EIRA stage One Cmpleted Stage Tw Cmpleted Yes Yes Prcedural Dcumentatin Review Grup Assurance and Date April 2013 Apprving Bdy and Date Apprved Management Executive (ME)April 2013 Date f Issue May 2013 Review Date and Frequency Cntact fr Review Executive Lead Signature Apprving Executive Signature September/Nvember 2013 (then annually) Deputy Chief Operating Officer Chief Operating Officer Chief Executive

3 Cntents Page 1 Intrductin 4 2 Purpse and Outcmes 4 3 Definitins Used 5 4 Key Respnsibilities/Duties 5 5 Managing the Plicy and Prcedures 6 6 Mnitring Cmpliance and Effectiveness 8 7 References 8 8 Appendix A- Index t the prcedures fr Waiting List and Patient Access Management 9 Prcedures Final V6 April

4 Trust Plicy and Prcedures Waiting List and Patient Access Management 1. Intrductin This plicy utlines relevant rules, respnsibilities and actins by which the Trust will manage patients thrugh their pathways: Natinal 18 week Referral t Treat (RTT) Outpatient/Inpatient/Daycase Waiting list management. Natinal Cancer Waiting Times fr all suspected cancers Patient Access Natinal and Lcal Targets Assciated lcal targets 2. Purpse and Outcmes This plicy and prcedures set ut the rules and definitins fr hw we will manage 18 week pathway and cancer/suspect cancer referrals. Applicatin f the plicy principles will ensure that each patient s RTT clck starts and stps fairly and cnsistently in accrdance with an agreed structured methdlgy. Treatment decisins will be fair and transparent. At an peratinal level this translates int the adptin f the fllwing key principles: The management f ur patients will be cnsistent with the NHS 18 Week Target / Cancer 14, 31 and 62 day targets and the guidelines which apply t these targets. The management f patients will be fair, cnsistent and transparent and cmmunicatin with patients will be clear and infrmative. The management f ur patients will be cnsistent with the Human Rights Act 1998 and the Equality Act Patients seen in utpatients, diagnstics r admitted as inpatients/day cases will be seen accrding t clinical pririty and in chrnlgical rder n the 18RTT and cancer pathway. We will acknwledge the rights f individuals t agree a date t suit their persnal circumstances. Internal cnsultant t cnsultant referrals criteria is: Direct referrals will be apprpriate fr: Suspected cancer Urgent prblems fr which delay wuld be detrimental t the patient s health. The expectatin here wuld be that the patient needs t be seen within 2 weeks. Referral as part f the same clinical prblem Part f the recgnised pathway f care fr the cnditin r as part f a pre-perative assessment Transfer f respnsibility f care fr an nging cnditin when it wuld be mre cnvenient fr the patient t be seen in a different lcatin. Referral back t General Practitiner (GP) will be apprpriate fr: Prcedures Final V6 April

5 Cnditins that are unrelated t the presenting prblems and d nt require urgent referral Incidental findings Cnditins that can be dealt with by the Clinical Cmmissining Grup Referral Queries If there is any dubt as t whether a patient needs t be managed by the hspital r whether a patient shuld be ffered a chice it wuld be advisable fr the cnsultant t cntact the GP t discuss the case. Patients will nly be added t a waiting list if there is an expectatin f treating them and they are clinically fit and ready t undertake the treatment. Except cancer cases. 3. Definitins Used Staff refers t ALL staff wh are invlved in a patient s care and treatment and in particular t thse with respnsibility fr patient access and chice. Patient refers t NHS patients unless explicitly stated therwise. 4. Key Respnsibilities/Duties The fllwing are required t instigate apprpriate actins t ensure the successful implementatin f the plicy within their area(s) f cntrl: Management Executive (ME) - Apprval f the plicy. Medical Advisry Cmmittee (MAC) - Cnsultatin and clinical input. Chief Operating Officer Respnsible fr Waiting List and Patient Access Management. Directr f Strategy and Partnership - Participate with the Executive Directrs in mnitring the Trust and Directrate perfrmance against cmmissining, cntract and service agreements, natinal and lcal standards and strategies, undertaking benchmarking, reprting and review wrk as necessary. Divisinal Directrs and Divisinal Medical Directrs Respnsible fr the verall applicatin and adherence t this plicy and prcedures within their area f respnsibility. Apprval f leave with less than 6 weeks ntice must be authrised by the Divisinal Directr and Divisinal Medical Directr. Cnsultants Cnsistent applicatin and adherence f plicy and principles. Prcedures Final V6 April

6 Cnsideratin will be given by teams f cnsultants fr crss cver arrangements during perids f annual leave. In sme circumstances, it may be apprpriate t agree prtcls fr grading and accepting r rejecting referrals. A minimum f 6 weeks ntice is necessary fr cnsultant and medical staff planned leave (in accrdance with sectin 3.1 in the Overarching Leave Plicy) t ensure patient appintment dates are hnured t reduce the need fr changes and cancellatins. All leave requests must be authrised by the Lead clinician and General Manager/Assistant General Manager. All referrals (electrnic and paper) will be reviewed and priritised within 2 wrking days f receipt except fr visiting cnsultants (alternative arrangements will be agreed lcally) and cancer (separate rules will apply fr 2 week wait (2WW) and screening. Administrative staff must be allwed t accept the bking n behalf f the service if the 2 day target cannt be achieved t ensure n delays are built int the 18 week target. Specialist Nurses - Cnsistent applicatin and adherence f plicy and principles General Manager Respnsible fr the applicatin f the plicy at Business Unit level and the delivery f natinal and lcal targets and training specific t staff rles within their area f respnsibility. Assistant General Managers r equivalent Respnsible fr the implementatin f plicy and prcedures and training fr relevant staff grups in their areas f respnsibility. Assistant Directr f Strategy and Partnership Respnsible fr perfrmance mnitring waiting list t ensure external targets are delivered. Assciate Directr f Infrmatin Management & Technlgy (IM&T) Respnsible fr the prvisin and accuracy f infrmatin and data quality reprts. Respnsible fr the cntent and delivery f training. Head f Infrmatin Respnsible fr prviding infrmatin and analysis supprt t mnitr targets and adherence t plicy. Respnsible fr the training and educatin f data quality fficers and infrmatin analysts. Respnsible fr the cntent f training prgrammes. Head f Recrds Management - Respnsible fr ensuring all admin staff wrking in utpatients r day case, including thse staff that are nt directly respnsible t them, are fully trained and cmply with mandatry training. Managers, Administratrs, Secretaries and relevant Health Prfessinals Respnsible fr day t day management and applicatin and escalatin as apprpriate t area f wrk. Divisinal Medical Staffing Officers Respnsible fr escalating, t the apprpriate General Manager, ccasins when they cannt achieve the minimum 6 Prcedures Final V6 April

7 weeks ntice required fr changes t dctrs rta s t Outpatient / Day case Team Leaders. This ntice perid is necessary t allw changes t bking rules t take place. Cancer Centre Manager/Audit - Respnsible fr ensuring that staff adhere t the cancer waiting times thrugh the audit prgramme. Respnsible fr the cntent f training material relevant t cancer pathways management. 5. Managing the Plicy and Prcedures fr Waiting List and Patient Access Management The Trust recgnises the cmplexity f waiting list and patient access management. Natinal rules are ften cmplex and n ccasin have cmpeting requirements. The prcedures cntained within this plicy give staff a clear directin and expectatin fr the implementatin. The Trust will use this plicy t demnstrate hw t apply rules fairly and with equity in prvisin f planned care. 5.1 Gvernance structure In rder t ensure that rbust gvernance prcess are in place key staff grups have been identified detailing their RTT rle and their training requirements. Please refer t sectins 4 and 5 f the Waiting List and Patient Access Management Prcedures. The three levels f training are: Generic Trust wide fr all staff invlved in a patients pathway PAS in depth explanatin f cdes uses and effect n reprting f pathways Infflex in depth tracking and data capture fr cancer pathways Service specific specific pathway rules fr that patient area. Areas where training issues are nt being reslved will be raised at Patient Access Grup (PAG) and escalated if required. 5.2 Data Quality Infrmatin Services, Data Quality Supprt Officers (3) and Cancer Centre Audit staff will supprt and mnitr data quality issues within the Clinical Divisins. They will c-rdinate validatin f patients waiting and mnitr key indicatr such as: - Number and length f suspensin perids - System Did Nt Attend (DNA) - Adherence t plicy e.g. patients being discharged fllwing DNA. 5.3 Divisinal Waiting List, Validatin Staff and Cancer Centre Audit Team staff These staff grups are respnsible fr nging validatin and feeding back t staff n repeated prblems t imprve data quality. This feedback may be via key cntacts in the service areas. Managers shuld ensure that: Prcedures Final V6 April

8 Validatin and feedback t staff is nging Apprpriate resurces are available Where this plicy is nt being fllwed escalatin is taken as detailed. 5.4 Reprting and Escalatin The Infrmatin and Cancer Centre Audit Team staff are respnsible fr reprting and mnitring waiting list targets and data quality issues. Cncerns with data quality will be raised initially thrugh the key cntacts and then escalated t the General Manager and Assistant Directr f Strategy and Partnership if necessary. General data quality r prcess anmalies will be taken t PAG fr discussin and, where specific t particular areas, be brught t the relevant General Managers attentin. Issues that are sufficiently cncerning r cannt be managed / reslved by the membership f PAG will be escalated t the Chief Operating Officer and Divisinal Directrs meeting. Where there is a cncern abut achievement f targets this will be directly escalated t the General Manager and Divisinal Directr as well as the Assistant Directr f Strategy and Partnership t liaise with Clinical Cmmissining Grups. There is a detailed Key Respnsibilities fr Adherence t Waiting List Plicy in the Trust Prcedures fr Waiting List and Patient Access Management Appendix D. 6. Mnitring Cmpliance and Effectiveness Mnitring cmpliance and effectiveness will be thrugh the Trust Patient Access Grup. Mnitring Requirement : 1. The Trust can demnstrate cmpliance in relatin t the standards which must be used by all healthcare prfessinals fr the implementatin f natinal plicy. 2. The Trust can demnstrate cmpliance with training and educatin. 3. Cancer waiting times are mnitred by Divisins with the Chief Operating Officer n a weekly basis Mnitring Methd: 1. Crprate audits and reprting thrugh the patient access grup using an agreed set f key perfrmance indicatrs. 2. Reprts frm Divisins and IM&T. Reprt Prepared by: 1.Assciate Directr f IM&T 2.Divisinal General Managers and Assciate Directr f IM&T Prcedures Final V6 April

9 Mnitring Reprt presented t: Patient Access Grup Frequency f Reprt 1.Mnthly 2.Training Reprts Twice a year 7. References Trust Plicy fr Safeguarding Children2010 Trust Intranet Cmmissining Plicy fr Prcedures f Limited Clinical Value.2010 (External plicy written by Derby City PCT, circulated t patient access grup members in March 2011) Individual Funding Request Plicy (External plicy written by Derby City PCT circulated t patient access grup members in March 2011) Patient Transprt Plicy (as at May 2012 in develpment) Access t health services fr military veterans: pririty treatment Gateway Reference A Cde f Cnduct fr Private Practice Recmmended Standards f Practice fr NHS Cnsultants January Appendix A Cntents Prcedures Page 1 Cnsultants Respnsibilities 1 2 Divisinal Management Respnsibilities 3 3 Data Quality Team (Infrmatin Services) 5 4 Outpatient and Day case Admin/Receptin Staff, Cnsultant Secretaries and ther health prfessinals (specialist nurses, physitherapists etc) 6 5 Training All Staff 8 Prcedures Final V6 April

10 6 Outpatient Bking and Referral Management 12 7 Current Methds f Referral t Access Services 12 8 General Principles 12 9 Summary f Guidelines fr Managing New Referrals WW Referrals - Receiving, Prcessing and Bking Exceptins t the 2WW rule New Paper Referrals - Receiving, Prcessing and Bking Obstetric Referrals Chse and Bk Referrals - Receiving, Prcessing and Bking Fllw-up Appintments X- Inpatient Patient (XIP) Appintments 17 Cntents 17 Changing/Cancelling Appintments at Patient s Request New and Fllw-up Page Hspital Cancellatins New and Fllw-up Patients wh d nt attend (DNA) New and Fllw-up Cmmunicatin Ambulance Transprt Diagnstics; Imaging 19 Prcedures Final V6 April

11 23 Referrals Inpatient /Day case Waiting List Suspensins- Maximum length/number f suspensins Cancellatins and DNAs Admissin t Hspital Cancer Referral t Treatment Week Referral t Treatment Inter Prvider Referrals Cancer patients Tertiary Referrals 29 Cntents Page Appendix B Inter prvider transfers Treatment status fr same cnditin referrals 30 Appendix C Inter Prvider Transfer Frm (Minimum Data Set) 31 Appendix D Key Respnsibilities fr Adherence t Waiting List Plicy 32 Appendix E 18 Week Flw Chart 34 Appendix F Glssary f Terms 38 Prcedures Final V6 April

12 WAITING LIST AND PATIENT ACCESS MANAGEMENT PROCEDURES 1. Cnsultants Respnsibilities Cnsultants clinically manage the needs f individual patients accessing Trust services cnsistently. 1.1 Leave and Clinic Cver A minimum f 6 weeks ntice fr cnsultant and medical staff planned leave must be given t ensure patient appintment dates are hnured. All leave requests must be authrised by the Lead clinician r General Manager/Deputy General Manager. 1.2 Pririty Treatment fr Military Veterans (Outpatient/Daycase/Inpatient) If it is agreed that the cnditin is service related they must be priritised ver ther patients with the same level f clinical need. Hwever, they must nt be given pririty ver ther patients with mre urgent clinical needs. 1.3 Trust respnsibilities regarding patients with learning disability Where a persn is recgnised as having a learning disability the Cnsultant shuld ensure that the Learning Disability Liaisn Nurse is cntacted via the Safeguarding Team t supprt the team, the patient and their carers / family with access t the appintment and any reasnable adjustments that may be required during subsequent appintments / treatment episdes. 1.4 Outpatient Referrals 14.1 With the exceptin f cancer 2WW and screening, all referrals (electrnic and paper) will be reviewed and priritised within 2 wrking days f receipt except fr visiting cnsultants (alternative arrangements will be agreed lcally) Cancer 2WW and cancer screening referrals must be reviewed and priritised within 24 hurs f receipt If these standards are nt adhered t, administrative staff will accept the bking n behalf f the service t ensure n delays are built int the 18 week target Advice and Guidance requests (Chse and Bk) must be respnded t within 3 wrking days (urgent) r 5 wrking days (rutine) f the request being made If a 2WW referral is deemed inapprpriate, frm the infrmatin prvided, cnsultants must cntact the GP by telephne t discuss the referral. If, after the discussin, the GP agrees t dwngrade the referral, the GP must rerefer the patient using a standard urgent r rutine letter. The cnsultant must nte the date, time and utcme f the discussin n the 2WW frm, which must be filed in the casentes. The patient must be reclassified and the cancer audit team infrmed. Prcedures Final V6 April

13 weeks (21 days) ntice must be given t the patient when agreeing an appintment date. The nly exceptins t this are:- Where it is clinically urgent (e.g. cancer 2WW referrals) Screening appintments i.e. bwel, breast and varian cancer screening Where a patient makes themselves available at shrt ntice Internal cnsultant t cnsultant referrals (Outpatients and Inpatients) will nly be made if: Suspected cancer Urgent prblems fr which delay wuld be detrimental t the patients health the expectatin here wuld be that the patient needs t be seen within 2 weeks. Referral as part f the same clinical prblem Part f the recgnised pathway f care fr the cnditin r as part f a pre perative assessment. Transfer f respnsibility f care fr an nging cnditin when it wuld be mre cnvenient fr the patient t be seen in a different lcatin Referral back t a GP wuld be apprpriate fr: Cnditins that are unrelated t the presenting prblems and d nt require urgent referral. Incidental findings Cnditins that can be dealt with by the primary care team Referral Queries If there is any dubt as t whether a patient needs t be managed by the hspital r whether a patient shuld be ffered a chice it will be advisable fr the cnsultant t cntact the GP t discuss the case. 1.5 Inpatients / Day cases Patients must nly be added t a treatment waiting list r bked fr surgery when they are ready and able T Cme In (TCI) fr their appintment/treatment Cancer patients must be given the earliest pssible TCI date (within their 31 r 62 day target) whichever is the earliest. Please refer t the cancer centre team fr the cancer target date infrmatin N pauses can be applied t patients n a suspected cancer r diagnsed cancer pathway A TCI frm must be used by ALL cnsultants and cmpleted fr each patient, Prcedures Final V6 April

14 including thse wh have been seen at peripheral and private hspitals An 18 week clck pause will be applied where a patient exceptinally needs t delay their inpatient treatment e.g. peple in the teaching prfessin A decisin t treat letter must be sent t the GP Patients with the same pririty will be treated in chrnlgical rder, unless the patient has specifically chsen a later TCI date themselves When selecting patients fr listing, it is essential t select patients n clinical grunds and length f wait DNAs where safeguarding issues (Adults and Children) are a factr must be alerted t the GP, the Health Visitr Liaisn Nurse (based in CED), family and children s scial care as necessary and in accrdance with the Trust plicy n Safeguarding: Management f DNA s weeks (21 days) ntice must be given t the patient when agreeing a TCI date. The nly exceptins t this are:- Where it is clinically urgent (e.g. cancer 2WW referrals). Patients must be given the earliest pssible TCI date Different rules apply t patients with suspected r diagnsed cancer. Where a patient makes themselves available at shrt ntice Where the patient negtiates a date with the cnsultant during their cnsultatin. 2 Divisinal Management Respnsibilities 2.1 Patients with a learning disability and their families / carers must be supprted with reasnable adjustments t ensure access t treatment 2.2 Patients must be ffered a minimum f 2 dates. One must give 21 days ntice f appintment t demnstrate reasnableness and supprt t patient chice and fair and equitable access fr all grups f patients. 2.3 All cancer patients must be listed nce a decisin t treat r undertake a diagnstic prcedure has been made. 2.4 Ensure patients are seen within their maximum waiting time. 2.5 Use infrmatin reprts t actively help plan capacity t ensure achievement f waiting time targets with n breaches. 2.6 Actively mnitr referrals and bking rules t respnd flexibly t demand and deliver flexible capacity. 2.7 Changes t bking rules must be authrised by a General Manager/Deputy and agreed with the Outpatient Services Manager/Deputy. The exceptins are: Prcedures Final V6 April

15 Adhc requests with n reductin t patient bking numbers Changes t medical staff rta s Additins f target 2WW s r urgent slts fr patients abut t breach. 2.8 Respnsible fr having systems in place t ensure patients d nt breach the 14, 31 and 62 days cancer waiting time and the 18 week referral-t-treatment targets. Cancer Centre staff will mnitr pathways and escalate patients t the apprpriate Divisinal Medical Directr r Divisinal Directr. 2.9 Ensure staff cmply with PAS data quality standards Ensure systems allw, where apprpriate and with the agreement f the clinician fr new patients t be ffered the pprtunity f an appintment with a cnsultant wh has a shrter waiting time Mnitr and manage the reasns fr DNAs, patient and hspital cancellatins, remvals (particularly remvals withut treatment) and additins t the waiting list. Review these cases as necessary t ensure that the best service pssible is prvided t patients as sme f these may be indicative f ther underlying prblems, fr example delays in sending ut appintments, language needs, patient learning disabilities, etc. Review the trends in data e.g. ethnicity, age and gender. DNAs resulting frm issues relating t prtected characteristics (e.g. disability, language needs) need t be taken int accunt Fr planned patients staff must enter a date n t PAS in the Urgency/Date field indicating when a patient will be seen Advise the PAS Supprt Team f any new waiting list requirements at least 6 weeks befre the start date is needed Take ultimate respnsibility fr the cntent f the Directry f Services making sure regular updates are applied Managing flexible capacity t ensure slts are always available Ensure applicatin f clinical leave as stated in the plicy Fllwing discussins and agreement with the relevant clinic admin lead and Data Quality Supprt Officer (DQSO) cmplete and submit a clinic template frm (change frm fr bking rules new and existing) t the PAS Supprt Team. 2 weeks ntice must be given Ensure bking rules reflect apprpriate levels f capacity fr new and fllw-up cnsultatins and mnitr variances in new t fllw up ratis Annually review bking rules with clinicians t ensure perfrmance management and Key Perfrmance Indicatr s (KPIs) are cnsidered. Prcedures Final V6 April

16 2.20 Ensure that suspected cancer tw-week wait referral patients are seen within 14 days f the clck start/date request received. Ptential breaches must be escalated well in advance Ensure planned/utpatient patients are treated by their due date/cancer waiting time Ensure patients are listed in chrnlgical rder and discuss cases f nn cmpliance with the cnsultant Ensure staff include the minimum data set infrmatin i.e. date f riginal referral and clck status when referring t anther prvider Ensure nly patients wh are fit and ready t be treated are added t the active waiting list All cancer patients must be listed nce a decisin t treat r undertake diagnstic prcedure has been made Ensure ward staff recrd real time admissins, discharges and transfers n PAS. 3 Data Quality Team (Infrmatin Services) 3.1 The Data Quality Team wrk clsely with the Divisinal Analyst, csting, and frnt line staff and are respnsible fr identifying, training and maintaining data quality excellence acrss all areas f delivery. The Data Quality Supprt Officers (DQSO) are respnsible fr raising the prfile f data quality acrss each divisin and assist staff with any queries. 3.2 What is Data Quality? Quality data is vital t the decisin making prcesses f ur rganisatin. It frms the basis fr meaningful planning and alerts services t deviatin frm expected trends. It will ensure the nature f care prvided is accurately and fully captured and that prper reimbursement fr services prvided takes place. 3.3 The Cancer Centre Team will be respnsible fr cancer data quality and will wrk in cnjunctin with the Trust s Data Quality Team regarding any requests fr data. 3.4 Examples f gd quality data are: Ensuring referrals r TCI frms are entered nt PAS in a timely manner. Recrding all ffers f appintments / TCI dates n PAS. Ensuring patient s details (address, phne number, GP etc.) are up t date at every appintment / admissin. Ensuring the crrect dates are recrded fr the start f a patient s pathway / referral and request received date / date n waiting list and any suspensin perid. Dcumenting any perids in which the patient is nt available. Prcedures Final V6 April

17 Ensuring that crrect pathways are picked up. Onging validatin f missing clck starts and lng waiters t ensure patients are treated within the apprpriate timescales. 3.5 Standards All staff have a respnsibility t ensure that high quality data is captured acrss a wide range f systems and prcesses. The quality f infrmatin prduced impacts n: Patient management Generating incme thrugh Payment by Results (PbR) Mnitring and reprting n natinal and lcal targets Service management, planning and develpment. 3.6 Cre elements f high quality data are t ensure that prcesses allw fr accurate, cnsistent, timely and cmplete recrding f infrmatin. Fr supprt and advice abut cmpliance cntact the relevant Data Quality Supprt Officers (DQSO) fr yur area. 4. Outpatient and Daycase Admin/Receptin Staff, Cnsultant Secretaries and ther health prfessinals (specialist nurses, physitherapists etc) 4.1 Ensure all referrals (electrnic and paper) are accepted, rejected r changed within the fllwing trust timescales frm receipt t ensure that the patient is bked int an apprpriate clinic. Pririty Primary Care Turnarund Time (wrking days) Trust Turnarund Time (wrking days) 2WW 24 hurs 24 hurs Screening 24 hurs 24 hurs Urgent 24 hurs 3 days Rutine 3 days 3 days Advice and Guidance Nne Urgent 3 days Rutine- 5 days 4.2 If the standard fr 2WW s is nt adhered t administrative staff will accept the bking t ensure the patient is nt unduly disadvantaged and delays nt incurred. 4.3 Supprt the achievement f natinal targets (90% admitted, 95% nne admitted, 92% in cmplete pathways) plus cancer waiting time targets. 4.4 Escalate issues such as ptential breaches, insufficient capacity r untypical remval frm the waiting list t their line manager. Prcedures Final V6 April

18 4.5 Changes t bking rules being required utside the 2 weeks ntice perid will nt be actined withut the authrisatin in frm the relevant General/Deputy Manager. 4.6 Requests fr new clinics t be set up n PAS must be authrised by the apprpriate General/Deputy Manager at least 2 weeks befre the expected start date. 4.7 Subsequent clinic changes must be authrised and prcessed in line with these prcedures. 4.8 Where cnsultant initiated clinic cancellatins are requested with less than 6 weeks ntice, team leaders must cntact the relevant General/Deputy Manager as sn as pssible fr investigatin and actin. 4.9 Ensure patients are ffered the pprtunity t chse and agree a date within the maximum waiting time using either partial r full bking Where peratinally pssible the appintment needs f the patient will be taken int accunt such as religius festivals, statutry bank hlidays, times f appintments (e.g. patients requiring carers and patients wh are carers) Ensure the special needs f the patient are taken int accunt such as fnt size fr appintment letter r bking an interpreter fr the appintment Ensure the 21 day guarantee is maintained when we cancel a patient n day f treatment fr a nn clinical reasn If a patient with a suspected cancer r a diagnsis f cancer is cancelled n the day f prcedure fr a nn clinical reasn, a patient must be bked in t the next earliest pssible slt t ensure that they meet target dates. Refer t the Cancer Centre Team fr target date infrmatin Mnitr the fllw up review and planned lists t ensure patients are nt waiting lnger than their due return date. If this is the case this must be escalated Ensure suspected Cancer 2 WW s are seen within 14 days f receipt f referral (paper)/date f Unique Bking Reference Number (UBRN) cnversin date r attempted cnversin date (electrnic). If this timescale cannt be met the escalatin prcedures must be fllwed When agreeing a TCI date, ensure patients are ffered at least 2 dates. One date must give 21 days ntice t demnstrate reasnableness. The nly exceptins t this are:- When it is clinically urgent (e.g. cancer 2WW referrals plus cancer screening) When a patient makes themselves available at shrt ntice. When the patient negtiates a date with the cnsultant during their cnsultatin Ensure all ffer dates are recrded n PAS t prvide an audit trail. Prcedures Final V6 April

19 4.18 A waiting list pause will autmatically be created by PAS fr patients wh decline 2 r mre reasnable ffers fr admissin i.e. the date f ffer is mre than 3 weeks (21 Days) befre the TCI date ffered and a further TCI date has been accepted. Care must be taken if the patient is n a cancer pathway n pauses can be applied t patients n a suspected cancer r diagnsed cancer pathway Shrt ntice TCI dates ffered t patients but nt accepted will nt cmprmise the patient s psitin in terms f their waiting time A patient cannt be a private and NHS fr the treatment f ne cnditin during a single visit t a NHS rganisatin Any patient changing their status frm Private t NHS is entitled t NHS services n exactly the same basis f clinical need as any ther NHS patient. Private t NHS fr 18 week RTT clck see Ensure the minimum data set i.e. date f referral and clck status set is added t referrals frm utside the Trust Inter prvider transfers - In the event that this will cause an immediate waiting list breach, the patient must nt be added t a waiting list withut agreement with the apprpriate General/Deputy Manager All patients with suspected r diagnsed cancer must be immediately added t a waiting list upn receipt f request/referral Patients wh mve ut f the area have the ptin t remain n ur waiting list. Fr thse transferring t anther hspitals waiting list it is essential t send the 18 week details with the referral. See Transfer f care - In the event f a patient being transferred frm ne cnsultant s waiting list t anther the riginal date n list must be retained. 5. Training All Staff Training arrangements 5.1 Fur levels f training are required: Generic Trust wide fr all invlved in a patients pathway PAS Training in depth explanatin f cdes used in PAS and effect n reprting f pathways Service specific Specific pathway rules fr that patient area Infflex in depth tracking and data capture fr cancer pathways 5.2 Generic training - will be develped by Data Quality staff in cnjunctin with e- Learning department. An n-line training and assessment package will be cmmissined and apprved by the Patient Access Grup. This will cver the general understanding f RTT clcks and targets etc. in the table belw and Prcedures Final V6 April

20 explain key respnsibilities under the patient access plicy. This will be mandatry as part f inductin and thereafter every 2 years. 5.3 PAS Training - will be delivered by PAS Trainers with supprt n training material frm Data Quality and PAG sub-grup selected t advise n this. This will be delivered in an interactive training sessin with separate curses fr new users and refresher curses fr existing users. Once all staff have undertaken an initial training curse future refresher curses culd be delivered n-line, with an pprtunity t bk a face t face curse if required. Detailed wrked examples will be used t demnstrate which cdes shuld be entered and the effect n the patient s pathway. 5.4 Service specific - training will be delivered in the Divisin by nminated key cntacts (previusly referred t as Super Users). These staff will be n hand t reslve queries as they arise and t explain lcal pathways that may nt fit generic mdels. These staff can cntact Data Quality fr further advice and supprt. It is the respnsibility f each divisin t reflect changes in their nminated key cntacts. 5.5 Infflex - will be delivered by IT Trainers with supprt n training material frm Cancer Centre Audit staff. 5.6 See table belw. Staff Grup RTT Rle Training Outcme Recrd referrals Out Patient Admin staff new patients Out Patient Admin staff fllw up Capture crrect start dates and treatment status Fllw up n missing infrmatin frm intraprvider transfers Recrd clinic utcmes based n infrmatin prvided frm clinic Understand inter prvider transfers and clck rules General understanding f RTT clcks and targets etc. Understand hw utcme treatment status affects clcks and hw t enter cdes n PAS Medical Secretaries and Waiting List Clerks Add patient t a review list r bking future appintments and recrd treatments status List patients fr treatment r investigatins and recrd RTT status General understanding f RTT clcks and targets etc. Understand the patient access plicy and their respnsibilities. Understand hw WL and admin cntact treatment status affects clcks and hw t enter cdes n PAS Prcedures Final V6 April

21 Capture crrect start dates and treatment status fr patients ging straight t test fllw up missing infrmatin frm intraprvider transfers and stp clcks fr thse referred nt anther prvider fr treatment. Understand inter prvider transfers and clck rules. General understanding f RTT clcks and targets etc. Understand the patient access plicy and their respnsibilities. Ward Receptinists Medical Staff Nursing staff Enter admin cntacts fr patients wh have had a diagnstic test and n further treatment (r appts) required. Enter treatment status n admissin and if patients are cancelled and / r re-listed Indicate treatment status n utpatient utcme frms, TCI frms and letters referring patients n t ther Clinicians / Prviders Enter treatment status n admissin and if patients are cancelled and / r re-listed. General understanding f RTT clcks and targets etc. Understand inter prvider transfers and clck rules. General understanding f RTT clcks and targets etc. General understanding f RTT clcks and targets etc. Infrmatin Quality Staff and Data Supprt Medical Staff in utpatient clinics in cmpleting utcme treatment status cdes. Reprt n perfrmance and supprt validatin prcess. Ability t prvide cmprehensive guidance and supprt n RTT clcks and targets etc. Prcedures Final V6 April

22 Managers Mnitr cmpliance with the patient access plicy. Ensure staff are trained t understand RTT rules and hw t enter data. Understand the patient access plicy and their respnsibilities. General understanding f RTT clcks and targets etc. Ensure apprpriate validatin is undertaken and that patient access plicy is adhered t. Escalatin pint fr perfrmance issues. Understand the patient access plicy and their respnsibilities. IT Training Authrity t schedule additinal clinical capacity where needed t avid breaches. Deliver training t PAS users and supprt the Trust e-learning tls t ensure key staff grups understand RTT rules and hw t enter data n PAS. Understand hw treatment status affects clcks and hw t enter cdes n PAS General understanding f RTT clcks and targets etc. Staff identified as being a specialist fr RTT pathways within Divisins and Recrds Management Prvide expert advice and supprt in pathway management within their speciality area. Cmprehensive understanding f all elements f the 3 training levels. Identify and escalate training and educatin issues arising frm validatin t relevant Prcedures Final V6 April

23 General Manager/Head f Service Ensure staff are trained t understand Cancer rules/pathways All staff General understanding f Cancer rules/pathways. 6 Outpatient Bking and Referral Management 6.1 Admin peratinal staff must ensure that the standards f practice fr waiting list and patient access management are fllwed. 7. Current Methds f Referral t Access Services 7.1 Electrnic Bking System (EBS) referral via the Chse and Bk system is the expected methd fr all new patient referrals. This is where the patient has bked int a specific clinic slt and a referral letter/ prfrma has been attached t the bking. 7.2 Paper Referrals are still accepted. 8. General Principles 8.1 If the patient was discharged mre than 6 mnths ag GPs will have t re-refer fr the same cnditin 8.2 Open appintments acrss all specialties are valid fr 6 mnths frm the last appintment 8.3 Review f referrals must be cmpleted within 2 wrking days the exceptin being fr visiting cnsultants 8.4 Rejected Referrals referrals are nt expected t be rutinely rejected see The Chse and Bk Directry f Service will be regularly updated and refined t ensure that infrmatin is accurate, current and reflects the services ffered. In the event that a rejectin is the nly apprpriate actin, a brief explanatin must be prvided t the GP. 8.6 Chse and Bk Operatinal Manager will audit rejected referrals n a regular basis and prvide slutins fr the issues. 8.7 Redirected Referrals utpatient clinic staff will redirect as instructed t the crrect service/clinic. 8.8 The Date Request Received in PAS cnstitutes a clck start. This is the date an attempt was made t cnvert a UBRN int a bking fr Chse and Bk patients and the date the referral letter was received int the Trust fr paper referrals. Prcedures Final V6 April

24 8.9 Internal cnsultant t cnsultant referrals criteria is: Direct referrals will be apprpriate fr: Suspected cancer Urgent prblems fr which delay wuld be detrimental t the patient s health. The expectatin here wuld be that the patient needs t be seen within 2 weeks. Referral as part f the same clinical prblem Part f the recgnised pathway f care fr the cnditin r as part f a pre-perative assessment Transfer f respnsibility f care fr an nging cnditin when it wuld be mre cnvenient fr the patient t be seen in a different lcatin. Referral back t GP will be apprpriate fr: Cnditins that are unrelated t the presenting prblems and d nt require urgent referral Incidental findings Cnditins that can be dealt with by the Clinical Cmmissining Grup Referral Queries If there is any dubt as t whether a patient needs t be managed by the hspital r whether a patient shuld be ffered a chice it wuld be advisable fr the cnsultant t cntact the GP t discuss the case Patients will nly be added t a waiting list if there is an expectatin f treating them and they are clinically fit and ready t undertake the treatment. Except cancer cases Where peratinally pssible the appintment needs f the patient will be taken int accunt such as religius festivals, statutry bank hlidays, times f appintments (e.g. patients requiring carers and patients wh are carers) All demgraphics must be checked befre arriving the patient n PAS t ensure that data quality and cntract/payment standards are achieved Admin staff/secretaries wh wrk Chse and Bk must view and actin all wrk lists daily in accrdance with the Daily Checks guidance issued by the PAS Team The EBS spl (fr chse and bk patients) must be checked thrughut the day t highlight any cancellatins and prevent patients frm being recrded as a DNA When bking patient appintments utside Chse and Bk (in PAS) staff must select the crrect EBS line entry frm the Bk New Appintment screen t ensure the cntinuatin f the 18 week RTT clck r cancer pathway. 9. Summary f Guidelines fr Managing New Referrals 9.1 A New Referral will be required fr: a) Same specialty new cnditin b) Previusly discharged new cnditin Prcedures Final V6 April

25 c) Previusly discharged same cnditin - where new request is 6 mnths after discharge f the riginal referral WW Referrals - Receiving, Prcessing and Bking 10.1 Chse and Bk is the expected methd fr all 2WW referrals with the exceptin f tertiary referrals The 14 and 62 day clck starts n either: the date the UBRN is cnverted t a bking OR the date the patient chse t defer t prvider due t n appintments being available 10.3 Patients must be seen within 14 days f the date request received Symptmatic Breast (nn 2ww - nt suspected cancer) referrals will be sent n a standard referral letter but must be seen within 14 days f the date request received Fr Faxed and Clinical Assessment Services (CAS) bked utside Chse and Bk (in PAS) three attempts must be made t cntact the patient, ne f which must be in the evening. If a bking is made within 24hurs f receipt f the referral the appintment in PAS will be recrded as fully bked. If n cntact is made an appintment letter will be sent. These appintments will be recrded in PAS as partially bked If n appintments are available within 14 days lcal escalatin prcedures must be fllwed Once diagnsis has been cnfirmed patients will receive first treatment within 62 days f the date request received and within 31 days f the decisin t treat, whichever is snest. 11. Exceptins t the 2WW rule 11.1 Inapprpriate 2WW referral - If, frm the infrmatin prvided by the GP, a clinician deems a 2WW referral inapprpriate, they must cntact the GP by telephne t discuss the referral. If after discussin, the GP agrees t dwngrade the referral, the GP must re-refer the patient using a standard urgent r rutine letter. The clinician must nte the date, time and utcme f the discussin n the 2WW frm, which must be filed in the ntes. The clinician must then ensure that the relevant member f the cancer audit team is infrmed f this decisin If a referral letter has been upgraded t a 2WW by the cnsultant, the pririty must be recrded as urgent (nt Target) in PAS and the target wait grup left blank 12 New Paper Referrals - Receiving, Prcessing and Bking Prcedures Final V6 April

26 12.1 All referrals prcessed thrugh the Referral Prcess Office in Recrds Management Demgraphic and special needs infrmatin checked and amended as necessary n PAS. Referrals will be date stamped and registered within 24 hurs f receipt and frwarded t the apprpriate clinic area t be added t the Registered Referrals list Out-patient clinics will ensure all patients are added t the apprpriate clinicians Registered Referrals List. Open/unnamed referrals will be allcated by the Team Leader relevant t their area f wrk With the exceptin f cancer 2WW and screening all referrals must be reviewed within 2 wrking days f receipt by an apprpriate individual fr priritisatin. Lcal agreements must be fllwed fr visiting cnsultants. Arrangement must be in place fr when cnsultants are n leave r when they d nt attend n a regular basis Cancer 2WW and cancer screening referrals must be reviewed and priritised within 24 hurs f receipt The 18 week clck starts n the day the referral is received and date stamped int the Trust On receipt f referrals back frm the clinician the fllwing will be initiated: Admin staff must enter the clinical grading pririty n PAS Urgent requests will be bked immediately Rutine requests will be bked in accrdance with the Partial Bking Prcess. Patients failing t respnd will result in them being discharged and the referral returned t the GP with a cvering letter generated frm PAS Referrals marked as Straight T Test (STT) will be discharged frm the registered referral list and frward t apprpriate department. Inapprpriate referrals will be discharged frm the registered referrals list and the clinician will ntify the referring clinician. This excludes 14 day cancer referrals (see 11.1). When an appintment is bked the patient will be sent a cnfirmatin letter It is the respnsibility f each Team leader/supervisr t husekeep the Registered Referrals list. 13. Obstetric Referrals 13.1 Referrals and dating scans are managed directly by Ante-natal services t lcally agreed prcedures. 14. Chse and Bk Referrals - Receiving, Prcessing and Bking Prcedures Final V6 April

27 14.1 The first indicatin that an appintment bking has been made is the receipt f an aut-generated ntificatin n the lcal EBS spl Referrals are nly visible n the Referrals fr Review wrk list nce bth the appintment bking has been made and the referral attached All referrals are printed ff and prcessed by the Referral Prcess Office in Recrds Management with the exceptin f the fllwing which are managed by the relevant clinic areas: 2ww referrals (including Symptmatic Breast) Pain Management Palliative Rehabilitatin Onclgy (Established Diagnsis) Haematlgy Diagnstic Physilgical Measurement Rapid Access Chest Pain 14.4 With the exceptin f cancer 2WW and screening all referrals must be reviewed within 2 wrking days f receipt by an apprpriate individual fr priritisatin. Lcal agreements must be fllwed fr visiting cnsultants. Arrangement must be in place fr when cnsultants are n leave r when they d nt attend n a regular basis. If these standards are nt adhered t, administrative staff will accept the bking n behalf f the service t ensure n delays are built int the 18 week target Cancer 2WW and cancer screening referrals must be reviewed and priritised within 24 hurs f receipt The cancer clck starts n either: the date the UBRN is cnverted t a bking OR the date the patient chse t defer t prvider due t n appintments being available 14.7 Referrals n the Referrals fr Review wrk list must be actined (accepted, rejected, changed) by the admin staff within 3 days wrking days f receipt r as a minimum daily fr 2WW. When an appintment is bked the patient will be sent a cnfirmatin letter. It is the respnsibility f each Team leader/supervisr t husekeep the Referrals fr Review wrk list. 15. Fllw-up Appintments 15.1 Patients will nly be fllwed up where there is a specific clinical need fllwing the specialty prtcl. Prcedures Final V6 April

28 15.2 Fully Bked will nly be recrded when bking a further appintment at the time f leaving clinic Partially Bked will be recrded at all ther times e.g. when bking frm a review list Patients wh fail t respnd t the partial bking prcess (including patients with a suspected r diagnsed cancer) within 3 weeks will be discharged frm the review list and referred back t the Cnsultant fr a clinical decisin t be made regarding nging clinical care. The GP will be advised accrdingly. 16. X- Inpatient Patient (XIP) Appintments 16.1 An XIP appintment is bked fr a patient requiring a fllw up appintment, within the same specialty as the inpatient stay, after an elective, planned r emergency admissin It is the ward staff respnsibility t prvide clinic admin staff with the crrect methd f admissin fr the clinic bking n PAS. 17. Changing/Cancelling Appintments at Patient s Request New and Fllw-up 17.1 Patients have an additinal ptin t cancel and change their Outpatient appintment n line, via the Derby Hspitals website. These requests will be actined by the Referrals Prcessing Office. Chse and Bk appintments cancel and change using the Chse and Bk telephne appintments line r website In the event a patient cancels a 2ww wait appintment a further appintment must be given within 14 days f the riginal date request received/ubrn cnversin. If this is nt pssible and the new appintment is ver 14 days escalate t General/Deputy Manager If patient requests a rearrangement r cancellatin within 24 hurs f the appintment time it must be recrded as a patient cancellatin If a patient is unable t attend due t being a current Inpatient, this must be recrded n PAS as a change/cancellatin by patient With the exceptin f Antenatal and 2WW, if a patient cancels the same appintment twice they must be: New Patient - remved frm the registered referral list and referred back t their GP. Fllw-up referred t the cnsultant fr discharge t GP Patients can change Chse & Bk appintments at any time - this is ut f Trust cntrl The EBS spl must be checked thrughut the day fr patient cancellatins t ensure they are nt recrded as a DNA. Prcedures Final V6 April

29 17.8 If a patient has t leave a clinic prir t being seen (clinic ver running r ther circumstances) their appintment must be changed t ensure that they are nt penalised in the 18 week cycle. The clck will cntinue ticking If a child s appintment is cancelled twice the issues/cncerns assciated with this must be reviewed and assessed by the Cnsultant. Refer t Trust plicy fr Safeguarding Children. 18. Hspital Cancellatins New and Fllw-up 18.1 New appintments can be changed by clinic admin staff prviding there is n breach t the waiting time targets. Ptential breaches must be brught t the attentin f the apprpriate General/Deputy Manager fr advice and reslutin Appintments will be re-bked with the patient s agreement as clse t their riginal appintment date as pssible. Only in exceptinal circumstances will a patient be cancelled twice A cancer 2ww appintment cannt be cancelled withut the authrity f a General/Deputy Manager. 19 Patients wh d nt attend (DNA) New and Fllw-up 19.1 Any qualified prvider (AQP) states it is in the patient s interest t ensure that mechanisms are in place t minimise the number f patients wh fail t attend pre arranged appintments. If a patient DNAs an appintment they shuld be ffered ne further appintment. Shuld they fail t attend this appintment the fllwing will ccur: Adults - Where there are ptential safeguarding issues the safeguarding team shuld be infrmed. Where there are n safeguarding issues they will be discharged back t their GP Cancer patients can be referred back t their GP after multiple (tw r mre) DNAs if this is agreed with the cnsultant Children - will autmatically be ffered anther appintment. In DNA cases all cnsultants must identify whether safeguarding issues are a factr and whether the DNA cnstitutes ptential neglect f medical needs. The Trust plicy fr Safeguarding: Management f DNA shuld be referred t. Where safeguarding issues are identified the safeguarding team shuld be cntacted. Children wh fail t attend a secnd utpatient appintment will be discharged back t their GP and the Health Visitr Liaisn Nurse (based in CED) shuld be infrmed. Cancer patients can be referred back t their GP after multiple (tw r mre) DNAs if this is agreed with the cnsultant. Prcedures Final V6 April