PATIENT ACCESS POLICY

Transcription

1 PATIENT ACCESS POLICY Page 1 of 44 Printed Copies may become out of date. Check online to ensure you have

2 CONTENTS AND PAGE NUMBERS Patient Access Policy... 1 Contents And page numbers... 2 EXECUTIVE SUMMARY/ INTRODUCTION... 4 purpose and scope... 4 duties and responsibilities... 5 Chief Operating Officer... 5 Director of Finance... 6 Managers... 6 Consultants... 6 Information Management & Technology (I M &T)... 6 Medical Records... 7 Choose and Book Directory of Services... 7 Appointments/Waiting List Coordinators... 7 Wards & Departments... 7 Theatre/Ward Managers... 7 Pre operative Staff... 7 Medical Secretaries... 7 Referrers (e.g. GPs, Dentists, Opticians) and Clinical Commissioning Groups... 8 MANAGING WAITING LISTS, SCHEDULING AND BOOKING... 8 Patient Administration System... 9 Booking systems... 9 Referrals/Requests... 9 Prior Approval Scheme(s)... 9 Special requirements Referrals from Other NHS Organisations Outside of England See Appendix 6 for additional information Consultant to Consultant Referrals Inappropriate referrals/requests Mismatch of Consultant Interest and Patient Needs Insufficient/illegible Clinical Information Down Grading of a referral Determining Priority of a Referral Equality and Diversity / Special Requirements Timeliness of and Adding a Patient to the Waiting List week pathways Elective Admissions Patient Transfers Patients listed for Bilateral procedures or for more than one procedure Private Patients Reasonable Notice Cancellations Re-instatement on the waiting list Re-instatements for Clinical Reasons Re-instatement following an Inappropriate Removal DNAs (Did not Attend) Active Monitoring Exceptions for removals from the waiting list Recording Clinical Outcomes ( Cashing-up ) Clinic Template Changes Retrieval of Medical Records Patient Correspondence Management Information OUTPATIENT BOOKING AND SCHEDULING Introduction Page 2 of 44 Printed Copies may become out of date. Check online to ensure you have

3 Choose and Book Paper/Other referrals letters Follow-up Appointments Diagnostic Intervention Follow-up Overbooking of Clinic Templates New to Review Ratios Private Utilisation of OPD inpatient/daycase WAITING LISTS Introduction Selecting patients for admission Categorising Patients on the Waiting List Waiting list Management Pre-op Assessment Service Patient Transfers DIAGNOSTIC (non endoscopy) WAITING LIST Introduction Diagnostic Procedures Imaging Referrals Data Definitions Booking system Potential Breeches Launch Plan / Policy Implementation Key Staff Groups Medical Records and OP managers are responsible for providing: Senior Managers are responsible for Medical Staff are responsible for Training/Update Sessions Patient Access Procedures Review and Monitoring Policy Reviews Effectiveness Reviews Monitoring Achievement of Standards in the Patient Access Policy Monitoring of the DOCUMENTED PROCESS Patient Access Policy Sources/ References Glossary of Terms DEFINITIONS/ABBREVIATIONS ABBREVIATIONS ASSOCIATED DOCUMENTS APPENDIX 1 KEY PERFORMANCE TARGETS APPENDIX 2 sop FOR MANAGING PATIENTS ON A SUSPENDED WAITING LIST APPENDIX 3 sop FOR MANAGING PATIENTS ON A PLANNED WAITING LIST APPENDIX 4 Protocol for Referrals from Outpatients Clinics To Other Specialties / Trusts 40 APPENDIX 5 Referrals from Other NHS ORganisations outside of England EQUALITY IMPACT ASSESSMENT Document Information Box (Completed by AUTHORISED DIVISIONAL/CORPORATE SERVICE Librarian) Page 3 of 44 Printed Copies may become out of date. Check online to ensure you have

4 EXECUTIVE SUMMARY/ INTRODUCTION The principles and definitions of the 18 week target count the referral to treatment (RTT) waiting times in totality. This is a positive step and allows the Trust to focus on delivering shorter waits and quality care for patients. The length of time a patient needs to wait for hospital treatment is an important quality issue and is a visible and public indicator of the efficiency of the hospital services provided by the Trust. The successful management of patients who are waiting for elective treatment is the responsibility of a number of key individuals and organisations including Hospital Doctors, General Practitioners (GP s), Consortium Commissioning Groups and Trust Managers. If patients who are waiting for treatment are to be managed effectively it is essential for everyone involved to have a clear understanding of their roles and responsibilities. This document defines roles and responsibilities and establishes guidelines to assist staff in the effective management of waiting lists. Simon Wright Chief Operating Officer PURPOSE AND SCOPE The policy aims to provide the Trust with a consistent approach to the management of waiting lists, scheduling and booking across the organisation in accordance with National and local frameworks and definitions. This policy document applies to all patients who are referred to Warrington and Halton Hospitals NHS Foundation Trust (WHHFT). This policy document applies to all WHHFT staff involved in the management of patient access to WHHFT services. This policy has been designed to provide consistency and eliminate all duplicate systems throughout the Trust. It is imperative that the Hospital IT System is the single store of data used for the management of all waiting lists. It is essential that the electronic Hospital IT System is fully functional and that effective training and support is given to those staff involved in waiting list management. This will help improve data quality and improve confidence in the accuracy of waiting list information. Appropriate training programmes should support staff with special regard given to newly recruited staff. Divisions are responsible for ensuring that all staff involved in the content of this policy, both clinical and clerical, receive initial training and regular updates. The Trust will hold a record of patients waiting for an appointment/admission on computer systems approved by the Trust s Information Department. It will be current, accurate, and complete and subject to regular audit and validation. The Trust will not Page 4 of 44 Printed Copies may become out of date. Check online to ensure you have

5 hold deferred waiting lists. Trust administrative staff must not keep local records of patients choosing to wait or defer a reasonable offer of an appointment/admission. Patients should only be referred to the Trust if they are ready, willing and available to be treated within 18 weeks. The Trust will agree a convenient date and time with patients for appointments or admission following either partially or fully booked systems. Patients will be seen in clinical priority order when attending outpatients, diagnostic testing, or when admitted for elective day case or inpatient procedures. Patients of equal clinical priority will be treated in chronological order. A patient will only be placed on a waiting list for admission if:- o There is a sound clinical indication for the operation o The patient is clinically and socially ready to undergo surgery Appropriate, relevant and timely referral information is required to enable a patient to be offered an appointment or admission. Patients should be listed on the Decision to Admit (DTA) date and tracked according to the 18 week rules and definitions. Communications with patients should be informative, clear and concise. All additions to or removals from waiting lists must be made in accordance with this policy. Reasonable offer of date rules apply to all patients. The Trust will seek to make best use of its resources to the benefit of all patients by seeking to reduce the number of patients who Do Not Attend (DNA). Patients will be encouraged to be responsible for keeping their appointments. Out-Patients should only be followed up if there is a clinical need and all clinical information is available. The Trust will endeavour to work towards inclusion and equal access for all service users and is committed to ensuring that no equality target group (Black & Minority Ethnic, Age, Gender, Disability, Religion, and Sexual Orientation & Transgender) are discriminated against or disadvantaged by this policy and associated procedures. DUTIES AND RESPONSIBILITIES This section outlines the key responsibilities of key groups of staff within the Trust in relation to this policy. The list is not exhaustive and each group will have other roles and responsibilities that are not listed here. Chief Operating Officer The Chief Operating Officer will ensure the waiting list policy is implemented and adhered to. The Chief Operating Officer will performance manage the implementation of the Patient Access Policy via the KPI group, which reports directly to the Trust Board (via performance monitoring). The Chief Operating Officer will ensure the Trust is maximising its clinic and theatre capacity whilst adhering to the NHS Executive guidelines regarding: i) Total number on waiting list. ii) Cancelled operations/clinics iii) Waiting times targets. iv) Suspended Waiting List. Page 5 of 44 Printed Copies may become out of date. Check online to ensure you have

6 v) Planned Waiting List Director of Finance The Director of Finance will ensure robust and timely information is produced by the Information Team and made available to Trust management as appropriate. Managers The Managers will be responsible for ensuring all patients receive treatment within national and locally agreed targets, and that all staff adhere to the Trust Patient Access Policy and associated procedures. Management Teams will be responsible for monitoring the following:- i) Total number on waiting list. ii) Cancelled operations/clinics. iii) Waiting times targets. iv) Suspended Waiting List. v) Planned Waiting List. Consultants Each Consultant will decide which patients require adding to a waiting list and their clinical priority. Consultants will be responsible for the care of all patients listed on their waiting list including those suspended within National and locally agreed targets. Consultants and their clinical teams are required to provide at least six weeks notice before the date for commencement of the leave period, and submit the relevant form to the relevant Clinical Lead for approval. Requests that are submitted at less than six weeks notice that result in a loss of clinical activity will only be granted following an agreement to replace that activity at no additional cost to the Trust. The only exceptions to this rule will be following unforeseen circumstances or emergency situations. Consultants will be responsible for reviewing patient s records for those requiring rescheduling following a hospital cancellation to ensure patient care is not compromised. Consultants and their clinical teams will be responsible for ensuring all Choose and Book referrals and paper referrals are reviewed within one working day of receipt into the organisation. Consultants are responsible for ensuring their clinical teams complete electronic discharge summaries within 24 hours of a patient discharge. Information Management & Technology (I M &T) The information system trainers will work with users to ensure that training needs are met and underpinned with effective training and documentation. The I M & T Department will ensure: Data entry is accurate and complies with national and local data standards. Consistent waiting list reporting is achieved internally and externally. System changes are actioned in liaison with suppliers. Page 6 of 44 Printed Copies may become out of date. Check online to ensure you have

7 Software and process changes are implemented in liaison with users. Produce data quality reports on a monthly basis. Medical Records Clerks will be responsible for locating case-notes, preparing and delivering notes to the appropriate clinic/reception area prior to the clinic/patient admission taking place within the department remit. Choose and Book Directory of Services The Out patient Access Manager will be responsible for maintaining the Directory of Services (Dos) and ensuring outpatient referral processes are reviewed in line with the evolvement of Choose and Book. Appointments/Waiting List Coordinators The Appointments / Waiting List Coordinators will be responsible for adding and administration of patients to the OP/IP/DC/Diagnostic waiting list(s) on the Hospital IT System, as appropriate to their role. The day-to-day maintenance and management of waiting lists and PTLs is the responsibility of all Trust staff involved in the operational management of scheduling and booking admission/appointments. The waiting list/ptls must be validated routinely to ensure that that the waiting list does not contain patients who no longer require an admission/appointment. PTLs will contain a list of patients who are on the waiting list who require an admission/appointment within a defined period to meeting local/national waiting time targets. Wards & Departments Wards and Departments must ensure patients are admitted and discharged on the Hospital IT System; recording out-comes against pre-admissions if patients DNA or CANCEL. Ensure all case-notes are available for admission date and all patients movements within the hospital are accurately recorded on the IT system i.e. ward transfers, hospital transfers, admitting consultant changes, discharged. Theatre/Ward Managers Theatre/Ward Managers must contact the Waiting List Manager or SMOC (out of hours) before cancelling patients due to lack of bed availability, advising on the patient s length of wait and relevant circumstances and also inform Waiting List Coordinator/ Management Team of hospital cancellations in order to facilitate a new TCI date that is within 28 days. Pre operative Staff If patients are not medically fit for surgery, this must be clearly communicated to the GP together with what is an acceptable level of fitness and a clear management plan. Medical Secretaries Medical Secretaries must ensure all patient/gp correspondence is typed within 24 hours of a patient event and that the Hospital IT System is updated accordingly. Medical Page 7 of 44 Printed Copies may become out of date. Check online to ensure you have

8 Secretaries must also complete a minimum data set (MDS) form for patients being referred to another provider. Referrers (e.g. GPs, Dentists, Opticians) and Clinical Commissioning Groups Referrers and Clinical Commissioning Groups will: Adhere to WHHFT local Patient Access Policy and associated procedures. Comply with agreed referral pathways / criterion. Explain to patients their obligations to attend for appointments. Manage patients and review them as appropriate when informed by WHHFT that the patient has DNA d their admission/appointment and has been removed from the waiting list. Use their best endeavours to maximise the utilisation of the Choose and Book systems for referral of patients. Manage patients and review them as appropriate when informed by WHHFT that the patient has cancelled their admission on more than one occasion and has been removed from the waiting list. Manage patients and review them as appropriate when informed by WHHFT that they have not responded to a validation letter and have been removed from the waiting list. Manage patients and review them as appropriate when informed by WHHFT that the patient is not clinically fit to have the required procedure at the time of decision to treat. MANAGING WAITING LISTS, SCHEDULING AND BOOKING The successful management of patients who wait for elective outpatient appointments and treatments is the responsibility of a number of key individuals and organisations including General Practitioners, Trust Clinicians, Clinical Commissioning Groups and Trust Managers. Service Commissioners must ensure that long-term service agreements are established with sufficient capacity to ensure that no patient waits more than the guaranteed maximum time. Failure to commission and commit resources to funding adequate capacity will lead to longer waiting lists and times.. Trust Staff have an important role in managing Waiting Lists effectively. Treating patients and delivering a high quality, efficient and responsive service ensuring prompt communications with patients is a core responsibility of the hospital and the wider local health community. It is the responsibility of the Trust and of all staff to ensure that this policy is implemented in a fair and consistent manner to ensure that no equality target groups are discriminated against or disadvantaged by the implementation of this policy and associated procedures. The accuracy of published data is of paramount concern to the Trust. In support of data accuracy all transactions made on the Hospital IT System will be performed by staff in accordance with the training manual. This will be given to staff on completion of the relevant training course and prior to access rights being issued. An up to date document will be made available on the Trust s Intranet. Page 8 of 44 Printed Copies may become out of date. Check online to ensure you have

9 See Appendix 1 for a list of Key Performance Targets Patient Administration System To ensure consistency and the standardisation of reporting with Commissioners and the NHS Executive, all waiting lists are to be managed within the Hospital IT System. Manual Waiting list systems must not be used within the Trust. Booking systems To ensure that the Trust meets the targets for offering patient choice at first outpatient appointment and ultimately at all stages of a patient s journey the following booking systems will be adopted as best practice across the Trust: - Choose and Book* - Full Booking* - Partial Booking* * For definitions see Glossary The Trust expects that all new Outpatient referrals to elective outpatient Consultant clinics will be fully booked using the Choose and Book system. Referrals/Requests The Trust expects that all patients have had relevant access targets explained to them by their referrer, along with their responsibilities to make themselves available for their appointment prior to referral. The Trust expects one referral to be made for each separate condition. Referral letters/requests content must be clear and concise stating the clinical priority, reason for referral or request. The Trust s preferred method of referral management is by means of a pooled methodology, therefore where possible, referral letters/requests should be addressed to a specialty/service (i.e. Dear Dr Cardiology Clinic/CT Superintendent) to allow that specialty/service to direct the referral/request to the most appropriate member of the team and shortest waiting time. Where it is explicit that the patient has chosen or needs to see a particular consultant-led team, this must be written in the referral/request with the reason for this stated clearly. If the patient is referred using Choose and Book, the named clinician facility should be used. Prior Approval Scheme(s) GPs are no longer required to gain pre authorisation from their respective CCGs before making appropriate referrals into secondary care. The expectation is that GPs will manage the assessment of potential PLCPs within primary care and trusts will receive GP referrals directly. Where the GP is satisfied that the patient meets the PLCP criteria this will be clearly stated and documented and the trust may proceed with the specific treatment requested. Page 9 of 44 Printed Copies may become out of date. Check online to ensure you have

10 All other referrals will be for a consultant opinion only, and only if the consultant considers that the patient meets the PLCP criteria should treatment be offered. GP and Trust colleagues should therefore make patients aware that an initial referral does not automatically constitute authorisation for treatment. Following outpatient assessment the consultant will inform the GP either that the patient clearly meets the criteria and treatment will proceed, or that the patient does not meet the criteria. Patients who fulfil the criteria may then be placed on a waiting list according to their clinical need. The patient s notes should clearly reflect exactly how the criteria were fulfilled, to allow for case note audit to support contract management. Should the patient not meet the eligibility criteria this should be recorded in the patient s notes and the consultant should return the referral back to the explaining why the patient is in eligible for treatment? For any patients who do not meet the PLCP policy but it is deemed that the patient shows clinical exceptionality, an application for funding on exceptional grounds can be made from either primary or secondary care to NHS Merseyside s Individual Funding Request (IFR) team. Special requirements it is the responsibility of the referrer to indicate in the referral letter any special requirements a patient may have in terms of speech and sign interpretation, religious, cultural needs and disabilities (see section Equality & Diversity). Referrals from Other NHS Organisations Outside of England Non-contract elective referrals from NHS organisations outside of England will not be treated without prior approval from the appropriate health authority (please see Appendix 6 for a comprehensive list of non-england NHS organisations.). Referrals that are received from NHS organisations outside of England without a standard letter of authorisation will be returned by the Trust to the referrer to seek approval. It is the responsibility of the referrer to inform the patient of any subsequent delays to treatment. Consultants have a responsibility to ensure that internal outpatient referrals following emergency treatments are subject to the policy and guidelines set out by the different non-england organisations. See Appendix 6 for additional information. Consultant to Consultant Referrals All consultant to consultant referrals either internally or externally must be:- - in accordance with the Protocol for Referrals from Out Patient Clinics to Other Specialists / Trusts (Appendix 5) and - must be accompanied by an 18 week tracking proforma with the Minimum Data Set (MDS) completed. Page 10 of 44 Printed Copies may become out of date. Check online to ensure you have

11 - Notified to the patient s GP informing them of all new referrals explaining the reason for the referral and setting out the expectations. - Following identification of another condition outside the original referral remit the patient must be referred back to the GP. Inappropriate referrals/requests If the referral/request is for a service not provided by the Trust then the referral/request must be returned to the original referrer with advice. The Booking office must be informed and the referral/ request closed off the Hospital IT System. Mismatch of Consultant Interest and Patient Needs If a referral has been made to an individual who does not have the necessary skills for the needs of the patient, the professional prioritising the referral should re-route the referral to an appropriate colleague, prior to seeing the patient in clinic. Insufficient/illegible Clinical Information If the referral/ request does not provide sufficient/illegible information for the health care professional to make a decision, the letter should be returned to the original referrer. Down Grading of a referral If a healthcare professional wishes to down grade a Two Week Wait (2WW) or Urgent referral the prioritising healthcare professional must have a clinical conversation with the original referrer (documented in the notes) and the referrer asked to withdraw the two week wait referral status before any changes to the request are made on the Hospital IT System. Determining Priority of a Referral All patients who are added to a Meditech waiting list must be given a clinical priority of either Urgent or Routine. Equality and Diversity / Special Requirements The Trust strives to ensure that every service user is treated with dignity and respect in a safe environment. The services provided will be delivered in a fair and equitable manner. The Trust will not tolerate any practices that result in the provision of a lower standard of service due to unlawful discrimination. The services provided will be accessible and sensitive to the needs of the diverse community and will not disadvantage any service user on the grounds of age, disability, race, nationality, ethnic origin, gender, religion, beliefs, sexual orientation, caring commitments, social/economic background, HIV status, gender reassignment or any other difference. The Trust firmly believes that all services should be responsive and adaptive to individual needs of service users and carers. The Trust will ensure that these needs are at the centre of service delivery, as opposed to tradition or fear of change. Its services will not be based on assumptions, stereotypes and prejudice of any groups, but on information gained through consulting with service users, carers and the public. Page 11 of 44 Printed Copies may become out of date. Check online to ensure you have

12 In line with Trust procedures, all staff are required to obtain as much information on individual service users and carers needs, and to act on this information. This may include acquiring aids for a disabled person, contacting an interpreter for a non-english speaking patient, providing access to religious materials and/or delivering services that are culturally sensitive to the needs of service users and carers. All requests will be considered and the Trust will endeavour to ensure the highest quality services are delivered within the resources at its disposal. All special requirements must be notified to the appropriate department when informed of the appointment/admission date in order that the service can be booked. Where an appointment/admission date is cancelled/rescheduled, the appropriate department must be informed in order that the service required can be cancelled/rescheduled and avoid being charged. Interpreter - Where a patient requires an interpreter for an appointment /admission this must be highlighted at the top of a referral/request and also must be clearly state the exact type of interpreter required. Advocacy requests and enquires to: Patient Advocacy and Liaison Service (PALS) at WHHFT. Patient Transport patient transport for all first outpatient attendances must be booked by the patient, subject to meeting the eligibility criteria. Subsequent, patient transport arrangements will be booked via the patient transport office at WHHFT. War Pensioners - War pensioners should receive priority treatment but only if the condition referred into is directly attributable to injuries sustained during war periods. Overseas Visitors patient identified as an overseas visitor should be referred to the Chargeable Patients Officer. Disabilities/Special needs - The Trust is committed to providing, wherever possible, a booking system to support the requirements of individuals with disabilities, this may involve for example; booking an appointment time that is more suitable to their needs. We will continually work towards ensuring that individuals with disabilities are not disadvantaged by this policy; we will, through the Impact Assessment process & involvement with local disability groups, identify areas of concern and work in partnership to reduce or wherever possible eliminate these issues. Religious/Ethnicity The Trust is committed to providing, wherever possible, a flexible booking system to support the ethnic/religious requirements of service users, for example, more suitable appointments times or female interpreter for female service users. We will continually work towards ensuring that individuals due to their ethnic/religious requirements are not disadvantaged by this policy; we will, through the Impact Assessment process, in consultation with BME group, identify areas of concern, and work in partnership to reduce or wherever possible eliminate these issues. Page 12 of 44 Printed Copies may become out of date. Check online to ensure you have

13 Timeliness of and Adding a Patient to the Waiting List All patients requiring an appointment or treatment must be added to the Hospital IT System within 1 working day of the decision to refer/admit (DTA). The date of addition to the waiting list should always be the date the decision or receipt of referral was made, not the date of the transaction on the system. The decision to add a patient to a waiting list must be made by a Consultant, or under an arrangement agreed with the Consultant. It is the Consultants responsibility to list patients in chronological order. Decision to add to wait list or refer to diagnostics must be initiated at the point of decision. 18 week pathways All patients identified as starting a new 18 week pathway must have an 18 week pathway unique identifier created on MEDITECH. This is created when prompted to add an 18 week pathway on MEDITECH when registering a patient and/or adding a patient to the waiting list. Elective Admissions Only add patients to Waiting List when they have accepted Consultant advice for elective treatment. All elective patients must be listed for admission on MEDITECH within 1 working day of the Decision to Admit (DTA). Patients who subsequently become unfit or unable to accept an offered admission date due to personal/social reasons will have their clock adjusted. Patient Transfers When accepting the transfer of a patient from another Trust s waiting list, the DTA date used must be the date that the patient was added to the originating Trust s waiting list, not the date they were added to the WHHFT waiting list. Patient transfers will only be accepted with an inter-provider transfer form. Patients listed for Bilateral procedures or for more than one procedure Patients who require bilateral procedures will only be listed for the first side. Once the patient is fit, ready and able to have the second side done a new waiting list entry/clock start will be made. Private Patients If the patient is to be seen privately, the prioritiser or medical secretary must inform the appropriate booking office clerks to close the patient s episode off Hospital IT System. Where a patient has been seen privately, but needs to be listed for an NHS elective admission/appointment the patient must be treated in the same way as an NHS referral/request. For an outpatient appointment the referral/request source of referral will be recorded as PP. Page 13 of 44 Printed Copies may become out of date. Check online to ensure you have

14 HC(80)10 annex D and the DH Waiting Times website sets out guidance in relation to managing patients on to the NHS inpatient waiting list following private consultation. Reasonable Notice Outpatient Appointments: Patient attending outpatients will be offered two alternative dates with one weeks notice within the agreed local access time for the related specialty Diagnostic Appointments: Patients attending diagnostic tests will be offered two alternative dates with one weeks notice within the maximum waiting time of 6 weeks. Offers of Admission: Patients arranging their admission date will be offered two alternative dates with three weeks notice within the 18 week referral to treatment time. In the event that the patient cannot attend any of the dates offered, PAS will be updated to show the first of the offers as a deferment of the first appointment. The patient will then be offered a further appointment no more than two weeks from the second reasonable offer date but within the access time as specified above. If the patient is still unable to commit to an appointment after the three offers they will be returned to the care of their GP or referring clinician. Cancellations Patient Cancellations/Deferrals The principles and definitions of the 18 week target count the referral to treatment (RTT) waiting times in totality. The 18 week clock continues uninterrupted whilst the patient delays their treatment. However for diagnostics, patient deferrals and resets will be reflected and will adjust the diagnostic six week maximum waiting time. Outpatients: New patients will be allowed to cancel their appointment date where reasonable notification has been given to the Trust. Reasonable notification is defined as 48 hours prior to the date of attendance. However, by offering Patient Choice, patient cancellations should be minimised. Therefore, once a patient has accepted an offer that has been made within the definitions of reasonable notice, the patient will be given the opportunity to rearrange their appointment one further time. If the patient makes any further changes to their appointment they will be returned to the care of their GP or referring clinician. Admissions: If a patient wishes to rearrange their admission date or pre-assessment date, they will be given the opportunity to agree a new date at the time of the cancellation. If a patient wishes to rearrange their admission date a second time, they will be removed from the waiting list and referred back to their GP. If a patient is unsure as to whether they wish to proceed with surgery, the Admission Office will inform the patient s clinician for a decision to be made as to whether to discharge or review the patient in outpatients. If a patient wishes to be reinstated on the waiting list, a letter must be received from their GP within a 14 day period of removal from the waiting list. Following a referral letter being received by the Admissions Office, the patient will be reinstated on the waiting list and the clock reset Page 14 of 44 Printed Copies may become out of date. Check online to ensure you have

15 Diagnostics: Patients will be offered the next available diagnostic appointment. If the patient is unable to attend on this date they will be offered two alternative dates with at least one week s notice and within the maximum times (for diagnostics the National target is 6 weeks. In the event that the patient cannot attend on any of the offered dates PAS will be updated with the first and second reasonable offers. The patient will then be offered one further appointment within two weeks of the second reasonable offer date. within the overall 6 weeks target. If the patient is still unable to commit to an appointment, they will be returned to the care of their GP or referring clinician. The final offer will be recorded in PAS and a letter will be sent to their referring clinician advising of this action. This will stop the 18 week clock. Please note that the 18 week clock clock continues uninterrupted whilst the patient delays their diagnostic test. However, patient deferrals and resets will be reflected and adjust the maximum waiting time Hospital cancellations: No hospital imposed cancellations should occur at any stage of the pathway. As patients will only be offered appointments / admission within a three week window it is envisaged that all clinics / theatre sessions will be confirmed and appropriately staffed. In the event of sickness etc. divisions should attempt to cross cover clinics. Consultants and their clinical teams are required to provide at least six weeks notice before the date for commencement of the leave period, and submit the relevant form to the relevant Clinical Lead for approval. Where a patient s appointment/admission date is cancelled by the hospital with less than 6 weeks notice the patient will be offered an alternative date within 2 weeks ensuring that the appropriate waiting time target is not breached. Where a patient s admission date is cancelled by the hospital on the day the patient will be given the opportunity within 3 working days to agree an alternative date no later than 28 days from the cancellation date ensuring that the appropriate waiting time target is not breached. Re-instatement on the waiting list Patients who have been removed from the waiting list without being treated can be reinstated in exceptional circumstances. This may be if it is felt to be clinically appropriate to do so or if it is discovered there has been an administrative error. Patients who fail to attend (DNA) their pre-assessment or their admission will be reviewed by the Consultant or a member of the team, removed from the waiting list and returned to the care of their GP. The exception to this will be if there are compelling medical or social reasons why the patient should remain on the waiting list. The Trust will try to find a convenient date for patients who decline a reasonable offer of admission or who otherwise cancel an admission date so that they are treated as quickly as possible. Patients who decline more than one reasonable offer will be removed from the waiting list and returned to the care of their GP. Page 15 of 44 Printed Copies may become out of date. Check online to ensure you have

16 Patients who have been removed from the waiting list can be re-instated if it is in the best interests of their health for this to happen or if they have been removed inappropriately. Re-instatements for Clinical Reasons A patient may have been removed from the waiting list but now reinstatement is judged to be clinically appropriate. If a patient has been removed from the waiting list for reasons other than treatment and if the removal was as a result of following this policy and good practice guidance, reinstatement onto the waiting list will be a new episode of care. Patients who were removed as a result of a DNA or declining at least two reasonable offers of admission should not be re-instated using the original DTA date. However, it may not be necessary to ask the GP to re-refer by letter or for the patient to be seen in outpatients if their clinical circumstances have not changed within a 3 month period. In this case, patients will be put onto the waiting list as a new episode of care as the result of a telephone request. All circumstances should be recorded on the Hospital IT System to ensure a complete audit trail. Patients will only be re-instated as the result of a consultant decision. The consultant may also decide to take previous periods of waiting into account, change the patient s priority on the list and treat them earlier than other routine patients. Re-instatement following an Inappropriate Removal If the patient was removed from the waiting list and the removal was later found to be a mistake, then the patient must be re-instated without prejudice, as if he or she has never been removed. This is achieved by deleting the incorrect cancellation on the Hospital IT System. This maintains the original DTA date. No periods of suspension for the period that the patient was not on the waiting list must be entered. DNAs (Did not Attend) DNAs New Patients or Admissions for Treatment: Where a New urgent or routine priority patient has agreed an appointment date with reasonable notice and this has been clearly communicated to them (except for children where relevant legislation overrides this) and then subsequently does not attend (DNA) the patient will be referred back to the GP (or other referrer) and/or removed from the OP/IP/DC waiting list. Suspected cancer patients will be offered a second appointment/admission date. Should the patient subsequently DNA the second appointment/admission date the patient s case notes will be reviewed by the lead clinician and a decision on the further management of the patient will be made i.e. referred back to GP (or other referrer). Vulnerable Adults / Children where it is felt clinically appropriate to retain clinical responsibility, a further appointment is offered to the patient, the clock will continue from the date of referral. Routine follow-up/review and urgent or suspicious cancer patients who DNA appointments will be will be referred back to the GP (or other referrer). If however, Page 16 of 44 Printed Copies may become out of date. Check online to ensure you have

17 following review of case notes by the Consultant a further appointment is required the patient will be appointed via the partial booking process. Active Monitoring An 18 week clock maybe stopped when it is clinically appropriate to start a period of monitoring without clinical intervention or diagnostic procedures at this stage. If a patient who is being actively monitored decides within a 6 week period to proceed with their treatment, then a new 18 week clock would start. After a 6 month period they would need to be re referred into the consultant led service. Exceptions for removals from the waiting list Patients should not be removed from the waiting list if: They have declined two reasonable offers where previously they had an appointment/admission cancelled by the hospital or If the patient is clinically urgent or has a life threatening condition. Recording Clinical Outcomes ( Cashing-up ) All patient outcomes such as removals, admission/attendance, cancellations and DNAs should be recorded on Hospital IT System on the same day of the event. Following all outpatient attendances/dnas the clinic outcome form must be completed and returned to the appropriate reception and recorded on the Hospital IT System within 24 hours of the event. The reception clerks will produce a list of patients from the Hospital IT System without an outcome for the 18 week pathway 24 hours after the end of each clinic session. Secretaries and consultants are responsible for supplying the missing data within 2 working days of the clinic. Coding should indicate whether a clock has stopped or still ticking for the patients RTT. Treatment commencing and previously commenced is the clinician s decision. Clinic Template Changes Clinicians wishing to change templates must do so in conjunction with the Outpatients and Medical Records Service Manager and the Clinical Director for the Division. If a decision cannot be jointly made, the matter must be referred to the appropriate Associate Director of Operations/Exec Director. To avoid patients being inconvenienced a go-live commencement date for template changes must be agreed with the Senior Manager for Access, Booking & Choice. Retrieval of Medical Records Medical Records are an integral part of patient care and must be made available according to the agreed standards and targets outlined in the Medical Records Policy. Patient Correspondence Where a partial booking process is used an acknowledgement letter must be sent to the patient confirming that they have been placed on a waiting list and the expected waiting Page 17 of 44 Printed Copies may become out of date. Check online to ensure you have

18 time for an appointment/admission date. The letter must be sent within one working day of registration on to the Hospital IT System. As soon as a mutually agreed date has been arranged with the patient a confirmation letter must be sent to the patient. The letter is an audit trail of the arrangements and should contain the following core details: Patient s name Date letter sent to patient Date and time of admission/appointment agreed Where to report on arrival Response required from the patient Named contact for queries relating to admission/appointment Reference to instructions for admission/appointment and/or booklet Request to check bed is available on day of admission Reasons for checking bed availability Information about the planned treatment Any relevant patient Information must be sent or given to the patient prior to the admission/appointment date. Management Information Information for Hospital Management and Clinicians: Detailed information on hospital activity is available on the Trust s intranet system within the performance section and is updated monthly by the I M & T department. Waiting list pivot tables containing PTL information can be uploaded on to desktops of Trust staff on request for active monitoring. Information for Strategic Health Authority / Department of Health: Statistical information is submitted to the Department of Health to meet the statutory requirements as published in the data manual. QM08 returns may also be viewed in the performance section of Synapse. OUTPATIENT BOOKING AND SCHEDULING Introduction Since the implementation of the Choose and Book (CaB) appointment system, there are two processes in operation for managing referrals, i.e. electronic (CaB) and paper referrals. To accommodate these system changes, the policy will describe both processes. Choose and Book Choose and Book is the national electronic means for referring clinicians to refer a patient for their first outpatient appointment. The implementation of CaB is now mainstream within the Trust and is the preferred option for receiving referrals. Page 18 of 44 Printed Copies may become out of date. Check online to ensure you have

19 Referral Letters must be electronically attached to CaB by the referrer within 3 working days of the appointment request (decision to refer), where the appointment is more than 5 days in advance. Where the appointment is within less than 5 days then the referral must be attached within 24 hours. Accept and Reject Referrals all referrals must be accepted or rejected by the receiving clinical team within 1 working day. Referrals outstanding after 5 days will be automatically accepted by the Access, Booking & Choice team. Clinical teams will have a responsibility to review any patients booked into the wrong service whose referral was not accepted or rejected by the clinical team. Rejected Referrals - where a referral has been clearly referred into a clinically inappropriate service the referral must be rejected on CaB with a clear definitive reason and possible alternative action to be taken by the referrer. Redirection where a referral has been booked into a clinically inappropriate clinic within a service then the referral must be redirected in the appropriate clinic. Slot Availability it is the responsibility of the service management teams to ensure that there are sufficient slots available on CaB to ensure patients have reasonable choice of dates and times within the agreed national/local waiting times. Service Management teams must utilise the Future Slot Utilisation report on CaB to monitor slot availability and forward plan for any identified capacity constraints. The Access, Booking & Choice team will also alert service management teams when there are risks to slot availability. Polling Range - the maximum Polling ranges for slot availability on Choose & Book will managed by the CaB Manager with the agreement of the service management team in line with national/local guidelines on waiting times. Directory of Services (DOS) - the CaB Manager will manage the Trust s DoS on CaB. The group clinical directors will be responsible for reviewing and signing off the DoS on annual basis or when a service changes. The DoS must provide a clear description of the service and the clinics provided. Paper/Other referrals letters These include non-choose and book GP referrals, tertiary referrals, internal consultant to consultant referrals, external consultant to consultant referrals. All paper referrals must be processed within the following policy guidance in order to avoid patients being disadvantaged or delayed in accessing appointments. Receipt & Registration of Paper Referrals: All paper referrals must be sent directly to the appointments department at WHHFT.. Referrals received directly by a service or consultant must be date stamped and sent to the Appointments Department at WHHFT immediately (hand delivered to avoid delay). Registration of tertiary referrals : When registering a tertiary referral the name of the referring specialty and hospital must be recorded in the Referral Comments field on Hospital IT System. Page 19 of 44 Printed Copies may become out of date. Check online to ensure you have

20 Arranging a 1st Outpatient Appointments for Paper Referrals: Paper referrals will be processed in line with choose and book in order to that patients have fair and equitable access to services. Patients will be contacted and offered a provisional appointment prior to the referral being reviewed by the clinical team. Accepting and rejecting paper referrals: The same principles outlined for electronic CaB referral apply to paper referrals other than the outcome of the review of the referral will be manually recorded on the referral and returned directly to the Appointments Team within 2 working days for an Urgent or 5 working days for a routine. Follow-up Appointments Patients requiring follow up appointments within eight weeks should be offered a mutually agreed appointment time at hospital attendance using the Clinic Outcome Form. This must be recorded on the Hospital IT System as follow-up booked in clinic and will be counted as a fully booked appointment. Patients will also have the option to leave their Clinic Outcome Form with a receptionist or deposit it within the designated box within Main OPD. The patient will be contacted nearer the due date to agree a date and time for their follow-up. Diagnostic Intervention Follow-up Directorates will need to put in place full booking for all diagnostic interventions, coordinated with the relevant clinical follow up. Overbooking of Clinic Templates Overbooking of clinic templates is only permitted following authorisation from the outpatient clinic consultant and/or his/her medical secretary. Requests must be documented and retained for verification, if required. Templates will be booked according to their set up. A clinic will not be deemed overbooked if there are slots available for other booking types on other templates. New to Review Ratios The Information Department will provide clinical teams with regular information on ratios. Directorates should regularly review their follow-up ratios in comparison with regional and national norms and ensure that internal policies are reviewed to ensure optimum use of outpatient capacity. Private Utilisation of OPD The Outpatient department is available for private use pending room availability. Please refer to the Chargeable Patients Officer for further details relating to costs. Applications should be made to the Chargeable Patients Officer requesting the clinic room requirements. Any extra support such as a nurse needs to be arranged separately with the appropriate lead nurse. The consultant will be invoiced after the clinic has taken place. Page 20 of 44 Printed Copies may become out of date. Check online to ensure you have

21 INPATIENT/DAYCASE WAITING LISTS Introduction The administration and management of Inpatient/Daycase waiting lists must be consistent, easily understood, patient focused and responsive to clinical decision making. If patients who are waiting for treatment are to be managed effectively it is essential for everyone involved to have a clear understanding of their roles and responsibilities. Selecting patients for admission The process of selecting patients for admission and subsequent treatment is a complex activity. It entails balancing the needs and priorities of the patient and Commissioners against the available resources of theatre time and staffed beds. To ensure that the Trust meets the targets for offering patient choice of admission date, booking systems will adopt best practice offering partial or fully booked dates. The following key principles apply: Patients will be treated in a timely and effective manner Clinically urgent patients will be treated as a priority and within the shortest waiting times possible Non-clinically urgent patients (routine) will be treated in turn based on their length of time on the waiting lists if no other factors need consideration All patients will be treated within locally and nationally agreed maximum waiting times targets Primary Targeting Lists (PTL) methodology will be used to facilitate equity for nonclinically urgent patients but this will also assist the organisation from creating small numbers of long waiting patients and potentially breaching the maximum waiting times target. The only exceptions are booked patients. These patients will have agreed their admission date within 1 working day of the decision to add to the waiting list but booked patients must be given a date that is commensurate with this principle. Categorising Patients on the Waiting List Patients will be added to one of three waiting list types: Active Waiting List: Patients who are fit, ready and able to come for treatment Suspended Waiting/Patients with a clock pause (not applicable to outpatients/radiology): Patients on the Active List who are not ready for admission for social reasons For further explanation please See Appendix 3 Standard Operating Procedure for managing patients on a suspended waiting list. Page 21 of 44 Printed Copies may become out of date. Check online to ensure you have

22 Planned Waiting List : Planned waiting list patients are those who are waiting to be recalled to hospital for a further stage in their course of treatment or surgical intervention. These patients are not waiting for treatment, only for planned continuation of treatment. There has to be a clinical reason as to why a patient cannot have the procedure undertaken earlier for them to be added to the planned waiting list. Examples include: Check endoscopic procedures Age/growth related surgery Series of pain relieving injections Planned patients must be allocated time in operating sessions and offered an admission date, either as an inpatient or day case. They should be recorded on a separate planned waiting list to ensure they are not overlooked for admission. The planned list must be checked monthly and patients due in the following month should be booked onto Meditech and sent a TCI letter. The waiting list supervisors will confirm via to the Waiting List Manager and Assistant General Manager that all patients have been allocated an appointment within their planned month. It is the responsibility of the waiting list staff to ensure planned patients are allocated an admission date within the planned month of treatment. Please see Appendix 4 Standard Operating Procedure for managing patients on a planned waiting list in Related Policy s and Local Procedures section Waiting list Management Adding Patients to Waiting Lists for Admission: All patients must be listed for admission on MEDITECH on the day the Decision to Admit (DTA) was made. A patient will only be placed on a waiting list if there is a sound clinical indication for surgery and the patient is clinically and socially ready to undergo surgery within the 18 week pathway. Patients who subsequently become unfit or unable to accept an offered admission date due to personal/social reasons will have their clock adjusted as per below. If a patient is either unfit or unready for surgery they will be returned to the care of their GP to be re-referred when they are fit and ready within the 18 week path or referred for further advice or management in secondary care if appropriate. The patient will be reviewed again in outpatients when the wait list decision can be made If the patient is unable to accept the offer of admission they will be asked to contact the Trust again within two weeks of their decision to proceed so that they can be added to the waiting list from their original date of listing Page 22 of 44 Printed Copies may become out of date. Check online to ensure you have

23 Clock Pauses: A clock may be paused only where a decision to admit has been made, and the patient has declined at least 2 reasonable appointment offers for admission. The clock is paused for the duration of time between the earliest reasonable offer and the date from which the patient makes themselves available again for admission. A clock can only be paused for a maximum of 3 months. If a patient is unavailable for admission from the point at which the decision to admit is made, then this may mean that offering actual dates which meet the reasonable criteria would be inappropriate. In these circumstances, the clock should be paused from the earliest reasonable offer date that we would have been able to offer the patient. Unfit for Surgery: Patients who will not be clinically fit for treatment will be discharged back to their GP. If deemed clinically fit by the GP within 3 months of the discharge, the GP can contact the hospital and the patient, following pre-op assessment, will be offered a further appointment. If the patient becomes clinically fit after 3 months of discharge and still requires the intervention then the patient will be asked to see his GP to be re referred for a new clinical assessment. If the patient is unfit e.g. has a cold or other minor illness, or needs echo or anaesthetic review at preoperative assessment. The clock continues to run and the patient is brought back or contacted with a maximum of 4 weeks. Decision to Admit Date (DTA): The DTA date for patients on an existing 18 week pathway to be recorded on MEDITECH is the date DTA was made and the waiting list entry must be linked to the appropriate 18 week pathway on MEDITECH. For patients not on an 18 week pathway the DTA date is the date the DTA was made. Pre-op Assessment Service Pre-op assessment minimises the risk of late cancellations by ensuring that the patient is as fit as possible for surgery and anaesthetic and that the patient wishes to undergo the procedure. It is therefore essential that the Pre-Op Assessment procedure is followed by all staff. If a patient DNAs their pre-assessment appointment their surgery date will be cancelled and the patient removed from the waiting list. The GP and patient will be notified. If at pre-assessment the decision is made to defer surgery due to the patient not being fit, then the surgery will be cancelled and the patient will be removed from the waiting list until deemed fit for surgery. Patient Transfers Transfers to other Hospitals/Consultants: The Trust s resources must be used efficiently to ensure the maximum number of patients is treated within the resources available. Page 23 of 44 Printed Copies may become out of date. Check online to ensure you have

24 The Trust and its Consultants will work in partnership to create additional capacity to treat patients from its waiting lists. This may involve working with other NHS Trusts and independent providers. This will help ensure shorter waiting times for treatment. Transfer between Waiting Lists within the Trust: This may be appropriate where the patient has been added to a waiting list for a specific procedure, and it is subsequently possible to treat the patient sooner or more effectively in an alternative manner, e.g. as a day case instead of inpatient. If transferring the patient from an inpatient to a day case list the intended management code needs to be altered within MEDITECH. Transfer of patients between the 2 hospital sites within the Trust does not require the agreement of the patient or their GP. If a transfer will result in treatment by a different consultant, the patient has the right to refuse the transfer. If the patient refuses to be transferred to the care of a different consultant, their waiting time should not be affected. The decision to admit details must be transferred to the new waiting list code in MEDITECH. Treatment at Private or Independent Hospitals under WHHFT contract: Patients may be offered the opportunity for treatment at a private or independent hospital to shorten their waiting time. These patients are identified by Consultant/Service/Lead Manager. It is important that the patients remain on WHHFT s waiting list until they have been accepted by the new provider. The transfer must always be with the consent of the patient, their GP and the transferring consultant. The patient has the right to refuse transfer, and remain on the Trust s waiting lists with no change in status. Service/Lead Managers must ensure that patients are pre-admitted on MEDITECH prior to the admission date and ensure the patients are admitted and discharged on MEDITECH within 24 hours of the patient discharge. If a patient DNA s they are removed from the waiting list and not offered a further date. They are referred back to the CCG and/or GP. DIAGNOSTIC (NON ENDOSCOPY) WAITING LIST Introduction The administration and management of waiting lists must be consistent, easily understood, patient focused and responsive to clinical decision making. Diagnostic tests are recorded on more than one computer system (MEDITECH, RIS and specialty-specific databases) which complicates the monitoring of such patients waiting. In addition, diagnostic tests are performed as both inpatients and outpatients so both sections 3.0 Page 24 of 44 Printed Copies may become out of date. Check online to ensure you have

25 and 4.0 of the Patient Access Policy should be referred to for further guidance, as well as the key policy principles outlined in section 2.0. Diagnostic Procedures Imaging - Magnetic Resonance Imaging Imaging - Computer Tomography Imaging - Non-obstetric ultrasound Imaging - Barium Enema Imaging - DEXA Scan Physiological Measurement - Audiology - pure tone audiometry Physiological Measurement - Cardiology - echocardiography Physiological Measurement - Cardiology - electrophysiology Physiological Measurement - Neurophysiology - peripheral neurophysiology Physiological Measurement - Respiratory physiology - sleep studies Physiological Measurement - Urodynamics - pressures & flows Imaging Referrals Referrals will only be accepted by electronic requisition or imaging request cards The Imaging Department will be responsible for communicating appointment arrangements to the patient. Requests will be processed in the imaging department on the date of receipt. The date that the request is received into the department will be logged as the referral date. Referral Protocols - Where referral protocols exist, Consultants and GPs must use these to ensure the appropriateness of their request. If the radiologist feels the referral does not match the protocol of the test the request card will be returned to the referrer for further information. Data Definitions Diagnostic waiting list - All tests/procedures for which patients are waiting. irrespective of the referral route, (i.e. whether the patient was referred by a GP or by a hospital-based clinician or other route) and also irrespective of the setting in which they are carried out (e.g. inpatient ward, x-ray department, outpatient clinic etc.). Planned tests/procedures (surveillance) - A procedure or series of procedures carried out as part of a treatment plan which are required for clinical reasons to be carried out at a specific time or repeated at a specific frequency. Examples include: 6 month check cystoscopy regular blood tests Unscheduled tests/procedures - Diagnostic tests or procedures carried out on patients following an emergency admission, (as well as any diagnostic tests/procedures on Page 25 of 44 Printed Copies may become out of date. Check online to ensure you have

26 patients in A&E). If not carried out immediately, these should be added to the active waiting list. Booking system Directorates will need to put in place full booking for all diagnostic interventions. This will not include angiography/biopsy referrals which will be addressed via a separate pathway. Potential Breeches In the case of a potential AED, outpatient, inpatient, diagnostic, cancer or 18 week breach, a period of validation may be require to determine whether there is legitimate breach or not. LAUNCH PLAN / POLICY IMPLEMENTATION As the Patient Access Policy replaces a number of existing Policies, the majority of the practices described are already implemented. It is the responsibility of the Medical Records and OP team to deliver regular update training sessions to and Corporate staff. This should encompass staff, clinical and non-clinical who are responsible for patient access. Key Staff Groups The following staff are responsible for ensuring that an effective Trust-wide training schedule exists under the supervision of the Medical Records and OP management team: IT Department Managers Senior Managers/Lead Managers Lead Nurses Consultants AHP Managers (including Pharmacy, Psychology) Training and Development will display details of training sessions, which may form part of the Trust s Mandatory Training Programme Medical Records and OP managers are responsible for providing: regular training/update sessions Updates to the Patient Access Policy Senior Managers are responsible for Nomination of staff to attend training/update sessions. Requesting additional training sessions for significant numbers of staff, when attendance at the planned sessions is clinically difficult Page 26 of 44 Printed Copies may become out of date. Check online to ensure you have

27 Ensure that clinical staff receive update training on patient access standards/targets from their own professional group Medical Staff are responsible for Ensuring that they are aware of the key issues relating to Patient Access Policy, including Observing the guidance given in this policy Attending pre-arranged Awareness Sessions, including the Junior Doctors induction, or requesting specific dates for sessions from the Managers Ensuring that junior medical staff are aware of their responsibilities via the above mechanism Training/Update Sessions A workshop will be scheduled for the implementation of Patient Access Policy where the service operational management teams will attend and develop a training/communication plan. Service operational management teams will be responsible for the development of local operational procedures and training of staff to ensure the implementation of Patient Access Policy is adhered to. Updates to the Patient Access Policy will be communicated/discussed at the weekly Key Performance Indicator Meeting and monthly via the meetings. Patient Access Procedures The Patient Access Policy will be available on the Policy Database on the Trust Intranet. Hard copies are available from the appropriate Senior Manager. REVIEW AND MONITORING Policy Reviews The Policy will be reviewed on an annual basis. In addition the Policy may be amended as required to take account of changes to national targets. Effectiveness Reviews Monitoring and review of the effectiveness of the Policy will be carried out at the Outpatient/Diagnostic/Inpatient PTL performance meetings. These groups report to the KPI Group, which subsequently reports into the Trust Board. Monitoring Achievement of Standards in the Patient Access Policy Page 27 of 44 Printed Copies may become out of date. Check online to ensure you have

28 The aim of the Patient Access Policy is to improve access to services for patients. It is essential that performance against the standards within the policy are monitored and improved upon to protect patients access to the Trust s services. The monitoring of internal systems, rather than purely monitoring data outputs of the systems (e.g. spells, attendances etc), is an integral part of the Trust s plans to modernise its services and reduce waiting times. Teams will be responsible for looking at the information and deciding appropriate action. The Access, Booking & Choice Team, Data Quality Manager and Clinical Systems Trainers will be instrumental in working with Trust staff to implement changes to practice. The standards to be achieved, the department responsible for collecting the information and the frequency of the collection are outlined in the table overleaf. MONITORING OF THE DOCUMENTED PROCESS PATIENT ACCESS POLICY NHSLA /CQC Minimum requirement s Process for monitoring e.g. audit All patients will be added to the waiting list within 1 working day of the decision to admit/refer Waiting lists are validated regularly included planned and suspended waiting lists. The waiting list will not include patients who have declined 2 or more reasonable offers of admission/app ointment Responsible individual/ group/committe e Waiting List Teams Waiting List Managers Waiting List Manager Frequency of monitoring At least Monthly At least Monthly At least Monthly Responsible individual/gr oup/ committee for review of results Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Responsibl e individual/g roup/ committee for developme nt of action plan Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Responsible individual/gro up/ committee for monitoring action plan and implementatio n Clinical Quality Contract Meeting Clinical Quality Contract Meeting Clinical Quality Contract Meeting Page 28 of 44 Printed Copies may become out of date. Check online to ensure you have

29 NHSLA /CQC Minimum requirement s Process for monitoring e.g. audit All patients will be contacted/see n preoperatively to assess fitness for procedure Patients listed for a procedure identified as one of the basket of daycase treatments will be added to the waiting list & treated as day-cases unless there is a clinical reason Patients who DNA under the DNA policy will be removed from the waiting list. Number of patients cancelled on the day of admission/ope ration for nonclinical reasons will not exceed the agreed target. Written and telephone contact with patients will be recorded on MEDITECH Hospital initiated Responsible individual/ group/committe e Assistant General Managers Assistant General Managers Waiting List Managers Assistant General Manager/ Waiting List Manager Information Department Theatre Information Frequency of monitoring At Least Quarterly At least Monthly At least Monthly At least Monthly At Least Quarterly At least Monthly Responsible individual/gr oup/ committee for review of results Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Integrated Responsibl e individual/g roup/ committee for developme nt of action plan Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Integrated Responsible individual/gro up/ committee for monitoring action plan and implementatio n Clinical Quality Contract Meeting Clinical Quality Contract Meeting Clinical Quality Contract Meeting Clinical Quality Contract Meeting Clinical Quality Contract Meeting Clinical Quality Contract Page 29 of 44 Printed Copies may become out of date. Check online to ensure you have

30 NHSLA /CQC Minimum requirement s Process for monitoring e.g. audit inpatient/dayc ase cancellations will be reported to the Business Support and Waiting List Manager on a daily basis Responsible individual/ group/committe e Manager Frequency of monitoring Responsible individual/gr oup/ committee for review of results Governance Group s Responsibl e individual/g roup/ committee for developme nt of action plan Governance Group s Responsible individual/gro up/ committee for monitoring action plan and implementatio n Meeting Patients will only be reinstated onto the waiting list in exceptional circumstances Patients who are transferred to other providers for treatment will be transferred as per this Policy Teams Teams At least Monthly At Least Quarterly Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Integrated Governance Group s Clinical Quality Contract Meeting Clinical Quality Contract Meeting SOURCES/ REFERENCES Choice at Referral Guidance Framework st May 2007, DOH DH_ East Kent Hospitals NHS Trust, 18 weeks Principles, Access Policy Overview June 2007 Salford Royal NHS Trust, Patient Access Policy DOH Updated 18 Clock rules (Gateway 6468) DSCN Notice 09/2007 Earliest Reasonable Offer Date DSCN Notice 07/2003 Reasonable Notice to Patients DOH 18 Weeks - Defining Success presentation August 2007 (Source: Martin Clayton, NHS Northwest) Annex A Principles and Definitions Tackling Hospital Waiting: the 18 week Patient Pathway- an Implementation Framework 10 May 2006 HC (80)10 annex D and DH Waiting Times website Department of Health Page 30 of 44 Printed Copies may become out of date. Check online to ensure you have

31 GLOSSARY OF TERMS DEFINITIONS/ABBREVIATIONS For the purposes of the policy, the following terms have the meanings given below: Active Waiting List Computerised Tomography (CT) Could Not Attend (CNA) Choose and Book Day Cases (DC) Department of Health (DOH) Did Not Attend (DNA) Dual Energy X-ray Absortionometry (DEXA) Patients awaiting elective admission for treatment and are currently available to be called for admission. A CT scan (computerised tomography) also known as CAT scan (computed axial tomography) is a specialised x-ray test that gives clear pictures of the inside of the body. In particular, it can give good pictures of 'soft' tissues of the body which do not show on ordinary x-ray pictures. Patients who notify the hospital that they are unable to attend a previously agreed appointment. Electronic system by which GPs can refer patients directly to a service and can either book the appointment with the patient or the patient can book at their own convenience via Health space on the Internet or the National Telephone appointment line. 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 over night. The Department of Health works to improve the quality and convenience of care provided by the NHS and social services. 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. A DEXA scan is used to measure the density of bones. It is mainly used to diagnose and assess osteoporosis ('thinning of the bones'). Elective Admissions Fully Booking 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. Patients awaiting an elective admission/appointment who have been given an opportunity to agree an appointment/admission date with 24 hours of the decision to refer/admit. These patients form part of the active waiting list. This process should also be used where the waiting time is Page 31 of 44 Printed Copies may become out of date. Check online to ensure you have

32 Hospital Initiated Cancellation Independent Booking Service (IBS) Individual Treatment Plan Inpatients (IP) Magnetic Resonance Imaging (MRI) MEDITECH NCEOPD Outpatients (OP) Partial Booking Primary Targeting List Planned Admissions Positron Emission Tomography (PET) Clinical Commissioning Group (CCG) less than 6 weeks. A cancellation of admission by the hospital A telephone appointments service that makes the link between the referral sent using the Choose and Book system but there is no IT interface with the provider units booking system. A plan prepared with patients who are on suspension to ensure that they are treated to meet the maximum waiting time. Patients who require admission to the hospital for treatment and are intended to remain in hospital for at least one night. MRI scan is a safe and painless test which can provide detailed pictures from within your body. The computer system used by the Trust to record patient transactions. National Confidential Enquiry into Patient Outcome & Death Patients referred by a general practitioner or another clinical professional i.e. another Consultant/Dental Practitioner for clinical advice or treatment not requiring admission Where the waiting time is greater than 6 weeks for an admission/appointment the patients will be placed on the appropriate Consultant waiting list. A letter of acknowledgement of the referral is sent to the patient with an indication of the length of wait. An appointment will be agreed with the patient a minimum of 3 weeks in advance of the expected due date. A list of all patients whose treatment needs to be planned to meet target wait times 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. PET (positron emission tomography) is a type of scan that can show how body tissues are working and not just what they look like. Organisations responsible for primary care services and commissioning of acute services. Suspended Waiting List A list of patients awaiting elective admission who are currently unsuitable for admission due to some underlying medical or social reason. Page 32 of 44 Printed Copies may become out of date. Check online to ensure you have

33 TCI To Come In, the date of a patient s admission to hospital Ultrasound (U/S) An ultrasound scan is a safe and painless test which uses sound waves to create images of organs and structures inside the body ABBREVIATIONS AWLE CaB DA DNA DOL DTA DTL GDP GP PTLs TCI Add/Amend Waiting List Entry Choose and Book Date Agreed Did Not Attend Date on List Decision to Admit Decision to List General Dental Practitioner General Practitioner Primary Targeting List To Come In Page 33 of 44 Printed Copies may become out of date. Check online to ensure you have

34 ASSOCIATED DOCUMENTS Prior Approval Scheme 04 Sec B, Part service specs_plcp_v0.3.doc Page 34 of 44 Printed Copies may become out of date. Check online to ensure you have

35 APPENDIX 1 KEY PERFORMANCE TARGETS Subject National and Local Target week referral to treatment target DH requirement for any specialty (clause 43.4) Monitor Trust level achievement 2. Diagnostic waiting times maximum stage of treatment wait. 3. Direct access audiology treatment Percentage of patients seen within 18 weeks in respect of Consultant-led Services to which the 18 Weeks Referral-To- Treatment Standard applies Percentage of diagnostic waits > 6 weeks Percentage of patients seen within 18 weeks for direct access audiology treatment 4. Cancer targets Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer Percentage of patients receiving first definitive treatment within one month of a cancer diagnosis Proportion of patients waiting no more than 31 days for second or subsequent cancer treatment - surgery Proportion of patients waiting no more than 31 days for second or subsequent cancer treatment - drug Threshold For admitted 90% and over for the year And For non-admitted 95% and over for the year Operating standard of 99% for the year Operating standard of 95% for the year Operating standard of 93% for the year Operating standard of 96% for the year Operating standard of 94% for the year Operating standard of 98% for the year Flexible specialty specific internal targets are in place for all new outpatient appointments A maximum wait of 6 weeks for all diagnostic waits. The GP is required to approve and down grading of a patient referred on the CFT pathway Page 35 of 44 Printed Copies may become out of date. Check online to ensure you have

36 Subject National and Local Target treatments Proportion of patients receiving first definitive treatment for cancer within 62 days of - an urgent GP referral for suspected cancer - referral from an NHS Cancer Screening Service - following a consultant s decision to upgrade the Patient priority Threshold Operating standard of 85% for the year Operating standard of 90% for the year Operating standard of 90% for the year A clinician will be able to upgrade non-gp referrals to a 62 day pathway where appropriate Internal referrals will also be subject to the 62 day target. 5. Hospital cancellations after admission for nonclinical reasons Within 5 calendar days offer the patient a new date falling within 28 calendar days of the original treatment date or fund treatment at a date and time of the service users choice. Within an annual threshold of 95% Trust internal target to offer the patient a new appointment within 3 working days 6 Consultant to Consultant referrals Ensuring all referrals relate to permitted treatments. 7. Choice of date and time elective inpatients and day case and outpatient booking 100% of patients attending as a day case or inpatient must be booked with a choice of date 100% of referred patients attending as a new outpatient must be booked with choice of date and time 8. Reasonable notice period An offer for admission for treatment is considered reasonable when it is for a date with at least 3 weeks notice from the offer Page 36 of 44 Printed Copies may become out of date. Check online to ensure you have

37 Subject National and Local Target date. Threshold In agreement in NHS Warrington, reasonable notice has been defined for outpatients and diagnostics, including day cases, as one week from the date of the offer. Page 37 of 44 Printed Copies may become out of date. Check online to ensure you have

38 APPENDIX 2 SOP FOR MANAGING PATIENTS ON A SUSPENDED WAITING LIST \\nch\dfs\userdata\ collaw\mydocs\suspended Waiting List SOP.doc Page 38 of 44 Printed Copies may become out of date. Check online to ensure you have

39 APPENDIX 3 SOP FOR MANAGING PATIENTS ON A PLANNED WAITING LIST \\nch\dfs\userdata\ collaw\mydocs\planned List SOP.doc Page 39 of 44 Printed Copies may become out of date. Check online to ensure you have

40 APPENDIX 4 PROTOCOL FOR REFERRALS FROM OUTPATIENTS CLINICS TO OTHER SPECIALTIES / TRUSTS There will be no referrals from Outpatient Clinics to other consultant specialties or other Trusts except in the limited circumstances below. IF IN DOUBT PLEASE CONTACT THE PATIENT S GP BY TELEPHONE 2. Permitted Referrals The following exclusion criteria should be applied to consultant / specialty or referral into other Trusts. 1. Where the referral is within the remit of the original referral. 2. Cancer / Suspected Cancer. 3. Life threatening / clinically urgent conditions. 4. When a patient specifically asks that a diagnosis is not shared with their GP. 5. Pre-operative assessments. 6. From Accident and Emergency to clinics which will avoid admission, enable rapid assessment and / or treatment when the patient s condition meets criteria 2 or 3 noted above. 7. Pregnant Women for complications arising during pregnancy which meet either criteria 2 or 3 noted above. 8. Referrals into externally funded clinical studies. 3. Making a Permitted Referral 1. Ensure the consultant with the responsibility for the care of the patient agrees that the referral is required ie ensure that there is a consultant approval for the referral. 2. Discuss the referral with the patient. 3. Ensure that the patient s GP receives a letter informing them of the new referral explaining the reasons for the referral in setting out the expectations of the referral. 4. Ensure that the patient is seen by a Senior Registrar or above at the first appointment for the new referral. 4. Referrals back to the GP Following identification of another condition outside the remit of the original referral: 1. Discuss the findings with the patient. 2. Ensure the GP receives a letter describing the new condition identified and asking the GP to consider the management of this condition. PLEASE DO NOT RAISE PATIENT EXPECTATIONS THAT A NEW REFERRAL WILL BE MADE. FOR THE PATIENTS WHO FALL OUTSIDE THE PERMITTED CRITERIA FUTURE MANAGEMENT OF THE PATIENT IS THE RESPONSIBILITY OF THE PATIENT S GP. 5. Review GP Practices and NHS Warrington will monitor and feedback on the compliance with this protocol. IF IN DOUBT PLEASE CONTACT THE PATIENT S GP BY TELEPHONE. Page 40 of 44 Printed Copies may become out of date. Check online to ensure you have

41 Page 41 of 44 Printed Copies may become out of date. Check online to ensure you have

42 APPENDIX 5 REFERRALS FROM OTHER NHS ORGANISATIONS OUTSIDE OF ENGLAND IPC Funding Request.doc prior authorisation letter ncea all trustsboards doc List of Non-England Organisations: Wales Abertawe Bro Morgannwg University LHB - covers Swansea, Neath, Port Talbot and Bridgend Aneurin Bevan LHB - covers Gwent Betsi Cadwaladr University LHB - covers north Wales Cardiff and Vale University LHB - covers Cardiff and the Vale of Glamorgan Cwm Taff LHB - covers Rhondda Cynon Taff and Merthyr Tydfil Hywel Dda LHB - covers Ceredigion, Carmarthenshire and Pembrokeshire Powys Teaching LHB - covers Powys Scotland NHS Ayrshire and Arran NHS Borders NHS Dumfries and Galloway NHS Fife NHS Forth Valley NHS Grampian NHS Greater Glasgow and Clyde NHS Highland NHS Lanarkshire NHS Lothian NHS Orkney NHS Shetland NHS Tayside NHS Western Isles Northern Ireland Health and Social Care Board The Health and Social Care Board (HSCB) is the organisation within the health service in Northern Ireland that is responsible for assessing the needs of their local population, commissioning services to meet those needs and monitoring the performance of services. Page 42 of 44 Printed Copies may become out of date. Check online to ensure you have

43 EQUALITY IMPACT ASSESSMENT To be completed and attached to any policy or procedural document when submitted to the appropriate committee for consideration and approval. 1 Does the policy/guidance affect one group less or more favourably than another on the basis of: Yes/No Comments Physical Disability NO Learning Difficulties/Disability or Cognitive NO Impairment Mental Health NO Race NO Carer NO Nationality NO Ethnic origins (including gypsies and NO travellers) Culture NO Religion or belief NO Gender (Male, Female and Transsexual) NO Sexual orientation including lesbian, gay NO and bisexual people Age NO 2 Is there any evidence that some groups are affected differently? 3 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4 Is the impact of the policy/guidance likely to be negative? NO N/A NO 5 If so can the impact be avoided? N/A 6 What alternatives are there to achieving the N/A policy/guidance without the impact? 7 Can we reduce the impact by taking different action? N/A Page 43 of 44 Printed Copies may become out of date. Check online to ensure you have

44 Item DOCUMENT INFORMATION BOX (COMPLETED BY AUTHORISED DIVISIONAL/CORPORATE SERVICE LIBRARIAN) Type of Document Title Value Policy Published Version Number Version 5 Patient Access Policy Publication Date September 2013 Review Date September 2016 Author s Name + Job Title CQC Standard Measure Outcome 4, 6 & 15 NHSLA General Standard Standard 1 NHSLA Maternity Standard Consultation Body/ Person Gordon Robinson, OPD & MR Service Manager N/A Key Performance Indicators Meeting & Warrington CCG Consultation Date October 2012/2013 Approval Body Approval Date September 2013 Ratified by (insert the name of the subcommittees to Governance Committee) on behalf of Board of Directors or for Integrated Governance Boards for local procedural documents Governance Committee due to no trust subcommittee relevant for this policy Governance Committee Ratification Date September 2013 Author Contact 5116 Librarian Division Specialty (if local procedural document) Ward/Department (if local procedural document) Readership (Clinical Staff, all staff) Information Governance Class (Restricted or unrestricted) OPD & MR Service Manager WC&SS All Trust staff, Clinical Commissioning Groups, General Practitioners and Patients Unrestricted Page 44 of 44 Printed Copies may become out of date. Check online to ensure you have