The CQC have identified the following Must do s and Should do s in relation to outpatient services:

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1 Report to: Council of Governors Meeting Date: 18 th November 2015 Subject: Outpatient Programme Board Update Author: Rob Walker, Interim Deputy Chief Operating Officer 1. Introduction This paper provides a general update to Governors on the work of the Outpatient Programme Board to improve the patient and staff experience of our outpatient services together with improved productivity and efficiency. The paper also provides an update on the management of specific incidents relating to the administration and management of outpatient services. 2. Background The CQC have identified the following Must do s and Should do s in relation to outpatient services: Must do s KMH & Newark - Ensure systems and processes are effective in identifying where quality and safety are being compromised and in responding appropriately and without delay. Specifically, systems and processes to identify and respond to outpatient appointment issues. KMH - Ensure any remedial actions taken to address outpatient appointment issues are regularly audited to give assurance improvement has taken place. KMH & Newark - Ensure robust and effective governance links and oversight are established and maintainted between outpatient services at Newark and Kings Mill Hospitals. Should do s KMH & Newark - Ensure patient records are available when patients attend outpatient and diagnostic imaging clinic appointments. KMH - Ensure systems and processes are operated effectively to minimise delays for patients in outpatient clinics. KMH - Ensure that the paediatric allergy clinic meets the 18 week referral to treatment target The Trust also has a Section 29A warning notice in force, which is provided for under the Health and Social care Act 2008 that requires improvement in the provision of outpatient services. Page 1 of 8

2 Previous reports to the Council of Governors have highlighted how historical custom and practice in the management of outpatient waiting lists and administrative processes combined with the migration of the Patient Administration System (PAS) from the McKesson system to the Medway system and the reconfiguration of administrative services led to a deterioration in the outpatient service causing a number of issues. Two major issues in particular were identified in February 2015: Patients that had not had their outpatient attendance confirmed (reconciled) and the outcome of these patients had not been satisfactorily recorded in the electronic system. A growing number of patients that were overdue their follow-up appointment. In response, a dedicated task force was put in place in March 2015 to investigate and address these issues. Progress was reported at the last CoG meeting in August 15 and a further update is provided later in this report. In addition to these, two other significant issues have arisen that are being subjected to the same level of scrutiny: Patients that are referred in on the e-referral system, formally Choose & Book, could not be offered an appointment due to insufficient outpatient capacity and were waiting for excessing periods of time. Patients that have their appointment cancelled have been managed on a separate cancellations waiting list, but this process did not provide visibility of the original date the patient was required to be seen. This presents a risk that patients could DNA or be cancelled multiple times and become very overdue without this being noticed. The Outpatient Programme Board was established in June 2015 to provide strategic oversight and direction to outpatient improvement work and this committee is now driving the service forward. Its overriding purpose is to deliver a significant and sustainable improvement in the experience of patients accessing outpatient services. This will also have the further benefits of improving the efficiency of the outpatient service to increase productivity and financial performance. 3. Update on Outpatient Issues / Incidents 3.1 Unreconciled outpatient appointments In February 2015 the Trust identified that almost 10,000 patients did not have the outcome of their outpatient adequately reconciled. This was subject to a detailed investigation, which was summarised in the report to the CoG in August It was concluded that no patient had come to harm as a result Page 2 of 8

3 of this. A full investigation report has now been through the Trust governance committee processes and signed off. The number of unreconciled appointments now stands at around 1,400 patients, but it should be noted that this is a transient population. All appointments are currently being reconciled within 15 days of the appointment and there is a plan in place to reduce this to 10 days by the end of December An upgrade to the Saviance e-check in system that is used in the clinics is currently being piloted in Clinic 6 at KMH. This presents the opportunity to realise real-time electronic reconciliation by the clinician as they see each patient. The pilot has so far been hampered by a number of technical issues. This has been escalated to the highest level with the supplier and we anticipate rapid resolution. By mid-december we anticipate being able to evaluate the benefits to decide whether to roll it out further. 3.2 Overdue follow-up appointments Also reported last time, it was identified in February 2015 that approximately 8,400 patients were overdue their follow-up appointment. This has been thoroughly investigated and a full investigation report completed. No patient was found to have come to harm as a result of this. The total number of patients overdue their follow-up has been reduced to 2,250 in November 2015, approximately half of which are in Ophthalmology. Additional capacity continues to be sought to drive this down further with the provision of independent sector support on site from the 14 th November initially for 3 months.. At the time of writing, no patient is currently awaiting an appointment date who is more than 12 weeks overdue. Again it should be noted that this is a transient group and not part of the original 8, e-referral Appointment Slot Issues In September 2015, it was identified that approximately 2,000 patients were sat on the e-referral appointment slot issues list (ASI), unable to get an appointment. 410 were urgent patients with the longest wait of 19 weeks in ophthalmology. Most of these patients have now been seen in clinic and an assessment made to identify if they have come to any harm as a result of the delay. The last few patients all have appointments and are due to come through clinic in the coming weeks. At the moment, no harm has been identified. A full incident investigation report will be brought forward to the governance committee in due course. As a result of the issue, additional capacity was sourced and the ASI list has been reduced significantly. It now stands at approximately 440 with the longest wait referred in June for paediatric Page 3 of 8

4 Dermatology. Work continues to reduce it further. Again it should be noted that this is a transient group and not part of the original 2, Cancelled Appointments List This issue came to light very recently. When a patient has an appointment booked which is subsequently cancelled by the hospital, they drop on to a specific cancelled appointments list from which they are re-booked. However, when this occurs we lose visibility of the original date they were due to be seen and there is a risk that patients could DNA or be cancelled multiple times without anyone realising quite how far they are overdue, which could present a clinical risk. This issue is being investigated as per previous incidents. The patients are being prioritised for booking back in to clinic based on risk and their waiting time. They will each be assessed to identify if any harm has been caused. The investigation will be fully reported in due course. There are 215 patients on the list. Now that the risk has been identified, this cancelled appointments list is being phased out and the patient put back on to the new outpatient waiting list or follow-up review list as appropriate. 4. Outpatient Programme Board Progress Report The Board has a cross section of members representing various stakeholders in the outpatient service across both King s Mill and Newark Hospitals. It meets fortnightly to keep a close reign on the progress of improvement plans. A dashboard of measures has been established to monitor key performance metrics such as the volume of patient complaints and concerns received the utilisation of clinic appointment slots, appointments cancelled by the hospital at short notice, DNA rate and availability of patient notes in time for the appointment. The Board is underpinned by a taskforce of key operational stakeholders and senior managers that form the Outpatient Capacity Meeting that has been meeting daily to make urgent progress on the issues. The frequency of this meeting has recently been reduced to twice weekly, but nevertheless it remains a very high priority for all concerned and there is a stark focus on continuous improvement. A review of quarter 2 complaints and concerns by the Patient Experience team shows that the majority of patient concerns (88%) relate to the outpatient service. The top 3 themes are: Access to the appointments team Page 4 of 8

5 Cancelled appointments without notification Waiting time for appointment 4.1 Access to the Appointments Team Calls to the appointments team / call centre go in to a hunt group which contains a number of extensions for the various call handlers in the department. An analysis of call handling data for this hunt group, using a 7 day snapshot of calls in November 2015, shows that 68% of calls go unanswered. This indicates that a poor service is currently being provided to patients, which reinforces the patient concerns. The difficulty that patients are facing getting through to the appointments team is also likely to manifest itself in an increased level of DNAs by patients who are trying to get through to change their appointments, but can t. Whilst 68% is a very high level of unanswered calls, it is important to understand that this will contain a lot of repeat calls and increasing the capacity of the call centre is likely to have a significant positive impact on the number of calls answered. The call centre has been transferred from the Planned Care and Surgery (PC&S) Division in to what is now the Diagnostics and Outpatients (D&O) Division in to which outpatient services are being centralised. D&O now contains all of the outpatient services on the KMH site including outpatient clinical staff, reception staff, clinic preparation staff (who ensure the patient notes are available), appointments team and the booking team. Recruitment is continuing in earnest to expand the appointments team up to the budgeted level and the call handling performance will be regularly monitored to track improvement. A review is also being carried out on the calls going in to this team from other sources to ensure that the vast majority of their capacity is focused on answering calls from patients and not dealing with other issues. New call centre technology has been ordered which will go live during January 2016, which will provide immediate visibility of the performance of the call centre so we can see the call volumes and waiting times in real time. 4.2 Cancelled Appointments without Notification There have been a number of examples where individual patients or whole clinics full of patients are turning up for appointments that don t exist. It is clearly unacceptable for any patient to experience such an issue and where this does occur we are encouraging staff, in accordance with the duty of candour, to be open an honest about what has occurred and we are endeavouring to find clinicians to get the patients seen rather than turn them away. However, on occasion this has not been possible. The fact that the patients are not expected means that clinicians are not allocated to see them and the Page 5 of 8

6 patient notes have not been prepared. Solving these issues in very short order when a patient turns up unexpectedly is difficult and we need to prevent such situations from arising. There are a number of reasons why patients are turning up unexpectedly and we are investigating each of these to get to the root cause and solve the problems to prevent re-occurrence. Examples include: When a patient s appointment is cancelled at short notice by the hospital they may not receive the cancellation letter before the date of their appointment. It is now policy that any patient whose appointment is cancelled with less than 2 weeks notice is telephoned. There is a technical issue which has been raised with the Medway supplier whereby some letters are going to a ghost printer and are never actually being sent to patients. We have experienced a number of issues where clinical staff have booked leave, but the clinic has not been cancelled. There have been particular issues in Ophthalmology which has also reconfigured all of its clinics recently. To address this: o Any request for leave with less than 6 weeks notice now has to be approved by the Divisional General Manager. o All leave when approved is ed through to the Booking team for action. o Specifically for Ophthalmology the Patient Pathway Co-ordinators are now looking 2 weeks ahead at the clinics and reconciling this with the leave records. There have also been clinic autogeneration issues where clinics are generated but do not exist and booking staff see it as open capacity and book into it. This is a technical issue that will improve with the next upgrade. Actions to manage this are being undertaken manually when identified by the booking team and NHIS. The risk however is that some may be missed and patients will turn up inadvertantly. We anticipate further unforeseen issues in this area and some issues are as yet unresolved. This remains work in progress. 4.3 Waiting time for appointment Waiting times continue to be a focus not only of the Outpatient Programme Board but also of the Referral to Treatment Time Steering Group. The issues here are very much specialty specific depending on the capacity and demand gap for each of them. A great deal of progress has been made to increase outpatient capacity to maintain new outpatient waiting times whilst reducing the number of patients who are overdue their follow-up appointment see later. However, some challenges remain and others will occur over time as referral patterns change, clinical practice and pathways evolve over time and when capacity is lost, particularly where this is unforeseen. Page 6 of 8

7 Ophthalmology capacity is a particular challenge and an independent sector provider is being brought in to increase capacity until we can get back to a sustainable position. A range of other actions are taking place across challenged specialties. The Trust also has a problem with its waiting list information. This is a complex issue to describe succinctly, but in essence patients could be on a number of different lists and managing all of these different lists in concert to ensure patients get seen in a timely manner and in the right order presents operational staff with a significant challenge. It also presents data quality challenges. The Trust plans to introduce a single patient tracking list to consolidate these various lists in to one place. The Information Department are leading on this and it is currently in the testing phase to evaluate the logic. In essence it is being sanity checked by the Information Department itself and the specialty management teams. The advice of the national team responsible for providing support to Trusts to meet referral to treatment times has also been sought. This is a very significant change that is likely to expose a lot of data quality issues and will require a lot of man hours to validate the information to ensure it is accurate. We also have to educate staff across the pathway to ensure Medway is being used correctly and the national RTT rules are being correctly applied in the first place. Ultimately we need to prevent errors from being made to reduce the amount of validation effort required to correct them. The Information Department team is being expanded to increase capacity to carry out training and to correct errors. At the moment there is no system in place to forecast capacity and demand for outpatients on a rolling basis and as a result the specialty management teams end up reacting to problems rather than seeing them coming and preventing them. A system is being introduced to resolve this by looking at the number of clinic appointment slots available in the future compared to the expected demand to identify any potential gap so that extra capacity can be planned. It is not always easy to source that extra capacity, but this will at least give the specialties a heads up and can only improve the situation. This will be introduced initially for 2 week wait appointment slots for cancer patients before being rolled out fully. Fully implementing this will require automation because the amount of man hours required to do this manually is significant. This is being investigated with the Information Department and remains work in progress. 4.4 Other areas of improvement that are ongoing, but not already discussed include: Increasing the utilisation of clinic appointment slots to be more productive and reduce waiting times. Page 7 of 8

8 Implementing a new Elective Access, Booking and Choice policy. Recruitment has been continuing to increase the number of clinic reception staff. An induction programme and competency package has also been introduced. Recruitment has been continuing to increase the number of clinic preparation staff. The process will also be mapped to identify any opportunities for improvement. Implementing a new management structure for the appointments and booking team. Reviewing the capacity of the appointments and booking team as well as systems and processes. Reviewing the text messaging and interactive voice messaging appointment reminder service. Re-evaluating the KPI for availability of patient notes. Ensuring Newark MIU notes are scanned in to be available in time for KMH fracture clinic appointments. Improvements to the physical environment in clinic. Reorganisation of patient notes storage at Newark Hospital. The integration of King s Mill and Newark outpatient governance arrangements. Ongoing audit of patient notes to assess compliance with the Access policy and Referral to Treatment Time rules. Improving communication with staff about the issues and the improvements that are happening. 5. Conclusion The improvement of our outpatient services remains a top priority to provide a much better patient experience and to meet the expectations of the CQC articulated in the Must do s, Should do s and Section 29A improvement notice. The focus of senior managers in correcting and sustaining changes in this area will continue but fundamentally requires significant technical and information support to be successful. Page 8 of 8

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