All staff involved with patients being admitted to hospital

Transcription

1 Document title: Document number: Staff involved in Development (job titles): Document author/owner: Directorate: Department: For use by: Patient Access Policy DN449 Directorate Managers Safeguarding Lead Booking office Manager Business Change Manager Bed Manager Assistant Directorate Managers Director of Clinical Services Operations Cardiology/Surgery All staff involved with patients being admitted to hospital Review due: April 2016 This is a controlled document. Whilst this document may be printed, the electronic version maintained on the Trust s Intranet is the controlled copy. Any printed copies of this document are not controlled. Papworth Hospital NHS Foundation Trust. Not to be reproduced without written permission. Key points of this document Overview of the process of managing the patient pathway and waiting list, in line with national and local standards Duties, roles and responsibilities outlined in respect of this policy both with the individuals, departments and the patient Key targets stated for each pathway and monitoring process 1

2 INDEX Item No Page No 1. Introduction 3 2. Scope 3 3. Objectives 3 4. National Operating Standards 4 5. Outpatient appointments 5 6. Diagnostic appointments 7 7. Pre-op assessment appointments 7 8. Elective Admissions 7 9. War veterans Exceptional circumstances Information to patients Performance Management Duties, Roles and Responsibilities 10 Appendix A 13 2

3 1. Introduction The purpose of this policy is to ensure all patients requiring access to outpatient appointments, elective inpatient treatment, elective day case treatment and diagnostic tests are managed consistently, according to national and local frameworks and definitions. The policy is designed to ensure fair and equitable access to hospital services and the appropriate allocation of resources (beds, theatres, clinics etc). The main determination of when patients are treated is their clinical priority. Patients with similar needs should be treated in chronological order. Timely regard should also be paid to National targets for access and any other mandatory requirements relating to patient access. To ensure effective use of resources local Commissioners may restrict the scope of services that are available to its population. Where Commissioners implement a change to services purchased, Papworth will amend access to these services accordingly 2. Scope This policy aims to ensure that patients have their care planned and receive health care according to their clinical priority. This policy defines how patients should be managed if they do not attend for an appointment or repeatedly cancel an appointment. It should ensure that non attendance at an appointment is managed fairly and safely across the health economy it serves. It supports the reduction in waiting times, cancelled appointments and the achievement of patient access targets. It relates to all patients referred to Papworth, regardless of the location of the actual appointment or treatment. Policy implementation applies to all staff managing patients under the care of Papworth, regardless of the actual location of the appointment or treatment. 3. Objectives The objective of this policy is to ensure that patients are treated in order of clinical priority and as soon as possible from the point of referral. There are national target timescales for delivery of treatment or aspects of treatment, which vary from time to time according to national policy. This document sets out the standards of access for Papworth patients and is consistent with the directorates Bed Management and Escalation policies. Cardiology patients transferred urgently from a network hospital must be admitted and treated within: - 24 hours of referral for Acute Coronary Syndrome of Tirofiban - 48 hours of referral for Acute Coronary Syndrome patients not on Tirofiban - 24 hours of referral for Pacing Transfers with a temporary wire inserted - 4 days of referral for Pacing Transfers without a temporary wire inserted Cardiac surgery patients transferred urgently from a network hospital must be admitted within seven days of referral 3

4 For all new referrals the maximum waiting time is 18 weeks from the point of referral to the onset of first definitive treatment Patients originally referred by a GP with suspicious of cancer under the two week wait/fast track rule must be treated within 62 days of GP referral. This also includes those patients upgraded by a Consultant to a 62 day pathway. All patients with suspected cancer must be treated within 31 days of decision to treat. All patients who require subsequent treatment for cancer must be treated with 31 days of decision to treat. All new diagnostic procedures must be performed within six weeks of the request / referral for test 4. National Operating Standards The Trust will provide access to services and treatment within the defined timeframes as detailed in the NHS Operating Framework. The NHS Operating Framework can be located by the following link: _ pdf The Trust will also comply with the NHS England Business Plan and Putting Patients First document, with specific link to section 16 of the document which outlines the following to comply with : The Link to this document is pdf Key deliverables Delivery of all NHS Constitution standards for elective care services throughout 2014/15. These are: Admitted patients to start treatment within a maximum of 18 weeks from referral 90%. Non-admitted patients to start treatment within a maximum of 18 weeks from referral 95%. Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral 92%. Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral 99%. Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP 93%. Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) 93%. Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96%. Maximum 31-day wait for subsequent treatment where that treatment is surgery 94%. Maximum 31-day wait for subsequent treatment where that treatment is an anticancer drug regimen 98%. Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 94%. 4

5 Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85%. Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers 90%. Maximum 62-day wait for first definitive treatment following a consultant s decision to upgrade the priority of the patient (all cancers) no operational standard set. All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient s treatment to be funded at the time and hospital of the patient s choice. Minimise Mixed Sex Accommodation breaches. Mental health Care Programme Approach (CPA): the proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period 95%. Zero tolerance of over 52 week waiters. No urgent operation to be cancelled for a second time. Ensure we continue to report publicly performance on each of the above measures. 4.1 Patient entitlement to free NHS treatment The Trust has a legal obligation to identify patients who are not eligible for free NHS treatment. The National Health Service provides healthcare for people who live in the United Kingdom. People who are not ordinarily a resident of this country are not automatically entitled to free NHS treatment, regardless of their nationality, whether they have an NHS Number, hold a British Passport, have lived and paid National Insurance contributions and taxes in this country in the past. All NHS Trusts have legal obligation to: Ensure that patients who are not ordinarily resident in the UK are identified. Assess liability for charges in accordance with Department of Health Overseas Visitors Regulations. Charge those liable to pay in accordance with Department of Health Overseas Visitors Regulations. All patients should be asked to complete an Overseas Visitor Pre-Attendance form prior to their attendance; the patient will then send back the form to the Health Records Department. The Health Records Department will review the form to establish eligibility, and may contact the patient, if further information or documentation is required. Where it is not possible to send the form prior to attendance, then on the patient s arrival to the hospital the form should be given to the patient to complete. Once the Overseas Visitor Pre-Attendance Form is reviewed and it is found that a patient is not an ordinary resident of the UK then a stage 2 interview is required and one of the following should be contacted: Patient Services Manager Deputy Patient Services Manager Deputy Patient Services Officer A patient s entitlement to free NHS treatment can change and therefore the pre-attendance form needs to be completed once a year and recorded in the case notes and on ipm PAS for ALL patients. 5

6 4.2 Choose & Book referrals It is now possible for GPs to use the national Choose & Book system for indirect booking of GP referrals to Papworth. The following standards apply for processing Choose & Book referrals: Priority Primary Care Turnaround Time Trust Turnaround Time Urgent 24 hours 3 days Routine 3 days 5 days 4.3 Inappropriate referrals Where a Consultant deems that a patient has been inappropriately referred, the GP will be advised as to the most appropriate management of the patient. 4.4 Patients requiring commissioner approval No referral for an excluded procedure will be accepted without an exceptional treatment approval form. If the referral does not have the relevant approval, the referral should be rejected and returned to the GP for them to request exceptional treatment funding via the relevant commissioning panel. In some instances, it will not be apparent until the outpatient consultation that the patient requires an excluded procedure. When it is identified at the outpatient consultation the relevant clinician should refer the patient back to the GP for them to progress the exceptional treatment panel approval. 5. Outpatient appointments 5.1 Reasonable notice New and follow-up Outpatient appointments For a verbal offer to be deemed reasonable, the patient must be offered a minimum of two appointment dates on different days, with a minimum of two calendar weeks notice For a written offer to be deemed reasonable, the patient must be offered an appointment date with a minimum two calendar weeks notice Earlier dates can be offered if available and acceptable 2 week wait Cancer proforma referrals As a tertiary lung cancer centre, two week wait/fast track referrals with suspected cancer should be directed to the local district general hospitals in the first instance, in keeping with the local cancer network pathway. In the event that Papworth receives a two week wait referral directly from the GP, this should be see directly by the Oncology team rather than in the QAC clinic. 5.2 Appointment Non-Attendance (DNA) Providing reasonable notice of the appointment was communicated to the patient/carer, DNAs will be managed as follows: New Patients Adult Patients will be returned to the referrer if they DNA their second new outpatient appointment following discussion with the clinical team. 2WW Cancer proforma patients In the rare event that a 2 WW patient is being seen at Papworth and DNAs their first appointment, they will be offered a second 6

7 appointment. If the patient subsequently DNAs this second appointment, the case notes will be reviewed by the lead Clinician and a decision on further management will be made ie refer back to GP. 2 week wait referrals can only be downgraded by the GP. If the Consultant thinks that the referral is inappropriate, this should be discussed with the GP and the GP asked to withdraw the 2 week referral status. Children and Vulnerable adults The doctor must consider whether there is a safeguarding risk if the patient does not attend, and then act accordingly in following any concerns up. It is their responsibility to liaise with the referrer to assess this risk and consider further actions if appropriate. Follow-up patients Routine adult patients should be returned to the referrer. A further appointment will only be made if the treating clinician requires the patient to be seen. Patients with suspected cancer the case notes should be reviewed by the treating Clinician and a decision on further management will be made i.e. refer back to GP or district general hospital. Children and Vulnerable adults a clinical decision is made to either offer an alternative appointment or discharge back to the GP. This is left to the discretion and expertise of the Consultant / senior doctor provided that: - It can be demonstrated that the appointment was clearly communicated to the patient ie correct demographics, contact information - Discharging the patient is not contrary to the patient s best clinical interests - There are no Safeguarding concerns (For further guidance on DNAs in children and young adults or any safeguarding concerns, please refer to Appendix A) 5.3 Patient Cancellations New and Follow-up patients If patients telephone to cancel and rearrange an appointment, a new appointment date should be agreed at the time. Patients who cancel two consecutive appointments without a justified reason will be discussed with the clinical team. Patient Availability If a patient cancels their appointment due to a long term medical condition which is unlikely to resolve in less than two weeks, then the patient should be discharged back to their GP/referring clinician. Likewise, if patients are unavailable for social reasons, then they should also be discharged back to their GP/referring clinician. Cancer Pathway Patients May only be referred back to their GP/referring clinician in agreement with the patient 5.4 Hospital Cancellations A minimum of 6 weeks notice is required for any planned cancellation, reduction or changes Clinic cancellations or reductions at less than 6 weeks notice will only be approved in an emergency or in exceptional circumstances Where cancellations are initiated by the Trust, patients should be rebooked in a timely manner. 6. Diagnostic appointments 7

8 6.1 Reasonable notice A minimum of two weeks notice and one date should be applied to constitute a reasonable offer. Earlier dates can be offered if available and acceptable. Where patients do not agree dates within a reasonable timescale they should be discharged back to their GP/referring clinician. Where patients have not been given reasonable notice, they should not be discharged back to their GP. 6.2 Did not attend (DNA) If a patient DNAs they will be contacted through telephoning and then a subsequent letter if we were unable to contact them. Further discussion with the clinical team would be held. 6.3 Patient Cancellation The referring Clinician will be informed if the patient cancels two consecutive appointments, having had reasonable notice of the appointment or agreed the date. 6.4 Hospital Cancellation A minimum of 6 weeks notice is required for any planned cancellation, reduction or changes. Appointment cancellations or reductions at less than 6 weeks notice will only be approved in an emergency or in exceptional circumstances. Where cancellations are initiated by the Trust, patients should be rebooked in a timely manner 7. Pre-op assessment appointments 7.1 Did not Attend (DNA) It may be appropriate to offer the patient a further date, or to remove the patient from the waiting list and refer back to their GP. Patient cancellation. Patients who cancel two consecutive appointments, having had reasonable notice of the appointment or agreed the date, will be returned to their GP. 7.2 Hospital cancellation A minimum of 6 weeks notice is required for any planned cancellation, reduction or changes. Appointment cancellations or reductions at less than 6 weeks notice will only be approved in an emergency or in exceptional circumstances. Where cancellations are initiated by the Trust, patients should be rebooked in a timely manner. 8. Elective Admissions 8.1 Reasonable notice A minimum of three weeks notice and one date should be applied to constitute a reasonable offer. Earlier dates can be offered if available and acceptable. For patients on a cancer pathway, reasonable is classed as any offered appointment between the start and end point of 31 or 62 day standards. Where patients decline reasonable offers, a pause can be applied and alternative treatment dates offered. 8

9 8.2 Did Not Attend (DNA) The reasons for non-attendance should be established. Patients will be returned to the GP unless exceptional circumstances dictate otherwise. 8.3 Patient Cancellation If a patient cancels an admission date, they will be offered another appointment, suspended as appropriate and / or discussed with the clinical team. 8.4 Hospital cancellations If an agreed admission date is cancelled by the hospital at any stage up to and including the day of admission, a new date should be agreed with the patient within seven days. If the operation is cancelled by the hospital on the actual day of admission, a new operation date will be given which should be within 28 days of the original operation date. 8.5 Suspended waiting list Patients who are deemed to be medically unfit for admission will be reviewed and discussed with the clinical team and suspended and / or removed as appropriate. Patients who are fit, but unavailable for social reasons, may be placed on the suspended waiting list. 8.6 Patients requiring more than one listing for different conditions It is the Consultant s responsibility to familiarise themselves with the patient s medical condition and any other current listings that may affect the patients wait. For complex procedures, where it is unlikely that multiple procedures can be performed within the required timeframe, the patient will be reviewed and may be suspended or removed as appropriate. If patients are removed from the waiting list the GP will be informed. 8.7 Bilateral procedures The first operation should be added to a waiting list and linked to a pathway in the normal way. The second operation should be added to the waiting list but not linked to an 18 week pathway. The start date of the pathway for the second procedure will be the date the patient became fit and was ready for the second procedure Planned procedures Patients on planned waiting lists will normally have had previous treatment and they are to receive a further course of treatment. Patients who are on the planned lists are not included in any calculation on the size of the waiting list because their procedures would not be done sooner if resources were not a constraint. Examples of procedures which should be on a planned list are: Patients waiting for more than one procedure where the procedures need, for clinical reasons, to be undertaken in a certain order. Patients proceeding to the next stage of treatment ie: patients undergoing chemotherapy, or removal of metalwork. Staged surgery or bilateral procedures. The first stage of such procedures should be included on the normal waiting list, but all subsequent procedures are listed at follow up appointments which would commence with a new pathway. Patients where the procedure would not be appropriate until the patient reaches a certain age/stage of growth. 9

10 Patients on the planned waiting list will be managed in accordance with the clinically agreed timescales set by the Clinician. 8.9 Tertiary referrals Inter-provider transfer forms will be completed for any patient who is: Referred on to a tertiary provider Where patients are referred to Papworth as a tertiary referral, the referring hospital is expected to complete a tertiary referral and send the required referral information (e.g. imaging). This is to ensure national compliance regarding provision of information for onward referrals Prior Authorisation Some PCTs require Papworth to check with them before proceeding to treat patients. These patient referrals should be processed as normal; with the referral on PAS left as pending with a comment to indicate that prior authorisation is being sought from the PCT. Once obtained the PCT authorisation should be recorded on PAS and the referral authorised. Throughout this process the RTT clock continues to run. 9. War veterans War veterans should receive priority treatment if the condition is directly attributable to injuries sustained during the war periods and for which they receive their war pension, as stated in DOH Directive HSG(97)31NHS Executive The referrer must ensure that all relevant information is clearly communicated within the referral letter. 10. Exceptional circumstances Patients should not be penalised where exceptional circumstances prevent them from attending an appointment. Staff should exercise discretion in such situations, seeking guidance from their line manager if required. However, certain circumstances may still arise whereby returning the patient back to the care of their GP would clinically be in their best interest and the safest course of action. These instances will be managed on an individual basis in discussion with relevant parties. 11. Information to patients Patients should receive appropriate written confirmation when they have been added to a waiting list. The patient should be given contact details to notify the Trust of any changes to their circumstances or to raise queries about their appointment. All patients attending the hospital should receive Papworth Hospital Information, Location Map and Patient and Visitor Information booklets. 10

11 Communication with patients should be informative, clear and concise and make the process of waiting list management and booking transparent, as set out in this policy. The trust s website and URL should be included in all patient and professional carer information. 12. Performance Management 12.1 Performance Report A performance report on this Patient Access Policy should be compiled on a monthly basis by the relevant Departments in the Trust s balanced scorecard which is submitted to the Board on a regular basis. Key performance indicators compiled on a monthly basis will include: - Number of admitted patients treated within 18 weeks - Number of non-admitted patients seen with 18 weeks - Number of DNAs - Number of CNAs - Number of GP new referrals - Performance against the 31 day and 62 day cancer standards - Performance in delivering urgent cardiac surgery and cardiology patient transfer and treatment targets 12.2 Priority Target List (PTL) A priority target list is compiled by the Trust which sets out the patient priority order for clinic appointments, diagnostic tests and admission / treatment as dictated by this policy Escalation The PTL for each management group will be under review as appropriate. The Director of Operations will be informed should there be any problems around issues such as: - Demand, activity, and capacity trends that influence the PTL - Progress in clearing any backlog or implementing plans to address a backlog - Current and anticipated pressure points - Plans to address pressure points Procedures should be put in place in all areas for escalating problems or compliance with this policy Suspected breaches A breach report should be completed with the following information: - Patient ID - The standard or standards that are likely to breach - Reason/s for suspected breach - Recovery plan or input required to avoid the suspected breach This will be sent and discussed with the Director of Operations. The Director of Operations is responsible for ensuring the relevant details are communicated externally Key Information A number of information reports are produced on a regular basis using information covered by this policy or to support delivery of the policy. The relevant department has overall responsibility for collating and distributing this information including: - Performance on delivery of the 31 and 62 day cancer standards - Performance on delivery of urgent cardiac surgery and cardiology patient transfers - Priority target lists 11

12 - Number of admitted patients treated within 18 weeks - Number of non-admitted patients seen with 18 weeks - Number of DNAs - Number of CNAs - Number of GP new referrals 13. Duties, Roles and Responsibilities Director of Operations The Director of Operations is responsible for the development, ratification, implementation and monitoring of this policy through the directorate management structure. The Director of Operations will ensure that this policy is updated in response to changes in national policy and local arrangements agreed with Commissioners. Directorate Managers To ensure policy compliance within their areas of responsibility. To ensure all staff within their area of responsibility are aware of the access policy and how it should be implemented within their individual roles. Proactively plan and manage demand, capacity, activity and any backlog to ensure that all patients are treated according to clinical priority and within the target timescales set out in this policy. Ensure that PAS is the primary information system used for recording data on patient pathways at Papworth, and that as a consequence PAS is a comprehensive, up to date record of each patient s waiting time. Monitor departmental progress in delivering this policy, by reviewing and acting on the performance reports listed in this policy, and implementing all actions to improve performance that are agreed in reviews with the Director or Operations. Clinicians Ensure all referrals are reviewed as soon as possible by an appropriate clinician. This should be within the timeframe required as pre the targets set for the different pathways and depending on urgency. This should ideally be within 3 working days for non urgent referrals, of receipt of referral. To provide clinical judgement on further management of patients following a DNA or multiple patient cancellations. Ensure that clinically urgent patients are treated or seen in clinical priority order, and thereafter in strict chronological order within the target timescales set out in this policy. Work with the Directorate Managers to balance the demand for the service with the available capacity To comply with annual leave and study leave policies to ensure there is a minimum of six weeks notice To ensure patients are not listed unless medically fit and ready for procedure. Ensure that all clinical decisions that have an impact on a patient s pathway are communicated to administrative staff for recording on PAS. Business Support Manager Ensure that mechanisms are in place to enable the Trust to capture date accurately, that the reports are compiled and distributed on a regular basis, and ensure that all contractual obligations and requests from the Trust s commissioners are met. Will manage the 18 weeks RTT Central Office including the Reporting Team, Navigations Team and Admin Team to capture, process and report upon RTT information. 12

13 Medical Secretaries and Booking Office Staff Ensure that all patient pathways are administered in line with this policy and that departmental procedures are followed. Anticipate and resolve problems with implementing this policy, escalating to the relevant service manager any capacity or other problems that they cannot resolve. Provide clear and transparent explanations of this policy to patients, working proactively to minimise delay and maximise patient convenience and choice of appointment or admission dates. Ensure that PAS is maintained as the primary record of the patient pathway and that all relevant events on the pathway are recorded on PAS in line with this policy and any supporting procedures. Develop systems to ensure that patients cannot be booked beyond their target treatment date without discussion with the directorate manager or deputy Ensure staff comply with the policy for suspending patients which is outlined in national policy statements and therefore should be complied with as per the rules outlined. Eighteen Weeks RTT Team Identify and resolve anomalies in RTT recording Highlight potential breaches to Directorate Managers Validate waiting lists Provide information and escalate to Business Support Manager. Maintain RTT rules base Review and resolve complex unknown clock starts and stops Resolve unknown clock starts (UKCS) added by Booking Office using rules based on a daily basis Record referrals received with no clock start Update PAS when clock starts are determined Telephone chasing of unknown clock starts Clinic Co-ordinators Will ensure that all clinic outcomes and patient waiting time are recorded on PAS by the end of the day when the clinic is held 13

14 Appendix A Safeguarding of Children and Young Adults The final judgement of whether to offer another appointment is based on the professional judgement of the Consultant / senior doctor. The reviewing doctor must discuss with the safeguarding lead prior to documenting in the notes. Referrals into the service from GPs or other professionals should clearly state if there are any Safeguarding issues within the family. This information should be considered by the Consultant when making decisions regarding offering a further appointment. The Paediatric service currently offers both letters inviting a child to an appointment but also a telephone reminder service. Consideration is given to ensuring that those with language or communication difficulties have adequate notice or appointments and support is available on the day. Professionals referring into the service should highlight any such issues to ensure the family are given the support they require to attend OPD. DNAs will be identified during the clinic session, and the notes reviewed by the Consultant / senior doctor (middle grade or equivalent) at this time. Consideration must be given to the following: - Urgency of the referral - Significance of clinical information provided in the referral letter - Any existing Safeguarding concerns in the family - Any other mitigating circumstances - Future appointments with the service The doctor must then to consider whether there is a safeguarding risk in the non attendance and then act accordingly in following any concerns up. It is their responsibility to liaise with the referrer to assess this risk and consider further actions if appropriate. (see section below on non engagement where the child is at risk). A letter detailing DNA appointment details should be sent to the referring GP or Health Professional with a copy to the Health Visitor or School Nurse (dependent on child s age). This letter should clearly state what action the GP is expected to take in response. Certain groups of children are particularly vulnerable and therefore need special consideration. These include: - Children under 12 years old - Those known to social care / on a child protection plan - Those on medication - Children / YP with mental health problems - Children with long term conditions where close monitoring is vital to improved outcomes, eg: Diabetes, Cystic Fibrosis, Cardiac conditions - Children with a disability - Travelling families / those seeking asylum and the homeless 14

15 With persistent DNAs the practitioner should contact other professionals involved with the family to establish whether the child is engaging elsewhere. This is especially relevant where the child or family is particularly vulnerable and has a long term health condition eg: school, Health Visitors, GP etc. If families refuse or persistently fail to attend appointments and there is sufficient concern, practitioners should contact Social Care to make a referral this should be verbal and followed up in writing within 48 hours. If the baby, child or young person is discharged: - A letter is sent to the GP stating the reason for discharge - The opportunity for the GP to re-refer back to the Consultant A copy of the discharge letter and any DNA letters are sent to the Health Visitor or School Nurse (dependent on the child s age). It is also advisable to send a copy to parents / carers of the child or young person. For follow up patient DNAs a clinical decision is made to either offer an alternative appointment or discharge back to the GP. This is left to the discretion and expertise of the Consultant / senior doctor provided that: - It can be demonstrated that the appointment was clearly communicated to the patient ie: correct demographics, contact information - Discharging the patient is not contrary to the child s best clinical interest. - There are no safeguarding concerns (see below) DNAs where the child / family are subject to a child protection plan or looked after children For children who are subject to a child protection plan, any non engagement should be reported as soon as possible to the family social worker Staff should inform the Trust Safeguarding team of their concerns via a Cause for Concern stating the details of the referral to social care. All actions should be documented fully in the child s health/medical record. An alternative appointment should be offered within the shortest possible time and this communicated clearly to the family by letter and via a telephone reminder. A copy of this should be sent to GP, HV / School Nurse and Social Care. 15

16 What key element(s) need(s) monitoring as per local approved policy/ procedure or guidance? Element to be monitored Complianc e with policy. review by looking at 30 sets of notes each year Who will lead on this aspect of monitoring? Name the lead and what is the role of the multidisciplinary team or others. What tool will be used to monitor/check/ observe/assess/ inspect/ authenticate that everything is working according to this key element from the approved policy/ procedure? How often is the need to monitor each element? How often is the need complete a report? How often is the need to share the report? Who or what committee will the completed report goes to. How will each report be interrogated to identify the required actions and how thoroughly should this be documented in e.g. meeting minutes. Lead Tool Frequency Reporting arrangements Assistant Directorate Managers and the Business Development Manager Assess that the pathway and review has been followed to assess a set number of patient notes. Validation of the list occurs on a monthly basis Validation of the waiting list is undertaken weekly. Spot check of notes to be yearly 30 sets OEG Directorate Operational Groups Executive Directors meeting Which committee, department or lead will undertake subsequent recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes? Acting on recommendations and Lead(s) Directorate Managers for each service OEG will be the committee responsible for review and any changes required The booking office and the Business Change team will work together to review and monitor How will system or practice changes be implemented the lessons learned and how will these be shared? Change in practice and lessons to be shared Validation of the list and individual patients will highlight any deficits in the policy. This will need to be flagged via the Directorate Operational Group in the first instance and any changes to the document will need to go via OEG 1

17 DNxx Patient Access Policy Further document information Approval this is required for all Operational Executive Group documents. Approval should be by the relevant committee(s)*. State the name(s) of the committee(s) and the full date(s) of the relevant meeting(s): *In exceptional circumstances only, approval can be by Chair s Action or by appropriate ED or NED state full date of approval Approval date (this version) (Day, month, year): Approval by Board of Directors or Committee of the Board (required for Strategies and Policies only): Date (Day, month, year): This document supports: standards and legislation include exact details of any CQC & NHSLA standards supported Key associated documents: Suspend policy for Patients Counter Fraud In creating/revising this document, the contributors have considered and minimised any risks which might arise from it of fraud, theft, corruption or other illegal acts, and ensured that the document is robust enough to withstand evidential scrutiny in the event of a criminal investigation. Where appropriate, they have sought advice from the Trust s Local Counter Fraud Specialist (LCFS). Page 17 of 17