Referral Desk Aid & Audit Data Collection Template

Beechdale Health Centre

Referral Desk Aid & Audit Data Collection Template

Document Control

A.Confidentiality Notice

This document and the information contained therein is the property of Beechdale Health Centre.

This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Beechdale Health Centre.

B.Document Details

Classification: / internal
Author and Role: / sally bills- receptionist
Organisation: / Beechdale Health Centre
Document Reference: / referral desk aid & audit
Current Version Number: / 1
Current Document Approved By: / sally bills
Date Approved: / 31.12.2012

C.Document Revision and Approval History

Version / Date / Version Created By: / Version Approved By: / Comments
1 / 31.12.2012 / Sally Bills / Sally Bills / Created from default document

Beechdale Health Centre

Referral Desk Aid

All staff in the Practice who complete Referral Documents will use the following checklist of Patient Information as a minimum, to ensure that such documents contain everything that the other service, individual, team or agency will need to ensure the needs of the person who uses services are met safely.

You may wish to create a template in your clinical system that can be completed at the time of the consultation to ensure all data is being captured.

Name
Gender
Date of birth
Address
Unique ID number
Emergency contact details
Any persons acting on behalf of patient, plus contact details
Care records up to point of transfer
Assessed needs
Known preferences and relevant diverse needs
Relevant previous medical history
Any managed infections
Any current medicines taken
Any allergies
Key contact at sending provider
Reason for transfer
Any advance decision
Any assessed suicide / homicide or risk of self-harm or others

Audit of Referrals

To provide evidence and demonstrate that the Practice is compliant with CQC Outcome 6B, it is recommended that the Practice undertakes an audit of referral documentation on a regular basis (e.g. Monthly, Quarterly, Six-Monthly).

In addition, you can incorporate an audit of how long it takes from the consultation to the referral letter being issued.

Determining how many Referral Documents you need to review, so that you can be confident your findings are an accurate representation of all Referral Documents

If the Practice issues a small number of referral documents during the period (e.g. up to 20), all referral documents will need to be reviewed.

However, if the Practice issues more than 20 Documents during the period, it is possible to review only a sample of the referral documents that have been issued, to be save time yet still be confident that the findings are representative of the entire number of referrals documents issued.

The actual number of documents that will need to be reviewed during each period is called THE SAMPLE SIZE.

The SAMPLE SIZE depends on 3 things:-

1)THE POPULATION - The total number of Referral documents issued during the period concerned (e.g. Monthly, Quarterly, Six-Monthly).

2)THE MARGIN OF ERROR – This is the amount of error you can tolerate. 5% is the most common choice.

3)THE CONFIDENCE LEVEL – The amount of uncertainty you can tolerate. 90%, 95% or 99% are the most common choices

The table overleaf enables you to identify the actual sample size of referral documents you need to review for each of the above 3 Confidence Levels, with a 5% margin of error, for a total number of Referral documents issued in the period between 5 and 1,000.

Total No.
Referral documents issued during the period / 5% Margin of Error / Total No.
Referral documents issued during the period / 5% Margin of Error
Confidence Level / Confidence Level
90% / 95% / 99% / 90% / 95% / 99%
Minimum Sample Size / Minimum Sample Size
5 / 5 / 5 / 5 / 235 / 127 / 147 / 174
10 / 10 / 10 / 10 / 240 / 128 / 148 / 177
15 / 15 / 15 / 15 / 245 / 129 / 150 / 180
20 / 19 / 20 / 20 / 250 / 131 / 152 / 182
25 / 23 / 24 / 25 / 260 / 133 / 156 / 188
30 / 28 / 28 / 29 / 270 / 136 / 159 / 193
35 / 32 / 33 / 34 / 280 / 138 / 163 / 198
40 / 35 / 37 / 38 / 290 / 141 / 166 / 203
45 / 39 / 41 / 43 / 300 / 143 / 169 / 207
50 / 43 / 45 / 47 / 310 / 145 / 172 / 212
55 / 46 / 49 / 51 / 320 / 147 / 175 / 217
60 / 50 / 53 / 56 / 330 / 149 / 178 / 221
65 / 53 / 56 / 60 / 340 / 151 / 181 / 226
70 / 56 / 60 / 64 / 350 / 153 / 184 / 230
75 / 59 / 63 / 68 / 360 / 155 / 187 / 234
80 / 62 / 67 / 72 / 370 / 157 / 189 / 238
85 / 65 / 70 / 76 / 380 / 159 / 192 / 242
90 / 68 / 74 / 80 / 390 / 160 / 194 / 246
95 / 71 / 77 / 84 / 400 / 162 / 197 / 250
100 / 74 / 80 / 88 / 420 / 165 / 201 / 258
105 / 76 / 83 / 91 / 440 / 168 / 206 / 265
110 / 79 / 86 / 95 / 460 / 171 / 210 / 272
115 / 81 / 89 / 99 / 480 / 174 / 214 / 279
120 / 84 / 92 / 102 / 500 / 176 / 218 / 286
125 / 86 / 95 / 106 / 520 / 179 / 222 / 292
130 / 89 / 98 / 109 / 540 / 181 / 225 / 298
135 / 91 / 101 / 113 / 560 / 183 / 229 / 304
140 / 93 / 103 / 116 / 580 / 185 / 232 / 310
145 / 95 / 106 / 120 / 600 / 187 / 235 / 316
150 / 97 / 109 / 123 / 620 / 189 / 238 / 321
155 / 99 / 111 / 126 / 640 / 191 / 241 / 327
160 / 101 / 114 / 130 / 660 / 193 / 244 / 332
165 / 103 / 116 / 133 / 680 / 194 / 246 / 337
170 / 105 / 119 / 136 / 700 / 196 / 249 / 341
175 / 107 / 121 / 139 / 725 / 198 / 252 / 347
180 / 109 / 123 / 142 / 750 / 200 / 255 / 353
185 / 111 / 126 / 145 / 775 / 201 / 258 / 358
190 / 112 / 128 / 148 / 800 / 203 / 260 / 363
195 / 114 / 130 / 151 / 825 / 204 / 263 / 368
200 / 116 / 132 / 154 / 850 / 206 / 265 / 373
205 / 117 / 134 / 157 / 875 / 207 / 268 / 378
210 / 119 / 137 / 160 / 900 / 209 / 270 / 383
215 / 121 / 139 / 163 / 925 / 210 / 272 / 387
220 / 122 / 141 / 166 / 950 / 211 / 274 / 391
225 / 124 / 143 / 169 / 975 / 212 / 276 / 396
230 / 125 / 145 / 171 / 1000 / 214 / 278 / 400

Undertaking the Audit

To assist in this undertaking, the Audit Data Collection Template on Pages 6 & 7 has been produced.

The following notes will help correct completion of the Template:

Patient Reference Number:

Use of this criterion will maintain patient confidentiality, yet still enable speedy reference to be made to a specific referral, should this be required.

Date of Consultation / Date Document was issued / No. Working Days to issue the document: Recording this data will enable identification of the efficiency of the Practice in issuing referral documents and a comparison of actual time taken with target times to be made.

Clinician involved:

Recording this data will facilitate identification and rectification of any referral issues that are specific to a particular Clinician.

Patient Information that should be included in the Referral Document:

This features the list of the 18 Patient Criteria identified by the CQC that should be included (as a minimum) in each referral document issued by the Practice.

For each document in the sample, one of the following options should be recorded on the template against each criterion:

Y – This information has been included in the referral document

N – This information has NOT been included in the referral document, but should have been.

N/A – This information is not relevant to this particular referral.

Once the data has been entered in the Audit Template, it will need to be aggregated and the results summarised.An example of an aggregated data report is to be found on Pages 8 & 9 (N.B. Data is hypothetical).

A written summary report will also need to be compiled which identifies the issues arising and planned action to redress them (See hypothetical examples on Pages 10 & 11)

Decide on an acceptable Benchmark

The Audit is a continuous improvement tool and before it is undertaken, the Practice will need to decide what an acceptable benchmark is going to be:

For checking the referral informationhas been recorded, the % of referrals meeting the all the criteria will need to be set. (e.g. 90%; 95%; 99%). The results of the audit will then need to be compared to this benchmark.
For checking how long it is taking for the referrals documents to be completed, you also need to consider the criteria as well as the benchmark (e.g. 95% of routine letters will be issued within 5 working days of the consultation, 95% of urgent letters will be issued within 1 working day of the consultation)

If the benchmark / criteria is achieved, the Practice has evidence that it performed to the required benchmark level.

However, if the results are below the benchmark, an action plan will be required to determine what action is to be taken, by when and by whom, prior to the next audit date, when the above cycle will need to be repeated.

Doc. Ref – Version – Filename: Referral Desk Aid & Audit Data Collection TemplatePage 1 of 11

Beechdale Health Centre

Referrals Audit Data Collection Template

Patient
Reference
Number / Date of Consultation / Date Referral document issued / No. Working Days to issue Doc / Clinician Involved / Patient Informationthat should be included in the Referral Document / NOTES / COMMENTS
Name / Gender / Date of birth / Address / Unique ID number / Emergency contact details / Any persons acting on behalf of patient, plus contact details / Care records up to
point of transfer / Assessed needs / Known preferences and relevant diverse needs / Relevant previous
medical history / Any managed infections / Any current medicines taken / Any allergies / Key contact at sending provider / Reason for transfer / Any advance decision / Any assessed suicide / homicide or risk of self-harm or others
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Patient
Reference
Number / Date of Consultation / Date Referral document issued / No. Working Days to issue Doc / Clinician Involved / Patient Information that should be included in the Referral Document / NOTES / COMMENTS
Name / Gender / Date of birth / Address / Unique ID number / Emergency contact details / Any persons acting on behalf of patient, plus contact details / Care records up to
point of transfer / Assessed needs / Known preferences and relevant diverse needs / Relevant previous
medical history / Any managed infections / Any current medicines taken / Any allergies / Key contact at sending provider / Reason for transfer / Any advance decision / Any assessed suicide / homicide or risk of self-harm or others

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Beechdale Health Centre

Referrals Audit – Aggregated Data Report

Period 1st July 2011 > 30th September 2011

Total No. Referral Documents Issued in this period / 660
Margin of Error / 5%
Confidence Level / 95%
Sample Size (No. Referral Documents actually reviewed) / 244
Audit re time taken for Referral Document to be issued:
Overall Average Number of Working Days to issue Referral Doc / 4.3
Average Number of Working Days to issue Referral Doc by Clinician 1 / 3.7
Average Number of Working Days to issue Referral Doc by Clinician 2 / 4.2
Average Number of Working Days to issue Referral Doc by Clinician 3 / 5.3
Average Number of Working Days to issue Referral Doc by Clinician 4 / 4
Audit re checking the Patient information has been recorded:
Patient Information to be Included: / No.
Recorded / Overall
% Achievement / Variance
V
Benchmark
(95%)
Patient Name / 244 / 100% / 5%
Gender / 240 / 98% / 3%
Date of Birth / 232 / 95% / 0%
Address / 238 / 97% / 2%
Unique ID Number / 205 / 84% / -11%
Emergency contact details / 188 / 77% / -18%
Any persons acting on behalf of patient, plus contact details / 175 / 71% / -24%
Care records up to point of transfer / 236 / 96% / 1%
Assessed needs / 224 / 91% / -4%
Known preferences and relevant diverse needs / 216 / 88% / -7%
Relevant previous medical history / 241 / 98% / 3%
Any managed infections / 239 / 98% / 3%
Any current medicines taken / 244 / 100% / 5%
Any allergies / 237 / 97% / 2%
Key contact at sending provider / 220 / 90% / -5%
Reason for transfer / 237 / 97% / 2%
Any advance decision / 216 / 88% / -7%
Any assessed suicide / homicide or risk of self-harm or others / 205 / 84% / -11%

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Clinician 1 / Clinician 2 / Clinician 3 / Clinician 4
No.
Recorded / %
Achieved / Variance
v
B’Mark / No.
Recorded / %
Achieved / Variance
v
B’Mark / No.
Recorded / %
Achieved / Variance
v
B’Mark / No.
Recorded / %
Achieved / Variance
v
B’Mark
Total No.Sampled Referrals
by Clinician / 58 / 66 / 63 / 57
Patient Name / 58 / 100% / 5% / 66 / 100% / 5% / 64 / 100% / 5% / 57 / 100% / 5%
Gender / 58 / 100% / 5% / 63 / 95% / 0% / 62 / 98% / 3% / 57 / 100% / 5%
Date of Birth / 56 / 97% / 2% / 62 / 94% / -1% / 59 / 94% / -1% / 55 / 96% / 1%
Address / 57 / 98% / 3% / 64 / 97% / 2% / 62 / 98% / 3% / 55 / 96% / 1%
Unique ID Number / 48 / 83% / -12% / 50 / 76% / -19% / 55 / 87% / -8% / 52 / 91% / -4%
Emergency contact details / 53 / 91% / -4% / 50 / 76% / -19% / 45 / 71% / -24% / 40 / 70% / -25%
Any persons acting on behalf of patient, plus contact details / 52 / 90% / -5% / 43 / 65% / -30% / 45 / 71% / -24% / 35 / 61% / -34%
Care records up to point of transfer / 55 / 95% / 0% / 64 / 97% / 2% / 62 / 98% / 3% / 55 / 96% / 1%
Assessed needs / 50 / 86% / -9% / 60 / 91% / -4% / 62 / 98% / 3% / 52 / 91% / -4%
Known preferences and relevant diverse needs / 47 / 81% / -14% / 62 / 94% / -1% / 59 / 94% / -1% / 48 / 84% / -11%
Relevant previous medical history / 57 / 98% / 3% / 65 / 98% / 3% / 63 / 100% / 5% / 56 / 98% / 3%
Any managed infections / 58 / 100% / 5% / 66 / 100% / 5% / 63 / 100% / 5% / 52 / 91% / -4%
Any current medicines taken / 57 / 98% / 3% / 66 / 100% / 5% / 64 / 100% / 5% / 57 / 100% / 5%
Any allergies / 56 / 97% / 2% / 64 / 97% / 2% / 62 / 98% / 3% / 55 / 96% / 1%
Key contact at sending provider / 50 / 86% / -9% / 58 / 88% / -7% / 56 / 89% / -6% / 56 / 98% / 3%
Reason for transfer / 58 / 100% / 5% / 66 / 100% / 5% / 56 / 89% / -6% / 57 / 100% / 5%
Any advance decision / 47 / 81% / -14% / 60 / 91% / -4% / 54 / 86% / -9% / 55 / 96% / 1%
Any assessed suicide / homicide or risk of self-harm or others / 53 / 91% / -4% / 46 / 70% / -25% / 55 / 87% / -8% / 51 / 89% / -6%

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Example Action Plan re time taken for Referral Document to be issued:

ISSUE / ACTION TO BE TAKEN / BY WHOM / BY WHEN / OUTCOME
Excessive time delay between consultation and referral letters being issued / Investigate possible admin reasons, e.g. holidays, sickness etc. and report back to practice manager / Secretary / 06.10.11 / Typist on leave for 2 weeks during audit period.
One clinician only dictating once per week, which greatly reduces amount of time left for typing before deadline is breached.
Discussion with clinicians / PM / 10.10.11 / Agreed that clinicians will dictate every other day to reduce delay in sending tapes for typing.
To re-audit in 3 months

Example Action Plan re checking the Patient information has been recorded:

ISSUE / ACTION TO BE TAKEN / BY WHOM / BY WHEN / OUTCOME
Patient ID No.
not recorded / Consider creating template within clinical system with all relevant information included.
Discuss at practice meeting
Ensure all referrers have a copy of the desk aid
Remind all referrers via intranet and at practice meeting about the need to capture information / IT Lead
Secretary
PM / 30.09.11
30.09.11
30.09.11 / Discussed at meeting and agreed to go ahead. To be in place by 15.10.11
Completed
Completed
Emergency contact details not recorded / As item 1 above
Reception staff to opportunistically gather this information
Alter new patient registration form to ask this question / As 1 above
Reception Mgr
Secretary / As 1 above
Ongoing
30.09.11 / As 1 above
Continue indefinitely
Added to form
Person acting on behalf of patient, plus contact details / As item 1 above / As 1 above / As 1 above / As 1 above
Assessed needs / As item 1 above / As 1 above / As 1 above / As 1 above
Known preferences and relevant diverse needs / As item 1 above
Reception staff to opportunistically gather this information
Alter new patient registration form to ask this question / As 1 above
Reception Mgr
Secretary / As 1 above
Ongoing
30.09.11 / As 1 above
Continue indefinitely
Added to form
Key contact at sending provider / As item 1 above / As 1 above / As 1 above / As 1 above
Any advance decision / As item 1 above
Alter new patient registration form to ask this question / As 1 above
Secretary / As 1 above
30.09.11 / As 1 above
Added to form

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