STANDARD OPERATING PROCEDURES FOR
18 WEEK CONSULTANT LED AND ALLIED HEALTH PROFESSIONAL LED PATHWAYS
The purpose of this procedure document is to ensure all Wye Valley NHS Trust staff are aware of the way the Trust manages patient 18 Week Referral to Treatment Consultant Led and Allied Health Professional pathways and their roles and responsibilities to achieve this. It is vital these are correctly recorded on the Patient Administration Systems giving a concise view of the Trust position with regard to patient access and treatment pathways, to assist with capacity planning ensuring patients are seen timely, chronologically and fairly in relation to the NHS Constitution, Patient Choice and the Standard National Contract for Acute and Community Services.
This procedure document must be read and acted upon in accordance with the Trust’s Access Policy.
Key Performance Indicators (KPI) within this document are drawn directly from the Access Policy and staff will be competency managed according to KPI compliance and objectives set within Staff Performance and Development Reviews (SPDR)
This Document is to aid staff in understanding 18 Week RTT Pathways and entering data onto PAS Systems. It does not replace formal PAS or ORMIS training and is aimed at staff competent at using both systems
Table of Contents
1. Scope
2. Introduction
3. Statement of Intent
4. Definitions
5. Duties
6. 18 Week Clock Starts / Stops / Procedures
7. Training
8. Monitoring Compliance with these procedures
9. References / Bibliography
10. Related Trust Policy / Procedures
Appendices
1 Key Performance Indicators
2 WVT process for managing Electronic Referral System (eRS) ASI work lists
3 Internal Referral flow chart
4 Policy for patients who require appointments for assessment, review and/or
treatment – use of planned (pending or review) lists
5 Inter Provider Transfer process
6 Standard Operating Procedure – Information Required on ORMIS as Standard
7 Guidance for the Management of Inpatient Waiting Lists (Fit, Ready & Available
Policy
1. Scope
This policy and procedure document relates to all Wye Valley NHS Trust (WVT) employees managing patient 18 Week Referral to Treatment (RTT) pathways, waiting lists and booking management; detailing all processes for managing patient pathways across WVT services.
All WVT employees must refer to these Standard Operating Procedures (SOPs) and supporting documents, policies and procedures; ensuring that all patient 18 Week RTT pathways are validated, and Patient Administration Systems (PAS) are correctly recording pathways for Clock Starts / Stops / Pauses within outpatient and inpatient outcomes, waiting lists and referrals.
This policy is applicable to:
· All staff working within WVT
· All third party contractors working with WVT
· All third party personnel working within WVT
2. Introduction
Since 2008, Wye Valley NHS Trust has had a duty of care to ensure all patients receive 1st Definitive Treatment to manage their illness or disease within 18 Weeks from receipt of referral for Consultant Led Pathways and since 2011 for Allied Health Professional led pathways.
Underlying 18 Week RTT is the principle that patients should receive excellent care without unnecessary delay.
To monitor this, monthly returns are submitted detailing WVT performance across specialties showing the number of patients who received 1st Definitive Treatment within 18 Weeks from referral, either within outpatient or inpatient settings. It also details those specialties who breached the 18 Week target and by how many weeks. This information is published by NHS England and is available for patients on the Patient Choice website. It is also available on the Electronic Referral System (e-RS) to allow patients choice when deciding where they would like to be treated.
In June 2015, it was agreed that the incomplete pathway operational standard should became the sole measure of patients’ constitutional right to start treatment within 18 weeks with a target of 92%.
This emphasises that those patients who choose to wait longer should have their wishes accommodated without being penalised. The tolerance of 8% set for achievement of the incomplete pathway waiting time operational standard is there to take account of the following situations that might lead to a longer waiting time:
• Patients who choose to wait longer for personal or social reasons
• Patients for whom it is clinically appropriate to wait longer (this does not include clinically complex patients who can and should start treatment within 18 weeks)
• Patients who fail to attend appointments they have agreed.
The Trust will still monitor and report internally on the Admitted and Non-Admitted performance targets.
Medical or surgical Consultant Led care Referrals can come from various sources as well as General Practitioners. These include:
• Nurse Practitioners
• GPs with a special interest
• Allied Health Professionals
• A&E
• Consultants
• Dentists (although not for referrals to primary dental services provided by dental undergraduates in hospital settings)
WVT Access Policy Statement and Access Policy Standard Operating Procedures details how referrals into the Trust will be managed and these must be read in conjunction with this Policy. The RTT pathway is from receipt of referral to 1st Definitive Treatment or discharge without treatment.
These Standard Operating Procedures provide a practical guide for the use of everyone charged with waiting list and booking management to ensure patient 18 Week pathways are managed at every stage of the patient journey from referral to first outpatient appointment, to diagnostic investigations, to 1st Definitive Treatment to manage their condition, whether this be within the specialty to which the patient was originally referred or by internal referral to another specialty or service within the Trust or with tertiary referral to another provider.
Welsh patients will be treated equally and chronologically within Welsh RTT Rules.
Welsh patients will be validated for Monmouthshire at 26 weeks and Powys at 36 weeks.
3. Statement of Intent
WVT will manage every referral fairly, equitably and transparently by using the Access Policy and ensuring all activity for 18 Week RTT is monitored by the use of a Patient Pathway Validation tool (PPV), Trustwide PTL and Key Performance Indicators (KPI).
Patients will be booked according to priority and chronologically.
Where patients do not receive definitive first treatment within 18 Weeks from referral they will be fully validated and the reasons for the failure to treat within 18 Weeks will be escalated daily; ensuring senior management and WVT Board are fully aware of the Trust 18 Week RTT position.
The Trust will, by use of its Access Policy:
· Ensure all referrals are recorded on the PAS Systems within 24 hours of receipt into the Trust
· Patients who cancel two consecutive negotiated EROD new outpatient appointments may be returned to the care of their GP and the clock will be stopped
· Patients who do not attend (DNA) for an outpatient or inpatient appointment may be removed from the waiting lists and returned to the care of their GP by clinical decision
· Patients will be added to an inpatient waiting list within 24 hours of the decision to admit – the waiting list start date being the date of the decision to admit
· Patients will only be added to the inpatient waiting list if they are clinically and socially ready for admission
· Patients who cancel two confirmed negotiated EROD offer dates for admission will be removed from the waiting list and returned to the care of their GP
· Patients on an inpatient waiting list may delay treatment but this should not be for more than 8 weeks (and clinical advice may be sought on the implications of any delay) – their 18 week clock will continue ticking and no time is taken out for reporting. The “pause” should be shown on PAS for auditing purposes.
· Patients on an inpatient waiting list who wish to delay treatment for more than 8 weeks should be returned to the care of their GP, for re-referral and fast track back to the inpatient waiting list when they are available for treatment
· Patients under review, where a decision has been made not to treat, may be kept under Active Monitoring (but must be removed from the Inpatient Waiting List under clinical guidance).
3.1 RTT Status
The Trust will ensure all patient 18 Week RTT pathways are correctly recorded and that staff are fully trained to enter correct RTT status at every stage of the patient journey, whether this be in the form of an outcome form for administrative staff to enter on PAS Systems or as direct pathway validation ie:
· Outpatient depart RTT Status outcome
· Inpatient discharge RTT Status outcome
· Outpatient Appointment Cancellation
· Contact outcomes
· Administrative RTT Status outcome – Ad Hoc entry on referral Patient Pathway tab
RTT Status will not be entered on cancelled waiting lists outcomes as these cannot be amended if incorrect. Ad hoc entries should be entered for all cancellations.
3.2 Escalation Process
4. Definitions
RTT Referral to Treatment
GP General Practitioner
WVT Wye Valley NHS Trust
CAB Choose & Book
PAS Patient Administration System
PTL Patient Tracking List
KPI Key Performance Indicator
SOPs Standard Operating Procedures
SPDR Staff Performance and Development Reviews
DNA Did Not Attend
IP Inpatient
WL Waiting List
OP Outpatient
PPID Patient Pathway Identifier
ORMIS Theatre Electronic System
EROD Earliest Reasonable Offer Date
5. Duties
5.1 Chief Operating Officer
The Chief Operating Officer is the responsible director for this policy and for ensuring 18 Week RTT targets are met within WVT.
5.2 Head of Patient Access
The Head of Patient Access is the responsible officer for ensuring Standard Operating Procedures are adhered to.
The Head of Patient Access will ensure the RTT Recovery Plan is maintained and will report directly to the Chief Operating Officer.
5.3 Divisional Operational Directors and General Managers
Divisional Operational Directors and General Managers are responsible for ensuring 18 Week RTT targets are met within their Divisions by ensuring capacity planning is regularly carried out and that outpatient clinic and inpatient capacity is sufficient to ensure elective and emergency pathways are maintained.
Divisional Operational Directors and General Managers will report any shortfalls immediately to the Chief Operating Officer ensuring no patients breach 18 Weeks from referral to 1st Definitive Treatment, and that these are managed chronologically, in order of priority and in accordance with WVT Access Policy rules.
Divisional Operational Directors and General Managers will ensure staff are correctly and daily validating the Trustwide PTL and PPV and will action all notifications of potential or actual breaches immediately; ensuring capacity is available for patients to be treated.
5.4 Head of Information
The Head of Information is responsible for ensuring the Patient Tracking List (PTL) for 18 Week pathways is produced weekly/daily as required.
The Head of Information will escalate potential or actual breaches to the Chief Operating Officer daily immediately they are identified.
5.5 Operational Support Managers
Operational Support Managers (OSMs) are responsible for ensuring all 18 Week RTT pathways are fully validated and correct on WVT PAS and ORMIS Systems and that these are managed chronologically, in order of priority and in accordance with WVT Access Policy rules.
Operational Support Managers (OSMs) are responsible for ensuring all staff involved in managing 18 Week RTT pathways are fully trained and understand 18 Week rules and are able to put these into practice ensuring all patients are treated within 18 Weeks from referral to 1st Definitive Treatment.
Operational Support Managers (OSMs) will attend weekly PPV/PTL Review meetings (or send representatives), reporting on all pathways which may breach and how these will be managed.
Operational Support Managers (OSMs) will ensure the PPV is validated daily and will escalate potential or actual breaches to the General Managers immediately they are identified.
Operational Support Managers (OSMs) will negotiate with Consultant staff for extra capacity in outpatients and inpatients to ensure patients do not breach 18 Weeks from referral to 1st Definitive Treatment.
Compliance with the Access Policy and 18 Week RTT rules will be measured using Key Performance Indicators and all staff will be measured against these (see Appendix 1)
5.6 Consultant and Clinical Staff
All Consultant and Clinical Staff should be fully conversant with 18 Week Consultant Led Pathway rules and able to put these into practice.
All Consultant and Medical Staff are responsible for ensuring they know where patients are on their 18 Week RTT pathways and for taking action to ensure patients are treated within 18 Weeks from referral to 1st Definitive Treatment.
Consultant and Clinical Staff will work closely with Operational Support Managers (OSMs) to ensure capacity is available in outpatients and inpatients to ensure WVT 18 Week targets are met and that these are managed chronologically, in order of priority and in accordance with WVT Access Policy rules.
Consultant and Clinical Staff are responsible for correctly completing outcome forms for patients; ensuring the 18 Week RTT statuses is correct and reflects where the patient is on the 18 Week pathway.
Compliance with Access Policy and 18 Week RTT rules will be measured using Key Performance Indicators and all staff will be measured against these (see Appendix 1)
5.7 Medical Secretaries
Medical Secretaries are responsible for ensuring patients are seen to ensure they are treated within 18 Weeks from referral to 1st Definitive Treatment.