Waiting Time and Elective Surgery Access Policy

ManagingElective Surgery patients in ACT public hospitals

DGD16/015 Issue date: July 2016

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

Waiting Time and Elective Surgery Access Policy

CONTENTS

1INTRODUCTION

2REFERRING PATIENTS FOR ELECTIVE SURGERY

2.1Elective Surgery Categorisation

2.2 Re-classification of the Clinical priority Urgency Category

2.3Excluded Procedures

2.4Completion of the Request for Admission Form (RFA)

2.5Submitting a RFA

2.6Processing a RFA

2.7Listing Date

2.8Variations from Standard Bookings

3MANAGING PATIENTS ON THE WAITING LIST

3.1Calculating Waiting Times

3.2 ‘Treat in turn’

3.3Clinical Review

3.4Ready for Surgery (RFS)

3.4.1Delayed Patients

3.4.2Declined Patients

3.5Not Ready for Surgery (NRFS)

3.5.1Not Ready for Surgery – Staged Patients

3.5.2Not ready for surgery – Pending Improvement of Clinical Condition

3.5.3Not Ready for Surgery – Deferred for Personal Reasons

3.6Admission Process

3.7Hospital Initiated Postponement (HIP)

3.8Patient Initiated Postponement:

3.9Reporting of Hospital Initiated Postponements (HIPs)

4DEMAND MANAGEMENT

4.1Demand Management Escalation

4.2Transferring Patients to another Facility for surgery

4.3Removing Patients from the Waiting List

5RECORD KEEPING

5.1Postponement of Planned Admission

5.2Removal of Patients from the Waiting List (other than admission)

6AUDITING THE WAITING LIST

6.1 Clerical Audit

6.2Request for Admission (RFA) Audit

7DOCTOR’S LEAVE – TEMPORARY OR PERMANENT

7.1Resignation, Retirement or Sudden Death

8DEFINITIONS

9APPENDICES

Appendix 1 - Patient Notification Letter

Appendix 2 – Audit letter

Appendix 2 – Audit letter

Appendix 3 - Removal from Waiting List Letter

Appendix 4 – Reclassification of Clinical Priority form

Appendix 5 – Notification to patient of Registration on the waiting list

Appendix 6 – Urgency Category outside National Guidelines

Appendix 7 – Letter to GP advising of patient who smokes

Appendix 8 – GP Notification Letter

Appendix 9 – Minimum Data Set Incomplete

Appendix 10 – Paediatric Notification Letter

Appendix 11 – Excluded Procedure notification

10REFERENCES

11ACRONYMS

12NATIONAL ELECTIVE SURGERY URGENCY CATEGORY GUIDELINE

CARDIO THORACIC SURGERY

OTOLARYNGOLOGY HEAD AND NECK SURGERY

GENERAL SURGERY

GYNAECOLOGY SURGERY

NEUROSURGERY

OPHTHALMOLOGY SURGERY

ORTHOPAEDIC SURGERY

PAEDIATRIC SURGERY

PLASTIC & RECONSTRUCTIVE SURGERY

UROLOGICAL SURGERY

VASCULAR SURGERY

1INTRODUCTION

Each year approximately 12,000 people from the Australian Capital Territory (ACT) and the surrounding region have elective surgery as patients of the ACT public hospital system.

Surgery is defined as procedures listed in the surgical operations section of the Commonwealth Medical Benefits Schedule. Surgery is classified as either emergency surgery, elective surgery or other surgery on the basis of a patient’s presentation and subsequent care.

Emergency surgery is defined as surgery to treat trauma or acute illness subsequent to an emergency presentation. The patient may require immediate surgery or present for surgery at a later time following this unplanned presentation. This includes where the patient leaves hospital and returns for a subsequent admission. Emergency surgery also includes unplanned surgery for admitted patients and unplanned surgery for patients already waiting for an elective surgery procedure (for example, in cases of acute deterioration of an existing condition).

Elective Surgery is defined as planned surgery that can be booked in advance as a result of a specialist clinical assessment resulting in placement on an elective surgery waiting list.

Other surgery is where the procedure cannot be defined as either emergency surgery or elective surgery, for example, transplant surgery and planned obstetric procedures.

Elective surgery in the public hospital system is provided through the use of waiting lists, which are registers of patients who are waiting for elective care. Patients are placed on a waiting list and assigned to a clinical priority urgency category depending on the seriousness of their condition. Clinical priority urgency categories 1, 2, and 3 referred to in this document are consistent withthe National Elective Surgery Urgency Category guidelines developed in conjunction with the Australian Institute of Health and Welfare (AIHW) and the Royal Australian College of Surgeons (RACS) to enable improved consistency and reporting of elective surgery.

The capacity of the public health system to provide elective surgery is influenced by a number of crucial factors. These include the demand for emergency surgery, demand for the surgical specialty, demand for hospital beds due to emergency and urgent medical care, the supply of surgeons, anaesthetists and nursing staff, theatre capacity, scheduling and management practices, and effective discharge planning of patients from hospital.

Managing elective surgery and waiting lists is a key priority for the ACT Government and
ACT Health. The community insists on transparency and accountability and patients expect timely, accessible and high quality patient-centred services. Failure to comply with ACT Health Policy may form part of ongoing divisional and/or individual performance reviews.

Hospitals have a responsibility for ensuring compliance with the contents of this document, and that processes are in place to:

  • Implement the framework
  • Identify staff roles and responsibilities
  • Validate the accuracy and integrity of reported data
  • Regularly review individual hospital performance against Locally and Nationally set key performance indicators
  • Train and educate staff managing elective surgery and the waiting lists

The framework seeks to:

  • Support active management of patients waiting for elective surgery
  • Support best practice in elective surgery waiting list management
  • Identify the rights and responsibilities of hospitals, referring surgeons and patients
  • Improve communication among patients, hospitals, referring surgeons and community providers
  • Support meaningful reporting to the public by hospitals and the government

The following principles underpin the Policy:

  • Referrals forelective surgery are clinically appropriate and are representative of a suitable treatment for the patient’s condition
  • Patients are provided with easy to understand information about access to elective surgery and their rights and responsibilities
  • Public patients are the shared responsibility of the hospital, the referring surgeon and the relevant specialty
  • Patients waiting forelective surgery are fully informed about, and have consented to the procedure/treatment
  • All documentation is complete, legible and accurate
  • Waiting list management services are provided in an efficient, transparent and patient-centred manner
  • Theelective surgery waiting list is managed to ensure patients are treated equitably within clinically appropriate timeframes and with priority given to patients with an urgent clinical need
  • The scheduling of surgery is undertaken in consideration of available capacity
  • Hospitals minimise the impact and inconvenience to patients whose surgery they postpone
  • Theelective surgery waiting list is managed to promote the most effective use of available resources
  • Patients are categorised in accordance with National Elective Surgery Urgency Categories
  • There is valid, reliable and accountable reporting of access toelective surgery

RESPONSIBILITIES

Responsibilities of the Patient:

  • Follow the procedures and advice outlined in the information provided
  • Advise the hospital of any change in desire to undergo the procedure/treatment
  • Follow hospital admission procedure and advise of any changes to the proposed admission, such as availability or change of address or other contact details
  • Attend any preadmission appointments as required and present on the day of admission

Responsibilities of the General Practitioner (GP):

  • Arrange referral for patients to a hospital that has surgeons with the appropriate expertise and the least waiting time for the anticipated surgical procedure (outpatient waiting time and travelling time should also be considered)
  • Provide the hospital with appropriate health information and personal details of the patient with referral
  • Liaise with the referring surgeon if there is a change in any indications for surgery or a change in patient’s health that may have implications for surgery and treatment

Responsibilities of the Surgeon or delegate (Registrar):

  • Explain the proposed procedure/treatment,options for treatment and potential complications and the anticipated length of stay, using an interpreter if required.
  • Explain that the procedure may be performed by another surgeon and/or another hospital
  • Consent forms are to be completed and signed by the surgeon and patient contemporaneously
  • If consent is provided by the person prior to their current admission, they are to have their consent reconfirmed on the ward or in the Surgical Admissions Area prior to transfer into the theatre suite. The staff member confirming consent will need to ensure that the person signs the confirmation of consent part of the Consent to Treatment form as part of this process
  • Assign a clinical priority urgency category for the procedure/treatment using the National Elective Surgery Urgency Category guidelines
  • If a patient is classified as staged, the time interval when the patient will be ready for surgery should be indicated
  • Ensure that Request For Admission (RFA) forms are legible and the minimum data set is completed
  • Forward completed RFA’s directly to the Central Wait List Service within 5 working days of signing and dating the RFA
  • Initiate prompt and appropriate communication with the referring GP regarding the proposed management of the patient
  • Referring doctors should ensure that they are able to perform the patient’s surgery within the clinical priority urgency category timeframe that they assign (excepting patients who may require multimodality therapies as parts of their treatment plan e.g. some colorectal surgery). The referring doctorshould advise the relevant hospital executive if they are unable to provide the service and discuss an appropriate management plan for the patient. As a result doctors should not submit category oneRFA’s when they will be away during that period, unless they have pre-discussed a management plan with the relevant hospital. Such RFA’s will be returned to the surgeon to make such plans. Referring doctors must advise patients of their current waiting time for surgery if added to their elective surgery waiting list. This ensures the patient is informed about their approximate wait time and can make an informed decision regarding their care that may include proceeding with the referring surgeon, being referred to another surgeon and/or exploring other options such as utilising private health insurance. All clinicians are provided with their Wait List on a quarterly basis. This information will enable the clinician to provide patients with an accurate estimation of their current waiting times
  • Review the waiting list and verify with the hospital
  • Inform patients if a RFA is not accepted and the patient not placed on the elective surgery waiting list

Responsibilities of the Central Wait List Office:

  • Comply with local procedures/protocols for administrative processes that support this Policy
  • Ensure all documentation and electronic data input is accurate, legible and complete
  • Ensure procedures included in the excluded list of procedures are not added to the waiting list without approval from the Director – Territory Wide Surgical Services

Responsibilities of the Surgical Booking Office:

  • Comply with local procedures/protocols for administrative processes that support this Policy
  • Undertake all relevant audits to ensure all documentation and electronic data input is accurate, legible and complete
  • Assist in planning for patients surgery and patient notification for surgery and pre-admission appointments
  • Review and management of all patients listed on the elective surgery waiting list

Responsibilities of the Clinical Director of Surgical Services (TCH) / Director of Medical Services (CHC):

  • Ensure clinician compliance with this Policy
  • Promote efficient and effective waiting list management by clinicians within their hospital
  • Liaise with the Director - Territory Wide Surgical Services for escalation of any issues

Responsibilities of the Director of Territory Wide Surgical Services:

  • Provide advice on Territory wide issues relating to surgery
  • Review and manage applications to perform excluded procedures
  • Promote compliance with this Policy
  • Act as an adjudicator for issues that require resolution

2REFERRING PATIENTS FOR ELECTIVE SURGERY

All patients referred for an elective surgery procedure must have a RFA form completed. The RFAand consent to treatment forms,located in the Planned Hospital Admission Booklet for Surgical and Medical Care,will only be accepted if completed by Consultant Clinicians and Registrarscurrently contracted to ACT Health, and appropriately credentialed with the Medical and Dental Appointments Advisory Committee and the respective hospital.

The referring surgeon must:

  • Complete an approved RFA Form ensuring the minimum data set is complete, legible and accurate
  • Assign a clinical priority urgency category consistent with the National Elective Surgery Urgency Categoryguideline and providea clinically verifiable reason to assign a different category (if required)
  • Ensure patients are fully informed about the risks and benefits of the procedure and have consented to the treatment offered[1]
  • Consent to be completed by the surgeon performing the surgery or his delegate e.g. Registrar
  • If consent is provided by the person prior to their current admission, they are to have their consent reconfirmed on the ward or in the Surgical Admissions Area prior to transfer into the theatre suite. The staff member confirming consent will need to ensure that the person signs the Confirmation of Consent part of the Consent to Treatment form as part of this process
  • Ensure patients are ready for surgery and ready to accept a surgery date
  • Forward the completed RFA to the CentralWait List Service within 5 working days of signing the RFA
  • Ensure the RFA is signed and dated on page 4
  • Inform patients that while generally public patients will be admitted under the care of the referring surgeon, this is not guaranteed
  • Inform patients that the location of their surgery can vary and they will be allocated a surgery site appropriate to their surgical requirements
  • Ensure that they are able to perform the patients surgery within the clinical priority urgency category timeframe that they assign (excepting patients who may require multimodality therapies as part of their treatment plan e.g. some colorectal surgery)
  • If a RFA is presented for a procedure(s) a surgeon is unable to perform, for any reason, the RFA is not to be added to the surgeons’ waiting list and should be returned to the doctor’s rooms as soon as possible
  • Inform the patient of an approximate waiting time for surgery

2.1Elective Surgery Categorisation

Categorisation of elective surgery patients is prioritised by clinical urgency and is required to ensure patients receive care in a timely and clinically appropriate manner. A clinical urgency priority is assigned by the referring surgeon using the National Elective Surgery Urgency Categories as a guide. Categories assigned outside the guidelines must have a clinically verifiable reason documented in the section provided on the RFA. RFAs received with a clinical priority urgency category outside of the National Guidelines and no documentation of a clinically verifiable reason will be added to the elective surgery Wait List in accordance with the National Guidelines. The Specialist Surgeon will be notified by letter (Appendix 6) that this has occurred. If a clinically verifiable reason exists for allocation to a higher/lower category, the Specialist Surgeon will be required to submit a re-categorisation form for processing within 7 days stating the clinically verifiable reason for change.

Elective Surgery is categorised into the following 3 categories which are defined as:

Category 1:Procedures that are clinically indicated within 30 days.

Category 2:Procedures that are clinically indicated within 90 days.

Category 3:Procedures that are clinically indicated within 365 days.

2.2 Re-classification of the Clinical priority Urgency Category

Re-classification of a patients assigned clinical priority urgency category to higher category (eg category 2 to category 1)must only occur following a clinical assessment/review of the patient by a medical officer and reflect a change in the patient’s condition that has occurred after the patient has been added to the elective surgery waiting list. This review could be done by phone for some patients, but patients should be offered a face to face assessment if they so desire, and clinically practicable.

Reclassification to a lower category (category 1 to category 2) the patient must be directly informed by the clinician, and reasons given to the patient.

Re-classification cannot occur following a review of clinical notes only, but can occur following receipt of investigative results that indicate a deteriorating, or improving condition.

Re-classification is independent of the outlined processes related to the National Elective Surgery Urgency Category Guideline when a patient is first added to the elective surgery waiting list.

Re-classification must not be used to facilitate ‘on time’ surgery when difficulties in scheduling may arise.

Authority to reclassify a patient’s clinical priority urgency category may only be undertaken by the Consultant or Delegate, who must complete the reclassification of clinical priority form, stating a clinical reason for the change. The clinical reason for the change may reflect deterioration in the patient’s condition or an improvement/reassessmentof the patient’s condition. There-classification will not be processed if a form is not completed or the form is incomplete.

Documentation of a re-classification must be recorded in the patient electronic record (ACTPAS) giving the reason for the change. Patients must be advised of any change in their clinical priority urgency category and a brief summary of the telephone conversation recorded in the patient’s electronic record.

Should the referring surgeon complete a new RFA form assigning a new clinical urgency category, this can only be accepted if the patient has signed the consent form or there is evidence that a clinical review/assessment of the patient has occurred.

If the new RFA has a different principle procedure listed, the original waiting list entry should be removed as ‘procedure no longer required’. The new RFA is then logged onto the elective surgery waiting list with the new procedure listing date being backdated to the original listing date.