Bedford Hospital NHS Trust: Examining the Management of the Inpatient Waiting List

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Examines, end-to-end, the impatient waiting list process of Bedford Hospital NHS Trust to identify areas of process improvement and further action.

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Bedford Hospital NHS Trust: Examining the Management of the Inpatient Waiting List

  1. 1. Bedford Hospital Trust Bedford Hospital NHS Trust Examining the Management of the Inpatient Waiting List © 2003 Peter Louis. All Rights Reserved
  2. 2. Bedford Hospital NHS Trust © 2003 Peter Louis. All Rights Reserved ii
  3. 3. Contents Contents .............................................................................................................. iii Glossary ................................................................................................................ v Executive summary............................................................................................... 1 Background ........................................................................................................... 3 Methodology ......................................................................................................... 4 The NHS and Bedford BHS Trust...................................................................... 4 The waiting list process ..................................................................................... 5 Process maps.................................................................................................... 6 Results & findings ................................................................................................. 9 Specialities ........................................................................................................ 9 Ear, Nose and Throat .................................................................................... 9 General Surgery and Urology ...................................................................... 11 Gynaecology ................................................................................................ 18 Ophthalmology............................................................................................. 20 Oral Maxillo-Facial ....................................................................................... 22 Trauma and Orthopaedics ........................................................................... 23 Support departments ....................................................................................... 26 Accident and Emergency ............................................................................. 26 Admissions Department ............................................................................... 26 Bed Manager ............................................................................................... 27 Critical Care ................................................................................................. 28 Inpatient PAC............................................................................................... 28 Medical Records .......................................................................................... 28 Outpatient Process ...................................................................................... 29 Reginald Hart Inpatient Ward....................................................................... 29 Tavistock Day Case Ward ........................................................................... 30 Theatre Process .......................................................................................... 31 Waiting List Department............................................................................... 31 Waiting List Manager ................................................................................... 33 Discussion .......................................................................................................... 35 Outpatient clinic ............................................................................................... 35 Allocation of TCI dates .................................................................................... 37 Creation of theatre schedules.......................................................................... 42 Managing patient cancellations ....................................................................... 44 Managing DNAs .............................................................................................. 46 Managing hospital cancellations – surgical fitness .......................................... 49 Managing hospital cancellations – hospital resources..................................... 53 Use of PiMS .................................................................................................... 54 Further action ...................................................................................................... 55 Waiting list management best practice ............................................................ 55 Centralised versus decentralised Admissions ................................................. 55 © 2003 Peter Louis. All Rights Reserved iii
  4. 4. Day surgery ..................................................................................................... 55 Effect of ward processes on the management of inpatient waiting lists ........... 55 Acknowledgements ............................................................................................. 56 References.......................................................................................................... 57 Appendix A – PiMS ............................................................................................. 59 Appendix B – Targets and guidelines ................................................................. 63 Waiting List Targets ......................................................................................... 63 Waiting List Guidelines .................................................................................... 64 Placement and Removals ............................................................................ 64 Primary Targeting Lists ................................................................................ 66 Inpatient and Day Case Procedures ............................................................ 66 Pre Assessment........................................................................................... 67 Monitoring Cancellations and DNAs ............................................................ 67 Guidelines Developed by the Trust ................................................................. 68 Appendix C – Interview scope............................................................................. 69 © 2003 Peter Louis. All Rights Reserved iv
  5. 5. Glossary Checklist: Checklist is a piece of software widely used for waiting list management. Clinical priority: This defines the priority given to a patient during an outpatient appointment. Clinician: A health care professional engaged in the care of patients, as distinguished from one working in other areas. Specifically, within the process maps developed, “clinician” refers to a consultant or less senior doctor. Consultant team: This team includes all the staff that work with the consultant in assigning TCI dates to patients. Critical care: Health care provided to a critically ill patient during a medical emergency or crisis. Day case/surgery: A surgical procedure for elective patients where patients return home on the same day on which the procedure is performed. DNA - Did Not Attend: A DNA is a patient who fails to turn up for an appointment, PAC or operation without giving prior notice. Domain Expert This individual has detailed knowledge of a process, activity or event. DTA - Decision to Admit: The decision made by a clinician during an outpatient appointment that a patient needs further treatment. Elective Patient: © 2003 Peter Louis. All Rights Reserved v
  6. 6. A patient admitted to hospital for a planned procedure after an outpatient consultation. Emergency: Service offers care to patients who arrive with urgent problems and who have not usually been seen previously by a general practitioner Emergency bed service: This service covers the assignment of beds to the emergencies arrived at the hospital. GP - General practitioner: These doctors provide family health services to a local community. They are usually based in a surgery or GP practice and are often the first port of call for most patients with a concern about their health. GPs refer patients who need more help to specialists, such as hospital consultants. House officer: An intern or resident employed by a hospital to provide service to patients while receiving training in a medical specialty. Inpatient: Persons admitted to health facilities which provide board and room, for the purpose of observation, care, diagnosis or treatment. Medical Records: The department that holds information concerning patient medical history. Nurse Practitioner: A registered nurse with advanced training in a particular area of health care, e.g., paediatric nurse practitioners has additional education in the care of children. O/P – Outpatient A patient referred to a consultant by a GP or consultant. O/P referral letter: © 2003 Peter Louis. All Rights Reserved vi
  7. 7. A letter sent by the Consultant to a patients referrer to inform them of the outcome of the outpatient appointment O/P Clinic: An administrative arrangement enabling patients to see a health professional at a consultant clinic, nurse clinic, midwife clinic, family planning clinic, or at any other clinic. Outlier: An outlier is a patient who occupies a bed in an incorrect ward i.e. a urology patient in an orthopaedic ward. PTL – Primary Targeting List: The PTL is the list provided by the Waiting List Department outlining the patients with the longest waiting time and therefore highest priority. PAC - Pre-Assessment Clinic: A clinic that assesses general health and fitness of patients for surgical procedures. PAAF - Patient Awaiting Admission Form: A form that details patient information, procedure and TCI date. PiMS - Patient Information Management System: PIMS is the Patient Information Management System used by Bedford Hospital NHS Trust. Preoperative care form: The preoperative care form is filled by a nurse on the ward before surgery takes place Referrer: The Referrer is the healthcare worker who referred a patient to the hospital Referral letter: This provides information on the patient and the reason for referral to a consultant Registrar: © 2003 Peter Louis. All Rights Reserved vii
  8. 8. This grade of medical staff is a member of a consultant‟s team. Routine: That is the name given to a usual, habitual, regular clinical priority. Senior clinical officer: This grade of medical staff is a member of a consultant‟s team. SHO – Senior House Officer: This grade of medical staff is a member of a consultant‟s team. Side of Operation: The area to be operated upon in theatre must be marked before surgery can go ahead. This must be done by a clinician qualified to carry out the surgery. Soon: That is the name given to a case that needs to be attended faster than a routine clinical priority. Specialist: One who devotes himself to diseases of particular parts of the body, as the eye, the ear, the nerves, etc. Surgical case: The surgical case relating to an operative procedure. T-Card: These cards are used to record patient information, mainly at the Trauma and Orthopaedics specialty. T-Card board: This board is used to display the T-card of each patient, and is a visual tool to manage the state of each patient on the waiting list. TCI date – To Come In date The date when a patient is scheduled to attend the hospital for a procedure © 2003 Peter Louis. All Rights Reserved viii
  9. 9. TCI list: The list shows the patients that have been given TCI dates. Theatre list: The list shows the date of operation for each patient and the resources assigned to each of them (theatre, ward, time …) Tracer: Medical Records enter the person/dept to which patient notes are booked out from the library on a tracer Waiting list: The patients awaiting an inpatient or day case procedure Walk in patient: This is name given to patients who have their PAC on the same day as their outpatient appointment. © 2003 Peter Louis. All Rights Reserved ix
  10. 10. Executive summary The Inpatient Waiting List Project was initiated in February 2003 by Bedford Hospital NHS Trust in cooperation with Cranfield University to look at the inpatient waiting list process The aim was to provide a set of observations that would provide insight into how the process could be improved. The objectives of the project were to:  acquire knowledge of inpatient and day case management processes  acquire knowledge of the use and capabilities of relevant information systems  construct and analyse the „AS-IS‟ maps of the processes. Cranfield University was contracted to investigate the waiting list process of six surgical specialities and the administrative and clinical departments that were an integral part of the process. In total, 53 staff members at the Trust were interviewed. A complete list is provided in the Interview Scope in Appendix C. The methodology used by the team to achieve the objectives of the project consisted of a number of key stages: 1. Understanding the NHS and Bedford NHS Trust 2. Investigating and understanding the inpatient waiting list process at the Trust 3. Developing process maps to represent the inpatient waiting list process at the Trust 4. Analyzing the IDEF3 process maps to develop observations The main observations were: 1. Evidence of unclear working practices. The process maps indicated that on occasions, there were no clear channels of communication or ownership of responsibility for reporting information on, for example, DNAs or cancellations, within Trust. 2. There was duplication of both data and effort. Patient information was stored external to PiMS in private information stores, such as Access, © 2003 Peter Louis. All Rights Reserved 1
  11. 11. diaries or T-Boards. Moreover, information that was already contained in PiMS, such as which patient and TCI information, was re-entered into PiMS by the Theatre Department to create the operating list of each consultant. In conclusion, scope exists to standardise the waiting list management process by examining what best practices are performed within the Trust to reproduce those practices within the waiting list processes of other consultants. This report contains the in-depth knowledge required in order to achieve this. Nonetheless, other areas that may be considered include:  benefits of having a decentralised admission process versus a centralised admission process  whether opportunities exist to undertake more surgical procedures as day surgeries  a survey of best practice knowledge among other clinical and ward staff not interviewed as well as patients. © 2003 Peter Louis. All Rights Reserved 2
  12. 12. Background Bedford Hospital NHS Trust is a dynamic organisation open to new ideas that improve patient services. The hospital management team is working to achieve the implementation of a successful Inpatient Waiting List Management Policy. One of the main purposes of the NHS Plan is to improve waiting times for patients. To improve the inpatient waiting list at Bedford Hospital, firstly, the hospital wanted to better understand the process. To achieve this, the following objectives were identified to:  acquire knowledge of inpatient and day case management processes  acquire knowledge of the use and capabilities of relevant information systems  construct and analyse the „AS-IS‟ maps of the process. © 2003 Peter Louis. All Rights Reserved 3
  13. 13. Methodology The methodology used by the team to achieve the objectives of the project consisted of a number of key stages: 1. Understanding the NHS and Bedford NHS Trust 2. Investigating and understanding the inpatient waiting list process at the Trust 3. Developing process maps to represent the inpatient waiting list process at the Trust 4. Analyzing the process maps to develop observations To implement the above four-stage methodology, the team utilized a set of project management techniques and tools. The MOT (setting a Mission, determining a number of Objectives and specifying a series of Tasks) project planning and management methodology was closely followed. To support MOT, the project team had weekly team meetings that monitored the project against the plan and against the budget. The NHS and Bedford BHS Trust This required that the team investigate and understand the drivers for change within the NHS:  The need to reinvest in the NHS after several years of neglect  The need to make NHS more efficient and effective at delivering services catered towards its customer – the patient Although the NHS is the largest organisation in Europe, investment levels in real terms have been falling steadily and investment within the NHS is lagging behind investment levels in similar institutions within Europe. Associated with this lack of investment, NHS working practices have changed little since its beginnings. The NHS Plan promised real investment, but this had to be linked to changes that made the organisation more effective at delivering patient services at cost savings to the public. However, cost savings brought through improvements in effectiveness and efficiency were to be reinvested in the NHS to deliver more services. © 2003 Peter Louis. All Rights Reserved 4
  14. 14. Coupled with these drivers for change were a set of guidelines and targets that were set by the Department of Health and various agencies and independent bodies. These targets and guidelines were investigated to determine how they applied to the management of inpatient waiting lists. Additionally, the team investigated the Trust, to understand its history, its problems and the role the Trust played within the Bedfordshire community. The waiting list process This phase of the project methodology required that the team investigate the inpatient waiting list process at the Trust. Firstly, however, it was necessary to establish the project data requirements: 1. Data scope – what specialities and departments were to be mapped 2. Data sources – those persons or systems that would provide information and data on the waiting list process 3. Data content – what information was going to be elicited from the various persons or systems The data scope, sources and content were initially identified by visiting the hospital‟s website, by talking to the project sponsors about candidate departments, by talking to the course supervisors who have experience in assisting the NHS through the Modernisation Agency and by having a series of introductory meetings with several key staff members at the Trust. The data scope and sources were finalised by asking the project sponsors to provide a set of specialities and departments, and a corresponding list of individuals who should be interviewed. This list included 53 staff members: Group Department 12 Consultants ENT - 3 General Surgery - 2 OMF - 1 Urology - 1 Trauma & Orthopaedics - 1 Gynaecology - 2 Anaesthesia - 2 23 Consultant secretaries Ophthalmology © 2003 Peter Louis. All Rights Reserved 5
  15. 15. ENT General Surgery OMF Urology Trauma & Orthopaedics Gynaecology 18 Support and clinical staff Waiting List Manager A+E Manager Day Case Manager Bed Manager Admissions Department Waiting List Department Theatre Manager Ward Clerk Medical Records Department of Anaesthesia Pre-assessment Clinic Outpatient Department The initial visits to the Trust also allowed the team to discover various sources of quantitative data that could be investigated. These sources were:  Checklist  Patient Information Management System (PiMS)  Cancelled Operations Diagnostic Toolkit The team then arranged a set of interviews and information requests to elicit information from the identified data sources. However, the team determined that data from PiMS was fed into the Cancelled Operations Diagnostic Toolkit and the Checklist capacity planning application. Hence, the team decided to focus on collecting data from PiMS. Process maps In parallel to collecting data and interviewing hospital staff, the team developed the IDEF3 process maps of the waiting list process. The IDEF3 method was chosen to describe and document the processes as it captured knowledge in a structured way and within the context of a scenario (story). This scenario then provides an overall view that can be decomposed into other processes. Furthermore, IDEF3 captures precedence and causality © 2003 Peter Louis. All Rights Reserved 6
  16. 16. relationships between situations and events in a form that is natural to domain experts. The main advantages of IDEF3 are:  Records the raw data resulting from fact-finding interviews in systems analysis activities  Determines the impact of an organisation's information resource on the major operation scenarios of an enterprise  Documents the decision procedures affecting the states and life-cycle of critical shared data, particularly manufacturing, engineering, and maintenance product definition data.  Makes system design and design trade-off analysis. The IDEF3 maps were to be created after a debriefing of the interviewer and within one or two days of the knowledge being captured. To standardise map development, the team agreed and followed the following procedures: 1. Processes, actions, activities, etc. were to be taken from a set of standard active verbs 2. Objects names were to be selected from a set of standard object names 3. Standard abbreviations for objects were to be used 4. Use of standard processes where possible 5. Maps would be reviewed by other team members during development 6. Maps should fit on one page of A4 and be readable 7. PiMS usage should be identified 8. Use of already developed “template” maps for higher level processes 9. Use of “Goto” notes to identify map linkages 10. Inclusion of process descriptions – where possible 11. Process notes should be written to capture information not readily observed on the maps The team evaluated several tools that could be used to develop the IDEF3 maps. The evaluation showed that ProSim 7 had several advantages over © 2003 Peter Louis. All Rights Reserved 7
  17. 17. other possible tools to create the IDEF3 maps. The main advantages of using ProSim 7 over other software tools were:  It is a specialised IDEF3 modelling tool  It allows the publishing of the knowledge base in html After the maps were developed with ProSim 7, the interviewer validated the “AS IS” model with the interviewee by walking the interviewee through the entire captured process. This was to ensure that any omissions or corrections were detected. These changes were then fed back into the process maps to update the “AS IS” Model to correctly reflect the actual process. Once all maps were validated, the team then indexed the maps for easy referencing and created an html version of the maps to facilitate navigation and publishing by the Trust. In total, 32 process maps were developed and verified. An example process map for the outpatient process of a consultant in Gynaecology is illustrated in Figure 1. SPR MAKES DTA & ASSIGNS PRIORITY CONS MAKES DTA & ASSIGNS PRIORITY X X IF PRIORITY IS URGENT X X IF PRIORITY IS ROUTINE CONS OFFERS PATIENT TCI DATE FROM DIARY X SPR OFFERS PATIENT TCI DATE FROM DIARY SHO OFFERS PATIENT TCI DATE FROM DIARY Figure 1: Outpatient process for a consultant in Gynaecology © 2003 Peter Louis. All Rights Reserved 8
  18. 18. Results & findings Specialities Ear, Nose and Throat The following describes the waiting list processes for Mr Arasaratnam (Map Number 03.0.0.0), Mr Frampton (Map Number 04.0.0.0) and Mr Hoare (Map Number 05.0.0.0). Admission Process It has to be said, that everyone within the ENT speciality, works in a very similar way. What follows is a description of the processes and information flows that occur, highlighting any relevant differences among the three secretaries interviewed: The process starts at the clinic, where Consultant, Registrar, SHO or Junior Doctor makes decision to admit, fills in the PAAF, and they assign priority to patients as follows:  Mr Arasaratnam divides his patients into urgent, soon and routine. It is rare that he gives a date to the patient at the clinic.  Mr Frampton divides his patients into urgent and routine and he sometimes assigns a date to the patient at the clinic. (This happens when it is a very urgent situation or a special occasion.)  Mr Hoare divides his patients into urgent, soon and routine and he sometimes assigns a date to the patient at the clinic. (This happens when it is a very urgent situation or a special occasion.) Once the secretary has received the PAAF and patient notes at her office, she checks them and she allocates TCI dates to the patients. It is only Charlotte Mobbs, secretary to Mr Hoare, the one that does this together with the consultant and, instead of putting the information into a diary, they use an Access database that Mr Hoare created in 1997. This TCI list, is emailed by the secretary to Admissions Department, and is at this point when the patients are first added to the waiting list. The Admissions Department is the one in charge of sending a letter to the patient, offering a date for pre-op assessment and for the operation. © 2003 Peter Louis. All Rights Reserved 9
  19. 19. The day before of the theatre session, the secretary reviews her diary, allocates operation order, creates and emails the Theatre List to theatre staff, doctors and wards. (Charlotte Mobbs, secretary to Mr Hoare, would review her database and make these decisions together with the consultant) It is also important to mention that Charlotte Mobbs is the only secretary in this speciality that creates her Theatre list straight away on PiMS. Hospital Cancellations When there is a cancellation by hospital at the PAC, the secretary receives the cancellation from the ward. She adds a reason for the cancellation into the dairy (Charlotte Mobbs, uses her database), reallocates the theatre time and does what is appropriate for each situation (suspend the patient or cancel the operation because it is no longer required). In both of the previous cases, she informs Admissions Department about it. When there is a cancellation by hospital at the OP, the secretary receives the cancellation from ward, consultant, Admissions Department or Theatre. She adds a reason for the cancellation into the dairy (Charlotte Mobbs, uses her database) and does what is appropriate for each situation. The most common of the cancellations by hospital at the OP is the lack of beds, and in this case she has to allocate a new date within 28 days. Mr Hoare mentioned that he also has to cancel quite often because of the equipment, sometimes there is no time to sterilise the equipment to be able to use it twice a day. Patient DNAs When there is a DNA at the pre-op assessment, the ward informs the secretary of the DNA and then she informs Admissions Department so they can find out the reason of the DNA. When the secretary knows the reason, she does what appropriate for each situation. When there is a DNA at the op, the ward or the Admissions Department informs the secretary. Once she is informed from Admissions about the reason of the DNA, they (consultant and secretary) decide what to do with the patient (suspending, cancelling, allocating another date...) depending on the case. Patient Cancellations When there is a cancellation by patient, the secretary receives the cancellation from Admissions Department or directly from the patient. She adds reason for the cancellation into the dairy (Charlotte Mobbs, uses her database), reallocates the theatre time and does what is appropriate for each situation - suspend the patient or cancel the operation because it is no longer © 2003 Peter Louis. All Rights Reserved 10
  20. 20. required. In both of the previous cases, she informs Admissions Department about it. General Surgery and Urology The following describes the waiting list processes for Mr Tisi (Map number 11.0.0.0). Admission Process Only Mr Tisi makes the decision to admit. He specifies priority as either urgent or routine and allocates TCI dates to all patients except those who require minor surgery in the laser clinic. Mr Tisi fills in a standard PAAF and passes one copy to his secretary and one copy to the Admissions Department to add the patient to his waiting list. Mr Tisi‟s secretary maintains an outlook and physical diary and these are used to create a theatre list the day before surgery. Mr Tisi, specifies the order that the patients will be operated upon and then the list is emailed to the Theatre Department. Hospital Cancellations If one of Mr Tisi‟s patients is to be admitted for surgery, they attend a PreAssessment Clinic (PAC) straight after their outpatient appointment. If at the PAC the patient is deemed unfit to attend surgery, they are asked to contact Mr Tisi‟s secretary once they are fit and Mr Tisi is informed and does not proceed with that patient‟s PAAF. If the patient is unfit on the day of the operation and it is a minor problem, like a cold, Mr Tisi will allocate a new TCI date. If the problem is more serious, Mr Tisi will remove the patient from the waiting list and refer the patient back to their GP or may choose to see them as an outpatient. If a patient is cancelled due to a lack of hospital resources then they are allocated a new TCI date. Patient DNAs According to his secretary, Mr Tisi does not have DNAs at either the PAC or operation. Patient Cancellations © 2003 Peter Louis. All Rights Reserved 11
  21. 21. In the case of a patient cancellation, Mr Tisi‟s secretary is notified either by the patient or by the Admissions Department. She notifies Mr Tisi and if the patient notifies the secretary directly then she informs the Admissions Department. If the patient states that they no longer require surgery, she asks the Admissions Department to remove the patient from the waiting list and Mr Tisi informs the patient‟s GP of the removal via letter. If the patient states that they are unfit for surgery, she consults with Mr Tisi and he decides whether the patient should be removed from the waiting list or suspended. If the patient requires suspension, Mr Tisi‟s secretary will ask the Admissions Department to suspend the patient from the waiting list. If the patient simply cannot attend the specified TCI date, Mr Tisi will allocate a new one and his secretary will inform the Admissions Department. If time permits, Mr Tisi will reallocate any free theatre time at his outpatient clinic. Use of PiMS Mr Tisi‟s secretary uses PiMS to check patient information and also to check the waiting times of patients for the minor operations clinic. If these patients wait more than 6 months, she will transfer them to Mr Tisi‟s waiting list to ensure they are operated upon, as soon as possible. The following describes the waiting list processes for Mr Parsons (Map number 9.0.0.0) Admission Process In Mr Parsons‟ team, Mr Parsons, the Staff Grade, Registrar and SHO make the decision to admit. They specify priority as either urgent, soon or routine and allocates TCI dates to all patients except those who only require very minor surgery in the laser clinic. They fill in a standard PAAF and pass one copy to Mr Parsons‟ secretary and one copy to the Admissions Department to add the patient to his waiting list. Mr Parsons‟ secretary maintains a physical diary and this is used to create a theatre list the day before surgery. Mr Parsons specifies the order that the patients will be operated upon and then the list is emailed to the Theatre Department. Hospital Cancellations If at the PAC or on the day of operation the patient no longer requires surgery or is unfit for an operation, they are removed from the waiting list. If a patient is cancelled on the day of operation due to a lack of hospital resources, they are allocated a new TCI date within 28 days. © 2003 Peter Louis. All Rights Reserved 12
  22. 22. Patient DNAs If a patient does not attend their PAC, Mr Parson‟s secretary will try to establish contact with the patient. If she cannot do this, the patient is removed from the waiting list. If she does and the patient no longer requires surgery or is unfit for an operation, they are removed from the waiting list. If they contact Mr Parsons‟ secretary within 48 hours and did not attend for any other reason, Mr Parsons‟ secretary will arrange a PAC for the patient. Patient Cancellations In the case of a patient cancellation, Mr Parson‟s secretary is notified either by the patient or by the Admissions Department. If the patient notifies the secretary directly, she informs the Admissions Department. If the patient states that they no longer require surgery, she asks the Admissions Department to remove the patient from the waiting list and informs the patient‟s GP of the removal via letter. If the patient states that they are unfit for surgery they are removed from the waiting list and asked to contact Mr Parsons‟ secretary when they are fit. If the patient simply cannot attend the specified TCI date, Mr Parsons‟ secretary will allocate a new one and inform the Admissions Department. If time permits, Mr Parsons will reallocate any free theatre time at his outpatient clinic. Use of PiMS Mr Parsons‟ secretary uses PiMS to check patient information. She also uses the PTL to cross check her own waiting list records. The following describes the waiting list processes for Mr Callam (Map number 6.0.0.0). Admission Process In Mr Callam‟s team, Mr Callam, the Staff Grade, Registrar and SHO make the decision to admit. They specify priority as either urgent or routine. The clinicians fill in a standard PAAF and pass it to Mr Callam‟s secretary and one copy is sent to the Waiting List Department to add the patient to Mr Callam‟s waiting list. Mr Callam‟s secretary maintains a physical diary and also files PAAFs to maintain the waiting list. Mr Callam specifies TCI dates for patients with at least two weeks notice. His secretary informs the Admissions Department of these dates. The diary is used to create a theatre list the day before surgery. Mr Callam specifies the order that the patients will be operated upon and then the list is taken to the Theatre Department by the HO. © 2003 Peter Louis. All Rights Reserved 13
  23. 23. Hospital Cancellations If at the PAC or on the day of operation the patient no longer requires an operation, they are removed from the waiting list. If they are deemed unfit to attend surgery then they are suspended from the waiting list. If a theatre slot becomes available after the PAC for one of the reasons above or if a patient does not attend, then Mr Callam‟s secretary will again try to reallocate the theatre time. If a patient is cancelled on the day of operation due to a lack of hospital resources then they are allocated a new TCI date and will be treated as an urgent patient. Patient DNAs If a patient does not attend their PAC or operation then Mr Callam‟s secretary will try to establish contact with the patient. If she cannot do this then the patient is removed from the waiting list. If she does and the patient no longer requires an operation then they are removed from the waiting list. If they are unfit to attend surgery then they are suspended from the waiting list. If they did not attend for any other reason then Mr Callam‟s secretary will arrange for the patient to be seen as an outpatient. Patient Cancellations In the case of a patient cancellation Mr Callam‟s secretary is notified by either the patient or the Admissions Department. She notifies Mr Callam and if the patient states that they no longer require surgery, Mr Callam informs the patient‟s GP of the removal via letter, which is copied to the Waiting List Department. If the patient requires suspension, Mr Callam‟s secretary will ask the Admissions Department to suspend the patient from the waiting list. If the patient simply cannot attend the specified TCI date, Mr Callam will allocate a new one when allocating other TCI dates and his secretary will inform the Admissions Department. If time permits, Mr Callam‟s secretary will reallocate any free theatre time. If necessary, she will offer a TCI date to a patient before informing the Admissions Department of the TCI date. The following describes the waiting list processes for Mr Skipper (Map number 10.0.0.0) As Mr Callam except © 2003 Peter Louis. All Rights Reserved 14
  24. 24.  Only Mr Skipper and his Staff Grade make the decision to admit.  TCI dates are given to patients at the outpatient clinic if the waiting list length is at a manageable level  Mr Skipper creates his own theatre list and takes it to the Theatre Department  If a patient requires removal from the waiting list the Admissions Department will be asked to do this and also an outpatient appointment is arranged for the patient  Mr Skipper‟s secretary uses PiMS to check patient information. The following describes the waiting list processes for Mr Waterfall (Map number 22.0.0.0) (UROLOGY) Admission Process In Mr Waterfall‟s team, Mr Waterfall, the Staff Grade, Registrar and SHO make the decision to admit. They specify priority as either urgent, soon or routine. The clinicians fill in a standard PAAF and pass it to Mr Waterfall‟s secretary and one copy is sent to the Waiting List Department to add the patient to Mr Waterfall‟s waiting list. Mr Waterfall‟s secretary maintains a physical diary and also creates T-cards to maintain the waiting list. Mr Waterfall‟s secretary specifies TCI dates for patients with at least two weeks notice. She informs the Admissions Department of these dates. The diary is used to create a theatre list the day before surgery. Mr Waterfall specifies the order that the patients will be operated upon and then the list is emailed to the Theatre Department by the secretary. Hospital Cancellations If at the PAC or on the day of operation the patient no longer requires an operation then they are removed from the waiting list. If they are deemed unfit to attend surgery then they are suspended from the waiting list. In both cases the patients GP is informed via letter. If a theatre slot becomes available after the PAC for one of the reasons above or if a patient does not attend then Mr Waterfalls secretary will again try to reallocate the theatre time. © 2003 Peter Louis. All Rights Reserved 15
  25. 25. If a patient is cancelled on the day of operation due to a lack of hospital resources then they are allocated a new TCI date and will allocated a TCI date within 28 days. Patient DNAs If a patient does not attend their PAC or operation then Mr Waterfall‟s secretary will try to establish contact with the patient. If she cannot do this then the patient is removed from the waiting list. If she does and the patient no longer requires an operation then they are removed from the waiting list. If they are unfit to attend surgery then they are suspended from the waiting list. If they did not attend for any other reason then they will be allocated a new TCI date. Patient Cancellations In the case of a patient cancellation, the patient or the Admissions Department notifies Mr Waterfall‟s secretary. She notifies Mr Waterfall and if the patient has notified her, she informs the Admissions Department. If the patient states that they no longer require surgery, the secretary arranges them an outpatient appointment and also asks the Admissions Department to remove the patient from the waiting list. If the patient requires suspension, Mr Waterfall‟s secretary will ask the Admissions Department to suspend the patient from the waiting list. If the patient simply cannot attend the specified TCI date, the secretary will allocate a new one when allocating other TCI dates and will inform the Admissions Department. If time permits, Mr Waterfall‟s secretary will reallocate any free theatre time. If necessary, she will offer a TCI date to a patient before informing the Admissions Department of the TCI date. Use of PiMS Mr Waterfall‟s secretary uses PiMS to check patient information and to confirm appointments. She uses the PTL to highlight patients who are close to the 12-month deadline. The following describes the waiting list processes for Mr Eldin (Map number 7.0.0.0) As Mr Waterfall except  Only Mr Eldin and his Registrar make the decision to admit. © 2003 Peter Louis. All Rights Reserved 16
  26. 26.  TCI dates are given to patients at the outpatient clinic if the patient‟s priority is urgent.  Mr Eldin uses a non-standard PAAF and has urgent and 3 month priority for endoscopies. For all other procedures urgent, early or when convenient are the priorities specified.  The theatre list is sent to Theatre Department, Anaesthetics and Wards.  A letter is not sent to the patients GP if a patient is suspended from the waiting list. The following describes the waiting list processes for Mr Foley (Map number 8.0.0.0) Admission Process In Mr Foley‟s team, Mr Foley, the Staff Grade, Registrar and SHO make the decision to admit. They specify priority as either urgent, soon or routine. The clinicians fill in a non-standard PAAF and pass it to Mr Foley‟s secretary and one copy is sent to the Waiting List Department to add the patient to Mr Foley‟s waiting list. Mr Foley‟s specialist nurse maintains a physical diary and files PAAFs to maintain the waiting list. She specifies TCI dates for patients with at least two weeks notice. She also informs the Admissions Department of these dates. The diary is used to create a theatre list the day before surgery. Mr Foley‟s specialist nurse specifies the order that the patients will be operated upon and then the list is emailed to the Theatre Department, Clinicians, Waiting List Department and Anaesthetists. Hospital Cancellations If at the PAC or on the day of operation the patient no longer requires an operation then they are removed from the waiting list. If they are deemed to be unfit to attend surgery then they are suspended from the waiting list. However if on the day of operation the patient only has a minor condition like a cold a new TCI date will be arranged. If a patient is cancelled on the day of operation due to a lack of hospital resources then they are allocated a new TCI date within 28 days. Patient DNAs © 2003 Peter Louis. All Rights Reserved 17
  27. 27. If a patient does not attend their PAC or operation then Mr Foley‟s specialist nurse will contact the Admissions Department. Patient Cancellations In the case of a patient cancellation Mr Foley‟s specialist nurse is notified by either the Admissions Department or by checking PiMS. If the patient states that they no longer require surgery they are removed from the waiting list. If the patient requires suspension they are suspended from the waiting list. If the patient simply cannot attend the specified TCI date, Mr Foley‟s specialist nurse will allocate a new one and will inform the Admissions Department. If time permits Mr Foley‟s specialist nurse will reallocate any free theatre time. Gynaecology The following describes the waiting list processes for Mr Budden (Map Number 12.0.0.0) and Mrs Wallace (Map Number 13.0.0.0). Admission Process During the outpatient appointment, if a patient requires further treatment, the Consultant or his Registrar makes a DTA and assigns a clinical priority. The Consultant, Registrar or SHO (“the clinician”) offers the patient an appropriate TCI date from the Consultant‟s diary. If the patient and the clinician agree on a TCI date, the clinic nurse enters the patient details, procedure and TCI date onto the T-Card, which is received by the Consultant‟s secretary after clinic. If the patient and clinician are unable to agree a TCI date, the patient is invited to call the secretary to agree a TCI date from the diary. Once a TCI date has been agreed, the secretary adds the patient to the waiting list on PiMS with his/her TCI date and sends a letter to the referrer. Five days prior to TCI dates in the diary, the secretary sends patients notes for this TCI date to the wards. The day before the next theatre for the clinician, the secretary creates a theatre list from the diary and sends it to the theatre secretaries and theatre Manager. Hospital Cancellations If a patient is cancelled on the day of surgery by the ward (secretary is informed by the bed manager, ward or patient) or by the theatre (secretary © 2003 Peter Louis. All Rights Reserved 18
  28. 28. informed by the Consultant or theatre secretary), the secretary re-books the patient procedure to be within 28 days of cancellation. If a patient is cancelled at the nurse PAC, the clinic nurse informs the secretary. The clinician offers the patient an appropriate TCI date from the team‟s diary. If the patient and clinician are unable to agree a TCI date, the patient is invited to call the secretary to agree on a TCI date from the diary. Once a TCI date has been agreed, the secretary cancels the previous TCI date and enters the new TCI date onto PiMS. Patient DNAs DNAs have not occurred at a nurse PAC. If a patient DNA the operation, the patient notes are returned from the ward to the secretary with a DNA status. Normally, the ward‟s senior nurse or sister calls the secretary about the DNA. The ward may also enter the DNA status onto PiMS. For certain DNAs (generally, day surgery procedures such as sterilisations or terminations), the secretary does not consult with the Consultant but contacts the referrer to inform her/him of the DNA. If the secretary informs the Consultant, she may either contact the referrer as above or contact the patient either to re-book the operation or to remove the patient from the waiting list on PiMS. Patient Cancellations If a patient wants to change his/her TCI date, the secretary offers the patient a new TCI from the diary and enters the information onto PiMS. If the patient does not want the procedure, the secretary may or may not consult with the Consultant. Where the Consultant is not informed (e.g. for sterilisations or terminations), the secretary may write the referrer before removing the patient from waiting list. Where the Consultant is informed, if the Consultant advises the removal of the patient, she may contact the referrer before removing the patient from the waiting list. Otherwise, the Consultant may request an outpatient appointment for the patient. For cancelled TCI dates, if time permits, the secretary attempts to replace the cancelled TCI slot with an appropriate patient from the diary. If a patient cancels the nurse PAC, then patient is offered a PAC on ward. © 2003 Peter Louis. All Rights Reserved 19
  29. 29. Ophthalmology This following describes the waiting list processes for Mrs Pieris (Map Number 14.0.0.0). Admission Process During the outpatient appointment, if a patient requires further treatment, the Consultant, Associate Specialist, Staff Grade, Hospital Practitioner or Senior Clinical Officer makes a DTA (“the clinician”) and assigns a clinical priority. The clinician then fills in the PAAF. The clinic nurse sends a copy of the PAAF to the Waiting List Department. Using the patient‟s clinic bundle, the secretary creates a T-card and sends a letter to the referrer. A nurse PAC date is booked for urgent patients and nonurgent patients receive a nurse PAC date once their T-card has progressed to a free PAC date on the T-board. After the nurse PAC, the secretary updates T-Cards and allocates TCI dates to T-Cards given the patient‟s clinical priority and DTA date. A TCI letter from PiMS with Dr PAC and Dr Post Assessment Clinic dates is then sent to the patient. The day before the next theatre session for the clinician, the secretary creates a theatre list from the T-cards and sends it to the clinic receptionist, eye theatre receptionist, theatre secretaries and the wards. (She also places the list in the Dr PAC.) The clinic receptionist then enters TCI dates onto PiMS. Hospital Cancellations If a patient is cancelled on the day of surgery by the ward (secretary is informed by the ward, clinic nurse, clinician or eye theatre receptionist) or by the theatre (secretary informed by the clinic nurse, clinician or eye theatre receptionist), the secretary allocates a new TCI date and calls the patient to re-book. She then amends the theatre list and sends it to the normal distribution. If a patient is cancelled at the Doctor PAC, the clinic nurse or Clinician informs the secretary. The secretary cancels the TCI and post assessment dates and notifies the Waiting List Department to suspend or remove the patient as advised by the Consultant. If the patient is removed, the referrer is notified. © 2003 Peter Louis. All Rights Reserved 20
  30. 30. At the same time, the secretary attempts to fill the cancelled TCI slot with a patient – normally a “one-stop” patient. The theatre list is amended and sent to the normal distribution. Patient DNAs The clinic nurse or Clinician tells the secretary of DNAs that occur at nurse PACs. If the patient does not want to be re-booked, the Waiting List Department is asked to remove the patient from the waiting list. If the patient wants to re-book, the secretary allocates a new nurse PAC date as before. The secretary then sends an appointment letter to the patient. The clinic nurse or clinician tells the secretary of DNAs that occur at Dr PAC. If the patient does not want to be re-booked, the Waiting List Department is asked to remove the patient from the waiting list. If the patient wants to rebook, the secretary allocates a Dr PAC date if one is available before TCI date or allocates new a TCI date and books Dr PAC and Post Assessment dates. The secretary then sends an appointment letter to the patient. If a DNA occurs on operation day, the ward, eye theatre receptionist or clinician tells the secretary. The secretary may inform the theatre secretary about the DNA. The clinician may ask the secretary to find a replacement patient. In this case, the secretary attempts to contact an appropriate patient who can come in for surgery. This is generally a “one stop” patient and the theatre list is amended and sent to the normal distribution. Patient Cancellations If a patient wants to change his/her TCI date, for the first cancellation, the secretary allocates a new TCI, Dr PAC and Post Assessment dates and sends an appointment letter to the patient. For subsequent cancellations, the above occurs or the secretary asks the Waiting List Department to suspend or remove the patient. If the patient is to be removed, a letter is sent to the referrer. If the patient does not want the procedure, the secretary will ask the Waiting List Department to suspend or remove the patient. If the patient is to be removed, a letter is sent to the referrer. For cancelled TCI dates, if time permits, the secretary attempts to replace the cancelled TCI slot with an appropriate patient after reviewing the T-Cards. An updated theatre list is sent to the normal distribution. © 2003 Peter Louis. All Rights Reserved 21
  31. 31. If a patient cancels the Dr PAC, the secretary books a Dr PAC date if one is available before the TCI date or allocates a new TCI date and books Dr PAC and Post Assessment dates. The secretary then sends an appointment letter to the patient. If a patient cancels the nurse PAC, the secretary books a new nurse PAC. The secretary also reviews the T-Cards and books a replacement patient. Oral Maxillo-Facial This following describes the general waiting list processes for Consultants Mr Simpson (Map Number 16.0.0.0) and Mr Chan (Map Number 15.0.0.0). Admission Process During the outpatient appointment, if a patient requires further treatment, the Consultant, Associate Specialist, Registrar or SHO (“the clinician”) makes a DTA and assigns a clinical priority. If the priority is urgent, the clinician may offer the patient an appropriate TCI date from the Consultant‟s diary. If a date is offered, the clinician fills the General Anaesthesia Waiting List (GA W/L) Card and the secretary or clinician adds the patient‟s details to the diary. GA W/L Cards are then sent to the Waiting List Department. Monthly, the secretary reviews the GA W/L Cards and this may include the PTL to allocate TCI dates given the patient priority and DTA. The secretary then enters these patients in the GA W/L Diary (under TCI date) and sends the list to the Admissions Department. One or more days before the next theatre session for the clinician, the secretary creates a theatre list from the diary and sends it to the wards, theatre secretaries and theatre Manager. Hospital Cancellations If a patient is cancelled on the day of surgery by the ward (secretary is informed by the bed manager, ward, Admissions Department or Waiting List Manager) or by the theatre (secretary informed by the Admissions Department or by the clinician), the secretary allocates a new TCI date and calls the patient to re-book. She then amends the theatre list and sends it to the normal distribution. If a patient is cancelled at the Doctor PAC, the clinician informs the secretary. The secretary then asks the Admissions Department to cancel the patient‟s TCI date, to suspend the patient or to remove the patient from the waiting list. If the patient is to be removed, a letter is sent to the referrer. © 2003 Peter Louis. All Rights Reserved 22
  32. 32. Patient DNAs For DNAs at the Dr PAC, the clinic nurse contacts the secretary who asks the Admissions Department to validate the patient or to send a PAC appointment to the patient if the secretary has offered the patient a PAC date. If a patient DNA at an operation, the secretary is notified by the Consultant or Ward. The secretary then asks the Waiting List Department to remove the patient from the waiting list and sends a letter to the referrer indicating the removal. Patient Cancellations The Admissions Department or the patient contacts the secretary to cancel an appointment. If a patient wants to change his/her TCI date, for the first cancellation, the secretary offers the patient a new TCI date and enters patient and operation details into the GA diary. Admissions is sent a new TCI date for the patient. For a second cancellation, either the patient accepts the original date or the secretary asks the Waiting List Department to remove the patient from the waiting list. A letter is sent to the referrer if a removal occurs. If the patient does not want the operation, the secretary will ask the Waiting List Department to remove the patient. If the patient is to be removed, a letter is sent to the referrer. For cancelled TCI dates, if time permits, the secretary attempts to replace the cancelled TCI slot with an appropriate patient. If a patient cancels the Doctor PAC, then a patient is offered a new PAC and Admissions is asked to send a letter to the patient. Trauma and Orthopaedics The following describes the waiting list processes for Mr Rawlins (Map Number 20.0.0.0), Mr Handley (Map Number 18.0.0.0), Mr Riley (Map Number 21.0.0.0), Mr Nel (Map Number 19.0.0.0) and Mr Edge (Map Number 17.0.0.0). Admission Process © 2003 Peter Louis. All Rights Reserved 23
  33. 33. It has to be said that everyone within the TRAUMA and ORTHOPAEDICS speciality, works on a very similar way. Here, there is a description of the process and flow of information, highlighting any relevant differences among the team. Everything starts at the clinic, where Consultant, Registrar, SHO or Junior Doctor fill in the PAAF, and assign priority to the patients as follows:  Mr Rawlins divides his patients into urgent, soon and routine and it is very rare that he gives a date to the patient at the clinic.  Mr Handley divides his patients into urgent, soon and routine and he never assigns a date to the patient at the clinic.  Mr Riley divides his patients into urgent, soon and routine and he sometimes assigns a date to the patient at the clinic. (This happens when it is a very urgent situation or a special occasion)  Mr Nel divides his patients into very urgent, urgent, soon and routine. Sometimes, with the very urgent ones he assigns a date at the clinic.  Mr Edge divides his patients into urgent, soon and routine. Sometimes he assigns a date to the patient at the clinic, but this does not happens very often. Once the secretary has received PAAF and patient notes at her office, she checks them, transcribes all the relevant information onto the T-Card Board and they type and send the clinic letter to the General Practitioner. (it should be mentioned that Anne Wright, secretary to Mr Handley, is the only secretary that types the clinic letter straight away onto PiMS). Each of the five secretaries we talked to in this speciality, use a T-Card board to organise their patient‟s information. The secretary allocates TCI dates to the patients by checking the T-Card Board. It is only in the cases of Anne Wright and Diana Wiser, when the secretary allocates the TCI dates to the patients on her own. The other three secretaries do this job together with the consultant. In the case of Anne Wright, she confirms the date that she is allocating, by telephoning the patient. By doing this, she avoids many cancellations by patient and DNAs. They all place the T-Cards with TCI date assigned, in the allocated date column, and they create and email the TCI list to the Admissions Department and anyone else required. The day before of the theatre session, the secretary reviews her T-Card Board, allocates operation order, creates and emails the theatre list to theatre © 2003 Peter Louis. All Rights Reserved 24
  34. 34. staff, doctors and wards. They all do this by their own, using their experience and knowledge, except from Susan Reid who does this together with Mr Rawlins, her consultant. Hospital Cancellations When there is a cancellation by hospital at the PAC, the secretary receives the cancellation from the ward or the Admissions Department. She adds reason for the cancellation onto the T-Card, reallocates the theatre time and does what is appropriate for each situation. (suspend the patient or cancel the operation because it is no longer required) In both of the previous cases, she informs Admissions Department about it. When there is a cancellation by hospital at the OP, the secretary receives the cancellation from ward, consultant, Admissions Department or theatre. She adds reason for the cancellation onto the T-Card, and does what is appropriate for each situation. The most common of the cancellations by hospital at the OP is the lack of beds, and in this case, she has to allocate a new date within 28 days. Diana Wiser says that sometimes she is not informed about the cancellation by hospital (she finds it out several days after). Patient DNAs When there is a DNA at the pre-op assessment, the ward informs the secretary of the DNA and then she informs Admissions Department so they can find out the reason of the DNA. When the secretary knows the reason, she does what appropriate for each situation. When there is a DNA at the op, the ward or the Admissions Department informs the secretary. Once she is informed from admissions about the reason of the DNA, they (consultant and secretary) decide what to do with the patient (suspending, cancelling, allocating another date...) depending on the case. Patient Cancellations When there is a cancellation by patient, the secretary receives the cancellation from Admissions Department or directly from the patient. She adds reason for the cancellation onto the T-Card, reallocates the theatre time and does what is appropriate for each situation. (suspend the patient or cancel the operation because it is no longer required) In both of the previous cases, she informs Admissions Department about it, so they can do what is needed. © 2003 Peter Louis. All Rights Reserved 25
  35. 35. Support departments Accident and Emergency Accident and Emergency (Map number 2.0.0.0) A+E deal with two types of patients heralded and non-heralded. If a patient is heralded then a specialist consultant is specified prior to the patient arriving to A+E. If the patient is non-heralded then they will either be treated by A+E or a specialist consultant will be specified once the A+E doctor has diagnosed the patients condition. After examining the patient the consultant will decide whether or not the patient can be treated and discharged, needs to be transferred to another consultant or whether they need to be admitted as an inpatient. If admitted the patient may affect elective patients if a bed or theatre slot that had been booked is used. This could result in a patient being cancelled. Admissions Department Admissions Process (Map Number 23.0.0.0) The Admissions Supervisor receives removal requests from secretaries and patients; suspension requests from secretaries and the PAC nurse; and cancellation requests from patients and the Bed Manager. She also processes requests to admit patients. A removal request results in a patient being removed from the waiting list on PiMS. The Removal from Inpatient Waiting List Form is filled and the secretary is informed. A suspension request results in the patient being suspended from the waiting list on PiMS and the secretary is notified. A cancellation request results in the TCI being cancelled on PiMS for that patient and a confirmation of acceptance results in that acceptance being noted on PiMS. During the admission process, the Admissions Supervisor enters details of the patient admittance (if required) and TCI date onto PiMS. A TCI letter from PiMS and a pro forma are sent to the patient. After 48 days, a list of patients who have not responded is printed and these patients are called. If a patient is uncontactable, then the GP is contacted for the patient‟s telephone number and address. © 2003 Peter Louis. All Rights Reserved 26
  36. 36. The patient is called with the number from the GP. However, if the patient is still uncontactable, either the secretary may continue to call or she sends another TCI Letter and Pro Forma. At any stage where the patient is contactable, the patient is asked to indicate whether they would like to be removed from the waiting list, suspended from the waiting list or confirmed on the waiting list. DNA Process If a patient DNA‟s on the day of surgery, the ward calls the Admissions Supervisor. The Admissions Supervisor enters a DNA status for the patient onto PiMS and may inform the secretary about the DNA. Bed Manager Bed Manager (Map Number 30.0.0.0) The bed manager receives different information from different meetings with different people, like for instance:  Every Friday, bed manager, waiting list manager and matron day surgery have a meeting to create the TCI list for the weekend (Monday included) and for the following week.  Every day from Monday to Thursday, the bed manager receives from the Admissions Department the TCI lists for the next day, and she also shares information with them about patient‟s beds.  Every day, bed manager receives the theatre list from theatre. With all this information and being in constant contact with wards, theatres, consultants and any other department required, she allocates beds and amends the theatre list, returning it to the theatre. Bed manager is also in charge of managing the emergency beds. If she needs to cancel any operation, she will have to contact to Leah Caleb (waiting list manager) or Ian Campbell if there is a serious problem to discuss. If there is a DNA at the operation, the bed manager is informed by the relevant ward and she will inform the Admissions Department, so they can do what is needed. © 2003 Peter Louis. All Rights Reserved 27
  37. 37. Critical Care Critical Care (Map number 28.0.0.0) The Critical Care Department is primarily for emergency patients but on occasions will house elective patients who require a high level of care after surgery. In this case the bed can only be provisionally booked right up until the day of surgery. If the bed is required for an emergency patient before the day of operation up until the morning of surgery then the elective patient‟s consultant will be informed and the patients operation is likely to be cancelled until a critical care bed is available. Inpatient PAC Inpatient PAC (Map number 26.0.0.0) In general, all the inpatients come for their pre-assessment clinic two weeks before the operation. Once the pre-assessment clinic is done, different things can happen:  Patient is ok. In this case, the patient will come for the operation as planned.  Patient is unfit. The pre-assessment clinic nurse will discuss with the relevant doctor what needs to be done. It could be suspending the patient, referring the patient back to the General Practitioner or referring the patient to other specialist required.  The operation is no longer required. The pre-assessment nurse informs the Admissions Department and the consultant‟s secretary. Medical Records Medical Records (Map number 31.0.0.0) Prior to examining or operating upon a patient the doctor must have access to the patient‟s notes so that any previous conditions that may affect the outcome can be identified. Medical Records store and retrieve all patient notes within the hospital. If the patients notes can not be located then their surgery may be cancelled, for this reason Medical Records employs „Missing‟ Clerks whose role is to locate notes that cannot be located in the Medical Records library. © 2003 Peter Louis. All Rights Reserved 28
  38. 38. Outpatient Process Outpatients (Map number 1.0.0.0) The majority of inpatients on the waiting list feed in from the outpatient process. The hospital receives referrals for a patient to seen as an outpatient. These referrals come from many sources but most come from GPs. The referral will either be for a specified consultant at the hospital or will be addressed to „Dear Doctor‟. If a consultant has not been specified, then the patient will be allocated to the consultant in the required speciality with the shortest waiting list. In some specialities the hospital has recently introduced generic codes which allow the consultant to specified later in the outpatient process. When the patient is examined in the outpatient appointment the consultant may make a decision to admit the patient in which case they will be added to that consultant‟s inpatient waiting list. In some circumstances the patient may actually be admitted from the outpatient process which may affect resources specified for elective inpatients. Reginald Hart Inpatient Ward Reginald Hart Inpatient Ward (Map number 27.0.0.0) Only Inpatients visit the Reginald Hart Ward for surgery. The Ward Clerk prepares lists of patients due to come to the ward each day and their arrival is noted on PiMS. If a patient does not attend the relevant parties (theatre etc) will be informed. On the day before or the day of a patients operation the patient will be seen by a consultant and an anaesthetist prior to the operation. If for any reason the operation has to be cancelled the relevant parties (theatre etc) will be informed. If the operation goes ahead the patient will recover and if there are no problems the patient is discharged on PiMS. If the patient is unwell and takes longer than expected to recover this may affect hospital resources reserved for other elective inpatients. © 2003 Peter Louis. All Rights Reserved 29
  39. 39. Tavistock Day Case Ward Tavistock Day Case Ward (Map number 25.0.0.0) Patients visit the Tavistock Day Case Ward for either PACs or for day surgery. The Ward Clerk prepares lists of patients due to come to the ward each day and their arrival is noted on both these forms and on PiMS. If a patient does not attend the patients consultant will be informed. Patients coming for the Day Case pre-assessment clinic can do it in two different ways:  They can come as “walk-in” patients. They mean by walk-in, when they come straight from the clinic (on the same day)  They can come as ordinary patients. In general, all the inpatients come for their pre-assessment clinic two weeks before the operation. Once the pre-assessment clinic is done, different things can happen:  Patient is ok. In this case, the patient will come for the operation as planned.  Patient is unfit. The pre-assessment clinic nurse will discuss with the relevant doctor what needs to be done. It could be suspending the patient, referring the patient back to the General Practitioner or referring the patient to other specialist required.  The operation is no longer required. The pre-assessment nurse informs the Admissions Department and the consultant‟s secretary. Once the pre-assessment is done the pre-assessment nurse and the relevant consultant will make the appropriate decision for the relevant patient. On the day of a patients operation the patient will be seen by a consultant and an anaesthetist prior to the operation. If for any reason the operation has to be cancelled the relevant parties (theatre etc) will be informed. If the operation goes ahead the patient will recover and if there are no problems the patient is discharged on PiMS. If the patient is unwell and needs to be admitted as an inpatient this may affect hospital resources reserved for elective inpatients. © 2003 Peter Louis. All Rights Reserved 30
  40. 40. Theatre Process Theatre process (Map Number 29.0.0.0) What happens at the theatre is that they receive weekly a TCI list from the Waiting List Manager, and they receive every day the different theatre lists, coming from each of the secretaries. With all this information, the theatre secretary creates the day before of the theatre session, the final theatre list and she enters all the information onto the PiMS. Once the final list is created, the theatre secretary sends a copy of it to the required ward, to the bed manager, to the X-ray department and to the pathology laboratory. When a cancellation by patient occurs, the relevant ward or the consultant team informs her, so she cancels onto PiMS. When a cancellation by hospital occurs, it could be for several reasons:  Cancellation due to the operation is no longer required. In this case, the consultant team informs the theatre secretary and she cancels onto PiMS.  Cancellation due to a lack of resources. The theatre secretary receives the cancellation from the ward and then she cancels onto PiMS.  Cancellation due to the patient is unfit for surgery. The ward or the consultant team informs about the cancellation and the theatre secretary cancels then onto PiMS.  Cancellation due to a skill-mix at the theatre. The consultant team informs the theatre secretary so she enters the cancellation onto PiMS.  Cancellation by bed manager. Either the bed manager or the consultant informs the theatre secretary and she enters the cancellation onto PiMS. Waiting List Department Waiting List Department (Map Number 24.0.0.0) Long Waiter Report © 2003 Peter Louis. All Rights Reserved 31
  41. 41. The Waiting List Supervisor receives this report daily from the IT Department and scans it for patients approaching the current 12-month deadline. Secretaries are then asked for TCI dates for these patients. Waiting List Process The Waiting List Department receives waiting list forms (PAAFs, GA Waiting List Card, T-Cards, etc.) from outpatient clinics. Patient details are entered onto PiMS. However, if a form has a TCI date, it is handed to the Admissions Department. Otherwise, a day case letter is sent to the patient with a reply slip. Patient Validation Manual Process The Waiting List Information Coordinator receives removal requests from secretaries, suspension requests from secretaries and patient validation requests from secretaries. A removal request results in a patient being removed from the waiting list on PiMS. If that request is from the patient, the Removal from Inpatient Waiting List Form is filled and a copy is sent to the GP. A suspension request, results in the patient being suspended on the waiting list on PiMS. During patient validation (manual) process, the Waiting List Supervisor sends a letter to the patient with a reply slip. If the patient does not reply within 14 days, the GP is contacted for the patient‟s telephone number and address. If the telephone number is different, the secretary calls the patient. If the number is the same, the secretary writes the patient and gives the patient 14 days to reply. If the patient is contactable, the patient is asked to confirm whether she/he would like to be removed, suspended or kept on the Waiting List. Otherwise, the patient is removed from the Waiting List on PiMS. Patient Validation Auto Process The Waiting List Supervisor receives removal and suspension requests from secretaries and the Waiting List Manager. The Waiting List Supervisor also validates 8-month waiters automatically through PiMS – at least once a week. A removal request results in a patient being removed from the waiting list on PiMS. If that request is from an urgent patient, the Waiting List Information Coordinator informs the Waiting List Manager. For any other priority, either the ward is informed (if the patient has been treated) or the Waiting List Manager is informed (if the patient has not been treated). © 2003 Peter Louis. All Rights Reserved 32
  42. 42. During patient validation (auto) process, the Waiting List Information Coordinator selects the validation option from PiMS and creates the first set of validation letters. Patients are checked to ensure that they are not on the waiting list. Patients with urgent priorities are referred to the appropriate secretary and patients with TCI dates are not validated. Letters are sent and patients have 21 days to reply. If a reply is not received, then a second validation letter option is selected from PiMS. Patients are checked to ensure that they are not on the waiting list. Urgent patients are referred to the appropriate secretary and patients with TCI dates are not validated. Letters are sent and patients have 21 days to reply. Both of the validation letters require that the patient indicates whether she/he would like to remain on the waiting list, to be suspended from the waiting list or to be removed. If no reply is received during the validation process, the Waiting List Information Coordinator removes the patient and sends a letter to the GP and the appropriate consultant. Waiting List Manager Waiting List Manager (Map number 32.0.0.0) The Waiting List Manager has several roles. She fulfils a pivotal role between the Admissions Department, Waiting List Department, Bed Manager and Theatre Department. She is responsible for the management of the Waiting List and Admissions Departments and therefore to ensure that the hospital meets government targets relating to patient waiting time. The Waiting List Manager or one of her staff meets daily with the Bed Manager to check whether there are enough beds to house all scheduled elective patients. If this is not the case then depending upon the gravity of the problem an emergency bed state may be declared. If this is the case the Waiting List Manger will attend an emergency bed meeting where potential cancellations will be discussed and possibly the decision to cancel will be made. In all cases cancelling patients is avoided if possible. The Waiting List Manager produces the monthly theatre schedule and reallocates theatre time that may occur because of staff holiday or illness. If a patient is cancelled in theatre the Waiting List Manager will liaise with the Theatre Department to try to fit the patient in elsewhere. In some cases the patient may be transferred to a private hospital to ensure that their surgery is carried out within the 12 month deadline. Also extra theatre sessions are organised occasionally to reduce long waiting lists. © 2003 Peter Louis. All Rights Reserved 33
  43. 43. There are in place waiting list initiatives with several private hospitals to reduce waiting times for problem waiting lists. © 2003 Peter Louis. All Rights Reserved 34
  44. 44. Discussion Before the IDEF3 maps were analysed, the team identified a set of eight areas that were critical to the functioning of the waiting list process at the Trust. The waiting processes for the consultants were then analysed under these core areas. These areas are illustrated in Figure 2. Figure 2: Waiting list core areas for analysis Outpatient clinic Who makes DTA Out of the 20 consultant processes investigated, it was found that the DTA was made only by the consultant in one case, by the consultant or registrar in seven cases and by the consultant, registrar or another doctor in 12 cases. The results are illustrated in Figure 3. © 2003 Peter Louis. All Rights Reserved 35
  45. 45. Who makes DTA? 12 12 Consultant only Consultant and Registrar 10 Consultant, Registrar and Others 8 7 6 4 2 1 0 Figure 3: Who makes DTA What priorities are assigned to patients? The priorities assigned to patients included not only standard priorities, such as Urgent and Routine (in 7 cases), but variations from the standard, such as Very Urgent, Routine and Soon (in 1 case). A summary of the priorities are found is shown in Figure 4. Priorities Used Urgent and Routine Urgent, Routine and Soon Very Urgent, Routine and Soon Others 1 1 11 7 Figure 4: Priorities used © 2003 Peter Louis. All Rights Reserved 36
  46. 46. Allocation of TCI dates When are TCI dates given? In investigating the circumstances under which TCI dates were given, it was determined that in 4 cases consultants always offered a patient a TCI date in clinic; in 8 cases, patients only received a TCI date if they were urgent; in 6 cases, TCI dates were never offered in clinic and in 1 case, TCI dates were offered if possible. The results are presented in Figure 5. When are TCI dates given at the O/P Clinic? 8 8 All Patients Never Urgent Patients When Possible 6 7 6 5 4 4 3 2 1 1 0 Figure 5: When are TCI dates given? Is the standard PAAF used? It was determined that the standard PAAF form was used by 14 consultants whilst other forms (GA W/L card, T-Card, old PAAF form, etc) were used in the 6 other cases. The results are presented in Figure 6. © 2003 Peter Louis. All Rights Reserved 37
  47. 47. Is standard PAAF used? 6 Yes No 14 Figure 6: Is the standard PAAF used? What means are used to manage patients awaiting TCI dates? To mange the allocation of TCI dates, it was found that in 7 cases Patient Awaiting Admittance Forms (PAAFs) were filled in a folder and accessed when necessary; in 8 cases a T-Card board was used to process T-Cards; in 1 case a bespoke database was used; and in 4 cases, TCI dates were provided immediately from a diary. The results are summarised in the Figure 7. What means are used to manage patients awaiting TCI dates? 8 PAAFs filed in a folder 8 7 T-Card Board Bespoke database 7 TCI dates allocated at Outpatient Clinic 6 4 5 4 3 2 1 1 0 Figure 7: What means are used to mange patients awaiting TCI dates? © 2003 Peter Louis. All Rights Reserved 38
  48. 48. Who allocates TCI dates? In 4 cases, patients received TCI dates from clinicians during the outpatient appointment. In 2 cases, patients received TCI dates from the clinician after the outpatient appointment. However, in 11 cases, the secretary or specialist nurse allocated TCI dates to patients after the outpatient appointment. This information is illustrated in Figure 8. Who allocates the patients TCI dates? 11 Clinician in Outpatient clinic 11 10 Secretary or Spec Nurse post Outpatient clinic 9 Consultant & Secretary post Outpatient clinic 8 7 Consultant post Outpatient clinic 6 5 4 4 3 3 2 2 1 0 Figure 8: Who allocates TCI dates? What means are used to manage patients with TCI dates? It was found that many different means were used to manage patients who were given TCI dates. The two most common means involved just using a diary (9 cases) or a T-Card board (6 cases). PiMS was actually used in 2 cases and even this involved using a diary in the outpatient clinic. The results are presented in Figure 9. © 2003 Peter Louis. All Rights Reserved 39
  49. 49. What means are used to manage patients with TCI dates? 9 Outlook & Physical diary PIMS & Physical diary 9 Physical diary 8 Physical diary & T-card board 7 6 6 T-card board Bespoke database 5 4 2 3 2 1 1 1 1 0 Figure 9: What means are used to manage patients with TCI dates? Who enters TCI dates into PiMS? In 17 cases, this was done by the Admissions Department; and in three cases, the consultant secretary entered TCI dates into PiMS. Figure 10 illustrates these results. Who enters TCI dates into PiMS 17 3 Admissions Department Consultants Secretary Figure 10: Who enters TCI dates? What other departments are informed of TCI dates? © 2003 Peter Louis. All Rights Reserved 40
  50. 50. In 16 cases, no other department was notified once TCI dates were assigned to patients; in two cases, the Waiting List Manager was notified; in one case, the Waiting List Manager, Theatre Department, wards and Anaesthetist were informed. This is illustrated in Figure 11. What other departments are informed of TCI dates? 20 18 16 14 12 10 8 6 4 2 0 None Waiting List Manager Waiting List Manager, Theatre Department, Wards, Anesthetists Theatre Department Figure 11: What other departments are Informed of TCI dates? What is the PTL used for? Only 2 secretaries used the PTL principally to select long waiters to offer them TCI dates. in 9 cases it was used to crosscheck patients to ensure, for example, that treated patients were not reallocated a TCI date or that “lost” patients who did not appear on waiting lists held within the consultant practice were found. The results are presented in Figure 12. © 2003 Peter Louis. All Rights Reserved 41
  51. 51. What is PTL used for? 3 6 2 9 Not used Cross checking Produce TCI List Unknown Figure 12: What is the PTL used for? Creation of theatre schedules Who allocates theatre list order? In 11 cases, the consultant orders the theatre list. In 2 cases, the consultant and his secretary ordered the theatre list. In the other seven cases, the secretary or specialist nurse ordered the theatre list. The results are presented in Figure 13. Who allocates theatre order? 11 Consultant Secretary or Spec Nurse Consultant & Secretary 12 10 7 8 6 2 4 2 0 Figure 13: Who allocates the theatre list? © 2003 Peter Louis. All Rights Reserved 42
  52. 52. Which departments are informed of the theatre list? The theatre list was found to be sent to 5 different people. In most cases, however, the theatre list was sent solely to the Theatre Department. After that, in 6 cases, it was sent to the Theatre Department & wards; and in 4 case, the Theatre Department, wards and Anaesthetist are informed. The results for this question are presented in Figure 14. Which Departments are informed of theatre dates? 1 4 7 2 6 Theatre Department Theatre Department & Wards Theatre Department & Waiting List Manager Theatre Department, Wards, Anesthetists Theatre Department, Anesthetists, Waiting List Manager & Department Figure 14: Which departments are informed of the theatre list? How long before the operation is the theatre list provided? In 16 cases, the theatre list was provided the day before the operation, in 1 case, the theatre list was provided 1 or 2 days before the operation; and in 2 cases, the theatre list was provided 2 days before the operation. This is illustrated in Figure 15. © 2003 Peter Louis. All Rights Reserved 43
  53. 53. How long before Operation is theatre list provided? 1 day 1-2 days 2 days 1 week 20 18 16 14 12 10 8 6 4 2 0 Figure 15: How long before operation is theatre list produce? Managing patient cancellations Who informs the secretary of a patient cancellation? In 3 cases, the patient informed the secretary directly; in 16 cases, the Admissions Department or patient informed the secretary; and in 1 case, the Admissions Department or PiMS informed the secretary. This is presented in Figure 16. Who informs Secretary of Patient cancellation? 1 3 16 Admissions Department or Patient Directly Patient Directly From PiMS or Admissions Department Figure 16: Who informs secretary of patient cancellation © 2003 Peter Louis. All Rights Reserved 44
  54. 54. If operation is not required, what steps are taken? In most cases, the patient was removed from the waiting list. In 14 cases, the Admissions or Waiting List Department performed the removal; in 4 additional cases, this same scenario occurred but the patient was also offered an outpatient appointment. In the other two cases, the secretary either removed the patient from the waiting list or the patient received an outpatient appointment. This is illustrated in Figure 17 below. Patient cancellation - If operation not required what steps are taken? 14 Admissions/Waiting List Department asked to remove patient from Waiting List 14 Admissions/Waiting List Department asked to remove patient from Waiting List and Outpatient appointment arranged 12 10 Secretary removes patient from Waiting List or Outpatient appointment arranged 8 6 4 4 2 2 0 Figure 17: If operation not requires, what steps are taken If a patient is unfit for surgery, what steps are taken? Predominantly, if a patient was unfit for surgery, the Admissions or Waiting List Department was asked to suspend the patient from the waiting list. In 2 cases, the patient was cancelled and asked to phone when fit. The results are presented in Figure 18. © 2003 Peter Louis. All Rights Reserved 45
  55. 55. Patient cancellation - If patient is unfit for surgery (acute) what steps are taken? 1 1 2 1 15 Admissions/Waiting List Department asked to suspend patient from Waiting List Admissions/Waiting List Department asked to remove patient from Waiting List and Patient asked to phone when fit Appointment cancelled and Patient asked to phone when fit Appointment cancelled or Secretary suspends Patient from Waiting List Unknown Figure 18: If a patient is unfit for surgery, what steps are taken? Managing DNAs Who informs the secretary of a DNA at the PAC? In 3 cases, DNAs did not occur at the PAC. Where they did occur, in 14 cases, the ward or PAC clinician informed the secretary of the DNA. The results are illustrated in Figure 19. Who informs Secretary of DNA at PAC? 1 3 2 14 DNAs at PAC do not occur Ward or PAC clinician Ward or Admissions Department Ward, PAC clinician, Waiting List Department or from PiMS Figure 19: Who informs the secretary of the DNA at the PAC? © 2003 Peter Louis. All Rights Reserved 46
  56. 56. Who contacts the patient if a DNA occurs at the PAC? In 8 cases, the secretary contacted the patient to find out why the DNA had occurred; in nine cases, the secretary asked the Admissions Department to contact the patient about the DNA; in 3 cases; DNAs did not occur. This is illustrated below in Figure 20 Who contacts Patient if DNAs PAC occurs? 9 9 DNAs at PAC do not occur 8 Secretary 8 Admissions Department 7 6 5 4 3 3 2 1 0 No of Consultants Figure 20: Who contacts the patient if a DNA occurs at the PAC? Who informs the secretary of a DNA on the day of operation? DNAs on the day of operation did not occur for four consultants but they did occur there were up to 5 ways by which a secretary would be informed of the DNA. In one case, the secretary was only made aware of the DNA once she received and read the patient‟s notes. Although, in two other cases, either the secretary received the notes or she was informed by the ward. However, in nine cases, the secretary was informed by the ward or by the Admissions Department. Figure 21 illustrates the results. © 2003 Peter Louis. All Rights Reserved 47
  57. 57. Who informs Secretary of DNA on day of operation? 1 2 4 2 1 1 9 DNAs at operation do not occur/Secretary not informed Ward or Admissions Department When notes received Consultant or Admissions Department Ward or when notes received Ward or Consultant Ward, Consultant or Theatre Department Figure 21: Who informs secretary of DNA on the day of operation? Who contacts patient if DNA occurs on the day of operation? In 4 cases, action was not required as DNAs did not occur. In 2 cases, it was found that the patient was not contacted. In 9 cases, however, the Admissions Department was asked to contact the patient. The full results are presented in Figure 22. Who contacts patient if DNA occurs on the day of operation? 7 7 By Secretary By Admissions Department 6 DNAs at operation do not occur/Secretary not informed 5 By Secretary if Consultant requests 4 4 No contact 4 Unknown 3 2 2 2 1 1 0 Figure 22: Who contacts the patient if DNA occurs on the day of operation © 2003 Peter Louis. All Rights Reserved 48
  58. 58. Managing hospital cancellations – surgical fitness Who informs the secretary of hospital cancellations at PAC? It was found that in 16 cases, the Ward or clinician informed the secretary of a hospital cancellation; in 3 cases, the PAC clinician, Admissions or Waiting List Department informed the secretary; and in 1 case, the secretary as aware of the hospital cancellation after having received the returned patient‟s notes. This information is summarised in Fig 24. Who informs Secretary of Hospital cancellation at PAC? 1 3 16 Ward or PAC clinician PAC clinician or Admissions/Waiting List Department When notes received Fig 24: Who informs the secretary of hospital cancellations at PAC? If operation is not required, what steps are taken? In 3 cases, this did not occur. Where this did occur, the Admissions Department or Waiting List Department was asked to remove the patient from the waiting list in 13 cases. In the other four cases, the Admissions Department or Waiting List Department was asked to remove the patient from the waiting list and an outpatient appointment was arranged. The results are illustrated in Figure 24. © 2003 Peter Louis. All Rights Reserved 49
  59. 59. If operation not required what steps are taken? Admissions/Waiting List Department asked to remove patient from Waiting List 13 14 Admissions/Waiting List Department asked to remove patient from Waiting List and Outpatient appointment arranged 12 Does not occur 10 8 4 6 3 4 2 0 Figure 24: If operation is not required, what steps are taken? If patient is unfit for surgery, what steps are taken? Primarily, the Admissions or Waiting List Department was asked to suspend the patient from the Waiting List – this occurs in 13 cases. In two cases, the operation was cancelled and the patient was given a new TCI date. The full results are summarised in Figure 25. If patient is unfit for surgery what steps are taken? 2 1 1 2 1 13 Patient not ever added to Waiting List and asked to contact when fit Admissions/Waiting List Department asked to suspend patient from Waiting List Admissions/Waiting List Department asked to remove patient from Waiting List and Patient asked to phone when fit Appointment cancelled or Secretary suspends Patient from Waiting List Appointment cancelled or Patient given another TCI date Admissions/Waiting List Department asked to remove or suspend Patient from Waiting List Figure 25: If patient unfit for surgery, what steps are taken? Who informs secretary of hospital cancellation on day of operation? © 2003 Peter Louis. All Rights Reserved 50
  60. 60. No clear reply was received for this question. Any number of persons could inform the secretary of this cancellation. The replies, however, were grouped and are summarised in Figure 26 Who informs Secretary of Hospital cancellation on day of operation? - No clear answer Common answers were 12 Ward Admissions/Waiting List Department 12 Theatre Department Bed manager 9 Clinician 10 When notes received 8 7 8 6 3 4 2 2 0 No of Consultants Figure 26: Who informs secretary of hospital cancellation on day of operation? If operation not required, what steps are taken? This did not occur in 6 cases. In the remainder of the cases, the secretary asked the Admission or Waiting List Department to remove the patient from the waiting list. However, in only three of these cases, was the patient offered an outpatient appointment (Figure 27). © 2003 Peter Louis. All Rights Reserved 51
  61. 61. If operation not required what steps are taken? 3 6 11 Does not occur Admissions/Waiting List Department asked to remove patient from Waiting List Admissions/Waiting List Department asked to remove patient from Waiting List and Outpatient appointment arranged Figure 27: If operation not required, what steps are taken? If a patient is unfit for surgery, what steps are taken? In 2 cases, this did not occur. In 14 cases, the Admissions or Waiting List Department was asked to suspend the patient from the Waiting List. In 2 cases, the patient‟s operation was cancelled and the patient was given a new TCI date. The results are presented in Figure 28. If patient is unfit for surgery what steps are taken? 1 2 Does not occur 2 1 Admissions/Waiting List Department asked to remove patient from Waiting List and Patient asked to phone when fit Admissions/Waiting List Department asked to suspend patient from Waiting List Appointment cancelled or Patient given another TCI date Unknown 14 Figure 28: If patient is unfit for surgery what steps are taken? © 2003 Peter Louis. All Rights Reserved 52
  62. 62. Managing hospital cancellations – hospital resources If a patient is cancelled due to a lack of resources, who informs the secretary? No clear reply was received for this question. Any number of persons could inform the secretary of this cancellation. The replies, however, were grouped and are summarised in Figure 29. If patient is cancelled due to a lack of hospital resources who informs Secretary 17 Ward 18 Admissions/Waiting List Department Bed manager 16 Theatre Department Clinician 14 12 When notes received 12 10 7 8 6 6 4 4 1 2 0 Figure 29: If a patient is cancelled due to a lack a lack of resources, who inform the secretary? If a patient is cancelled due to a lack of resources, what steps are taken? In all cases, the secretary attempted to offer the patient a TCI date within 28 days of the cancellation date. This is illustrated in Figure 30. © 2003 Peter Louis. All Rights Reserved 53
  63. 63. If patient is cancelled due to a lack of hospital resources, what steps are taken? 20 18 16 14 12 10 8 6 4 2 0 If possible patient allocated new TCI date within 28 days Figure 30: If a patient is cancelled due to a lack of resources, what steps are taken? Use of PiMS Most specialities used PiMS only to access patient information. In fact, in eight cases, PiMS was not used. However, it was determined that PiMS was used not only in the Admissions Department but also in Gynaecology and Ophthalmology to perform the Admission process. The use of PiMS in Gynaecology mirrored how PiMS was used in the Admissions Department since Gynaecology performed the complete admission process – adding, cancelling and removing patients and offering pre-assessment appointments. PiMS use in Ophthalmology, however, was limited to adding patients and offering pre-assessment appointments with removals, suspensions or cancellations being referred to the Admissions Department. In general, the features used between the various specialities and departments are summarised in Appendix A. © 2003 Peter Louis. All Rights Reserved 54
  64. 64. Further action The following are suggestions for further work at Bedford Hospital NHS Trust: Waiting list management best practice Analysis of Consultant Waiting list management processes to identify possible best practice and the effect that any changes might have. Information sources such as Quantitative data, beacon trusts, guidelines and targets relevant to this area could be examined in this study. Centralised versus decentralised Admissions Investigation into what tangible benefit a centralised or decentralized Admissions Department would provide to the Trust. Day surgery The NHS Plan and recent advice from the Department of Health have indicated that scope existed to perform more surgical procedures as day surgery. An analysis could be conducted to determine if such opportunities exist at the Trust. Effect of ward processes on the management of inpatient waiting lists Interviews with more clinical and ward staff, as well as patients, to identify other opportunities for improvement. This could involve the elicitation of process knowledge from ward clerks, nurses and doctors about management of discharging, PiMS updating, Outliers, Bed Blockers etc. © 2003 Peter Louis. All Rights Reserved 55
  65. 65. Acknowledgements Cranfield University would like to thank the management and staff of Bedford Hospital NHS Trust for their enthusiasm and support in making this project a success. Additionally, Cranfield University would like to thank the six Master Associates for their exceptional work on this project: Juan Eguino Mandy Lin Isaac Perez-Llorca Peter Louis Paul Nower Oscar Zamora
  66. 66. References Audit Commission. (2001). Acute Hospital Portfolio – Day Surgery (WWW document). http://ww2.audit-commission.gov.uk/publications/pdf/daysurgery.pdf. (accessed 20 Apr 2003). Bailey, T. (2003). Inpatient Waiting List Policy (Draft). Bedford Hospital NHS Trust. Bedford. Cahill J. (1999). Basket Cases and Trolleys – Day Surgery Proposals for the Millennium. Journal of One Day Surgery, 9(1), 11-12. Department of Anaesthesia. (n.d.). Selection of Patients for Day Surgery. Bedford Hospital NHS Trust. Bedford. Department of Health. (1999). Getting Patients Treated (WWW document). http://www.doh.gov.uk/pub/docs/doh/waitingl.pdf. (accessed 10th February 2003). Department of Health. (2000a). NHS Plan (WWW document). http://www.doh.gov.uk/nhsplan/nhsplan.pdf. (accessed 10th February 2003). Department of Health. (2002b). NHS Cancer Plan (WWW document). http://www.doh.gov.uk/cancer/pdfs/cancerplan.pdf. (accessed 10th February 2003). Department of Health. (2001a). Priorities and Planning Framework 2002/2003 (WWW document). http://www.doh.gov.uk/planning2002-2003/index.htm#wait. (accessed 20th April 2003). Department of Health. (2002a). Final Performance Indicators for Acute & Specialist Trusts (WWW document). http://www.doh.gov.uk/performanceratings/2003/acute_list.html. (accessed 20th April 2003). Department of Health. (2002c). Day Surgery: Operational Guide (WWW document). http://www.doh.gov.uk/daysurgery/day-surgery.pdf. (accessed 20th April 2003). Modernisation Agency (2002). Operating Theatre and Pre-operative Programme: National Good Guidance on Pre-operative Assessment for Day Surgery. (WWW document). http://www.modern.nhs.uk/theatre/7511/8100/Final%20Preop%20guidance%2010.09 .doc. (accessed 25 April 2003) Modernisation Agency (2003). Operating Theatre and Pre-operative Programme: National Good Guidance on Pre-operative Assessment for Inpatient Surgery. (WWW document). http://www.modern.nhs.uk/theatre/7511/11434/in%20pat%20guidance%2014.3.03.do c (accessed 25 April 2003) McNamara, J. (2002a). Common Procedures as Day Surgery at Bedford Hospital. Department of Anaesthesia, Bedford Hospital NHS Trust. Bedford. McNamara, J. (2002b). Uncommon Procedures as Day Surgery at Bedford Hospital. Department of Anaesthesia, Bedford Hospital NHS Trust. Bedford. National Patients Access Team. (2001). Primary Targeting Lists. Modernisation Agency. (WWW document). http://www.modern.nhsuk.org/5556/COHORTMANAGEMENT-PTLapproach-Revised1.doc. (accessed 18th March 2003).

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