A time close to our heartsA time close to our hearts

Measurement of referral-to-treatment waiting timeMeasurement of referral-to-treatment waiting time

David AdlerDavid AdlerHead of Healthcare ImprovementHead of Healthcare Improvement

Beds & Herts SHABeds & Herts SHA

RTT MeasurementRTT Measurement

ContentsContents

ScopeScope

PracticalitiesPracticalities

Issues particularly relevant to Cardiology pathwaysIssues particularly relevant to Cardiology pathways

National and local actionNational and local action

MilestonesMilestones

Mar’06Mar’06 13 – 26 – 2613 – 26 – 26 (Theoretical max >1yr)(Theoretical max >1yr)

Mar’07Mar’07 11 – 13 – 2011 – 13 – 20 (Theoretical max 44 weeks)(Theoretical max 44 weeks)

Mar’08Mar’08 5 – 6 – 115 – 6 – 11 (Theoretical max 22 weeks)(Theoretical max 22 weeks)

Dec’08Dec’08 4 – 4 – 104 – 4 – 10 (Theoretical max 18 weeks)(Theoretical max 18 weeks)

Tolerance = ? %Tolerance = ? %

Scope of RTT measurementScope of RTT measurement

GP IP/STOP D OP

18 Weeks

GP Visit1st OutpatientAppointment

Decision to treat

Treatment

Referral Start of treatment

Prospective Retrospective

Key pathway pointsKey pathway points

ReferralReferral – record on PAS – record on PAS Opportunity to ‘tag’ the referral.Opportunity to ‘tag’ the referral.

Outpatient attendance(s)Outpatient attendance(s) - record on PAS - record on PAS Opportunity to record outcome(s).Opportunity to record outcome(s).

Decision to treatDecision to treat – record on clinic outcome slip &/or on – record on clinic outcome slip &/or on specially created PAS field.specially created PAS field.

Start of treatmentStart of treatment – record on PAS if date of admission for – record on PAS if date of admission for procedure; otherwise may have to be as for decision to treat.procedure; otherwise may have to be as for decision to treat.

Measurement ProcessMeasurement Process

Recording – how the data is collected and recordedRecording – how the data is collected and recorded

Extraction – how queries are constructedExtraction – how queries are constructed

Reporting – in what detail and format, by whom, whenReporting – in what detail and format, by whom, when

Action – otherwise there’s no point!Action – otherwise there’s no point!

Referral First Care plan Start of consultation agreed treatment

Patient waiting for first

consultation

Diagnostic phase &/or patient awaiting follow-up outpatient

attendance(s)

Patient waiting to start care plan

Patient tagged with I.D.

unique to the referral.

All events recorded on PAS must include the referral I.D.

(All 4 boundary events must be recorded for local management

purposes).

PAS query at any time will reveal patient progress

(waits and phases) to date.

Performance report

PAS query after start of treatment will reveal

actual historical data on waits.

Forecasts of total waiting time.

Feedback to Choose & Book

systems, to inform patients, clinicians and commissioners

Analysis and decisions on action to improve service. Also link to ISIP.

Recording

Extraction

Reporting

Action Choice, by patients and commissioners

Patient tagged with

I.D. unique to the referral.

All events recorded on PAS must include the referral I.D.

(All 4 boundary events must be recorded for local

management purposes).

Recording

PAS query at any time will reveal patient progress

(waits and phases) to date.

PAS query after start of treatment will reveal actual historical data

on waits.

Extraction

Forecasts of total waiting time.

Feedback to Choose & Book

systems, to inform patients, clinicians and commissioners

Reporting

Performance report

Analysis and decisions on action to improve service.

Also link to ISIP.

ActionChoice, by patients and commissioners

10

Current waiting time silosCurrent waiting time silos

GP written referral to first outpatient attendanceGP written referral to first outpatient attendance Outpatient wait, currently max 13wOutpatient wait, currently max 13w

Wait for diagnostic testWait for diagnostic test Only the time from request until the test itselfOnly the time from request until the test itself MR and CT, currently max 26wMR and CT, currently max 26w

Time on admission waiting listTime on admission waiting list Admission wait, currently max 26wAdmission wait, currently max 26w

Common issuesCommon issues

Definition of time and source of referralDefinition of time and source of referral

Definition of start of treatmentDefinition of start of treatment

Suspensions and deferralsSuspensions and deferrals

Cardiology ClinicsCardiology Clinics

Palpitation / arrhythmiaPalpitation / arrhythmia

CHD (mainly in RACPC rather than general clinics)CHD (mainly in RACPC rather than general clinics)

HypertensionHypertension

Heart failureHeart failure

Dizziness, syncopeDizziness, syncope

Cardiac pathology in pregnancyCardiac pathology in pregnancy

(Screening for) potentially inherited cardiac conditions(Screening for) potentially inherited cardiac conditions

Cardiology pathway issuesCardiology pathway issues

Long-term conditionsLong-term conditions

Which new spells of hospital consultant care are Which new spells of hospital consultant care are regarded as new referrals and which as continuity of regarded as new referrals and which as continuity of care plan treatment? And who checks / decides?care plan treatment? And who checks / decides?

Cardiology pathway issuesCardiology pathway issues

Hospital consultant-led outpatient work in community Hospital consultant-led outpatient work in community settingssettings

Ensure that any referral, consultation and procedure Ensure that any referral, consultation and procedure dates are recorded and reported alongside hospital dates are recorded and reported alongside hospital PAS data.PAS data.

Be clear about which work is and is not part of an Be clear about which work is and is not part of an 18w pathway.18w pathway.

Cardiology pathway issuesCardiology pathway issues

Tertiary careTertiary care

Ensure that key dates up to and including start of Ensure that key dates up to and including start of treatment are recorded and reported alongside treatment are recorded and reported alongside secondary care data; and…..secondary care data; and…..

Ensure completion of whole pathway records, to Ensure completion of whole pathway records, to help resolve issues listed under long-term conditions.help resolve issues listed under long-term conditions.

Define clearly what constitutes start of treatment.Define clearly what constitutes start of treatment.

Cardiology pathway issuesCardiology pathway issues

Defining, recording and reporting key pathway datesDefining, recording and reporting key pathway dates

ReferralReferral(Which ones are included and which excluded)?(Which ones are included and which excluded)?

First outpatient attendanceFirst outpatient attendance(How is this collected if at a one-stop shop or with a MDT)?(How is this collected if at a one-stop shop or with a MDT)?

Decision to treat / agreement on care planDecision to treat / agreement on care plan(Who defines it ; who records it and how)?(Who defines it ; who records it and how)?

Start of treatmentStart of treatment(Who defines it ; who records it and how)?(Who defines it ; who records it and how)?

5

2004/05 Total Waiting Time : General Surgical Procedures

0

5

10

15

20

25

30

35

40

Speci

alty

Inguin

al h

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Sigm

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Lumpec

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Chole

cyst

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Colono

scopy

Haem

orrh

oids

Gastro

scopy

Excis

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kin le

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Umbili

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Mas

tect

omy

Anal f

istu

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Circum

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Excis

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ctum

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nia

Hemic

olect

omy

Lesio

n of c

olon

We

ek

s WL Weeks

Diag Weeks

Out Pat Weeks

2004/05 Total Waiting Time : General Surgical Procedures

0

2

4

6

8

10

12

14

16

18

Speci

alty

Inguin

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We

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Diag Weeks

WL Weeks

GP referred patients - waits for first outpatient attendance and completion of outpatient treatment 2004/05

0

5

10

15

20

25

30

3510

0 G

en

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101

Uro

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11

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Ea

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And

Th

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130

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log

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140

Ora

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16

0 P

last

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180

A &

E

191

Pai

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ana

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30

0 G

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301

Ga

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302

End

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303

Ha

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32

0 C

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330

De

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340

Th

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40

0 N

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410

Rh

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Ca

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501

Obs

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510

Ob

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Na

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800

Onc

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Specialty

Ave

rag

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First outpatient attendanceOutpatient treatment completeTreatment started 18 weeksDiagnosis complete 11 weeksAttend outpatients 5 weeks

ActionAction

NationalNational Pioneer sitesPioneer sites Tactical solution mid-2006Tactical solution mid-2006 Strategic solution by 2007?Strategic solution by 2007?

DH website DH website www.18weeks.nhs.ukwww.18weeks.nhs.uk

Local: Local: Find out and join in what’s happening on 18w.Find out and join in what’s happening on 18w. Ensure that solutions are developed that suit CardiologyEnsure that solutions are developed that suit Cardiology The local CHD network could help develop solutions. The local CHD network could help develop solutions.

3

Local actionLocal action

Get the right organisations and people involvedGet the right organisations and people involved

PCTPCT Acute TrustAcute Trust SHASHA

Chief execsChief execs – the leaders and watchers – the leaders and watchers 18w leads18w leads – the encouragers – the encouragers Information managersInformation managers – the measurers – the measurers Clinical championsClinical champions – the keen clinical leaders – the keen clinical leaders

The carrots:

intellectual challenge

+

opportunity to study what really happens to our patients

+

worthwhile objective

Local networking

RecommendationsRecommendations

Keep it simple with few ‘rules’Keep it simple with few ‘rules’

Start with key dates - referral and start of treatmentStart with key dates - referral and start of treatment(ignore suspensions, DNAs etc initially)(ignore suspensions, DNAs etc initially)

Start with retrospective data (it may take longer to establish real time tracking)Start with retrospective data (it may take longer to establish real time tracking)

Try to ‘tag’ patients from the start of their journeyTry to ‘tag’ patients from the start of their journey

PioneersPioneers

8 sites across England8 sites across England

Pioneers with CHD focus:Pioneers with CHD focus: East KentEast Kent GatesheadGateshead Royal Devon & ExeterRoyal Devon & Exeter South BedfordshireSouth Bedfordshire

Tactical RTT solution by June 2006Tactical RTT solution by June 2006 RetrospectiveRetrospective ProspectiveProspective

Other pioneer sites:

Huntingdonshire

Kings, London

North Nottinghamshire

Oldham