bedford hospital nhs trust: examining the management of the inpatient waiting list

8/13/2019 Bedford Hospital NHS Trust: Examining the Management of the Inpatient Waiting List

1/81


2/81

2003 Peter Louis. All Rights Reserved ii

Bedford Hospital NHS Trust


3/81

2003 Peter Louis. All Rights Reserved iii

Contents

Contents .............................................................................................................. iiiGlossary ................................................................................................................ vExecutive summary ............................................................................................... 1Background ........................................................................................................... 3Methodology ......................................................................................................... 4

The NHS and Bedford BHS Trust ...................................................................... 4The waiting list process ..................................................................................... 5Process maps .................................................................................................... 6

Results & findings ................................................................................................. 9Specialities ........................................................................................................ 9

Ear, Nose and Throat .................................................................................... 9General Surgery and Urology ...................................................................... 11Gynaecology ................................................................................................ 18Ophthalmology ............................................................................................. 20Oral Maxillo-Facial ....................................................................................... 22Trauma and Orthopaedics ........................................................................... 23

Support departments ....................................................................................... 26Accident and Emergency ............................................................................. 26Admissions Department ............................................................................... 26Bed Manager ............................................................................................... 27Critical Care ................................................................................................. 28Inpatient PAC ............................................................................................... 28Medical Records .......................................................................................... 28Outpatient Process ...................................................................................... 29Reginald Hart Inpatient Ward ....................................................................... 29Tavistock Day Case Ward ........................................................................... 30Theatre Process .......................................................................................... 31Waiting List Department............................................................................... 31Waiting List Manager ................................................................................... 33

Discussion .......................................................................................................... 35Outpatient clinic ............................................................................................... 35

Allocation of TCI dates .................................................................................... 37Creation of theatre schedules.......................................................................... 42Managing patient cancellations ....................................................................... 44Managing DNAs .............................................................................................. 46Managing hospital cancellationssurgical fitness .......................................... 49Managing hospital cancellationshospital resources ..................................... 53Use of PiMS .................................................................................................... 54

Further action ...................................................................................................... 55Waiting list management best practice ............................................................ 55Centralised versus decentralised Admissions ................................................. 55


4/81

2003 Peter Louis. All Rights Reserved iv

Day surgery ..................................................................................................... 55Effect of ward processes on the management of inpatient waiting lists ........... 55

Acknowledgements ............................................................................................. 56References.......................................................................................................... 57

Appendix APiMS ............................................................................................. 59

Appendix BTargets and guidelines ................................................................. 63Waiting List Targets ......................................................................................... 63Waiting List Guidelines .................................................................................... 64

Placement and Removals ............................................................................ 64Primary Targeting Lists ................................................................................ 66Inpatient and Day Case Procedures ............................................................ 66Pre Assessment ........................................................................................... 67Monitoring Cancellations and DNAs ............................................................ 67

Guidelines Developed by the Trust ................................................................. 68Appendix CInterview scope............................................................................. 69


5/81

2003 Peter Louis. All Rights Reserved v

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 mapsdeveloped, clinician refers to aconsultant or less senior doctor.

Consultant team:

This team includes all the staff that work with the consultant in assigning TCIdates 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 thesame 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 operationwithout 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 apatient needs further treatment.

Elective Patient:


6/81

2003 Peter Louis. All Rights Reserved vi

A patient admitted to hospital for a planned procedure after an outpatientconsultation.

Emergency:

Service offers care to patients who arrive with urgent problems and who havenot usually been seen previously by a general practitioner

Emergency bed service:

This service covers the assignment of beds to the emergencies arrived at thehospital.

GP - General practitioner:

These doctors provide family health services to a local community. They areusually based in a surgery or GP practice and are often the first port of call formost patients with a concern about their health. GPs refer patients who needmore help to specialists, such as hospital consultants.

House officer:

An intern or resident employed by a hospital to provide service to patientswhile receiving training in a medical specialty.

Inpatient:

Persons admitted to health facilities which provide board and room, for thepurpose 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 ofchildren.

O/POutpatient

A patient referred to a consultant by a GP or consultant.

O/P referral letter:


7/81

2003 Peter Louis. All Rights Reserved vii

A letter sent by the Consultant to a patients referrer to inform them of theoutcome of the outpatient appointment

O/P Clinic:

An administrative arrangement enabling patients to see a health professionalat a consultant clinic, nurse clinic, midwife clinic, family planning clinic, or atany other clinic.

Outlier:

An outlier is a patient who occupies a bed in an incorrect ward i.e. a urologypatient in an orthopaedic ward.

PTLPrimary Targeting List:

The PTL is the list provided by the Waiting List Department outlining thepatients with the longest waiting time and therefore highest priority.

PAC - Pre-Assessment Clinic:

A clinic that assesses general health and fitness of patients for surgicalprocedures.

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 BedfordHospital 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 aconsultant

Registrar:


8/81

2003 Peter Louis. All Rights Reserved viii

This grade of medical staff is a member of a consultants team.

Routine:

That is the name given to a usual, habitual, regular clinical priority.

Senior clinical officer:


SHOSenior House Officer:


Side of Operation:

The area to be operated upon in theatre must be marked before surgery cango 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 aroutine clinical priority.

Specialist:

One who devotes himself to diseases of particular parts of the body, as theeye, 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 andOrthopaedics specialty.

T-Card board:

This board is used to display the T-card of each patient, and is a visual tool tomanage the state of each patient on the waiting list.

TCI dateTo Come In date

The date when a patient is scheduled to attend the hospital for a procedure


9/81


10/81

2003 Peter Louis. All Rights Reserved 1

Executive summary

The Inpatient Waiting List Project was initiated in February 2003 by BedfordHospital NHS Trust in cooperation with Cranfield University to look at theinpatient waiting list process The aim was to provide a set of observationsthat 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 informationsystems

construct and analyse the AS-IS maps of the processes.

Cranfield University was contracted to investigate the waiting list process ofsix surgical specialities and the administrative and clinical departments thatwere an integral part of the process. In total, 53 staff members at the Trustwere interviewed. A complete list is provided in the Interview ScopeinAppendix 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 theTrust

3. Developing process maps to represent the inpatient waiting list process atthe Trust

4. Analyzing the IDEF3 process maps to develop observations

The main observations were:

1. Evidence of unclear working practices. The process maps indicatedthat on occasions, there were no clear channels of communication orownership 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,


11/81


diaries or T-Boards. Moreover, information that was already containedin PiMS, such as which patient and TCI information, was re-enteredinto PiMS by the Theatre Department to create the operating list ofeach consultant.

In conclusion, scope exists to standardise the waiting list managementprocess by examining what best practices are performed within the Trust toreproduce those practices within the waiting list processes of otherconsultants. This report contains the in-depth knowledge required in order toachieve this.

Nonetheless, other areas that may be considered include:

benefits of having a decentralised admission process versus acentralised admission process

whether opportunities exist to undertake more surgical procedures asday surgeries

a survey of best practice knowledge among other clinical and ward staffnot interviewed as well as patients.


12/81


Background

Bedford Hospital NHS Trust is a dynamic organisation open to new ideas thatimprove patient services. The hospital management team is working toachieve the implementation of a successful Inpatient Waiting ListManagement Policy.

One of the main purposes of the NHS Plan is to improve waiting times forpatients. To improve the inpatient waiting list at Bedford Hospital, firstly, thehospital wanted to better understand the process. To achieve this, thefollowing objectives were identified to:

acquire knowledge of inpatient and day case management processes

acquire knowledge of the use and capabilities of relevant informationsystems

construct and analyse the AS-IS maps of the process.


13/81


Methodology

The methodology used by the team to achieve the objectives of the projectconsisted of a number of key stages:

1. Understanding the NHS and Bedford NHS Trust

2. Investigating and understanding the inpatient waiting list process at theTrust

3. Developing process maps to represent the inpatient waiting list processat the Trust

4. Analyzing the process maps to develop observations

To implement the above four-stage methodology, the team utilized a set ofproject management techniques and tools. The MOT (setting a Mission,determining a number of Objectives and specifying a series of Tasks) projectplanning and management methodology was closely followed. To supportMOT, the project team had weekly team meetings that monitored the projectagainst the plan and against the budget.

The NHS and Bedford BHS Trust

This required that the team investigate and understand the drivers for changewithin the NHS:

The need to reinvest in the NHS after several years of neglect

The need to make NHS more efficient and effective at deliveringservices catered towards its customerthe patient

Although the NHS is the largest organisation in Europe, investment levels inreal terms have been falling steadily and investment within the NHS is laggingbehind investment levels in similar institutions within Europe.

Associated with this lack of investment, NHS working practices have changedlittle since its beginnings. The NHS Plan promised real investment, but thishad to be linked to changes that made the organisation more effective atdelivering patient services at cost savings to the public. However, costsavings brought through improvements in effectiveness and efficiency were to

be reinvested in the NHS to deliver more services.


14/81


Coupled with these drivers for change were a set of guidelines and targetsthat were set by the Department of Health and various agencies andindependent 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, itsproblems 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 necessaryto establish the project data requirements:

1. Data scopewhat specialities and departments were to be mapped

2. Data sourcesthose persons or systems that would provideinformation and data on the waiting list process

3. Data contentwhat information was going to be elicited from thevarious persons or systems

The data scope, sources and content were initially identified by visiting thehospitals website, by talking to the project sponsors about candidatedepartments, by talking to the course supervisors who have experience inassisting the NHS through the Modernisation Agency and by having a seriesof introductory meetings with several key staff members at the Trust.

The data scope and sources were finalised by asking the project sponsors toprovide a set of specialities and departments, and a corresponding list ofindividuals who should be interviewed. This list included 53 staff members:

Group Department

12 Consultants ENT - 3General Surgery - 2OMF - 1Urology - 1Trauma & Orthopaedics - 1Gynaecology - 2Anaesthesia - 2

23 Consultant secretaries Ophthalmology


15/81


ENTGeneral SurgeryOMFUrology

Trauma & OrthopaedicsGynaecology

18 Support and clinical staff Waiting List ManagerA+E ManagerDay Case ManagerBed ManagerAdmissions DepartmentWaiting List DepartmentTheatre ManagerWard Clerk

Medical RecordsDepartment of AnaesthesiaPre-assessment ClinicOutpatient Department

The initial visits to the Trust also allowed the team to discover various sourcesof 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 elicitinformation from the identified data sources. However, the team determinedthat data from PiMS was fed into the Cancelled Operations Diagnostic Toolkitand the Checklist capacity planning application. Hence, the team decided tofocus on collecting data from PiMS.

Process maps

In parallel to collecting data and interviewing hospital staff, the teamdeveloped the IDEF3 process maps of the waiting list process.

The IDEF3 method was chosen to describe and document the processes as itcaptured knowledge in a structured way and within the context of a scenario(story). This scenario then provides an overall view that can be decomposedinto other processes. Furthermore, IDEF3 captures precedence and causality


16/81


relationships between situations and events in a form that is natural to domainexperts. 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 themajor operation scenarios of an enterprise

Documents the decision procedures affecting the states and life-cycleof critical shared data, particularly manufacturing, engineering, andmaintenance product definition data.

Makes system design and design trade-off analysis.

The IDEF3 maps were to be created after a debriefing of the interviewer andwithin one or two days of the knowledge being captured. To standardise mapdevelopment, the team agreed and followed the following procedures:

1. Processes, actions, activities, etc. were to be taken from a set ofstandard active verbs

2. Objects names were to be selected from a set of standard objectnames

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 descriptionswhere possible

11. Process notes should be written to capture information not readilyobserved 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


17/81


other possible tools to create the IDEF3 maps. The main advantages of usingProSim 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 theAS IS model with the interviewee by walking the interviewee through theentire captured process. This was to ensure that any omissions or correctionswere detected. These changes were then fed back into the process maps toupdate the AS IS Model to correctly reflect the actual process.

Once all maps were validated, the team then indexed the maps for easyreferencing 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 processmap for the outpatient process of a consultant in Gynaecology is illustrated inFigure 1.

X

SHO OFFERS

PATIENT TCI

DATE FROM

DIARY

SPR OFFERS

PATIENT TCI

DATE FROM

DIARY

CONS OFFERS

PATIENT TCI

DATE FROM

DIARY

XX

IF PRIORITY IS

ROUTINE

IF PRIORITY IS

URGENTXX

CONS MAKES

DTA &

ASSIGNS

PRIORITY

SPR MAKES

DTA &

ASSIGNS

PRIORITY

Figure 1: Outpatient process for a consultant in Gynaecology


18/81


Results & findings

Specialities

Ear, Nose and Throat

The following describes the waiting list processes for Mr Arasaratnam (MapNumber 03.0.0.0), Mr Frampton (Map Number 04.0.0.0) and Mr Hoare (MapNumber 05.0.0.0).

Admission Process

It has to be said, that everyone within the ENT speciality, works in a verysimilar way. What follows is a description of the processes and informationflows that occur, highlighting any relevant differences among the threesecretaries interviewed:

The process starts at the clinic, where Consultant, Registrar, SHO or JuniorDoctor makes decision to admit, fills in the PAAF, and they assign priority topatients as follows:

Mr Arasaratnam divides his patients into urgent, soon and routine. It israre that he gives a date to the patient at the clinic.

Mr Frampton divides his patients into urgent and routine and hesometimes assigns a date to the patient at the clinic. (This happenswhen it is a very urgent situation or a special occasion.)

Mr Hoare divides his patients into urgent, soon and routine and hesometimes assigns a date to the patient at the clinic. (This happenswhen it is a very urgent situation or a special occasion.)

Once the secretary has received the PAAF and patient notes at her office, shechecks them and she allocates TCI dates to the patients.

It is only Charlotte Mobbs, secretary to Mr Hoare, the one that does thistogether with the consultant and, instead of putting the information into adiary, they use an Access database that Mr Hoare created in 1997.

This TCI list, is emailed by the secretary to Admissions Department, and is atthis point when the patients are first added to the waiting list. The AdmissionsDepartment is the one in charge of sending a letter to the patient, offering adate for pre-op assessment and for the operation.


19/81


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 reviewher database and make these decisions together with the consultant) It is also

important to mention that Charlotte Mobbs is the only secretary in thisspeciality that creates her Theatre list straight away on PiMS.

Hospital Cancellations

When there is a cancellation by hospital at the PAC, the secretary receivesthe cancellation from the ward. She adds a reason for the cancellation into thedairy (Charlotte Mobbs, uses her database), reallocates the theatre time anddoes what is appropriate for each situation (suspend the patient or cancel theoperation 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 thecancellation from ward, consultant, Admissions Department or Theatre. Sheadds a reason for the cancellation into the dairy (Charlotte Mobbs, uses herdatabase) and does what is appropriate for each situation. The most commonof the cancellations by hospital at the OP is the lack of beds, and in this caseshe has to allocate a new date within 28 days. Mr Hoare mentioned that healso has to cancel quite often because of the equipment, sometimes there isno 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 thesecretary of the DNA and then she informs Admissions Department so theycan 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 Departmentinforms the secretary. Once she is informed from Admissions about the

reason of the DNA, they (consultant and secretary) decide what to do with thepatient (suspending, cancelling, allocating another date...) depending on thecase.

Patient Cancellations

When there is a cancellation by patient, the secretary receives thecancellation from Admissions Department or directly from the patient. Sheadds reason for the cancellation into the dairy (Charlotte Mobbs, uses herdatabase), reallocates the theatre time and does what is appropriate for each

situation - suspend the patient or cancel the operation because it is no longer


20/81


required. In both of the previous cases, she informs Admissions Departmentabout it.

General Surgery and Urology

The following describes the waiting list processes for Mr Tisi (Map number11.0.0.0).

Admission Process

Only Mr Tisi makes the decision to admit. He specifies priority as either urgentor 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 passesone copy to his secretary and one copy to the Admissions Department to addthe patient to his waiting list. Mr Tisissecretary maintains an outlook andphysical diary and these are used to create a theatre list the day beforesurgery. Mr Tisi, specifies the order that the patients will be operated uponand then the list is emailed to the Theatre Department.


If one of Mr Tisispatients is to be admitted for surgery, they attend a Pre-Assessment Clinic (PAC) straight after their outpatient appointment. If at thePAC the patient is deemed unfit to attend surgery, they are asked to contactMr Tisissecretary once they are fit and Mr Tisi is informed and does notproceed with that patients PAAF. If the patient is unfit on the day of theoperation and it is a minor problem, like a cold, Mr Tisi will allocate a new TCIdate. If the problem is more serious, Mr Tisi will remove the patient from thewaiting list and refer the patient back to their GP or may choose to see themas 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 oroperation.



21/81


In the case of a patient cancellation, Mr Tisissecretary is notified either by thepatient or by the Admissions Department. She notifies Mr Tisi and if thepatient notifies the secretary directly then she informs the AdmissionsDepartment. If the patient states that they no longer require surgery, she asks

the Admissions Department to remove the patient from the waiting list and MrTisi informs the patients GP of the removal via letter. If the patient states thatthey are unfit for surgery, she consults with Mr Tisi and he decides whetherthe patient should be removed from the waiting list or suspended. If thepatient requires suspension, Mr Tisissecretary will ask the AdmissionsDepartment to suspend the patient from the waiting list. If the patient simplycannot attend the specified TCI date, Mr Tisi will allocate a new one and hissecretary will inform the Admissions Department. If time permits, Mr Tisi willreallocate any free theatre time at his outpatient clinic.

Use of PiMS

Mr Tisissecretary uses PiMS to check patient information and also to checkthe waiting times of patients for the minor operations clinic. If these patientswait more than 6 months, she will transfer them to Mr Tisiswaiting list toensure they are operated upon, as soon as possible.

The following describes the waiting list processes for Mr Parsons (Mapnumber 9.0.0.0)

Admission Process

In Mr Parsons team, Mr Parsons, the Staff Grade, Registrar and SHO makethe decision to admit. They specify priority as either urgent, soon or routineand allocates TCI dates to all patients except those who only require veryminor surgery in the laser clinic. They fill in a standard PAAF and pass onecopy to Mr Parsons secretary and one copy to theAdmissions Department toadd the patient to his waiting list. Mr Parsons secretary maintains a physicaldiary 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 thenthe list is emailed to the Theatre Department.


If at the PAC or on the day of operation the patient no longer requires surgeryor 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 hospitalresources, they are allocated a new TCI date within 28 days.


22/81


Patient DNAs

If a patient does not attend their PAC, Mr Parsonssecretary will try to

establish contact with the patient. If she cannot do this, the patient is removedfrom the waiting list. If she does and the patient no longer requires surgery oris unfit for an operation, they are removed from the waiting list. If they contactMr Parsons secretary within 48 hours and did not attend for any other reason,Mr Parsons secretary will arrange a PAC for the patient.


In the case of a patient cancellation, Mr Parsonssecretary is notified either bythe patient or by the Admissions Department. If the patient notifies the

secretary directly, she informs the Admissions Department. If the patientstates that they no longer require surgery, she asks the AdmissionsDepartment to remove the patient from the waiting list and informs thepatients GP of the removal via letter. If the patient states that they are unfit forsurgery they are removed from the waiting list and asked to contact MrParsons secretary when they are fit. If the patient simply cannot attend thespecified TCI date, Mr Parsons secretary will allocate a new one and informthe Admissions Department. If time permits, Mr Parsons will reallocate anyfree theatre time at his outpatient clinic.

Use of PiMS

Mr Parsons secretary uses PiMS to check patient information. She also usesthe PTL to cross check her own waiting list records.

The following describes the waiting list processes for Mr Callam (Map number6.0.0.0).

Admission Process

In Mr Callamsteam, Mr Callam, the Staff Grade, Registrar and SHO makethe decision to admit. They specify priority as either urgent or routine. Theclinicians fill in a standard PAAF and pass it to Mr Callamssecretary and onecopy is sent to the Waiting List Department to add the patient to Mr Callamswaiting list. Mr Callamssecretary maintains a physical diary and also filesPAAFs to maintain the waiting list. Mr Callam specifies TCI dates for patientswith at least two weeks notice. His secretary informs the AdmissionsDepartment of these dates. The diary is used to create a theatre list the daybefore 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.


23/81



If at the PAC or on the day of operation the patient no longer requires anoperation, they are removed from the waiting list. If they are deemed unfit toattend surgery then they are suspended from the waiting list.

If a theatre slot becomes available after the PAC for one of the reasons aboveor if a patient does not attend, then Mr Callamssecretary will again try toreallocate the theatre time.

If a patient is cancelled on the day of operation due to a lack of hospitalresources then they are allocated a new TCI date and will be treated as anurgent patient.

Patient DNAs

If a patient does not attend their PAC or operation then Mr Callamssecretarywill try to establish contact with the patient. If she cannot do this then thepatient is removed from the waiting list. If she does and the patient no longerrequires an operation then they are removed from the waiting list. If they areunfit to attend surgery then they are suspended from the waiting list. If theydid not attend for any other reason then Mr Callamssecretary will arrange forthe patient to be seen as an outpatient.


In the case of a patient cancellation Mr Callamssecretary is notified by eitherthe patient or the Admissions Department. She notifies Mr Callam and if thepatient states that they no longer require surgery, Mr Callam informs thepatients GP of the removal via letter, which is copied to the Waiting ListDepartment. If the patient requires suspension, Mr Callamssecretary will askthe Admissions Department to suspend the patient from the waiting list. If the

patient simply cannot attend the specified TCI date, Mr Callam will allocate anew one when allocating other TCI dates and his secretary will inform theAdmissions Department. If time permits, Mr Callamssecretary will reallocateany free theatre time. If necessary, she will offer a TCI date to a patient beforeinforming the Admissions Department of the TCI date.

The following describes the waiting list processes for Mr Skipper (Map number10.0.0.0)

As Mr Callam except


24/81


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 TheatreDepartment

If a patient requires removal from the waiting list the AdmissionsDepartment will be asked to do this and also an outpatient appointmentis arranged for the patient

Mr Skipperssecretary uses PiMS to check patient information.

The following describes the waiting list processes for Mr Waterfall (Mapnumber 22.0.0.0) (UROLOGY)

Admission Process

In Mr Waterfallsteam, Mr Waterfall, the Staff Grade, Registrar and SHOmake the decision to admit. They specify priority as either urgent, soon orroutine. The clinicians fill in a standard PAAF and pass it to Mr Waterfallssecretary and one copy is sent to the Waiting List Department to add thepatient to Mr Waterfallswaiting list. Mr Waterfallssecretary maintains aphysical diary and also creates T-cards to maintain the waiting list. MrWaterfallssecretary specifies TCI dates for patients with at least two weeksnotice. She informs the Admissions Department of these dates. The diary isused to create a theatre list the day before surgery. Mr Waterfall specifies theorder that the patients will be operated upon and then the list is emailed to theTheatre Department by the secretary.


If at the PAC or on the day of operation the patient no longer requires anoperation then they are removed from the waiting list. If they are deemed unfitto attend surgery then they are suspended from the waiting list. In both casesthe patients GP is informed via letter.

If a theatre slot becomes available after the PAC for one of the reasons aboveor if a patient does not attend then Mr Waterfalls secretary will again try toreallocate the theatre time.


25/81


If a patient is cancelled on the day of operation due to a lack of hospitalresources then they are allocated a new TCI date and will allocated a TCIdate within 28 days.

Patient DNAs

If a patient does not attend their PAC or operation then Mr Waterfallssecretary will try to establish contact with the patient. If she cannot do thisthen the patient is removed from the waiting list. If she does and the patient nolonger requires an operation then they are removed from the waiting list. Ifthey 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 newTCI date.


In the case of a patient cancellation, the patient or the Admissions Departmentnotifies Mr Waterfallssecretary. She notifies Mr Waterfall and if the patienthas notified her, she informs the Admissions Department. If the patient statesthat they no longer require surgery, the secretary arranges them an outpatientappointment and also asks the Admissions Department to remove the patientfrom the waiting list. If the patient requires suspension, Mr Waterfallssecretary will ask the Admissions Department to suspend the patient from thewaiting list. If the patient simply cannot attend the specified TCI date, thesecretary will allocate a new one when allocating other TCI dates and willinform the Admissions Department. If time permits, Mr Waterfallssecretarywill reallocate any free theatre time. If necessary, she will offer a TCI date to apatient before informing the Admissions Department of the TCI date.

Use of PiMS

Mr Waterfallssecretary uses PiMS to check patient information and toconfirm 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 number7.0.0.0)

As Mr Waterfall except

Only Mr Eldin and his Registrar make the decision to admit.


26/81


TCI dates are given to patients at the outpatient clinic if the patientspriority 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 whenconvenient are the priorities specified.

The theatre list is sent to Theatre Department, Anaesthetics andWards.

A letter is not sent to the patients GP if a patient is suspended from thewaiting list.

The following describes the waiting list processes for Mr Foley (Map number

8.0.0.0)

Admission Process

In Mr Foleysteam, Mr Foley, the Staff Grade, Registrar and SHO make thedecision to admit. They specify priority as either urgent, soon or routine. Theclinicians fill in a non-standard PAAF and pass it to Mr Foleyssecretary andone copy is sent to the Waiting List Department to add the patient to MrFoleyswaiting list. Mr Foleysspecialist nurse maintains a physical diary andfiles PAAFs to maintain the waiting list. She specifies TCI dates for patientswith at least two weeks notice. She also informs the Admissions Departmentof these dates. The diary is used to create a theatre list the day beforesurgery. Mr Foleysspecialist nurse specifies the order that the patients will beoperated upon and then the list is emailed to the Theatre Department,Clinicians, Waiting List Department and Anaesthetists.


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 tobe 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 likea cold a new TCI date will be arranged.

If a patient is cancelled on the day of operation due to a lack of hospitalresources then they are allocated a new TCI date within 28 days.

Patient DNAs


27/81


If a patient does not attend their PAC or operation then Mr Foleysspecialistnurse will contact the Admissions Department.


In the case of a patient cancellation Mr Foleysspecialist nurse is notified byeither the Admissions Department or by checking PiMS. If the patient statesthat they no longer require surgery they are removed from the waiting list. Ifthe patient requires suspension they are suspended from the waiting list. If thepatient simply cannot attend the specified TCI date, Mr Foleysspecialistnurse will allocate a new one and will inform the Admissions Department. Iftime permits Mr Foleysspecialist nurse will reallocate any free theatre time.

Gynaecology

The following describes the waiting list processes for Mr Budden (MapNumber 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. TheConsultant, Registrar or SHO (the clinician) offers the patient an appropriateTCI date from the Consultants diary.

If the patient and the clinician agree on a TCI date, the clinic nurse enters thepatient details, procedure and TCI date onto the T-Card, which is received bythe Consultants secretary after clinic.

If the patient and clinician are unable to agree a TCI date, the patient is invitedto call the secretary to agree a TCI date from the diary. Once a TCI date hasbeen 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 notesfor this TCI date to the wards. The day before the next theatre for theclinician, the secretary creates a theatre list from the diary and sends it to thetheatre secretaries and theatre Manager.


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


28/81


informed by the Consultant or theatre secretary), the secretary re-books thepatient 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 theteams diary.

If the patient and clinician are unable to agree a TCI date, the patient is invitedto call the secretary to agree on a TCI date from the diary. Once a TCI datehas been agreed, the secretary cancels the previous TCI date and enters thenew 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 tothe secretary with a DNA status. Normally, the wards senior nurse or sistercalls the secretary about the DNA. The ward may also enter the DNA statusonto PiMS.

For certain DNAs (generally, day surgery procedures such as sterilisations orterminations), the secretary does not consult with the Consultant but contactsthe referrer to inform her/him of the DNA.

If the secretary informs the Consultant, she may either contact the referrer asabove or contact the patient either to re-book the operation or to remove thepatient from the waiting list on PiMS.


If a patient wants to change his/her TCI date, the secretary offers the patient anew 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. forsterilisations or terminations), the secretary may write the referrer beforeremoving the patient from waiting list.

Where the Consultant is informed, if the Consultant advises the removal of thepatient, she may contact the referrer before removing the patient from thewaiting list. Otherwise, the Consultant may request an outpatient appointmentfor the patient.

For cancelled TCI dates, if time permits, the secretary attempts to replace thecancelled TCI slot with an appropriate patient from the diary.

If a patient cancels the nurse PAC, then patient is offered a PAC on ward.


29/81


Ophthalmology

This following describes the waiting list processes for Mrs Pieris (Map Number14.0.0.0).

Admission Process

During the outpatient appointment, if a patient requires further treatment, theConsultant, Associate Specialist, Staff Grade, Hospital Practitioner or SeniorClinical 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 patients clinic bundle, the secretary creates a T-card and sends aletter to the referrer. A nurse PAC date is booked for urgent patients and non-urgent patients receive a nurse PAC date once their T-card has progressed toa free PAC date on the T-board.

After the nurse PAC, the secretary updates T-Cards and allocates TCI datesto T-Cards given the patients clinical priority and DTA date. A TCI letter fromPiMS with Dr PAC and Dr Post Assessment Clinic dates is then sent to thepatient.

The day before the next theatre session for the clinician, the secretary createsa theatre list from the T-cards and sends it to the clinic receptionist, eyetheatre receptionist, theatre secretaries and the wards. (She also places thelist in the Dr PAC.) The clinic receptionist then enters TCI dates onto PiMS.


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 bythe theatre (secretary informed by the clinic nurse, clinician or eye theatrereceptionist), the secretary allocates a new TCI date and calls the patient tore-book. She then amends the theatre list and sends it to the normaldistribution.

If a patient is cancelled at the Doctor PAC, the clinic nurse or Clinician informsthe secretary. The secretary cancels the TCI and post assessment dates andnotifies the Waiting List Department to suspend or remove the patient asadvised by the Consultant. If the patient is removed, the referrer is notified.


30/81


At the same time, the secretary attempts to fill the cancelled TCI slot with apatientnormally a one-stop patient. The theatre list is amended and sentto the normal distribution.

Patient DNAs

The clinic nurse or Clinician tells the secretary of DNAs that occur at nursePACs. If the patient does not want to be re-booked, the Waiting ListDepartment is asked to remove the patient from the waiting list. If the patientwants 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 re-book, the secretary allocates a Dr PAC date if one is available before TCI dateor 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 orclinician tells the secretary. The secretary may inform the theatre secretaryabout the DNA.

The clinician may ask the secretary to find a replacement patient. In thiscase, the secretary attempts to contact an appropriate patient who can comein for surgery. This is generally a one stop patient and the theatre list isamended and sent to the normal distribution.


If a patient wants to change his/her TCI date, for the first cancellation, thesecretary allocates a new TCI, Dr PAC and Post Assessment dates andsends an appointment letter to the patient. For subsequent cancellations, theabove 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 thereferrer.

If the patient does not want the procedure, the secretary will ask the WaitingList Department to suspend or remove the patient. If the patient is to beremoved, a letter is sent to the referrer.

For cancelled TCI dates, if time permits, the secretary attempts to replace thecancelled TCI slot with an appropriate patient after reviewing the T-Cards. Anupdated theatre list is sent to the normal distribution.


31/81


If a patient cancels the Dr PAC, the secretary books a Dr PAC date if one isavailable before the TCI date or allocates a new TCI date and books Dr PACand Post Assessment dates. The secretary then sends an appointment letterto 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 MrSimpson (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, theConsultant, Associate Specialist, Registrar or SHO (the clinician) makes aDTA and assigns a clinical priority. If the priority is urgent, the clinician mayoffer the patient an appropriate TCI date from the Consultants diary. If a dateis offered, the clinician fills the General Anaesthesia Waiting List (GA W/L)Card and the secretary or clinician adds the patients details to the diary. GAW/L Cards are then sent to the Waiting List Department.

Monthly, the secretary reviews the GA W/L Cards and this may include thePTL to allocate TCI dates given the patient priority and DTA. The secretarythen enters these patients in the GA W/L Diary (under TCI date) and sendsthe list to the Admissions Department.

One or more days before the next theatre session for the clinician, thesecretary creates a theatre list from the diary and sends it to the wards,theatre secretaries and theatre Manager.


If a patient is cancelled on the day of surgery by the ward (secretary isinformed by the bed manager, ward, Admissions Department or Waiting ListManager) or by the theatre (secretary informed by the Admissions Departmentor by the clinician), the secretary allocates a new TCI date and calls thepatient to re-book. She then amends the theatre list and sends it to thenormal 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 patientsTCI 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.


32/81


Patient DNAs

For DNAs at the Dr PAC, the clinic nurse contacts the secretary who asks theAdmissions Department to validate the patient or to send a PAC appointmentto 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 orWard. The secretary then asks the Waiting List Department to remove thepatient from the waiting list and sends a letter to the referrer indicating theremoval.


The Admissions Department or the patient contacts the secretary to cancel anappointment.

If a patient wants to change his/her TCI date, for the first cancellation, thesecretary offers the patient a new TCI date and enters patient and operationdetails 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 thesecretary 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 WaitingList Department to remove the patient. If the patient is to be removed, a letteris sent to the referrer.

For cancelled TCI dates, if time permits, the secretary attempts to replace thecancelled TCI slot with an appropriate patient.

If a patient cancels the Doctor PAC, then a patient is offered a new PAC andAdmissions is asked to send a letter to the patient.

Trauma and Orthopaedics

The following describes the waiting list processes for Mr Rawlins (MapNumber 20.0.0.0), Mr Handley (Map Number 18.0.0.0), Mr Riley (MapNumber 21.0.0.0), Mr Nel (Map Number 19.0.0.0) and Mr Edge (Map Number17.0.0.0).

Admission Process


33/81


It has to be said that everyone within the TRAUMA and ORTHOPAEDICSspeciality, works on a very similar way. Here, there is a description of theprocess and flow of information, highlighting any relevant differences among

the team.

Everything starts at the clinic, where Consultant, Registrar, SHO or JuniorDoctor fill in the PAAF, and assign priority to the patients as follows:

Mr Rawlins divides his patients into urgent, soon and routine and it isvery rare that he gives a date to the patient at the clinic.

Mr Handley divides his patients into urgent, soon and routine and henever assigns a date to the patient at the clinic.

Mr Riley divides his patients into urgent, soon and routine and hesometimes assigns a date to the patient at the clinic. (This happenswhen 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. Sometimeshe assigns a date to the patient at the clinic, but this does not happensvery often.

Once the secretary has received PAAF and patient notes at her office, shechecks them, transcribes all the relevant information onto the T-Card Boardand they type and send the clinic letter to the General Practitioner. (it shouldbe mentioned that Anne Wright, secretary to Mr Handley, is the only secretarythat types the clinic letter straight away onto PiMS). Each of the fivesecretaries we talked to in this speciality, use a T-Card board to organise theirpatients information. The secretary allocates TCI dates to the patients bychecking the T-Card Board.

It is only in the cases of Anne Wright and Diana Wiser, when the secretaryallocates the TCI dates to the patients on her own. The other three secretariesdo this job together with the consultant. In the case of Anne Wright, sheconfirms the date that she is allocating, by telephoning the patient. By doingthis, she avoids many cancellations by patient and DNAs.

They all place the T-Cards with TCI date assigned, in the allocated datecolumn, and they create and email the TCI list to the Admissions Departmentand 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


34/81


staff, doctors and wards. They all do this by their own, using their experienceand knowledge, except from Susan Reid who does this together with MrRawlins, her consultant.


When there is a cancellation by hospital at the PAC, the secretary receivesthe cancellation from the ward or the Admissions Department. She addsreason for the cancellation onto the T-Card, reallocates the theatre time anddoes what is appropriate for each situation. (suspend the patient or cancelthe 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. Sheadds reason for the cancellation onto the T-Card, and does what isappropriate for each situation. The most common of the cancellations byhospital at the OP is the lack of beds, and in this case, she has to allocate anew date within 28 days. Diana Wiser says that sometimes she is notinformed about the cancellation by hospital (she finds it out several daysafter).

Patient DNAs

When there is a DNA at the pre-op assessment, the ward informs thesecretary of the DNA and then she informs Admissions Department so theycan 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 Departmentinforms the secretary. Once she is informed from admissions about thereason of the DNA, they (consultant and secretary) decide what to do with thepatient (suspending, cancelling, allocating another date...) depending on thecase.


When there is a cancellation by patient, the secretary receives thecancellation from Admissions Department or directly from the patient. Sheadds reason for the cancellation onto the T-Card, reallocates the theatre timeand does what is appropriate for each situation. (suspend the patient orcancel the operation because it is no longer required) In both of the previouscases, she informs Admissions Department about it, so they can do what isneeded.


35/81


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 isheralded then a specialist consultant is specified prior to the patient arriving toA+E. If the patient is non-heralded then they will either be treated by A+E or aspecialist consultant will be specified once the A+E doctor has diagnosed thepatients condition.

After examining the patient the consultant will decide whether or not thepatient can be treated and discharged, needs to be transferred to anotherconsultant or whether they need to be admitted as an inpatient.

If admitted the patient may affect elective patients if a bed or theatre slot thathad 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 andpatients; suspension requests from secretaries and the PAC nurse; andcancellation requests from patients and the Bed Manager. She alsoprocesses requests to admit patients.

A removal request results in a patient being removed from the waiting list onPiMS. The Removal from Inpatient Waiting List Form is filled and thesecretary is informed. A suspension request results in the patient beingsuspended from the waiting list on PiMS and the secretary is notified. Acancellation request results in the TCI being cancelled on PiMS for thatpatient and a confirmation of acceptance results in that acceptance beingnoted on PiMS.

During the admission process, the Admissions Supervisor enters details of thepatient admittance (if required) and TCI date onto PiMS. A TCI letter fromPiMS and a pro forma are sent to the patient. After 48 days, a list of patientswho have not responded is printed and these patients are called. If a patientis uncontactable, then the GP is contacted for the patients telephone number

and address.


36/81


The patient is called with the number from the GP. However, if the patient isstill uncontactable, either the secretary may continue to call or she sendsanother TCI Letter and Pro Forma. At any stage where the patient is

contactable, the patient is asked to indicate whether they would like to beremoved from the waiting list, suspended from the waiting list or confirmed onthe waiting list.

DNA Process

If a patient DNAs on the day of surgery, the ward calls the AdmissionsSupervisor. The Admissions Supervisor enters a DNA status for the patientonto 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 withdifferent people, like for instance:

Every Friday, bed manager, waiting list manager and matron daysurgery have a meeting to create the TCI list for the weekend (Mondayincluded) and for the following week.

Every day from Monday to Thursday, the bed manager receives fromthe Admissions Department the TCI lists for the next day, and she alsoshares information with them about patients 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 needsto cancel any operation, she will have to contact to Leah Caleb (waiting listmanager) 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 therelevant ward and she will inform the Admissions Department, so they can dowhat is needed.


37/81


Critical Care

Critical Care (Map number 28.0.0.0)

The Critical Care Department is primarily for emergency patients but onoccasions will house elective patients who require a high level of care aftersurgery. In this case the bed can only be provisionally booked right up untilthe day of surgery. If the bed is required for an emergency patient before theday of operation up until the morning of surgery then the elective patientsconsultant will be informed and the patients operation is likely to be cancelleduntil 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 weeksbefore the operation. Once the pre-assessment clinic is done, different thingscan happen:

Patient is ok. In this case, the patient will come for the operation asplanned.

Patient is unfit. The pre-assessment clinic nurse will discuss with therelevant doctor what needs to be done. It could be suspending thepatient, referring the patient back to the General Practitioner orreferring the patient to other specialist required.

The operation is no longer required. The pre-assessment nurse informsthe Admissions Department and the consultants secretary.

Medical Records

Medical Records (Map number 31.0.0.0)

Prior to examining or operating upon a patient the doctor must have access tothe patients notes so that any previous conditions that may affect theoutcome can be identified. Medical Records store and retrieve all patientnotes 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.


38/81


Outpatient Process

Outpatients (Map number 1.0.0.0)

The majority of inpatients on the waiting list feed in from the outpatientprocess. The hospital receives referrals for a patient to seen as an outpatient.These referrals come from many sources but most come from GPs. Thereferral will either be for a specified consultant at the hospital or will beaddressed to Dear Doctor.

If a consultant has not been specified, then the patient will be allocated to theconsultant in the required speciality with the shortest waiting list. In some

specialities the hospital has recently introduced generic codes which allow theconsultant to specified later in the outpatient process.

When the patient is examined in the outpatient appointment the consultantmay make a decision to admit the patient in which case they will be added tothat consultants inpatient waiting list.

In some circumstances the patient may actually be admitted from theoutpatient process which may affect resources specified for electiveinpatients.

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 Clerkprepares lists of patients due to come to the ward each day and their arrival isnoted 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 seenby a consultant and an anaesthetist prior to the operation. If for any reasonthe operation has to be cancelled the relevant parties (theatre etc) will beinformed.

If the operation goes ahead the patient will recover and if there are noproblems the patient is discharged on PiMS.

If the patient is unwell and takes longer than expected to recover this mayaffect hospital resources reserved for other elective inpatients.


39/81


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 dayand their arrival is noted on both these forms and on PiMS. If a patient doesnot attend the patients consultant will be informed.

Patients coming for the Day Case pre-assessment clinic can do it in twodifferent ways:

They can come as walk-in patients. They mean by walk-in, when theycome 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 weeksbefore the operation. Once the pre-assessment clinic is done, different thingscan happen:

Patient is ok. In this case, the patient will come for the operation asplanned.

Patient is unfit. The pre-assessment clinic nurse will discuss with therelevant doctor what needs to be done. It could be suspending thepatient, referring the patient back to the General Practitioner orreferring the patient to other specialist required.

The operation is no longer required. The pre-assessment nurse informsthe Admissions Department and the consultants secretary.

Once the pre-assessment is done the pre-assessment nurse and the relevantconsultant will make the appropriate decision for the relevant patient.

On the day of a patients operation the patient will be seen by a consultant andan anaesthetist prior to the operation. If for any reason the operation has to becancelled the relevant parties (theatre etc) will be informed.

If the operation goes ahead the patient will recover and if there are noproblems the patient is discharged on PiMS.

If the patient is unwell and needs to be admitted as an inpatient this mayaffect hospital resources reserved for elective inpatients.


40/81


Theatre Process

Theatre process (Map Number 29.0.0.0)

What happens at the theatre is that they receive weekly a TCI list from theWaiting 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 thetheatre session, the final theatre list and she enters all the information ontothe PiMS.

Once the final list is created, the theatre secretary sends a copy of it to therequired 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 consultantteam 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, theconsultant team informs the theatre secretary and she cancels ontoPiMS.

Cancellation due to a lack of resources. The theatre secretary receivesthe cancellation from the ward and then she cancels onto PiMS.

Cancellation due to the patient is unfit for surgery. The ward or theconsultant team informs about the cancellation and the theatresecretary cancels then onto PiMS.

Cancellation due to a skill-mix at the theatre. The consultant teaminforms the theatre secretary so she enters the cancellation onto PiMS.

Cancellation by bed manager. Either the bed manager or theconsultant informs the theatre secretary and she enters thecancellation onto PiMS.

Waiting List Department

Waiting List Department (Map Number 24.0.0.0)

Long Waiter Report


41/81


The Waiting List Supervisor receives this report daily from the IT Departmentand 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 WaitingList Card, T-Cards, etc.) from outpatient clinics. Patient details are enteredonto PiMS. However, if a form has a TCI date, it is handed to the AdmissionsDepartment. Otherwise, a day case letter is sent to the patient with a replyslip.

Patient Validation Manual Process

The Waiting List Information Coordinator receives removal requests fromsecretaries, suspension requests from secretaries and patient validationrequests from secretaries.

A removal request results in a patient being removed from the waiting list onPiMS. If that request is from the patient, the Removal from Inpatient WaitingList Form is filled and a copy is sent to the GP. A suspension request, resultsin the patient being suspended on the waiting list on PiMS.

During patient validation (manual) process, the Waiting List Supervisor sendsa letter to the patient with a reply slip. If the patient does not reply within 14days, the GP is contacted for the patients telephone number and address. Ifthe telephone number is different, the secretary calls the patient. If thenumber is the same, the secretary writes the patient and gives the patient 14days to reply.

If the patient is contactable, the patient is asked to confirm whether she/hewould 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 fromsecretaries and the Waiting List Manager. The Waiting List Supervisor alsovalidates 8-month waiters automatically through PiMSat least once a week.A removal request results in a patient being removed from the waiting list onPiMS. If that request is from an urgent patient, the Waiting List InformationCoordinator informs the Waiting List Manager. For any other priority, eitherthe ward is informed (if the patient has been treated) or the Waiting ListManager is informed (if the patient has not been treated).


42/81


During patient validation (auto) process, the Waiting List InformationCoordinator selects the validation option from PiMS and creates the first set ofvalidation letters. Patients are checked to ensure that they are not on thewaiting 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 arechecked to ensure that they are not on the waiting list. Urgent patients arereferred to the appropriate secretary and patients with TCI dates are notvalidated.

Letters are sent and patients have 21 days to reply. Both of the validationletters require that the patient indicates whether she/he would like to remainon 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 InformationCoordinator removes the patient and sends a letter to the GP and theappropriate 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 betweenthe Admissions Department, Waiting List Department, Bed Manager andTheatre Department. She is responsible for the management of the WaitingList and Admissions Departments and therefore to ensure that the hospitalmeets government targets relating to patient waiting time.

The Waiting List Manager or one of her staff meets daily with the BedManager to check whether there are enough beds to house all scheduledelective patients. If this is not the case then depending upon the gravity of theproblem an emergency bed state may be declared. If this is the case theWaiting List Manger will attend an emergency bed meeting where potential

cancellations will be discussed and possibly the decision to cancel will bemade.

In all cases cancelling patients is avoided if possible. The Waiting ListManager produces the monthly theatre schedule and reallocates theatre timethat may occur because of staff holiday or illness. If a patient is cancelled intheatre the Waiting List Manager will liaise with the Theatre Department to tryto fit the patient in elsewhere. In some cases the patient may be transferred toa private hospital to ensure that their surgery is carried out within the 12month deadline. Also extra theatre sessions are organised occasionally toreduce long waiting lists.


43/81


There are in place waiting list initiatives with several private hospitals toreduce waiting times for problem waiting lists.


44/81


Discussion

Before the IDEF3 maps were analysed, the team identified a set of eightareas that were critical to the functioning of the waiting list process at theTrust. The waiting processes for the consultants were then analysed underthese 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 DTAwas made only by the consultant in one case, by the consultant or registrar inseven cases and by the consultant, registrar or another doctor in 12 cases.The results are illustrated in Figure 3.


45/81


Figure 3: Who makes DTA

What priorities are assigned to patients?

The priorities assigned to patients included not only standard priorities, suchas 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 arefound is shown in Figure 4.

Figure 4: Priorities used

Priorities Used

7

11

1

1

Urgent and Routine

Urgent, Routine and Soon

Very Urgent, Routine and Soon

Others

1

7

12

0

2

4

6

8

10

12

Who makes DTA?

Consultant only

Consultant and Registrar

Consultant, Registrar andOthers


46/81


Allocation of TCI dates

When are TCI dates given?

In investigating the circumstances under which TCI dates were given, it wasdetermined that in 4 cases consultants always offered a patient a TCI date inclinic; in 8 cases, patients only received a TCI date if they were urgent; in 6cases, TCI dates were never offered in clinic and in 1 case, TCI dates wereoffered if possible. The results are presented in Figure 5.

4

6

8

1

0

1

2

3

4

5

6

7

8

When are TCI dates given at the O/P Clinic?

All Patients

Never

Urgent Patients

When Possible

Figure 5: When are TCI dates given?

Is the standard PAAF used?

It was determined that the standard PAAF form was used by 14 consultantswhilst other forms (GA W/L card, T-Card, old PAAF form, etc) were used inthe 6 other cases. The results are presented in Figure 6.


47/81


Is standard PAAF used?

14

6

Yes

No

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 PatientAwaiting Admittance Forms (PAAFs) were filled in a folder and accessedwhen necessary; in 8 cases a T-Card board was used to process T-Cards; in1 case a bespoke database was used; and in 4 cases, TCI dates wereprovided immediately from a diary. The results are summarised in the Figure7.

7

8

1

4

0

1

2

3

4

5

6

7

8

What means are used to manage patients awaiting TCI dates?

PAAFs filed in a folder

T-Card Board

Bespoke database

TCI dates allocated atOutpatient Clinic

Figure 7: What means are used to mange patients awaiting TCI dates?


48/81


Who allocates TCI dates?

In 4 cases, patients received TCI dates from clinicians during the outpatientappointment. In 2 cases, patients received TCI dates from the clinician after

the outpatient appointment. However, in 11 cases, the secretary or specialistnurse allocated TCI dates to patients after the outpatient appointment. Thisinformation is illustrated in Figure 8.

4

11

3

2

0

1

2

3

4

5

6

7

8

9

10

11

Who allocates the patients TCI dates?

Clinician in Outpatient clinic

Secretary or Spec Nurse post

Outpatient clinic

Consultant & Secretary postOutpatient clinic

Consultant post Outpatient clinic

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 whowere given TCI dates. The two most common means involved just using adiary (9 cases) or a T-Card board (6 cases). PiMS was actually used in 2cases and even this involved using a diary in the outpatient clinic. The resultsare presented in Figure 9.


49/81


1

2

9

1

6

1

0

1

2

3

4

5

6

7

8

9

What means are used to manage patients with TCI dates?

Outlook & Physical diary

PIMS & Physical diary

Physical diary

Physical diary & T-card board

T-card board

Bespoke database

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 threecases, 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?


50/81


In 16 cases, no other department was notified once TCI dates were assignedto patients; in two cases, the Waiting List Manager was notified; in one case,the Waiting List Manager, Theatre Department, wards and Anaesthetist wereinformed. This is illustrated in Figure 11.

0

2

4

6

8

10

12

14

16

18

20

What other departments are informed of TCI dates?

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