elective surgery waitlist management resource guide...this resource guide provides practical advice...

Version 1.1 Published 21 November 2019

ELECTIVE SURGERY WAITLIST

MANAGEMENT RESOURCE

GUIDE

A Resource Guide for Effective Management of Elective Surgical lists within NSW Public Hospitals

1 Version 1.1 Published 21 November 2019

CONTENTS What is this Resource guide? How do I use it? .................................................................................. 2

Acknowledgement............................................................................................................................. 2

Accepting a patient onto the Waiting List .......................................................................................... 3

What is an Indicator procedure Code (IPC)? ............................................................................... 3

Which IPC should I use? ............................................................................................................. 3

How do I manage a non-recommended clinical priority category (CPC)? .................................... 3

Do we do that procedure? ............................................................................................................... 10

How do I manage the introduction of new health technologies? .............................................. 10

Steps to take when an RFA is received with a procedure or health technology not previously

done at your hospital ............................................................................................................... 11

What about cosmetic and discretionary surgery?..................................................................... 12

Steps to take when managing cosmetic and discretionary surgery: .......................................... 13

Managing patients on the Waiting List ............................................................................................. 15

How do I book operating lists? ................................................................................................. 15

Capacity and Demand Management: Transfer to another surgeon or hospital within the District

or Network. ............................................................................................................................. 16

Notifying patients, GPs and Treating doctors of additions and changes .................................... 19

Keeping records and auditing the waitlist ........................................................................................ 20

Requirements .......................................................................................................................... 20

What do I do with the completed Audits and Reports? ............................................................ 22

What happens when a Doctor takes leave or resigns? .............................................................. 28

Committees ..................................................................................................................................... 30

Monthly Perioperative Governance meeting ............................................................................ 30

Evaluating compliance and management of the elective surgery list ........................................ 30

References: ..................................................................................................................................... 39

Waiting time and Elective Surgery Policy.................................................................................. 39

Advice for Referring and Treating Doctors – Waiting Time and Elective Surgery Policy ............. 39

Operating Theatre Efficiency Guidelines .................................................................................. 39

NSW Framework for New Health Technologies and Specialised Services .................................. 39


What is this Resource guide? How do I use it? Each year more than 225,000 patients in NSW public hospitals have elective surgery procedures. The

Waiting Time and Elective Surgery Policy (PD2012_011) was developed to ensure clinically

appropriate, consistent and equitable management of elective surgery patients in public hospitals

across NSW.

This resource guide provides practical advice on various aspects of the waitlist policy, examples of

processes for decision making, escalation and communications around waitlist management.

It is designed to assist surgery and waitlist managers to administer the policy. It does not serve as a

replacement for the policy. If there is any perceived discrepancy between the information contained

in this resource guide and the Waiting Time and Elective Surgery Policy, the policy will always take

priority.

Acknowledgement NSW Ministry of Health would like to acknowledge the dedication and contribution of the members

of the Working Group in the development of this resource guide.

Janelle Atkins Surgical Bookings Manager, Hastings Macleay Clinical Network, Mid North

Coast Local Health District

Lisa Bridge Waiting List Coordinator, Children’s Hospital Westmead, Sydney Children’s

Health Network

Catherine Cleal Patient Services Manager, Orange Health Service, Western NSW Local Health

District

Angela Hardy Waitlist Manager, Royal North Shore Hospital, Northern Sydney Local Health

District

Ashleigh Mills OPERA Implementation Officer, Hunter New England Local Health District

Melinda Pascoe Principal Policy Officer – Surgical Services, System Purchasing Branch, NSW

Ministry of Health

Debra Pithers Surgical Waitlist Coordinator, Illawarra Shoalhaven Local Health District

Shivana Prasad Manager Patient Registration, Royal Prince Alfred Hospital, Sydney Local

Health District

Vincent Salomon Senior Policy Officer – Surgical Services, System Purchasing Branch, NSW

Ministry of Health

Wendy Stone Nurse Manager, Waiting List Coordinator, St George Hospital, South Eastern

Sydney Local Health District

Jamie Wheeler Waitlist Manager Liverpool Hospital, District Waitlist Coordinator, South

Western Sydney Local Health District


Accepting a patient onto the Waiting List

What is an Indicator procedure Code (IPC)?

Indicator Procedure Codes are a list of codes for common procedures. They were created in order to

give a specific indication of performance in particular areas of elective care provision, as a relatively

small number of procedures account for the bulk of the elective surgery workload.

IPC’s were introduced nationally as a way to monitor the volume, median wait and on time

performance of frequently performed elective surgeries. NSW uses IPCs for the same purpose. This

data can assist in planning and resource allocation, auditing and performance monitoring.

Which IPC should I use?

The primary procedure from the consent form should always be selected when choosing the IPC. If

you are in doubt of what the primary procedure is, the treating doctor who referred the patient should

be contacted for clarification

An alphabetised list of IPCs is available in IB2012_004 Advice for Treating Doctors – Waiting Time and

Elective Surgery Policy

How do I manage a non-recommended clinical priority category (CPC)?

Each hospital should have a defined process for the review and management of a Recommendation

for Admission (RFA) form where there is a clinical priority assigned that differs from that

recommended in IB2012_004 Advice for Treating Doctors – Waiting Time and Elective Surgery Policy.

A list of recommended CPCs is available in IB2012_004 Advice for Treating Doctors – Waiting Time and

Elective Surgery Policy.

Where there is no recommended CPC for a procedure, the principles and intention of the three clinical

priority categories should be considered by the treating doctor when allocating the CPC.

https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/IB2012_004.pdf



An example process for the management of non-recommended CPC’s may be as follows:

1. RFA received, checked for minimum data set and CPC checked against reference list.

2. Where there is a query about the appropriateness of the CPC a discussion should occur

between the treating doctor and senior management to resolve the issue and ensure that the

patient is added to the elective surgery list within 3 working days from receipt of the RFA.

3. If clinical information is provided to support the non-recommended CPC – send the RFA to the

Director of Medical Services (DMS) or delegate for review and decision to accept or not.

4. If no clinical information has been provided to support the non-recommended CPC, send the

RFA to the Director of Medical Services (DMS) or delegate who can contact the treating doctor

if required. This may be via telephone or in the form of a letter (an example of this letter can

found below: Clinical supporting documentation for allocation of Clinical Priority Category.

If there is no clinical evidence provided on the RFA then the reference list CPC should be used

until clarification is sought from the treating doctor.

5. Once reviewed and a decision made by DMS the non-recommended CPC will either be

accepted or declined.

6. If accepted this should be documented on the RFA and on the PAS system. A letter may be

sent back to the treating doctor confirming this (an example of this letter can be found below:

Acceptance of allocation of Clinical Priority Category.

7. If the non-recommended CPC is declined, the Referring Doctor should be informed in writing.

(An example letter can be found below: Assigned Clinical Priority Category not accepted) and

the RFA added to the elective surgery list using the recommended CPC.

8. If following a request to the treating doctor no supporting clinical information is received, a

letter can be sent advising that the recommended clinical priority category will be used (an

example letter can be found below: Failure to provide clinical supporting documentation for

allocation of Clinical Priority Category).

9. If a patient’s clinical priority category is changed after they have been added to the waiting

list, they must be notified in writing of the revised clinical priority category and expected

waiting time (an example letter can be found below: Change of Clinical Priority Category).

LHD Name Hospital Name

Hospital address Locked Mail Bag / PO box

Tel (02) Fax (02) Website:

Treating Doctor’s Name Address SUBURB STATE Postcode Dear

Clinical supporting documentation for allocation of Clinical Priority Category (CPC)

Patient Details

Procedure CPC allocated on RFA

Reference list CPC

Patient Name D.O.B

We received a recommendation for admission (RFA) for the patient listed above. The allocated CPC differs from the reference list CPC in IB2012_004 Advice for Referring and Treating Doctors – Waiting Time and Elective Surgery Policy.

Appropriate categorisation of patients with similar conditions enhances the health systems ability to manage patient access equitably, so that priority is given to the patients with the greatest clinical need. Individual patient exceptions to the recommended Clinical Priority Categorisation are facilitated by supporting documentation. The received RFA does not include sufficient clinical information to support the allocated CPC. We request that you provide further clinical information to support the allocation of the higher clinical priority category within 14 days. While we are waiting for the supporting documentation the reference list CPC will be assigned. Your response will be reviewed and considered by the hospital’s medical administration or equivalent and you will be notified of the decision. If no response is received within 14 days, the reference list CPC will continue to be used to manage the care of the patient. Yours sincerely,

Waitlist Manager Name DMS or delegate Name Position Position Date







Acceptance of allocation of Clinical Priority Category

Patient Details


Reference list CPC

Patient Name D.O.B

Thank you for providing the requested clinical information. The documentation has been reviewed by <Name, Position> and has been accepted. The clinical priority that you allocated to the patient will remain. The patient administration system has been updated to reflect the allocated CPC Yours sincerely,






Assigned Clinical Priority Category (CPC) not accepted

Patient Details


Reference list CPC

Patient Name D.O.B

Thank you for providing the requested clinical information. The documentation has been reviewed by <Name, Position>, and based on an assessment of the supporting documentation, the allocated clinical priority category has not been accepted. Appropriate categorisation of patients with similar conditions enhances the health systems ability to manage patient access equitably, so that priority is given to the patients with the greatest clinical need. The clinical priority category as per reference list IB2012_004 Advice for Referring and Treating Doctors will be applied. For further information please contact <DMS or delegate Name, Position and contact number>. Yours sincerely,





Treating Doctor’s Name Address SUBURB STATE Postcode Dear Failure to provide clinical supporting documentation for allocation of Clinical Priority

Category (CPC)

Patient Details


Reference list CPC

Patient Name D.O.B

We refer to the letter sent to you on <DATE> regarding the allocation of the clinical priority category to the patient listed above. In the letter you were requested to provide further clinical information to support the allocation of the higher clinical priority category within 14 days. Unfortunately no response has been received. In line with the Waiting Time and Elective Surgery Policy the reference list CPC has been allocated. For further information please contact <DMS or delegate Name, Position and contact number>. Yours sincerely,





Name Address SUBURB STATE Postcode Dear

Change of Clinical Priority Category

As you are aware, you were referred to <hospital> for elective surgery. The date you were registered on the elective surgery list was <date>. I write to advise that the clinical priority category allocated to your surgery did not match the recommended clinical priority contained in the Waiting Time and Elective Surgery Policy. Your clinical history and documentation has been reviewed by the <DMS Name, Position> and a decision has been made to change your clinical priority category from <CPC> to <CPC> as of <date>. Your expected waiting time for surgery is < >. Your treating doctor <name> has been advised of this change. For further information or if you have any concerns that you wish to discuss, please contact <Treating Dr Name> Yours sincerely,



Do we do that procedure? A doctor may only refer patients to the waiting list for procedures for which the doctor has been given

privileges by the relevant credentials committee.

If in doubt, don’t add the patient to the waitlist and check with the Director of Surgery or equivalent.

How do I manage the introduction of new health technologies?

Decisions made regarding the introduction of new procedures, interventions and new health

technologies in NSW should be made taking into consideration available evidence, cost implications

and the requirement of the health system to provide contemporary high quality clinical services.

A Local Health District/Network New Interventions Assessment Committee or equivalent must

formally approve new procedures.

A RFA for a new procedure/intervention/ technology should not be accepted by the hospital until

approval for the procedure has been given. A copy of the decision should be forwarded to the

hospital’s admissions manager.

An example of how to manage this process would be as follows:

1. RFA received, checked for minimum data set

2. Identified new procedure or health technology and treating doctor has not sought approval

prior to submitting RFA

3. RFA is not accepted – Patient is not added to the list. Patient is informed of the approval

process

4. RFA returned to treating doctor

5. Treating doctor seeks approval according to the local process for the New Interventions

Access Committee. NSW Health has created the NSW Framework for New Health

Technologies and Specialised Services, a guide for districts, networks and pillars to support

their role in locally evaluating new health technologies

6. If the procedure is approved the patient is added to the elective list from the date of approval

and the treating doctor is informed of decision

7. If the procedure is declined the treating doctor is informed in writing.

8. The treating doctor is to inform the patient of the decision.

https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2018_023.pdf



Steps to take when an RFA is received with a procedure or health technology not previously

done at your hospital


What about cosmetic and discretionary surgery?

The list of cosmetic and discretionary procedures can be found in section 2.3 of the Waiting time and

Elective Surgery Policy. Each hospital should have a local approval process in place to manage RFA’s

for surgeries that appear in this list of cosmetic and discretionary procedures.

It is the responsibility of the treating doctor to seek approval for cosmetic and discretionary

procedures to be completed in any public hospital facility. The approval of the LHD/Network program

director of surgery or equivalent should be sought in consultation with senior management.

Objective medical criteria supporting the decision for surgery should be documented on the RFA and

used during the clinical decision and review process.

For procedures not appearing on the list or where there is doubt about the nature of the proposed

surgery, the request should be referred to the Local Health District/Network Program Director of

Surgery or equivalent for review prior to the patient being added to the waiting list.

An example of how to manage this process is on the following page.




Steps to take when managing cosmetic and discretionary surgery:

Scenario 1: RFA received for a cosmetic or discretionary surgery and clinical supporting

documentation is provided by the treating doctor:


2. Identified cosmetic or discretionary procedure and supporting clinical documentation has

been provided by the treating doctor.

3. RFA is date stamped. Patient is informed of the approval process

4. RFA sent for review and approval of the LHD/Network Director of Surgery and Senior Hospital

Management or delegate according to local process

5. If the procedure is approved the patient is added to the elective list from the date of receipt

of RFA. Treating doctor is informed of decision

6. If the procedure is declined. The treating doctor is informed in writing.


8. It is a requirement of the policy that the patient is added to the waitlist within 3 days of receipt

of RFA.

Scenario 1:


Scenario 2: RFA received for a cosmetic or discretionary surgery and clinical supporting

documentation has not been provided by the treating doctor:


2. Identified cosmetic or discretionary procedure and no supporting documentation is provided.

3. RFA is date stamped. Patient is informed of the approval process

4. RFA sent for review and approval of the LHD/Network Director of Surgery and Senior Hospital

Management or delegate according to local process.

5. Letter sent to doctor requesting clinical information

6. If the procedure is approved the patient is added to the elective list from the date of receipt

of RFA. Treating doctor is informed of decision

7. If the procedure is declined. The treating doctor is informed in writing.


9. It is a requirement of the policy that the patient is added to the waitlist within 3 days of receipt

of RFA. If the approval process is to take longer than 3 days, the patient should be added to

the waitlist and removed if the procedure is not approved.

Scenario 2:


Managing patients on the Waiting List

How do I book operating lists?

With limited resources and the requirement to complete surgery within the assigned clinical time

frame, ensuring that lists are booked suitably is very important. Operating theatres are one of the

most expensive hospital services to run due to high levels of staffing and equipment costs. With this

in mind, the goal when scheduling operating sessions is to minimise sessions that over-run and

minimise sessions that finish early.

Where possible patients should be treated in turn, however to fill lists it may be necessary to move a

patient up the list. For example in a 4 hour session, the next two patients due may both be 3 hour

operations. These would not fit within the session, so it is necessary to book case 1 and then move

down the list and select a 1 hour case to ensure that the session is fully utilised but is not overbooked.

Short notice patients should be utilised where there is a cancellation at short notice – ensure that the

principles outlined in section 5.6 of the Waiting time and Elective Surgery Policy are followed.

Weekly Theatre Session Review

A weekly meeting should occur where the sessions booked for the next 7-10 days are reviewed. Each

session is individually reviewed to ensure that the session is resourced, that the cases booked will fit

into the session and any available time can be filled.

This is also the opportunity to flag patients who may require additional care, special equipment or

have previously been postponed. Review of the previous weeks finish times should also be considered

to guide future bookings.

Required attendees: Nurse Manager Perioperative Services (Chair)

Waitlist Manager

Operating Theatre Nurse Unit Manager

Staff member responsible for ordering equipment/loan sets

Optional attendees: Patient flow/bed manager

Surgical booking clerks

Operating Theatre efficiency

When reviewing efficiency, it is important to note that each measure when viewed in isolation does

not adequately reflect the efficiency of an operating theatre. When viewing operating theatre

efficiency the following metrics should be considered:

OT utilisation

anaesthetic care time

first case on time start

cancellation on the day of surgery

turnover time

Underrun and overrun times.

The Operating Theatre efficiency guidelines provides further information around operating theatre

efficiency.

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/252436/operating-theatre-efficiency-guidelines.pdf


Capacity and Demand Management: Transfer to another surgeon or hospital within the

District or Network.

To ensure that patients on the elective surgery waiting list receive their surgery within the clinically

recommended timeframe, it may be necessary to put in place additional management strategies.

The goal is to focus on the patient, and to provide access to elective surgery within the assigned

clinical priority timeframe.

Section 5.9 of the Waiting time and Elective Surgery Policy outlines the options available for avoiding

exceeding clinical priority timeframes.

For appropriate patients who have elected to be treated as Medicare patients, there is the option

for the patient to be transferred to a surgeon with a shorter waiting time within the hospital or to

another hospital.

It is important that when a patient is registered onto the elective surgery waiting list, they are made

aware, that while they will generally be admitted under the care of their referring surgeon, this is

not guaranteed. The hospital may transfer their care to another surgeon or hospital in order to

provide surgery within the clinically recommended timeframe. This information is printed on the

patient notification letter found in Appendix 2 of the Waiting Time and Elective Surgery Policy.

Prior to any contact with the patient, the hospital needs to consider a number of factors to ensure

that communications with the patient are clear and consistent and the process is as easy as possible

for the patient. These include:

the circumstances of the patient, this includes their age, available support, transport options

including travel distances, the patients physical condition and the required procedure.

an agreement from the referring doctor for the transfer of the patient,

a new treating doctor to accept care of the patient,

acceptance by the new hospital (if applicable) including consideration of equipment

requirements etc.

a date for surgery or expected waiting time

clinical review requirements by the new treating doctor (must be at no cost to the patient)

a preadmission clinic date if required

When contacting the patient a genuine offer including a date of surgery (or estimated waiting time)

and details of the new surgeon and hospital (if applicable) must be provided.

Note: If a patient declines a genuine offer, the patient must remain ‘Ready for Care’ and the details

of the declined the offer must be recorded.

Removal from the waitlist for deferring or declining a genuine offer with another doctor on two

occasions should not be used as a means of coercing the patient into accepting the transfer to an

alternate doctor or hospital.

The key message to the patient should focus on providing access for their surgery, and the

commitment of the hospital to provide the surgery within the recommended clinical priority

timeframe.

https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2012_011

https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2012_011


Example conversation with a patient

This is not a call script, however the key principles mentioned above are covered in this example

conversation with the patient.

Good morning/afternoon (patients Name) my name is (caller’s name and details) and I am

calling from (Hospital Name) hospital.

I am calling about your elective surgery booking under Dr (Referring Doctor’s name) for

(procedure).

It is currently estimated that your waiting time for surgery will be (current estimated waiting

time).

To reduce waiting times, we are offering patients the opportunity to have their surgery done

by another surgeon or hospital (if applicable).

We are able to offer you the opportunity to have your surgery on (Insert specific date of

offer) or with a reduced waiting time (insert length of expected waiting time) with Dr (name

of new Dr).

Would you like to accept this offer with Dr (insert new Dr Name)?

You may need to have an appointment with Dr (insert new Dr Name) in order for him to

meet you and discuss the surgery. If this is needed, there will be no cost to you.

Do you have any questions?

If the patient does not accept the offer:

I understand that you are concerned with having your surgery with a different doctor.

Dr (original doctor’s name) has a lot of patients on the waiting list, so we may not be able to

offer you a date for your surgery within the timeframe that Dr (original doctor’s name)

requested.

With this in mind I need to advise you that if you decline two genuine offers of treatment

with another doctor you may be removed from the waiting list.

This would be discussed with Dr (insert original doctors name) before a decision was made

to remove you from the list.

Would you like some time to have a think about your options?

I will give you a call tomorrow to allow you some time to think about this offer and discuss it

with your family if you wish to.

Any decisions about removing a patient from the waitlist who has declined two genuine offers for

surgery dates must be discussed with the treating doctor as outlined in section 5.10 of the Waiting

Time and Elective Surgery Policy. The goal of transferring patients is to give access to elective surgery

for patients within their clinical priority timeframe.

When the patient accepts transfer to a new doctor

- The patient's listing date and history must be that of the original booking. In this way an

accurate record of waiting time is maintained.

- The patient’s current clinical priority category must be maintained, unless altered after

clinical review by the new treating doctor.


When the patient accepts transfer to a new hospital within the District/Network

- Original RFA sent to new hospital

- Copy of RFA kept at original hospital

- The booking at the hospital where the patient will be treated is entered with the same listing

date and history as the booking at the original hospital, and with the current clinical priority

category

- When new hospital confirms patient has been added to the waitlist, the patient can be

removed from the waitlist at original hospital using reason code ‘treated elsewhere’ (at

another hospital within LHD)

When the patient declines transfer

- The hospital must record the reason for patients declining a planned admission date on the

electronic waiting list and on the patient’s RFA.

- If a patient declines a genuine offer, the patient must remain ‘Ready for Care’.

- Where the patient declines two genuine offers of treatment with another doctor or at

another hospital, then the patient should be advised that they may be removed from the

waiting list.

- The Local Health District Program Director of Surgery should review the patient’s status on

the waiting list in consultation with the original treating doctor prior to the patient being

removed from the waiting list.


Notifying patients, GPs and Treating doctors of additions and changes

There are a number of occasions during the patient’s elective surgery journey where communication

is required with the patient, their general practitioner and the treating doctor. Below is a table that

provides guidance of who to notify and how to notify them.

Reason for Notification

Notification in writing Notification can be made verbally

Patient GP Treating Doctor

Patient GP Treating Doctor

Referral received is incomplete and requires further information

Supporting documentation required for CPC allocation

Referral has not been accepted

The patient has been placed on the elective surgery waiting list

Within 3 days

Within 3 days

Changes have been made to a patient’s original CPC by an authorised doctor

The patient’s ready for care CPC has been changed

The patient’s ready for surgery status has been changed for clinical reasons

The patient’s ready for surgery status has been changed for personal reasons

Time limits for not ready for surgery – deferred for personal reasons e.g. 15, 45 + 180 days

Patient declines treatment, fails to arrive or requests removal

Confirmation of surgery date (for procedures in less than 10 working days)

Confirmation of surgery date (for procedures in more than 10 working days)

Notice of hospital initiated postponement (for procedures > 10 working days away

The patient has been removed from the elective surgery waiting list other than for admission

Notification of new PAD following a cancellation

Within 5 days

Doctor's leave - Temporary and Permanent

Cells filled with this colour indicate a policy requirement


Keeping records and auditing the waitlist

Requirements

Frequent monitoring, auditing and reporting is designed to ensure that patients are being correctly

managed while on the list for elective surgery, that the patients are being treated in turn and the

management of the waitlist is a fair, clinically appropriate and transparent process.

Each hospital is required to nominate a person responsible for the clerical audit of the hospital waiting

list. This includes conducting audits and reporting the outcome to the relevant manager.

There are both weekly and monthly auditing and reporting requirements which are outlined in Section

6.5, 7.1, 7.2 and 7.3 of the policy. Below is a table that outlines the clerical audit and monthly audit

requirements under the policy. The table is split by patient administration system CERNER and iPM as

they are the two systems with the highest users across the state

Available reports in iPM for completing

weekly and monthly audits and reports


MONTHLY

Policy

Ref

Requirement

Frequency

Available Report iPM

Extra Information

6.5 Compile a list of patients who

have been removed from waitlist

Monthly

RSE_WLIST 40 - REMOVALS FROM THE WAITLIST or RSE_WLIST44/WLIO11_SBB removals from WL EXCL. DUE TO ADMISSION

Provided to senior hospital executive for sign off

6.5 Patients who have incurred a delay

Monthly

RES_WLIST37 ADMISSION DELAYS

Executive Officer and District/Network CEO/delegate

6.5 Patients who have had 2 or more delays

Monthly

WLI013_SBB PATIENTS WITH 2 OR MORE ADMISSION DELAYS


6.5 Patients who have been delayed and do not have a rescheduled PAD

Monthly

WLI014_SBB PATIENT DELAYS WITH NO RESCHEDULED TCI


6.5 Duplicate bookings

Monthly

RSE_WLIST 45 or WLI007_SBB DUPLICATE BOOKINGS AT THE SAME FACILITY

Monitored by District/Network monthly

6.5 DOS cancellation/ postponement after arrival

At time of SN027A - Theatres KPI Report SurgiNet

Inform executive officer

7.2 Provide treating doctor with comprehensive list of patients on waitlist

Monthly RSE_WLIST34 – WAITLIST SUMMARY BY AMO

Send to each treating doctor. Treating doctor to confirm list with waiting time coordinator

7.3 Review patients on list for > 6 months

When patient on

list > 6 months

Batch Review Letter and Phone call with alternate treatment options where available, advice for clinical reassessment, hospital/ district/network contact details

Available reports in iPM for completing

weekly and monthly audits and reports


WEEKLY

Policy

Ref

Requirement

Frequency

Available Report iPM

Extra Information

7.1 Ascertain whether a patient

has already had their procedure

Weekly RSE_WLIST 40 - REMOVALS FROM THE WAITLIST or WLI008_SBB PLANNED ADMISSION DATE PASSED

Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees

7.1 Check for duplicate bookings Weekly RSE_WLIST 45 or WLI007_SBB DUPLICATE BOOKINGS AT THE SAME FACILITY


7.1 Check correct CPC assigned

Weekly RSE_WLIST42 - CATEGORY 1,2,3 WAITLIST REPORT


7.1 Update status review date for Cat 4 patients

Weekly RSE_WLIST12 - STATUS REVIEW or RSE_AUDIT04 - WL OPEN SUSPENSION W PRIORITY NOT = 9 RSE_AUDIT 11 WL PRIORITY =9 AND NO CURRENT SUSPENSION RSE_AUDIT 12 - WL SUSPENSIONS W.OUT RESUME DATE


7.1 Review exceeded PAD

Weekly WLI008_SBB PLANNED ADMISSION DATE PASSED


7.1 Identify patients on list admitted through ED for same procedure

Weekly RSE_WLIST39 - EMERGENCY ADMISSION AND HAS ACTIVE WL BOOKING


7.1 Number of patients removed and reasons for removal from the waiting list

Weekly RSE_WLIST 40 - REMOVALS FROM THE WAITLIST or WLI008_SBB PLANNED ADMISSION DATE PASSED


7.1 Ensure delayed patient is rescheduled for next available theatres session in consultation with treating doctor

Weekly WLI014_SBB PATIENT DELAYS WITH NO RESCHEDULED TCI


CERNER: available reports for completing

weekly and monthly audits and report


MONTHLY

Policy

Ref

Requirement

Frequency

Available Report CERNER

Extra Information

6.5 Compile a list of patients who

have been removed from waitlist

Monthly

SWSLHD + SLHD BK_PTS_REMOVALS FOR A PERIOD MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR040_WL_PT_REMOVALS

Provided to senior hospital executive for sign off

6.5 Patients who have incurred a delay

Monthly

SWSLHD + SLHD 952_PM_DELAY_PAT_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR031_DELAY_IN_LAST_MONTH


6.5 Patients who have had 2 or more delays

Monthly

SWSLHD + SLHD 952_PM_DELAY_PAT_SSW

SLHD Performance Unit data extracted from WLCOS for the month for admitted or WL patients or the above report MNCLHD + NNSWLHD 855_DELAYED_TWICE_SUMMARY NSLHD + CCLHD 855_WR032_WL_DELAY_GREATER


6.5 Patients who have been delayed and do not have a rescheduled PAD

Monthly

SWSLHD + SLHD 952_PM_DELAY_PAT_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR008_DELAY_NOT_RESCH


6.5 Duplicate bookings

Monthly

SWSLHD + SLHD 952_PM_WL_MULTI_ENTRY_DTL_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR049_WL_DUP_BOOKING

Monitored by District/Network monthly

6.5 DOS cancellation/ postponement after arrival

At time of SN027A or SN 034 - Theatres KPI Report SurgiNet

Inform executive officer

7.2 Provide treating doctor with comprehensive list of patients on waitlist

Monthly SWSLHD + SLHD 952_PM_WL_LIST_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR022-wl_BY_AMO

NSLHD: Automated WL Report, executed from WL Mgt App

Send to each treating doctor. Treating doctor to confirm list with waiting time coordinator

7.3 Review patients on list for > 6 months

When patient on

list > 6 months

SWSLHD + SLHD REPORT AUTOMATED – CHEKCLIST OF PATIENTS ON WLIST > 6 MONTHS MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR019_LTR_AUDIT

Letter +and Phone call with alternate treatment options where available, advice for clinical reassessment, hospital/ district/network contact details

CERNER: available reports for completing

weekly and monthly audits and report


WEEKLY

Policy

Ref

Requirement

Frequency

Available Report Cerner

Extra Information

7.1 Ascertain whether a patient

has already had their procedure

Weekly SWSLHD + SLHD 952_PM_BOOK_PASTDATE_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR010_PLANNED_ADM_PASSED


7.1 Check for duplicate bookings Weekly SWSLHD + SLHD 952_PM_WL_MULTI_ENTRY_DTL_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR049_WL_DUP_BOOKING


7.1 Check correct CPC assigned

Weekly SWSLHD + SLHD MNCLHD + NNSWLHD, NSLHD + CCLHD 855_WR005_BOOOKED_PATS_AMO


7.1 Update status review date for Cat 4 patients

Weekly SWSLHD + SLHD WL-Status Review Date MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR017_STATUS_REVIEW


7.1 Review exceeded PAD

Weekly SWSLHD + SLHD 952_PM_BOOK_PASTDATE_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR010_PLANNED_ADM_PASSED


7.1 Identify patients on list admitted through ED for same procedure

Weekly SWSLHD + SLHD 952_PM_WL_ADM_VEGM_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WL_ED_RECLASS


7.1 Number of patients removed and reasons for removal from the waiting list

Weekly SWSLHD + SLHD BK – removals during a period MNCLHD, NNSWLHD, NSLHD + CCLHD 855_REMOVALS_FRM_AMO_SPEC_IPC or 855_WR040_WL_PT_REMOVALS


7.1 Ensure delayed patient is rescheduled for next available theatres session in consultation with treating doctor

Weekly SWSLHD + SLHD 952_PM_DELAY_PAT_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR008_DELAY_NOT_RESCH



What do I do with the completed Audits and Reports?

Records relating to audits must be kept for three years. Documentation must provide a clear audit

trail and must be readily available to validate any changes made to a patient’s booking

Reports and Audits run in line with PD2012_011 require circulation, sign off and tabling at the

appropriate committee.

At the conclusion of the audit, a report is signed by the person running the report which outlines:

the audit conducted, the methodology used, problems identified, recommendations for

improvement, number of patients removed and the reason for removal. Location of the audit

documents for review if required.

The audit report is sent to the relevant manager for example: Nurse Manager Perioperative services

(or equivalent) to be tabled at the next Perioperative governance (or equivalent) meeting. A copy of

the audit and the audit letter is stored within the waitlist office for the required 3 year period.

Below are examples of 3 audit reports to assist in meeting the requirements of the policy

1. WEEKLY

A report signed by the responsible person conducting the audit to be sent to the relevant

manager and appropriate committees and be available on request

2. MONTHLY

A report signed by the appropriate person conducting the audit to be provided to the hospital

executive and tabled at the appropriate committee

3. QUARTERLY

An evaluation of the audit process must be conducted regularly (at least quarterly) by the staff

responsible for waiting list management at each facility

Weekly elective surgery waitlist

clerical audit report


Date audit completed:

Policy Ref.

Audit Requirement Methodology (Report

name/type)

Issues Identified

Y/N

Corrections made / Comments

7.1

Ascertain whether a patient has already had their procedure

7.1

Check for duplicate bookings

7.1

Check correct CPC assigned

7.1

Update status review date for Category 4 patients

7.1

Review exceeded planned admission dates

7.1

Identify patients on list admitted through ED for same procedure

7.1

Ensure delayed patient is rescheduled for next available theatre session

7.1

Number of patients removed and reasons for removal from the waiting list

Recommendations for improvement:

Location of audit files:

Name and signature of auditor:

Name and signature of manager:

Date: Date:

This report should be submitted to relevant manager and be tabled at the relevant Governance

Committee monthly.

Elective surgery waitlist monthly

report for Hospital Executive


Date of report:

Policy Ref.

Audit Requirement Methodology (Report

name/type)

Issues identified

Y/N

Corrections made / Comments

6.5

Patients who have been removed from waitlist

6.5

*Patients who have incurred a delay

6.5

*Patients who have had 2 or more delays

6.5

*Patients who have been delayed and do not have a rescheduled PAD

6.5

Duplicate bookings

6.5

Patients cancelled or postponed after admission on their day of surgery

7.2

Comprehensive list of patients for each treating doctor

List supplied directly to each treating doctor

* This report must also be supplied to the LHD/Network CEO or delegate

Recommendations for improvement:

Location of audit files:

Name and signature of auditor:

Name and signature of Senior Hospital

Executive:

Date: Date:

This report should be submitted to relevant executive/manager and be tabled at the relevant

Governance Committee monthly.

Evaluation of the Elective

Surgery Waitlist Audit Process


An evaluation of the audit process must be conducted regularly (at least quarterly) by the staff responsible for waiting list management at each facility

Date of evaluation: Evaluation period:

Evaluation of weekly elective surgery clerical audit:

1. Weekly clerical audit has been completed in line with section 7.1 of the Waiting Time

and Elective Surgery Policy and includes:

Ascertaining whether the patient has already had their procedure/treatment

Checking for duplicate bookings

Ensuring Clinical Priority Category is appropriately assigned

Updating status review date for Category 4 patients

Reviewing exceeded planned admission dates

Identifying patients on list admitted through emergency department for

the same procedure

Ensuring delayed patients are rescheduled for the next available theatre

session in consultation with the treating doctor

Weekly clerical audit conducted Y/N

Elements of clerical audit meet policy requirements Y/N

Evidence of corrections or required actions completed

weekly Y/N

Issues identified with weekly clerk

Recommendations

Weekly audit report generated and sent to relevant manager

Y/N

Reports are signed by relevant manager Y/N

Reports are tabled at relevant governance

committee meeting Y/N

Recommendations




Evaluation of elective surgery waitlist monthly reporting:

2. Hospital has a documented process for removing patients from the waiting list

A list of patients who have been removed from the waiting list is provided monthly Y/N

List of removed patients is authorised and signed by a senior hospital executive monthly

Y/N

3. Monthly reports are completed in line with section 6.5 of the Waiting Time and Elective

Surgery Policy:

Removals from the waitlist for reasons other than admission

Patients who have incurred a delay during the previous month

Patients on list who have had two or more delays to their admission

All delayed patients who do not have a rescheduled planned admission date

Duplicate bookings

Any patients cancelled or postponed by the hospital or doctor after arrival to

hospital on the day of admission

Monthly reports conducted Y/N

Elements of monthly report meet policy requirements Y/N

Evidence of corrections or

required actions completed Y/N

Monthly report has been signed by a senior hospital

executive

4. Monthly report must be provided to the LHD/Network CEO or delegate monthly:

Patients who have incurred a delay during the previous month

Patients on list who have had two or more delays to their admission

All delayed patients who do not have a rescheduled planned admission date

Monthly reports conducted Y/N

Monthly report has been sent to LHD/Network CEO

Issues identified with monthly reporting process

Recommendations




Requirement Yes/No Comment:

A person is nominated and is responsible for the clerical audit and reporting outcomes to the relevant management Y/N

Name of person:

The LHD/Network has a person responsible for monitoring the clerical audit program across all hospitals, maintaining clerical audit standards and addressing issues arising from the audits Y/N

Name of person:

Audit documents are available for past 3 years Y/N

Location of audit documents

Auditor :

Name and signature:

Senior Hospital Executive:

Name and Signature:

DATE: DATE:

This report should be submitted to relevant executive/manager and tabled at the relevant

governance committee.


What happens when a Doctor takes leave or resigns?

Section 8 of the policy covers doctors leave and resignation.

It is important that waitlist managers are given as much notice as possible in order to minimise the

impact and disruption on patients who are affected. Doctors should give 6 weeks’ notice of intended

leave. A process should be in place at all hospitals whereby doctors leave is managed through medical

administration.

Operating theatre sessions should not be vacated by a doctor without an approved leave form. A

management plan for affected patients should be developed and implemented for all leave.

An example of an approval and communication process would be as follows:

1. Doctor intends to take leave and completes a leave form which is submitted to the Head of

Department or Director Medical Services (dependent on local process).

2. Leave request is reviewed including the upcoming demand for the doctor to see if additional

time may be required to complete upcoming cases within their clinical timeframe.

3. Advice is provided by doctor for management of any patients already booked into the

session to be vacated.

4. Notice is provided to waitlist manager and operating theatres.

5. Vacated sessions are filled according to local process.

During the leave period or after a doctor has resigned, no further patients should be added to the

doctor’s waiting list unless approved by the District/Network Program Director of Surgery

If a RFA is received for a doctor that is on leave, the RFA should not be added to the waitlist. The issue

should be escalated to the Director of Medical Services or delegate for assistance.

In cases where a doctor will no longer be working at the hospital through either planned or unplanned

resignation a management plan should immediately be developed and implemented. Section 8 of the

Waiting Time and Elective surgery policy should be followed. An example of a letter to send to patients

is detailed below.

Name Address SUBURB STATE Postcode Dear We write to inform you that <TREATING DOCTOR NAME> is no longer performing surgery at <HOSPITAL NAME>. We are currently working to transfer `your care to another surgeon within <insert LHD/NETWORK> to ensure your procedure can be completed. This transfer of care will not disadvantage you and your place on the elective surgery waitlist will be maintained. Once an alternate doctor has been assigned to your care, we will notify you in writing. A clinical review may be required. If so, this will be completed at no cost to you. Your current clinical priority is <INSERT CATEGORY> <DAYS> it is expected that your date for surgery will be within <NUMBER> months. Please complete the section below to indicate if you wish to remain on the elective surgery list at <<HOSPITAL NAME> and return it in the provided envelope within 14 days. For further information or if you have any concerns that you wish to discuss, please contact the elective surgery bookings office on <insert number>. Yours sincerely,


Please tick one of the boxes below:

I still require my surgery and I am ready for surgery at this time. I agree to be transferred to another surgeon

I wish to be taken off the waiting list. I decline to be transferred to another surgeon

I wish to be taken off the waiting list, as I no longer require the surgery


Committees Monthly Perioperative Governance meeting

The waiting list manager should attend this meeting as it is a forum to highlight upcoming demand

and capacity issues or predictions, escalate any concerns and to table and provide feedback from the

previous months audits and reports conducted in line with PD2012_011.

Weekly elective surgery clerical audit reports, monthly executive reports and quarterly clerical audit

evaluations should be tabled at this meeting.

Evaluating compliance and management of the elective surgery list

Effective management of the elective surgery waitlist requires strong processes and communication.

There are a number of stakeholders involved with providing care to patients requiring surgery. A

regular review of the overall elective waitlist management process is advisable at regular intervals.

The checklist below outlines the various policy requirements of elective surgery waitlist management

from the Waiting Time and Elective Surgery Policy and can be used to review your current practice

and align areas that need improvement to meet the requirement of the policy.

Elective Surgery Waitlist

Management Self-Assessment


The Waiting Time and Elective Surgery Policy was developed to promote clinically appropriate,

consistent and equitable management of elective surgery patients and waiting lists in public hospitals

across NSW.

The aim of completing the self-assessment is to highlight the areas of the policy that are being met

and the areas where there is need for development and improvement.

Policy Ref.

Requirement Fully Compliant

Partially Compliant

Non Compliant

Receiving a Recommendation for Admission (RFA) and adding a Patient to the List

3 Each RFA is date stamped upon receipt

3.1 Each RFA is checked for the minimum data set prior to being added to the waitlist

3.1 Where there is incomplete information the referring doctor is contacted for clarification

3.1 Each RFA is added to the waitlist within 3 working days of receipt

3.1 Patients are not added to the waitlist who are NRFC at the time of receiving the RFA (excludes staged procedures)

3.1 RFAs submitted as ‘staged’ procedures must indicate the time interval when the patient will be ready for care

3.1 RFAs are only accepted if the patient’s clinical condition requires surgical intervention within 12 months

3.3 Patients are not booked for the same procedure with different doctors at my hospital

3.3 Bilateral procedure RFA’s are only accepted for patients undergoing both procedures during the same admission

Areas for improvement:

Total Total Total

Managing Clinical Priority Categories (CPC) and Public vs Private Election Status

3.1 The clinical priority code is checked against the reference list CPC prior to adding the patient to the waitlist

3.1 A process is in place to query the CPC when there is a variance from the reference list

3.1 If there is no clinical evidence provided on the RFA the Reference List CPC is used until clarification is sought from the treating doctor

2.1 CPC changes are only made by an authorised doctor

2.1 Written advice of any CPC change is always sent to the treating doctor

2.5 Patients who elect to be treated as public patients are informed that in line with Medicare principles they will be assigned a doctor by the hospital







Policy Ref.


Partially Compliant

Non Compliant

4.2 A notification letter is sent to each patient within 3 working days of the patient being added to the waitlist

4.3 A notification letter is sent to the GP nominated by the patient within 3 working days of the patient being added to the waitlist


Total Total Total

Cosmetic, Discretionary and New Procedures

2.3 The RFA is checked for cosmetic and discretionary procedures prior to being added to the waitlist

2.3 The treating doctor seeks approval prior to submitting an RFA for a cosmetic or discretionary procedure

2.3 Each RFA is checked for new procedures – a RFA is not accepted for a procedure not provided at the hospital

2.3

A process is in place for approval of new procedures prosthesis/new health technologies at my hospital


Total Total Total

Not Ready for Care (NRFC) and Clinical Review

5.5 I understand the definitions of Staged and Deferred patients

5.3 A status review date is set each time a patient is placed into Category 4

5.5 Patients in NRFC are managed in accordance with the policy

5.5.2 For every NRFC patient the reason is recorded on the RFA and on the electronic waiting list

5.5 Category 1 patients are not deferred without a discussion with the treating doctor

5.5 Deferred patients do not exceed the allowable NRFC days

Category 1: 15 NRFC days



5.5

5.5

5.5 Patients are advised that if they defer > 2 occasions or exceed the maximum number of NRFC days may be removed from the waiting list

5.5 Staged RFAs have the NRFC timeframe indicated and the RFC CPC allocated by the treating doctor




Policy Ref.


Partially Compliant

Non Compliant


Total Total Total

Planned Admission Dates

5.6 Patients are treated in turn at my hospital according to their clinical need

5.6 Planned admission dates are provided with as much notice as possible to patients

5.6 A process is in place to select patients for admission at short notice

5.7 Patients who are postponed by the hospital or doctor for non-clinical reasons remain ready for care

5.7.1 A process is in place when selecting patients for postponement to ensure equitable management

5.7.1 Postponement process involves the relevant medical and OT staff, bed manager, waitlist manager and senior hospital management

5.7.1 Postponed patients are allocated a new date within 5 working days

5.7.1 Postponed patients are rescheduled on the next available list

5.7.2 Patients postponed or cancelled for non-clinical reasons on the day of surgery are notified by a senior member of the surgical/medical team or senior hospital manager

5.7.2 Patients postponed or cancelled for non-clinical reasons on the day of surgery are reported to relevant personnel

5.8 Patients who postpone an agreed date for personal reasons are managed in line with the policy requirements

5.8 Patients on list at my hospital have not postponed on more than 2 occasions for personal reasons

5.9 Strategies are in place to ensure patients receive surgery within their assigned clinical priority timeframes

5.9 I know who to escalate concerns to for patients who are at risk of exceeding their clinical timeframe

5.9 Patients are assigned their Planned Admission Date in the following timeframes:

CPC 1: On booking

CPC 2: Within 45 days

CPC 3: Within 270 days

5.9.1 A process is in place to transfer care of patients to other doctors in order to avoid exceeding clinical priority timeframes

5.9.1 If a patient requires a clinical review – this is arranged by the hospital at no cost to the patient




Policy Ref.


Partially Compliant

Non Compliant

5.9.1 Patients who decline two genuine offers of treatment with another doctor are advised that they may be removed from the waiting list

5.9.2 A process is in place to transfer care of patients to another facility within the LHD/Network:

Original listing date, history and CPC is maintained

Original RFA is sent to the new hospital and a copy saved at the original hospital

Once confirmation is received that the booking has been added to the list at the new hospital, booking at original site is removed (reason code treated elsewhere)

5.9.2 Where there is a transfer to another hospital outside of the LHD/Network, the patient remains on the list until the procedure is completed


Total Total Total

Removing a Patient From the List other than for Admission

5.10 When a patient is removed from the waitlist for reasons other than admission I know the steps to follow

5.10 The treating doctor is informed when a patient is removed from the waitlist for reasons other than admission

5.10 Authority is sought prior to removing Category 1 patients from the waiting list other than for admission

5.10 The GP is advised of removal of patients other than for admission

5.10 Senior Medical Officer or delegate authorises removals where required

5.10 I compile a list of patients who have been removed other than for admission for authorisation by a senior hospital executive monthly

5.10 I am aware that patients who defer > 2 occasions or exceed the maximum number of NRFC days may be removed from the waiting list


Total Total Total




Policy Ref.


Partially Compliant

Non Compliant

porting and Auditing the Waitlist

6 All changes to a patient’s booking are documented both on the RFA and on the Patient Administration System

6.5 A report is provided to the hospital executive officer and LHD/Network CEO or delegate monthly which includes

Patients who have incurred a delay

Patients who have incurred multiple delays

Delayed patients who have not been provided a new PAD

Patients removed from the waitlist other than for admission

Duplicate bookings

Patients postponed by the hospital or doctor after arriving to the hospital

7.1 I know who is responsible for the clerical audit of the hospital waiting list

7.1 My LHD/Network has a person responsible for monitoring the clerical audit program across all hospitals

7 Records relating to audits are kept for 3 years

7 Records relating to audits are available for review on request

7.1 A clerical audit of the waiting list is undertaken at least weekly. The audit includes: Ascertaining whether the patient has already has their

procedure/treatment

Checking for duplicate bookings

Ensuring clinical priority category is appropriately assigned

Updating Status Review Date for Category 4 patients

Reviewing Exceeded Planned Admission Dates

Identifying patients on waiting list admitted through emergency department for the same procedure

Ensuring delayed patient is rescheduled for next available theatre session in consultation with treating doctor

7.1 A report signed by the responsible person conducting the audit is sent to the relevant manager

7.1 Clerical Audit reports are tabled at the appropriate committees

7.1 The audit process at my hospital is evaluated quarterly

7.2 Each doctor at my hospital is sent a list of their patients monthly

7.2 Each doctor confirms their list and provides feedback to the hospital on required changes

7.3 An audit letter is sent to patients on list for >6 months to see if they still require surgery and the responses are documented along with any actions taken


Total Total Total




Policy Ref.


Partially Compliant

Non Compliant

Managing Doctors Leave – Temporary and Permanent

8 Planned Leave and Planned Resignation

A process is in place for leave approval prior to a doctor vacating their elective list at my hospital

Doctors provide 6 weeks’ notice of intended leave

Management plans are created for patients who are affected by a doctor taking leave

Doctors taking leave are involved in creating a management plan for affected patients

No patients are added to a doctors list when they are on leave or no longer working at the hospital unless approved by the District/Network Program Director of Surgery

I know how to escalate concerns about patients affected by leave

Resignation

A letter is available to send to patients advising of the resignation and providing advice about their management plan

GPs are notified of the resignation with advice about the patients management plan

If clinical review is required for patients, this is arranged by the hospital at no cost to the patient

8 Unplanned Leave and Unplanned Resignation

A process is in place for managing unplanned leave at my hospital

Relevant personal are available for consultation in creating management plans: Surgeon, Head of surgery, Manager theatres, Hospital Executive etc.

No patients are added to the doctors waiting list when a doctor is on unplanned leave or has resigned from my hospital

If clinical review is required for patients, this is arranged by the hospital at no cost to the patient


Total Total Total




Best Practice Guidelines Fully Compliant

Partial Non-compliant

Participation in Committees and Meetings

I meet regularly with my manager to discuss the progress of the elective surgery list and raise areas of concern

My hospital has a weekly waitlist meeting where upcoming theatre bookings and sessions are reviewed

My hospital has an inpatient bed platform to guide daily elective surgery admissions

I attend a monthly perioperative governance meeting to provide feedback on progress of the elective surgery list, escalate concerns and table audits and reports

Elective surgery session data is reviewed and feedback is provided to ensure that lists are correctly booked

The Operating Theatre master template is reviewed annually to ensure that the upcoming demand of each surgical specialty can be met

An escalation system has been identified for managerial issues e.g. obtaining dates from doctor for patients approaching their clinical timeframe, NRFC issues e.g. patient requesting to be deferred when registered onto the waiting list, surgeon leave, large volume of RFAs received from a surgeon’s rooms.

I receive feedback after an issue has been escalated

In my LHD/Network waiting time coordinators/managers meet regularly to share learning and receive information


Total Total Total

Training for Staff

Orientation and training is provided to all staff involved in booking elective surgery at my hospital

All staff have access to the relevant policies PD2012_011 and IB2012_004

All staff have received waiting list PAS training

2 staff are trained in using WLCOS

Clerical errors are discussed to improve data quality

The elective surgery booking team meet at least monthly


Total Total Total




Overall Assessment:

Compliant Partially compliant Non-compliant

Processes and procedures are in place and are well adhered to

The staff involved with managing the elective surgery list are aware of the requirements of the policy

The team collaborates to ensure patients requiring elective surgery have equitable access in a clinically appropriate timeframe

Processes and procedures have been created

Processes and procedures are not always adhered to

There is opportunity for improvement and development

Processes and procedures are not in place or not adhered to

Staff involved in managing the elective surgery lists are not aware of their requirements

Suggested Actions

Continue to monitor

Complete self-assessment in 6 months

Review areas for improvement

Identify gaps and work on solutions with hospital and team

Provide further education and training to staff

Review areas for improvement

Seek advice from LHD/Network on improvement strategies

Seek advice from MoH on improvement strategies

Provide further education and training to staff

Overall areas for improvement


References:

Waiting time and Elective Surgery Policy

https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_011.pdf

Advice for Referring and Treating Doctors – Waiting Time and Elective Surgery Policy


Operating Theatre Efficiency Guidelines

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/252436/operating-theatre-

efficiency-guidelines.pdf

NSW Framework for New Health Technologies and Specialised Services


https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_011.pdf



