18 Weeks

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18 Weeks
at Secondary Care
Julie Juden Frimley Park Hospital NHS Foundation
Trust
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Our challengeby December 2008

• 18 Weeks is about delivering
• the right care
• at the right time
• of the right quality
• without unnecessary delays
• 18 Weeks is about taking away worry, reducing
  anxiety
• FPH Patient Experience and Involvement Working
  Group

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Our challengeby December 2008

• Multiple referral sources for Secondary care
• GP
• GPSI GPs with a Special Interest / other
  triage or
• two tier services (NB clock already ticking.)
• GDP Dentists
• Optometrist Orthoptist
• AE, Minor Injuries Units, Walk in Centres, GUM
  clinic
• Referrals from other PCT sources
• Consultant to consultant referrals for new
  conditions
• Screening Programmes

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Our challengeby December 2008

• What does this mean?
• Thousands of patients referred with a problem
• /- investigations done before arrival
• FPH - per week has 1000 patients referred by GP
• (including military) and a further 235
  Consultant to
• Consultant referrals across 23 specialities
• All need an assessment, /- diagnostics, a
  diagnosis
• and management/treatment plan to decide next
  steps
• which may include discharge

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Our challengeby December 2008

• First stage of care
• Care could be delivered on a variety of sites
• Main hospital site with all diagnostics
• Plus 3 other sites in the area with varying
  diagnostic support
• Some patients have had emergency admissions that
• then go into 18 week pathways
• Multiple patient pathways (differences between
  medicine and surgery), with varying diagnostics,
  treatment options and partners in care for
  patient care delivery

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Our challengeby December 2008

• For patients already under our care where the
• treatment plan is changing (watchful wait changes
  to active management)
• Treatment plan needs to be agreed at follow-up
  Outpatient Clinic
• Treatment plan agreed for subsequent IP
  treatment
• Plus
• May involve diagnostics at other organisations
• May involve care if necessary at tertiary
  centres,
• Both of these make some pathways more complex,
• and timings more critical

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Our challengeby December 2008

• Solutions/ Approach
• Reducing waits for patients outpatients,
  diagnostics, elective admissions (Clearing
  backlog)
• Every specialty to review their own current
  pathways
• (times taken), review against national pathways
• Improve communication and reduction of wastage/
  
• duplication, unnecessary steps and Lean
• principles is critical
• Designing new pathways that sustain 18 weeks
• Identifying the hidden waits

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Issue Measuring Patient Pathways
18 Weeks
1st OutpatientAppointment
Decision to treat
Diagnostic Pathway
Admission Start of outpatient treatment
Fitting of medical device Start of watchful
waiting/ active monitoring No need for
treatment in secondary care Patient declines
treatment

• Multiple referral sources

Measuring where thousands of patients are on
pathways at at any one time, and ensure they
complete in the maximum of 18 weeks
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Issue Measuring Patient Pathways

• Performance measures
• RTT data getting this right, and where
  multiple organisations involved the target is
  shared
• Patient sampling becomes critical as to how
  patients are informed about 18 weeks, where they
  are on pathways, expectations of next steps,
  patient information, how staff communicate with
  patients

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Solution Outpatient Bookmarks

• Introduced for all specialities
• Assists in capturing stops and starts in clinic
  setting
• Completed by consultant and delivered by patient
  to reception desk
• Back-room data entry, currently onto CLi
• Only part of the jigsaw puzzle
• PAS updates to help us piece together the waits

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Structure and Work plan

• 4 directorates
• Reviewing national pathways and local processes

• Solving measuring the whole pathway
• Outpatient Bookmarks
• Work to improve RTT quality
• Training for all staff

• Patient Experience Group
• Helping us realise what 18 Weeks means to
  patients
• 18 Weeks National Patient Questionnaire

Executive support Membership includes Chief Exec,
Clinical Lead, Exec Directors, GMs, Service
Improvement, Information

• Leading on Inter-Trust Transfers St Georges
  Project
• Feed into Surrey Programme Board
• Liaise with other Surrey Trusts and PCT reps
• Link with SHA
• Link with GPs

• Corporate message for 18 Weeks
• Launch Event - Chief Executive
• Inform article
• Webpage on Intranet
• Internet page on Trust website

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Pilot Project FPH, St Georges SW London
Cardiac Network

• Aim of Project
• To review how 18 week care can be delivered
  across organisations
• To develop general principles that can be adopted
  by other specialties and other organisations
• To agree the time required on the pathway for the
  different organisations for common cardiac
  pathways
• To improve communication
• Agreement by Surrey 18 week Programme board
• to adopt guiding principles across the 4
• acute trusts

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Pilot Project

• Commenced 20th March 07
• Involves Clinical, Managerial, Service
  Improvement
• staff from both organisations and SW London
• network
• FPH has a Local project team (medical records,
  IT,
• clinicians, 18 week members data analyst and
  
• project lead), linking to joint group
• Involves the transfer of care between secondary
  and
• tertiary hospitals

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Pilot Project

• Goes further than Inter-hospital transfers
  includes
• the electives and a total journey time of
  max 18
• weeks
• Requires improvement in communication and
• information (referrals, diagnostic results,
  clock start
• dates, discharge summaries back to secondary
  care)
• Investigate and utilise (following option
  appraisal),
• the use of IT to transfer information/results

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Pilot Project - Progress

• Clinical discussions
• Review of the handover - what needs to be
  done
• Review where duplication occurs (e.g.
  unnecessary
• repetition of diagnostics)
• Need to factor in choice and ways to
  communicate with other
• organisations
• Discussions on time required on the pathway by
  the different
• care providers, with clinical reasons a
  priority
• Exploring local pre-assessments
• Identified some delays (angio procedure to
  getting on W/L)

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Pilot Project - Progress

• Clinical discussions (cont)
• Identified more to do before handover
• Structured joint multi-disciplinary meetings
  at secondary care
• (with the patient)
• All necessary tests completed (including
  dopplers) before joint
• meeting, criteria being developed
• Discuss treatment and put on the waiting list
  that day (saves 2
• weeks)
• Need IT solutions to reduce administrative
  delays

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Pilot Project - Progress

• Communication
• Trial of referral proforma including clock
  start date (will generate accurate RTT data)
  commenced
• Agreement to share actual RTT data, to allow
  progress to be monitored
• Both IT departments investigating ways to
  transfer letters/referrals and diagnostics (e.g.
  digital echo angio images) electronically
• Reviewing where / what more information can be
  given to patients preparing for the next stages
  in advance to reduce
• need for factoring in thinking time
• Local project team set up (medical records, IT,
  clinicians,
• 18 week members data analyst and project lead)

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What does it all mean?

• Patients waiting for treatment will begin to
  experience a different kind of service from the
  NHS
• An end to unnecessary waiting and fewer hospital
  appointments
• Earlier relief of symptoms, pain or discomfort
• Reduced anxiety due to earlier diagnosis and
  treatment
• The ability to provide improved care
• Doing more of the same, doing some things
  differently

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What does it all mean?
18 Weeks is about taking away worry, reducing
anxiety FPH Patient Experience and Involvement
Working Group May 07