Understanding the information challenges of delivering 18 weeks

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Understanding the information challenges of
delivering 18 weeks

• Rachel McDonald Jenny Bareham

December 2006 Version 0.1
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Contents

• RTT Referral to Treatment
• Setting the context 18 weeks measurement
• Steps towards national monitoring
• Defining clock starts and clock stops
• National monitoring key messages and dates
• Next steps
• Using information to support service improvement
• Further guidance/information

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Setting the context 18 weeks measurement (1)

• By December 2008, no one will have to wait
  longer than 18 weeks from GP referral to hospital
  treatment.Announced in NHS Improvement Plan,
  June 2004
• We cant deliver 18 weeks if we cant measure it
• But
• Historically the NHS has not monitored on a
  patient pathway basis
• And the scale is huge 12 million patients a
  year will be covered by 18 weeks
• Existing data collections focus on discrete parts
  of the pathway

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Setting the context 18 weeks measurement (2)

• Long term solution to RTT measurement will be
  delivered by CfH via SUS
• Need for a short-term, low key approach to RTT
  measurement in the interim
• DH have worked with 8 pioneer health communities
  during 2006, including Luton Dunstable, on
  developing this approach tactical approach to
  RTT measurement
• More on this from Luton Dunstable later

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Key dates towards national monitoring

• Jan 06 pioneers selected
• Apr 06 pioneers start collecting RTT data
• May 06 18 weeks implementation framework
  published, including Principles Definitions
  annex
• August 06 DSCN 17/2006 and pioneer reports
  published
• Summer 06 Step 1 - baselining exercise
• Oct 06 Step 2 - start of preliminary data
  collection
• Jan 07 Step 3 - start of mandatory national
  monitoring

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Data Set Change Notices (DSCNs)

• DSCN 17/2006 published Aug 2006
• Gives details on
• national 18 weeks monitoring requirements
• short term approaches to 18 weeks measurement
• Further DSCNs to follow
• Data standards to support 18 weeks
• Changes to content frequency of CDS messages
• Inter-trust referrals minimum data set?

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Clock starts
Clock starts

• Referral from / after
• GP or GPSI
• General Dental Practitioner
• Optometrist and Orthoptist
• AE consultant, MIU, WIC, GUM clinic
• Screening programmes (for non-malignant
  conditions)
• Decision to treat made at follow up outpatient
  appointment
• Decision to treat made for subsequent inpatient
  treatment
• Referrals from other primary care professionals
  where PCTs have approved these mechanisms locally
• Consultant to consultant referral for a
  different condition (other than the one in the
  original referral) agreed by primary care
• Not included in 18 weeks
• Direct referrals to therapies, health sciences
  (e.g. audiology) and non-consultant led services
  in mental health

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Clock starts
Clock starts

• For most patients, the start of the RTT period
  begins when their GP refers them to a consultant
  in secondary care.
• The clock starts when the patient makes an
  appointment for their first outpatient attendance
  or assessment
• CB when UBRN converted
• Non-CB when referral received by trust
• Other clock starts include
• After watchful waiting
• When a consultant recognises a new condition

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Clock stops
Clock stops

• Treatment decision that stop the clock
• Start of first definitive treatment
• Admission as day case or inpatient
• Start of outpatient treatment
• Fitting of medical device decided on by
  consultant
• Start of watchful waiting/active monitoring
• No need for treatment in secondary care
• Patient declines treatment

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Clock stops
Clock stops

• The clock stops at the start of first definitive
  treatment
• First definitive treatment can be described as
  the first treatment that is intended to manage a
  persons disease, condition or injury.
• The clock stops if the treatment that is started
  is intended to avoid further intervention.
• Treatment can be given in outpatients or
  inpatients
• Other clock stops include
• Fitting of medical device decided on by
  consultant
• Start of watchful waiting/active monitoring
• No need for treatment in secondary care
• Patient declines treatment
• Patient death

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National monitoring of RTT times

• National monitoring of RTT times commenced in Nov
  06 (returns for Oct 06 period)
• First three months are voluntary but strongly
  encouraged
• Mandatory returns from Feb 07 (for Jan 07 period)
• Provider commissioner data collection through
  Unify
• Various support documents available including
• Data collection template for providers
• Data definitions guidance
• Unify user guide
• Sample scenarios (due this week)
• FAQ (due this week)

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National monitoring of RTT times

• The provider return looks at RTT times, by
  commissioning PCT, for
• Part 1a completed pathways for admitted
  patients
• Part 1b completed pathways for non-admitted
  patients
• Part 2 incomplete pathways
• PCT Commissioner returns produced by Unify from
  the data submitted by providers
• For the start of national monitoring, the length
  of the RTT period should be measured on an
  unadjusted basis - from the date the 18 week
  clock starts to the date that the 18 week clock
  stops

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Next steps outstanding issues

• Data definitions published in November focus on
  existing policy rules
• It is recognised there are some unresolved areas
• Planned patients
• Clock starts for intermediate services
• Defining reasonableness for 18 weeks
• DNAs/cancellations
• Patient initiated delays
• Patients with clinical complexity and/or
  co-morbidity
• Additional policy guidance to be issued late
  2006.

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Measurement in improvement

• We cant deliver 18 weeks if we cant measure it
• Why?
• How will we know what to change?
• How will we know whether the changes we have made
  have had an impact?
• Information is essential in driving service
  change
• Provides an evidence base for effective decision
  making
• Ability to track and monitor impact of any change
  
• Aids future planning

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What does the data tell us?
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Baseline Exercise ADMITTED PATHWAY HEADLINES
Average (mean) RTT times by specialty
Significant gap approaching one-half of 18
weeks. Need to understand the orthopaedics
problem at sub-specialty level
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BASELINE EXERCISE SUB-SPECIALTY ANALYSIS
ORTHOPAEDICS, HIGHEST VOLUMES PROCEDURESWhat
are the individual procedures with the longest
RTT times in orthopaedics?
Median and range for RTT waits by orthopaedic
procedure, excluding the longest 10 of RTT waits
Procedures with longest average RTT times.
Top of range, excluding top 10
Median RTT
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18 Weeks RTT Baseline Exercise

• What do the data show?
• First 19 hip replacement records for one Trust
  (not a proper sample, but)
• Significant amount of variation in the system
  along all parts of pathway
• No information yet on what happens in the goo

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BASELINE EXERCISE SUB-SPECIALTY ANALYSIS
ORTHOPAEDICS, HIGHEST VOLUMES PROCEDURESStage
of treatment times contribution to RTT
Average time spent in each stage of the RTT
pathways, selected orthopaedic procedures
Across these 4 procedures, the main source of
variability is in the interval between DTT and
admission Ii.e. the inpatient wait stage). The
outpatient wait and goo phases are
comparatively stable across the 4 procedures
Knee replacement
Release of nerve
KNEE REPLACEMENTS Nearly 50 of the RTT time for
all joint replacements (hips and knees) is spent
in the IP wait stage.
CARPAL TUNNEL Just over one-third of RTT time
was for the IP wait. An equal proportion was
spent in the goo stage.
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Application to Service Improvement

• Using the data to drive service improvements in
  the right (targeted) areas, e.g. knee replacement
  inpatient problem
• How?
• Using what we know
• Tools and techniques
• No Delays Achiever
• Maximum Impact Shorter Pathways
• Using Statistical Process Control charts to track
  and monitor changes in a process to show normal
  variation and identify triggers for actions

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Summary

• Measuring patient pathways and RTT times is a
  fundamental change to the way the NHS measures
• National mandatory monitoring of RTT times starts
  in January 07, with voluntary data collection
  from Oct 06
• Using information to drive service improvement is
  essential in meeting 18 weeks
• Target and track improvements on the right
  problem
• Target known service improvement tools and
  techniques to resolve problems in the pathway

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Key documents

• Tackling hospital waiting the 18 Week patient
  pathway. An implementation framework , May 2006
  - in particular, Annex A Principles and
  definitions for the 18 week patient pathway
  http//www.dh.gov.uk/assetRoot/04/13/46/69/0413466
  9.pdf
• 2. Data Set Change Notices (DSCNs)
• DSCN 10/2006 notification DSCN, May 2006
• DSCN 17/2006 mandating policy DSCN, Aug 2006
• http//www.connectingforhealth.nhs.uk/dscn/
• 3. Pioneer reports http//www.18weeks.nhs.uk/pio
  neers

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Further guidance and information

• For queries on data collection
• data18weeks_at_dh.gsi.gov.uk
• For general queries on 18 weeks
• 18weeks_at_dh.gsi.gov.uk
• www.18weeks.nhs.uk
• Latest news
• Official publications
• National Projects homepages
• Best practice guidance and case studies
• Tools and Techniques
• For access to the No Delays Achiever
• www.institute.nhs.uk/nodelaysachiever