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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
2 Version 1.1 Published 21 November 2019
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
3 Version 1.1 Published 21 November 2019
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.
4 Version 1.1 Published 21 November 2019
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).
5 Version 1.1 Published 21 November 2019
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
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
Acceptance of allocation of Clinical Priority Category
Patient Details
Procedure CPC allocated on RFA
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,
Waitlist Manager Name DMS or delegate Name Position Position Date
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
Assigned Clinical Priority Category (CPC) not accepted
Patient Details
Procedure CPC allocated on RFA
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,
Waitlist Manager Name DMS or delegate Name Position Position Date
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 Failure to provide 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 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,
Waitlist Manager Name DMS or delegate Name Position Position Date
LHD Name Hospital Name
Hospital address Locked Mail Bag / PO box
Tel (02) Fax (02) Website:
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,
Waitlist Manager Name DMS or delegate Name Position Position Date
10 Version 1.1 Published 21 November 2019
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.
11 Version 1.1 Published 21 November 2019
Steps to take when an RFA is received with a procedure or health technology not previously
done at your hospital
12 Version 1.1 Published 21 November 2019
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.
13 Version 1.1 Published 21 November 2019
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:
1. RFA received, checked for minimum data set
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.
7. The treating doctor is to inform the patient of the decision.
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:
14 Version 1.1 Published 21 November 2019
Scenario 2: RFA received for a cosmetic or discretionary surgery and clinical supporting
documentation has not been provided by the treating doctor:
1. RFA received, checked for minimum data set
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.
8. The treating doctor is to inform the patient of the decision.
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:
15 Version 1.1 Published 21 November 2019
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.
16 Version 1.1 Published 21 November 2019
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.
17 Version 1.1 Published 21 November 2019
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.
18 Version 1.1 Published 21 November 2019
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.
19 Version 1.1 Published 21 November 2019
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
20 Version 1.1 Published 21 November 2019
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
18 Version 1.1 Published 21 November 2019
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
Executive Officer and District/Network CEO/delegate
6.5 Patients who have been delayed and do not have a rescheduled PAD
Monthly
WLI014_SBB PATIENT DELAYS WITH NO RESCHEDULED TCI
Executive Officer and District/Network CEO/delegate
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
19 Version 1.1 Published 21 November 2019
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
7.1 Check correct CPC assigned
Weekly RSE_WLIST42 - CATEGORY 1,2,3 WAITLIST REPORT
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
7.1 Review exceeded PAD
Weekly 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 Identify patients on list admitted through ED for same procedure
Weekly RSE_WLIST39 - EMERGENCY ADMISSION AND HAS ACTIVE WL BOOKING
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
CERNER: available reports for completing
weekly and monthly audits and report
20 Version 1.1 Published 21 November 2019
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
Executive Officer and District/Network CEO/delegate
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
Executive Officer and District/Network CEO/delegate
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
Executive Officer and District/Network CEO/delegate
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
21 Version 1.1 Published 21 November 2019
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
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 SWSLHD + SLHD 952_PM_WL_MULTI_ENTRY_DTL_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR049_WL_DUP_BOOKING
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
7.1 Check correct CPC assigned
Weekly SWSLHD + SLHD MNCLHD + NNSWLHD, NSLHD + CCLHD 855_WR005_BOOOKED_PATS_AMO
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
7.1 Review exceeded PAD
Weekly SWSLHD + SLHD 952_PM_BOOK_PASTDATE_SSW MNCLHD, NNSWLHD, NSLHD + CCLHD 855_WR010_PLANNED_ADM_PASSED
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
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
Report signed by the responsible person conducting the audit must be sent to the relevant manager and tabled at appropriate committees
22 Version 1.1 Published 21 November 2019
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
23 Version 1.1 Published 21 November 2019
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
24 Version 1.1 Published 21 November 2019
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
25 Version 1.1 Published 21 November 2019
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 the Elective
Surgery Waitlist Audit Process
26 Version 1.1 Published 21 November 2019
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
Evaluation of the Elective
Surgery Waitlist Audit Process
27 Version 1.1 Published 21 November 2019
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.
28 Version 1.1 Published 21 November 2019
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,
Waitlist Manager Name DMS or delegate Name Position Position Date
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
30 Version 1.1 Published 21 November 2019
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
31 Version 1.1 Published 21 November 2019
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
Elective Surgery Waitlist
Management Self-Assessment
32 Version 1.1 Published 21 November 2019
Policy Ref.
Requirement Fully Compliant
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
Areas for improvement:
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
Areas for improvement:
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
Category 2: 45 NRFC days
Category 3: 180 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
Elective Surgery Waitlist
Management Self-Assessment
33 Version 1.1 Published 21 November 2019
Policy Ref.
Requirement Fully Compliant
Partially Compliant
Non Compliant
Areas for improvement:
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
Elective Surgery Waitlist
Management Self-Assessment
34 Version 1.1 Published 21 November 2019
Policy Ref.
Requirement Fully Compliant
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
Areas for improvement:
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
Areas for improvement:
Total Total Total
Elective Surgery Waitlist
Management Self-Assessment
35 Version 1.1 Published 21 November 2019
Policy Ref.
Requirement Fully Compliant
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
Areas for improvement:
Total Total Total
Elective Surgery Waitlist
Management Self-Assessment
36 Version 1.1 Published 21 November 2019
Policy Ref.
Requirement Fully Compliant
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
Areas for improvement:
Total Total Total
Elective Surgery Waitlist
Management Self-Assessment
37 Version 1.1 Published 21 November 2019
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
Areas for improvement:
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
Areas for improvement:
Total Total Total
Elective Surgery Waitlist
Management Self-Assessment
38 Version 1.1 Published 21 November 2019
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
39 Version 1.1 Published 21 November 2019
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
https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/IB2012_004.pdf
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/GL2018_023.pdf