Coventry and Rugby Clinical Commissioning Group Warwickshire North Clinical Commissioning Group

Managing patients through low intervention pathways

Coventry and Rugby Clinical Commissioning Group Warwickshire North Clinical Commissioning Group

VERSION CONTROL

Version: 1.0

Ratified by: Governing Body Meetings in Common

Date ratified: 29 March 2018

Name of originator/author: Kay Holland Interim Elective Care Senior Advisor

Name of responsible committees: Executive Group

Date issued: 4 April 2018

Review date: April 2021

VERSION HISTORY

Date Version Comment / Update

29 March 2018 1.0 Approved by Governing Body Meetings in Common

Commissioning Policy: Coventry and Rugby CCG (CRCCG) & Warwickshire North

CCG (WNCCG)

Treatment Managing patients through low intervention pathways

Indication Outpatients, Day & Short Stay Surgery

Criteria In line with ensuring patients are seen and treated in the most appropriate setting in the right place and at the right time CRCCG and WNCCGexpects that the provider will manage patients through the lowest possible intervention pathway consistent with good clinical practice.

Where a patient’s condition permits them to access lower intervention and support pathways, the Provider should ensure that the patient is referredinto these services rather than continue into full outpatient/inpatient settings. Equally for those patients deemed of low clinical risk following a procedure, the CCGs expect the Provider to manage the patient’s follow-ups on a patient-initiated follow-up pathway or virtual clinic pathway.

The expectation is that pathways for surgical procedures should be optimised and aligned to the definitions of length of stay in the BADS Directory (5th Edition or any future revisions to this Directory).

There should be a clear distinction in practice, and in recording, between:

True Day Cases – procedures requiring the use of a full operating theatre environment for which general or appropriate local anaestheticcare is provided;

Minor Surgery – local anaesthetic, outpatient procedures, where care can be provided in a suitable alternative environment.

For the avoidance of any doubt, Commissioners expect the provider toundertake procedures in line with the proportions detailed in the BADSDirectory (5th Edition or subsequent revision) and in line with any clinical commissioning policies.

Equality ImpactAssessment

See attached

Equality Impact Assessment (EIA)

Policy/Service Managing patients

through low intervention

pathways

Person

completing EIA

Kay Holland

Date of EIA 28/02/18 Accountable

CCG Lead

Andrea Green

NHS Coventry and

Rugby Clinical

Commissioning Group

Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate

discrimination, advance equality of opportunity, and foster good relations

with protected groups.

This EIA assesses the impact of the policy on protected groups.

Who Affected CCG registered patients

Protected Group Likely to

be a

differential

impact?

Protected Group Likely to be a

differential

impact?

Age No Race No

Disability No Religion or belief No

Gender reassignment No Sex No

Marriage and civil partnership No Sexual orientation No

Pregnancy and maternity No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups

and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please

explain.

The impact of this policy has been discussed and all protected characteristics and Human Rights values given due regard.

Please summarise where further action is required and when the projects/decision will be reviewed.

The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.

1

Enc J3 Quality Impact Assessment Tool Stage 1 The following assessment screening tool will require judgement against all listed areas of risk in relation to quality. Each proposal will need to be assessed whether it will impact adversely on patients / staff / organisations.

Where an adverse impact score greater than eight is identified in any area, this will require a more detailed impact assessment to be carried out, using the escalation proforma.

Insert your assessment as positive (P), negative (N) or neutral (N/A) for each area. Record your reasons for arriving at that conclusion in the comments column. If the assessment is negative, you must also calculate the score for the impact and likelihood and multiply the two to provide the overall risk score. Insert the total in the appropriate box.

Title of scheme:

Managing patients through low intervention pathways

CCGs covered by the scheme: (only one QIA is required for each scheme even in multiple CCGs are involved)

Coventry & Rugby CCG and Warwickshire North CCG

Lead CCG: (the CCG that will coordinate the completion of the QIA in consultation with involved CCGs)

Coventry & Rugby CCG

Project Lead for scheme:

Mark Roscoe and Gerard Dillon

Senior Responsible Officer: Clare Hollingworth

Brief description of scheme:

Where a patient’s condition permits them to access lower intervention and support pathways, the Provider should ensure that the patient is referred into these services rather than continue into full outpatient/inpatient settings.

Intended Quality Improvement Outcome/s:

Patients seen and treated in the most appropriate setting, in the right place and at the right time;

Patients will be managed through the lowest possible intervention pathway consistent with good clinical practice.

Methods to be used to monitor quality impact:

Pathways reviews GP Feedback No significant increase in complaints

2

P/N or N/A

Risk Score (if N)

Comments (include reason for identifying impact as positive, negative or neutral)

Risk > 8 Stage 2 assessment required) Y/N If Y complete stage 2 proforma)

Duty of Quality Could the proposal impact positively or negatively on any of the following:

a) Compliance with

NHS Constitution right to: - Quality of Care

and Environment

- Nationally

approved

treatments/ drugs

Respect, consent and confidentiality

- Informed choice

and involvement

- Complain and redress -

b) Partnerships

- Safeguarding children or adults

P

P

N/A

N

N/A

N/A

2

Patients are seen and treated in the most appropriate setting in the right place and at the right time. Lowest intervention pathways are consistent with good clinical practice. Compliance with respect, consent and confidentiality will not be affected by the introduction of low intervention pathways. Patients may prefer to be treated via more traditional pathways. Patients’ rights to complain / redress will not be affected.

No

NHS Outcomes Framework Could the proposal impact positively or negatively on the delivery of the five domains:

1. Preventing people from dying prematurely

N/A Lower intervention pathways only offered if the patient’s condition can be managed appropriately.

No

2. Enhancing quality of life P Patients are seen and treated in the most appropriate setting in the right place and at the right time.

No

3. Helping people recover from episodes of ill health or following injury

P Patients are seen and treated in the most appropriate setting in the right place and at the right time.

No

4. Ensuring people have a positive experience of care

P Patients are seen and treated in the most appropriate setting in the right place and at the right time.

No

5. Treating and caring for people in a safe environment and protecting them from avoidable harm

P Patients are seen and treated in the most appropriate setting in the right place and at the right time. Low intervention pathways are consistent with good clinical practice

No

3

Access Could the proposal impact positively or negatively on any of the following:

a) Patient Choice

b) Access

c) Integration

N

P

N/A

2

Patients may prefer to be treated via more traditional pathways. Low intervention pathways should improve access to services.

No

4

10

Post Implementation Review (use the template below to record outcomes of reviews- if more than one is required cut and

paste the box below)

Signed off by:

Position:

Signature: Date of review:

Requires review at Clinical Quality and Governance Committee: Y/N

Date considered at Clinical Quality and Governance Committee :

Logged on spreadsheet: Y/N

Date:

Name of person completing assessment: Kay Holland

Position: Interim Elective Care Senior Advisor

Signature: Date of assessment: 28th February 2018

Reviewed by:

Position:

Signature: Date of review:

Proposed frequency of review: Six monthly/ Quarterly/ Monthly/ Other please specify:

(minimum monitoring is six monthly (scores 6 or below) , Every 4 months (scores 8-9), quarterly (scores 10-12) and monthly ( 15-20)- weekly or more frequent (score 25) Use boxes below to record outcome of reviews

Have the anticipated quality impacts been realised? Y/N Comments:

Have there been any unanticipated negative impacts? Y/N Comments:

Are any additional mitigating actions required? Y/N Comments:

Do any amendments need to be made to the scheme? Y/N Comments:

Reviewed by:

Position:

Signature: Date of review:

5

Step 1 – Calculate the Possible Impact

When calculating the impact you should choose the most appropriate domain for the identified risk from the left hand side of the table then work along the columns in the same row to assess the severity of the risk on the scale of 1 to 5 (at the top of the column) to determine the impact score.

IMPACT 1 2 3 4 5

Domains Negligible Minor Moderate Major Catastrophic

Minimal Minor injury or Moderate injury requiring Major injury leading to Incident leading to injury illness, requiring professional intervention long-term death

requiring minor incapacity/disability no/minimal intervention intervention or treatment.

Safety of patients, staff or public (physical or psychological harm)

No time off work

Requiring time off work for >3 days

Requiring time off work for 4-14 days

Requiring time off work for >14 days

Multiple permanent injuries; or Irreversible health effects

Increase in length of hospital stay by 1-3 days

Increase in length of hospital stay by 4-15 days

Increase in length of hospital stay by >15 days

An event which impacts on a large number of patients

RIDDOR/agency reportable incident

Mismanagement of patient care with long- term effects

An event which impacts on a small number of patients

Peripheral Overall treatment Treatment or service has Non-compliance with Totally

element of or service significantly reduced national standards unacceptable level

treatment or suboptimal effectiveness with significant risk to or quality of service patients if unresolved treatment/service

suboptimal

Informal Formal complaint Formal complaint (stage 2) Multiple complaints/ Gross failure of Quality

Complaints

complaint/ inquiry

(stage 1) complaint independent review patient safety if findings not acted on

Audit Local resolution Local resolution (with potential to go to independent review)

Low performance rating

Inquest/ ombudsman inquiry

Single failure to meet internal standards

Repeated failure to meet internal standards

Critical report Gross failure to meet national standards

6

IMPACT 1 2 3 4 5

Domains Negligible Minor Moderate Major Catastrophic

Short-term low Uncertain delivery of key Non-delivery of key staffing level objective/service due to objective/service due that lack of staff to lack of staff

temporarily Unsafe staffing level or competence (>1 day)

Unsafe staffing level or competence (>5 days)

Ongoing unsafe staffing levels or competence

reduces

Human resources/ organisational

service quality (< 1 day)

development/ Low staff morale Loss of key staff Loss of several key staff

staffing/ competence

Poor staff attendance for Very low staff morale No staff attending mandatory/key training mandatory training

No staff attending mandatory/ key training

/key training on an ongoing basis

Statutory duty/ No or minimal Breech of statutory Single breech in statutory duty Enforcement action Multiple breeches in inspections impact or legislation statutory duty

breech of Reduced performance rating if unresolved

Challenging external recommendations/ improvement notice

Multiple breeches in statutory duty

Prosecution guidance/

statutory duty

Improvement notices Complete systems change required

Low performance rating Zero performance rating

Critical report Severely critical report

Rumours Local media Local media coverage – National media National media

coverage – coverage with <3 days coverage with >3 service well below days service well reasonable public below reasonable

expectation public expectation.

MP concerned Adverse publicity/

reputation not relevant to QIA

Not relevant to QIA

(questions in the House)

Potential for public concern

short-term reduction in public confidence

long-term reduction in public confidence

Total loss of public confidence

Elements of public expectation not being met

Business objectives/ Insignificant <5 % over project 5–10 % over project budget Non-compliance with Incident leading >25% Projects cost increase/ budget national requirements over project budget

schedule slippage

10–25 % over project budget

Schedule slippage Schedule slippage Schedule slippage Schedule slippage

Key objectives not met Key objectives not met

7

1 2 3 4 5

Negligible Minor Moderate Major Catastrophic

Finance including claims

Small loss Risk of claim remote

Loss of 0.1–0.25 per cent of budget

Loss of 0.25–0.5 per cent of budget

Uncertain delivery of key objective/Loss of 0.5– 1.0 per cent of budget

Non-delivery of key objective/ Loss of >1 per cent of budget

Claim less than £10,000

Claim(s) between £10,000 and £100,000

Claim(s) between £100,000 and £1 million

Failure to meet specification/ slippage

Purchasers failing to pay on time

Loss of contract / payment by results

Claim(s) >£1 million

Service/business interruption

Loss/ interruption of >1 hour

Loss/ interruption of >8 hours

Loss/ interruption of >1 day Loss/ interruption of >1 week

Permanent loss of service or facility

Environmental impact

Minimal or no impact on the environment

Minor impact on environment

Moderate environment

impact on Major impact environment

on Catastrophic impact on environment

8

Step 2 – Calculate how likely the risk is to happen (likelihood)

Now work out the likelihood score. Look at the frequency and probability columns and identify which best describe how often you think the risk is likely to occur. Now make a note of the corresponding ‘risk score’ (1-5 in the right hand column).

Likelihood Description Risk Score

Almost Certain Will undoubtedly occur, possibly frequently 5

Likely Will probably occur but it is not a persistent issue 4

Possible May occur occasionally 3

Unlikely Do not expect it to happen but it is possible 2

Rare Cannot believe that this will ever happen 1

9

Appendix 2: Quality Impact Assessment Tool Stage 2 - Escalation proforma To be completed when the initial impact assessment indicates a high risk (8 or above) and a more detailed assessment is required. On identification of a high risk business case, commissioning decision or business plan this proforma must be submitted along with the business case to inform the decision making process and ensure informed choice. A copy of the complete impact assessment must be submitted to the next available Clinical Quality and Governance Committee to ensure scrutiny from a quality perspective.

Background and context of the business case/plan/decision for approval.

What are the benefits?

What are the risks if the business case is not approved?

What are the high risks that the initial impact assessment indicates to certain groups or quality

What plans are in place to ensure identified risks are mitigated?

After mitigation, what are the remaining residual risks?

10

Recommendations for the Clinical Quality and Governance Committee to consider.

Assessment completed by

Name:

Position:

Date:

Line Manager/SRO Review

Name:

Position:

Date: