INFORMATION STANDARDS GOVERNANCE PROCESS INFORMATION ... Stay Surgeries-Dec.pdf · INFORMATION STANDARD FINAL PROPOSAL FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD

INFORMATION STANDARDS GOVERNANCE PROCESS

INFORMATION STANDARD

FINAL PROPOSAL FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD

SHORT STAY SURGERY ACTIVITY

PHASE 1

DECEMBER 2008

Welsh Information and Governance Standards Board Revised Monitoring Arrangements for Short Stay Surgery Activity

_________________________________________________________________________________________________________ Document: Information Standards Final Proposal for Revised Monitoring Arrangements for Short Stay Surgery Activity Author: David Hawes Page: 2 of 46

INFORMATION STANDARD FINAL PROPOSAL

FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD

This document should be completed using the GUIDANCE ON COMPLETING THE “INFORMATION STANDARD FINAL PROPOSAL NOTIFICATION” SUBMISSION TEMPLATE

REVISION HISTORY Date of this revision: 11/12/2008

Version no.

Revision date Summary of Changes Changes

marked 1.0 08/12/2008 First draft n/a

1.1 11/12/2008 Updated following comments from CHIP Programme Director and Welsh Assembly Government colleagues

No

SUBMITTED BY:

Document completed by: David Hawes

Role & organisation: Data Quality Improvement Manager, Corporate Health Information Programme, Programme Management Unit, WAG

FEEDBACK TO BE PROVIDED TO: Feedback will be provided on the Proposal within 10 days of the WIGSB meeting. If the feedback is to be directed to another nominee please provide the name and contact details below.

Name: David Hawes Email: [email protected]

SUBMISSION PURPOSE Proposal submitted for: Formal Approval If this Proposal submission is not for formal approval then please state the specific aspects on which you would like more detailed comments.

Specific Areas for WIGSB to comment on when not submitting for formal approval at the Proposal stage



SECTION 1: BACKGROUND 1. Information Standards Reference Number [from Information Services Division] IGRN2008/024 2. Name of Information Standard Short Stay Surgery Activity 3. Type of change Amendment to existing standard 4. Type of standard [Select all that apply] Operational 5. Introduction In November 2001, the Audit Commission published the Basket of Procedures 2000 – a set of 25 procedures for which day surgery rates would be measured for performance management purposes1. These procedures were established following a review of the original basket, which had been developed more than ten years previous, and included full consultation with the British Association of Day Surgery (BADS) to ensure that the selected procedures still met the criteria for inclusion. That criteria specified that the procedures: • Are commonly performed, so account for a large volume of surgery; • Are suitable for treatment as a daycase; • Would not generally be performed as an outpatient, thus focussing attention on the potential to treat

more inpatients as daycases. In Wales, the Basket of Procedures 2000 was adopted as a suitable measure of day surgery performance. In 2006, a set of Productivity and Efficiency targets were introduced into NHS Wales2. These ‘Core Measures’ included a requirement that Trusts comply with a range of day surgery rates for 15 of the 25 procedures listed in the Basket of Procedures 2000 – known as Core Measure 3. The Basket of Procedures 2000 has not been updated in terms of the range of procedures covered since November 2001 (some minor updates have been made to the associated OPCS codes as a result of updates to the OPCS classification) and as such it is widely accepted that the current basket is outdated and does not reflect the best practice implemented in hospitals today. To provide an innovative and high standard of care in an appropriate setting, clinicians have increasingly sought to move the delivery of certain procedures, such as hysteroscopy and varicose vein procedures, from the day surgery setting into outpatients. This clearly represents an improvement for the patient in terms of the delivery of care. However, this change in practice (along with other service delivery changes over time) has an adverse effect on day surgery performance from both a local benchmarking and national reporting perspective. In September 2006, the Wales Audit Office (WAO) published a report on day surgery performance in Wales3. One of the themes of the report was that the current Audit Commission basket did not accurately reflect modern approaches to service delivery. Furthermore, there is concern within the service in relation to the lack of recognition and understanding for short stay inpatient procedures and day surgery patients who require an extended recovery (overnight) period. It can be argued that such procedures are inappropriately in the current day surgery basket.

1 Day Surgery – Specification of Codes for Basket of Procedures 2000 (2001). Audit Commission. 2 WHC (2006) 079 3 Making Better Use of NHS Day Surgery in Wales (2006). Wales Audit Office.



This submission is to inform WIGSB of the formulisation of a revised approach to the monitoring of short stay surgery activity in NHS Wales. This standard will replace a number of existing standards concerned with the monitoring of short stay activity and the means by which Trusts should record such activity. The standard is designed for introduction in two phases:

- Phase 1: The replacement of the Audit Commission Basket of 25 Daycase Procedures with a revised short stay surgery basket based on the British Association of Day Surgery (BADS) Directory of Procedures. To include a revision of the online reporting tool(s) for providing performance management reporting functionality at a national level.

- Phase 2: The introduction of monitoring arrangements of procedures considered most clinically

appropriate to be undertaken within an outpatient setting. The review of the current definitions for ‘daycase’ and ‘outpatient procedure’ activity reporting.

This document outlines the development proposal associated with phase 1 only. 6. Sponsor Simon Dean – Director of Service Delivery & Performance Management DHSS, Welsh Assembly Government Tel: 029 2082 5850 Email: [email protected] 7. Developer(s) Phase 1: Terry Gill - Performance Management, Waiting Times & Emergency Care Branch, Welsh Assembly Government Tel: 029 2082 5257 Email: [email protected] David Hawes – Data Quality Improvement Manager, Corporate Health Information Programme Tel: 029 2020 7606 Email: [email protected] 8. IImmpplleemmeennttaattiioonn DDaattee Phase 1: Service to be notified of agreed changes in December 2008. A detailed implementation plan for phase 1 of the project is outlined in Section 12.



SECTION 2: BUSINESS JUSTIFICATION 9. Purpose The purpose of this standard is to replace the Audit Commission Basket of Procedures 2000 with a new, clinically appropriate basket for short stay surgery NHS Wales based on the BADS Directory of Procedures 2007. Phase 1 of this development has the two principal aims are: • The reappraisal of the means by which short stay surgery performance is measured in NHS Wales

and to develop a set of procedures that will form the basis of benchmarking and performance arrangements;

• To update the current online reporting tool(s) for providing performance management reporting

functionality at a national level. 10. Scope The introduction of the standard(s) under phase 1 will cover the following service areas: • The interim basket will include procedures associated with activity recorded primarily within the

Admitted Patient Care (APC) data set only; • The British Associated of Day Surgery (BADS) Directory of Procedures shall be used as a basis for

the development of a NHS Wales short stay surgery basket; • The national reporting tool to be updated will be the eWebIndicators online reporting tool4, which is

managed and maintained by Health Solutions Wales (HSW) and hosted on the Health of Wales Information Service (HOWIS) intranet site.

The following exclusions are noted: • This project is concerned with facilitating change to the national online reporting tools only. The

implementation of any local Trust monitoring and/or reporting arrangements associated with the Project are the sole responsibility of the service.

• Any new and/or revised targets introduced will be applicable to Welsh organisations only. Although

data relating to activity undertaken in English NHS Trusts is collected in Wales, it will not be subjected to the same monitoring arrangements.

• The service itself is responsible for ensuring compliance with any revised targets associated with

short stay surgery and outpatient procedures. 11. FFuunnddiinngg

CENTRAL FUNDING There are two areas of phase 1 where funding implications must be considered. These are: • Providing the necessary funding associated with the development of the eWebIndicators online

reporting tool by HSW;

It is not yet known whether the resource implications associated with updating the online reporting tool are catered for within the current HSW / WAG Service Level Agreement (SLA). Should its

4 http://eproducts.wales.nhs.uk/webindicators



development require additional funding to complete within agreed timescales, this will be met by the Service Delivery and Performance Management, Directorate with the approval of the HSW SLA Steering Group within WAG.

• If required, ensuring appropriate funding is made available to ensure appropriate licensing of the use

of the BADS Directory of Procedures in NHS Wales;

Again, should any fees be required to secure a license to use BADS in Wales, these shall also be met by the Service Delivery and Performance Management Directorate of WAG.

The exact funding implications will be established and assessed through consultation and during the lifespan of Phase 1 of the project. SERVICE FUNDING This standard will not impact on Trust operational processes and therefore it is not felt that there is any significant funding impact to consider. Whilst Trusts may wish to replicate the proposed basket on local systems, this is regarded as an optional development. Therefore, should Trusts wish to pursue this option, funding for some developments are to be met by the Trusts themselves. 12. Support A letter of support in relation to this standard has bee provided by Simon Dean, Director of Service Delivery and Performance Management, Welsh Assembly Government. It can be viewed in Appendix A. A Task & Finish group will be established for each phase of the project. The membership of these two groups is likely to differ given the differing skill requirements associated with each phase. The membership of the Task & Finish group associated with phase 1 is as follows: • Chair: Terry Gill – Performance Manager, Performance Management, Waiting Times & Emergency Care

Branch, DHSS, WAG • David Hawes – Data Quality Improvement Manager, CHIP • Darren Griffiths – Deputy Director of Planning, Abertawe Bro Morgannwg University NHS Trust • Gordon Craig – Head of Information and Coding, Cwm Taf NHS Trust • Sue Churchill – Performance Improvement Manager, Delivery & Support Unit • Karen Barker – Service Manager, Hywel Dda NHS Trust • Karen O’Doherty – Clinical Coding Advisor, Information Services Division, WAG • Keith Howkins – Data Analyst, HSW • Mike Fealey – Senior Service Development and Improvement Manager, NLIAH • Richard Jones – Policy Support Officer, Performance Management, Waiting Times & Emergency Care

Branch, DHSS, WAG



SECTION 3: HEALTH INFORMATION STRATEGIC AND OPERATIONAL FIT 13. Strategic Fit This proposal links to the wider NHS strategic aim of ensuring that appropriate monitoring arrangements are in place in relation to day and short stay surgery in Wales in order to promote and encourage best clinical practice. This view was endorsed by the Derek Wanless Review of Health & Social Care5: • ‘We also need a robust approach to ensuring good and modern practice is implemented in Wales. There are

numerous areas where we could improve system performance by universalising best practice. For example, Trusts in Wales typically carry out lower levels of day surgery than those in England. We need to work with auditors and best practice units systematically to benchmark and scrutinise elements of service to ensure they are in line with good practice.’

The necessity to refine the Audit Commission Basket of 2000 to better reflect clinical practice is also supported in the Innovation in Care document Guide to Good Practice: Day Surgery in Wales6: • ‘The adoption of a definition that allows the inclusion of any surgical treatment, in which the patient is admitted,

treated and discharged in less than 24 hours.’ Furthermore, the failure to update the basket in Wales is reflected in the Wales Audit Office 2006 report Making Better Use of Day Surgery in Wales7: • ‘Where clinically appropriate, day surgery delivers benefits for patients undergoing elective surgery. It reduces

the length of stay in hospital, thereby lowering costs to the NHS, and the risk of hospital-acquired infections.’ • ‘The proposed Welsh list of day surgery procedures should be amended annually to include any new procedure

performance as day surgery so as to progressively expand the list and provide an incentive/challenge to practitioners to expand their scope.’

• ‘… the Assembly Government should develop systems to measure 23:59 and other short-stay surgery across a

wider range of procedures… Where possible, Trusts should use existing patient administration systems to measure the time between admission and discharge in hours, rather than days.’

14. Operational Fit This standard does not affect the recording of data in Trust PAS systems or the collection of PAS data extracts into the national database – PEDW. The standard will make use of existing flows and data will continue to be collected, and submitted to PEDW as already defined in the NHS Wales Data Dictionary. eWEBINDICATORS INFRASTRUCTURE This standard will necessitate the revision of the national reporting tool(s) associated with short stay surgery. At present, reporting functionality is provided via eWebIndicators – an online Aquarius software package that is managed and maintained by Health Solutions Wales. The revised basket will be replicated within eWebIndicators, thus providing a national tool whereby performance against the selected procedures can be regularly monitored. A sub-set of the revised short stay surgery basket will be monitored for performance management purposes. The selection of this sub-set and setting of any associated targets is the sole responsibility of the Performance Management, Waiting Times & Emergency Care Branch, DHSS, WAG.

5 Derek Wanless (2003). The Review of Health & Social Care in Wales. Welsh Assembly Government 6 Innovations in Care (2004). Guide to Good Practice: Day Surgery in Wales. Welsh Assembly Government 7 Auditor General for Wales (2006). Making Better Use of Day Surgery in NHS Wales. Wales Audit Office



15. Known standards in use nationally and internationally Scotland In Scotland, same day surgery performance is monitored at a national level using a basket of 19 procedures, which have been derived from the Audit Commission Basket of Daycases 2000. This includes both day surgery activity and surgical procedures undertaken in an outpatient setting. Over the last two years, the Scottish Government Health Directorates have taken a more active approach in encouraging NHS Boards to increase the amount of same day care they undertake. It has adopted the BADS Directory of Procedures and produced a BADS information system to allow benchmarking. All Scottish NHS Boards are being encouraged to adopt the BADS information system. Its use is being promoted through the Planned Care Improvement Programme, as it is recognised that it allows managers and clinicians to monitor performance and identify where changes in practice/management have resulted in a positive change and where potential for improvement still exists. The performance targets associated with BADS are currently only aspirational, since it is recognised that there are ongoing concerns relating to the completeness and accuracy of outpatient activity information. Therefore, whilst this issue is addressed, NHS Boards are advised to monitor performance using both the BADS information system and the national basket of 19 procedures. It is anticipated that the BADS Directory of Procedures will be used as the sole means of monitoring same day surgery performance in the future. England In England, the Audit Commission Basket of Daycases 2000 is still the focal point for day surgery performance monitoring. According to the commission, 75% of the 25 procedures should be carried out as daycases and this benchmark is applied to assess the performance of English NHS Trusts. It is one of fifteen high level indicators of efficiency included in the 'NHS Better Care, Better Value’ programme, which is used by the Department of Health (DoH) to assess Trust performance, inform on potential efficiency savings and to generate ideas on how such savings might be achieved. A link to the programme website is attached for reference: http://www.productivity.nhs.uk At a recent conference on day surgery it was stated that the DoH was looking into the possibility of reviewing its use of the Audit Commission basket and moving towards the BADS Directory of Procedures, with a wider emphasis on short stay surgery as opposed to delivery of same day care via admitted patient care activity. Further confirmation in relation to the current arrangements in England will be included for information in the final proposal submitted to WIGSB.



SECTION 4: THE PROPOSAL 16. Proposed Solution In order to better reflect recent improvements in clinical care and best practice, the proposed solution is that NHS Wales adopts a new basket for short stay surgery, based on the British Association of Day Surgery (BADS) Directory of Procedures. The procedures proposed for inclusion, as described in the BADS Directory of Procedures [2007 Edition], are as follows: 1. Anterior +/- posterior colporrhaphy (including primary repair of enterocele) 2. Arthroscopy of knee including menisectomy, meniscal or other repair 3. Autograft anterior cruciate ligament reconstruction 4. Bunion operations with or without internal fixation and soft tissue correction 5. Carpal tunnel release 6. Correction of squint 7. Diagnostic laparoscopy 8. Dupuytren’s fasciectomy 9. Endoscopic resection of prostate (TUR) 10. Endoscopic resection/destruction of lesion of bladder 11. Excision / destruction of lesion of anus 12. Excision of ganglion 13. Excision/biopsy of breast tissue +/- localisation 14. Excision/biopsy of lesion of pinna 15. Excision of lesion of penis 16. Extraction of cataract +/- implant 17. Laparoscopic cholecystectomy 18. Laparoscopy and therapeutic procedures including laser, diathermy and destruction e.g.

endometriosis, adhesiolysis, tubal surgery 19. Myringotomy +/- insertion of tube, suction clearance 20. Oophorectomy and salpingectomy (inc. bilateral) 21. Operation/exploration of sheath of tendon (e.g. trigger finger) 22. Operations on foreskin - circumcision, division of adhesions 23. Operations to manage female incontinence 24. Polypectomy of internal nose 25. Primary repair of inguinal hernia 26. Removal of internal fixation from bone/joint, excluding k-wires 27. Repair of umbilical hernia 28. Septoplasty of nose 29. Therapeutic (including endoscopic) operations on uterus (including endometrial ablation) 30. Tonsillectomy 31. Transluminal procedures on femoral artery 32. Tympanoplasty 33. Varicose vein surgery 34. Vitrectomy

A full breakdown of the OPCS-4.4 codes associated with each procedure description is specified in Appendix B. The specification outlining how APC activity data will be analysed in order to report performance against the procedures outlined above is specified in Appendix C. In developing the interim basket presented outlined in this proposal, it is necessary to summarise the efforts of the Short Stay Surgery (Phase 1) Task and Finish Group, which has triggered progress in a number of key areas: Basket Selection Data analysis from the APC and Outpatient Activity national databases using the OPCS-4.4 coding specification in the BADS directory has provided the reference for several iterations of the revised basket culminating in the proposed basket above.



Some general principles of selection were applied, with a few exceptions, in order to select procedures for the draft basket which was issued for consultation. These were: • Reasonable levels of activity carried out across Wales (typically over 500 cases); • Representative of delivery of procedures across Trusts and specialties; • The basket also includes procedures other than those considered appropriate for same day delivery

in keeping with the BADS philosophy – i.e. 23:59 and <72 hour surgery; • Procedures commonly carried out in an outpatient setting have largely been excluded and will be

addressed in phase 2. In phase 1, this basket will be populated with procedures identified as being specific (or mostly specific) to the APC data set. Clinical Coding An investigation into the robustness and completeness of the OPCS-4.4 codes against procedures from the BADS directory has been coordinated by members of the group via Accredited Clinical Coding (ACC) colleagues in the service. Feedback received from clinical coding colleagues and during the consultation indicated general acceptance of the proposed OPCS-4.4 code inclusions, but with a few anomalies. These are summarised as in Section 5 – Impact Assessment, although it should be noted here that it is not intended to deviate from or adjust the codes that are used in the directory at this stage. In support of this new basket, a new online reporting tool for short stay surgery will be developed. Performance monitoring reporting against a sub-set of the current Audit Commission Basket of Procedures 2000 is currently provided via eWebIndicators. Its update will be explored via the consultation exercise. Finally, the introduction of a new basket necessitates an update to the NHS Wales Data Dictionary, since the current Audit Commission Basket of 25 Procedures is listed in Appendix J and will need to be replaced. A DSCN will be developed through the DSCN Sub Group and subsequently issued to the service to formally communicate this update. It will then be replicated via the online NHS Wales Data Dictionary at the earliest opportunity. 17. Fitness for Purpose The standards outlined in this proposal are achievable through the current PAS functionality and PEDW infrastructure. The following will be an indication of a successful implementation; • Full implementation of a revised short stay surgery basket for NHS Wales, to be specified within the

2009/10 Annual Operating Framework;

• A functioning national online reporting tool for short stay surgery, which should be available to all NHS Wales staff via eWebIndicators;

• A revised Appendix J of the NHS Wales Data Dictionary, which outlines the new short stay surgery basket in detail.

The following considerations will need to be taken into account: • The impact of incomplete and/or uncoded clinical coding will need to be considered. At present, the

national target for clinical coding completeness is 95% completeness within three months of episode end date. Some Trusts are failing to achieve this and investigation has shown that uncoded activity can have a significant effect on reported performance against coding-related indicators.

• Whilst every attempt has been made to exclude procedures where a significant volume are undertaken in an outpatient setting, it is likely the some procedures listed in the interim basket will be undertaken



in outpatients in some Trusts. This shall need to be considered and analyses of Trust activity will need to be undertaken to monitor any changes in activity recording which do not comply with national data definitions and the setting in which they are delivered.

18. Testing / Pilot It is not considered necessary to test or pilot the collection of the data required for the proposed basket, as data collection for PEDW is already an established data collection routine. This standard simply provides a revised focus for a more appropriate mechanism for monitoring short stay surgery activity in Wales using PEDW as its source. It will be necessary to test and pilot the revised online reporting tool that will be used to monitor performance against the new basket. This will be managed internally between Health Solutions Wales and the Performance Management, Waiting Times & Emergency Care Branch of WAG. Health Solutions Wales will develop the tool in beta form on its offline development site. Consistency testing will ensure the final reporting tool complies with the specification as outlined by the Welsh Assembly Government Performance Management, Waiting Times & Emergency Care Branch. A draft specification for the online report is outlined in Appendix E. 19. Information Governance

As the proposed solution utilises PEDW infrastructure, which already has PIAG (Patient Information Advisory Group) approval, there are no Information Governance issues. 20. Commercial Considerations

There are no commercial issues which will impact upon the proposed standard.



SECTION 5: IMPACT ASSESSMENT 21. Impact Assessment A consultation document was issued to the service on Friday 14th November 2008. Given the tight deadlines associated with phase 1, a turnaround time of two weeks was specified, with a requirement that respondents provided feedback on the proposed interim short stay surgery basket by Friday 28th November 2008. The consultation document was circulated to the following staff groups/organisations: • Short Stay Surgery Leads, NHS Trusts • Information Leads, NHS Trusts • Health Solutions Wales • Short Stay Surgery (Phase 1) Task & Finish Group

A copy of the consultation documentation is included in Appendix F for information. The responses received are outlined in detail in Appendix G. In developing the proposed basket some initial considerations, analyses and development work was undertaken. This can be summarised as follows: • The Performance Management, Waiting Times & Emergency Care Branch, DHSS, WAG undertook an

analysis of 2007/08 APC and outpatient activity data in order to understand the distribution and volume of all the procedures outlined in the BADS Directory of Procedures. Using this analysis, procedures with a significantly low volume (i.e. less than 500 cases) and/or where a considerable amount of activity (i.e. more than 500 cases) was recorded within the outpatient activity national database were removed from the draft interim basket for short stay surgery. Furthermore, in most instances procedures were selected where reasonable volumes were apparent across all Welsh NHS Trusts (based on 2008/09 Trust configurations). A broad specialty coverage was also sought.

• The Short Stay Surgery (Phase 1) Task & Finish Group then considered the revised draft basket and

further updated it, removing those procedures considered applicable to the outpatient setting. This was done using the expert knowledge of the clinical leads amongst the group.

• This produced an updated draft basket, which was then circulated to organisations with whom

Accredited Clinical Coders were employed. Feedback was requested as to the OPCS-4.4 clinical codes associated with the procedure descriptions as specified in the BADS Directory of Procedures. Each was asked if they felt the clinical codes associated with each procedure fully reflected the description and, where appropriate, suggest any omissions/additions to the proposed codes inclusive to each procedure description. Feedback was received from five organisations. Detail as to the manner in which this feedback affected the final basket will be provided in the final proposal submitted to WIGSB.

• Following these processes, the draft interim short stay surgery basket was then signed off out of

committee by the Short Stay Surgery (Phase 1) Task & Finish Group in readiness for consultation. • Following consultation, the Short Stay Surgery (Phase 1) Task & Finish Group met once again to consider

the main issues before formally signing off the proposed short stay surgery basket as outlined in this document.

It is accepted that the two week period for consultation on this revised basket for short stay surgery is not ideal. However, given the extremely tight timescales associated with its implementation and sign-off, this was considered the maximum time allowable given the circumstances. The results of the feedback will be issued to the service at approximately the same time as the Annual Operating Framework (AOF) guidance. It is acknowledged, that this plan does not make substantive allowance for considerable opposition to the proposed basket. However, it is felt this is mitigated by the fact that the proposal is for the introduction of an interim short stay surgery basket, and that it will be subject to further review as part of phase 2. Furthermore, given the ongoing calls from the service that the current Audit Commission Basket of



Daycases is outdated, it is anticipated that the proposed changes will be welcomed within the service, as will the intention to review the definitions for daycase and outpatient procedure activity during phase 2. A number of issues were highlighted in the consultation and at the Development Proposal stage of the Information Governance process. These are summarised below, along with the proposed response to each issue or concern: The Use of Finished Consultant Episodes (FCEs) vs. Spells for Performance Monitoring Concern was expressed as to the use of FCEs for monitoring performance as opposed to campus and/or Trust spells. Reference was made both at WIGSB and via the consultation that if monitoring arrangements are to extend into the realm of short stay surgery (i.e. where the length of stay of an admission may extend beyond 0 days), then it would be more appropriate to monitor the entire patient stay rather than simply the first FCE of a spell. For example, if a patient is admitted for a total of 5 days, yet is transferred from the admitting consultant to another on the first day of that admission, the reported FCE length of stay is zero (0). It is argued that this presents a risk that (i) Trusts may ‘game’ activity in order to artificially improve reported performance and (ii) is not reflective of the patient experience. The Short Stay Surgery (Phase 1) Task & Finish Group agreed with these arguments. However, it agreed to make the recommendation to use FCEs for analysis in the short term for a number of reasons: (i) Analysis of PEDW activity data has shown that the presence of multi-episode elective spells is

low. For 2007/08 activity, 93% of inpatient spells and 98.1% of daycases are made of up just one FCE. Therefore, the use of FCEs can be regarded as generally safe for performance reporting in this context. A summary of the PEDW analysis described is provided in Appendix D for information;

(ii) The sub-set of the short stay surgery basket that will be used for performance management

purposes as part of the 2009/10 Annual Operating Framework will be principally comprised of procedures predominantly carried out as daycases. Again, this means that the use of FCEs to monitor performance can be regarded as generally safe. The development of the sub-set described is still in progress and is being taken forward by the Welsh Assembly Government;

(iii) The methodology for generating Trust spells from PEDW activity data, which is being developed

by Health Solutions Wales, has not yet been finalised and agreed with the service. Therefore, using it to monitor short stay surgery performance is likely to lead to inaccuracies;

Therefore, in response to the consultation and WIGSB concerns, it is proposed that FCEs are used to monitor performance against the proposed short stay surgery basket in the immediate term. However, a move towards monitoring performance based on Trust spells will be considered as part of phase 2 of the project, by which time it is envisaged an agreed methodology for generating Trust spells from PEDW activity data will be in place and, thus, enable accurate and reliable monitoring of performance. The Use of Admission Method ‘81’ / Intended Management ‘1’ – ‘5’ (i.e. Hospital Transfers) Concern was expressed in WIGSB as to the use of Admission Method ‘81’ with Intended Management ‘1’ – ‘5’ in the reporting specification, since it is known that the use of these codes for recording hospital and/or Trust transfers is not consistent across Wales. These concerns were raised at the meeting of the Short Stay Surgery (Phase 1) Task & Finish Group on Thursday 4th December, where they were supported by the Data Quality Improvement Manager from the Corporate Health Information Programme. Given the likely instances of this activity occurring in respect of those procedures outlined in the proposed basket will undoubtedly be extremely low in number, the group agreed that this activity type should be removed from the analysis specification, as outlined in Appendix C, whilst data quality concerns remain unaddressed.



Clinical Coding Feedback & Recommended Additions/Deletions to the Proposed Basket A number of anomalies were identified during the consultation on the OPCS-4.4 codes, as specified in Appendix B, that are to be used to monitor performance against the interim short stay surgery basket. Furthermore, suggested additions to the procedures that should be included within each procedure description were made by some respondents. Whilst it was felt that some of these suggestions and concerns were justified, the Short Stay Surgery (Phase 1) Task & Finish Group felt that any deviation from the code inclusions/exclusions, as outlined in the BADS Directory of Procedures [2007 Edition], would be detrimental to the approach being followed. The group felt it would be more appropriate to take the issues highlighted to future meetings of the BADS Council, on which NHS Wales has representation, to ensure that such concerns and suggestions can be put forward when the council develops future editions of the directory. The next scheduled update is due for publication in June 2009. The concerns raised as part of this consultation will be forwarded to the council for consideration for this release of the directory. Therefore, whilst the concerns have been recognised, it is proposed that the OPCS-4.4 codes, as outlined in the BADS Directory of Procedures [2007 Edition] (and summarised in Appendix B) will be those used for monitoring performance against the new basket in the short term. Licensing / Approval for Use of BADS in NHS Wales Whilst not a direct concern raised during the consultation, the requirement to ensure NHS Wales gains approval for the use of BADS in Wales remains outstanding. Appropriate approval from the BADS Council is considered to be essential prior to full implementation of the interim short stay surgery basket in Wales. This approval is being actively sought through direct communications with senior members of the BADS council and it is anticipated that formal approval will have been forthcoming by the time reporting mechanisms have been put in place for monitoring performance against the short stay surgery basket in Wales, currently scheduled for January 2009. Reported Same Day Surgery Performance Historically, only patients whose Intended Management stated that they were designated daycases were included in reported performance against zero (0) days. Following discussion with the service, it is proposed that zero (0) days performance includes patients whose intended management specifies them as inpatients (i.e. intended to stay overnight) yet were discharged on the same day as their admission.



SECTION 6: IMPLEMENTATION PLAN

22. Implementation plan A updated development plan (correct as at Friday 12th December 2008) for phase 1 of the standard is provided below for further information: Milestone Deadline Status Phase 1 – The replacement of the Audit Commission Basket of Procedures 2000 with an interim basket of short stay procedures based on the British Association of Day Surgery (BADS) Directory of Procedures Assemble Task & Finish Group 23rd Oct 2008 Complete – 23/10/2008 Agree PID and Phase 1 Objectives 23rd Oct 2008 Complete – 23/10/2008 BADS Specification Clarification / Clearance 31st Oct 2008 Pending Submit WIGSB Documentation - Requirement Notification (Phases 1 and 2) - Development Proposal (Phase 1 only)

20th Nov 2008 Completed – 20/11/2008

Service Consultation (2 weeks) 28th Nov 2008 Completed – 28/11/2008 Post-Consultation Analysis & Review - Agree Final Basket 5th Dec 2008 Completed – 04/12/2008

Issue Guidance to Service 19th Dec 2008 Pending Issue Efficiency Basket via AOF 19th Dec 2008 Pending Submit WIGSB Documentation - Final Proposals 18th Dec 2008 Pending

Update National Online Reporting Tools & Supporting Guidance Post-Dec 2008 In progress

Phase 2 – The introduction the outpatient procedure theme and review and enhancement of current definitions of daycases and outpatient procedures To be confirmed subject to approval of ongoing work package

23. Official Documentation None applicable.



SECTION 7: MAINTENANCE AND REVIEW

24. Maintenance Process In order to prevent it from becoming outdated and unreflective of current surgical practice, it is essential that the basket is maintained on a regular basis. It is likely that it will require maintenance on an annual basis, as it will need to appropriately reflect future updates to the BADS Directory of Procedures and, where applicable, should also recognise ongoing updates to the OPCS-4 clinical coding classification. A first-stage review of the interim basket will be undertaken as part of Phase 2 of the project. In addition to introducing monitoring arrangements for those procedures considered most clinically appropriate to the outpatient setting, the appropriateness of those procedures outlined in this proposal will also be reviewed. A 2008 Edition of the BADS Directory of Procedures is scheduled for publication in June 2008. Any changes that affect those procedures monitored in the interim short stay surgery basket for Wales will be incorporated into the monitoring arrangements accordingly. Subsequent ongoing processes for reviewing and updating the basket on an annual basis following completion of phase 2 are yet to be agreed. It is the intention that such maintenance processes will be agreed as part of phase 2 of the project. 25. Planned review dates Subject to approval of the ongoing work package, an initial review into the interim basket proposed in this document will be undertaken in phase 2 (i.e. 2009/10) – target completion date December 2009. Subsequent arrangements for reviewing the basket on an annual basis thereafter will be agreed as part of phase 2 and will be taken through the NHS Wales Information Governance process for due consideration.



APPENDIX A – LETTER OF SUPPORT


Document: Information Standards Final Proposal for Revised Monitoring Arrangements for Short Stay Surgery Activity Author: David Hawes

Page: 18 of 46

APPENDIX B – PROPOSED INTERIM SHORT STAY SURGERY BASKET FOR NHS WALES The following table outlines in detail the proposed interim short stay surgery basket for NHS Wales. It outlines the OPCS-4.4 codes that underpin each procedure description. These are identical to those described in the BADS Directory of Procedures [2007 Edition]:

# Procedure OPCS 4.4 Code OPCS 4.4 Code Category OPCS 4.4 Procedure Code DescriptionP231 Other Repair Of Prolapse Of Vagina Anterior And Posterior Colporrhaphy NecP232 Other Repair Of Prolapse Of Vagina Anterior Colporrhaphy NecW82.1 Therapeutic Endoscopic Operations On Semilunar Cartilage Endoscopic Total Excision Of Semilunar CartilageW82.2 Therapeutic Endoscopic Operations On Semilunar Cartilage Endoscopic Resection Of Semilunar Cartilage NecW82.3 Therapeutic Endoscopic Operations On Semilunar Cartilage Endoscopic Repair Of Semilunar CartilageW82.8 Therapeutic Endoscopic Operations On Semilunar Cartilage Other SpecifiedW82.9 Therapeutic Endoscopic Operations On Semilunar Cartilage UnspecifiedW831 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Endoscopic Drilling Of Lesion Of Articular CartilageW832 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Endoscopic Fixation Of Lesion Of Articular CartilageW833 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Endoscopic Shaving Of Articular CartilageW834 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Endoscopic Articular Abrasion ChondroplastyW835 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Endoscopic Articular Thermal ChondroplastyW836 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Endoscopic Excision Of Articular Cartilage NecW837 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Endoscopic Osteochondral AutograftW838 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage Other SpecifiedW839 (+Z846) Therapeutic Endoscopic Operations On Other Articular Cartilage UnspecifiedW841 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure Endoscopic Repair Of Intraarticular LigamentW842 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure Endoscopic Reattachment Of Intraarticular LigamentW843 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure Endoscopic Division Of Synovial PlicaW844 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure Endoscopic Decompression Of JointW845 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure Endoscopic Drilling Of Epiphysis For Repair Of Articular CartilageW846 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure Endoscopic Excision Of Synovial PlicaW848 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure Other SpecifiedW849 (+Z846) Therapeutic Endoscopic Operations On Other Joint Structure UnspecifiedW851 Therapeutic Endoscopic Operations On Cavity Of Knee Joint Endoscopic Removal Of Loose Body From Knee JointW852 Therapeutic Endoscopic Operations On Cavity Of Knee Joint Endoscopic Irrigation Of Knee JointW853 Therapeutic Endoscopic Operations On Cavity Of Knee Joint Endoscopic Autologous Chondrocyte Implantation Of Knee JointW858 Therapeutic Endoscopic Operations On Cavity Of Knee Joint Other SpecifiedW859 Therapeutic Endoscopic Operations On Cavity Of Knee Joint UnspecifiedW871 Diagnostic Endoscopic Examination Of Knee Joint Diagnostic Endoscopic Examination Of Knee Joint And Biopsy Of Lesion Of Knee JointW878 Diagnostic Endoscopic Examination Of Knee Joint Other SpecifiedW879 Diagnostic Endoscopic Examination Of Knee Joint UnspecifiedW881 Diagnostic Endoscopic Examination Of Other Joint Diagnostic Endoscopic Examination Of Joint And Biopsy Of Lesion Of Joint NecW888 Diagnostic Endoscopic Examination Of Other Joint Other SpecifiedW889 Diagnostic Endoscopic Examination Of Other Joint Unspecified

3 Autograft anterior cruciate ligament reconstruction W742 Other Reconstruction Of Ligament Reconstruction Of Intraarticular Ligament Nec

W791 Soft Tissue Operations On Joint Of Toe Soft Tissue Correction Of Hallux ValgusW792 Soft Tissue Operations On Joint Of Toe Excision Of Bunion NecW793 Soft Tissue Operations On Joint Of Toe Syndactylisation Of Lesser ToesW798 Soft Tissue Operations On Joint Of Toe Other SpecifiedW799 Soft Tissue Operations On Joint Of Toe UnspecifiedW591 Fusion Of Joint Of Toe Fusion Of First Metatarsophalangeal Joint And Replacement Of Lesser Metatarsophalangeal JointW592 Fusion Of Joint Of Toe Fusion Of First Metatarsophalangeal Joint And Excision Of Lesion Of Lesser Metatarsophalangeal JointW593 Fusion Of Joint Of Toe Fusion Of First Metatarsophalangeal Joint NecW594 Fusion Of Joint Of Toe Fusion Of Interphalangeal Joint Of Great ToeW595 Fusion Of Joint Of Toe Fusion Of Interphalangeal Joint Of Toe NecW596 Fusion Of Joint Of Toe Revision Of Fusion Of Joint Of ToeW598 Fusion Of Joint Of Toe Other SpecifiedW599 Fusion Of Joint Of Toe UnspecifiedW151 Division Of Bone Of Foot Osteotomy Of Neck Of First Metatarsal BoneW152 Division Of Bone Of Foot Osteotomy Of Base Of First Metatarsal BoneW153 Division Of Bone Of Foot Osteotomy Of First Metatarsal Bone NecW154 Division Of Bone Of Foot Osteotomy Of Head Of Metatarsal BoneW155 Division Of Bone Of Foot Osteotomy Of Midfoot Tarsal BoneW156 Division Of Bone Of Foot Cuneiform Osteotomy Of Proximal Phalanx With Resection Of Head Of First MetatarsalW158 Division Of Bone Of Foot Other SpecifiedW159 Division Of Bone Of Foot Unspecified

Arthroscopy of knee including menisectomy, meniscal or other repair

Anterior +/- posterior colporrhaphy (including primary repair of enterocele)

Bunion operations with or without internal fixation and soft tissue correction

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5 Carpal tunnel release A651 Release Of Entrapment Of Peripheral Nerve At Wrist Carpal Tunnel Release

C311 Combined Operations On Muscles Of Eye Recession Of Medial Rectus Muscle And Resection Of Lateral Rectus Muscle Of EyeC312 Combined Operations On Muscles Of Eye Bilateral Recession Of Medial Recti Muscles Of EyesC313 Combined Operations On Muscles Of Eye Bilateral Resection Of Medial Recti Muscles Of EyesC314 Combined Operations On Muscles Of Eye Bilateral Recession Of Lateral Recti Muscles Of EyesC315 Combined Operations On Muscles Of Eye Bilateral Resection Of Lateral Recti Muscles Of EyesC316 Combined Operations On Muscles Of Eye Recession Of Lateral Rectus Muscle And Resection Of Medial Rectus Muscle Of EyeC318 Combined Operations On Muscles Of Eye Other SpecifiedC319 Combined Operations On Muscles Of Eye UnspecifiedC321 Recession Of Muscle Of Eye Recession Of Medial Rectus Muscle Of Eye NecC322 Recession Of Muscle Of Eye Recession Of Lateral Rectus Muscle Of Eye NecC323 Recession Of Muscle Of Eye Recession Of Superior Rectus Muscle Of EyeC324 Recession Of Muscle Of Eye Recession Of Inferior Rectus Muscle Of EyeC325 Recession Of Muscle Of Eye Recession Of Superior Oblique Muscle Of EyeC326 Recession Of Muscle Of Eye Recession Of Inferior Oblique Muscle Of EyeC327 Recession Of Muscle Of Eye Recession Of Combinations Of Muscles Of EyeC328 Recession Of Muscle Of Eye Other SpecifiedC329 Recession Of Muscle Of Eye UnspecifiedC331 Resection Of Muscle Of Eye Resection Of Medial Rectus Muscle Of Eye NecC332 Resection Of Muscle Of Eye Resection Of Lateral Rectus Muscle Of Eye NecC333 Resection Of Muscle Of Eye Resection Of Superior Rectus Muscle Of EyeC334 Resection Of Muscle Of Eye Resection Of Inferior Rectus Muscle Of EyeC335 Resection Of Muscle Of Eye Resection Of Superior Oblique Muscle Of EyeC336 Resection Of Muscle Of Eye Resection Of Inferior Oblique Muscle Of EyeC337 Resection Of Muscle Of Eye Resection Of Combinations Of Muscles Of EyeC338 Resection Of Muscle Of Eye Other SpecifiedC339 Resection Of Muscle Of Eye UnspecifiedC341 Partial Division Of Tendon Of Muscle Of Eye Tenotomy Of Medial Rectus Muscle Of EyeC342 Partial Division Of Tendon Of Muscle Of Eye Tenotomy Of Lateral Rectus Muscle Of EyeC343 Partial Division Of Tendon Of Muscle Of Eye Tenotomy Of Superior Rectus Muscle Of EyeC344 Partial Division Of Tendon Of Muscle Of Eye Tenotomy Of Inferior Rectus Muscle Of EyeC345 Partial Division Of Tendon Of Muscle Of Eye Tenotomy Of Superior Oblique Muscle Of EyeC346 Partial Division Of Tendon Of Muscle Of Eye Tenotomy Of Inferior Oblique Muscle Of EyeC347 Partial Division Of Tendon Of Muscle Of Eye Tenotomy Of Combinations Of Muscles Of EyeC348 Partial Division Of Tendon Of Muscle Of Eye Other SpecifiedC349 Partial Division Of Tendon Of Muscle Of Eye UnspecifiedC351 Other Adjustment To Muscle Of Eye Transposition Of Muscle Of Eye NecC352 Other Adjustment To Muscle Of Eye Lengthening Of Muscle Of Eye By Muscle SlideC353 Other Adjustment To Muscle Of Eye Insertion Of Adjustable Suture Into Muscle Of EyeC358 Other Adjustment To Muscle Of Eye Other SpecifiedC359 Other Adjustment To Muscle Of Eye UnspecifiedJ091 Diagnostic Endoscopic Examination/Liver Using Laparoscope Diagnostic Endoscopic Examination Of Liver And Biopsy Of Lesion Of Liver Using LaparoscopeJ092 Diagnostic Endoscopic Examination/Liver Using Laparoscope Laparoscopic Ultrasound Examination Of Liver And Biopsy Of Lesion Of LiverJ093 Diagnostic Endoscopic Examination/Liver Using Laparoscope Laparoscopic Ultrasound Examination Of Liver NecJ098 Diagnostic Endoscopic Examination/Liver Using Laparoscope Other SpecifiedJ099 Diagnostic Endoscopic Examination/Liver Using Laparoscope UnspecifiedT431 Diagnostic Endoscopic Examination Of Peritoneum Diagnostic Endoscopic Examination Of Peritoneum And Biopsy Of Lesion Of PeritoneumT432 Diagnostic Endoscopic Examination Of Peritoneum Diagnostic Endoscopic Examination Of Peritoneum And Biopsy Of Lesion Intraabdominal Organ NecT433 Diagnostic Endoscopic Examination Of Peritoneum Diagnostic Endoscopic Ultrasound Examination Of PeritoneumT434 Diagnostic Endoscopic Examination Of Peritoneum Diagnostic Endoscopic Ultrasound Examination Of Peritoneum And Biopsy Of Intraabdominal OrganT438 Diagnostic Endoscopic Examination Of Peritoneum Other SpecifiedT439 Diagnostic Endoscopic Examination Of Peritoneum UnspecifiedT521 Excision Of Other Fascia Palmar FasciectomyT522 Excision Of Other Fascia Revision Of Palmar FasciectomyT541 Division Of Fascia Division Of Palmar Fascia

Diagnostic laparoscopy

Dupuytren’s fasciectomy

Correction of squint6

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M651 Endoscopic Resection Of Outlet Of Male Bladder Endoscopic Resection Of Prostate Using ElectrotomeM652 Endoscopic Resection Of Outlet Of Male Bladder Endoscopic Resection Of Prostate Using PunchM653 Endoscopic Resection Of Outlet Of Male Bladder Endoscopic Resection Of Prostate NecM658 Endoscopic Resection Of Outlet Of Male Bladder Other SpecifiedM421 Endoscopic Extirpation Of Lesion Of Bladder Endoscopic Resection Of Lesion Of BladderM422 Endoscopic Extirpation Of Lesion Of Bladder Endoscopic Cauterisation Of Lesion Of BladderM423 Endoscopic Extirpation Of Lesion Of Bladder Endoscopic Destruction Of Lesion Of Bladder NecM428 Endoscopic Extirpation Of Lesion Of Bladder Other SpecifiedM429 Endoscopic Extirpation Of Lesion Of Bladder UnspecifiedH481 Excision Of Lesion Of Anus Excision Of Polyp Of AnusH482 Excision Of Lesion Of Anus Excision Of Skin Tag Of AnusH483 Excision Of Lesion Of Anus Excision Of Perianal WartH488 Excision Of Lesion Of Anus Other SpecifiedH489 Excision Of Lesion Of Anus UnspecifiedH491 Destruction Of Lesion Of Anus Cauterisation Of Lesion Of AnusH492 Destruction Of Lesion Of Anus Laser Destruction Of Lesion Of AnusH493 Destruction Of Lesion Of Anus Cryotherapy To Lesion Of AnusH498 Destruction Of Lesion Of Anus Other SpecifiedH499 Destruction Of Lesion Of Anus UnspecifiedT591 Excision Of Ganglion Excision Of Ganglion Of WristT592 Excision Of Ganglion Excision Of Ganglion Of Hand NecT593 Excision Of Ganglion Excision Of Ganglion Of KneeT594 Excision Of Ganglion Excision Of Ganglion Of FootT598 Excision Of Ganglion Other SpecifiedT599 Excision Of Ganglion UnspecifiedT601 Reexcision Of Ganglion Reexcision Of Ganglion Of WristT602 Reexcision Of Ganglion Reexcision Of Ganglion Of Hand NecT603 Reexcision Of Ganglion Reexcision Of Ganglion Of KneeT604 Reexcision Of Ganglion Reexcision Of Ganglion Of FootT608 Reexcision Of Ganglion Other SpecifiedT609 Reexcision Of Ganglion UnspecifiedB283 Other Excision Of Breast Excision Of Lesion Of BreastB284 Other Excision Of Breast Re-Excision Of Breast MarginsB288 Other Excision Of Breast Other SpecifiedB289 Other Excision Of Breast UnspecifiedB322 Biopsy Of Breast Biopsy Of Lesion Of Breast NecB323 Biopsy Of Breast Wire-Guided Biopsy Of Lesion Of BreastB328 Biopsy Of Breast Other SpecifiedB329 Biopsy Of Breast UnspecifiedD021 Extirpation Of Lesion Of External Ear Excision Of Lesion Of External EarD022 Extirpation Of Lesion Of External Ear Destruction Of Lesion Of External EarD028 Extirpation Of Lesion Of External Ear Other SpecifiedD029 Extirpation Of Lesion Of External Ear UnspecifiedD061 Other Operations On External Ear Biopsy Of Lesion Of External EarN271 Extirpation Of Lesion Of Penis Excision Of Lesion Of PenisN272 Extirpation Of Lesion Of Penis Cauterisation Of Lesion Of PenisN273 Extirpation Of Lesion Of Penis Destruction Of Lesion Of Penis NecN274 Extirpation Of Lesion Of Penis Extracorporeal Shockwave Lithotripsy To Lesion Of PenisN278 Extirpation Of Lesion Of Penis Other SpecifiedN279 Extirpation Of Lesion Of Penis Unspecified

Endoscopic resection of prostate (TUR)

Endoscopic resection/destruction of lesion of bladder

Excision / destruction of lesion of anus

Excision of ganglion

Excision/biopsy of breast tissue +/- localisation

Excision of lesion of penis

Excision / Biopsy of lesion of pinna

9

10

11

12

13

14

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C711 Extracapsular Extraction Of Lens Simple Linear Extraction Of LensC712 Extracapsular Extraction Of Lens Phacoemulsification Of LensC713 Extracapsular Extraction Of Lens Aspiration Of LensC718 Extracapsular Extraction Of Lens Other SpecifiedC719 Extracapsular Extraction Of Lens UnspecifiedC721 Intracapsular Extraction Of Lens Forceps Extraction Of LensC722 Intracapsular Extraction Of Lens Suction Extraction Of LensC723 Intracapsular Extraction Of Lens Cryoextraction Of LensC728 Intracapsular Extraction Of Lens Other SpecifiedC729 Intracapsular Extraction Of Lens UnspecifiedC731 Incision Of Capsule Of Lens Membranectomy Of LensC732 Incision Of Capsule Of Lens Capsulotomy Of Anterior Lens CapsuleC733 Incision Of Capsule Of Lens Capsulotomy Of Posterior Lens CapsuleC734 Incision Of Capsule Of Lens Capsulotomy Of Lens NecC738 Incision Of Capsule Of Lens Other SpecifiedC739 Incision Of Capsule Of Lens UnspecifiedC741 Other Extraction Of Lens Curettage Of LensC742 Other Extraction Of Lens Discission Of CataractC743 Other Extraction Of Lens Mechanical LensectomyC748 Other Extraction Of Lens Other SpecifiedC749 Other Extraction Of Lens UnspecifiedC751 Prosthesis Of Lens Insertion Of Prosthetic Replacement For LensC752 Prosthesis Of Lens Revision Of Prosthetic Replacement For LensC753 Prosthesis Of Lens Removal Of Prosthetic Replacement For LensC754 Prosthesis Of Lens Insertion Of Prosthetic Replacement For Lens Using Suture FixationC758 Prosthesis Of Lens Other SpecifiedC759 Prosthesis Of Lens UnspecifiedJ181 (+Y752) Excision Of Gall Bladder Total Cholecystectomy And Excision Of Surrounding TissueJ183 (+Y752) Excision Of Gall Bladder Total Cholecystectomy NecQ381 Other Therapeutic Endoscopic Operations On Fallopian Tube Endoscopic Freeing Of Adhesions Of Fallopian TubeQ382 Other Therapeutic Endoscopic Operations On Fallopian Tube Endoscopic Injection Into Fallopian TubeQ388 Other Therapeutic Endoscopic Operations On Fallopian Tube Other SpecifiedQ389 Other Therapeutic Endoscopic Operations On Fallopian Tube UnspecifiedQ391 Diagnostic Endoscopic Examination Of Fallopian Tube Diagnostic Endoscopic Examination Of Fallopian Tube And Biopsy Of Lesion Of Fallopian TubeQ398 Diagnostic Endoscopic Examination Of Fallopian Tube Other SpecifiedQ399 Diagnostic Endoscopic Examination Of Fallopian Tube UnspecifiedQ491 Therapeutic Endoscopic Operations On Ovary Endoscopic Extirpation Of Lesion Of OvaryQ492 Therapeutic Endoscopic Operations On Ovary Endoscopic Freeing Of Adhesions Of OvaryQ493 Therapeutic Endoscopic Operations On Ovary Endoscopic Drainage Of Cyst Of OvaryQ494 Therapeutic Endoscopic Operations On Ovary Endoscopic Drilling Of OvaryQ498 Therapeutic Endoscopic Operations On Ovary Other SpecifiedQ499 Therapeutic Endoscopic Operations On Ovary UnspecifiedT421 Therapeutic Endoscopic Operations On Peritoneum Endoscopic Resection Of Lesion Of PeritoneumT422 Therapeutic Endoscopic Operations On Peritoneum Endoscopic Destruction Of Lesion Of PeritoneumT423 Therapeutic Endoscopic Operations On Peritoneum Endoscopic Division Of Adhesions Of PeritoneumT424 Therapeutic Endoscopic Operations On Peritoneum Endoscopic Removal Of Foreign Body From PeritoneumT428 Therapeutic Endoscopic Operations On Peritoneum Other SpecifiedT429 Therapeutic Endoscopic Operations On Peritoneum UnspecifiedD151 Drainage Of Middle Ear Myringotomy With Insertion Of Ventilation Tube Through Tympanic MembraneD152 Drainage Of Middle Ear Suction Clearance Of Middle EarD153 Drainage Of Middle Ear Incision Of Ear Drum NecD158 Drainage Of Middle Ear Other SpecifiedD159 Drainage Of Middle Ear Unspecified

Extraction of cataract +/- implant

Laparoscopic cholecystectomy

Laparoscopy and therapeutic procedures including laser, diathermy and destruction e.g. endometriosis, adhesiolysis, tubal surgery

Myringotomy +/- insertion of tube, suction clearance

16

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Q221 (+Y752) Bilateral Excision Of Adnexa Of Uterus Bilateral SalpingoophorectomyQ222 (+Y752) Bilateral Excision Of Adnexa Of Uterus Bilateral Salpingectomy NecQ223 (+Y752) Bilateral Excision Of Adnexa Of Uterus Bilateral Oophorectomy NecQ228 (+Y752) Bilateral Excision Of Adnexa Of Uterus Other SpecifiedQ229 (+Y752) Bilateral Excision Of Adnexa Of Uterus UnspecifiedQ231 (+Y752) Unilateral Excision Of Adnexa Of Uterus Unilateral Salpingoophorectomy NecQ232 (+Y752) Unilateral Excision Of Adnexa Of Uterus Salpingoophorectomy Of Remaining Solitary Fallopian Tube And OvaryQ233 (+Y752) Unilateral Excision Of Adnexa Of Uterus Unilateral Salpingectomy NecQ234 (+Y752) Unilateral Excision Of Adnexa Of Uterus Salpingectomy Of Remaining Solitary Fallopian Tube NecQ235 (+Y752) Unilateral Excision Of Adnexa Of Uterus Unilateral Oophorectomy NecQ236 (+Y752) Unilateral Excision Of Adnexa Of Uterus Oophorectomy Of Remaining Solitary Ovary NecQ238 (+Y752) Unilateral Excision Of Adnexa Of Uterus Other SpecifiedQ239 (+Y752) Unilateral Excision Of Adnexa Of Uterus UnspecifiedQ241 (+Y752) Other Excision Of Adnexa Of Uterus Salpingoophorectomy NecQ242 (+Y752) Other Excision Of Adnexa Of Uterus Salpingectomy NecQ243 (+Y752) Other Excision Of Adnexa Of Uterus Oophorectomy NecQ248 (+Y752) Other Excision Of Adnexa Of Uterus Other SpecifiedQ249 (+Y752) Other Excision Of Adnexa Of Uterus UnspecifiedQ251 (+Y752) Partial Excision Of Fallopian Tube Excision Of Lesion Of Fallopian TubeQ258 (+Y752) Partial Excision Of Fallopian Tube Other SpecifiedQ259 (+Y752) Partial Excision Of Fallopian Tube UnspecifiedT711 Excision Of Sheath Of Tendon TenosynovectomyT721 Other Operations On Sheath Of Tendon Reconstruction Of Sheath Of TendonT722 Other Operations On Sheath Of Tendon Biopsy Of Lesion Of Sheath Of TendonT723 Other Operations On Sheath Of Tendon Release Of Constriction Of Sheath Of TendonT724 Other Operations On Sheath Of Tendon Exploration Of Sheath Of TendonT728 Other Operations On Sheath Of Tendon Other SpecifiedT729 Other Operations On Sheath Of Tendon UnspecifiedN301 Operations On Prepuce PrepuceplastyN302 Operations On Prepuce Freeing Of Adhesions Of PrepuceN303 Operations On Prepuce CircumcisionN304 Operations On Prepuce Dorsal Slit Of PrepuceN305 Operations On Prepuce Stretching Of PrepuceN306 Operations On Prepuce Manual Reduction Of PrepuceN308 Operations On Prepuce Other SpecifiedN309 Operations On Prepuce UnspecifiedM533 Vaginal Operations To Support Outlet Of Female Bladder Introduction Of Tension-Free Vaginal TapeM536 Vaginal Operations To Support Outlet Of Female Bladder Introduction Of Transobturator TapeM538 Vaginal Operations To Support Outlet Of Female Bladder Other Specified

24 Polypectomy of internal nose E081 Other Operations On Internal Nose Polypectomy Of Internal NoseT192 Simple Excision Of Inguinal Hernial Sac Unilateral HerniotomyT193 Simple Excision Of Inguinal Hernial Sac Ligation Of Patent Processus VaginalisT198 Simple Excision Of Inguinal Hernial Sac Other SpecifiedT199 Simple Excision Of Inguinal Hernial Sac UnspecifiedT201 Primary Repair Of Inguinal Hernia Primary Repair/Inguinal Hernia Using Insert/Natural MaterialT202 Primary Repair Of Inguinal Hernia Primary Repair/Inguinal Hernia Using Insert/Prosthetic MaterialT203 Primary Repair Of Inguinal Hernia Primary Repair Of Inguinal Hernia Using SuturesT204 Primary Repair Of Inguinal Hernia Primary Repair/Inguinal Hernia And Reduction Of Sliding HerniaT208 Primary Repair Of Inguinal Hernia Other SpecifiedT209 Primary Repair Of Inguinal Hernia Unspecified

26 Removal of internal fixation from bone/joint, excluding k-wires W283 Other Internal Fixation Of Bone Removal Of Internal Fixation From Bone Nec

T241 Primary Repair Of Umbilical Hernia Repair Of Umbilical Hernia Using Insert Of Natural MaterialT242 Primary Repair Of Umbilical Hernia Repair Of Umbilical Hernia Using Insert Of Prosthetic MaterialT243 Primary Repair Of Umbilical Hernia Repair Of Umbilical Hernia Using SuturesT248 Primary Repair Of Umbilical Hernia Other SpecifiedT249 Primary Repair Of Umbilical Hernia Unspecified

28 Septoplasty of nose E036 Operations On Septum Of Nose Septoplasty Of Nose Nec

Oophorectomy and salpingectomy (inc bilateral)

Operation / Exploration of sheath of tendon (e.g.. trigger finger)

Operations on foreskin - circumcision, division of adhesions

Operations to manage female incontinence

Primary repair of inguinal hernia

Repair of umbilical hernia

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Q161 Other Vaginal Operations On Uterus Vaginal Excision Of Lesion Of UterusQ162 Other Vaginal Operations On Uterus Balloon Ablation Of EndometriumQ163 Other Vaginal Operations On Uterus Microwave Ablation Of Endometrium NecQ164 Other Vaginal Operations On Uterus Free-Circulating Saline Ablation Of EndometriumQ165 Other Vaginal Operations On Uterus Radiofrequency Ablation Of EndometriumQ166 Other Vaginal Operations On Uterus Photodynamic Ablation Of EndometriumQ168 Other Vaginal Operations On Uterus Other SpecifiedQ169 Other Vaginal Operations On Uterus UnspecifiedQ171 Therapeutic Endoscopic Operations On Uterus Endoscopic Resection Of Lesion Of UterusQ172 Therapeutic Endoscopic Operations On Uterus Endoscopic Cauterisation Of Lesion Of UterusQ173 Therapeutic Endoscopic Operations On Uterus Endoscopic Cryotherapy To Lesion Of UterusQ174 Therapeutic Endoscopic Operations On Uterus Endoscopic Destruction Of Lesion Of Uterus NecQ175 Therapeutic Endoscopic Operations On Uterus Endoscopic MetroplastyQ176 Therapeutic Endoscopic Operations On Uterus Endoscopic Microwave AblationQ177 Therapeutic Endoscopic Operations On Uterus Endoscopic Balloon Ablation Of EndometriumQ178 Therapeutic Endoscopic Operations On Uterus Other SpecifiedQ179 Therapeutic Endoscopic Operations On Uterus UnspecifiedF341 Excision Of Tonsil Bilateral Dissection TonsillectomyF342 Excision Of Tonsil Bilateral Guillotine TonsillectomyF343 Excision Of Tonsil Bilateral Laser TonsillectomyF344 Excision Of Tonsil Bilateral Excision Of Tonsil NecF347 Excision Of Tonsil Bilateral Coblation TonsillectomyF348 Excision Of Tonsil Other SpecifiedF349 Excision Of Tonsil UnspecifiedL631 Transluminal Operations On Femoral Artery Percutaneous Transluminal Angioplasty Of Femoral ArteryL632 Transluminal Operations On Femoral Artery Percutaneous Transluminal Embolectomy Of Femoral ArteryL633 Transluminal Operations On Femoral Artery Percutaneous Transluminal Embolisation Of Femoral ArteryL634 Transluminal Operations On Femoral Artery Arteriography Of Femoral ArteryL635 Transluminal Operations On Femoral Artery Percutaneous Transluminal Insertion Of Stent Into Femoral ArteryL638 Transluminal Operations On Femoral Artery Other SpecifiedL639 Transluminal Operations On Femoral Artery UnspecifiedD141 Repair Of Eardrum Tympanoplasty Using GraftD142 Repair Of Eardrum Tympanoplasty NecD144 Repair Of Eardrum Combined Approach TympanoplastyD148 Repair Of Eardrum Other SpecifiedD149 Repair Of Eardrum UnspecifiedL841 Combined Operations On Varicose Vein Of Leg Combined Operations On Primary Long Saphenous VeinL842 Combined Operations On Varicose Vein Of Leg Combined Operations On Primary Short Saphenous VeinL843 Combined Operations On Varicose Vein Of Leg Combined Operations On Primary Long And Short Saphenous VeinL844 Combined Operations On Varicose Vein Of Leg Combined Operations On Recurrent Long Saphenous VeinL845 Combined Operations On Varicose Vein Of Leg Combined Operations On Recurrent Short Saphenous VeinL846 Combined Operations On Varicose Vein Of Leg Combined Operations On Recurrent Long And Short Saphenous VeinL848 Combined Operations On Varicose Vein Of Leg Other SpecifiedL849 Combined Operations On Varicose Vein Of Leg UnspecifiedL851 Ligation Of Varicose Vein Of Leg Ligation Of Long Saphenous VeinL852 Ligation Of Varicose Vein Of Leg Ligation Of Short Saphenous VeinL853 Ligation Of Varicose Vein Of Leg Ligation Of Recurrent Varicose Vein Of LegL858 Ligation Of Varicose Vein Of Leg Other SpecifiedL859 Ligation Of Varicose Vein Of Leg UnspecifiedL871 Other Operations On Varicose Vein Of Leg Stripping Of Long Saphenous VeinL872 Other Operations On Varicose Vein Of Leg Stripping Of Short Saphenous VeinL873 Other Operations On Varicose Vein Of Leg Stripping Of Varicose Vein Of Leg NecL874 Other Operations On Varicose Vein Of Leg Avulsion Of Varicose Vein Of LegL875 Other Operations On Varicose Vein Of Leg Local Excision Of Varicose Vein Of LegL876 Other Operations On Varicose Vein Of Leg Incision Of Varicose Vein Of LegL878 Other Operations On Varicose Vein Of Leg Other SpecifiedL879 Other Operations On Varicose Vein Of Leg UnspecifiedC791 Operations On Vitreous Body Vitrectomy Using Anterior ApproachC792 Operations On Vitreous Body Vitrectomy Using Pars Plana Approach

Varicose vein surgery

Therapeutic (inc endoscopic) operations on uterus (inc endometrial ablation)

Tonsillectomy

Transluminal operations procedures on femoral artery

Tympanoplasty

Vitrectomy

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APPENDIX C – DATA SPECIFICATION for PEDW DATA ANALYSIS The following selection criteria will be applied to PEDW data when generating reported performance against the NHS Wales short stay surgery basket: • Site Code of Treatment = Welsh NHS Trusts and Powys LHB only; • Reported performance based on Finished Consultant Episodes;

– OPCS-4.4 code must be present in first episode of a spell (i.e. episode number = ‘1’). • OPCS-4.4 codes as specified in the BADS Directory of Procedures [2007 Edition];

– See Appendix B for further information; – Inclusion and exclusion notes/codes apply.

• Admission Method in ('11', '12', '13', '14',) – i.e. elective episodes only; • Patient classification in ('1', '2') – i.e. inpatients and 'uncleansed' daycases only; • Administrative category <> '02' – i.e. private patients excluded.



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APPENDIX D – AN ANALYSIS OF MULTI-EPISODE ELECTIVE ACITIVTY IN PEDW The following tables summarise the prevalence of spells with more than one FCE for elective inpatient and daycase activity on PEDW. This is reported by showing the number of episodes where episode number = 1, episode number = 2, episode number = 3 etc: 2007/08 Elective INPATIENT Activity No. of Episodes Episode NumberTrust 1 2 3 4 5 6 7 8 9 10 11+ Grand TotalABM University NHS Trust 26726 680 305 29 13 2 2 1 27758Cardiff & Vale NHS Trust 20368 314 136 16 11 4 20849Cwm Taf NHS Trust 8285 2548 747 375 173 97 51 19 17 11 17 12340Gwent Healthcare NHS Trust 16659 357 82 6 1 1 17106Hywel Dda NHS Trust 10174 193 94 12 4 10477North Wales NHS Trust 14180 542 215 102 59 40 31 22 18 14 210 15433North West Wales NHS Trust 7578 301 68 20 11 3 1 7982Powys Teaching LHB 961 23 7 1 992Velindre NHS Trust 887 887Grand Total 105818 4958 1654 561 272 147 85 42 35 25 227 113824% of Records 93.0% 4.4% 1.5% 0.5% 0.2% 0.1% 0.1% 0.0% 0.0% 0.0% 0.2% 100.0% 2007/08 Elective DAYCASE Activity No. of Episodes Episode NumberTrust 1 2 3 4 5 6 7 8 9 10 11+ Grand TotalABM University NHS Trust 47970 51 29 48050Cardiff & Vale NHS Trust 41906 4 41910Cwm Taf NHS Trust 13658 2673 606 219 102 60 40 27 17 18 67 17487Gwent Healthcare NHS Trust 32955 26 2 32983Hywel Dda NHS Trust 27089 5 27094North Wales NHS Trust 28128 30 28158North West Wales NHS Trust 12533 21 1 12555Powys Teaching LHB 2204 2204Velindre NHS Trust 920 920Grand Total 207363 2810 638 219 102 60 40 27 17 18 67 211361% of Records 98.1% 1.3% 0.3% 0.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0%



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APPENDIX E – DRAFT SPECIFICATION FOR ONLINE REPORTING TOOL (eWebIndicators) The following table outlines the DRAFT specification provided to Health Solutions Wales by the Welsh Assembly Government in relation to the online reporting of performance against the proposed basket. PLEASE NOTE: - A final specification is to be agreed between WAG and Health Solutions Wales in January 2009.

- The procedure descriptions present within this table are not consistent with the proposed basket. The final version will be consistent with the procedure descriptions as described in Appendix B.

Basket Description

All Basket Descriptions

Primary repair of inguinal hernia 2065 56% 774 21% 536 15% 285 8% 3660

Diagnostic laparoscopy 633 67% 160 17% 116 12% 40 4% 949

Repair of umbilical hernia 531 59% 162 18% 122 14% 83 9% 898

Therapeutic (lincluding endoscopic) operations on uterus (lincluding endom 1543 69% 455 20% 190 8% 49 2% 2237

Laparoscopy and therapeutic procedures lincluding laser, diathermy and d 385 52% 228 31% 82 11% 47 6% 742

Vitrectomy using pars plana approach 221 37% 261 44% 84 14% 26 4% 592

Correction of squint 415 84% 70 14% 6 1% 1 0% 492

Arthroscopy of knee including menisectomy, meniscal or other repair 4195 73% 1080 19% 389 7% 98 2% 5762

Carpal tunnel release 2571 96% 76 3% 15 1% 9 0% 2671

Dupuytren’s fasciectomy 714 69% 228 22% 82 8% 18 2% 1042

Exploration of sheath of tendon 512 87% 43 7% 20 3% 12 2% 587

Endoscopic resection/destruction of lesion of bladder 610 27% 471 21% 546 25% 598 27% 2225

Operations on foreskin - circumcision, division of adhesions 1305 78% 254 15% 80 5% 30 2% 1669

Exision of lesion of penis 514 96% 10 2% 2 0% 7 1% 533

Tonsillectomy 36 1% 2379 71% 865 26% 68 2% 3348

Septoplasty of nose 92 9% 769 73% 180 17% 14 1% 1055

Polypectomy of internal nose 79 14% 338 60% 124 22% 26 5% 567

Tympanoplasty 35 7% 291 61% 141 29% 13 3% 480

Laparoscopic cholecystectomy 263 9% 1097 39% 901 32% 546 19% 2807

Anterior +/- posterior colporrhaphy (lincluding primary repair of enterocele) 8 1% 25 2% 66 6% 935 90% 1034

Operations to manage female incontinence 105 18% 156 27% 186 32% 135 23% 582

Oophorectomy and salpingectomy 37 7% 78 14% 84 15% 346 63% 545

Autograft anterior cruciate ligament reconstruction 96 20% 277 56% 68 14% 50 10% 491

Endoscopic resection of prostate (TUR) 16 2% 14 1% 93 10% 853 87% 976

Transluminal operations procedures on femoral artery 121 19% 188 30% 197 32% 115 19% 621

Grand Total 17102 47% 9884 27% 5175 14% 4404 12% 36565

Drop down Lists

Other Views: * 23hr:59min Proxy = 1 day stayEpisode Duration by Date (Month or Finanacial Year) * 72 Hour Proxy = 3 day stayEpisode Duration by Trust

Basket Date Basket Trust Provider

All Welsh Providers

Basket Episode Duration

All Episode Durations

Procedures and data are included for illustrative purposes only

Short Stay Surgery Performance: Basket by Episode Duration by Procedure

2007/08

Procedure Total0 Day 23:59 Proxy* < 72 Hours Proxy* > 72 Hours Proxy*

Number of Cases / % of Total


_________________________________________________________________________________________________________ Document: Information Standards Final Proposal for Revised Monitoring Arrangements for Short Stay Surgery Activity Author: David Hawes

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APPENDIX F – CONSULTATION DOCUMENT

Short Stay Surgery Review – Phase 1 Consultation Document

SHORT STAY SURGERY REVIEW

PHASE 1

CONSULTATION EXERCISE

NOVEMBER 2008


WIGSB Final Proposal - Short Stay Surgery Activity v1.1 (FINAL)

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SHORT STAY SURGERY REVIEW – PHASE 1 CONSULTATION All completed templates must be returned by Friday 28th November 2008 either: (i) by email to [email protected] or, (ii) hard copy to Richard Jones, Performance Management Policy

Development, Waiting Times and Emergency Care , Welsh Assembly Government, Cathays Park, Cardiff, CF10 3NQ

ORGANISATION

CONTACT NAME

JOB TITLE

PHONE NUMBER

E-MAIL

Your comments on each aspect of this proposal are sought.

Please enter your comments in the boxes provided. Due to the tight timescales only a single response from each named contact (see distribution list in Appendix 4) will be considered. It follows therefore, that the named contact is responsible for coordinating the feedback response on behalf of their organisation where appropriate. Important Information for NHS Trusts Feedback from the clinical community is essential and designated Short Stay Surgery leads in Trusts are urged to canvass the views of clinicians in their organisations. To avoid duplication, Trust Short Stay Surgery Leads are advised to liaise with their local Information Leads and between them ensure that all other relevant parties are consulted - e.g. clinical coders, performance management.



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1. The selection of procedures for initial draft NHS Wales short stay surgery basket Please note: This will be further reviewed and amended in 2009 during phase 2 of this work.

The following general principles of selection should be considered;

• Reasonable levels of activity; • Genuine potential to improve / change delivery; • Avoid procedures that are at the ceiling of performance delivery; • Representative of themes of short stay surgery for both inpatients and daycases; • Typically representative of delivery across trusts and specialty areas; • Significant variation in performance across Wales; and • Basket should comprise a manageable number for assessment / monitoring

purposes.

Note that these principles are not an exclusive requirement and other suggestions such as specialist, topical and ‘interesting’ procedures are welcomed and will be considered.

Also note that work on reporting procedures appropriate to delivery in an outpatient setting will be taken forward in phase 2. Given the ongoing issues with recording this activity it is proposed that such procedures are omitted from the interim basket (see analysis pack for guidance on content and numbers). Your views as to the appropriateness of these selection criteria are sought.

2. Specification for intended data analysis

In the absence of the HES specification please comment on the interim specification, as outlined in Appendix 2.



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3. Robustness and completeness of OPCS-4.4 codes used by BADS to describe procedures

Specific consideration should be given to procedures within the proposed basket and suggested additions to the draft basket.

4. Reporting structures and presentation style and content

Comments are also sought on continuation of the Audit Commission basket.

5. General comments around the BADS approach, development proposals

and issues related to ongoing benchmarking and performance monitoring/assessment



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SHORT STAY SURGERY REVIEW – PHASE 1 PROPOSAL Background In November 2001, the Audit Commission published the Basket of Procedures 2000 – a set of 25 procedures for which day surgery rates would be measured for performance management purposes8. These procedures were established following a review of the original basket, which had been developed more than ten years previously, and included full consultation with the British Association of Day Surgery (BADS) to ensure that the selected procedures still met the criteria for inclusion. The criteria specified that the procedures: • Are commonly performed, so account for a large volume of surgery; • Are suitable for treatment as a daycase; and • Would not generally be performed as an outpatient, thus focussing attention on

the potential to treat more inpatients as daycases. In Wales, the Basket of Procedures 2000 was adopted as a suitable measure of day surgery performance. In 2006, a set of Productivity and Efficiency targets were introduced into NHS Wales9. These ‘Core Measures’ included a requirement that Trusts comply with a range of day surgery rates for 15 of the 25 procedures listed in the Basket of Procedures 2000 – set out as Core Measure 3. The Basket of Procedures 2000 has not been updated in terms of the range of procedures covered since November 2001 and as such it is widely accepted that the current basket is outdated and does not reflect the best practice implemented in hospitals today. To provide an innovative and high standard of care in an appropriate setting, clinicians have increasingly sought to move the delivery of certain procedures, such as hysteroscopy and varicose vein procedures, from the day surgery setting into outpatients. This clearly represents an improvement for the patient in terms of the delivery of care. However, this change in practice, along with other service delivery changes over time, has an adverse effect on day surgery performance from both a local benchmarking and national performance perspective. In September 2006, the Wales Audit Office (WAO) published a report on day surgery performance in Wales10. One of the themes of the report was that the current Audit Commission basket did not accurately reflect modern approaches to service delivery. Furthermore, there is concern within the service in relation to the lack of recognition and understanding for short stay inpatient procedures and day surgery patients that require an extended recovery (overnight) period. In NHS Scotland, same day surgery is monitored at a national level using a set of 19 procedures, which is based on the Audit Commission basket. This includes both day surgery activity and surgical procedures undertaken in an outpatient setting. However, over the last two years it has begun to adopt the BADS Directory of Procedures (2007 edition) and has produced a BADS information system for Scottish NHS Boards to facilitate benchmarking. It is anticipated that the BADS directory will be used as the sole means of monitoring same day surgery performance in the future.

8 Day Surgery – Specification of Codes for Basket of Procedures 2000 (2001). Audit Commission. 9 WHC (2006) 079 10 Making Better Use of NHS Day Surgery in Wales (2006). Wales Audit Office.



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In NHS England, day surgery performance is still measured at a national level using the Audit Commission basket of 25 procedures. According to the commission, 75% of the 25 procedures should be carried out as daycases and this benchmark is applied to assess the performance of organisations. At a recent conference on Day Surgery it was stated that the Department of Health (DoH) was looking at the possibility of revising its plans around the Audit Commission basket and moving towards the BADS directory with a wider emphasis on short stay surgery as opposed to same day delivery. BADS Directory of Procedures The British Association of Day Surgery has published a Directory of Procedures (2007 edition) covering 166 procedures across nine surgical sub specialities which set challenging targets for surgical teams. The key features of the BADS Directory of Procedures (2007 edition) are: • A wider range of procedures are listed when compared with existing audit

baskets; • The directory is ‘owned’ by the clinical profession; • The basket approach for audit can be easily drawn from the directory; • It features a set of aspirational performance targets that will encourage

excellence and improvement; and • The targets are based on actual data and performance;

Each procedure within the BADS directory is listed against four possible headings. These are divided between two possible treatment areas for true same day surgery and then two further lengths of stay options as shown below. Definition of Length of Stay in BADS Directory of Procedures (2007 edition)

Procedure Room Operation that may be performed in a suitable clean environment outside of theatres

Day Surgery Traditional day surgery 23 Hour Stay Patient admitted and discharged within 24 hours Under 72 Hour Stay Patient admitted and discharged within 72 hours

The following table shows a typical extract from the directory where BADS have taken the top procedures for each specialty and provided OPCS 4.4 inclusion and exclusion codes and then HRG coding in the final column.

(C) British Association of Day Surgery (2007)



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The procedures and supporting performance benchmarks included in the 2007 directory are based on 2004/05 Hospital Episode Statistics (HES) data analysis from English trusts. The BADS website can be accessed using the following link: http://www.daysurgeryuk.org/content/default.asp Project Objectives The aim of the Short Stay Surgery Review is to: 1. Reappraise the means by which short stay surgery performance is measured in

NHS Wales; 2. Develop a set of procedures that will form the basis of future benchmarking and

performance arrangements; and 3. Review current definitions around daycase and outpatient procedure recording

and, where appropriate, provide updates. The Project is to be organised into two phases over two years, as outlined below. • Phase 1 – To review and replace the Audit Commission Basket of Procedures

2000 with an interim basket of short stay surgery procedures based on the British Association of Day Surgery (BADS) Directory of Procedures. This will monitor procedures carried out in an admitted patient care setting only;

• Phase 2 – Introduce monitoring arrangements for those procedures considered clinically most appropriate to the outpatient setting and incorporate into the basket. Furthermore, review and replace current definitions for daycases and outpatient procedures.

The focus of this consultation is on Phase 1 only. However it is anticipated that further consultation will be required on phase 2 proposals at some point during 2009 subject to approval of the ongoing work package. It is intended that the proposed changes (phase 1 only) will become effective prior to the circulation of the Annual Operating Framework (AOF), planned for 12th December 2008, thus allowing sufficient time for a subset of the revised basket to be included the Efficiency & Productivity measures for 2009/10. It is anticipated that reporting analysis via HOWIS for the revised basket will be made available in January 2009, at which point the Audit Commission basket analysis will be discontinued. Task and Finish Group Progress The Task and Finish group have made significant progress in a number of areas of development that support the proposals in this document, namely: Basket Selection Data analysis from the Admitted Patient Care (APC) and Outpatient Activity national databases using the OPCS-4.4 coding specification in the BADS directory has



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provided the reference for several iterations of the revised basket culminating in the basket proposal attached as Appendix 1. Due to timescales, this should be viewed as work in progress thus far as opposed to group’s final consensus of the finished product. Some general principles of selection were applied in order to select procedures for the draft basket with a few exceptions. These were: • Reasonable levels of activity carried out across Wales (typically over 500 cases); • Representative of delivery of procedures across Trusts and specialties; • The basket also includes procedures other than those considered appropriate for

same day delivery in keeping with the BADS philosophy – i.e. 23:59 and <72 hour surgery; and

• Procedures commonly carried out in an outpatient setting have largely been excluded and will be addressed in phase 2.

Data Specification The data specification used to produce the analysis is attached as Appendix 2. The aspirational targets in the BADS directory are based on HES data from England and it is proposed that Wales replicates this as far as possible to facilitate benchmarking. However, the precise detail of the HES specification has not yet been confirmed and the attached represents a working specification subject to change. The Task & Finish Group agreed that this would not have a significant impact on the numbers in the analysis. Clinical Coding An investigation into the robustness and completeness of the OPCS-4.4 codes against procedures from the BADS directory has been coordinated by members of the group via Accredited Clinical Coding (ACC) colleagues in the service. Again, this is an ongoing exercise but the general feedback to date, based on the draft basket, is one of general assuredness, with a few anomalies. This feedback is provided in the ‘analysis pack’ that accompanies this document. Please note, that it is not intended to deviate from or adjust the codes that are used in the directory at this stage. Reporting Arrangements Development of appropriate reporting structures is being taken forward with Health Solutions Wales (HSW) centred on the presentation of performance against the interim basket using a BADS style summary (as above) on HOWIS, using similar functionality to that of eWebIndicators. An illustrative example is attached in Appendix 3. The intention is to remove the current link to the Audit Commission basket11 at some point following the launch of the revised basket although this requires further dialogue, including feedback from this consultation exercise. 11 http://eproducts.wales.nhs.uk/webindicators/



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Information Governance Information Governance issues are being addressed, including the production of a Requirement Notification (for phases 1 and 2) and a Development Proposal (for phase 1 only). These are being presented at the next Welsh Information Governance Standards Board (WIGSB) meeting on 20th November 2008. It is planned that the final proposal (for phase 1 only) will be presented to WIGSB on 18th December 2008. Following formal approval from WIGSB, a DSCN will be drafted to ensure Appendix J of the NHS Wales Data Dictionary (which details the current Audit Commission basket) is appropriately updated to reflect the revised basket. This will be developed via the DSCN Sub Group and subsequently issued to the service. Other Issues A contact with BADS has recently been established and it is planned to develop this relationship further. There are significant opportunities to be gained through this engagement, not least the ability to influence the directory content in future years. NHS Wales already has a representative, Karen Barker (Service Manager – Hywel Dda NHS Trust), on the BADS Council Arrangements will be made for the purchase and distribution of the BADS Directory of Procedures (2007 edition) across Wales pending the outcome of this consultation. The 2008 directory will be published following the BADS annual conference in July 2009. Further information, including various project documentation in relation to phase 1 of the Short Stay Surgery Review can be found on the Corporate Health Information Programme website at: http://howis.wales.nhs.uk/sites3/page.cfm?orgid=460&pid=27008 Consultation Feedback Your feedback is requested in relation to the proposal to replace the Audit Commission Basket of Daycases with a revised Short Stay Surgery Basket for NHS Wales as part of phase 1 of the Short Stay Surgery Review. A proforma is provided at the front of this document. Respondents to this consultation exercise are requested to complete each section as advised. Any queries regarding its completion should be directed to [email protected]:



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Supporting Information To assist with the feedback process an analysis pack is provided that makes available the same information used by the Task and Finish group. The pack contains the following information: • Proposed basket as in Appendix 1; • Supporting analysis from APC dataset (provided in a separate zip file); • Data specification used to derive APC data above; • Supporting analysis from Outpatient minimum dataset; • Clinical coding analysis; • List of OPCS 4.4 codes used in BADS Directory of Procedures (2007 edition);

and • Audit Commission Basket of Procedures 2000



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Excision/biopsy of breast tissue +/- localisation 497 53% 159 17% 201 22% 76 8% 933 324

Excision/biopsy of lesion of pinna 756 91% 49 6% 14 2% 12 1% 831 21

Tympanoplasty 35 7% 291 61% 141 29% 13 3% 480 1

Myringotomy +/- insertion of tube, suction clearance 1398 82% 247 14% 61 4% 9 1% 1715 682

Septoplasty of nose 92 9% 769 73% 180 17% 14 1% 1055 0

Polypectomy of internal nose 79 14% 338 60% 124 22% 26 5% 567 2

Tonsillectomy 36 1% 2379 71% 865 26% 68 2% 3348 0

Excision / destruction of lesion of anus 374 66% 108 19% 63 11% 18 3% 563 1

Diagnostic laparoscopy 633 67% 160 17% 116 12% 40 4% 949 0

Laparoscopic cholecystectomy 263 9% 1097 39% 901 32% 546 19% 2807 0

Primary repair of inguinal hernia 2065 56% 774 21% 536 15% 285 8% 3660 0

Repair of umbilical hernia 531 59% 162 18% 122 14% 83 9% 898 0Therapeutic (lincluding endoscopic) operations on uterus (lincluding endometrial ablation) 1543 69% 455 20% 190 8% 49 2% 2237 29

Oophorectomy and salpingectomy (inc. bilateral) 37 7% 78 14% 84 15% 346 63% 545 1Laparoscopy and therapeutic procedures lincluding laser, diathermy and destruction eg endometriosis, adhesiolysis, tubal surgery 385 52% 228 31% 82 11% 47 6% 742 0

Anterior +/- posterior colporrhaphy (lincluding primary repair of enterocele) 8 1% 25 2% 66 6% 935 90% 1034 0

Correction of squint 415 84% 70 14% 6 1% 1 0% 492 0

Extraction of cataract +/- implant 18367 98% 271 1% 114 1% 20 0% 18772 1045

Vitrectomy 221 37% 261 44% 84 14% 26 4% 592 0

Excision of ganglion 499 89% 49 9% 7 1% 3 1% 558 4

Operation/exploration of sheath of tendon (e.g. trigger finger) 512 87% 43 7% 20 3% 12 2% 587 28

Removal of internal fixation from bone/joint, excluding k-wires 1114 66% 316 19% 159 9% 108 6% 1697 389

Carpal tunnel release 2571 96% 76 3% 15 1% 9 0% 2671 1

Dupuytren’s fasciectomy 714 69% 228 22% 82 8% 18 2% 1042 0

Arthroscopy of knee including menisectomy, meniscal or other repair 4195 73% 1080 19% 389 7% 98 2% 5762 1

Autograft anterior cruciate ligament reconstruction 96 20% 277 56% 68 14% 50 10% 491 0

Bunion operations with or without internal fixation and soft tissue correction 271 20% 635 48% 286 21% 141 11% 1333 0

Endoscopic resection/destruction of lesion of bladder 610 27% 471 21% 546 25% 598 27% 2225 4

Operations to manage female incontinence 105 18% 156 27% 186 32% 135 23% 582 0

Endoscopic resection of prostate (TUR) 16 2% 14 1% 93 10% 853 87% 976 0

Exision of lesion of penis 514 96% 10 2% 2 0% 7 1% 533 0

Operations on foreskin - circumcision, division of adhesions 1305 78% 254 15% 80 5% 30 2% 1669 0

Transluminal procedures on femoral artery 121 19% 188 30% 197 32% 115 19% 621 0

Varicose vein surgery 1044 53% 710 36% 167 9% 39 2% 1960 0

Grand Total 37259 72% 6831 13% 3581 7% 4008 8% 51679 1502

Recorded on 07/08 outpatient MDSProcedure Total0 Day 1 Day 2 Days > 2 Days


Appendix 1 Proposed [Interim] Short Stay Surgery Basket for NHS Wales (current all-Wales performance against proposed basket based on 2007/08 activity data is shown for information)



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Appendix 2 Data Specification for PEDW Data Analysis The following criteria were applied to the PEDW data extract used for the supporting analysis: • Finished Consultant Episodes • Episode end date between 01/4/2007 and 31/03/2008 • OPCS-4.4 codes in BADS Directory of Procedures (inclusion and exclusion

codes apply) • Admission method in ('11', '12', '13', '14', (81 with an intended management of 1

to 5)) – i.e. elective episodes • Site code of treatment = Welsh NHS trusts only • Patient classification in ('1', '2') – i.e. inpatients and 'uncleansed' daycases

only • Administrative category <> '02' – i.e. exclude private patients



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Appendix 3 Example of Proposed Online Reporting Tool

Basket Description

All Basket Descriptions

Primary repair of inguinal hernia 2065 56% 774 21% 536 15% 285 8% 3660

Diagnostic laparoscopy 633 67% 160 17% 116 12% 40 4% 949

Repair of umbilical hernia 531 59% 162 18% 122 14% 83 9% 898

Therapeutic (lincluding endoscopic) operations on uterus (lincluding endom 1543 69% 455 20% 190 8% 49 2% 2237

Laparoscopy and therapeutic procedures lincluding laser, diathermy and d 385 52% 228 31% 82 11% 47 6% 742

Vitrectomy using pars plana approach 221 37% 261 44% 84 14% 26 4% 592

Correction of squint 415 84% 70 14% 6 1% 1 0% 492

Arthroscopy of knee including menisectomy, meniscal or other repair 4195 73% 1080 19% 389 7% 98 2% 5762

Carpal tunnel release 2571 96% 76 3% 15 1% 9 0% 2671

Dupuytren’s fasciectomy 714 69% 228 22% 82 8% 18 2% 1042

Exploration of sheath of tendon 512 87% 43 7% 20 3% 12 2% 587

Endoscopic resection/destruction of lesion of bladder 610 27% 471 21% 546 25% 598 27% 2225

Operations on foreskin - circumcision, division of adhesions 1305 78% 254 15% 80 5% 30 2% 1669

Exision of lesion of penis 514 96% 10 2% 2 0% 7 1% 533

Tonsillectomy 36 1% 2379 71% 865 26% 68 2% 3348

Septoplasty of nose 92 9% 769 73% 180 17% 14 1% 1055

Polypectomy of internal nose 79 14% 338 60% 124 22% 26 5% 567

Tympanoplasty 35 7% 291 61% 141 29% 13 3% 480

Laparoscopic cholecystectomy 263 9% 1097 39% 901 32% 546 19% 2807

Anterior +/- posterior colporrhaphy (lincluding primary repair of enterocele) 8 1% 25 2% 66 6% 935 90% 1034

Operations to manage female incontinence 105 18% 156 27% 186 32% 135 23% 582

Oophorectomy and salpingectomy 37 7% 78 14% 84 15% 346 63% 545

Autograft anterior cruciate ligament reconstruction 96 20% 277 56% 68 14% 50 10% 491

Endoscopic resection of prostate (TUR) 16 2% 14 1% 93 10% 853 87% 976

Transluminal operations procedures on femoral artery 121 19% 188 30% 197 32% 115 19% 621

Grand Total 17102 47% 9884 27% 5175 14% 4404 12% 36565

Drop down Lists

Other Views: * 23hr:59min Proxy = 1 day stayEpisode Duration by Date (Month or Finanacial Year) * 72 Hour Proxy = 3 day stayEpisode Duration by Trust

Basket Date Basket Trust Provider

All Welsh Providers

Basket Episode Duration

All Episode Durations

Procedures and data are included for illustrative purposes only

Short Stay Surgery Performance: Basket by Episode Duration by Procedure

2007/08

Procedure Total0 Day 23:59 Proxy* < 72 Hours Proxy* > 72 Hours Proxy*




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Appendix 4 Consultation Distribution List Name Job Title Organisation Dr Richard Hughes Short Stay Surgery Lead Cardiff & Vale NHS Trust Darren Griffiths** Short Stay Surgery Lead Abertawe Bro Morgannwg NHS Trust Gordon Craig** Short Stay Surgery Lead Cwm Taf NHS Trust Mr Andrew Baker* Short Stay Surgery Lead North Wales NHS Trust Sandra Robinson Clark Short Stay Surgery Lead North West Wales NHS Trust

Mr Mark Henwood Short Stay Surgery Lead Hywel Dda NHS Trust Mr Peter Lewis Short Stay Surgery Lead Gwent Healthcare NHS Trust Gareth John Head of IPU Health Solutions Wales Ian Phillips Information Lead Abertawe Bro Morgannwg NHS Trust Alan Roderick Information Lead Cardiff & Vale NHS Trust Jack Attwood Information Lead Cwm Taf NHS Trust

Eric Lewis Information Lead Hywel Dda NHS Trust – Carmarthenshire

Mark Bouchier Information Lead Hywel Dda NHS Trust – Hywel Dda

Michelle Campbell Information Lead Hywel Dda NHS Trust – Pembrokeshire & Derwen

Jayne Griffiths Information Lead Gwent Healthcare NHS Trust Christine Fisher Information Lead North Wales NHS Trust – East Richard Walker Information Lead North Wales NHS Trust – Central Jeff Pye Information Lead North West Wales NHS Trust Dave Morrey Information Lead Velindre NHS Trust Lynda James Information Lead Powys Local Health Board Stefan Coghlan Chairman Welsh Consultants Committee David Gozzard Medical Director North Wales NHS Trust Andrew Lewis Associate Director NLIAH Richard Bowen Director Delivery & Support Unit

Pam Hall Programme Director Corporate Health Information Programme

Gordon McKenzie Head of Information Services Division Welsh Assembly Government

Stuart Davies Chief Executive Health Commission Wales

Sally Greenway Head of Information Standards Welsh Assembly Government

Sue Leake Head of Health Statistics & Analysis Unit Welsh Assembly Government

Elwyn Price-Morris Regional Director North Wales Regional Office Tony Hurrell Regional Director Mid & West Wales Regional Office Marion Andrews-Evans Regional Director South East Wales Regional Office

Steve Elliott Head of NHS Finance Welsh Assembly Government *Position unconfirmed **Not lead name but will coordinate feedback



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APPENDIX G – CONSULTATION RESPONSES 1. The selection of procedures for initial draft NHS Wales short stay surgery basket NameLesley LawNorth Wales Regional Office

Dr Richard HughesCardiff & Vale NHS Trust

Jayne GriffithsGwent Healthcare NHS Trust

Andrew LewisNational Leadership & Innovations Agency for Healthcare

Mark CommonNorth Wales NHS Trust (East)

Alan RoderickCardiff & Vale NHS Trust

Michelle CampbellHywel Dda NHS Trust (Pembrokeshire & Derwen)

Altaf HussainCwn Taf NHS Trust

Appropriate

In the short to medium term the criteria seem sound and appropriate but I would suggest that future development allow for more organisation-specific ‘baskets’, to allow for variation, as well as a core basket for central performance measurement.

For the longer term it may be worth cross referencing to a measure of ‘% of ALL surgery performed and discharged within two days ‘. Consistent achievement of this target will allow for the realisation of the target set in ‘Designed for Life’.

We broadly support the principles but are unclear as to what is meant by bullet points 3 and 4.We also feel that the principles should move away from the concept of a basket of procedures towards a proportion of activity delivered without need for an overnight stay, and proportion of activity delivered via 23hr 59 minutes. The reason for this comment is that the location and length of stay for procedures changes as medical technology advances and by placing procedures in a basket - the monitoring of this doesn’t encourage innovative practice.It would appear that a common sense approach is being adopted for the selection criteria which is welcomed. It is suggested however that as earlier work in this areas has indicated, it is appropriate for some daycase work to move into the outpatient procedure environment. This should also be captured and therefore specified up front for this initiative given the potential to change delivery.

Comments from performance, clinical and service managers have been sought. The collective view is that the move to recognise short stay surgery is positive. However, this initiative must provide a standard way of collecting and reporting data which takes account of variable ways/settings that some procedures are done. If this is achieved and comparable data is collected which allows accurate benchmarking, then the service welcomes the change.

We support the principles outlined above but are disappointed that outpatient procedures are not included in phase 1.

The BADS interim Short Stay Surgery Basket is a more comprehensive measure, due to –

1. It permits inclusion of short Inpatient stays, where the Audit Commission basket fails, by including Patient Class 2 only, and thus performance is skewed.

2. To move to phase 2, that is including OPT’s, will finally provide a holistic overview of Short Stay Basket procedures. It will however, demonstrate how patients are being treated, for the same procedure, but in a different environment. This can lead to questioning Clinical practices more easily.

3. To choose high volume related BADS procedures (34 in total), as an interim Short Stay performance measure, is a sensible starting point.

CommentsAgree with proposed principles would like to add:

In the past some previously day case procedures have moved to Minor Outpatient procedures (MOPS) recognition of this in calculations and review of activity needs to be included.- In the BADS process I see that there is a possibility of recording data for procedures undertaken in procedure rooms this could be used to capture MOPS.

Essentially OK, and I appreciate this is an interim ‘basket’.

However, FESS [Functional Endoscopic Sinus Surgery] should be included rather than nasal polypectomy because this is the modern procedure for nasal polyps.

The inclusion of vitrectomy is warranted but if you are considering this as a benchmarking exercise as well it must be considered that there are only two centres in Wales which perform this surgery (Cardiff and Swansea).

Transurethral resection of prostate is included. Using the traditional technique, this will only ever be a 48hr+ procedure. The availability of a laser for TURP is variable. Therefore, I consider it inappropriate for the initial basket.

Although knee arthroscopies are included, the future of orthopaedic surgery is certainly in arthroscopic surgery and shoulder procedures should be included. This should include subacromial decompressions and other therapeutic shoulder procedures.

Other procedures to include into the basket include extraction of impacted teeth and ureteroscopy with destruction of renal stones (with or without laser). Both of which are carried out in many Trusts around Wales.

If the list is growing too much, I would exclude ‘transluminal procedure on femoral artery’. These are more related to a diagnostic procedure than a therapeutic one.



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2. Specification for intended data analysis NameLesley LawNorth Wales Regional OfficeDr Richard HughesCardiff & Vale NHS TrustJayne GriffithsGwent Healthcare NHS Trust

Andrew LewisNational Leadership & Innovations Agency for HealthcareMark CommonNorth Wales NHS Trust (East)


Michelle CampbellHywel Dda NHS Trust (Pembrokeshire & Derwen)Altaf HussainCwn Taf NHS Trust

CommentsNo comment- I do not have sufficient knowledge in this area to comment

Seems fine to me.

We question the relevance of including Admission Method 81 (Transfer from another Hospital) with Intended Management 1) stating an Elective episode. The primary diagnosis field is required for some procedure analysis:Cataracts (as in original basket analysis)Bunion operations

Appropriate

No comment

Provider code needed in addition to site code, in view of organizational mergers and out-sourcing of future capacity requirements.Has consideration been given to the relationship of FCE and spells where patients are transferred between consultants?Has consideration been given to admission date data so as to link to Access 2009 stop clock points for patients journeys.How is residency or registered GP practice being taken into account?The specification as stated uses FCEs as the denominator. This is not appropriate as this indicator should be based on elective admissions, so for the avoidance of doubt, specialty and procedure on admission should be the driver and the records should be selected on the basis of completed admissions where the admission date is within a range. The specification in Annex 2 does not appear to include outpatient procedures but the accompanying analysis pack clearly contains outpatient data – this needs to be references in the specification. The analysis should be limited to admission methods 11, 12, 14 and 15. Planned treatments different in my view and not the focus of this indicator.

Agreed. Will need to include the meaning of Short stay, i.e. patient stay must be less than 3 Days duration, to be included within the basket.



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3. Robustness and completeness of OPCS-4.4 codes used by BADS to describe procedures NameLesley LawNorth Wales Regional Office





The gynaecology, dental and ophthalmology sections seem OK. But, a lady may have diathermy to a small lesion of endometriosis or a full resection of an extensive area of the disease but still be labelled with the same code, for clearly different procedures with different length of stay expectations.

Orthopaedic section would need specialist advice on the particular codes involved. Bunions have always been included in the old basket but the diversity of the codes for procedures performed these days illustrates the range of surgical procedures available and performed. Not all such techniques are appropriate for a patient to undergo and still be expected to go home the same day. More advice is required.

Urologically, I am pleased to see a delineation between endoscopic examination of the bladder with biopsy M45x and resection of bladder lesion M42x, which is a totally different ball game.

As commented in the papers, therapeutic gynaecology and intra-abdominal general surgery should only really be included in such a list of procedures if it is clearly stated that the procedure is performed laparoscopically – this is not clear through the codes listed.


The Trust supports the work carried out to date and recognises that it is work in progress. The Trust supports ongoing work to enhance this initiative and emphasises the need to embrace new clinical methods of delivery within the outpatient environment within this performance management indicator. It is hoped that the fact that outpatient data exists in the analysis pack is an indication that it is to be included – positive confirmation would be welcome.It would be helpful to have a “Description name/Heading or reference number“ for each procedure.

Current proposed basket includes most of the procedures. I would suggest to include all Lesser Toe procedures as well. Although K Wires are usually taken out in the OPD, a proportion in younger children are taken out under anaesthetic, therefore, this procedure also should be included in the basket.

CommentsSome procedures listed in Appendix 2 may now through service redesign be preformed in primary care such as carpal tunnel release. Is it proposed to capture primary care activity? To get a fuller picture of procedures carried out?The codes are voluminous and sometimes duplicates. In most sections there are get out clauses of procedure X. Unspecified/specified. This is positively unhelpful and will implicitly generate inaccuracies. However, this may sometimes be the only possible fit to a specific surgical procedure entered by either a clerk in coding or a theatre assistant (both not medically qualified).

I don’t know if you want me to go through every specific code (I’m sure there are persons greater than I experienced in coding). But, T201 is a nonsense as no natural material is used as an insert. This is followed by T203 (sutures used for hernia repair). The sutures are used to fix in the implant used in T202, and so on.

With Diagnostic laparoscopy, none of the cited codes are actually what is done in the vast majority of surgical cases. Therefore, the code would be for a specific or non-specific classification of a procedure, which is unhelpful.

General observation – some of the procedure headings do not seem to clearly specify exactly which procedures are grouped together into the basket. Some include procedures which aren’t mentioned in the heading whilst others exclude procedures because they are included in another BADs basket.

Specific issues are:One of the criticisms with the AC basket for Laparoscopy was that it was too broad. With therapeutic laparoscopy, it would preferable if just one or two procedures were included, such as ‘laparoscopic sterilisation’ and described as such.

Query whether TURP, anterior colporrhaphy and tonsillectomy should be included in BADS baskets as the selection of procedures outlined in section 1 states ‘representative of themes of short stay surgery for both inpatients and daycases’. These 3 procedures all show less than 2% with a 0 length of stay.

Including a primary diagnosis of M20.1 in the ‘Bunion’ basket would ensure that all procedures are for bunions.

No comment

Need clarification of order in which codes for procedures should be entered and implications where multiple procedures are undertaken at the same time – example where the patient is admitted for wire guided biopsy of breast and frozen section leads to mastectomy the order of coding would be wire biopsy first, Presumably this would then place the procedure in the basket. Similar examples exist for other codes whether multiple procedures are possible.

Again the basket should reflect current clinical technological processes and therefore we have some reservations around using procedures unless the basket is reviewed frequently.

The initial list of codes that were sent to the clinical coders contained inaccuracies and in several cases did not include some of the new OPCS 4.4 codes and seemed to be based on OPCS 4.3 and not OPCS 4.4., e.g Varicose veins, knee arthroscopy. These do not seem to be corrected in this version.



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4. Reporting structures and presentation style and content NameLesley LawNorth Wales Regional OfficeDr Richard HughesCardiff & Vale NHS TrustJayne GriffithsGwent Healthcare NHS TrustAndrew LewisNational Leadership & Innovations A f H lthMark CommonNorth Wales NHS Trust (East)Alan RoderickCardiff & Vale NHS TrustMichelle CampbellHywel Dda NHS Trust (Pembrokeshire & Derwen)Altaf HussainCwn Taf NHS Trust

CommentsI think we need to only have one system for reporting and as stated the Audit Commission basket has lost some credibility as they are out of date?

Essentially, only about 25 -30% of activity in modern short stay surgery units is reflected by looking at the Audit Commission Basket. Therefore, it is appropriate to widen the criteria to encompass the whole range of short stay surgery that is happening in Trusts. The continuation of the old basket acts to arrest clinical innovation and diversity.If the BADS specification is thoroughly checked and inaccuracies corrected, there is no need to continue with the Audit Commission Basket.

Current proposals certainly extend the Audit Commission Basket and also allows flexibility in respect of hospital stay upto 72 hours. This effectively means that surgeons would not shy away from listing patients for Day Surgery, just in case admission becomes necessary.

The Audit Commission basket must be replaced by a set of procedures that more accurately reflect current practice. The basket suggested in this consultation appears to represent a good first step.In our view this is out dated, clinically not relevant and doesn’t assist with service transformation.

This should be continued for reference purposes and continuity. I do not see any particular efficiency to be gained from its discontinuation and doubt that having this in addition to any new ‘basket’ will confuse in any way.For trend analysis, perhaps continue to the end of the Financial year.

Are we not using a reference number i.e. Basket 1 etc?



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5. General comments around the BADS approach, development proposals and issues related to ongoing benchmarking and performance monitoring/assessment NameLesley LawNorth Wales Regional Office





Another electronic tool available, which would be extremely helpful to Trusts, is the BADS efficiency score. This illustrates the efficiency of the short stay surgery system present in an individual Trust and demonstrates the potential capacity in bed days which could be realised if activity in a Trust for particular procedures was at the BADS aspirational level. I believe it would be a powerful ally to short stay surgery development by immediately getting buy-in from senior managerial staff.


More inclusive. However, what will the Performance Monitoring /assessment targets be measured upon. Will it be 0-1 day or up to 2.

Please acknowledge that a monthly performance summary of these measures will continue to change considerably as a result of Clinical coding updates.Appropriate

Welcome the proposed change but query with the introduction of OPCS 4.5 in April 2009 and subsequent revisions, who is going to ensure that the BADS specification is kept up to date with new codes and amendments ?

Although this can be seen as providing a more accurate measure of Day Surgery performance, it is very significantly more complex which may cause problems of it's own, will WAG / HSW be able to manage the volume of queries? Following collation of all the comments from this consultation will there be another opportunity to check the specification before it goes ‘live’? Noted that not all the comments from the coding consultation were taken on board.

Finally, comments included in this template refer to phase 1 only. Phase 2 raise additional concerns, for example, the accurate completion of the time of arrival on the ward. This will be a key element due to the need to monitor < 24 hours, > 72 hours. The recognition of OPD procedures will have a positive impact in a number of specialities, but in particular some Gynae procedures, it is disappointing that this is not considered at Phase 1 stage.

Will due consultation be undertaken for phase 2?I agree with the approach suggested in the consultation paper but refer back to my comments in the first box.

The BADs approach is an improvement to the current practice, but continues the same theme and misses the opportunity to encourage the service to consider the most appropriate environment for all patients, reducing length of stay for all patients to its optimum. The BADs approach also fails to take account for overall patient condition and ASA risk as an indicator of patient general fitness for procedure.This is an obvious enhancement to this area of activity but the need to capture outpatient procedures in a consistent manner whilst ensuring consistency and comparability across Wales must be recognised and included within this initiative. It is hoped that the obvious and well documented inconsistencies in data recording across Wales will no longer be a factor given the way in which this indicator is now being approached.

CommentsAgree with principle and approach, however potential individual approaches/targets may hinder bench marking?

Who will be responsible for setting targets, NHS or WAG?The percentages cited in the BADS Directory are aspirational and few units will be able to achieve, across the board, the percentages published. However, the individual procedure figures may be reached for specific procedures. This may be at the expense of other procedures possibly from other surgical specialities which may suffer from a different emphasis being applied – a possibility in the DGH setting. Even in the teaching hospital setting, I can envisage pockets of good performance either because certain Directorates may have bought into the short stay surgery ideal or/and there is surgical clinician direction in moving a particular service forward. The surgical drive (or lack of it) cannot be over-stressed.

Setting the level of ‘targets’ to be achieved is extremely difficult as the particular circumstances vary according to individual hospitals within Trusts.

On the benchmarking side, I would like to see adoption in Wales of the Scottish comparison tool. An electronic system with live comparison is easily achievable assuming coding issues are resolved throughout Wales.

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INFORMATION STANDARDS GOVERNANCE PROCESS INFORMATION ... Stay Surgeries-Dec.pdf · INFORMATION STANDARD FINAL PROPOSAL FOR NEW OR CHANGED (INCLUDING RETIRED) INFORMATION STANDARD