Coventry and Rugby Clinical Commissioning Group Warwickshire North Clinical Commissioning Group
Managing patients through low intervention pathways
Coventry and Rugby Clinical Commissioning Group Warwickshire North Clinical Commissioning Group
VERSION CONTROL
Version: 1.0
Ratified by: Governing Body Meetings in Common
Date ratified: 29 March 2018
Name of originator/author: Kay Holland Interim Elective Care Senior Advisor
Name of responsible committees: Executive Group
Date issued: 4 April 2018
Review date: April 2021
VERSION HISTORY
Date Version Comment / Update
29 March 2018 1.0 Approved by Governing Body Meetings in Common
Commissioning Policy: Coventry and Rugby CCG (CRCCG) & Warwickshire North
CCG (WNCCG)
Treatment Managing patients through low intervention pathways
Indication Outpatients, Day & Short Stay Surgery
Criteria In line with ensuring patients are seen and treated in the most appropriate setting in the right place and at the right time CRCCG and WNCCGexpects that the provider will manage patients through the lowest possible intervention pathway consistent with good clinical practice.
Where a patient’s condition permits them to access lower intervention and support pathways, the Provider should ensure that the patient is referredinto these services rather than continue into full outpatient/inpatient settings. Equally for those patients deemed of low clinical risk following a procedure, the CCGs expect the Provider to manage the patient’s follow-ups on a patient-initiated follow-up pathway or virtual clinic pathway.
The expectation is that pathways for surgical procedures should be optimised and aligned to the definitions of length of stay in the BADS Directory (5th Edition or any future revisions to this Directory).
There should be a clear distinction in practice, and in recording, between:
True Day Cases – procedures requiring the use of a full operating theatre environment for which general or appropriate local anaestheticcare is provided;
Minor Surgery – local anaesthetic, outpatient procedures, where care can be provided in a suitable alternative environment.
For the avoidance of any doubt, Commissioners expect the provider toundertake procedures in line with the proportions detailed in the BADSDirectory (5th Edition or subsequent revision) and in line with any clinical commissioning policies.
Equality ImpactAssessment
See attached
Equality Impact Assessment (EIA)
Policy/Service Managing patients
through low intervention
pathways
Person
completing EIA
Kay Holland
Date of EIA 28/02/18 Accountable
CCG Lead
Andrea Green
NHS Coventry and
Rugby Clinical
Commissioning Group
Aim of Work The Public Sector Equality Duty (PSED) requires us to eliminate
discrimination, advance equality of opportunity, and foster good relations
with protected groups.
This EIA assesses the impact of the policy on protected groups.
Who Affected CCG registered patients
Protected Group Likely to
be a
differential
impact?
Protected Group Likely to be a
differential
impact?
Age No Race No
Disability No Religion or belief No
Gender reassignment No Sex No
Marriage and civil partnership No Sexual orientation No
Pregnancy and maternity No
Describe any potential or known adverse impacts or barriers for protected/vulnerable groups
and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please
explain.
The impact of this policy has been discussed and all protected characteristics and Human Rights values given due regard.
Please summarise where further action is required and when the projects/decision will be reviewed.
The policy will be reviewed as and when new evidence or guidance is published and by no longer than three years after ratification by Governing Body.
1
Enc J3 Quality Impact Assessment Tool Stage 1 The following assessment screening tool will require judgement against all listed areas of risk in relation to quality. Each proposal will need to be assessed whether it will impact adversely on patients / staff / organisations.
Where an adverse impact score greater than eight is identified in any area, this will require a more detailed impact assessment to be carried out, using the escalation proforma.
Insert your assessment as positive (P), negative (N) or neutral (N/A) for each area. Record your reasons for arriving at that conclusion in the comments column. If the assessment is negative, you must also calculate the score for the impact and likelihood and multiply the two to provide the overall risk score. Insert the total in the appropriate box.
Title of scheme:
Managing patients through low intervention pathways
CCGs covered by the scheme: (only one QIA is required for each scheme even in multiple CCGs are involved)
Coventry & Rugby CCG and Warwickshire North CCG
Lead CCG: (the CCG that will coordinate the completion of the QIA in consultation with involved CCGs)
Coventry & Rugby CCG
Project Lead for scheme:
Mark Roscoe and Gerard Dillon
Senior Responsible Officer: Clare Hollingworth
Brief description of scheme:
Where a patient’s condition permits them to access lower intervention and support pathways, the Provider should ensure that the patient is referred into these services rather than continue into full outpatient/inpatient settings.
Intended Quality Improvement Outcome/s:
Patients seen and treated in the most appropriate setting, in the right place and at the right time;
Patients will be managed through the lowest possible intervention pathway consistent with good clinical practice.
Methods to be used to monitor quality impact:
Pathways reviews GP Feedback No significant increase in complaints
2
P/N or N/A
Risk Score (if N)
Comments (include reason for identifying impact as positive, negative or neutral)
Risk > 8 Stage 2 assessment required) Y/N If Y complete stage 2 proforma)
Duty of Quality Could the proposal impact positively or negatively on any of the following:
a) Compliance with
NHS Constitution right to: - Quality of Care
and Environment
- Nationally
approved
treatments/ drugs
Respect, consent and confidentiality
- Informed choice
and involvement
- Complain and redress -
b) Partnerships
- Safeguarding children or adults
P
P
N/A
N
N/A
N/A
2
Patients are seen and treated in the most appropriate setting in the right place and at the right time. Lowest intervention pathways are consistent with good clinical practice. Compliance with respect, consent and confidentiality will not be affected by the introduction of low intervention pathways. Patients may prefer to be treated via more traditional pathways. Patients’ rights to complain / redress will not be affected.
No
NHS Outcomes Framework Could the proposal impact positively or negatively on the delivery of the five domains:
1. Preventing people from dying prematurely
N/A Lower intervention pathways only offered if the patient’s condition can be managed appropriately.
No
2. Enhancing quality of life P Patients are seen and treated in the most appropriate setting in the right place and at the right time.
No
3. Helping people recover from episodes of ill health or following injury
P Patients are seen and treated in the most appropriate setting in the right place and at the right time.
No
4. Ensuring people have a positive experience of care
P Patients are seen and treated in the most appropriate setting in the right place and at the right time.
No
5. Treating and caring for people in a safe environment and protecting them from avoidable harm
P Patients are seen and treated in the most appropriate setting in the right place and at the right time. Low intervention pathways are consistent with good clinical practice
No
3
Access Could the proposal impact positively or negatively on any of the following:
a) Patient Choice
b) Access
c) Integration
N
P
N/A
2
Patients may prefer to be treated via more traditional pathways. Low intervention pathways should improve access to services.
No
4
10
Post Implementation Review (use the template below to record outcomes of reviews- if more than one is required cut and
paste the box below)
Signed off by:
Position:
Signature: Date of review:
Requires review at Clinical Quality and Governance Committee: Y/N
Date considered at Clinical Quality and Governance Committee :
Logged on spreadsheet: Y/N
Date:
Name of person completing assessment: Kay Holland
Position: Interim Elective Care Senior Advisor
Signature: Date of assessment: 28th February 2018
Reviewed by:
Position:
Signature: Date of review:
Proposed frequency of review: Six monthly/ Quarterly/ Monthly/ Other please specify:
(minimum monitoring is six monthly (scores 6 or below) , Every 4 months (scores 8-9), quarterly (scores 10-12) and monthly ( 15-20)- weekly or more frequent (score 25) Use boxes below to record outcome of reviews
Have the anticipated quality impacts been realised? Y/N Comments:
Have there been any unanticipated negative impacts? Y/N Comments:
Are any additional mitigating actions required? Y/N Comments:
Do any amendments need to be made to the scheme? Y/N Comments:
Reviewed by:
Position:
Signature: Date of review:
5
Step 1 – Calculate the Possible Impact
When calculating the impact you should choose the most appropriate domain for the identified risk from the left hand side of the table then work along the columns in the same row to assess the severity of the risk on the scale of 1 to 5 (at the top of the column) to determine the impact score.
IMPACT 1 2 3 4 5
Domains Negligible Minor Moderate Major Catastrophic
Minimal Minor injury or Moderate injury requiring Major injury leading to Incident leading to injury illness, requiring professional intervention long-term death
requiring minor incapacity/disability no/minimal intervention intervention or treatment.
Safety of patients, staff or public (physical or psychological harm)
No time off work
Requiring time off work for >3 days
Requiring time off work for 4-14 days
Requiring time off work for >14 days
Multiple permanent injuries; or Irreversible health effects
Increase in length of hospital stay by 1-3 days
Increase in length of hospital stay by 4-15 days
Increase in length of hospital stay by >15 days
An event which impacts on a large number of patients
RIDDOR/agency reportable incident
Mismanagement of patient care with long- term effects
An event which impacts on a small number of patients
Peripheral Overall treatment Treatment or service has Non-compliance with Totally
element of or service significantly reduced national standards unacceptable level
treatment or suboptimal effectiveness with significant risk to or quality of service patients if unresolved treatment/service
suboptimal
Informal Formal complaint Formal complaint (stage 2) Multiple complaints/ Gross failure of Quality
Complaints
complaint/ inquiry
(stage 1) complaint independent review patient safety if findings not acted on
Audit Local resolution Local resolution (with potential to go to independent review)
Low performance rating
Inquest/ ombudsman inquiry
Single failure to meet internal standards
Repeated failure to meet internal standards
Critical report Gross failure to meet national standards
6
IMPACT 1 2 3 4 5
Domains Negligible Minor Moderate Major Catastrophic
Short-term low Uncertain delivery of key Non-delivery of key staffing level objective/service due to objective/service due that lack of staff to lack of staff
temporarily Unsafe staffing level or competence (>1 day)
Unsafe staffing level or competence (>5 days)
Ongoing unsafe staffing levels or competence
reduces
Human resources/ organisational
service quality (< 1 day)
development/ Low staff morale Loss of key staff Loss of several key staff
staffing/ competence
Poor staff attendance for Very low staff morale No staff attending mandatory/key training mandatory training
No staff attending mandatory/ key training
/key training on an ongoing basis
Statutory duty/ No or minimal Breech of statutory Single breech in statutory duty Enforcement action Multiple breeches in inspections impact or legislation statutory duty
breech of Reduced performance rating if unresolved
Challenging external recommendations/ improvement notice
Multiple breeches in statutory duty
Prosecution guidance/
statutory duty
Improvement notices Complete systems change required
Low performance rating Zero performance rating
Critical report Severely critical report
Rumours Local media Local media coverage – National media National media
coverage – coverage with <3 days coverage with >3 service well below days service well reasonable public below reasonable
expectation public expectation.
MP concerned Adverse publicity/
reputation not relevant to QIA
Not relevant to QIA
(questions in the House)
Potential for public concern
short-term reduction in public confidence
long-term reduction in public confidence
Total loss of public confidence
Elements of public expectation not being met
Business objectives/ Insignificant <5 % over project 5–10 % over project budget Non-compliance with Incident leading >25% Projects cost increase/ budget national requirements over project budget
schedule slippage
10–25 % over project budget
Schedule slippage Schedule slippage Schedule slippage Schedule slippage
Key objectives not met Key objectives not met
7
1 2 3 4 5
Negligible Minor Moderate Major Catastrophic
Finance including claims
Small loss Risk of claim remote
Loss of 0.1–0.25 per cent of budget
Loss of 0.25–0.5 per cent of budget
Uncertain delivery of key objective/Loss of 0.5– 1.0 per cent of budget
Non-delivery of key objective/ Loss of >1 per cent of budget
Claim less than £10,000
Claim(s) between £10,000 and £100,000
Claim(s) between £100,000 and £1 million
Failure to meet specification/ slippage
Purchasers failing to pay on time
Loss of contract / payment by results
Claim(s) >£1 million
Service/business interruption
Loss/ interruption of >1 hour
Loss/ interruption of >8 hours
Loss/ interruption of >1 day Loss/ interruption of >1 week
Permanent loss of service or facility
Environmental impact
Minimal or no impact on the environment
Minor impact on environment
Moderate environment
impact on Major impact environment
on Catastrophic impact on environment
8
Step 2 – Calculate how likely the risk is to happen (likelihood)
Now work out the likelihood score. Look at the frequency and probability columns and identify which best describe how often you think the risk is likely to occur. Now make a note of the corresponding ‘risk score’ (1-5 in the right hand column).
Likelihood Description Risk Score
Almost Certain Will undoubtedly occur, possibly frequently 5
Likely Will probably occur but it is not a persistent issue 4
Possible May occur occasionally 3
Unlikely Do not expect it to happen but it is possible 2
Rare Cannot believe that this will ever happen 1
9
Appendix 2: Quality Impact Assessment Tool Stage 2 - Escalation proforma To be completed when the initial impact assessment indicates a high risk (8 or above) and a more detailed assessment is required. On identification of a high risk business case, commissioning decision or business plan this proforma must be submitted along with the business case to inform the decision making process and ensure informed choice. A copy of the complete impact assessment must be submitted to the next available Clinical Quality and Governance Committee to ensure scrutiny from a quality perspective.
Background and context of the business case/plan/decision for approval.
What are the benefits?
What are the risks if the business case is not approved?
What are the high risks that the initial impact assessment indicates to certain groups or quality
What plans are in place to ensure identified risks are mitigated?
After mitigation, what are the remaining residual risks?
10
Recommendations for the Clinical Quality and Governance Committee to consider.
Assessment completed by
Name:
Position:
Date:
Line Manager/SRO Review
Name:
Position:
Date: