Policy Directive Waiting Time and Elective Surgery Policy Summary The Waiting Time and Elective Surgery Policy is the reference guide for facilities to manage elective surgery and medical waiting lists. The policy covers the procedures that facilities are required to follow to adequately manage waiting lists to ensure that patients are treated within their clinical priority timeframe. Document type Policy Directive Document number PD2012_011 Publication date 01 February 2012 Author branch System Relationships and Frameworks Branch contact 9391 9324 Review date 20 October 2021 Policy manual Patient Matters File number 11/5771 Previous reference N/A Status Review Functional group Clinical/Patient Services - Medical Treatment, Information and Data, Surgical Applies to Local Health Districts, Specialty Network Governed Statutory Health Corporations, Affiliated Health Organisations, Dental Schools and Clinics, Public Hospitals Distributed to Public Health System, Divisions of General Practice, NSW Ambulance Service, Ministry of Health Audience Local Health Districts & Network Executives;Hospital General Managers;Admission/Booking Staff Secretary, NSW Health This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for NSW Health and is a condition of subsidy for public health organisations. POLICY STATEMENT WAITING TIME AND ELECTIVE SURGERY POLICY PURPOSE The Waiting Time and Elective Surgery Policy is the reference guide for facilities to manage elective surgical waiting lists. The policy covers the procedures that facilities are required to follow and adequately manage waiting lists. MANDATORY REQUIREMENTS This policy has been developed to promote clinically appropriate, consistent and equitable management of elective surgery patients and waiting lists in public hospitals across NSW. Local Heath Districts, Sydney Children’s Hospitals Network, St Vincent’s Health Network and hospitals must actively manage in compliance with the contents of this policy. IMPLEMENTATION Local Health Districts, Sydney Children’s Hospitals Network and St Vincent’s Health Network are responsible for the implementation of the Waiting Time and Elective Surgery Policy. The Chief Executive has overall responsibility for ensuring: • There are mechanisms in place to implement this policy • Compliance with NSW Department of Health requirements • Validation of the accuracy and integrity of reported data • Regular review of individual hospital performance • Training and education programs are in place for staff involved in managing elective patients and waiting lists • All patients requiring elective surgery/procedure (with an allocated surgical indicator procedure code) regardless of admission type are recorded on the Inpatient Patient Administration System (PAS)/WLCOS. The responsibilities of various positions under this policy are detailed in the Introduction (page 1) of the attached procedure. REVISION February 2012 Director-General Replaces PD2009_018. Updated to reflect (PD2012_011) amendments to current policy April 2009 Director-General Updated and replaced PD2006_020 (PD2009_018) March 2006 Director-General Policy released (PD2006_020) ATTACHMENT • Waiting Time and Elective Surgery Policy PD2012_011 Issue date: February 2012 Page 1 of 1 Waiting Time and Elective Surgery Policy POLICY Managing elective surgery patients in NSW public hospitals PD2012_011 Issue date: February 2012 Waiting Time and Elective Surgery Policy POLICY Contents 1. INTRODUCTION ...................................................................................................................1 2. REFERRING PATIENTS TO THE WAITING LIST ................................................................ 4 2.1. Clinical Priority Categories ............................................................................................ 4 2.2. Urgent Surgery - Inclusion/Exclusion Criteria ................................................................ 5 2.3. Cosmetic & Discretionary Surgery - Inclusion/Exclusion Criteria ................................... 5 2.4. Completion of Recommendation for Admission Form (RFA) ......................................... 8 2.5. Information for Patients ................................................................................................. 9 3. ACCEPTANCE OF RECOMMENDATION FOR ADMISSION FORM (RFA) ...................... 10 3.1. Completeness, Accuracy and Legibility ....................................................................... 10 3.2. Clinical Priority Timeframes ......................................................................................... 11 3.3. Variations from Standard Bookings ............................................................................. 11 4. REGISTRATION ON THE WAITING LIST .......................................................................... 13 4.1. Registration Requirements .......................................................................................... 13 4.2. Notification - Patient .................................................................................................... 13 4.3. Notification - General Practitioner ................................................................................ 13 5. MANAGING PATIENTS ON THE WAITING LIST .............................................................. 14 5.1. Compilation of a Waiting List ....................................................................................... 14 5.2. Waiting Times ............................................................................................................. 14 5.3. Clinical Review ............................................................................................................ 14 5.4. Ready for Care ............................................................................................................ 17 5.5. Not Ready for Care ..................................................................................................... 18 5.6. Admission Process ...................................................................................................... 20 5.7. Hospital Initiated Postponements ................................................................................ 22 5.8. Patient Initiated Postponements .................................................................................. 23 5.9. Avoiding Exceeding Clinical Priority Time Frames ....................................................... 24 5.10. Removing Patients from the Waiting List ..................................................................... 26 6. RECORD KEEPING ........................................................................................................... 28 6.1. Postponement of Planned Admission .......................................................................... 28 6.2. Exceeded Planned Admission Dates ........................................................................... 28 6.3. Procedure being Undertaken at Another Hospital within same LH District/Network ..... 28 6.4. Removal of Patients from the Waiting List (other than admission) ............................... 28 6.5. Reporting .................................................................................................................... 29 7. AUDITING THE WAITING LIST .......................................................................................... 30 7.1. Clerical Audit ............................................................................................................... 30 7.2. Review of Waiting List by Treating Doctor ................................................................... 31 7.3. Patient Audit ................................................................................................................ 31 8. DOCTOR’S LEAVE - TEMPORARY AND PERMANENT ................................................... 32 9. DEFINITIONS ..................................................................................................................... 35 10. APPENDICES ..................................................................................................................... 42 11. REFERENCES ................................................................................................................... 57 12. ACRONYMS .......................................................................................................................58 PD2012_011 Issue date: February 2012 Contents Page Waiting Time and Elective Surgery Policy POLICY 1. INTRODUCTION Each year approximately 200,000 patients have elective procedures/surgery in NSW public hospitals. Patients are placed on a waiting list and given a clinical priority depending on the seriousness of their condition. Clinical priority categories 1, 2, 3 referred to in this policy align with Commonwealth Categories in the National Data Dictionary. Managing elective surgery patients and waiting lists is a key priority for the Government and NSW Health. The community insists on transparency and accountability. Patients expect timely, accessible and high quality patient centred services. Waiting list management is a challenging, dynamic and complex process requiring input from and coordination by a multidisciplinary team. The Waiting Time and Elective Surgery Policy has been developed to promote clinically appropriate, consistent & equitable management of elective surgery patients and waiting lists in public hospitals across NSW and has been approved by the Surgical