baseline The baseline at July Previously there was a lack of consistency for: Pathways into specialist clinics; Policies, procedures and guidelines on referral process and definitions; Internal reporting on time to process referrals and see patients. Challenges identified in changing the way things were done: We are ‘special’ and do not need to conform; Increased data entry and data validation for all levels of clinical and non clinical staff; The GP interface with specialist clinics. The focus of the Women’s has been on reporting robust and sustainable VINAH data as demonstrated in the following slide of baseline data and progress to date.

progress to date The baseline and progress to date on Access Policy KPIs

access policy implementation To date: Steering Group established Project Officer appointed Gap analysis in progress Access Policy Implementation Project formally commenced April 2014

access policy implementation Target Process #1 Action plan Change AreaWho is involvedChangesMilestoneApril 2014 Status 1. Referral Screening Project Officer GP Liaison Officer Referral Access Centre Clinical Team Leaders IT personnel Website update – for tertiary and non tertiary referrals Aug 2014On track Update triage guidelines for clinicsAug 2014On track Minimum referral data requirements from GP Dec 2014Not started Communication strategy with GPs to facilitate patient registration and triage Jan 2015Not started Consultation re: inclusion criteria for tertiary referrals to Women’s Health Jan 2015Not started Develop audit tools for Access Policy compliance Feb 2015Not started

access policy implementation Target Process #2 Action plan Change AreaWho is involvedChangesMilestoneApril 2014 Status 2. Clinical prioritisation Project Officer GP Liaison Officer Clinical Team Leaders IT personnel Formalise criteria for urgent and routine referrals Sept 2014Not started Implement triage guidelineSept 2014Not Started Review and assessment of triage guidelines Feb 2015Not Started Develop data integrity tools for validation of triage process Apr 2015Not Started

access policy implementation Target Process #3 Action plan Change AreaWho is involvedChangesMilestoneApril 2014 Status 3. Addition to /validation of waiting list Project Officer GP Liaison Officer Clinical Team Leaders IT personnel Investigate alternative care providers with referring GP and supporting documentation for care transfer Sep 2014Not started Update website for non tertiary care pathway options Sep 2014Not started Develop resources for alternate care providers Sep 2014Not started Investigate enhancements to acknowledgement letters – eg. Include anticipated 1 st appointment date Oct 2014Not started Implement GP and patient letter enhancements Nov 2014Not started Assign responsibility for tracking pending referral follow -up Jun 2015Not started

The Women’s: Access Policy implementation Target Process #4 Action plan Change AreaWho is involvedChangesMilestoneApril 2014 Status 4. Discharge Project Officer GP Liaison Officer Clinical Team Leaders Heads of Units IT personnel Identify clinics with planned appointments = /> 12 months Sep 2014Not started Establish discharge criteria for each clinic Oct 2014Not started Develop standard discharge plan and letter for GP and patient Dec 2014Not started Establish criteria led discharge for Clinic Coordinators and Allied Health Dec 2014Not started Develop, implement and formalise discharge process Mar 2015Not started

challenges The Women’s are on track to align with the Access Policy by 1 July 2015, with the exception of two KPIs…but we are actively searching for solutions. The following KPIs are difficult to track in our Patient Management System: 1.Communication with the referrer about the findings of the initial assessment within 5 working days 2.Discharge summary sent to referrer within 5 working days Challenges include: Letters are dictated by Consultants and processed externally Consultants may only work one day week/fortnight thus letters not signed and mailed out until next time Consultant comes to clinic Letters are not interfaced in patient management system, therefore not able to be tracked against appointment