Why RTT systems fail

Why Pathway Management and 18 Week RTT Processes Are Failing

In most acute trusts, 18 week RTT management involves a PAS, spreadsheets, other IT systems and lots of manual intervention. Not only is this massively time consuming and inefficient, but it doesn't address the root causes of the issues you face. We look at those root causes - and the solutions that enable you to address them.

Ask people who aren’t very involved in pathway management, and this how they’d summarise a pathway:


You and I know, however, that the reality is hugely more complicated.

Here’s a list of various activities that can occur along the pathway

(Note: it’s by no means comprehensive.)


TCI offers

Patient cancellations

TCI rejections

Hospital cancellations

Diagnostics appointment booking

Cancelled admissions

Diagnostics results chasing

Pathway validation

Multiple pathways per patient

Clinical approval

Patients moved to external providers

Appointment rejections

Complicated RTT rules

Pre-op assessment and diagnostics

PAS recording anomalies


And here’s a list of the various people involved in the pathway

(Again, it’s not comprehensive.)

ID/Referral Clerks


Appointment Coordinators

IPT Clerks


Operational Managers

Waiting List Coordinators


Pre-op Clerks


Medical Secretaries

Data Quality Officers

Pathway Coordinators

Performance Managers


As a result, the reality of pathway management is as follows

First of all, the processes required to manage all these interconnecting and interdependent events is complicated, to say the least.

This is further compounded by the large number of disparate departments and individuals who involved in the process. Not only do they all need to interact with patient information, but they also need to interact with each other – and in a consolidated, centrally managed way.

Furthermore, the information is complicated and comes from multiple sources, adding to the overall complexity and making it more difficult to manage this vital element of a hospital’s administration.

There are many types of different patient pathway and different ways in which they’re handled depending on factors such as specialty. Medical and surgical specialties each have their own challenges, such as fitness for surgery/pre-operative assessment, lengthy diagnostic phases and an increasing number of treatment options trialled concurrently.

In addition, individual differences in patient co-morbidities, combined with factors such as social circumstances, introduce more complications. Pathways require collaboration and agreement between many different individuals and departments. And no two pathways are the same.

And you have all of these variables before you even think about capacity issues and day-to-day operational challenges – for example, winter pressures, an aging population and increasing numbers of technologies and treatments.

To say pathway management is complex is an understatement

However, in most hospital trusts, pathway management relies heavily on manually driven processes supported by some form of IT-based, information-centric systems.

These processes are often inconsistent, and are prone to duplication of work.

Why has pathway management evolved into a predominantly manual set of processes?

To date, there has been no single, central IT system that provides all the functionality trusts need to manage pathways effectively and efficiently.

The cornerstone of computerised pathway management systems in any hospital is its PAS or EPR system. Although heavily depended upon for administration of patient activity, the PAS falls short of providing adequate management and control.

As a result, trusts often add other technology-based systems to bridge the gap between what’s available from the PAS and what’s actually needed for day-to-day operations. Thus, whatever PAS or EPR they use, trusts all have an additional IT application – sometimes more than one – to help manage their patient pathways.

In the main, these additional systems are designed to collate and distribute information to the people involved in the pathway management process. This information is derived from huge amounts of data, the majority of which is held within the PAS.

Whenever large amounts of data are involved, the trust naturally turns to the Information Department. Information Departments respond using the resource they have at their disposal, and deliver ancillary systems as ‘report and list’ applications to assist with pathway management.

However, when you look at what’s required to manage pathways, these PAS/ancillary system combinations still fall way short of what’s actually needed. Therefore, every single element of pathway management not catered for by these systems has to be handled manually. The less these IT systems do, the more manual intervention is required.

The result: pathway management processes are manually intensive, time consuming, expensive, highly dependent on key individuals, massively inefficient and prone to error.

In these circumstances, 2 main issues affect the quality of a patient’s pathway

These are rooted in the fact that pathway management usually involves the PAS, ancillary reports with supplementary information from the Information teams, and manual processes.

While there are many other reasons why patient pathway and RTT systems fail, these 2 factors will be the root cause of virtually all others.

  1. Communication inconsistency and delay

A key aspect of pathway management is communication between individuals and departments. Unfortunately, this is often hampered by lack of availability, messages getting lost in the system, and inconsistent processes between and within departments.

Telephone calls, face-to-face communication and ad-hoc notes all contribute to creating the un-formalised, un-auditable and unreliable web of communication. And although email is the default method, it’s not infallible. The volume of emails we receive is at an all-time high. Discerning what’s important is increasingly difficult. As a result, essential actions in a pathway’s progress are missed or delayed, and individuals often have ‘to remember’ to action the next stage of the patient’s pathway.

  1. Multiple, uncontrollable spreadsheets

Spreadsheets are usually the base for the ancillary applications that run alongside the PAS.

More often than not, they’re chosen for their flexibility, simplicity and apparent ease of use. In many situations, spreadsheets offer all those benefits. Pathway management is not one of them.

When it comes to pathway management, spreadsheets are a totally inappropriate technology. Only the individual user can access the information they contain. And they’re not dynamic, so when they’re refreshed with the latest output from the PAS, any supplemental information is lost or has to be manually copied. Plus,

  • They only provide information, and don’t assist in communication
  • Information isn’t centrally managed and the risk of duplicated effort is high
  • They don’t provide any management to support processes
  • They’re not auditable
  • They’re very inefficient
  • Different versions of the same spreadsheets are often in use simultaneously, meaning staff are acting on different or out-of-date information

Spreadsheets also fail to deliver any of these following fundamental requirements:

  • The ability to show information on current and historic pathways, enabling the user to focus on current Patient Tracking Lists while retaining the history of previous activity
  • Automated workflows that can be configured to work seamlessly with the trust’s own processes, minimising disruption from change
  • A source of new information, as they merely reflect (often inaccurately) what’s on the PAS
  • Central storage that everyone can access, eliminating the chance of duplication and keeping everyone involved up to date
  • Reliable, efficient and auditable communication methods that enable all the different people, disciplines, departments and (in some cases) hospitals/trusts to work together efficiently
  • A single version of the truth

You need to say goodbye to spreadsheets and introduce automated workflows and governance

Attempting to resolve data quality and communication issues with manual spreadsheets is ineffective since the issue is not simply one of information. As long as trusts persist with managing pathways using Excel-based systems to support their PAS, the processes will be very manual and prone to all of the issues I’ve discussed.

The famous Einstein quote comes to mind: ‘Insanity: doing the same thing over and over again and expecting different results.’

So if you want to change the result, you need to change the way you do things.

For example: trusts with large open pathway lists who employ external validators to manually reduce the number are in reality just undertaking a point-in-time data quality exercise; they’re not making changes to their processes. Because they’re not addressing the root cause, they’ll soon have a new backlog and face the same problems again. It becomes a constant battle.

Similarly, those trusts unable to evidence their data, make mandatory submissions or provide internal operational reports all have the same thing in common: they lack confidence in their data. They’ll never effectively, efficiently or sustainably address their data quality issues without tackling the underlying causes.

So you should now be asking yourself, ‘What do I do?’

Your next step depends on your trust’s situation.

Our research has enabled us to identify common circumstances that trusts find themselves in with regards to pathway management. Insource are on hand to provide advice or consultancy with regards to pathway management. Feel free to get in touch on 0203 2727 4200 or email contact@insource.co.uk to arrange a session with our experts.