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Retrospective Review Reconciliation of findings from The 6 Study Areas with actions in The CHUFT Cancer Action Plan 1|Page 8th December 2014 Document Title Author Sponsoring Director Report on recommendations from The 6 studies and actions contained within The Cancer Action Plan Denise Gale – Cancer Programme Director Sean MacDonnell – Medical Director Evelyn Barker – Chief Operating Officer (Executive Lead for Cancer) This report was requested by NHS England to support the assurance that learning from the Retrospective Review Reports is being captured and acted on by Colchester Hospital University NHS Foundation Trust. 2|Page 8th December 2014 Contents Abbreviations and Acronyms Used in this report ………………………………………………………………………………………………………4 Cancer Waiting Times Guidance ....................................................................................................................................... 5 Executive Summary ........................................................................................................................................................... 6 1.0 Introduction ................................................................................................................................................................ 8 2.0 Cancer Action Plan ...................................................................................................................................................... 8 2.1 Cancer Action Plan Delivery - Monitoring methodology ............................................................................................ 8 3.0 Studies conducted by the Retrospective Review ........................................................................................................ 9 4.0 Themes identified in each of the Study areas............................................................................................................. 9 5.0 Status of actions identified in the Cancer Action Plan that relate to themes raised in the Retrospective Review .. 11 6.0 Themes/Actions arising which are not incorporated in the Cancer Action Plan. ..................................................... 19 7.0 Next steps ................................................................................................................................................................. 20 Appendix A ...................................................................................................................................................................... 21 Letter to Clinical Teams: Removal of patients from cancer pathways ........................................................................... 21 3|Page 8th December 2014 Abbreviations and Acronyms Used in this Report 2WW Two Week Wait IMT Incident Management Team CCG Clinical Commissioning Group IT Information Technology CHUFT Colchester Hospital University Foundation Trust MD Medical Director CNS Clinical Nurse Specialist COSD Cancer Outcome and Service Dataset CQC Care Quality Commission CUP Cancer of Unknown Primary CWT Cancer Waiting Times DNA Did Not Attend DTT Decision to Treat ECAD Earliest Clinically Appropriate Date ECRIC Eastern Cancer Registration and Information Centre FDT First Definitive Treatment MDT Multi-Disciplinary Team MDTC Multi-Disciplinary Team Coordinator MEHT Mid-Essex Health Trust NAO National Audit Office NE North East NEE North East Essex NHS National Health Service ONS Office for National Statistics OPD Outpatients’ Department PAS Patient Administration System PH Public Health (England) RMH Royal Marsden Hospital FT Full Time RRT Retrospective Review Team GDP General Dental Practitioner RTT Referral to Treatment GI Gastro-Intestinal SCN Strategic Clinical Network GMP General Medical Practitioner SCR Somerset Cancer Registry GP General Practitioner SI Serious Incident IMAS Interim Management and Support TYA Teenagers and Young Adults CAP Cancer Action Plan 4|Page 8th December 2014 Cancer Waiting Times Guidance All work was undertaken in reference to V8.0 http://www.nwlcn.nhs.uk/Downloads/Cancer%20Intelligence/Going%20Forward%20on%20Cancer%20Waits%20A% 20Guide%20Version%208.0.pdf Note. Decision to Treat (DTT) is defined in CWTs Guidance as “the date the patient agrees a treatment plan”. Two-Week Wait (2WW): This is defined as “urgent GP (General Medical Practitioner (GMP) or General Dental Practitioner (GDP)) referral for suspected cancer to first outpatient attendance”. Patients referred on this pathway are required to be seen in the Trust within fourteen calendar days from the receipt of their referral. Patients on this pathway are concurrently on both the 62-Day pathway (from receipt of referral) and 31 day 1st definitive treatment pathway (from Decision to Treat). 31-Day First Definitive Treatment: This is defined as “decision to treat to first definitive treatment”. Patients referred under this standard are required to commence first definitive treatment for a new cancer diagnosis within 31 days of the date of decision to treat being made. 62-Day Standard: This is defined as “urgent GP (GMP or GDP) referral for suspected cancer to first definitive treatment”. Patients referred with suspected cancer under the two-week wait standard (2WW) are required to commence first definitive treatment, if cancer is diagnosed, within 62 days from the date of receipt of referral for the suspected cancer, and within 31 days of the Decision to Treat. The 62-Day Screening: This is defined as “urgent referral from NHS Cancer Screening Programmes (breast, cervical (gynaecological) and bowel (Colorectal) for suspected cancer to first definitive treatment”. These patients are required to commence first definitive treatment, if cancer is diagnosed, within 62 days from the date of receipt of referral for the suspected cancer. 31-Day Subsequent Treatment: This is defined as “decision to treat/earliest clinically appropriate date (ECAD) to start of second or subsequent treatment(s) for all cancer patients including those diagnosed with a recurrence where the subsequent treatment is surgery, anti-systemic cancer treatment (drugs), or radiotherapy. These patients are required to commence treatment within 31 days of the date of decision to treat being made or earliest clinically appropriate date. Waiting Time Adjustment (First Seen) This records the number of days that patients should be removed from the calculated waiting time for the two week wait period and potentially the 62 day period (if cancer is confirmed). Waiting Time Adjustment (Treatment) This records the number of days that should be removed from the calculated waiting time between the date of decision to treat and the treatment start date i.e. the number of days that a clock can be paused for a 31 or 62 day period if a reasonable offer of treatment in admitted care has been declined. Consultant upgrade This is defined as “62 days from a consultant’s decision to upgrade the urgency of a patient (e.g. following a non- urgent referral) to first treatment for cancer. The non-urgent referral can be upgraded by a consultant (or authorised member of the consultant team as defined by local policy) because cancer is suspected.” 5|Page 8th December 2014 Executive Summary The themes and issues identified in each of the Retrospective Review studies have been correlated with specific actions/themes within the Cancer Action Plan. The majority of themes/issues identified in the Retrospective Review have either been addressed, or are on track for delivery; however, there are a number of generic issues identified which are not explicitly addressed in the Cancer Action Plan. These are detailed below with Table 3 (Page 16) with details of current actions that are being undertaken within the Trust to address these issues. Issue Operating Process Issue Poor documentation and record keeping Inadequate capacity (all other tumour sites) Urology – protocol for PSA monitoring Upper GI Lower GI Dermatology & Medical Photography Definition (in Retrospective Review Report) A substantive error in a process or a procedure, as opposed to the recording of that process or procedure. There were examples of incomplete and poor record-keeping as in other studies. MDT discussions were poorly documented at times with incomplete records Treatment or diagnostic facilities were inadequate excluding staffing issues, e.g. insufficient free slots on a theatre list There is a lack of protocol for PSA monitoring over time and how this relates to the CWT tool i) Delay in referral of patients to Broomfield for EUS/O-G cancer treatment, and Royal London for hepatobiliary pathway. ii) cancer pathways closed with no recorded authorisation following investigation i) Delay in pre-op assessments ii) Re-prioritising of cancer pathways ‘target’ to ‘routine’ before outcome of investigations confirmed i) Incorrect site referral and photography ii) Discharge without being seen by a clinician Table 1 (Page 9) identifies all the themes identified in the Retrospective Review studies whilst Table 2 (Page 11) details the current status of actions within the Cancer Action Plan. It should be noted however that Table 2 does not reflect the totality of actions within the Cancer Action Plan; the table shows those actions considered to be the most appropriate in demonstrating the current status of delivery to remedy the issue/theme identified in the Retrospective Review study. The table below summarises the number of actions identified in the Cancer Action Plan to address the themes highlighted by the Retrospective Review and the current status of delivery (as at end Nov 14). The status of delivery is coloured according to a Blue, Red, Amber, Green this is termed a BRAG status and is defined as follows: Blue action fully implemented; Red no progress made or progress is not expected to be made due to barriers; Amber progress being made towards completion of the action but overdue on completion date; Green action on track to complete in line with the completion date. The Retrospective Review themes have been grouped together to make it easier to assess whether the issue(s) have been addressed. Issue/Theme Data Entry Error Cancer Waiting Times Guidance Training Data/Inter Trust Referrals Investigations Pathways Shared Care – between Providers GP/Trust Communication Urology Lower Gastro-intestinal Inter-MDT referrals 6|Page No of actions identified in Cancer Action Plan relating to theme 9 3 4 4 9 6 1 5 8 1 1 8th December 2014 Blue Amber Green 9 3 2 1 6 3 0 4 6 1 0 0 0 2 0 0 2 0 0 2 0 1 0 0 0 3 3 1 1 0 0 0 0 Dermatology Quality Improvement Programme 1 1 0 1 1 0 0 0 Clinical and Administrative Record keeping Co-morbidities and safeguarding Total 4 4 0 0 2 59 2 42 0 8 0 8 Next Steps/future actions All residual actions from the Cancer Action Plan, identified themes from the Retrospective Review not addressed within the Cancer Action Plan, and actions identified from the 2014 peer review are being integrated into the Cancer Board Work Programme 2015 (first draft will be available mid December 14). The focus of the Trust will be on ensuring that the new structures, data collection and governance processes are fully embedded in the day to day functioning of the hospital. 7|Page 8th December 2014 1.0 Introduction This report, which is intended to be supplementary to the Retrospective Review study reports, has been requested by Incident Management Team to provide assurance that the themes identified during the completion of each of the study areas has been captured and acted upon through delivery of the Cancer Action Plan at Colchester Hospital University NHS FT. The report aims to Identify the themes in each of the reports Cross-reference with relevant actions identified in the Cancer Action Plan* Provide a BRAG (Blue, Red, Amber, Green) rating against whether the action has been delivered, is on track for delivery, or is not on target for delivery. A breakdown of the definitions of the BRAG ratings used in the Cancer Action Plan is contained within Section 2.0 below. Provide assurance to the CHUFT Executive Team/Trust Board and external partners that all the themes for improvement have been identified, have actions in place that are either delivered, or work in progress for delivery. 2.0 Cancer Action Plan The Cancer Action Plan was developed by CHUFT in conjunction with IMT. It was essentially an amalgamation of actions arising from several sources including Care Quality Commission (CQC) report (2013) Intensive Support Team Report and Recommendations (2013) NHS England Report : Immediate Review of Cancer Services at CHUFT (Dec 2013) – based on peer review of cancer pathways conducted in Nov/Dec 2013 IMT Action Log – this contained not replicated in any of the published reports. This includes actions identified by North East Essex Clinical Commissioning Group Trust defined actions not contained in any of the above sources 2.1 Cancer Action Plan Delivery - Monitoring methodology The Cancer Action Plan delivery has been monitored using the following methodology. Regular review of actions with Divisions (variable level of intensity depending on the action to be delivered) Applying a BRAG status to each of the actions (see Table 1 below for definitions) The Cancer Programme is overseen by a Cancer Steering Group which reports into the Executive Team. Membership includes the Executive Lead for Cancer, Cancer Programme Director, Trust Clinical Cancer Lead, Associate Director(s) of Operations (all Divisions), Programme Management Office (PMO) and Cancer Programme Project Manager. BRAG Blue Red Amber Green DEFINITION Action fully implemented No progress made or progress is not expected to be made due to barriers Progress being made towards completion of the action but overdue on completion date Action on track to complete in line with the completion date Journey Dashboard A journey dashboard has been developed internally to measure progress of completed actions. This dashboard encompasses the following : 8|Page To provide an assessment of evidence collated to support delivery of the action 8th December 2014 Whether the action has been embedded within the Division to demonstrate “Business as Usual”. A similar BRAG status and definition has been applied to both evidence and whether the action is embedded. Journey Dashboard (as at end November 2014) 3.0 Studies conducted by the Retrospective Review There are 6 study areas covered by the retrospective review : Study 1 : Report on Data Discrepancies in the CWT Tool Study 2 : Report on patients whose cancer pathway was over 91 days Study 3 : Report on delayed cancer diagnoses Study 4 : Report on the management of patients with upper gastrointestinal cancers Study 5: Urology – report on patients who have been lost to superficial bladder cancer surveillance Study 6: Surveillance – review of calls to the helpline, complaints, and significant events 4.0 Themes identified in each of the Study areas The themes identified from each of the study areas are summarised in Table 1. No. Table 1 : Summary of findings from all studies Theme Explanation of theme 1 Data Entry Errors 2 Misinterpretation of national guidance Operating process issue Data with other provider Coordinating investigations and assessments 3 4 5 9|Page CWT and other sources of information, including patient notes, match, although the data has not been updated. E.g. on another pathway, appointment brought forward, incorrect treatment entry. An incorrect entry appears to have been made as a result of a misunderstanding of the national cancer waiting times guidance. A substantive error in a process or a procedure, as opposed to the recording of that process or procedure. Data available on the CWT database but could not be checked against data in the patient notes which were held at another provider. Investigations were not sequentially ordered and acted on responsively leading to delay. Pathways were stopped before investigations were reported. The main cause of delay in Study 3 8th December 2014 Studies identified in Study 1 Study 4 Study 1 Study 1 Study 1 Study 2 Study 3 6 Uncoordinated and protracted pathways 7 Shared Care inadequate coordination 8 GP/Trust Communication Complex patients 9 10 11 12 13 14 Poor Documentation/ record keeping Urology Inadequate capacity Upper GI Lower GI relates to appropriately ordering, interpreting and using results. Pathways were not actively managed and patients tracked through the system. Excessive delays resulted from cancellation of appointments by the Trust and patients, delayed diagnostics and pre-operative assessment. Delays were often cumulative, with lack of co-ordination at the beginning of pathways adding up to significant delays, for example, between diagnosis and MDT discussion. There were numerous delays resulting from inadequate co-ordination and communication between CHUFT and other providers including Mid Essex Hospitals NHS Trust, Cambridge University NHS FT, Royal Brompton NHS FT, and Royal London (Barts Health NHS FT), particularly for Upper GI. Poor GP/Trust communication including on referral, in ordering and using tests and results, and on safeguarding issues. Delays were most prevalent where patients were elderly, had multiple co-morbidities, a rare tumour or multiple tumours that required transfer within the Trust between teams, e.g. inter-MDT referrals and referral for cardiology and anaesthetic assessments, and between hospitals. Their care provided particular challenges but was not prioritised. Patients requiring safeguarding did not always have an advocate to expedite and manage their appointments. There were examples of incomplete and poor record-keeping as in other studies. MDT discussions were poorly documented at times with incomplete records. Study 2 : Delays in cancer pathways due to investigations, including for renal cancer and occasional delay in diagnosis. Study 3 : The majority of patients who were entered onto the same 1st and 2nd pathways were in Urology. There is a lack of protocol for PSA monitoring over time and how this relates to the CWT tool. There was evidence of occasional poor responsiveness to investigation results causing delay, follow up of patients and bookings (e.g. with cancellation on day of surgery) indicating better systems need to be in place Treatment or diagnostic facilities were inadequate excluding staffing issues, e.g. insufficient free slots on a theatre list Study 2 : Delay particularly in relation to referral of complex patients to Broomfield for EUS and oesophageal cancer and the Royal London (Barts Health) for hepatobiliary carcinoma. Study 3 : Pathways were sometimes shut down with no recorded authorisation following endoscopy despite ongoing investigations and red flags. There is need for implementation of an iron deficiency protocol and clarity regarding referral for lower GI investigation following referral to upper GI and vice versa. In particular the hepatobiliary pathway should be reviewed. Study 2 : Delays in diagnostics (colonoscopy), pre-op assessments and follow up of patients who DNA. Need implementation of iron deficiency protocol with primary care. Earlier palliative care referral, incorrect recording of MRI and outcome. Study 3 : The limitation of sigmoidoscopy should be recognised. Following urgent rigid sigmoidoscopy in a number of cases the CWT 10 | P a g e 8th December 2014 Study 2 Study 3 Study 2 Study 2 Study 3 Study 2 Study 3 Study 2 Study 3 Study 2 Study 3 Study 2 Study 2 Study 3 Study 2 15 Inappropriate stopping and restarting cancer pathways 16 Consultant to Consultant referral Dermatology & Medical Photography 17 pathway was stopped or the priority downgraded from ‘target’ to ‘routine’ and a colonoscopy booked which later revealed a tumour. Such stops were inappropriate due to on-going investigation. There were numerous instances where pathways were stopped incorrectly, by non-clinical staff/managers working outside their responsibility. The clinical and CWT pathways are often not aligned and there is evidence of a significant lack of understanding of CWT guidance. Several pathways were closed incorrectly following a first DNA or cancellation. There was some confusion about consultant to consultant referrals with patients on occasion being referred back to their GP to re-refer back to the same or other consultants. There were particular issues related to medical photography in dermatology including incorrect site referral and photography , and discharge without being seen by a clinician or confirmation from histology. Study 3 Study 4 Study 3 Study 3 5.0 Status of actions identified in the Cancer Action Plan that relate to themes raised in the Retrospective Review Table 2 below details the findings from the study and the status of the action identified within the Cancer Action Plan (as at end November 14) as they relate to the issue identified/raised in the Retrospective Review studies. Table 2 : Summary of actions and status of delivery (as at end Nov 14) No. Finding and/or Recommendation No. Sources CAP Ref No. Action identified Current status Access Policy to include data collection and / data changes allowed within guidance. Trust Access Policy updated and includes reference to CWTs guidance. Separate Cancer Services Operational policy approved by Trust PDAC Committee detailing CWTs guidance and how data is recorded on Somerset system. Implemented. Confirmed in Cancer Services Operational Policy. Daily reports produced by Business Informatics and executed daily by MDTC team for validation of key data fields (date st st 1 seen, 1 treatment date, deceased patients). Action completed with ongoing monitoring in place. Letter to consultant team confirming details to be recorded in clinic letters/patient notes to enable non-clinical staff to accurately identify CWT milestones. Cancer Services Operational policy in place and signed off by Trust. Available on Trust Intranet for all staff. Daily suite of electronic reports implemented; generated by Business Informatics, identifies differences between PAS and Somerset for date st st 1 seen, 1 appointment, deceased patients - reports checked daily by MDT Co-ordinator team. B1.1 RR-1 RR-3 RR-4 B1.4 Intensive Support Team (IST) 1 Data Entry Errors (links to Rec. Nos. 6.2.2, 6.2.5, 6.2.6, 6.3.4, 6.4.1, 6.4.3 in the Retrospective Review Executive Summary report) External Visit Report Trust Action B2.5 B2.2 11 | P a g e Confirm expectations regarding timeliness and accuracy of data validation by MDT Coordinators. Process for making data changes. Daily updating of information from PAS 8th December 2014 Current BRAG status Blue Blue Blue Blue B4.1 Implementation and rollout of Somerset System (e.g. CWTs data collection first, then clinical modules for each MDT) B7.1 Develop clear terms of reference for weekly PTL meetings. B7.2 Ensure terms of reference have clear escalation of actions not progressed/ timescales Ensure divisional participation at weekly PTL meetings (Service Manager/AD) B7.3 B8 2 15 Misinterpretation of national guidance Inappropriate stopping and starting cancer pathways RCAs to be reviewed in weekly PTL meetings B1.1 Access Policy to include data collection and / data changes allowed within guidance. B1.1 Access Policy to include data collection and / data changes allowed within guidance. RR-1 RR-3 RR-4 IST Somerset system implemented for CWTs (completed March 14); rollout of system for live MDT data completion (completed Sept 14). Continuing to work with MDTs to improve knowledge of system to maximise benefits for pathway tracking. Implementation of Clinical Portal system (Medway) in December 14 will reduce the number of systems being used within the Trust. PTL process document agreed and ratified at Cancer Board meeting June 14. Process (including Root Cause Analysis) implemented Weekly action log produced and shared with service managers/clinical team(s). Blue Merging the 18 week and cancer PTL meetings (July 14) has enabled greater participation in the Cancer PTL by Associate Directors of Operations. The revised RCA process has been ratified at Cancer Board as part of the Cancer PTL process. The RCA process adopted is now consistent with that used by Royal Marsden. RCAs are being reviewed weekly by service managers. Trust Access Policy updated and includes reference to CWTs guidance. Separate Cancer Services Operational policy approved by Trust PDAC Committee detailing CWTs guidance and how data is recorded on Somerset system. Implemented. Blue Trust Access Policy updated and includes reference to CWTs guidance. Separate Cancer Services Operational policy approved by Trust PDAC Committee detailing CWTs guidance and how data is recorded on Somerset system. Implemented. See B1.1 above. Letter to consultant team confirming details to be recorded in clinic letter/patient notes to enable non-clinical staff to accurately identify CWT milestones. Blue Blue Blue Blue Blue (links to Rec. Nos. 6.2.7, and 6.4.2 in the Retrospective Review Executive Summary report) RR-1 2 15 Identifying key data milestones in the pathway RR-3 Inappropriate stopping and starting cancer pathways IST RR-4 B1.4 Confirm expectations regarding timeliness and accuracy of data validation by MDTCs (links to Rec. Nos. 6.2.7, and 6.4.2 in the Retrospective Review Executive Summary report) 12 | P a g e 8th December 2014 Blue RR-1 RR-3 RR-4 IST RR-3 RR-4 Training for data recording staff on CWTs guidance C2.1 RR-3 RR-4 Blue Improve support and advice to MDT Coordinator team including standard operating procedures. Develop competency framework. Cancer Services Operational policy approved by Trust PDAC Committee detailing CWTs guidance and how data is recorded on Somerset system. Implemented Development of e-learning module is additional work in progress to be able to test understanding and competence (working towards completion date of end Dec 14). Slippage on original completion date – working with external partner to develop system similar to that used for 18 weeks. Written protocols for each MDT detailing the tasks each MDT Coordinator undertakes on a daily/weekly basis to provide a sound foundation for robust cover in times of unplanned sickness and absence. The protocols are being developed using the IST toolkit and are expected to be completed by end December 14. Somerset system implemented for CWTs (completed March 14); rollout of system for live MDT data completion (completed Sept 14). Continuing to work with MDTs to improve knowledge of system to maximise benefits for pathway tracking. Strategic Clinical Network leading discussion with all Essex providers at Essex Cancer Forum/Lead Cancer Managers meetings. Final draft being circulated and Trusts to confirm adoption of the policy. On track for sign off and implementation by end Dec 14. CHUFT Minimum data set for inter-provider transfers is generated from Somerset. Mid Essex has granted read-only access to CHUFT to enable look-up of key data items. CHUFT is reciprocating this agreement. Plans to roll out read-only access to Basildon and Southend hospitals thus reducing the need for excessive data transfer of patient detail. Table included in SCN/EoE inter provider trust transfer policy by tumour site indicating optimal transfer day to enable treatment within cancer waiting times standards. Policy includes Blue C2.2 IST (links to Rec. Nos. 6.2.4, 6.2.7 and 6.3.3 in the Retrospective Review Executive Summary report) RR-3 RR-4 Trust Action C2.3 4 Dedicated training days completed Dec 13 and Feb 14. Ongoing programme of weekly training incorporated into weekly team meetings covering dedicated aspects of CWTs guidance. C1.1 IST Inappropriate stopping and starting cancer pathways Training programme for MDT Co-ordinator team. Written protocol for each tumour site based on what the MDTC/Data Clerk does on a daily/weekly basis RR-1 IST B4.1 Implementation and rollout of Somerset System (e.g. CWTs data collection first, then clinical modules for each MDT) External visit report F1.1 Implement inter-trust policy (from SCN East of England). IST F1.2 Review ITR form to ensure it is compliant with all relevant referral information External Visit report F1.3 Gain agreement for suitable milestones in Inter-Trust Referral policy for cross-site referrals and escalation arrangements if not met Data with other provider Inter-provider trust transfers (links to Rec. Nos. 6.7.1, 6.7.2 and 6.7.3 in the Retrospective Review Executive Summary report) 13 | P a g e 8th December 2014 Amber Amber Blue Green Green Green RR-2 RR-3 E1.1 (4) Escalation processes to service manager/ Associate Director of Operations E1.1 (5) Ensure targets are reported at an appropriate internal forum E2.1 Ensure mechanisms are clearly defined to discuss and progress patients outside of MDTs E2.2 Clarification of pathways for patients with non-specific symptoms IST External Visit Report G2.1.2 (3) Internal Governance arrangements to track patients External Visit Report G14.1 (3) Protocol for urgent cancer findings. IST G14.4 (2) Establishment of a process to ensure tumour sites can readily identify missing referrals and ensure they are followed up with diagnostic imaging. IST 5 Co-ordinating investigations and assessments IST Delayed or missing tests (links to Rec. Nos. 6.2.3, 6.2.6 and 6.6.1 in the Retrospective Review Executive Summary report) 5 Co-ordinating investigations and assessments External Visit Report Delayed or missing tests (links to Rec. Nos. 6.2.3 and 6.6.1 in the Retrospective Review Executive Summary report) 14 | P a g e escalation processes (CEO to CEO letter). Will be complete once all Essex hospitals have confirmed acceptance and implementation of Policy. Revised PTL process approved at Cancer Board May 14 and implemented. Patients at risk of delayed pathways highlighted and escalated to clinical teams/service managers. PTL process currently under revision to maximise effectiveness PTL meetings with dedicated specialties have increased to daily. Standards reported at weekly Performance and Activity meetings, with details of avoidable delays. All tumour site standard operational policies include details of how patients should be managed if decisions are required outside of MDTs to expedite patients through the pathway. Paper presented to Cancer Board (March 14) and encompassed in the Cancer Unknown Primary (CUP) standard operational policy (ratified at Cancer Board). On-going work in progress to further develop the management of patients presenting with non-specific symptoms. Cancer Services Operational Policy in place (approved by Trust PDAC Committee and on Trust staff intranet), implementation of single point of referral (Cancer Hub) for two week wait referrals, MDT Coordinator team moving from retrospective to prospective tracking mechanisms. Probable Unexpected Malignancy (PUMs) protocol approved at Cancer Board (May 14) and implemented. Incorporates GP direct access test results and internal unexpected findings. Includes escalation process to prevent patients being lost in the system. Monthly audit report to Cancer Board to ensure patients are tracked appropriately. Radiology operational policy reviewed Failsafe is for radiology to notify the Contact Centre (Cancer hub) of all suspected cancer findings - the cancer hub records all suspected cancers on Somerset and notifies the relevant MDT Coordinator/clinical team to ensure all patients with suspected cancer are being tracked. Radiology Standard Operational Policy approved by Trust PDAC Committee. PUMs policy ratified, audit completed weekly, 8th December 2014 Blue Blue Blue Green Green Blue Blue 6 Uncoordinated and protracted pathways 9 Complex patients (multiple comorbidities) 15 Inappropriate stopping and starting cancer pathways (links to Rec. Nos. 6.5.6, 6.7.1, 6.7.2, and 6.7.3 in the Retrospective Review Executive Summary report) IST G14.4 (6) RR-2 IST 14.4 (5) RR-2 RR-3 IST A2.1 IST A2.2 RR-3 RR-4 IST D1 RR-3 RR-4 IST E2.1 Ensure mechanisms are clearly defined to discuss and progress patients outside of MDTs RR-3 RR-4 E2.2 Clarification of pathways for patients with non-specific symptoms H1.3 Policy for patients who persistently DNA appointments/tests External Visit Report RR-3 RR-4 IST 15 | P a g e Ensure diagnostic imaging staff are aware of requirements outlined in the Trust policy "Procedure for Action to be Taken following a New or unsuspected Cancer (or other unexpected Diagnosis) from a radiological investigation". Implement use of diagnostic imaging PTL as mechanism for prioritising booking of patients. Review of all MDTs to ensure they are effective (using NCAT published "Characteristics of an Effective MDT" Feb 2010) Ensure MDTs are clear, action oriented and documented clearly in patient medical notes Ensure trust-wide Access Policy for Cancer includes clear definition of Consultant Upgrades presented to May to Cancer Board. Radiology Standard Operational Policy circulated to staff and available on Trust intranet. Implementation of Radiology system delayed until 2015, as a result of the trust wide implementation of the Medway system (Clinical Portal). Revised completion date. Blue Green Amber Trust has registered with the MDT-fit tool (Kings College/Green Medical) and is establishing a pilot to establish a robust process before rollout to all MDTs. MDT-fit tool is based on the NCAT publication. Roll out programme to be presented to Cancer Board once the process is clear. Trust Access Policy updated and includes reference to Consultant Upgrades. Separate Cancer Services Operational policy approved by Trust PDAC Committee detailing consultant upgrades. Letter from Medical Director to Trust Clinical Teams which includes recording of consultant upgrades (decision to upgrade). All tumour site standard operational policies include details of how patients should be managed if decisions are required outside of MDTs to expedite patients through the pathway. Paper presented to Cancer Board (March 14) and encompassed in the Cancer Unknown Primary (CUP) standard operational policy (ratified at Cancer Board). Ongoing work in progress to further develop the management of patients presenting with non-specific symptoms. Trust Access Policy and Cancer Services Operational Policy details the policy for patients who DNA appointments/tests consistent with Cancer Waiting Times Guidance. Trust is also working with CCG to produce a joint guidance document to complement the Trust Access Policy (work in progress) for areas of the CWTs guidance that are 8th December 2014 Blue Blue Green Blue 7 Shared care inadequate co-ordination RR-2 IST F2.2 Ensure Inter-trust referrals are monitored/tracked appropriately RR-Exec Summary B9 Single point of referral for two week wait (suspected cancers). RR-2 RR-3 IST H1.1 IST H1.2 RR-3 RR-4 IST H1.4 RR-3 RR-4 IST H3.1 Work with CCG to improve GP communication with patients Reason for referral to hospital, likely timescale for appointments (2ww) Information given to patients by GP when making an urgent suspected cancer referral (2ww) Review GP understanding of the referral process (links to Rec. Nos. 6.7.1, 6.7.2 and 6.7.3 in the Retrospective Review Executive Summary report) External Visit 8 15 GP / Trust communication (Safeguarding) Inappropriate stopping and starting cancer pathways (links to Rec. Nos. 6.7.4 in the Retrospective Review Executive Summary report) IST ambiguous or are specified in CWTs guidance as ‘for local agreement’. MDT Co-ordinator team track intertrust referrals for their tumour site. Relationships have been improved between Mid Essex and CHUFT MDT Co-ordinator teams. CHUFT has read-only access to Mid Essex Somerset system and is in process of giving reciprocal access to Mid Essex for CHUFT system. Delays in pathways escalated at tumour site PTL meetings. Implementation of Inter provider trust transfer policy will provide consistency across Essex. Somerset Cancer Registry developing upgrade to include inter-provider transfer form (with minimum data set) direct from the Somerset system. Cancer Hub implemented in Contact Centre as central point of referral for 2ww suspected cancers (December 2013). Monitors all Probable Unexpected Malignancies (incidental findings from Radiology) for suspected cancer. Two week wait patient information leaflet agreed with CCG (March 14). GPs have stocks of leaflet to give to patients they are referring to CHUFT on two week wait suspected cancer referral. Cancer Hub also has electronic copy of leaflet to send to patients with confirmation of appointment letter (if not booked through Choose & Book). Green Blue Blue 2ww referral forms have been updated (working in partnership with primary care) to ensure it is clearly documented whether GP has informed patient of suspected cancer referral. Formal launch date st 1 December 2014 - new 2ww forms available on Trust website. Revised forms have space for GP to indicate if any mobility, mental capacity or safeguarding issues need to be taken into account. 11 Urology (links to Rec. Nos. 6.5.1 in the Retrospective Review Executive Summary report) 16 | P a g e RR-2 RR-3 G8 1.1 Lack of up to date, accurate and agreed timed pathways for prostate, renal and bladder cancers. Agreement has been reached with the North East Essex Clinical Commissioning Group to implement a direct access gastroscopy diagnostic service. It is anticipated this will be in place by end January 15. Revised pathways signed off by Cancer Board; approved at revisit (April 14). MRI (prostate) now undertaken before TRUS biopsy negating the clinical delay between TRUS and MRI 8th December 2014 Blue RR-2 G8 1.2 External Visit Report 12 Inadequate capacity (Urology) Capacity Plan G8 1.5 Additional Theatre Sessions - All day Saturday lists Capacity Plan G8 1.6 Capacity Plan G8 1.7 Increased preassessment slots Associate specialist freed from On-call / appoint locum to backfill Associate Specialist Capacity Plan G8 1.9 Urology – protocol for PSA monitoring RR-3 Capacity Plan G8 1.3 Bladder surveillance Capacity Plan G8 1.4 Additional weekly surveillance clinic Lower GI – Follow up of patients who DNA RR-2 RR-3 H1.3 Policy for patients who persistently DNA appointments/tests RR-3 B7.7 Agree and implement process for the transfer of patients between MDTs. G9 1.2 Review Team to check and ensure that the (links to Rec. Nos. 6.5.2, 6.5.4, 6.6.1 and 6.6.3 in the Retrospective Review Executive Summary report) 14 Capacity issues/waiting time breaches - detailed capacity and forecast plan for Q4 Extend 2 half day theatre lists to full day theatre lists Additional weekly PSA clinics. (links to Rec. Nos. 6.5.2 and 6.5.5 in the Retrospective Review Executive Summary report) 16 Consultant to Consultant referral (inter-MDT referrals) (links to Rec. Nos. 6.7.5 in the Retrospective Review Executive Summary report) 17 Dermatology & Medical Photography 17 | P a g e External visit report IST report RR-3 (6 weeks). Despite original capacity plan being implemented (additional clinics, theatre sessions), the Urology service continues to experience capacity delays. The number of breaches is reducing but there are still a significant amount of 14 day, 62 day and 31 day pathway breaches. 6 consultants in post; 4 urology nurse specialists in post. Additional theatre sessions commenced on 4th January 2014 in line with capacity plan. Weekly additional session is continuing to address capacity issues Mobile theatre commissioned from Nov 14 to free up capacity in main theatres. Weekly extra session carried out to address capacity issues. Permanent Associate Specialist job plan accommodates extra theatre sessions. Fixed term contact for Associate Specialist appointed for 1 year. Additional theatre lists in place, sustainable capacity being factored into theatre programme. Additional weekly PSA clinics in place (commenced Dec 13). Monitoring of patients undertaken by specialty. Weekly surveillance clinics commenced 23/12/2013. Weekly extra session carried out to address capacity issues. Job plans and extra staffing required to permanently run surveillance clinics. Trust Access Policy and Cancer Services Operational Policy details the policy for patients who DNA appointments/tests consistent with Cancer Waiting Times Guidance. Trust is also working with CCG to produce a joint guidance document to complement the Trust Access Policy (work in progress) for areas of the CWTs guidance that are ambiguous or are specified in CWTs guidance as ‘for local agreement’. Incorporated into Standard Operational policy for single point of referral (Cancer Hub). On-going work to develop an inter-MDT referral form and process approved at Cancer Board (Nov 14). InterMDT referrals have been collated and monitored during 2014 to ensure appropriately recorded on Somerset. There has been much debate with Intensive Support Team, British 8th December 2014 Blue Blue Blue Blue Amber Blue Amber Blue Amber Amber (links to Rec. Nos. 6.5.2 and 6.5.5 in the Retrospective Review Executive Summary report) N/A Quality Improvement Programme External visit report Pathway Audits Retrospective Review Executive Summary Patient Involvement and Experience External Visit Report medical photography and triage by a consultant is compliant with two week wait guidance. B10 Continuous quality improvement programme for Cancer Specialties (peer review visits/SSG attendance/Trust investment) B4.1 Develop programme of rollout of Somerset System with timeline (e.g. CWTs data collection first, then clinical modules for each MDT) Live data collection at MDT direct onto Somerset system Association of Dermatologists and Intensive Management Team about the validity of the use of medical photography image as ‘straight to test’ for dermatology two week wait referrals. Agreed with IST (end October 14) to change the recording of medical photography as ‘straight to test’. Plan being formulated with IMT to manage the transition in recording change. Quality Improvement Programme ratified by Cancer Board May 14. Comprises a number of components including CWTs, patient experience, pathway audits. Blue links to Rec. Nos. 6.1.4, 6.1.5, 6.3.2, and 6.3.1, in the Retrospective Review Executive Summary report) N/A Clinical and administrative record keeping Retrospective Review Executive Summary links to Rec. Nos. 6.2.1, 6.2.2 and 6.4.4, in the Retrospective Review Executive Summary report) N/A Patients with comorbidities and Safeguarding issues B4.2 Retrospective Review Executive Summary B4.3 Reduce double-entry of data onto multiple systems B5 Live MDT Data Collection /clinical management in all tumour sites. Ensure all immediate actions/issues are addressed. Further assurance and better understanding is required about how the Board, (both executives and non-executives) is discharging its statutory responsibilities around safeguarding. Level 3 safeguarding compliance in Cancer Services to be added to Colchester Hospital Risk Register and should be reviewed by the Board. I1 links to Rec. Nos. 6.5.3, in the Retrospective Review Executive Summary report) I2 18 | P a g e All tumour sites (incl MDT members) have received training on Somerset for live data collection at MDT. Rollout programme complete for this aspect of Somerset Plan. Further work to ensure it is embedded in all MDTs. Rollout programme complete – all clinical teams have access to Somerset and training of clinical teams complete. The implemention of Somerset and the Clinical Portal (Medway) has reduced the volume of double-entry to multiple systems. All MDTs are now starting to collect data live at MDT and use the Somerset system for pro-active tracking of pathways. Training for Board members (Executive and non-Executive members) completed December 13. 8th December 2014 Blue Blue Blue Blue Blue 2ww referral forms have been amended to enable GPs to highlight safeguarding issues including mental capacity, mobility, and transport. Level 3 safeguarding added to Risk Register December 13. Staff training in levels 1 & 2 is mandatory and compliance with this training is monitored centrally. Blue 6.0 Themes/Actions arising which are not incorporated in the Cancer Action Plan. Table 3 below identifies the themes/actions which are not explicitly identified in the Cancer Action Plan and outlines areas of work that is ongoing to address the issues raised. Table 3 : Findings which do not specifically correlate with Cancer Action Plan actions No. Finding/ Recommendation Sources 3 Operating process issue RR-1 10 Poor documentation and record keeping, including decentralised record keeping Inadequate capacity (all other tumour sites) RR-2 RR-3 Urology – protocol for PSA monitoring Upper GI RR-3 12 12 a 13 RR-2 RR-2 RR-3 Action taken This has not been explicitly identified in the Cancer Action Plan but a number of areas of the Cancer Plan have addressed these issues. Structures & Processes, Data Collection & Governance, MDT Co-ordinator Training are the main areas of the Cancer Action Plan where these issues are being addressed. Highlighted as a recurrent theme at Cancer Board. Letter from Medical Director to all clinical teams detailing what information for cancer patients is required to be documented in clinical letters/patient notes to improve record keeping. This will be monitored through the Cancer Board. IST capacity and demand toolkit completed for all specialties for 18 weeks and Cancer st performance. Operational management are reviewing capacity in all areas, 1 appointments/tests, diagnostic capacity, and treatment capacity. Incorporated into performance improvement plan with Local Area Team and CCG. Additional weekly PSA clinics in place (see 12 in Table 2 above - Urology). No written protocol for PSA monitoring. The two issues highlighted in the Retrospective Review are not highlighted as specific actions within the Cancer Action Plan : a) Delay in referral of patients to Broomfield for EUS and O-G cancer, and Royal London for hepatobiliary cancer. b) Cancer pathways being closed with no recorded authorisation following endoscopy. The Cancer Action Plan includes a number of actions which relate to : Computer System Liver lesions – how they are managed Nurse leadership Job planning MDT Scheduling 14 17 N/A Lower GI – delay in preop assessments RR-2 Lower Gi – Reprioritising of pathways before investigations completed (from target to routine) Dermatology and Medical Photography RR-3 Patient Rights – NHS Constitution 19 | P a g e RR-3 RR Executive Summary The actions relating to Inter-trust referrals (see Section 4 in Table 2 above), the implementation of the Inter-provider trust transfer policy (EoE/SCN) and improved tracking processes within the MDT Co-ordinator team will all help to address these issues. These issues will be highlighted in the Cancer Board work programme for 2015 which is currently being formulated. IST capacity and demand toolkit completed for all specialties for 18 weeks and Cancer st performance. Operational management are reviewing capacity in all areas, 1 appointments/tests, diagnostic capacity (including endoscopy), and treatment capacity. Incorporated into performance improvement plan with Local Area Team and CCG. This issue has not been raised in the pathway peer review visit (Nov 13) and is not a specific action within the Cancer Action Plan however, this has been highlighted at Cancer Board and is encompassed within a letter from the Medical Director to Clinical teams Issues raised by Retrospective Review are: Incorrect site referral and photography Discharge without being seen by a clinician These specific issues were not highlighted in the pathway peer review visit and as such do not feature explicitly within the Cancer Action Plan. These issues will be added to the Cancer Board Work Programme being developed for 2015. Consideration to be given to auditing pathways that have occurred during 2014. North East Essex CCG and Trust to work together to ensure patients are aware of their rights and responsibilities. 8th December 2014 7.0 Next steps The Cancer Board Work Programme for 2015 is being developed to include the following : Residual actions not yet complete within the Cancer Action Plan Remedial actions identified in the 2014 Peer Review Programme (including National Audits) Actions identified in the Retrospective Review audits that are not specifically addressed within the existing Cancer Action Plan The first draft of the Cancer Board Work Programme will be considered by the Incident Management Team (external) and Trust Cancer Board (internal) during December 2014. 20 | P a g e 8th December 2014 Appendix A Letter to Clinical Teams: Removal of patients from cancer pathways all~consultants~and ~nurse~consultants.pdf 21 | P a g e 8th December 2014