Download Retrospective Review Reconciliation of findings from The 6 Study

Retrospective Review
Reconciliation of findings from
The 6 Study Areas with actions in
The CHUFT Cancer Action Plan
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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.
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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
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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
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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.”
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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
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No of actions identified in Cancer
Action Plan relating to theme
9
3
4
4
9
6
1
5
8
1
1
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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.
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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 :

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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
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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
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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
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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
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Confirm expectations
regarding timeliness and
accuracy of data
validation by MDT Coordinators.
Process for making data
changes.
Daily updating of
information from PAS
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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)
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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)
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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)
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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