Special Measures Action Plan
Colchester Hospital University
NHS Foundation Trust
Cancer Action Plan
31st August 2014
KEY
Delivered
On Track to deliver
Some issues – narrative disclosure
Not on track to deliver
1
Colchester Trust - Our improvement plan & our progress
What are we doing?
•
The Trust entered Special Measures following concerns about the standard of cancer care being delivered by the Trust.
•
The Trust has been given a variety of recommendations which have come from CQC visit report, the Intensive Support Team report, External Review Visit (published 19
December) focussed on Cancer Services. The recommendations covered the following areas of concern:
•
Failsafe paper processes
•
Audit of cancer waiting times data
•
Review of Cancer Services workload (including Oncology Consultants)
•
Cancer Pathways – Urology (bladder and prostate), Brain & Central Nervous System, Cancer of Unknown Primary Origin and Sarcoma
•
Governance arrangements
•
Safeguarding Adults & Children
•
The Trust has amalgamated the 331 recommendations from the reviews (set out above) into a Cancer Remedial Action Plan. All recommendations have been recognised
and accepted by the Trust. The actions within the Cancer Remedial Action Plan address all issues, with the overall aim to improve the quality of cancer services. We
envisage that improvements will be largely complete by 31 December 2014. The Trust will set out a longer-term plan to maintain progress and ensure that the actions lead to
measurable improvements in the quality and safety of care for patients.
•
The Trust established that there were a number of themes which encompassed all the recommendations
•
Governance structures and processes for managing patients on a cancer pathway
•
Data Collection & Data Governance
•
Management of patients on a Cancer pathway
•
Safeguarding Adults and Children
This document provides a high level summary of the ‘urgent actions’ under these themes but is not a comprehensive list of all actions or other actions being taken to improve.
We have set out our progress in making improvement against these actions. While we take forward our plans to address the 331 recommendations, the Trust will remain in
‘special measures’.
•
To ensure appropriate oversight and rapid improvement in cancer services the Trust has implemented the following changes:
•
Reconstitution of the Trust Cancer Board to include Multi-disciplinary Clinical Leads to oversee the decisions made relating to Cancer Services . The Trust Cancer
Board reports to the Trust Quality and Patient Safety Committee, a sub-committee of the Trust Board.
•
Appointment of Cancer Programme Director and Project Manager to drive the required improvements reporting to a Cancer Steering Group
•
A Project Management Office and Turnaround Director to oversee and give assurance to the delivery of the action plan.
2
Colchester Trust- Our improvement plan & our progress
Who is responsible?
•
Our actions to address the NHS England Cancer Services review report recommendations have been agreed by the Trust Board.
•
Our Chief Executive, Dr Lucy Moore is ultimately responsible for implementing actions in this document. Evelyn Barker, Chief Operating Officer, is the Executive Lead for
delivery of improvements in Cancer.
•
The Improvement Director assigned to Colchester Hospitals NHS Foundation Trust is Mark Davies, who will be acting on behalf of Monitor and in concert with the relevant
Regional Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further information on
this role please contact specialmeasures@monitor.gov.uk
•
Ultimately, our success in implementing the recommendations of the Trust’s Cancer Action Plan will be assessed by the Chief Inspector of Hospitals, who will re-inspect our
Trust within 12 months after entering the Special Measures programme.
•
If you have any questions about how we’re doing, contact Mark Prentice, Head of External Relations, mark.prentice@colchesterhospital.nhs.uk , 01206 742752.
How we will communicate our progress to you
•
We will update this progress report every month while we are in special measures.
•
There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement.
•
The Trust Board receives monthly updates in its public meeting.
Chair / Chief Executive Approval (on behalf of the Board):
Chair Name: Dr Sally Irvine
Signature:
Date 11 Sept 2014
Chief Executive Name: Dr Lucy Moore
Signature:
Date: 11 Sept 2014
3
Colchester Trust - Our improvement plan
Governance Structures and Processes for managing patients on a cancer pathway
Summary
of Main
Concerns
Well Led
Caring
Responsive
Effective
Summary of Urgent Actions
Required
Action
Owner
We will:
•
Ensure key roles
responsibilities and
accountabilities are
defined and appointed to
(e.g. Lead Cancer Clinician,
Lead Cancer Nurse,
Executive Lead for Cancer)
Medical
Director
•
Medical
Director
Review of all MDTs to ensure
they are effective (using
National Cancer Action Team
published "Characteristics of
an Effective MDT" Feb 2010).
Director of
Nursing
Agreed
Timescale
for
Implement
ation
Lead Cancer
Clinician/Exe
cutive Lead
for Cancer –
31 Jan 2014
External
Support/
Assurance
Progress
Monitor
Clinical
Commissio
ning Group
Green
Key roles have been defined in line with national
role descriptions as detailed in the Manual of
Cancer Standards. All roles have been appointed
to, with the Lead Cancer Nurse commencing in post
on 2nd November 14. Letters defining roles have
been sent to all MDT Clinical leads for
signature/agreement to responsibilities. Draft
letters have been prepared for all Clinical Nurse
Specialists which sets out role description – being
sent out by Director of Nursing w/c 1st September.
Strategic
Clinical
Network
Green
Review Programme is being developed using the
National Cancer Action Team “Effectiveness of
MDTs” document (published 2010). This
document was presented at Cancer Board May 14.
The Trust is on track to deliver by end December
14.
Lead Cancer
Nurse by 28
Feb 2014
31
December
2014
Revised deadline (if required)
4
Colchester Trust - Our improvement plan
Governance Structures and Processes for managing patients on a cancer pathway
Summary of Urgent
Actions Required
Action
Owner
Agreed
Timescale
for
Implemen
tation
Well Led
Responsive
•
Ensure that the
appropriate
Governance
Committees provide
assurance to the Board
of the quality of care
delivered
Medical
Director
31 March
2014
Monitor
Safe
Effective
•
Review the workload
of all Cancer Services
workforce
Medical
Director
(Clinician
s)
31 March
2014
National
Peer
Review
Programm
e
Summary
of Main
Concerns
Director
of
Nursing
(Nurses)
Chief
Operatin
g Officer
(Admin
Staff)
External
Support/
Assurance
Progress
Revised deadline (if required)
Blue
Cancer Board meeting monthly, with clear Agenda and
Minutes. Agreed Terms of Reference in place. Well
attended by Clinical Leads. The work programme of the
Cancer Board in 2014 is to monitor the delivery of the
Cancer Remedial Action Plan. Quarterly update of progress
to the Trust Quality & Patient Safety Committee in line with
Terms of Reference.
Amber
A Summary of vacancies recruited to, and additional posts
identified through external review has been completed
and is being monitored. All remaining vacancies have
been advertised and are being actively recruited. Clinical
workload review is incorporated into annual joint planning
cycle (commenced 1st April). Work on Medical workforce
has commenced with risks identified in Lower GI, Head &
Neck, and Dermatology. MDT Co-ordinator workload
being assessed using IST Workload Tool. Clinical Nurse
Workload review terms of reference agreed. CNS review
to determine if CNS workload is manageable (all tumour
sites) and sufficient to deliver support to the current
volume of cancer patients. Report on outcome of CNS
workload review presented at Cancer Board in August 14.
This piece of work will feed into the wider Nurse Review
being undertaken across the Trust by the Director of
Nursing. The outcome and recommendations of the
review will be passed to the Lead Cancer Nurse to take
forward.
5
Colchester Trust - Our improvement plan
Data Collection and Data Governance
Summary
of Main
Concerns
Agreed
Timescale for
Implementation
External
Support/
Assuran
ce
Chief
Operating
Officer
31 March 2014
Monitor
Green
The Trust Access Policy has reference to the
management of Cancer pathways within it. The
policy has been reviewed , circulated for
comments and submitted to the Trust policy
approval committee (PDAC). A separate Cancer
Services Operational Policy, detailing
management of patients on cancer pathways, has
been approved at the Trust PDAC Committee
(June 14) and includes a section on the
responsibilities of the MDT Co-ordinator team.
This document has been approved at Cancer
Board and has been shared with the MDT Coordinator team. This policy has been incorporated
into the Trust Access Policy, which is available on
the Trust Intranet.
Chief
Operating
Officer
28 February 2014
Monitor
Intensive
Support
Team
Amber
The development of MDT specialty based
Protocols governing the daily workload of each
MDT Co-ordinator has commenced. The
timescale for implementation is being reviewed
by the Trust – expected date for implementation
is end August 14. There has been some delay on
development of the MDT protocols resulting from
the implementation of Phase 2 of the Somerset
system. MDTC team have completed diary sheets
for a 2 week period to facilitate development of
the protocols. Diary sheets being collated and
analysed.
Summary of Urgent Actions
Required
Action
Owner
Safe
Well Led
Responsive
We will:
• Develop a Trust Cancer Access
Policy to provide guidance to our
staff for the management of
patients on a cancer pathway.
Responsive
Effective
•
Develop written protocols for
the Multi-disciplinary data team
setting out the application and
recording of data relating to
Cancer Waiting Times rules. This
is a failsafe method of ensuring
our staff have up to date and
accurate guidance
Progress
Revised deadline (if required)
6
Colchester Trust - Our improvement plan
Data Collection and Data Governance
Summary
of Main
Concerns
Summary of Urgent Actions Required
Action
Owner
Agreed
Timescale
for
Implement
ation
External
Support/
Assurance
Safe
Effective
•
Implement an electronic process for
reviewing adjustments on Cancer
Waiting Times database by hospital
staff to enable review and monitoring
by Information Team. This is a
failsafe process to assure ourselves
that any adjustments are consistent
with national guidance.
Chief
Operating
Officer
31 January
2014
Clinical
Commissio
ning Group
Responsive
Safe
•
Implement a nationally recognised
Information System to collate and
report cancer waiting times data.
The Somerset system being
implemented has built in failsafe
mechanisms to alert users when
inaccurate data is input.
Cancer
Programme
Director
28 February
2014
Monitor
Progress
Blue
Green
Revised deadline (if required)
Daily report comparing differences between CWTs
database and Patient Administration System
introduced end December 13. Reviewed daily by
Contact Centre and MDT Co-ordinator team.
Governance reports have been implemented which
identify changes made to data. The Somerset system
has a background facility which provides an audit of
data changes. Links to the daily/weekly reports are
received regularly.
Installation of Somerset system for collection of cancer
waiting times data completed 6th March 2014. The
training of key staff and migration of data between the
existing Cancer Waits database and Somerset is
complete. Data migration has been validated and
reconciled by Business Informatics.. A suite of
management reports is being developed by Business
Informatics to provide assurance to the Board. The
Somerset system feeds Qlikview, the management tool
used by the Trust to track its performance at specialty
level. Phase 2 Somerset implementation– programme
has commenced and most MDTs now have clinical data
input live at MDT by clinical staff. Completion of live
data collection (phase 2) is on schedule for end
September 14 but may be completed earlier.
7
Colchester Trust - Our improvement plan
Data Collection and Data Governance (continued)
Summar
y of
Main
Concern
s
Agreed
Timescale for
Implementation
External
Support/
Assurance
Chief
Operating
Officer
31 January 2014
Clinical
Commissioning
Group
Green
Review of weekly escalation processes has been completed.
Changes to the process have been implemented. A weekly Action
Log has been implemented which identifies constraints which may
delay patient pathways – this is reviewed by Service Managers
weekly . Detailed Terms of Reference for escalation processes
presented to Cancer Board in April 14. Comments from clinical
teams being collated. The 18 week and Cancer weekly PTL meetings
have now merged (June 14) to enable improved service
management representation. Effectiveness is being monitored at
the weekly Performance and Activity Review meetings, led by the
Chief Operating Officer.
Chief
Operating
Officer
31 March 2014
Clinical
Commissioning
Group
Green
The Contact Centre commenced on 23rd December 13 for internal
referrals. External (2ww) referrals commenced via Choose & Book
(end March 14) in conjunction with North East Essex CCG (and has an
nhs.net email address as a failsafe if Choose & Book slot
unavailable). An operational policy for the Contact Centre (Cancer
Hub)has been developed, which details how referrals are managed
with detailed timeframes . This was presented at Cancer Board
(April 14) for discussion and comment. GP practices are able to set
up a delivery/read receipt for these referrals to provide assurance of
receipt. The Inter-Trust Referral policy is in development in
partnership with other Essex Hospitals with whom cancer pathways
are shared (led by the Strategic Clinical Network). Anticipated date
for completion of the Inter-Trust Referral policy is dependent on
other external organisations, and is anticipated to be completed by
end October 14. All internal faxes have been replaced with nhs.net
secure email accounts.
Summary of Urgent
Actions Required
Action
Owner
Safe
Responsi
ve
We will:
• Make improvements
to our weekly cancer
escalation processes
ensuring there is a
failsafe method for
escalating patients
treatment pathways.
Safe
Effective
•
Implement an
electronic system of
single point of
receipt for GP
Suspected Cancer
Referrals, and
referrals to and
from other hospitals
for cancer pathways.
This is a failsafe
method of capturing
referrals which will
replace paper
referrals into the
Trust.
Progres
s
Revised deadline (if required)
8
Summary of
Main
Concerns
Timescale
for
Implementat
ion
External
Support/
Assurance
Chief
Operatin
g Officer
28 February
2014
Monitor
Intensive
Support Team
Blue
Initial training commenced December 13. Further
training day for Root Cause Analysis undertaken
mid February 14. Training relating to the new data
information system (Somerset) completed (7th & 14th
February). Regular training updates on issues
identified through the Weekly Escalation Processes
continue to be delivered through Team Meetings for
the MDT Co-ordinator & Data Clerk Team. Team
Meetings are taking place weekly with a standard
item on CWTs guidance – topics for
discussion/training are identified by the MDT Coordinator & Data Clerk Team.
Improve support and
advice to MDT Coordinator Team
including standard
operating procedures
to support
MDTCs/Data Clerks
roles/functions,
including escalation
processes This is a
failsafe method of
ensuring our staff are
following consistent
and accurate
guidance.
Chief
Operatin
g Officer
28 February
2014
Monitor
Intensive
Support Team
Green
The Cancer Services Standard Operational Policy
which details the Cancer Waiting Times guidance has
been reviewed. This document details how data is to
be recorded on the Somerset cancer data
information system. Policy presented to Cancer
Board April 14. The Operational Policy has been
approved by the Trust PDAC Committee May 14.
The daily protocols outlining the standard processes
required to support each MDT are being developed.
MDT Co-ordinator team compiling diary sheets
detailing daily/weekly commitments to facilitate
development of the MDTC protocols (anticipated to
be in place by mid October) to complement the
Standard Operational Policy.
Develop an electronic
failsafe competency
framework to ensure
MDTC/Data Clerks
knowledge and skills
are maintained
(similar to that used
for IT Governance)
which will be tested
annually.
Cancer
Program
me
Director
31 March
2014
Monitor
Intensive
Support Team
Amber
Cancer Services Standard Operational Policy
encompasses a competency framework. The Trust
has engaged an external provider of Referral to
Treatment (18 weeks) e-learning package to develop
a module for Cancer alongside the implementation
of RTT. A programme of development, testing and
implementation work for the cancer module has
been agreed with an anticipated go-live date of end
December 14/early Jan 15. This e-learning package
will enable the Trust to have annual assessment of
knowledge and competency of data collection staff.
Summary of Urgent
Actions Required
Action
Owner
Safe
Caring
Effective
We will:
• Develop a programme
of regular and
continuous training for
our MDT Co-ordinator
team which will
provide us with a
failsafe method of
ensuring our staff are
up-to date.
Safe
Responsive
Caring
•
•
Safe
Effective
Responsive
Progress
Colchester Trust - Our improvement
plan
Revised deadline (if required)
9
Colchester Trust - Our improvement plan
Data Collection and Data Governance (continued)
Summary of Urgent Actions
Required
Action
Owner
Agreed
Timescale for
Implementati
on
Well Led
Effective
•
Implement Inter-Trust Referral
policy (recommended by
Midlands & East of England
Strategic Clinical Network).
Medical
Director
31 October
2014
Strategic
Clinical
Network
Amber
Communication with external Trusts advising of the
adoption of this policy established - an Essex wide
meeting took place end April 14 with Trusts, the
Strategic Clinical Network (SCN) and the Cancer
Registry. The Trust anticipated date for completion,
subject to external organisations is October 2014.
Strategic Clinical Network agreed at Essex Cancer
Forum (June 14) to bring the Essex-wide policy back to
ECF October 14 for sign off. There is on-going internal
development work with the Contact Centre (Cancer
Hub) to ensure the implementation of this Policy is
completed as soon as it has been agreed by the Essex
Cancer Forum. Agreement has been reached with Mid
Essex Hospitals NHS Trust to provide read only access
to the Somerset, PAS and Pathology systems at both
hospitals which will improve the security of patient
data flows between the two hospitals and reduce the
risk of pathway delays as a result of poor exchange of
patient details. CHUFT has initiated internal
discussions to provide read only access to
Somerset/PAS with Information Team.
Safe
Effective
Responsive
•
Establish regular failsafe
monitoring programme to
ensure all referrals are made by
Day 42 and tracked
appropriately
Medical
Director
31 October
2014
Clinical
Commissioning
Group
Amber
Somerset implemented with data migration
completed. Monitoring of incoming and outgoing
tertiary referrals was expected to be monitored via
Somerset from 1 April 2014. Release of Somerset
module for Inter-Trust Referrals has slipped to
Autumn 2014 by Somerset Cancer Registry and is
outside of the control of the hospital. There is ongoing discussion with Cancer Services Division to
develop a mechanism for monitoring outgoing tertiary
referrals ahead of this deadline. MDT Co-ordinators
track individual patients via tumour site tracking
processes.
Summary
of Main
Concerns
External
Support/
Assurance
Progress
Revised deadline (if required)
10
Colchester Trust - Our improvement plan
Management of patients on a cancer pathway
Summary
of Main
Concerns
Summary of Urgent Actions
Required
Action Owner
Agreed
Timescale for
Implementation
External
Support/
Assurance
Progress
Revised deadline (if required)
Safe
Caring
Responsive
We will
• Ensure that patients
referred through 18 weeks
are upgraded onto a
Cancer Pathway (if there is
a suspicion of Cancer) .
Ensure trust-wide Access
Policy for Cancer has a
clear definition of
Consultant Upgrades
Chief Operating
Officer
31 March 2014
Monitor
Green
Clarification relating to Consultant Upgrade discussed at
Cancer Board February 14. All Consultant upgrades are
recorded on Somerset. Number of consultant upgrades
being monitored monthly through Cancer Hub – increase
in numbers of upgrades being recorded. Numbers of
consultant upgrades are reported monthly to the Cancer
Board as part of the regular performance report. There is
increasing level of confidence by the Trust Executive that
the previous level of under-reporting is being addressed
and monitored. The Cancer Access Policy has been
incorporated into the Trust Access Policy and has been
approved by the Trust internal Committee (PDAC) –
available on the Intranet. All Standard Operational
Policies for MDTs are being re-checked, through Sept 14
Peer Review upload/internal validation via CQUINs, to
ensure they encompass guidance for MDT teams when it
is appropriate to upgrade patients onto the 62 day cancer
pathway.
Well Led
Safe
Responsive
•
Divisional
Clinical
Directors
31 December
2014
Strategic
Clinical
Network .
Green
The Cancer Action Plan incorporates all recommendations
from previous peer reviews and has clear actions and
timescales. The Cancer Board is responsible for ensuring
delivery of all peer review remedial actions and this is
encompassed in its Terms of Reference. Trust document
confirming the annual cycle, process, timetable and
requirements for each MDT presented to Cancer Board
(July 14). Clinical Leads and MDTs have been given the
opportunity to comment/provide feedback on the
process document. To be ratified at Cancer Board August
14. This document will form the basis of the annual
planning, development and delivery cycle of peer review
which will be monitored through the Cancer Board.
Process document has been reviewed by Royal Marsden
who have recommended the timetable for data collection
to be reviewed.
Ensure that all
recommendations from
peer review are
implemented
11
Colchester Trust - Our improvement plan
Management of patients on a cancer pathway
Summary
of Main
Concerns
Summary of Urgent
Actions Required
Action Owner
Agreed
Timescale for
Implementation
External
Support/
Assurance
Effective
Responsive
•
Ensure that the Anal
Cancer Pathway is
implemented and is IOG
compliant
Medical Director
30 September 2014
Specialised
Commissioni
ng Group
Blue
Discussions are continuing with Specialised
Commissioning and the Strategic Clinical Network to
ensure compliance with Improving Outcomes
Guidance (IOG) is in line with agreed timetable.
CHUFT are referring all Anal Salvage Surgery patients
to Norfolk & Norwich hospital (upto 12 patients per
year) as an interim measure agreed with Specialised
Commissioning. There is a separate additional piece
of work which will be led by NHS England, Specialised
Commissioning Team to confirm an IOG compliant
solution for all hospitals in Essex. Essex wide meeting
taking place 6th August 2014.
Effective
Safe
•
Ensure Gynaecology
MDT has cover for
Consultant Oncologist
Medical Director
30 June 2014
Strategic
Clinical
Network
Blue
Recruitment commenced December 13. Consultant
Oncologist appointed – commences June 14.
Following induction, MDT cover will be in place by
end June 14. Additional Consultant Oncologist in
post. Cover for MDT will be monitored.
Effective
Responsive
Well Led
•
Ensure Urology service
has sufficient capacity to
treat patients
Chief Operating
Officer
31 March 2014
Monitor
Amber
Progress
Revised deadline (if required)
All actions to increase capacity are completed or on
course for completion. Additional clinics commenced
mid December; additional theatre capacity, including
weekend working, has been in place since January 14.
Recruitment for additional medical and nursing staff
has resulted in a 5th consultant who commenced early
March 14 and a 6th consultant commences in post
early November 14. Additional nursing posts and CNS
have been appointed. Performance is being closely
monitored to ensure additional capacity is having the
desired impact. Despite additional capacity,
sustainable achievement of the CWTs standards in
this specialty remain challenging.
12
Colchester Trust - Our improvement plan
Management of patients on a cancer pathway (continued)
Summary
of Main
Concerns
Summary of Urgent
Actions Required
Action Owner
Agreed
Timescale for
Implementati
on
External
Support/
Assurance
Progress
Revised deadline (if required)
Safe
Effective
Responsive
We will
• Ensure there are clear
documented pathways
for Urology (prostate
and bladder)
Multi-disciplinary
Team Clinical
Lead
30 December
13
External Visit
Review
Team
Blue
Prostate and Bladder cancer pathways have been
revised and assured by the visiting External Review
Clinical Lead. The Clinical Team are regularly auditing
this pathway and is part of the regular programme of
pathway audits to be presented at Cancer Board.
External revisit of prostate, bladder and renal
pathways (28th April 14) confirmed pathways assured.
No immediate risks or serious concerns identified.
Safe
Effective
Responsive
•
Ensure the Skin pathway
is compliant with cancer
waiting times guidance.
Medical Director
31 January 2014
Strategic
Clinical
Network
Red
Pathway has been reviewed by visiting External
Consultant and compliance with Cancer Waiting Times
guidance has been received. Pathway audit has been
deferred by agreement between the Clinical
Commissioning Group, Local Area Team, and the Trust.
Deadline for review of this pathway has been set for
end December 14. An internal spot audit assessing the
pathway against 2ww milestones has been conducted
and will be reported to Cancer Board Sept 14.
Safe
Effective
Responsive
•
Ensure there is a clear
documented pathway
for suspicious lesions
Medical Director
31 January 2014
Strategic
Clinical
Network
Blue
A process for the management of the pathway for
patients with suspicious lesions has been developed
and is incorporated within the Contact Centre
Operational Policy. Discussed and agreed at Cancer
Board March 14. External pathway revisit (14th April)
confirmed process assured.
13
Colchester Trust - Our improvement plan
Management of patients on a cancer pathway (continued)
Summary of Urgent
Actions Required
Action Owner
Agreed
Timescale for
Implementati
on
Safe
Effective
Responsive
•
Ensure there are robust
tracking methods for
Sarcoma patients
Medical Director
31 March 2014
Strategic
Clinical
Network
Blue
A Standard Operational Policy for the management of
Sarcoma patients has been developed and is being
implemented. Sarcoma pathways (bone and soft
tissue) ratified at Cancer Board March 14. Pathway
audit to be presented at Cancer Board. External
pathway revisit (14th April 14) confirmed pathway
assured.
Safe
Effective
Responsive
•
Ensure there is a clear
documented pathway
for Brain/Central
Nervous System patients
Medical Director
28 February
2014
Strategic
Clinical
Network
Blue
Revised pathway completed 16th December 13.
Agreed at Cancer Board February 14. Pathway revisit
took place 20th May 14 – pathway assured.
Safe
Effective
Responsive
•
There is clear MDT
structure and pathway
for Cancer of Unknown
Primary
Medical Director
31st March 2014
Strategic
Clinical
Network
Blue
Standard operational policy has been developed for
the management of patients who present with Cancer
of Unknown Primary. MDT structure reviewed –
anticipated to be in place mid April 14. The external
pathway revisit (April) has confirmed assurance of the
Cancer of Unknown Primary pathway.
Summary
of Main
Concerns
External
Support/
Assurance
Progress
Revised deadline (if required)
14
Colchester Trust - Our improvement plan
Management of patients on a cancer pathway (continued)
Safe
Effective
Responsive
•
Ensure all Cancer pathways
are regularly audited . This
is a failsafe process to
ensure that patients are
treated in line with agreed
pathways.
Medical
Director
31
Decem
ber
2014
Strategic
Clinical
Network
Amber
A programme of regular clinical audit of cancer
pathways is being presented to Cancer Board . The
outcome of the first pathway audit (Urology) was
presented at the March Cancer Board. Audit
programme agreed at Cancer Board March 14 covering
all tumour site pathways. Relevant pathway audits
presented at each Cancer Board. Programme of Cancer
pathway audits being monitored at Cancer Board.
Further work is being undertaken to ensure all tumour
sites are undertaking the monthly audit of at least 5
pathways (this differs by tumour site).
Safe
Effective
Responsive
Caring
Well Led
•
Develop a continuous
quality improvement
programme for cancer
specialties, to encompass
clinical peer review visit
recommendations
Trust
Clinical
Cancer
Lead
31 May
2014
Strategic
Clinical
Network
Blue
A draft document detailing each of the components of
the continuous quality improvement programme
presented to Cancer Board May 14. The key
components identified as contributing towards a
continuous quality improvement programme are in
place and are being regularly monitored.
Implementation is in progress and being monitored by
the Cancer Board and Quality & Patient Safety
Committee. The Continuous Quality Improvement
Programme to be submitted to Quality & Patient Safety
Committee June 14. Programme ratified by Cancer
Board June 14. Monitoring of all components of the
programme will be via Cancer Board.
Safe
Effective
Responsive
Caring
Well Led
•
NHS England – Follow up
report on the Management
of the above cancer
pathways (published July
2014).
Medical
Director
31 July
14
NHS England
/ Local Area
Team
Blue
NHS England has published a follow up report on the
Cancer pathways outlined above confirming that all
pathways, with the exception of skin pathway, have
been reviewed and are assured as safe. The report also
provided an update on the General Immediate Risks
identified in the original report (December 13) and
confirmation of the work the Trust has undertaken in
improving failsafe processes for the tracking of
patients, recording of data and management of
pathways.
15
Colchester Trust - Our improvement plan
Safeguarding Adults and Children
Summary
of Main
Concerns
Summary of Urgent
Actions Required
Action Owner
Agreed
Timescale for
Implementation
External
Support/
Assurance
Progress
Revised deadline (if required)
Safe
Responsive
Well Led
We will
• Confirm the NonExecutive Director lead
and ensure all board
members receive
training
Director of Nursing
End December
2013
Monitor
Blue
Non-Executive Director for Safeguarding
confirmed. Safeguarding training
completed.
Safe
Caring
•
Ensure that there are
policies and
procedures in place to
protect vulnerable
adults and children
Director of Nursing
End December
2013
Monitor
Clinical
Commissionin
g Group
Blue
Policies and procedures completed and
presented to Trust Board.
Safe
Caring
Responsive
•
Ensure the internal
Trust intranet has an etraining module
Director or Nursing
End December
2013
Clinical
Commissionin
g Group
Blue
E-training module for Safeguarding In
place mid December.
Medical Director
31 October 2014
NHS England
Green
•
Develop a
communications plan
for contacting all
patients (to convey
outcome) following
clinical-notes review
(duty of candour).
It has been agreed with NHS England
that this will be incorporated into
Retrospective Review programme
timetable under Duty of Candour. The
timetable for completion of the
Retrospective Review has been
extended to end October 14 with the
agreement of the External Assurance
Panel (comprising LAT, CCG,
Healthwatch representatives) and the
completion date has been amended to
reflect this.
Safe
Caring
16
Colchester Trust - Our improvement plan
Oversight and improvement action
Agreed Timescale for
Implementation
Outline details of how the progress is being monitored and supported during the
Special Measures programme. e.g. the appointment of an Improvement
Director by Monitor; the identification of a Buddy Trust to help support the
Special Measures Trust implement its Action Plan.
•
•
There is a multidisciplinary led external review structure, which is
overseeing the development and implementation of the Trust Cancer
Action Plan, comprising a clinical oversight group, an operational group
and an Executive Assurance Group. These groups encompass NHS England
Clinical Commissioning Group, Trust representatives, Essex County Council ,
health regulators (Monitor) and Health Watch (which represents patients
views).
Action owner
Progress
Confirm whether the action
has been started – its due
date or completed date
(detail month and year.)
Confirm who is responsible for
making sure each task is actioned.
Provide a brief
summary of why the
RAG colour was picked
for each particular
action
Mid December 13
Chief Executive
Blue
The Trust is
represented with
excellent attendance
on all groups
Colchester Trust - How our progress
is being monitored and supported
In addition to the above, there are regular Clinical Commissioning Group
oversight and assurance groups which meet weekly. These include :
a)
Review of the weekly process for reviewing patients on the cancer waiting
times database
b)
Weekly unscheduled visits/walkabouts by the Commissioners
c)
Weekly clinical scrutiny by GP partners –review of patient pathways
December 13
Cancer Programme Director
Blue
All groups are being
regularly attended
•
Trust Cancer Board has been reconstituted to include Multi-disciplinary
Team Clinical Leads , Clinical Nurse Specialists, and Service Managers, to
oversee the decisions made relating to Cancer Services . The Trust Cancer
Board reports to the Trust Board through the Quality and Patient Safety
Committee. The Cancer Board oversees and monitors the implementation
of the Trust Remedial Cancer Action Plan.
Mid December 13
Clinical Lead for Cancer Services
Blue
Reconstituted Board
commenced mid
December.
Effectiveness of the
Group to be monitored
throughout the year by
the Quality & Patient
Safety Committee
•
Appointment of Cancer Programme Director and Project Manager to drive
the required improvements.
Beg December 14
Medical Director
Blue
Cancer Programme
Director took up post
2nd December 13
Project Manager in post
from 27th February
2014
17
Colchester Trust - How our progress is being monitored and supported
Oversight and improvement action
Agreed Timescale for
Implementation
Outline details of how the progress is being monitored and supported during
the Special Measures programme. e.g. the appointment of an Improvement
Director by Monitor; the identification of a Buddy Trust to help support the
Special Measures Trust implement its Action Plan.
•
Action owner
Progress
Confirm whether the action
has been started – its due
date or completed date
(detail month and year.)
Confirm who is responsible for
making sure each task is actioned.
Provide a brief
summary of why the
RAG colour was picked
for each particular
action
A Cancer Services Steering Group to oversee and drive the
implementation of the Trust Cancer Action Plan has been established to
ensure progress against the Cancer Action Plan. This Group reports to
Trust Board through the Quality & Patient Safety Committee and the
Trust Turnaround Board. The Steering Group monitors the progress of
the Cancer Remedial Action Plan.
January 2014
Chief Operating Officer
•
A Programme Management Office has been implemented to provide
structure to the improvement programmes at the Trust including
Cancer. This includes the Cancer Services Steering Group which reports
to the Quality & Patient Safety Committee and Turnaround Board
chaired by the CEO.
January 2014
Chief Executive
Blue
Programme
Management Office
commenced January 14
•
Appointment of Improvement Director (by Monitor) to work with and
support the Trust to deliver the Cancer Action Plan.
Completed 20th January
2014
Chief Executive
Blue
Improvement Director
took up post week
commencing 20th
January
Blue
Cancer Services
Steering Group has
commenced and is
meeting weekly
18