NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
Lead person
responsible
Actions Required
Agreed
Timescale
Progress against identified
actions
LEADERSHIP AND MANAGEMENT GRIP
1
NHS Highland should identify, as a matter
of urgency, a new Executive lead for
cancer services delivery.
Roger Gibbins
Formally identify Executive
Lead
January 2007
Completed
Elaine Mead, Chief Operating
Officer identified as Executive
Lead
(in light of Medical Director leaving)
Meeting with Chairman and NONExecutive Directors to brief
following visit and give and
update on progress
Agreed monthly detailed updates
to Board
SYSTEMS & PROCESSES
2
Agree tumour specific patient pathways.
Lead Cancer Clinicians
General Managers
Previously developed
process maps of current
pathway must be reviewed,
against a 62 day timeline.
Revised tumour specific
milestones to be agreed by
all team members –
oncologists, specialty
consultants, managers,
specialist nurses & trackers
and disseminated widely.
Implementation of the
revised pathways
April 2007
Process maps identified in 3 or 4
main cancer sites but need to be
developed for Breast Cancer
pathway.
Discussion with managers and
lead clinician at meeting on
Monday 8 January 2007
identifying specific individual
accountabilities for delivering
cancer targets
Agreed pilot in ENT Head and
Neck to identify process issues
and encourage use of the tracker
information
Colorectal, Lung complete.
(pending CTT stage alerts)
Page 1 of 9
Last updated 23 March 07
NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
Lead person
responsible
Actions Required
Agreed
Timescale
Progress against identified
actions
Breast – Pathway agreed
Haematology being finalised
Urology - outline pathway
drafted, further consideration of
‘one-stop-shop’ approach to be
followed up.
3
Develop explicit pathways where intersite transfer takes place within NHS
Highland and agree how patients will be
tracked across the boundaries between
rural general hospitals and those aspects
of assessment, diagnosis and treatment
provided at Raigmore Hospital.
Leo McClymont RGH
Clinicians Gill McVicar,
Sheena Craig
Inter-related with issue 2
4
5
Mapping and agreement of tumour
specific pathways for the localities of
Argyll and Bute
NHS Highland should actively seek to
maximise coverage of numbers of
patients treated in last week of weekly
reporting
Elaine Mead
A & B Clinicians
Fiona Ritchie
Christine McIntosh &
General Managers
Ensure all potential cancer
patients are captured on the
CTT at point of
referral/vetting.
Agree pathway timescales
for onward referral to
Raigmore, if first seen at
Rural General
Hospital/location outwith
Raigmore
April 2007
Pathways in development for
Colorectal patients referred to
Raigmore from Caithness, and
Breast and Colorectal patients
from Belford.
Principle being applied for
alternative booking if timely local
appointment unavailable.
From the Top 20
assessments, formally
describe aspects of
assessment, diagnosis and
treatment that are provided
locally and those which
require inter-hospital
transfer to NHS Greater
Glasgow & Clyde.
March 2007
Combination of factors
identified to be reviewed;
WI patients diagnosed (5%)
Compliance with agreed
End January
2007
CHP GM progressing. Template
pathways issued to help inform
this work.
EM discussed with FR .
Christine McIntosh met with local
staff 9 February
Locality Manager (LIDGH) lead
this work with Practice
Development Nurse.
CMcI met key staff on 13 March,
lung and colorectal pathways in
draft.
Coverage and compliance
explanation (from CPST)
circulated to all key staff.
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NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
Lead person
responsible
Actions Required
Agreed
Timescale
CTT procedures – up to 15%
(Further clarity awaited from support team on
expected maximum coverage)
Improve compliance with
agreed procedures for CTT
Complete
Progress against identified
actions
Importance of focussing effort
patients are treated within the
target treating patients discussed
at DHS meeting 31 Jan 07.
Focus for all staff, with use of CTT
reports to
a) secure earliest first
appointment,
b) raise awareness of patients
pathway status at 31 days and
less
c) actively arrange treatment to
prevent breaches.
6
NHS Highland should move immediately
to implement weekly tracking,
prospective management and breach
review for patients from Argyll & Bute.
Fiona Ritchie
Implement CTT in Argyll and
Bute – manually add patients
per procedures
February 2007
Complete
Christine McIntosh agreed with
Tracking Coordinator and IT lead
the issue of PTL for each Locality
Manager – from W/E 18th
consistent approach by Locality
teams as per action 5 above.
Awareness raising session for
staff on 13 March (CMcI)
7
NHS Highland should involve
representation from primary care in its
weekly cancer performance meetings.
Elaine Mead
Identify Primary Care
representation at weekly
SSU meeting (equivalent) –
and formally agree
responsibilities of this role
January 2007
Complete
Primary care already engaged at
Cancer Waiting List meeting.
CHP GMs invited to meeting on
Monday 8 January 2007 and
participate in Cancer waiting list
meeting
Outlined relationship of meetings
and membership with team
securing local weekly meetings in
main localities
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Last updated 23 March 07
NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
Lead person
responsible
Actions Required
Agreed
Timescale
Progress against identified
actions
COO reviewed CTT data on ENT
and has agreement to pilot work
in referrals in this area
Referral protocols agreed
between primary and secondary
care in Colorectal to be expedited
Letter sent to all GPs by
Associate Medical Director.
Argyll and Bute letter to GPs
guiding referral point and use of
‘urgent’
Argyll and Bute local escalation
being agreed.
8
Clear feedback mechanisms to be put in
place over the quality, pace and routing of
referrals
Elaine Mead with
Lead Cancer Clinicians
CHP Clinical Directors
GMs and Directorate
Managers
Use weekly SSU
group/equivalent to highlight
issues, and responsibilities
for resolving/improving these
January 2007
Initial action Complete
ongoing
action
9
Develop a comprehensive escalation
policy
Christine McIntosh
Finalise Draft document
End of
February 2007
Complete
(A & B by mid
March)
January 2007
Complete
10
Ensure that all Teams responsible for
delivering the 62 day pathway clearly
understand the definition of the 62 target
from the date of urgent referral and not
receipt of urgent referral.
Leo McClymont
All Consultants
Managers
Promote improved
understanding of the
definitions -available on the
CTT at REPORTS section.
Through team
meetings
Targeted awareness
sessions
11
NHS Highland should identify those GP
practices (not utilising SCI Gateway)
where delays in receipt of referral are
occurring
Elaine Mead with
CHP Clinical Directors
Head of Planning
SSU General Manager
Clarify SCI gateway
implementation
End of
February/ beg
of March 2007
Communication issues discussed
at meeting on Monday 8 January
2007
Agreed to raise with Medical
Director and clinical directors for
reiteration.
Importance of the genuine use of
‘urgent’ status to be reinforced
through department meetings with
Clinicians
Use of SCI gateway discussed at
Cancer Waiting List group and
raised with primary care.
Identify referral delays
Complete
Practices to review internal
administrative arrangements
Alternatives now under
consideration to be trialled in ENT
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Last updated 23 March 07
NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
Lead person
responsible
Actions Required
Agreed
Timescale
including the use of faxed
referrals etc to speed up this
part of the pathway.
12
NHS Highland should set out an explicit
and detailed implementation plan for the
introduction of referral based protocols
(by specialty)
13
NHS Highland should implement revised
arrangements to accelerate reporting
from laboratories until the
implementation of digital reporting in
April 2007.
14
MDT meetings have proper co-ordination
Leo McClymont with
Cancer Leads
Review existing referral
patterns and criteria
Progress against identified
actions
Meeting to model OPD referrals in
order to change templates in ENT
underway as pilot work for other
cancer sites
April 2007
Complete
Engage primary care
colleagues in discussion by
specialty
Referral guidelines agreed in
colorectal. eHealth Dept finalising.
5/2/07 New National Cancer
Referral Guidelines available on
the website details widely
distributed.
Susan Eddie
Map and agree Pathology
reporting pathway for all
potential cancer patients
Include in laboratory project
agenda
April 2007
Complete
Briefing from local clinicians and
DGM provides detail of timescale
of implementation
SEHD Allocation of £200k
granted.
Elaine Mead
Leo McClymont
Christine McIntosh
Map coordination process for
each MDT
Finalise the work to agree
procedures for preparing
MDT lists, and radiological
reports (ensure that clinical
resources and input are
optimised)
Ensure action notes are
generated speedily after
each meeting.
April 2007
COO agreed actions with Cancer
Network Manager
COO engaged Nurse Consultant
and specialty nurses in advocacy
roles
Agreement that different
prioritisation of work is required to
ensure timely navigation of
patients through pathway. Further
resources secured to increase coordination.
Cancer Audit manager agreeing
more consistent approach with
lead consultants.
NHS FV MDT & Tracking
framework Document being
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NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
Lead person
responsible
Actions Required
Agreed
Timescale
Progress against identified
actions
reviewed for possible learning.
15
NHS Highland should ensure that
oncologists are fully involved in the
development of tumour specific patient
pathways and that opportunities for
concurrent or same day scheduling of
clinics are fully explored.
a)
Fundamental review of Oncology services
Elaine Mead
David Whillis
Leo McClymont
Susan Eddie
Rapid High level review of
oncology services
Complete
b)
NHS Highland should prioritise a demand
and capacity review of radiotherapy, and
action on Radiotherapy Waiting Times
Susa Eddie/ Ron ward
Finalise demand and
capacity work in
Radiotherapy and ensure
synergy with Chemotherapy
review
April 2007
Actions monitored at RT Waits
weekly meeting
c)
Chemotherapy Review
Clinical Leads – C Lane / I
Rudd
April 2007
Chemotherapy Review update –
Mapping of Macmillan unit
pathway complete. Follow up
maps planned in remote sites.
Data capture complete for Review
of use on in-patient beds – report
pending. Draft minimum
standards for Chemotherapy out
for comment. Nurse Consultant
following up feasibility of
expanding remote chemotherapy
within South east CHP with
Clinical director & Lead Nurse
.
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NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
management
support
Lead person
responsible
Actions Required
d)
Additional
Oncology
for
Susan Eddie
Establish SSU Cancer
Directorate
16
NHS Highland should review the Planned
Preventative Maintenance Arrangements
for its linear accelerators and any
diagnostic equipment with a view to
eliminating or minimising the loss of
capacity in routine operating
Susan Eddie
Review current
arrangements and make
alternative for PPM on linear
accelerators
Agreed
Timescale
Job Description for DGM agreed –
Grading and recruitment being
expedited.
January 2007
Complete
NHS Highland should consider the role of
the wider multidisciplinary Team and
consider how they can play a part in
managing patient flows in oncology.
Elaine Mead
Leo McClymont
Heidi may
(for Nursing and AHPs)
NHS Highland should prioritise a demand
and capacity review of theatres
March 2007
Complete
Also role enhancement
opportunities discussions
underway with CNS
Inter-related with issues 2,3,14,15
18
Redesign work underway in
RT, also Chemotherapy
review – mapping complete
Elaine Mead
Margaret Brown
Leo McClymont
Susan Eddie
Use Cancer Waiting times
summaries (tables for
2005/2006) to overlay
projections for theatre slots
required
COO requested this action as
immediate
Further information identifies
majority of PPM and QA work
undertaken outside core hours
April 2007
17
Progress against identified
actions
March 2007
Move of other PPM & QA outside
core hours being further
considered in light of HR
implications
COO discussed roles of cancer
specialist nurses with Nurse
Director and Nurse Consultant for
Cancer
Extension of roles in place in
endoscopy and urology
Cancer Nurse Consultant leading
work to further define the
contribution of CNS in helping to
pull patients through their 62 day
path.
Radiographer and CNS in training
to undertake RT review and
follow-up.
Initial discussion of extended
modelling of capacity requirement
had with Directorate General
Manager and Head of Planning
Trialling using the A & E
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NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
Lead person
responsible
Actions Required
Agreed
Timescale
Progress against identified
actions
decontamination room to free up
an extra theatre session per week
Vanguard Theatre in situ, and
freeing up further sessions during
March.
CLINICAL ENGAGEMENT
19
Prospective management of patients and
learning from breaches.
General Managers
Lead Clinicians
RGH Clinical Leads
Clinicians to be involved
within departments in
reviewing stage and 62-day
breach information and
agreeing action to resolve
February 2007
Complete
Service Managers to identify
with each specialty group
and manager what
information is required and
to whom it should be
routinely disseminated to
inform this process
20
Senior clinician is involved in its weekly
cancer performance review meetings.
Elaine Mead
Highland Clinical Lead for
Cancer to be involved in
SSU weekly meeting
Patients in ENT identified on
tracking tool as pilot
Case Study approach encouraged
– active in Urology, ENT and
Breast
Weekly patient details now
available in report form for
dissemination to all cancer
clinicians identifying all key
pathway points
COO and Cancer Network
manager reviewing all patients on
breach report. Improved
compliance with CTT
demonstrated in coverage %
January 2007
Completed
Cancer clinician invited to weekly
SSU cancer meeting
Cancer Nurse Consultant/CNS
attend routinely
INTER-HOSPITAL TRANSFERS
21
Establish explicit, documented Inter-
Paul Welford
Further develop Highland
Mid April 2007
Draft pathway developed
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NHS Highland Cancer Performance Improvement Action Plan: March 2007
Area for Improvement
22
23
Lead person
responsible
Actions Required
Agreed
Timescale
Progress against identified
actions
hospital Transfer Agreements with NHS
Lothian and NHS Grampian as a matter of
urgency.
Kerry Wilson
Christine McIntosh
NHS Highland needs to establish
explicit, documented Inter-hospital
Transfer Agreements with the various
hospitals in NHS Greater Glasgow &
Clyde where urgent or self referral is first
received by Lorn & Islands Hospital or by
Community Hospitals in Argyll & Bute.
Elaine Mead
Derek Leslie
Fiona Ritchie
NHS Highland should consider the help
that NOSCAN & WOSCAN could bring to
the urgent development of inter-hospital
transfer arrangements.
Christine McIntosh
Paul Welford
Discuss help available at
Cancer Waiting List meeting
End of
January 2007
Complete
As above, Liaison and Support
via General Manager Beatson
Oncology
Elaine Mead
Christine McIntosh
Leo McClymont
General Managers
Agree processes for Breach
review
January 2007
COO reviewing all patients that
have breached 62 days weekly
trend identification and discussion
with managers
Escalation Policy to identify
clear transfer arrangements
Review agreements in place
within NOSCAN & SCAN
Map and Agree procedures
and tracking responsibilities.
To be agreed across Health
Boards
April 2007
Evelyn Thomson
(WOSCAN)
Issue identified with Director of
Planning to be included in A&B
SLA
A & B lead progressing, and
CMcI supporting - with Liaison
and Support via General
Manager Beatson Oncology
BREACH REVIEW
24
Establish weekly breach review
Ensure that information on
trends of breaches of the 62
day cancer pathway are an
item for consideration at the
clinical governance
committee
March 2007
Trends being identified and
remedial action being taken
Formal pending and breach
review established in Argyll and
Bute
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Last updated 23 March 07