COLORECTAL CANCER COMPARATIVE REPORT

Transcription

1 SA C07/11 W SE Scotland Cancer etwork Prospective Cancer Audit in South East Scotland COLORECTAL CACER COMPARATIVE REPORT Report on Patients Diagnosed January - December 2009 at Borders General Hospital Dumfries and Galloway Royal Infirmary Queen Margaret Hospital, Dunfermline Victoria Hospital, Kirkcaldy Western General Hospital, Edinburgh St John's Hospital at Howden, Livingston Lead Clinicians: Mr M Hosny Mr S Whitelaw Mr T Daniel Mr R G Wilson/Mr BJ Mander Report prepared by: Peigi Muir, SCA Cancer Audit Facilitator Chair of SCA Colorectal Group Mr B.J. Mander Scan Audit Office, c/o Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU T: W: F Alison Allen@luht.scot.nhs.uk South East Scotland Cancer etwork (SCA) - Working regionally to improve cancer services

2 South East Scotland Cancer etwork Report on Colorectal Cancer Patients Diagnosed 1st January - 31st December 2009 COTETS Page umber DOCUMET HISTORY...3 COLORECTAL SCA GROUP CHAIR COMMET...4 ACTIO POITS Background to this report Datasets, definitions and measures Audit Processes and data recording Data Quality Clinical Sign-Off External QA Estimated Case Ascertainment...7 SUMMARY OF ACHIEVEMET AGAIST ATIOAL STADARDS: HEALTH BOARDS...8 SUMMARY OF ACHIEVEMET AGAIST ATIOAL STADARDS: SCA...9 SUMMARY OF ACHIEVEMET AGAIST ATIOAL STADARDS OT PREVIOUSLY REPORTED...10 OTES O SUMMARY OF STADARDS...11 SUMMARY OF PATIETS BY KEY CATEGORIES...12 STADARD 2: MULTIDISCIPLIARY WORKIG...17 STADARD 3: AUDIT...18 STADARD 4: WAITIG TIMES...19 STADARD 5: PREOPERATIVE PREPARATIOS/IVESTIGATIOS...21 STADARD 6: THERAPEUTIC MAAGEMET...25 STADARD 7: POSTOPERATIVE MAAGEMET...27 STADARD 8: OUTCOMES...28 GLOSSARY...30 SA C07/11 W 09/06/2011 2

3 SCA Comparative Colorectal Cancer Audit Report DOCUMET HISTORY Version Date Issued Description Distribution 1 st Draft of SCA Colorectal Cancer Comparative Report for sensechecking 11/10/2010 SCA Group /10/ nd Draft of SCA Colorectal Cancer Comparative Report incorporating comments received from sensechecking for discussion at Lead Clinicians Meeting on 5/11/10 SCA Clinicians Lead /12/2010 Inclusion of revised figures for Standard 5a1 Mr BJ Mander /01/2011 Inclusion of Chairman s comments and circulation to SCA Group for final comments SCA Group /01/2011 o further comments received therefore finally signed off. Report o. SA C07/11 allocated and lodged on SCA Audit Report Index 4W June 2011 Report o. SA C07/11 W Circulation to: Health board Clinical Governance Groups Regional Cancer Planning Group (for meeting on 23/02/2011) Published on SCA Website SA C07/11 W 09/06/2011 3

4 COLORECTAL SCA GROUP CHAIR COMMET SCA Comparative Colorectal Cancer Audit Report 2009 This report provides comprehensive data on the management of Colorectal Cancer in the South East of Scotland during Enormous credit should be given to the SCA audit team, and Peigi Muir in particular, for the quality of the data. This has been facilitated by local data collection teams. During 2009 in SCA 890 patients were diagnosed with colorectal cancer, 750 (84%) of whom underwent surgery, which was performed with curative intent in 88% of cases. The exceptional standard of surgical care across the region should be highlighted. Perioperative mortality for all patients undergoing surgery was less than1% and has fallen steadily over the last 5 years from 5.3% in These are World-class results. Complications caused by Anastomotic Dehiscence (leakage at the site of the surgical join) are very low (1.5% for colonic anastomosis, 5.6% for rectal anastomosis, and 9.4% for patients undergoing anastomosis following Total Mesorectal Excision). They fall well within the required national HSQIS standards of 5%, 10% and 20% respectively. One or two areas of the report are affected by difficulties in collecting appropriate data. This is particularly an issue within Lothian relating to data on DVT and Antibiotic prophylaxis. This is being resolved through coordination with the process for implementing the Scottish Patient Safety Programme. In Lothian and Dumfries & Galloway processes for recording of access to stoma therapists need to be improved. Other Action Points highlighted which we will be looking into further are: A similar number of patients received radiotherapy and chemotherapy across the network. It was noted however that patients from the Borders General Hospital appear to wait longer for the chemotherapy which may relate to the lack of cross cover for this service when the designated consultant is on leave. We will look into ways of addressing these issues. The report has also highlighted a large number of early stage cancers in Dumfries and Galloway and we will be looking into the reasons for this. The appropriate protocol for access to Clinical urse Specialists for patients with polyp cancers. This report focuses on reporting the existing HSQIS standards. We believe there are a number of areas we should focus on in the coming year. These include auditing the availability of laparoscopic colorectal surgery across the network, reviewing our morbidity rates in patients undergoing chemotherapy, and looking at our long-term outcome data. We hope that there will be opportunities to compare the results of the three Scottish cancer networks, as occurred at the national meeting of In order to compare our results more widely, we have also taken the first steps in 2010 in entering our data into the UK ational Bowel Cancer Audit. Mr B.J. Mander Chair SCA Colorectal Group SA C07/11 W 09/06/2011 4

5 ACTIO POITS Listed below are some possible areas for improvement identified through the report with proposed action outlined against each: Report Section Standard 2 Multidisciplinary Working Standard 4 Waiting Times Summary of Patients by Key Categories Table 10 Possible area for improvement Ensure that appropriate patients have access to a Clinical urse Specialist There is currently no protocol for care of early stage polyp cancer patients, so that it is unclear in what circumstances access to the CS is required. umbers of early-stage cancers are increasing because of screening Aim to ensure that wait for adjuvant chemotherapy is equitable for Borders i.e. for 95% of patients is not greater than 56 days from surgery Ensure comparability of staging across SCA review reasons for larger proportion of Dukes A patients in Dumfries & Galloway Proposed action Develop a protocol for care of patients with polyp cancer including a review of the appropriate circumstances for them to be referred to a CS may not be necessary in all cases Review service issues about availability of oncology cover Compare numbers of Dukes A cancers detected in other SCA areas paying particular attention to the numbers of lymph nodes harvested. Which clinical standard will this meet? QIS Standard 2a1 QIS Standard 4b1 o specific standard but comparability of staging required as essential component of ensuring equity of treatment SA C07/11 W 09/06/2011 5

6 1 Background to this report 1.1 This report is the eighth to present comparative data on patients newly diagnosed with colorectal cancer in South East Scotland Cancer etwork (SCA) at the following hospitals- Borders General Hospital, Dumfries and Galloway Royal Infirmary, Queen Margaret Hospital, Dunfermline, Victoria Hospital, Kirkcaldy, St John's Hospital at Howden, Livingston, and Western General Hospital, Edinburgh. 1.2 The report covers data on patients newly-diagnosed in the twelve months from 1 January to 31 December Lead Clinicians and staff involved in audit were as follows Borders General Hospital (BGH) Mr M Hosny Lynn Smith/Alistair Meikle Dumfries & Galloway Royal Infirmary (DGRI) Mr S Whitelaw Martin Keith Queen Margaret Hospital (Fife) Mr T Daniel Maureen Lamb Western General Hospital, Edinburgh (WGH) Mr RG Wilson Peigi Muir SCA Mr BJ Mander Peigi Muir 2 Datasets, definitions and measures 2.1 The dataset collected is the nationally-agreed core minimum dataset (as revised in 2009), with definitions published by ISD Scotland ( For further information contact Peigi Muir, SCA Audit Facilitator, Western General Hospital, Edinburgh. (peigi.muir@luht.scot.nhs.uk) 2.2 Data has been analysed against national Bowel Cancer HS Quality Improvement Scotland Clinical Standards (revised March 2008), published by the Clinical Standards Board for Scotland, now HS Quality Improvement Scotland (HS QIS), and the 2001 Cancer Strategy: Our ational Health. 2.3 Measurability criteria have been prepared by the SCA Cancer Audit Facilitator who co-ordinates this across the network to ensure consistency of analysis. 2.4 From this report focused on a subset of measures which previously had shown variable results or were key indicators of surgical quality. However from 2009 onwards a more comprehensive review of certain HS QIS Standards which were agreed by the SCA Colorectal Group has been undertaken. 3 Audit Processes and data recording 3.1 Collection of the nationally-agreed core minimum dataset continues in all hospitals in South East Scotland. Data capture is focused round the process for the weekly multidisciplinary meetings i.e. ensuring that data covering patient referral, investigation, and diagnosis is being picked up through the routine process. SA C07/11 W 09/06/2011 6

7 3.2 Surgical and Oncology data is obtained either from the clinical records (electronic systems and case notes) or by download from the Department of Clinical Oncology database within the Edinburgh Cancer Centre (ECC) 3.3 The process remains dependent on audit staff for capture and entry of data, and for data quality checking 3.4 Data is recorded on local Access databases, apart from in the Fife region where data is collected using E-case. 4. Data Quality 4.1 Clinical Sign-Off: This report compares data from reports prepared for individual hospitals and signed off as accurate following review by the lead clinicians from each service. Additionally, the collated SCA results are reviewed by lead clinicians, including the lead Oncologist, to assess variances and provide comments on results. 4.2 External QA: SCA Audit participates in external quality assurance (QA) of data by ISD Scotland, (i.e. when a sample of data is compared with the data definitions). There has not been an external QA of the whole Colorectal Dataset since Estimated Case Ascertainment: Case ascertainment has been estimated using Scottish Cancer Registration data for 2008 for comparison purposes (with exclusions of patients only certified on death certificates and fully private patients). Tables on case ascertainment and five year averages are contained in the relevant section: Standard 3 Audit (QIS Standard 3a3). Most patients are identified through weekly multidisciplinary meetings. The following sources are used to check for missing patients: 1. Pathology records 2. Death lists 3. Dept of Clinical Oncology retrospective database 4. Clinical urse Specialist database 5. Provisional Cancer Registration lists Peigi Muir SCA Audit Facilitator SA C07/11 W 09/06/2011 7

8 SUMMARY OF ACHIEVEMET AGAIST ATIOAL STADARDS: HEALTH BOARDS BGH DGRI FIFE LOTHIA ational Standard CSBS 8b: 100% of Patients to Start XRT within 4 wks of seeing an Oncologist 50.0% 46.2% 72.7% 66.7% 87.5% 85.7% 71.4% 85.7% 100.0% 86.7% 100.0% 100.0% 52.9% 45.8% 78.9% 89.5% 76.5% 77.8% 60.0% 60.0% 78.1% 92.3% 85.2% 83.0% QIS 5b1: The rectum and whole colon is visualised by Colonoscopy or CT Colonography preoperatively (or when this is not possible because of the nature of the tumour, within 12 months of resection) in 95% of patients undergoing treatment with curative intent. 39.7% 59.3% 58.3% 57.9% 83.3% 76.8% 33.6% 57.1% 49.3% 75.0% 65.6% 73.3% 56.1% 69.2% 77.1% 82.1% 88.3% 95.3% 42.1% 55.4% 56.3% 48.5% 91.1% 75.4% QIS Standard 5c1: A CT Scan of the chest, abdomen & pelvis is performed preoperatively (or postoperatively where preoperative scanning is not possible because of emergency presentation) in 90% of patients undergoing surgery for bowel cancer 86.3% 94.9% 95.8% 98.2% 100.0% 96.8% 86.0% 94.0% 95.7% 90.7% 94.5% 95.6% 88.5% 98.6% 97.9% 97.2% 98.6% 98.7% 86.6% 92.6% 82.0% 85.5% 88.3% 92.9% QIS 7c1: Anastomotic Dehiscence is not more than 5% after surgery resulting in colonic anastomosis /R /R 5.9% 5.3% 10.5% 0.0% /R /R 5.6% 4.8% 8.0% 3.4% /R /r 1.5% 3.6% 1.6% 0.0% /R /R 0.0% 1.5% 0.0% 2.4% QIS 7c2: Anastomotic Dehiscence is not more than 10% after surgery resulting in rectal anastomosis /R 5.0% 10.0% 0.0% 8.0% 0.0% /R 10.5% 0.0% 0.0% 4.8% 3.6% /R 8.7% 0.0% 0.0% 2.4% 4.5% /R 7.9% 13.5% 8.9% 3.8% 7.0% QIS 7c3: Anastomotic Dehiscence is not more than 20% after Anterior Resection with Total Mesorectal Excision for rectal cancer 0.0% 0.0% 10.0% 0.0% 20.0% 12.5% 10.5% 0.0% 0.0% 0.0% 18.8% 0.0% 0.0% 8.3% 0.0% 0.0% 3.8% 0.0% 14.3% 7.9% 14.7% 13.3% 5.6% 13.2% QIS 8a1: Treatment Related Mortality is less then 5% after elective surgery 9.8% 8.0% 0.0% 5.4% 2.4% 0.0% 7.5% 7.6% 0.0% 1,4% 0.0% 0.0% 4.5% 4.9% 1.7% 2.4% 0.8% 0.7% 2.9% 2.8% 2.4% 2.9% 2.1% 1.2% QIS 8b1: Permanent Stoma rate is not more than 40% in patients with rectal cancer 21.7% 31.6% 8.7% 21.4% 7.7% 23.8% 9.3% 19.0% 15.0% 15.4% 14.3% 27.6% 31.8% 25.6% 22.6% 14.0% 11.1% 9.5% 15.0% 16.0% 12.4% 6.3% 11.8% 9.5% SA C07/11 W 09/06/2011 8

9 SUMMARY OF ACHIEVEMET AGAIST ATIOAL STADARDS: SCA (See notes overleaf) ational Standard SCA CSBS 8b: 100% of Patients to Start XRT within 4 wks of seeing an Oncologist 56.3% 56.5% 80.0% 88.3% 88.3% 84.5% QIS 5b1: The rectum and whole colon is visualised by Colonoscopy or CT Colonography preoperatively (or when this is not possible because of the nature of the tumour, within 12 months of resection) in 95% of patients undergoing treatment with curative intent. 56.3% 59.0% 59.5% 59.5% 87.2% 79.3% QIS Standard 5c1: A CT Scan of the chest, abdomen & pelvis is performed preoperatively (or postoperatively where preoperative scanning is not possible because of emergency presentation) in 90% of patients undergoing surgery for bowel cancer 87.4% 94.3% 88.7% 89.7% 91.9% 94.9% QIS 7c1: Anastomotic Dehiscence is not more than 5% after surgery resulting in colonic anastomosis /R /R 1.3% 2.6% 1.8% 1.5% QIS 7c2: Anastomotic Dehiscence is not more than 10% after surgery resulting in rectal anastomosis /R 8.0% 7.7% 3.8% 4.1% 5.6% QIS 7c3: Anastomotic Dehiscence is not more than 20% after Anterior Resection with Total Mesorectal Excision for rectal cancer 9.2% 7.1% 10.3% 6.3% 8.4% 9.4% QIS 8a1: Treatment Related Mortality is less then 5% after elective surgery 5.3% 4.8% 1.7% 2.8% 1.6% 0.8% QIS 8b1: Permanent Stoma rate is not more than 40% in patients with rectal cancer 20.0% 20.3% 11.6% 11.4% 11.7% 13.7% SA C07/11 W 09/06/2011 9

10 SUMMARY OF ACHIEVEMET AGAIST ATIOAL STADARDS OT PREVIOUSLY REPORTED HS QIS Standard BGH DGRI FIFE LOTHIA SCA QIS Standard 2a1: All patients have access to a Clinical urse Specialist (CS) 97.5% 95.6% 97.6% 87.8% 91.9% QIS Standard 2b4: There is a weekly Multidisciplinary Team Meeting (MDT) at which all patients are discussed 97.4% 98.2% 99.5% 97.7% 98.2% QIS Standard 2b5: All patients for rectal cancer resection are reviewed at the MDT Meeting preoperatively, unless clinical circumstances dictate otherwise 100.0% 100.0% 100.0% 95.1% 97.5% QIS Standard 4b1: In a minimum of 95% of patients who receive adjuvant chemotherapy, the time between surgery and start of adjuvant chemotherapy is not more than 56 days 50.0% 94.1% 81.1% 79.5% 78.8% QIS Standard 5a1: Patients considered for elective treatment are assessed by digital rectal examination (DRE) and either computed tomography (CT) scanning or magnetic resonance imaging (MRI) scanning of the primary tumour 100.0% 100.0% 98.3% 99.3% 99.2% QIS Standard 5d1: All elective patients who require a stoma are assessed preoperatively by a CS with expertise in stoma care 100.0% 42.9% 100.0% 86.3% 88.2% QIS Standard 5e1: All patients receive DVT prophylaxis preoperatively 96.8% 96.7% 100.0% 59.1% 76.4% QIS Standard 5e2: All patients receive Antibiotic prophylaxis preoperatively 96.8% 92.3% 100.0% 58.9% 75.6% QIS Standard 6a2: All patients with histologically involved Circumferential Margin (CRM) after resection for rectal cancer, receive postoperative radiotherapy (with or without concurrent chemotherapy) unless there is a documented contraindication 0.0% 0.0% 100.0% 0.0% 8.3% QIS Standard 6b1: All distal resection margins are free of tumour 95.2% 98.9% 98.1% 94.7% 96.0% QIS Standard 6b2: In patients undergoing primary resection (i.e. without preoperative radiotherapy or chemoradiotherapy) for rectal cancer, a minimum of 90% of circumferential margins (CRM) are free of tumour 100.0% 94.7% 97.7% 94.9% 96.2% SA C07/11 W 09/06/

11 OTES O SUMMARY OF STADARDS From 2005 Treatment Related Mortality and Permanent Stoma Rate measures will be presented against Health Board of Surgery rather than Health Board of Diagnosis From 2007 Preoperative visualisation of the whole colon Anastomotic Dehiscence after colonic anastomosis Anastomotic Dehiscence after rectal anastomosis Anastomotic Dehiscence after anterior resection with TME Treatment Related Mortality Permanent Stoma Rate are measured against Bowel Cancer HS Quality Improvement Scotland Clinical Standards (revised March 2008) In order to bring data in line with national analysis, from 2008: Standard 5b1 has been measured excluding non definitive surgery Standard 7c2 has not been restricted to patients with rectal cancer only and TME has been excluded Standard 8a1 has been measured excluding non definitive surgery Performance against Standards, for patients diagnosed in 2008, is highlighted by a system of Colour-coding as follows: Green indicates 95.0% - 100% achievement against target Amber indicates 75% % achievement against target Red <75% target not achieved From 2009 CSBS Standard 9c: 100% of patients to have Chest X-Ray or CT Chest performed preoperatively will now be measured against QIS Standard 5c1: A CT Scan of the chest, abdomen and pelvis is performed preoperatively (or postoperatively where preoperative scanning is not possible because of emergency presentation) in 90% of patients undergoing surgery for bowel cancer SA C07/11 W 09/06/

12 SUMMARY OF PATIETS BY KEY CATEGORIES Table 1: Rectal v Other Colorectal patients, percentage of Patients undergoing Surgery o of Patients Diagnosed umber of patients diagnosed with rectal cancer umber of patients diagnosed with rectal cancer who had surgery All patients who had surgery BGH % % % DGRI % % % FIFE % % % WGH % % % SCA % % % Table 2: Rectal v Other Colorectal patients, percentage of patients undergoing definitive surgery (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) o of Patients Diagnosed umber of patients diagnosed with rectal cancer umber of patients diagnosed with rectal cancer who had definitive surgery All patients who had definitive surgery BGH % % % DGRI % % % FIFE % % % WGH % % % SCA % % % Table 3: Emergency v. Elective Surgery (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) All Patients who had Definitive surgery Emergency Elective ot Recorded Missing Data BGH % % 0 0.0% 0 0.0% DGRI % % 0 0.0% 0 0.0% FIFE % % 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% Clinical Comment by Mr T Daniel, Consultant Surgeon, Fife: The Central Referral Unit in Fife has been running for the past 5 years and allows for GPs to send all suspicion of cancer referrals to this unit where they should be reviewed and appointed within 14 days. As a result of this, particularly in the last 2-3 years, this appears to have been responsible for a downward trend in emergency admissions to hospitals in Fife. SA C07/11 W 09/06/

13 Table 4: Rectal Cancer Patients Emergency v. Elective Surgery (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) All Rectal Patients who had Definitive Surgery Emergency Elective ot Recorded Missing Data BGH % % 0 0.0% 0 0.0% DGRI % % 0 0.0% 0 0.0% FIFE % % 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% Table 5: Intent of Surgery (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) All Patients who had Definitive Surgery Curative Palliative ot Recorded Missing Data BGH % 6 9.7% 0 0.0% 0 0.0% DGRI % 2 2.2% 3 3.3% 0 0.0% FIFE % % 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 3 0.4% 0 0.0% Clinical Comment: Colonic stenting facilities are available within Lothian and Fife, with interventional radiology available every 2 3 weeks within DGRI and only 1 Gastroenterologist available to Borders. Borders patients can be sent to the Western General Hospital, Edinburgh for stenting purposes. Table 6: Intent of Surgery (All Patients with Rectal Cancer who had surgery (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc)) All Patients with Rectal Cancer who had Definitive Surgery Curative Palliative ot Recorded Missing Data BGH % 2 9.5% 0 0.0% 0 0.0% DGRI % 0 0.0% 1 3.3% 0 0.0% FIFE % 4 9.1% 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 1 0.5% 0 0.0% SA C07/11 W 09/06/

14 Table 7: Sex Total Patients Diagnosed Male Female BGH % % DGRI % % FIFE % % WGH % % SCA % % Table 8: Age at Diagnosis BGH DGRI FIFE WGH SCA < % 0 0.0% 2 1.0% 6 1.2% 9 1.0% % 3 2.7% % % % % % % % % % % % % % % % % % % % % % % % % 4 3.5% 8 3.9% 9 1.8% % Total % % % % % Table 9: Tumour Site Site of Tumour BGH % DGRI % Fife % WGH % SCA % Appendix Ascending Colon Caecum Colon Unspecified Descending Colon Hepatic Flexure Rectum Sigmoid Colon Splenic Flexure Transverse Colon Overlapping Lesion ot Recorded Missing Data Total SA C07/11 W 09/06/

15 Table 10: Dukes Stage BGH % DGRI % Fife % WGH % SCA % Dukes A Dukes B Dukes C Dukes C Dukes D Inapplicable ot Recorded Missing Data Total Clinical Comment: Mr S. Whitelaw, Lead Clinician, DGRI, noted the high percentage of Dukes A cancers within Dumfries & Galloway and felt that this was due to under staging i.e. numbers of lymph nodes harvested. Mr Mander, SCA Group Chair, offered to conduct a comparative study of the other SCA Health Boards. 1 umbers showing an inapplicable Dukes Staging include patients who had no surgery, or patients who had polypectomies, stents, or defunctioning stomas, for whom Dukes Stage would not be assessable. SA C07/11 W 09/06/

16 Table 11: Radiotherapy All Patients diagnosed with Rectal Cancer who received Radiotherapy or Chemoradiotherapy eoadjuvant Single Therapy eoadjuvant Combined Therapy Primary Radical Adjuvant Postoperative Palliative ot Recorded BGH % % 0 0.0% 0 0.0% % 0 0.0% DGRI % % 0 0.0% 0 0.0% 1 6.3% 0 0.0% FIFE % % 0 0.0% 2 7.4% 1 3.7% 0 0.0% WGH % % 2 3.8% 0 0.0% % 0 0.0% SCA % % 2 1.8% 2 1.8% % 0 0.0% Clinical Comment by Mr T Daniel, Consultant Surgeon, Fife: Mr Daniel noted that all rectal patients in Fife were seen by Oncologist who then decided whether neoadjuvant treatment was appropriate. Mr BJ Mander noted that the practice within Lothian was to discuss these patients at the MDM where a joint surgical/oncology decision was made as to the appropriateness of neoadjuvant treatment. Table 12: Chemotherapy All patients who received Chemotherapy or Chemoradiotherapy eoadjuvant Primary Chemotherapy Palliative Chemotherapy Adjuvant Chemotherapy ot Recorded BGH % 0 0.0% % % 1 3.6% DGRI % 0 0.0% % % 1 3.2% FIFE % 0 0.0% % % 0 0.0% WGH % 3 2.1% % % 0 0.0% SCA % 3 1.1% % % 2 0.8% SA C07/11 W 09/06/

17 STADARD 2: MULTIDISCIPLIARY WORKIG QIS Standard 2a1: All patients have access to a Clinical urse Specialist (CS) = All Colorectal Cancer Patients All patients who were seen by a Clinical urse Specialist (CS) All patients who were not seen by a Clinical urse Specialist (CS) ot Patient Recorded Refused Missing Data BGH % 2 2.5% 0 0.0% 0 0.0% 0 0.0% D&G % 5 4.4% 0 0.0% 0 0.0% 0 0.0% FIFE % 5 2.4% 0 0.0% 0 0.0% 0 0.0% WGH % % 0 0.0% 2 0.4% 0 0.0% SCA % % 0 0.0% 2 0.2% 0 0.0% Clinical Comment: Within Lothian, the high percentage of patients not seen by CS is attributable to the fact that there is no policy/protocol for polyp cancer patients to be referred to the CS Service. QIS Standard 2b4: There is a weekly Multidisciplinary Meeting (MDT) at which all patients are discussed = All Colorectal Cancer Patients (exc patients who died before treatment) All patients discussed at MDT All patients not discussed at MDT ot Recorded Missing Data BGH % 1 1.3% 1 1.3% 0 0.0% D&G % 2 1.8% 0 0.0% 0 0.0% FIFE % 1 0.5% 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 1 0.1% 0 0.0% QIS Standard 2b5: All patients for rectal cancer resection are reviewed at the Multidisciplinary Team Meeting (MDT) preoperatively, unless clinical circumstances dictate otherwise. = All rectal cancer patients undergoing resection (exc patients who died before treatment and emergency presentations) All patients diagnosed with rectal cancer - discussed preoperatively at MDT All patients diagnosed with rectal cancer - not discussed preoperatively at MDT ot Recorded Missing Data BGH % 0 0.0% 0 0.0% 0 0.0% D&G % 0 0.0% 0 0.0% 0 0.0% FIFE % 0 0.0% 0 0.0% 0 0.0% WGH % 5 4.9% 0 0.0% 0 0.0% SCA % 5 2.5% 0 0.0% 0 0.0% SA C07/11 W 09/06/

18 STADARD 3: AUDIT QIS Standard 3a.3: There is a minimum of 90% case ascertainment against cancer registry data Registration Registered in Audit Jan - Dec 2009 % Estimated Case Ascertainment 2009 BGH % DGRI % FIFE % LOTHIA % SCA % SCA umbers recorded in audit and 5 Year Averages Cancer Year Averages Registration 5 Year Average BGH DGRI FIFE LOTHIA SCA In Dumfries and Galloway, Cancer Registration includes all patients resident within this area. Some patients, however, choose to attend hospital in Carlisle and therefore diagnosis and treatment occur in England. While these patients are included in Cancer Registry figures they are not included in Dumfries & Galloway data which excludes patients diagnosed outwith Scotland, as per the national dataset. From 2009 onwards private patients and patients whose normal residence is outwith Scotland but who have any part of their treatment within the HS are included in the audit. For the purposes of data continuity and quality, these patients have been noted separately as follows: HS Lothian: 6 private patients who had part of their treatment within the HS HS Fife: 1 patient whose normal residence was outwith Scotland HS DGRI: 2 patients whose normal residence was outwith Scotland 2 Source: Scottish Cancer Registry SA C07/11 W 09/06/

19 STADARD 4: WAITIG TIMES QIS Standard 4b1: In a minimum of 95% of patients who receive adjuvant chemotherapy, the time between surgery and start of adjuvant chemotherapy is not more than 56 days = All patients receiving adjuvant chemotherapy All patients commencing adjuvant Chemotherapy <56 days from Surgery All patients commencing adjuvant chemotherapy >56 days from Surgery ot Recorded Missing Data BGH % % 0 0.0% 0 0.0% D&G % 1 5.9% 0 0.0% 0 0.0% FIFE % % 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% Clinical Comment: Only 1 Oncologist is available to BGH and therefore during holiday periods etc the waiting time from surgery to commencement of adjuvant chemotherapy can be increased. CSBS Standard 8b: Time from 1st seeing an Oncologist to the start of radiotherapy is not more than 4 weeks 3 = All rectal cancer patients receiving radiotherapy Within 4 weeks Over 4 weeks ot Recorded Missing Data BGH % % 0 0.0% 0 0.0% D&G % 0 0.0% 0 0.0% % FIFE % % 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 2 1.8% % of Patients receiving Radiotherapy within 4 weeks of seeing an Oncologist Over 6 years across SCA BGH 50.0% 46.2% 72.7% 66.7% 87.5% 85.7% DGRI 71.4% 85.7% 100.0% 86.7% 100.0% 100.0% FIFE 52.9% 45.8% 78.9% 89.5% 76.5% 77.8% WGH 60.0% 60.0% 78.1% 92.3% 85.2% 83.0% SCA 56.3% 56.5% 80.0% 88.3% 88.3% 84.5% 3 This measurement is no longer included within the Bowel Cancer HS Quality Improvement Scotland Clinical Standards (revised March 2008), it was however felt important to continue to monitor this within the SCA region. SA C07/11 W 09/06/

20 SCA % of patients receiving radiotherapy within 4 weeks of seeing an Oncologist 100.0% 80.0% 80.0% 88.3% 88.3% 84.5% 60.0% 40.0% 56.3% 56.5% SCA 20.0% 0.0% SA C07/11 W 09/06/

21 STADARD 5: PREOPERATIVE PREPARATIOS/IVESTIGATIOS QIS Standard 5a1: Patients being considered for elective treatment are assessed by digital rectal examination (DRE) and either computed tomography (CT) scanning or magnetic resonance imaging (MRI) scanning of the primary tumour = All rectal cancer patients (exc emergency presentations) Performed ot Performed Result ot Recorded Missing Data BGH % 0 0.0% 0 0.0% 0 0.0% D&G % 0 0.0% 0 0.0% 0 0.0% FIFE % 1 1.7% 0 0.0% 0 0.0% WGH % 1 0.7% 0 0.0% 0 0.0% SCA % 2 0.8% 0 0.0% 0 0.0% QIS Standard 5b.1: The rectum and whole colon is visualised by Colonoscopy or CT Colonography preoperatively (or when this is not possible because of the nature of the tumour, within 12 months of resection) in 95% of patients undergoing treatment with curative intent. = All colorectal cancer patients undergoing curative resection by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Visualised 1 ot Visualised Results /R Missing Data BGH % % 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% FIFE % 6 4.7% 0 0.0% 0 0.0% WGH % % 2 0.6% 0 0.0% SCA % % 2 0.3% 0 0.0% For DGRI: 1 = 23 14/23 not visualised 3/23 patients deceased prior to completion colonoscopy 3/23 patients attempted completion colonoscopy but investigation failed 1/23 patient refused all follow up 1/23 patient not fit for colonoscopy 1/23 patient now resident in orthern Ireland For Lothian: 1 = 42 Colonoscopies/CT Colon not performed + 42 incomplete colonoscopies 30/42 colonoscopies/ct Colon which were not performed were emergency presentations 12/42 colonoscopies/ct Colon which were not performed were elective presentations 28/42 colonoscopies which were incomplete are within 1 year post surgery 14/42 colonoscopies which were incomplete are over 1 year post surgery Clinical Comment: It was noted that the percentage attainment of this standard had improved generally but that there was still room for improvement. Preoperative Visualisation of the whole Colon throughout SCA Region and over 3 years BGH 57.9% 83.3% 76.8% DGRI 75.0% 65.6% 73.3% FIFE 82.1% 88.3% 95.3% WGH 48.5% 91.1% 75.4% SCA 59.5% 87.2% 79.3% SA C07/11 W 09/06/

22 QIS Standard 5c1: A CT Scan of the chest, abdomen and pelvis is performed preoperatively (or postoperatively where preoperative scanning is not possible because of emergency presentation) in 90% of patients undergoing surgery for bowel cancer Elective surgery patients having preoperative CT Chest Scan = All colorectal cancer patients undergoing elective resection by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) CT Chest Performed CT Chest ot Performed Result ot Recorded Missing Data BGH % 0 0.0% 0 0.0% 0 0.0% D&G % 0 0.0% 0 0.0% 0 0.0% FIFE % 2 1.4% 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% Emergency surgery patients having preoperative CT Chest Scan = All colorectal cancer patients undergoing emergency resection by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) CT Chest Performed CT Chest ot Performed Result ot Recorded Missing Data BGH % 0 0.0% 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% FIFE % 0 0.0% 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% All surgical patients who had CT Chest Scan = All colorectal cancer patients undergoing resection by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) CT Chest Performed CT Chest ot Performed Result ot Recorded Missing Data BGH % 2 3.2% 0 0.0% 0 0.0% D&G % 4 4.4% 0 0.0% 0 0.0% FIFE % 2 1.3% 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% SA C07/11 W 09/06/

23 QIS Standard 5c1: A CT Scan of the chest, abdomen and pelvis is performed preoperatively (or postoperatively where preoperative scanning is not possible because of emergency presentation) in 90% of patients undergoing surgery for bowel cancer Elective surgery patients having preoperative CT Abdomen & Pelvis = All colorectal cancer patients undergoing elective resection by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Liver Imaging Performed Liver Imaging ot Performed Result ot Recorded Missing Data BGH % 0 0.0% 0 0.0% 0 0.0% D&G % 0 0.0% 0 0.0% 0 0.0% FIFE % 2 1.4% 0 0.0% 0 0.0% WGH % 8 2.4% 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% Emergency surgery patients having preoperative CT Abdomen & Pelvis = All colorectal cancer patients undergoing emergency resection by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Liver Imaging Performed Liver Imaging ot Performed Result ot Recorded Missing Data BGH % 0 0.0% 0 0.0% 0 0.0% D&G % 1 5.9% 0 0.0% 0 0.0% FIFE % 0 0.0% 0 0.0% 0 0.0% WGH % 1 1.6% 0 0.0% 0 0.0% SCA % 2 2.0% 0 0.0% 0 0.0% All surgical patients having CT Abdomen & Pelvis = All colorectal cancer patients undergoing resection by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Liver Imaging Performed Liver Imaging ot Performed Result ot Recorded Missing Data BGH % 1 1.6% 0 0.0% 0 0.0% D&G % 1 1.1% 0 0.0% 0 0.0% FIFE % 2 1.3% 0 0.0% 0 0.0% WGH % 9 2.3% 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% SA C07/11 W 09/06/

24 QIS Standard 5d1: All elective patients who require a stoma are assessed preoperatively by a Clinical urse Specialist (CS) with expertise in stoma care = All patients presenting electively for surgery and having an operation involving stoma creation Patients seen preoperatively by CS with expertise in Stoma Care Patients ot seen preoperatively by CS with expertise in Stoma Care ot Recorded Missing Data BGH D&G FIFE WGH SCA % 8 6.7% 2 1.7% 4 3.4% The above table has been amended to avoid disclosure of potentially patient identifiable information QIS Standard 5e1: All patients receive DVT prophylaxis preoperatively = All colorectal cancer patients undergoing surgery by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Patients receiving DVT Prophylaxis Patients not receiving DVT Prophylaxis ot Missing Recorded Data BGH % 0 0.0% 2 3.2% 0 0.0% D&G % 0 0.0% 0 0.0% 3 3.3% FIFE % 0 0.0% 0 0.0% 0 0.0% WGH % 2 0.5% 7 1.8% % SCA % 2 0.3% 9 1.3% % QIS Standard: 5e2: All patients receive Antibiotic prophylaxis preoperatively = All colorectal cancer patients undergoing surgery by hospital of diagnosis (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Patients receiving Antibiotic Prophylaxis Patients not receiving Antibiotic Prophylaxis ot Missing Recorded Data BGH % 0 0.0% 2 3.2% 0 0.0% D&G % 3 3.3% 2 2.2% 2 2.2% FIFE % 0 0.0% 0 0.0% 0 0.0% WGH % 2 0.5% % % SCA % 5 0.7% % % For Lothian: The high percentage of missing data is directly attributable to the fact that this data item is only available within the casenotes, and is not recorded on any electronic system. However, from 2010 this information is recorded on the paper Surgical Safety Checklist forms completed under the Scottish Patient Safety Programme (SPSP). These have been made available to the audit facilitator making data capture more efficient. For DGRI: Due to data collection error 2 patients are missing data. These patients are now deceased and it has not been possible to gain access to casenotes. SA C07/11 W 09/06/

25 STADARD 6: THERAPEUTIC MAAGEMET QIS Standard 6a2: All patients with histologically involved Circumferential Margin (CRM) after resection for rectal cancer, receive postoperative radiotherapy (with or without concurrent chemotherapy) unless there is a documented contraindication = Rectal cancer patients undergoing a surgical procedure and having histologically involved Circumferential Margin (CRM) after surgery (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Patients receiving postoperative Radiotherapy for involved CRM Postoperative radiotherapy contra-indicated in patients with involved CRM ot Missing Recorded Data BGH % 0 0.0% 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% FIFE % 0 0.0% 0 0.0% 0 0.0% WGH % % 0 0.0% 0 0.0% SCA % % 0 0.0% 0 0.0% For Lothian 7/10 patients had preoperative radiotherapy/chemoradiotherapy 3/10 patients had contraindications to postoperative radiotherapy as indicated by Dr HA Phillips QIS Standard 6b1: All distal resection margins are free of tumour = All colorectal cancer patients undergoing surgery (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Surgical patients with clear distal resection margins Surgical patients with involved distal resection margins ot Recorded Inapplicable BGH % 1 1.6% 0 0.0% 2 3.2% D&G % 0 0.0% 1 1.1% 0 0.0% FIFE % 2 1.3% 1 0.6% 0 0.0% WGH % 0 0.0% 0 0.0% % SCA % 3 0.4% 2 0.3% % For Lothian 12/21 marked as inapplicable = no residual tumour post polypectomy 3/21 marked as inapplicable = no residual tumour post chemotherapy/chemoradiotherapy 2/21 marked as inapplicable = polypoidal tumours 4/21 marked as inapplicable = appendicele tumours SA C07/11 W 09/06/

26 QIS Standard 6b2: In patients undergoing primary resection (i.e. without preoperative radiotherapy or chemoradiotherapy) for rectal cancer, a minimum of 90% of Circumferential Margins (CRM) are free of tumour = All rectal cancer patients undergoing primary resection (exc patients having non definitive surgery i.e. Endoscopic treatment/stents/defunctioning Stomas/Bypass surgery etc) Surgical patients with clear CRM resection margins Surgical patients with involved CRM resection margins ot Recorded Inapplicable BGH % 0 0.0% 0 0.0% 0 0.0% D&G % 1 5.3% 0 0.0% 0 0.0% FIFE % 1 2.3% 0 0.0% 0 0.0% WGH % 3 5.1% 0 0.0% 0 0.0% SCA % 5 3.8% 0 0.0% 0 0.0% For Lothian: 3/59 patients had contraindications to preoperative radiotherapy as indicated by Dr HA Phillips SA C07/11 W 09/06/

27 STADARD 7: POSTOPERATIVE MAAGEMET QIS Standard 7c1: Anastomotic dehiscence is not more than 5% after colonic anastomosis = All colorectal cancer patients undergoing a surgical procedure involving anastomosis of the colon Anastomotic Dehiscence o Anastomotic Dehiscence ot Recorded Missing Data BGH % % 0 0.0% 0 0.0% DGRI % % 0 0.0% 0 0.0% FIFE % % 0 0.0% 0 0.0% WGH % % 5 3.0% 0 0.0% SCA % % 5 1.5% 0 0.0% For Lothian: Discharge summaries were not written in 5 cases and therefore postoperative complications have been marked as not recorded QIS Standard 7c2: Anastomotic dehiscence is not more than 10% after rectal anastomosis = All colorectal cancer patients undergoing a surgical procedure involving anastomosis of the rectum (excluding patients who had a total mesorectal excision (TME)) Anastomotic Dehiscence o Anastomotic Dehiscence ot Recorded Missing Data BGH % % 0 0.0% 0 0.0% DGRI % % 0 0.0% % FIFE % % 0 0.0% 0 0.0% WGH % % 4 3.1% 0 0.0% SCA % % 4 2.0% 3 1.5% For Lothian: Discharge summaries were not written in 4 cases and therefore postoperative complications have been marked as not recorded. QIS Standard 7c3: Anastomotic dehiscence is not more than 20% after anterior resection with total mesorectal excision for rectal cancer = All rectal cancer patients undergoing a surgical anterior resection and total mesorectal excision (TME) Anastomotic Dehiscence Rate after Anterior Resection with Total Mesorectal Excision (TME) BGH % DGRI % FIFE % WGH % SCA % Anastomotic Dehiscence Rate after Anterior Resection with TME (Total Mesorectal Excision) throughout SCA Region and over 6 years BGH 0.0% 0.0% 10.0% 0.0% 20.0% 12.5% DGRI 10.5% 0.0% 0.0% 0.0% 18.8% 0.0% FIFE 0.0% 8.3% 0.0% 0.0% 3.8% 0.0% WGH 14.3% 7.9% 14.7% 13.3% 5.6% 13.2% SCA 9.2% 7.1% 10.3% 6.3% 8.4% 9.4% SA C07/11 W 09/06/

28 STADARD 8: OUTCOMES QIS Standard 8a1: Treatment related mortality (defined as death occurring within 30 days of treatment (i.e. <=30)) is not >5% Treatment related mortality (defined as death occurring within 30 days of treatment (i.e. <=30)) by Health Board Area and Hospital of Surgery. = 1 All patients undergoing elective surgery by Health Board of diagnosis = 2 All patients undergoing elective surgery by Health Board of surgery ( 1 and 2 exclude patients having non-definitive surgery i.e. polypectomies, stents and defunctioning stomas) Health Board of Died <31 Days Diagnosis 1 following Surgery 2 Fife patients had surgery at the Western General Hospital, Edinburgh 4 BGH patients had surgery at the Western General Hospital, Edinburgh Comparative Table showing Treatment Related Mortality Rate by Health Board of Diagnosis and Health Board of Surgery Died <31 Days following Surgery Health Board of Surgery 2 BGH % Borders % DGRI % D&GRI % FIFE % QMH % LOTHIA % Lothian % SCA % SCA % Treatment Related Mortality throughout SCA Region and over 6 years SCA 5.3% 4.8% 1.7% 2.8% 1.6% 0.8% Treatment Related Mortality throughout SCA Region and over 6 years 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 5.3% 4.8% 2.8% 1.6% 1.7% 0.8% SA C07/11 W 09/06/

29 QIS Standard 8b1: Permanent stoma rate is not more than 40% in patients with rectal tumours In many cases it is not possible to tell if a stoma is permanent until a number of years have passed. For the purposes of this report, a stoma will be defined as permanent only for those procedures (abdominoperineal resection and colostomy and panproctocolectomy and ileostomy) where the stoma was fashioned with the intention of being permanent. Patients left with permanent stoma after rectal cancer surgery by Hospital Board area and Hospital of Surgery = 1 All rectal cancer patients undergoing elective surgery by Health Board of diagnosis = 2 All rectal cancer patients undergoing elective surgery by Health Board of surgery Patients left with Permanent Stoma, by Heallth Board of Diagnosis % Permanent Stoma Rate Patients left with permanent Stoma, by Health Board of surgery % Permanent Stoma Rate Health Board of Diagnosis 1 Health Board of Surgery 2 Borders BGH D&G DGRI Fife QMH/VHK Lothian Lothian SCA % SCA % The above table has been amended to avoid disclosure of potentially patient identifiable information 2 Fife patients had surgery at Western General Hospital, Edinburgh. SA C07/11 W 09/06/

30 GLOSSARY (Edited selection based on HS QIS Bowel Cancer Standards, published 2008) Adjuvant Therapy Anastomosis Anastomotic dehiscence Antibiotic prophylaxis Audit BGH Bowel Cancer Cancer centre Clinical Governance Clinical urse Specialist (CS) The Clinical Standards Board for Scotland/HS QIS From 1 st April 2011 the body encompassing these roles is Healthcare Improvement Scotland (HIS) Colon Colonic anastomosis The use of chemotherapy and/or radiotherapy in addition to surgery. The aim of adjuvant therapy is to destroy any cancer that has spread. An artificial connection, created by surgery, between two tubular organs or parts, especially between two parts of the intestine. For example, a junction created by a surgeon between two pieces of bowel which have been cut to remove the intervening section. Bursting open or splitting of the surgical connection between two sections of intestine The administration of antibiotics to reduce the risk of infection. The measuring and evaluation of care against best practice with a view to improving current practice and care delivery. Borders General Hospital A tube-like structure which runs from the stomach to the anus. It allows digestion of food and the discharge of waste products. The name given to a group of diseases that can occur in any organ of the body, and in blood, and which involve abnormal uncontrolled growth of cells. Cancer services are based in cancer centres. Such centres provide the entire spectrum of cancer care - both on-site and to associated cancer units. Ensures that patients receive the highest quality of care possible, putting each patient at the centre of his or her care. This is achieved by making certain that those providing services work in an environment that supports them and places the safety and quality of care at the top of the organisation's agenda. A clinical nurse specialist is a registered nursing professional who has acquired additional knowledge, skills and experience, together with a professionally and/or academically accredited post-registration qualification (if available) in a clinical speciality. They practice at an advanced level and may have sole responsibility for a care episode or defined client/group. The Clinical Standards Board for Scotland was a statutory body, established as a Special Health Board in April Its role was to develop and run a system of quality control for clinical services designed to promote public confidence that the services provided by the HS met nationally agreed standards, and to demonstrate that, within the resources available, the HS was delivering the highest possible standards of care. On January 2003, CSBS was merged, along with four other clinical effectiveness bodies, to form HS Quality Improvement Scotland (HS QIS) Part of the bowel. Also called the large intestine or large bowel. This structure has five major divisions: caecum, ascending colon, transverse colon, descending colon, and sigmoid colon. The colon is responsible for forming, storing and expelling waste matter into the rectum. A procedure in which a part of the colon is removed and the two remaining ends are rejoined. SA C07/11 W 09/06/