Colorectal NSSG. Constitution

Transcription

1 Colorectal NSSG Constitution For approvals and version control see Document Management Record on page 10 Ref No: AngCN-SSG-C7 Page 1 of 10

2 Table of Contents 1 Membership of the Colorectal NSSG (1A-201d) Terms of Reference (1A-201d) Purpose Service Planning Service Improvement / Redesign Service Quality Monitoring and Evaluation Workforce Development Research and Development Annual Work Plan and Report Membership Frequency of Meetings Data Collection (1C-118d) Minimum Dataset (MDS) MDT electronic registry data submission Clinical and Referral Guidelines (1A-202d, 203d, d, 1C- 103d 117d, 122d, 123d) Evidence of Agreement (1C-102d)...10 Page 2 of 10

3 1 Membership of the Colorectal NSSG (1A-201d) *Denotes Core NSSG members. NSSG Member Title and role within NSSG Deputy (if identified) Paul Cullen * Consultant Colorectal Surgeon at QEHKL NSSG Chair and Service Improvement James Pitt (Ipswich Hospital) Lead Cambridge Nigel Hall * Consultant Colorectal and General Surgeon Justin Davies Catherine Jephcott * (also represents Oncologist NSSG Research Lead and Oncology Charles Wilson Peterborough) Lead Sue Wilkinson Lead Colorectal Nurse Katie Sloan and Karen Goodwin Charles Wilson Consultant Clinical Oncologist Anal Cancer Lead Hugo Ford Bedford Max Wilde * Consultant General Surgeon Ahmed Eldin Karen Richards* Clinical Nurse Specialist and Lead for user issues and information for patient Adailia Paul and carers Hinchingbrooke Anthony Booth * Consultant Radiologist Rebecca Baranyovits Colorectal Nurse Specialist Dahila Marsh Emma Taggart Patient Pathway Coordinator Karen Harland Ipswich James Pitt * Claire Swann Rubin Soomal Sharon Whatling James Paget Roshan Lal * Consultant Colorectal Surgeon and Deputy NSSG Chair Colorectal Nurse Specialist Consultant Oncologist Deputy Anal Cancer Lead MDT Coordinator Consultant Colorectal Surgeon Kamal Aryal Consultant Colorectal Surgeon Mary Jordan Colorectal Nurse Specialist Helen Cox Judith Clegg Colorectal MDT Coordinator Page 3 of 10

4 Queen Elizabeth Hospital, Kings Lynn Consultant Colorectal Surgeon Zulfi Khan * Aejaz Syed Consultant Radiologist Radiology Lead Jonathan Easterbrook Marion Steward Colorectal Nurse Specialist Angela Simpson Norfolk and Norwich James Hernon * Consultant Colorectal Surgeon James Hernon Daniel Epurescu Medical Oncologist Debashis Biswas Jane McCulloch Colorectal Nurse Specialist Gek-Bee Cain Peterborough Alan Wells * Catherine Jephcott * (note also represents Cambridge) Consultant Colorectal and General Surgeon Oncologist NSSG Research Lead and NSSG Oncology Lead Rohit Makhija Abigail Hollingdale Angeline Boaden Consultant Nurse Colorectal Services Gaynor O Sullivan West Suffolk Tim Justin * Maggie Harold Sam Dhungana Consultant Colorectal & General Surgeon Colorectal Nurse Specialist Cancer Lead Manager Anglia Cancer Network Martin Bate* Sally Donaghey Project Manager AHP Lead Gemma Emsden Mary Emurla PCT Commissioner Representatives Groups and Project Support Officer Associate Director / Programme Manager Chris Youngman Commissioner, NHS Cambridgeshire Karen Hayton Patient Representatives Alan Stephens * Tony Rollo * Rae Berrill * Patient representative Patient representative Patient representative Cover each other Cancer Research Network Representatives Natalie Barber Vacant post Anglia East Cancer Research Network West Anglia Cancer Research Network Page 4 of 10

5 2 Terms of Reference (1A-201d) 2.1 Purpose The Network Site Specific Group (NSSG) is accountable to the Network Board and should be recognised as: The Board's primary source of clinical opinion on issues relating to cancer for the Network The group with corporate responsibility, delegated by the board, for co-ordination and consistency across the Network for cancer policy, practice guidelines, audit, research and service improvement. Consulting, where appropriate, with the relevant cross cutting network groups on issues involving chemotherapy, radiotherapy, cancer imaging, histopathology and laboratory investigation and specialist palliative care; and with the Head of Service on issues involving radiotherapy. 2.2 Service Planning NSSGs should ensure that service planning: Is in line with national guidance/standards (including reconfiguration where necessary). Covers the whole care pathway. Promotes high quality care and reduces inequalities in service delivery. Takes account of the views of patients and carers. Takes account of opportunities for service and workforce redesign. Establishes common guidelines, including clear referral guidelines. Recommend priorities for service development to the Network Policy Board. Ensure decisions become integrated into constituent organisational structures and processes. 2.3 Service Improvement / Redesign Review high impact changes to service areas and make recommendations for local applications. Requests for additional resources from NSSGs should be accompanied by evidence of involvement in service improvement/redesign. Develop/approve high quality information for patient, for use across the Network. Develop use of service improvement methodology. 2.4 Service Quality Monitoring and Evaluation Agree on priorities for common data collection (in line with national priorities e.g. for waiting times, Registries and NCASP), but go beyond this where possible. Review the quality and completeness of data, recommending corrective action where necessary. Produce audit data and participate in open review. Ensure services are evaluated by patients and carers. Monitor progress on meeting national cancer measures and ensure action plans agreed following peer review are implemented. Report identified risks/untoward incidents to ensure learning is spread. Page 5 of 10

6 2.5 Workforce Development Consider the overall workforce requirements for the NSSG. Consider the education and training needs of teams and, where appropriate, of individuals. Promote links between teams through rotation of staff. Take account of opportunities for skill mix changes. 2.6 Research and Development Agree a common approach to research and development, working with the network research team, participating in nationally recognised studies whenever possible. 2.7 Annual Work Plan and Report Draw the above together in an annual work plan in the context of a prioritised clinical governance development plan, for approval by the network board. Ensure this is fed into commissioning, with agreements specifying standards, service developments and improvement, data collection, audit, research, education and training. Provide an annual report of activity to feed health economy clinical governance reporting processes. 2.8 Membership NSSGs should be multidisciplinary: with representation from professionals across the care pathway; involve users in their planning and review; and have the active engagement of all MDT leads from the relevant constituent organisations in the Network. For purposes of continuity, each representative should have a named deputy. Core membership: - The MDT lead clinician from each MDT in the Network. - At least one nurse core member of a MDT in the Network. - A service improvement representative. - There should be a named Chair drawn from the above membership. - Two user representatives. - One of the NHS employed members of the NSSG should be nominated as having specific responsibility for users' issues and information for patients and carers. Membership should co-opt expertise as and when required. Sub-groups to be set up as necessary to discharge function. Membership of group will be reviewed on a two yearly basis. 2.9 Frequency of Meetings The Colorectal NSSG meets three times a year. Page 6 of 10

7 3 Data Collection (1C-118d) 3.1 Minimum Dataset (MDS) The Colorectal NSSG has agreed the MDS as follows: The Cancer Waiting Times (CWT) Including the new Going Further on Cancer Waits (GFoCW) standards, will be captured in accordance with DSCN 20/2008 and to the specified timetable as specified in the National Contract for Acute Services. The Cancer Registration Dataset, As specified in the National Contract for Acute Services. This is currently under review and is expected to be replaced by the Cancer Outcomes and Services Dataset (COSD) in late National Bowel Cancer Audit Programme (NBOCAP). All AngCN Trusts contribute to the National Bowel Cancer Audit, which measures aspects of process and outcome against a number of key standards or guidelines from NICE and the Association of Coloproctology of Great Britain and Ireland (ACPGBI). National Dataset for Colorectal Cancer Resection Histopathology Reports. The above data is collected by the Cancer Management teams in each Trust, is captured and stored on Trust hospital data systems as shown in the table below and is then imported to Open Exeter, the Eastern Cancer Registry and Information Centre (ECRIC) and NBOCAP. Where possible, all data should be inputted at source and transferred electronically. Trust Who captures data and how is it validated Data system CWT MDT Coordinator Cambridge Bedford Hinchingbrooke James Paget QEH, Kings Lynn Norfolk and Norwich Peterborough Clinical data - MDT Coordinator; some is imported directly from the pathology database and some is input directly by the surgeons (e.g. operation detail and ASA grade). quality checks the data. CWT added to Somerset by IT dept and MDT Coordinator proactively tracks the pts. Clinical data - MDT Coordinator works closely with the CNSs and consultants to input and validate the data. MDT Coordinator and quality checked by MDT Lead/CNS CWT - data is validated and uploaded to the National Database by Information Services. Clinical data is input by the MDT Co-ordinator and validated in conjunction with the Lead Clinician and Clinical Nurse Specialist CWT - filtered by the Information Dept who also run the validation checks for cancer services. Clinical data Pathway Coordinator/MDT Coordinator and validated by the MDT and Cancer Services. Clinical data - MDT Coordinator and then quality checked at the MDT by the nominated consultant. Collected by MDT Coordinator and checked by Consultant Nurse. JCIS Somerset Page 7 of 10

8 Trust Who captures data and how is it validated Data system West Suffolk Clinical data MDT Coordinator, booking clerk (2ww data), nurse and surgeon enters data which is validated fortnightly by the. Ipswich The data is collected by the cancer information team Infoflex 3.2 MDT electronic registry data submission ECRIC and the Network have developed a minimum dataset that MDTs are requested to send electronically each month to ECRIC. The dataset is a subset of the emerging national Cancer Outcomes and Services Dataset (COSD) that the Network has agreed is particularly important for ECRIC to collect to better understand cancer across the Network. Regular reports using InstantAtlas are provided on ECRIC s website detailing, Pathology; MDT Discussions and MDT data completeness. Reports are available via ECRIC s website (access is strictly monitored and by secure log-in only and the data is not available for the general public) and will be reported to NSSGs and the Network Board. Rather than report each MDT variable, ECRIC, in consultation with clinicians, have picked fields that highlight the level of data completeness for each tumour site. The minimum dataset is shown in the table below, with the most important data items highlighted in bold. MDT Data Item NHS No. Hospital No. First Name Surname Sex DoB Address Postcode MDT Date Consultant Name Consultant Code (if available) MDT Primary ICD10 Code Date of Diagnosis Clinical Diagnosis Y/N Recurrence Y/N Laterality Pre Treatment and Final Staging T, N, M Co-Morbidity Site Specific Staging/grade: Dukes, Breslow, Figo etc Treatment Intent Treatment Trust of Treatment Key Data Item Reported by Tumour Site Haematology All Breast, Lung Head and Neck (pre), Lower GI (pre and final), Lung (pre), Pancreatic (pre), Prostate (pre), Skin (final), Thyroid (pre), Upper GI (pre), Urology (pre) Gynae (Figo), Lower GI (Dukes), Prostate (Gleason), Skin (Breslow) Gynae, Haematology Page 8 of 10

9 4 Clinical and Referral Guidelines (1A-202d, 203d, d, 1C-103d 117d, 122d, 123d) The following Network-wide Guidelines have been produced and agreed by the NSSG, for current versions please see : Clinical Guidelines on the Management of Colorectal Cancer (AngCN-SSG-C5) (1C-103d) Clinical Guidelines on the Management of Anal Cancer (AngCN-SSG-C4) (1C-110d) Guidelines for the Referral and Management of Colorectal Cancer Patients suitable for Laparoscopic Surgery (AngCN-SSG-C11) (1C-122d and 123d) Please note the Guidelines on the Management of Colorectal Cancer (AngCN-SSG-C5) include the following: Referral guidelines (1A-203d and 205d, 1C-104d) Operational policies for colorectal diagnostic service (1A-202d, 1C-105d and106d) Investigation protocol (1C-107d) Clinical responsibility (1C-108 and 109d) Guidelines on the management of rectal cancer (1A-206d, 1C-111d) Colorectal Stenting Policy and named personnel (1C-113d) Policy on Referrals for Patients Outside the Agreed Primary Care Referral Process (1C-114d) Guidelines for surgical emergencies (1C-115d) Primary care referral guidelines (1C-116d) Assessment Protocol for Early Rectal Cancer (1C-117d) Please note the Guidelines on the Referral and Management of Colorectal Cancer Patients Suitable for Laparoscopic Surgery (AngCN-SSG-C11) include the following: The Network policy and list of laparoscopic colorectal cancer surgical practitioners (1C-122d) The Network criteria and referral guidelines on laparoscopic colorectal cancer surgery (1C- 123d) An appendix is kept for the laparoscopic guidelines which serve as evidence that individuals who are on the Colorectal NSSG agreed list of laparoscopic colorectal cancer surgical practitioners are suitably trained or exempt because they performed more than 20 laparoscopic resections prior to December This appendix is available from Network-wide Guidelines for the Resection of Liver Metastases have not yet been developed but will be in line with implementing the IOG recommendations for liver resections, which is ongoing and being led by the EoE SHA Specialist Commissioning Group (1A-207d, 1C-112d). Page 9 of 10

10 5 Evidence of Agreement (1C-102d) This Constitution has been agreed by: The Chair of the Network Board Name: Paul Watson Organisation: Suffolk PCT Date agreed: 29 June 2012 The Chair of the Colorectal NSSG Name: Paul Cullen Organisation: Queen Elizabeth Hospital, Kings Lynn Date agreed: 3 May 2012 The NSSG Members This document was discussed at the Colorectal NSSG meeting on 3 May 2012, was circulated by for review and feedback and was approved by Paul Cullen, the NSSG Chair, by . Document management Document history Review period: Two years or earlier in light of new evidence Date placed on electronic library: Authors: Colorectal NSSG Document Owner: Version number as approved and published: June Unique identifier: AngCN-SSG-C7 Anglia Cancer Network Tel: Monitoring the effectiveness of the Process a) Process for Monitoring compliance and Effectiveness - Review of compliance as determined by audit. Any non compliance to be presented by PQ Manager to the AngCN Business Meeting on an annual basis the minutes of this meeting are retained for a minimum of five years. b) Standards/Key Performance Indicators This process forms part of a quality system working to, but not accredited to, International Standard BS EN ISO 9001:2008. The effectiveness of the process will be monitored in accordance with the methods given in the quality manual, AngCN-QM. Equality and Diversity Statement This document complies with the Suffolk PCT Equality and Diversity statement an EqIA assessment is available on request to Anglia Cancer Network PQ Manager, Gibson Centre, Exning Road, Newmarket, CB8 7JG. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Page 10 of 10