Integrated Cancer Services Action Plan. Colchester Hospital University NHS Foundation Trust 31 March 2014

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1 Integrated Cancer Services Action Plan Colchester Hospital University NHS Foundation Trust 31 March KEY Implemented, clearly evidenced and externally approved On Track to deliver Some issues narrative disclosure Not on track to deliver 1

2 & our progress What are we doing? The Trust entered the Special Measures programme and was selected 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, Intensive Support Team report, External Review Visit (published 19 December) which encompasses all the reviews relating to 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 were recognised and accepted by the Trust. The actions within the Cancer Remedial Action Plan address all recommendations, with the overall aim to improve the quality of cancer services. We envisage that improvements will be largely complete by 31 December. 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 encompasses 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 urgent actions or other actions being taken to improve. We have also 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 Leads to oversee the decisions made relating to Cancer Services. The Trust Cancer Board reports to the Trust Quality and Patient Safety Committee. Appointment of Cancer Programme Director and Project Manager to drive the required improvements reporting to a Cancer Steering Group A Project Management Office and Turn Around Director to oversee the delivery of the action plan. 2

3 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, Kim Hodgson is ultimately responsible for implementing actions in this document. Sean MacDonnell, Medical Director, is the Executive Lead for delivery of improvements. 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 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, 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. Chair / Chief Executive Approval (on behalf of the Board): Chair Name: Sally Irvine Signature: Date: April Chief Executive Name: Kim Hodgson Signature: Date: April 3

4 Governance Structures and Processes for managing patients on a cancer pathway Implementatio n External Support/ 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 Director of Nursing Lead Cancer Clinician/Executiv e Lead for Cancer 31 January Lead Cancer Nurse by 28 February Monitor Commissionin g Group Key roles defined in line with national role descriptions indicated in the Manual of Cancer Standards and appointed to with the exception of the Lead Cancer Nurse. Lead Cancer Nurse recruitment has commenced but advertisement has been delayed. Post being advertised w/c 31 st March. Review of all MDTs to ensure they are effective (using National Cancer Action Team published "Characteristics of an Effective MDT" Feb 2010). Medical Director 31 December Strategic Review Programme is being developed - will be presented at Cancer Board May14. Ensure that the appropriate Governance Committees provide assurance to the Board of the quality of care delivered Medical Director 31 March Monitor Cancer Board meeting monthly, with clear Agenda and Minutes. Terms of Reference in place. Well attended by Leads. The work programme of the Cancer Board in is to monitor the delivery of the Cancer Remedial Action Plan. Monthly update of progress to the Quality & Patient Safety Executive. Review the workload of all Cancer Services workforce Medical Director (Clinicians) Director of Nursing (Nurses) (Administrative Staff) 31 March National Peer Review Programme A Summary of vacancies recruited to, and additional posts identified through external review has been completed. All remaining vacancies have been advertised and are being actively recruited. workload review is incorporated into annual joint planning cycle. MDT Coordinator workload being assessed using IST Workload Tool. 4

5 Data Collection and Data Governance Implementation External Support/ We will: Develop a Trust Cancer Access Policy to provide guidance to our staff for the management of patients on a cancer pathway. 31 March Monitor The Trust Access Policy has reference to the management of Cancer pathways within it. Separate dedicated Cancer Access Policy under consideration.. 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 28 February Monitor Intensive Support Team The first draft of a Standard Operational Policy detailing Cancer Waiting Times rules and application has been completed and is being reviewed. Consultation with clinical teams to be undertaken. Protocols governing the daily workload of each MDT Co-ordinator are being developed. 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. 31 January Commissioni ng Group Daily report comparing differences between CWTs database and Patient Administration System introduced end December. Reviewed daily by Contact Centre and MDT Coordinator team. Somerset implementation for the collection and recording of Cancer Waiting Times completed. Weekly/monthly governance reports being implemented. 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 Monitor Installation of Somerset system for collection of cancer waiting times data is complete. The training of key staff and migration of data between the existing Cancer Waits database and Somerset has been undertaken and data transfer being validated. 5

6 Data Collection and Data Governance (continued) Implementation External Support/ We will: Make improvements to our weekly cancer escalation processes ensuring there is a failsafe method for escalating patients treatment pathways. 31 January Commissioning Group Review of weekly escalation processes has been completed. Changes to the process have been implemented which are intended to improve managerial and clinical representation at weekly/monthly meetings and the overall effectiveness of the escalation processes. 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 to be presented to Cancer Board in April 14. 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. 31 March Commissioning Group The Contact Centre commenced on 23 rd December for internal referrals. External (2ww) referrals are timetabled to commence via Choose & Book at end March (in conjunction with North East Essex CCG). An operational policy has been developed (in draft form)n which details how referrals are managed with detailed timeframes and will be presented at Cancer Board (April 14). GP two week wait referrals are moving to Choose & Book from end March (with an nhs.net as a failsafe if C&B slot not available). Practices are able to set up a delivery/read receipt for these referrals to provide assurance of receipt.. 6

7 Data Collection and Data Governance (continued) Implementati on External Support/ We will: Develop a programme of regular and continuous training for our MDT Coordinator team which will provide us with a failsafe method of ensuring our staff are up-to date. 28 February Monitor Intensive Support Team. Initial training commenced Dec 13. Further training day for Root Cause Analysis undertaken mid February 14. Training relating to the new data information system (Somerset) completed (7 th & 14 th 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. Improve support and advice to MDT Co-ordinator 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. 28 February Monitor Intensive Support Team The first draft of a Cancer Services Standard Operational Policy detailing Cancer Waiting Times guidance and protocols outlining the standard processes required to support each MDT on a daily basis has been completed and is being reviewed. This document details how data is to be recorded on the Somerset cancer data information system. This policy will be presented to Cancer Board April 14. 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 Programme Director 31 March Monitor Intensive Support Team Discussions have commenced to develop an e- learning tool and competency framework for annual assessment of data collection staff. Cancer Services Standard Operational Policy encompasses competency framework. Implement Inter-Trust Referral policy (recommended by Midlands & East of England Strategic ). Medical Director 31 January Strategic Communication with external trusts advising of the adoption of this policy to be established. Meeting with neighbouring Trust mid March to agree adoption of the Policy. Final copy of Inter- Trust Referral Policy for ratification at Cancer Board requested from Strategic. Establish regular failsafe monitoring programme to ensure all referrals are made by Day 42 and tracked appropriately Medical Director 31 March Commissioning Group Somerset implemented with data migration complete. Monitoring of incoming and outgoing tertiary referrals will be monitored via Somerset from 1 April. 7

8 Management of patients on a cancer pathway Colchester Trust - Our improvement plan Action Owner Implementati on External Support/ We will Ensure that patients referred through 18 weeks are upgraded onto a Cancer Pathway (if there is a suspicion of Cancer). Ensure trustwide Access Policy for Cancer a clear definition of Consultant Upgrades Chief Operating 31 March Monitor Development of a dedicated Trust Cancer Access Policy to encompass when it is appropriate for MDT Teams to upgrade patients onto a 62 day cancer pathway is under development. Clarification relating to Consultant Upgrade discussed at Cancer Board Feb 14. All Consultant Upgrades will be recorded on Somerset through the Contact Centre (single point of referral) from 1 April 14. Ensure that all recommendations from peer review are implemented Divisional Directors 31 December Strategic. The Cancer Action Plan incorporates all recommendations from previous peer reviews and has clear actions and timescales. A dedicated peer review process for monitoring delivery of peer review actions to be presented to Cancer Board May 14. Ensure that the Anal Cancer Pathway is implemented and is IOG compliant Medical Director 30 September Specialised Commissionin g Group Discussions are continuing with Specialised Commissioning and the Strategic to ensure compliance with Improving Outcomes Guidance (IOG) is in line with agreed timetable. Ensure Gynaecology MDT has cover for Consultant Oncologist Medical Director 30 June Strategic Recruitment commenced December 13. Consultant Oncologist appointed expected to take up post June 14.. Ensure Urology service has sufficient capacity to treat patients Chief Operating 31 March Monitor 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 commenced. Additional consultant to be in place from beginning of March; additional nursing posts have been advertised. 8

9 Management of patients on a cancer pathway (continued) Implementati on External Support/ We will Ensure there a re clear documented pathways for Urology (prostate and bladder) Multidisciplinary Team Lead 30 December 13 External Visit Review Team Prostate and Bladder cancer pathways have been revised and assured by the visiting External Review Lead. The Team are regularly auditing this pathway and is part of the regular programme of pathway audits to be presented at Cancer Board. Ensure the Skin pathway is compliant with cancer waiting times guidance. Ensure there is a clear documented pathway for suspicious lesions Ensure there are robust tracking methods for Sarcoma patients Medical Director 31 January Strategic Medical Director 31 January Strategic Medical Director 31 March Strategic Pathway has been reviewed by visiting External Consultant and compliance with Cancer Waiting Times guidance has been received. Pathway audit will be undertaken to ensure compliance. A process for the management of the pathway for patients with suspicious lesions has been developed and is incorporated within the Contact Centre Operational Policy7. Discussed and agreed at Cancer Board March 14. 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. Ensure there is a clear documented pathway for Brain/Central Nervous System patients Medical Director 28 February Strategic Revised pathway completed 16 th December. at Cancer Board Feb 14. There is a clear MDT structure and pathway for Cancer of Unknown Primary Medical Director 31 s March Strategic 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. 9

10 Management of patients on a cancer pathway (continued) Implementation External Support/ 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 December Strategic 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. Develop a continuous quality improvement programme for cancer specialties, to encompass clinical peer review visit recommendations Trust Cancer Lead 31 May Strategic. The annual programme of cancer pathway audits will support the development of a continuous quality improvement programme, which will be overseen by the Cancer Board and Trust Governance Structures. The Trust is working with The Royal Marsden to develop a Strategy for Cancer which will support the continuous quality improvement programme. 10

11 Safeguarding Adults and Children Implementation External Support/ Revised deadline (if required) We will Confirm the Non-Executive Director lead and ensure all board members receive training Director of Nursing End December 2013 Monitor Non-Executive Director for Safeguarding confirmed. Safeguarding training completed. Ensure that there are policies and procedures in place to protect vulnerable adults and children Director of Nursing End December 2013 Monitor Commissioning Group Policies and procedures completed and presented to Trust Board. Ensure the internal Trust intranet has an e-training module Director or Nursing End December 2013 Commissioning Group E-training module for Safeguarding In place mid December. Develop a communications plan for contacting all patients (to convey outcome) following clinical-notes review (duty of candour). Medical Director 31 July NHS England It has been agreed with NHS England that this will be incorporated into Retrospective Review programme timetable under Duty of Candour. 11

12 Oversight and improvement action Implementation Action owner 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. 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 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 Group. These groups encompass NHS England Commissioning Group, Trust representatives, Essex County Council, Colchester Trust - How our progress health regulators (Monitor) and Health Watch (which represents patients views). Mid December 13 Chief Executive The Trust is represented with excellent attendance on all groups is being monitored and supported In addition to the above, there are regular 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 All groups are being regularly attended Trust Cancer Board has been reconstituted to include Multi-disciplinary Team Leads, 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. Appointment of Cancer Programme Director and Project Manager to drive the required improvements. Mid December 13 Lead for Cancer Services Reconstituted Board commenced mid December. Effectiveness of the Group to be monitored throughout the year by the Quality & Patient Safety Committee Beg December 14 Sean MacDonnell, Medical Director Cancer Programme Director took up post 2 nd December 13 Project Manager in post from 27 th February 12

13 Colchester Trust - How our progress is being monitored and supported Oversight and improvement action Implementation Action owner 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. 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 Service s 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. 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 Medical Director Steering Group has commenced and is meeting weekly January Chief Executive 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 20 th January Chief Executive Improvement Director took up post week commencing 20 th January 13