Special Measures Action Plan. Colchester Hospital University NHS Foundation Trust Cancer Action Plan 30 th November 2014

Transcription

1 Special Measures Action Plan Colchester Hospital University NHS Foundation Trust Cancer Action Plan 30 th November KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver 1

2 & our progress What are we doing? The Trust entered Special Measures following concerns about the standard of cancer care being delivered by the Trust. The Trust has been given a variety of recommendations which have come from CQC visit report, the Intensive Support Team report, Review Visit (published 19 December) focussed on Cancer Services. The recommendations covered the following areas of concern: Failsafe paper processes Audit of cancer waiting times data Review of Cancer Services workload (including Oncology Consultants) Cancer Pathways Urology (bladder and prostate), Brain & Central Nervous System, Cancer of Unknown Primary Origin and Sarcoma Governance arrangements guarding Adults & Children The Trust has amalgamated the 331 recommendations from the reviews (set out above) into a Cancer Remedial Action Plan. All recommendations have been recognised and accepted by the Trust. The actions within the Cancer Remedial Action Plan address all issues, with the overall aim to improve the quality of cancer services. We envisage that improvements will be largely complete by 31 December. The Trust will set out a longer-term plan to maintain progress and ensure that the actions lead to measurable improvements in the quality and safety of care for patients. The Trust established that there were a number of themes which encompassed all the recommendations Governance structures and processes for managing patients on a cancer pathway Data Collection & Data Governance Management of patients on a Cancer pathway guarding Adults and Children This document provides a high level summary of the urgent actions under these themes but is not a comprehensive list of all actions or other actions being taken to improve. We have set out our progress in making improvement against these actions. While we take forward our plans to address the 331 recommendations, the Trust will remain in special measures. To ensure appropriate oversight and rapid improvement in cancer services the Trust has implemented the following changes: Reconstitution of the Trust Cancer Board to include Multi-disciplinary Leads to oversee the decisions made relating to Cancer Services. The Trust Cancer Board reports to the Trust Quality and Patient ty Committee, a sub-committee of the Trust Board. Appointment of Cancer Programme and Project Manager to drive the required improvements reporting to a Cancer Steering Group A Project Management Office and Turnaround to oversee and give assurance to 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, Dr Lucy Moore is ultimately responsible for implementing actions in this document. Evelyn Barker, Chief Operating Officer, is the Executive Lead for delivery of improvements in Cancer. The Improvement 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 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. The Trust Board receives monthly updates in its public meeting. Chair / Chief Executive Approval (on behalf of the Board): Chair Name: Mr Peter Wilson Signature: Date December Chief Executive Name: Dr Lucy Moore Signature: Date: December 3

4 Governance Structures and Processes for managing patients on a cancer pathway of Urgent Actions Required Action Owner Timescale for Implement ation Well Led Caring 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 of Nursing Lead Cancer Clinician/Exe cutive Lead for Cancer 31 Jan Lead Cancer Nurse by 28 Feb Monitor Commissio ning Group Key roles have been defined in line with national role descriptions as detailed in the Manual of Cancer Standards. All roles have been appointed to, with the Lead Cancer Nurse commencing in post on 3 rd November 14. Letters defining roles have been sent to all MDT leads for signature/agreement to responsibilities. Review of all MDTs to ensure they are effective (using National Cancer Action Team published "Characteristics of an MDT" Feb 2010). Medical 31 December Strategic Amber Review Programme is being developed using the National Cancer Action Team ness of MDTs document (published 2010). This document was presented at Cancer Board May 14. The Trust is on track to deliver by end December 14. Trust has registered to use MDT-fit assessment tool (based on the above document) published by King s College London. It is intended to pilot in one MDT by end Dec 14, and complete a programme covering all MDTs during Development of the programme and appropriate training will be required for the assessment team. The Trust has agreed to pilot in Gynaecology, team have been registered with the external site and process has begun. 4

5 Governance Structures and Processes for managing patients on a cancer pathway of Urgent Actions Required Action Owner Timescale for Implemen tation Well Led Ensure that the appropriate Governance Committees provide assurance to the Board of the quality of care delivered Medical 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. Quarterly update of progress to the Trust Quality & Patient ty Committee in line with Terms of Reference Cancer Board work programme is being collated to include residual actions from Cancer Action Plan, peer review remedial actions, and any additional themes arising from the Retrospective Review. Review the workload of all Cancer Services workforce Medical (Clinician s) of Nursing (Nurses) Chief Operatin g Officer (Admin Staff) 31 March National Peer Review Programm e Green A of vacancies recruited to, and additional posts identified through external review has been completed and is being monitored. All remaining vacancies have been advertised and are being actively recruited. workload review is incorporated into annual joint planning cycle (commenced 1 st April). Work on Medical workforce has commenced with risks identified in Lower GI, Head & Neck, and Dermatology. MDT Co-ordinator workload has been assessed using IST Workload Tool. Nurse Workload review report on outcome of CNS workload review presented at Cancer Board in August 14. This piece of work will feed into the wider Nurse Review being undertaken across the Trust by the of Nursing. The outcome and recommendations of the CNS review has been passed to the Lead Cancer Nurse, who is now in post to take forward. Medical workforce review has some residual work to ensure sufficient time in job plans for MDT preparation and attendance. 5

6 Data Collection and Data Governance of Urgent Actions Required Action Owner Timescale for Implementation Assuran ce Well Led We will: Develop a Trust Cancer Access Policy to provide guidance to our staff for the management of patients on a cancer pathway. Chief Operating Officer 31 March Monitor The Trust Access Policy has reference to the management of Cancer pathways within it. The policy has been reviewed, circulated for comments and submitted to the Trust policy approval committee (PDAC). A separate Cancer Services Operational Policy, detailing management of patients on cancer pathways, has been approved at the Trust PDAC Committee (June 14) and includes a section on the responsibilities of the MDT Co-ordinator team. This document has been approved at Cancer Board and has been shared with the MDT Coordinator team. This policy has been incorporated into the Trust Access Policy, which is available on the Trust Intranet. 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 Chief Operating Officer 28 February Monitor Intensive Support Team Green The development of MDT specialty based Protocols governing the daily workload of each MDT Co-ordinator has commenced. The timescale for implementation is being reviewed by the Trust expected date for implementation is end August 14. There has been some delay on development of the MDT protocols resulting from the implementation of Phase 2 of the Somerset system. MDTC team have completed diary sheets for a 2 week period to facilitate development of the protocols. IST workload diary sheets collated and analysed. Draft protocols are being written based on the MDT Co-ordinator diary sheets. Breast protocol completed. 6

7 Data Collection and Data Governance of Urgent Actions Required Action Owner Timescale for Implement ation Implement an electronic process for reviewing adjustments on Cancer Waiting Times database by hospital staff to enable review and monitoring by Information Team. This is a failsafe process to assure ourselves that any adjustments are consistent with national guidance. Chief Operating Officer 31 January Commissio ning Group Daily report comparing differences between CWTs database and Patient Administration System introduced end December 13. Reviewed daily by Contact Centre and MDT Co-ordinator team. Governance reports have been implemented which identify changes made to data. The Somerset system has a background facility which provides an audit of data changes. Links to the daily/weekly reports are received regularly. 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 28 February Monitor Installation of Somerset system for collection of cancer waiting times data completed 6 th March. The training of key staff and migration of data between the existing Cancer Waits database and Somerset is complete. Data migration has been validated and reconciled by Business Informatics.. A suite of management reports is being developed by Business Informatics to provide assurance to the Board. The Somerset system feeds Qlikview, the management tool used by the Trust to track its performance at specialty level. Phase 2 Somerset implementation programme has commenced and most MDTs now have clinical data input live at MDT by clinical staff. Completion of live data collection (phase 2) is on schedule for end September 14 but may be completed earlier. All tumour sites using Somerset live at MDT. 7

8 Data Collection and Data Governance (continued) Summar y of Main Concern s of Urgent Actions Required Action Owner Timescale for Implementation Progres s Responsi ve We will: Make improvements to our weekly cancer escalation processes ensuring there is a failsafe method for escalating patients treatment pathways. Chief Operating Officer 31 January Commissioning Group Green Review of weekly escalation processes has been completed. Changes to the process have been implemented. A weekly Action Log has been implemented which identifies constraints which may delay patient pathways this is reviewed by Service Managers weekly. Detailed Terms of Reference for escalation processes presented to Cancer Board in April 14. Comments from clinical teams being collated. The 18 week and Cancer weekly PTL meetings have now merged (June 14) to enable improved service management representation. ness is being monitored at the weekly Performance and Activity Review meetings, led by the Chief Operating Officer. 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. Chief Operating Officer 31 March Commissioning Group Green The Contact Centre commenced on 23 rd December 13 for internal referrals. (2ww) referrals commenced via Choose & Book (end March 14) in conjunction with North East Essex CCG (and has an nhs.net address as a failsafe if Choose & Book slot unavailable). An operational policy for the Contact Centre (Cancer Hub)has been developed, which details how referrals are managed with detailed timeframes. This was presented at Cancer Board (April 14) for discussion and comment. GP practices are able to set up a delivery/read receipt for these referrals to provide assurance of receipt. The Inter-Trust Referral policy is in development in partnership with other Essex Hospitals with whom cancer pathways are shared (led by the Strategic ). Anticipated date for completion of the Inter-Trust Referral policy is dependent on other external organisations, and is anticipated to be completed by end October 14. All internal faxes have been replaced with nhs.net secure accounts. 8

9 of Main of Urgent Actions Required Action Timescale for Colchester Owner Trust - Our improvement plan Implementat ion Caring We will: Develop a programme of regular and continuous training for our MDT Co-ordinator team which will provide us with a failsafe method of ensuring our staff are up-to date. Chief Operatin g Officer 28 February Monitor Intensive Support Team Initial training commenced December 13. Further training day for Root Cause Analysis undertaken mid February 14. Training relating to the new data information system (Somerset) completed (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. Team Meetings are taking place weekly with a standard item on CWTs guidance topics for discussion/training are identified by the MDT Coordinator & Data Clerk Team. Caring Improve support and advice to MDT Coordinator Team including standard operating procedures to support MDTCs/Data Clerks roles/functions, including escalation processes This is a failsafe method of ensuring our staff are following consistent and accurate guidance. Chief Operatin g Officer 28 February Monitor Intensive Support Team Green The Cancer Services Standard Operational Policy which details the Cancer Waiting Times guidance has been reviewed. This document details how data is to be recorded on the Somerset cancer data information system. Policy presented to Cancer Board April 14. The Operational Policy has been approved by the Trust PDAC Committee May 14. The daily protocols outlining the standard processes required to support each MDT are being developed. MDT Co-ordinator team compiling diary sheets detailing daily/weekly commitments to facilitate development of the MDTC protocols to complement the Standard Operational Policy. Develop an electronic failsafe competency framework to ensure MDTC/Data Clerks knowledge and skills are maintained (similar to that used for IT Governance) which will be tested annually. Cancer Program me 31 December Monitor Intensive Support Team Green Cancer Services Standard Operational Policy encompasses a competency framework. The Trust has engaged an external provider of Referral to Treatment (18 weeks) e-learning package to develop a module for Cancer alongside the implementation of RTT. A programme of development, testing and implementation work for the cancer module has been agreed with an anticipated go-live date of end December 14/early Jan 15. This e-learning package will enable the Trust to have annual assessment of knowledge and competency of data collection staff. Delivery date agreed as end Dec 14 by Cancer Steering Group. 9

10 Data Collection and Data Governance (continued) Colchester Trust - Our improvement plan of Urgent Actions Required Action Owner Timescale for Implementati on Well Led Implement Inter-Trust Referral policy (recommended by Midlands & East of England Strategic ). Medical 31 st December Date change agreed with IMT in Nov 14 Strategic Green Communication with external Trusts advising of the adoption of this policy established - an Essex wide meeting took place end April 14 with Trusts, the Strategic (SCN) and the Cancer Registry. Strategic agreed at Essex Cancer Forum (June 14) to bring the Essex-wide policy back to ECF October 14 for sign off. There is on-going internal development work with the Contact Centre (Cancer Hub) to ensure the implementation of this Policy is completed as soon as it has been agreed by the Essex Cancer Forum. Agreement has been reached with Mid Essex Hospitals NHS Trust to provide read only access to the Somerset, PAS and Pathology systems at both hospitals which will improve the security of patient data flows between the two hospitals and reduce the risk of pathway delays as a result of poor exchange of patient details. CHUFT has initiated internal discussions to provide read only access to Somerset/PAS with Information Team. The date agreed with Strategic for agreement and implementation of the inter provider transfer policy is 31 st December (this date has been agreed with all 4 Essex Trusts). Establish regular failsafe monitoring programme to ensure all referrals are made by Day 42 and tracked appropriately Medical 31 October Commissioning Group Amber Somerset implemented with data migration completed. Monitoring of incoming and outgoing tertiary referrals was expected to be monitored via Somerset from 1 April. Release of Somerset module for Inter-Trust Referrals has slipped to Autumn by Somerset Cancer Registry and is outside of the control of the hospital. There is ongoing discussion with Cancer Services Division to develop a mechanism for monitoring outgoing tertiary referrals ahead of this deadline. MDT Co-ordinators track individual patients via tumour site tracking processes. Somerset Cancer Registry module for 10 inter-trust referrals has been confirmed as being in the Autumn update.

11 Management of patients on a cancer pathway of Urgent Actions Required Action Owner Timescale for Implementation Caring We will Ensure that patients referred through 18 weeks are upgraded onto a Cancer Pathway (if there is a suspicion of Cancer). Ensure trust-wide Access Policy for Cancer has a clear definition of Consultant Upgrades Chief Operating Officer 31 March Monitor Clarification relating to Consultant Upgrade discussed at Cancer Board February 14. All Consultant upgrades are recorded on Somerset. Number of consultant upgrades being monitored monthly through Cancer Hub increase in numbers of upgrades being recorded. Numbers of consultant upgrades are reported monthly to the Cancer Board as part of the regular performance report. There is increasing level of confidence by the Trust Executive that the previous level of under-reporting is being addressed and monitored. The Cancer Access Policy has been incorporated into the Trust Access Policy and has been approved by the Trust internal Committee (PDAC) available on the Intranet. All Standard Operational Policies for MDTs are being re-checked, through Sept 14 Peer Review upload/internal validation via CQUINs, to ensure they encompass guidance for MDT teams when it is appropriate to upgrade patients onto the 62 day cancer pathway. Well Led Ensure that all recommendations from peer review are implemented Divisional s 31 December Strategic. The Cancer Action Plan incorporates all recommendations from previous peer reviews and has clear actions and timescales. The Cancer Board is responsible for ensuring delivery of all peer review remedial actions and this is encompassed in its Terms of Reference. Trust document confirming the annual cycle, process, timetable and requirements for each MDT presented to Cancer Board (July 14). Ratified at Cancer Board August 14. This document will form the basis of the annual planning, development and delivery cycle of peer review which will be monitored through the Cancer Board. Process document has been reviewed by Royal Marsden who have recommended the timetable for data collection to be reviewed. Timetable has been aligned with July submission to national peer review database. 11

12 Management of patients on a cancer pathway Colchester Trust - Our improvement plan of Urgent Actions Required Action Owner Timescale for Implementation Ensure that the Anal Cancer Pathway is implemented and is IOG compliant Medical 30 September Specialised Commissioni ng Group Discussions are continuing with Specialised Commissioning and the Strategic to ensure compliance with Improving Outcomes Guidance (IOG) is in line with agreed timetable. CHUFT are referring all Anal Salvage Surgery patients to Norfolk & Norwich hospital (up to 12 patients per year) as an interim measure agreed with Specialised Commissioning. There is a separate additional piece of work which will be led by NHS England, Specialised Commissioning Team to confirm an IOG compliant solution for all hospitals in Essex. Essex wide meeting taking place 6 th August. Interim arrangement for video-link with NNUH was agreed in August. SCN providing support to establish this with NNUH. Meeting between CHUFT and NNUH took place mid October. Interim arrangements agreed and these have now been shared with Specialised Commissioners. Ensure Gynaecology MDT has cover for Consultant Oncologist Medical 30 June Strategic Recruitment commenced December 13. Consultant Oncologist appointed commences June 14. Following induction, MDT cover will be in place by end June 14. Additional Consultant Oncologist in post. Cover for MDT will be monitored. Well Led Ensure Urology service has sufficient capacity to treat patients Chief Operating Officer 31 March Monitor Green All actions to increase capacity are completed or on course for completion. Additional clinics commenced mid December; additional theatre capacity, including weekend working, has been in place since January 14. Recruitment for additional medical and nursing staff has resulted in a 5 th consultant who commenced early March 14 and a 6 th consultant commenced in post early November 14. Additional nursing posts and CNS have been appointed. Performance is being closely monitored to ensure additional capacity is having the desired impact. Despite additional capacity, sustainable achievement of the CWTs standards in this specialty remain challenging. Commissioning template completed and submitted to LAT.

13 Management of patients on a cancer pathway (continued) of Urgent Actions Required Action Owner Timescale for Implementati on We will Ensure there are clear documented pathways for Urology (prostate and bladder) Multi-disciplinary Team Lead 30 December 13 Visit Review Team Prostate and Bladder cancer pathways have been revised and assured by the visiting 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. revisit of prostate, bladder and renal pathways (28 th April 14) confirmed pathways assured. No immediate risks or serious concerns identified. Ensure the Skin pathway is compliant with cancer waiting times guidance. Medical 31 January Strategic Red Pathway has been reviewed by visiting Consultant and compliance with Cancer Waiting Times guidance has been received. Pathway audit has been deferred by agreement between the Commissioning Group, Local Area Team, and the Trust. Deadline for review of this pathway has been set for end December 14 but as yet there is no confirmed date from the Strategic for this to take place. An internal spot audit assessing the pathway against 2ww milestones has been conducted and was reported at the Cancer Steering Group in October. This audit informed the IST revisit in October, and together with the lack of substantive evidence to support the use of Dermascopic Image as a straight to test milestone for CWTs, the Trust is in discussion with the IMT, Monitor and CCG to develop a robust plan to change the way in which the first seen date is recorded for skin cancer. Ensure there is a clear documented pathway for suspicious lesions Medical 31 January Strategic A process for the management of the pathway for patients with suspicious lesions has been developed and is incorporated within the Contact Centre Operational Policy. Discussed and agreed at Cancer Board March 14. pathway revisit (14 th April) confirmed process assured. 13

14 Management of patients on a cancer pathway (continued) of Urgent Actions Required Action Owner Timescale for Implementati on Ensure there are robust tracking methods for Sarcoma patients Medical 31 March Strategic 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. pathway revisit (14 th April 14) confirmed pathway assured. Ensure there is a clear documented pathway for Brain/Central Nervous System patients Medical 28 February Strategic Revised pathway completed 16 th December 13. at Cancer Board February 14. Pathway revisit took place 20 th May 14 pathway assured. There is clear MDT structure and pathway for Cancer of Unknown Primary Medical 31 st 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. The external pathway revisit (April) has confirmed assurance of the Cancer of Unknown Primary pathway. 14

15 Management of patients on a cancer pathway (continued) Ensure all Cancer pathways are regularly audited. This is a failsafe process to ensure that patients are treated in line with agreed pathways. Medical 31 Decem ber Strategic Amber A programme of regular clinical audit of cancer pathways is being presented to Cancer Board. The outcome of the first pathway audit (Urology) was presented at the March Cancer Board. Audit programme agreed at Cancer Board March 14 covering all tumour site pathways. Relevant pathway audits presented at each Cancer Board. Programme of Cancer pathway audits being monitored at Cancer Board. Further work is being undertaken to ensure all tumour sites are undertaking the monthly audit of at least 5 pathways (this differs by tumour site). Caring Well Led Develop a continuous quality improvement programme for cancer specialties, to encompass clinical peer review visit recommendations Trust Cancer Lead 31 May Strategic A draft document detailing each of the components of the continuous quality improvement programme presented to Cancer Board May 14. The key components identified as contributing towards a continuous quality improvement programme are in place and are being regularly monitored. Implementation is in progress and being monitored by the Cancer Board and Quality & Patient ty Committee. The Continuous Quality Improvement Programme to be submitted to Quality & Patient ty Committee June 14. Programme ratified by Cancer Board June 14. Monitoring of all components of the programme will be via Cancer Board. Caring Well Led NHS England Follow up report on the Management of the above cancer pathways (published July ). Medical 31 July 14 NHS England / Local Area Team NHS England has published a follow up report on the Cancer pathways outlined above confirming that all pathways, with the exception of skin pathway, have been reviewed and are assured as safe. The report also provided an update on the General Immediate Risks identified in the original report (December 13) and confirmation of the work the Trust has undertaken in improving failsafe processes for the tracking of patients, recording of data and management of pathways. 15

16 guarding Adults and Children of Urgent Actions Required Action Owner Timescale for Implementation Well Led We will Confirm the Non- Executive lead and ensure all board members receive training of Nursing End December 2013 Monitor Non-Executive for guarding confirmed. guarding training completed. Caring Ensure that there are policies and procedures in place to protect vulnerable adults and children of Nursing End December 2013 Monitor Commissionin g Group Policies and procedures completed and presented to Trust Board. Caring Ensure the internal Trust intranet has an e- training module or Nursing End December 2013 Commissionin g Group E-training module for guarding In place mid December. Caring Develop a communications plan for contacting all patients (to convey outcome) following clinical-notes review (duty of candour). Medical 31 October NHS England Green It has been agreed with NHS England that this will be incorporated into Retrospective Review programme timetable under Duty of Candour. The timetable for completion of the Retrospective Review has been extended to end October 14 with the agreement of the Panel (comprising LAT, CCG, Healthwatch representatives) and the completion date has been amended to reflect this. 16

17 Oversight and improvement action Timescale for 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 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 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 ty Committee. The Cancer Board oversees and monitors the implementation of the Trust Remedial Cancer Action Plan. Appointment of Cancer Programme and Project Manager to drive the required improvements. Mid December 13 Lead for Cancer Services Reconstituted Board commenced mid December. ness of the Group to be monitored throughout the year by the Quality & Patient ty Committee Beg December 14 Medical Cancer Programme took up post 2 nd December 13 Project Manager in post from 27 th February 17

18 Colchester Trust - How our progress is being monitored and supported Oversight and improvement action Timescale for 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 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 Services Steering Group to oversee and drive the implementation of the Trust Cancer Action Plan has been established to ensure progress against the Cancer Action Plan. This Group reports to Trust Board through the Quality & Patient ty 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 ty Committee and Turnaround Board chaired by the CEO. January Chief Operating Officer Cancer Services Steering Group has commenced and is meeting weekly January Chief Executive Programme Management Office commenced January 14 Appointment of Improvement (by Monitor) to work with and support the Trust to deliver the Cancer Action Plan. Completed 20 th January Chief Executive Improvement took up post week commencing 20 th January 18