National Cancer Peer Review Programme Radiotherapy Service Evidence Guide
Forward This evidence guide has been formulated to assist organisations in preparing for peer review. The contents of this guide are not exhaustive and organisations should continue to tailor their policies to reflect activity of the respective team, whilst demonstrating compliance with the key questions. During the review process organisations will be required to demonstrate ownership of all policies, and assure visiting review teams that policy is reflective of practice. Agreement Where agreement to guidelines, policies, etc is required this should be stated clearly on the cover sheet of the documents including date and version. Similarly, evidence of guidelines, policies, etc requires written evidence unless otherwise specified. The agreement by a person representing a group or team (chair or lead, etc) implies that their agreement is not personal, but that they are representing the consensus opinion of that group. Confirmation of Compliance Compliance against certain measures will be the subject of spot checks or further enquires by peer reviewers when internal validation or a peer review visit is undertaken. When self assessing against these measures a statement of confirmation of compliance contained within the relevant key evidence document will be sufficient. 2
Key themes for a Radiotherapy Service Introduction With reference to the guidance on Key Themes, when completing a report, please provide comments including details of strengths, areas of development and overall effectiveness of the team/service. Any specific issues of concern or good practice should also be noted. It is important to demonstrate any measureable change in performance compared to previous assessments. Radiotherapy Service Key Themes: 1. Structure and function of the service Comment in relation to leadership, service configuration and workload. In addition, training and assessment requirements of core staff and responsibilities of core staff members. Service workload data, manpower and skill mix is also important here. Teams should specifically comment with regards to the following questions: Are all key core staff in place? What is the compliance with waiting times standards? How many patients by equality characteristic (race, age and gender) were treated in the previous year? 3. Patient experience Comment on information on and achievement of improvements to service delivery, patient experience and gaining feedback on patients experience, communication with and information for patients and other patient support initiatives. It may include information associated with communication with and information for patient, consent and other patient support initiatives and service improvement initiatives such as process mapping and capacity and demand analysis. This section of the report requires specific answers to: What are the national patient experience survey results? What are the local patient experience exercise feedback results? 4. Clinical outcomes / indicators Comment on the performance of the service. It is important to demonstrate any measurable change in performance compared to previous assessments. There should be a specific focus on the relative performance of the service in relation to the national range. Comment on compliance with submitting the radiotherapy dataset and results of network and local audits. 2. Coordination of care / patient pathways Comment on coordination and patient centred pathways of care, network guidelines and communication. For example, any measures relating to agreement of national and network guidelines and patient pathways, recording of treatment planning decisions, key worker and communication with GPs. Comment on service specifications, clinical protocols, SOPs, checking procedures, risk assessment, error and incident management and the quality system. 3
Evidence Requirements for Radiotherapy Peer Review 1. Introduction This section sets out the revised evidence requirements for the peer review of radiotherapy services. The revised requirements will be in place for the 2013/14 round of peer review during which radiotherapy departments will be required to undertake a self-assessment, together with internal validation. 2. Background The revised radiotherapy measures were published in April 2010. Since the previous review of radiotherapy services, changes to the peer review process meant that it was no longer a requirement to upload evidence against each measure. Evidence should be part of documentation that the service would need as part of the day to day management. For a radiotherapy service this is an operational policy, annual report and work programme. Following publication of the measures a group was established to identify the key documentation required for radiotherapy. It was agreed the same three documents could be used together with access to the QA systems for each department. Evidence guides were compiled to help services in their assessment. Radiotherapy services were visited in 2010/11 at which time it became apparent that the evidence requirements remained burdensome for the services. There was also a lack of clarity with regard to the extent of additional content held on the QA systems that should be checked by reviewers when assessing compliance. It was therefore agreed to review the requirements in order to minimise the burden whilst providing confidence of compliance with the cancer measures. 3. Revised Evidence There were some key issues taken into account when reviewing the evidence requirements: The workload required to produce the evidence. The need to re-educate reviewers to the new peer review process. Reducing duplication and producing evidence just for peer review. The need for confidence in the evidence presented to demonstrate compliance with the cancer measures. The quality management systems that are held within each radiotherapy service provide a wealth of information and processes that can be used to evidence compliance against the measures. There is not, however, a formal requirement for all the relevant information to be included. This prevented accepting the accreditation of the QA system as evidence, without the need to interrogate the system. Services were therefore required to create documents that could be uploaded onto the CQuINS web site specifically for peer review. It has been agreed that rather than create documents specifically for peer review, services can evidence their compliance by: 1. Including all the relevant documentation on the QA system. 2. Creating a controlled document within the quality system (see example, appendix 1) specifying the relevant documentation for each measure. This will then be verified by the annual quality system assessment. Please note that appendix 1 is only an example and can be developed to include IMRT measures. 24
3. The controlled document can then be uploaded onto CQuINS as evidence. An operational policy, annual report and work programme may be used to demonstrate compliance with the cancer measures not contained within the QA system, however, it is envisaged that services will work towards including all evidence on the QA system which will be referenced in the controlled document, ultimately reducing duplication of effort. 4. IV panels should carry out a spot check of the documents held on the QA system and record this on CQuINS. 5. IV panels should specifically review areas of previous non compliance. 6. External verification will focus on the IV process and confirmation that spot checks have been undertaken by the IV panel as well as previous non compliance. 7. At review visits, external reviewers will carry out spot checks of the documents held on the system and check specifically on previous non compliance. 4. Radiotherapy Reports From 2013/14, a single report will be required which will encompass radiotherapy department generic measures (11-3T-1), EBRT (11-3T-2) and IMRT (11-3T- 3). There will also be a separate report required for those radiotherapy services that provide a brachytherapy service (11-3T-4). 35
Radiotherapy Service Evidence Guide - Agreement Cover Sheet This Quality Controlled Document has been agreed by: Position: Chair of the NRG Name: Organisation: Date Agreed: Position: Head of Radiotherapy Service Name: Organisation: Date Agreed: Quality Controlled Document Review Date: 26
Appendix 1 Example of QA Controlled Document MAN-03 Peer Review gathering the evidence 1. Purpose The National Peer Review Programme: Includes expert clinical and patient/carer representation provides important information about the quality of clinical teams provides assessment of cancer services This document describes the responsibilities and process involved in the gathering of appropriate evidence to show compliance with Peer Review Measures 2. Scope The Directorate of Radiotherapy and Oncology and the Radiotherapy Physics department; to include Peer Review Measures Radiotherapy Department Generic Measures and Radiotherapy Department External Beam Radiotherapy Measures 4. References 4.1 software system used to maintain document control of Quality Management System documents 4.2 Trust Policies 4.3 Minutes of meetings as appropriate 5. Responsibilities 5.1 Clinical Director of Radiotherapy and Oncology is responsible for: 5.2 Head of Radiotherapy Physics is responsible for: 5.3 RSM is responsible for: 5.4 Quality System Manager responsible for: 6. Sources of evidence for Peer Review Measures 3. Definitions 3.1 Quality terms are those as defined in Quality Management Systems Requirements BS EN ISO 9001:2008 3.2 The Trust - the South Tees Hospitals NHS Foundation Trust 3.3 Peer Review Measures - National Cancer Peer Review Programme Manual for Cancer Services: Radiotherapy Measures 3.4 RSM Radiotherapy Services Manager 3.5 QMS Quality Management System 3.6 Quality System Manager - the Management Representative responsible for establishing and maintaining the Quality Management System 37
Evidence Peer Review Measure Document number Document name Location of evidence 11-3T-1 - RADIOTHERAPY DEPARTMENT GENERIC MEASURES 11-3T-101 Departmental Organisation QM1 Quality Manual pages 10 13 11-3T-102 Radiotherapy Physics (and Other Support Services) Service Level Agreement 11-3T-103 The Radiotherapy Multi-professional Team 11-3T-105 Departmental Representation on the Network Radiotherapy Group 11-3T-106 Quality Management System 11-3T-107 Quality System Controller 11-3T-108 Training in the Quality Management System GEN30 Introduction to the Quality Management System Attendance lists for above presentation 11-3T-109 Error Classification System and Error Recording GEN7 GEN21 GEN22 Control of nonconformances and complaints Reporting a radiation incident involving a patient Policy for the reporting of radiation incidents 11-3T-112 Post Incident Procedure APP108 Radiation incident form 11-3T-113 Patient Identification GEN6 Positive identification of patient 11-3T-114 Laterality Checks GEN29 Laterality checks 28
Evidence Peer Review Measure Document number Document name Location of evidence 11-3T-107 Quality System Controller 11-3T-108 Training in the Quality Management System GEN30 Introduction to the Quality Management System Attendance lists for above presentation 11-3T-109 Error Classification System and Error Recording GEN7 GEN21 GEN22 Control of nonconformances and complaints Reporting a radiation incident involving a patient Policy for the reporting of radiation incidents 11-3T-112 Post Incident Procedure APP108 Radiation incident form 11-3T-113 Patient Identification GEN6 Positive identification of patient 11-3T-114 Laterality Checks GEN29 Laterality checks 11-3T-115 Clinical Checks Prior to the Radiotherapy Process 11-3T-116 The Named Areas of Competence Training records 11-3T-117 Training Records Training records 11-3T-118 Retention of Documentation APP2 Register of quality records 11-3T-119 Patient Information and Consent GEN19 Obtaining written consent (Some site specific consent forms also available in Q- Pulse) 11-3T-120 Radiation Protection 39
Evidence Peer Review Measure Document number Document name Location of evidence 11-3T-121 Patient Experience Exercise 11-3T-122 The Departmental Staffing and Skill-Mix Review 11-3T-123 The Departmental Training and Education Strategy 11-3T-124 The Departmental Staffing Implementation Programme 11-3T-125 Development Proposal for the Training and Education Strategy 11-3T-126 Development Proposal for the Staffing Implementation Programme 11-3T-127 Risk Assessment of the Staffing Implementation Programme 11-3T-128 Staffing Levels for Therapeutic Radiographers and Related Professions 11-3T-129 Staffing Levels for Medical Physics 11-3T-130 Fulfilling the Training and Education Strategy 10 2
Evidence Peer Review Measure Document number Document name Location of evidence 11-3T-2 - RADIOTHERAPY DEPARTMENT EXTERNAL BEAM RADIOTHERAPY MEASURES 11-3T-201 Treatment Protocols RP List of radiotherapy protocols can be produced from Q- Pulse 11-3T-202 Off Protocol Procedure GEN16 Prescribing off protocol 11-3T-203 Standard Operating Procedures for Pre-Treatment Imaging EB-IM-1 Localisation, data acquisition, treatment plan verification and data transfer in imaging section 11-3T-204 Standard Operating Procedures for Treatment Planning EB-DOS-1 Dosimetry treatment plan preparation, treatment plan check and independent monitor unit calculation check 11-3T-205 Standard Operating Procedures for Treatment Delivery EB-XRT-1 Delivery of external beam radiotherapy 11-3T-206 Review of Clinical Target Volume to Planning Target Volume Margins 11-3T-207 Standard Operating Procedures for Quality Control of Equipment RPG-GEN1 Roles and responsibilities relating to the commissioning and ongoing maintenance of radiotherapy equipment 11-3T-208 External Quality Control 11-3T-210 Treatment Interruptions Audit (EBRT) 11-3T-211 Interruption Management Policy GEN17 Prioritisation of patients GEN17 Prioritisation of patients 11 3
Evidence Peer Review Measure Document number Document name Location of evidence 11-3T-213 Electronic Transfer of Computerised Planning Data 11-3T-214 Checks on Construction of the Radiotherapy Plan EB-DOS-1 Dosimetry treatment plan preparation, treatment plan check and independent monitor unit calculation check 11-3T-215 Checks on the Output of the Planning Process EB-DOS-1 Dosimetry treatment plan preparation, treatment plan check and independent monitor unit calculation check 11-3T-216 Protocol for Geometric Verification EB10 EB-XRT-38 EB-XRT-39 Verification of treatment area Geometric verification of palliative patients On set pre-treatment verification - Day zero 11-3T-225 Non Imaging Patient Set-up Checks EB-XRT-10 Routine set up instructions 11-3T-226 Treatment Unit Verification EB10 EB-XRT-10 EB-XRT-38 EB-XRT-39 Verification of treatment area Routine set up instructions Geometric verification of palliative patients On set pre-treatment verification - Day zero 11-3T-227 On-Treatment Clinical Checks GEN4 Patient Care Emergency work 11-3T-228 Checks Contingent on a Change in a Patient's Treatment 11-3T-229 In Vivo Dosimetry Development Proposal (EBRT) 12 2
Evidence Peer Review Measure Document number Document name Location of evidence 11-3T-230 In Vivo Dosimetry Risk Assessment (EBRT) 11-3T-230 In Vivo Dosimetry Risk Assessment (EBRT) 11-3T-232 In Vivo Dosimetry Protocol (EBRT) 11-3T-233 Treatment Prescription Records Patient notes Visir Archive Mosaiq 11-3T-234 Out of Hours Treatment Service (EBRT) EB2 Emergency work Emergency work 13 3
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