Colorectal Cancer Managed Clinical Network Activity Report April 2012 March 2013 Paul Horgan Professor of Surgery MCN Clinical Lead Kevin Campbell Network Manager 1
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 4 2. MCN WORKPLAN AND ACTIVITIES (REPORTING PERIOD 04/2012 TO 03/2013) 4 2.1 CORE OBJECTIVES 4 2.2 INDIVIDUAL MCN OBJECTIVES 5 3. QUALITY ASSURANCE / SERVICE DEVELOPMENT AND IMPROVEMENT 5 4. KEY PRIORITY AREAS FOR THE MCN IN THE NEXT 12 MONTHS 6 5. CONCLUSION 7 ACKNOWLEDGEMENT 8 2
Executive Summary Introduction The purpose of this document is to report the Colorectal Cancer Managed Clinical Network (MCN) activities in respect of: Performance against agreed work plan objectives; Outcomes achieved; and Challenges encountered and actions taken to remedy defined issues. This activity report covers the period April 2012 to March 2013. It also reports on key audit findings and resultant actions from the 2011 clinical audit, as well as looking forward from April 2013 to March 2014. MCN Objectives The Colorectal Cancer MCN has made progress and delivered a number of key objectives which include: Enhanced Recovery: Work initiated to develop a regional exemplar pathway has been suspended to allow time for resolution of local variations in practice. A further assessment of the potential for regional work to support local implementation will be made and if agreed the work will be progressed in 2013/14. Implementation of Regional Follow-up Guidelines: Indications are that local implementation has taken place and there is broad adherence to the guidance. Regional Clinical Audit: The 2011 clinical audit data report was published in January 2013. Action plans have been produced by the Boards in response to the issues highlighted in the report and progress against outstanding actions will be monitored by the MCN Advisory Board. Quality Performance Indicator (QPI) development: Colorectal Cancer QPIs were published in March 2013 and the revised clinical audit data set was implemented across Scotland from 1 April 2013. This programme will facilitate local service performance assessment and quality assurance and will also enable regional comparative assessment and periodic national comparative reporting of performance. Detect Cancer Early (DCE): The MCN has participated in discussions with the Scottish Government regarding the colorectal cancer specific component of the social marketing campaign. Key Priority Areas for the MCN in the next 12 months The MCN work plan has been developed with an emphasis on identifying outcomes that improve the quality of patient care and overall service efficiency. Below are the objectives to be progressed in the coming year: Continue to support the regional clinical audit programme and effectively utilise audit findings to inform and drive service improvement; Participate in the national review of referral guidelines in support of the DCE programme; Develop a regional service map, identifying the points of service delivery and the connections between them; and Regional Strategy for Management of Advanced/Metastaic disease. 3
1. Introduction The Colorectal Cancer Managed Clinical Network (MCN) was established over a decade ago with the ambition of delivering high quality, equitable clinical care to all colorectal cancer patients within the constituent NHS Boards that comprise the West of Scotland (WoS) region; Ayrshire & Arran, Forth Valley, Greater Glasgow and Clyde and Lanarkshire. The MCN continues to support and develop the clinical service for approximately 1,700 new colorectal cancer patients each year and management of this patient group relies heavily on close collaboration between surgeons, radiologists, pathologists, oncologists and clinical nurse specialists who comprise the 7 multi-disciplinary teams within the region. Of the 1,679 new diagnoses of colorectal cancer recorded by the MCN clinical audit programme in 2011, 940 (56%) were male and 739 (44%) female. Incidence rates for colorectal cancer have remained relatively unchanged over the last decade and the disease is most prevalent in both men and women aged over 60 years. Surgery remains the key component of treatment which has curative intent. The purpose of this document is to report the Colorectal Cancer MCN activities in respect of: Performance against agreed objectives; Outcomes achieved; Challenges encountered and actions taken to remedy defined issues; and Update on progress of actions identified from the Audit Report. MCN Governance Professor Paul Horgan has now replaced Mr Richard Molloy as Clinical Lead following his successful completion of his 3 year appointment. Dr Janet Graham has joined the Board, representing medical oncology. The input of all members of the MCN has been invaluable in supporting the delivery of the MCN work plan during 2012/13. 2. MCN Work plan and Activities (reporting period 04/2012 to 03/2013) 2.1 Core Objectives Enhanced Recovery after Surgery Work on developing a regional exemplar enhanced recovery patient pathway was initiated with the formation of a short-life working group. The group initially agreed an operational terms of reference, identifying specific outcomes and related timelines. The MCN subsequently agreed to suspend the work of this group pending resolution of local variation in practice within NHSGGC. The MCN will reconsider requirements for regional working in 2013/14. Implementation of Regional Follow Up Consensus Guidelines The Regional Colorectal Cancer Follow-up Guidelines were published and circulated for implementation in July 2012. Indications are that local implementation has taken place and there is broad adherence to the guidance. Regional Clinical Audit Programme Effective utilisation of audit data to support service improvement is a key objective of the Colorectal Cancer Managed Clinical Network. The report of 2011 audit data identified a number of aspects of service provision requiring further investigation by local health boards. 4
In response Boards have prepared actions plans identifying their findings, resulting actions and the progress made toward complete resolution. A revised national data set for colorectal cancer audit was introduced on 1 April 2013 as part of the implementation of the Colorectal Cancer Quality Performance Indicator (QPI) programme. This will promote national consistency and should promote good quality data recording. 2.2 Individual MCN Objectives National Quality Performance Indicator Development Programme The Scottish Cancer Taskforce Quality Subgroup is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. MCN members were well represented in the group tasked with developing the QPIs. The Colorectal Cancer QPIs were published in December 2012 and the revised clinical audit data set, which will capture the data require to assess these quality measures, will be implemented across Scotland from 1 April 2013. This programme will facilitate ongoing local and regional comparative assessment and will also enable periodic national comparative reporting of performance. Detect Cancer Early (DCE) The MCN participated in discussions with the Scottish Government and with colleagues from across Scotland regarding the colorectal cancer specific component of the social marketing campaign. Launched in February 2013 the focus is on the importance of screening in increasing the early detection of bowel cancer, and encouraging all men and women aged over 50 to participate in the screening programme. Survival Outcomes Analysis Work on determining survival outcomes was initiated within the MCN and will be progressed in partnership with the West of Scotland Cancer Surveillance Unit in 2013/14. 3. Quality Assurance / Service Development and Improvement The primary function of the MCN is to facilitate continuous clinical service improvement, supporting delivery of high-quality, equitable, treatment and care to patients with colorectal cancer in the West of Scotland. The prospective clinical audit programme underpins much of the regional service development and improvement work of the MCN and supports quality assurance (QA) by providing the means for regular assessment and reporting against recognised and agreed measures of service performance and quality. The annual regional quality assurance of service provision utilises sixteen nationally recognised Standards (Health Improvement Scotland (HIS) formerly Quality Improvement Scotland) and the latest report of audit data is based on 1,679 new diagnoses of colorectal cancer presenting in 2011, set against results obtained from the previous reporting period. The MCN QA process requires local multi-disciplinary teams to critically review and verify their own results before these are collated to provide a regional comparative report of performance against agreed measures. The report of the 2011 clinical audit data was published in January 2013 and can be found in the internet site. 5
Regional Audit and Governance Process In accordance with agreed governance procedures, Boards were asked to produce Action/Improvement Plans, in response to audit findings, to take forward recommendations set out in the Audit Report; the expectation thereafter is that these actions will be progressed and monitored via local governance structures. Plans are expected to be submitted to the Regional Information Manager within two months of publication of the report. An Action/Improvement Plan template is provided to ensure consistency and standardisation across the region. The MCN Manager/Clinical Lead will periodically review Board Action Plans to identify priorities for co-ordinated regional action and these, along with progress against specific Board actions are monitored by the MCN Advisory Board under the standing MCN Work Plan agenda item. Action Plan Progression Recommended actions on the basis of the key findings of the audit report were directed to Boards requesting that local plans are developed to address areas of deficiency identified. All of the Boards have produced Action/Improvement plans and outlined below is a summary of progress to-date: NHS Forth Valley and NHSGGC have reviewed CNS provision and identified actions are being progressed. Regionally, review of cases not presented to MDT identified that these are either patients with disease confirmed by histopathology following a polypectomy or those patients presenting as an emergency admission to hospital. The Lanarkshire and North Glasgow MDTs will continue to monitor referrals to stoma nurse, as appropriate. Ayrshire & Arran review the single case highlighted as not having received neo-adjuvant radiotherapy and identified that the patient has metastatic disease and was referred for palliative therapy. Ayrshire & Arran and Lanarkshire have both reviewed the cases (2) where involved distal margins were reported; the Lanarkshire review identified that one case was inaccurately recorded and the margins were in fact clear, in the second case the patient had undergone neo-adjuvant therapy and the tumour was not macroscopically detectable. A number of data completeness and quality actions identified were also reported as being progressed as appropriate. Across all Boards all the actions identified in the Board-specific action/improvement plans have been reviewed and a progress/action status provided in line with the governance framework. The actions identified as not yet fully implemented will be reviewed by the Advisory Board. Escalation Process Any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the Regional Lead Cancer Clinician and relevant NHS Board Cancer Clinical Lead by the MCN Clinical Lead. 4. Key Priority Areas for the MCN in the next 12 months The MCN work plan is currently being developed with an emphasis on identifying outcomes that improve the quality of patient care. Below are the areas of work currently being considered for the work plan in the coming year, 2013/14: Continue to support the regional clinical audit programme and effectively utilise audit findings to inform and drive service improvement. The existing NHS Health Care Improvement Scotland (formerly Quality Improvement Scotland) Standards will be superseded by National 6
Quality Performance Indicators in 2013. These QPIs measure performance and quality of treatment and care of colorectal cancer patients and have necessitated implementation of a revised data set aligned to these. Participate in the national review of referral guidelines in support of the DCE programme. Determine regional strategies for the management of locally advanced and metastatic colorectal cancer. The MCN intends to pursue a consensus agreement on the management of liver limited metastatic disease. Continue to progress work on survival outcomes analysis initiated during the previous year. Define and agree specific outcome measures and initiate data collation and preparation. Explore the possibility of utilising audit data to support identification and profiling of interval cancers. 5. Conclusion The MCN has made good progress in regard to the work plan and the continuing support of the Advisory Board members is critical to delivery of the identified outcomes. The Colorectal Cancer MCN continues to focus on improving quality of care through effective and efficient models of service delivery. The MCN recognises the critical role that clinical audit plays in underpinning this through regular regional comparative assessment of performance and quality assurance of treatment and care provided by individual MDTs. The recently agreed QPIs will further support this programme of continuous service improvement. The effectiveness of treatment and care provided will be further tested by the MCN proposed work on assessing survival outcomes. The MCN will continue to participate in and support regional and national strategies aimed at delivery improvements in quality and efficiency. The MCN recognises the need for collaboration both regionally and nationally in delivering incremental improvements. One of the most significant challenges to improving outcomes for colorectal cancer patients is to increase early detection rates and the MCN will continue to input, as requested, to the Detect Cancer Early programme and the national review of referral guidelines. The key area currently being considered by the MCN for regional work in 2013/14 is a regional strategy for the management of locally advanced and metastatic disease. 7
Acknowledgement This report represents the achievements and challenges progressed across the four partner NHS Boards of the : NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire We would like to thank all members and active participants in the cancer network for their continued support of the Managed Clinical Network, without their efforts this level of progress would not be possible. 8