Integrated Cancer Services Action Plan Colchester Hospital University NHS Foundation Trust 30 th June KEY Implemented, clearly evidenced and externally approved On Track to deliver Some issues narrative disclosure Not on track to deliver 1
& 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 Safeguarding 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 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 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 Safety 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 Turn Around to oversee and give assurance to the delivery of the action plan. 2
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, Lucy Moore is ultimately responsible for implementing actions in this document. Evelyn Barker, Chief Operating, 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 specialmeasures@monitor.gov.uk 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, 01206 742752. 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: Sally Irvine Signature: Date July Chief Executive Name: Lucy Moore Signature: Date: July 3
Governance Structures and Processes for managing patients on a cancer pathway Summary of Urgent Actions Required Action Owner Timescal e for Impleme ntation Progre ss 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) of Nursing Lead Cancer Clinician/ Executive Lead for Cancer 31 Jan Monitor Commissioni ng Group Amber 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 exception of the Lead Cancer Nurse. Lead Cancer Nurse Interviews being carried out on 6 th May. Lead Cancer Nurse role not appointed to. Post has been readvertised. Interviews were held on 30 th June and an offer has been made subject to references. The Royal Marsden is supporting us to find a suitable candidate for this role. Lead Cancer Nurse by 28 Feb Review of all MDTs to ensure they are effective (using National Cancer Action Team published "Characteristics of an Effective MDT" Feb 2010). 31 Decembe r Strategic Green Review Programme is being developed MDT-fit tool presented at Cancer Board May 14. We are seeking to identify suitable clinical resource to take this very important action. At present we are still on track to deliver by end December 14. 4
Governance Structures and Processes for managing patients on a cancer pathway Summary of Urgent Actions Required Action Owner Timescal e for Impleme ntation Progre ss Ensure that the appropriate Governance Committees provide assurance to the Board of the quality of care delivered 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 Quality & Patient Safety Committee in line with Terms of Reference. Review the workload of all Cancer Services workforce (Clinicians) of Nursing (Nurses) Chief Operating (Administrativ e Staff) 31 March National Peer Review Programme Amber A Summary 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 commencing 1 st April 14. Work on workforce has commenced with risks identified in Lower GI, Head & Neck, and Dermatology. MDT Co-ordinator workload being assessed using IST Workload Tool. Nurse Workload review terms of reference agreed. CNS review to determine if CNS workload is manageable (all tumour sites) and sufficient to deliver support to the current volume of cancer patients. 5
Data Collection and Data Governance Summary of Urgent Actions Required Action Owner Timescale for Implementation 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 31 March Monitor Green 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 Co-ordinator team. This policy is to be incorporated into the Trust Access Policy. 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 28 February Monitor Intensive Support Team Amber 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 July 14. 6
Data Collection and Data Governance Summary of Urgent Actions Required Action Owner Timescale for Implementation 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 31 January Commissio ning Group Daily report comparing differences between CWTs database and Patient Administration System introduced end December. 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 Green 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 Sept but may be completed earlier. 7
Data Collection and Data Governance (continued) Summary of Urgent Actions Required Action Owner Timescale for Implement ation We will: Make improvements to our weekly cancer escalation processes ensuring there is a failsafe method for escalating patients treatment pathways. Chief Operating 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. Effectiveness is being monitored within the Divisional governance boards. 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 31 March Commissioning Group Green The Contact Centre commenced on 23 rd December for internal referrals. (2ww) referrals commenced via Choose & Book (end March 14) in conjunction with North East Essex CCG (and has an nhs.net email 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. Anticipated date for completion of the inter-trust referral policy was originally end July 14 but is dependent on other external organisations. This deadline has slipped to end October 14 All internal faxes have been replaced with nhs.net secure email accounts. 8
Data Collection and Data Governance (continued) Summary of Urgent Actions Required Action Owner Timescale for Implement ation 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. Chief Operating 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. Team Meetings are taking place weekly with a standard item on CWTs guidance topics for discussion/training are identified by the MDT Co-ordinator & Data Clerk Team. 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 Operating 28 February Monitor Intensive Support Team Green The Cancer Services Standard Operational Policy details the Cancer Waiting Times guidance has been completed and is being 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. 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 31 March Monitor Intensive Support Team Amber 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. This action has slipped due to implementation of Somerset system. The Trust is reviewing the options for delivering the e-learning tool and will be confirmed by end June 14. 9
Data Collection and Data Governance (continued) Summary of Urgent Actions Required Action Owner Timescale for Implement ation Implement Inter-Trust Referral policy (recommended by Midlands & East of England Strategic ). 30 th June Strategic Amber Communication with external trusts advising of the adoption of this policy established - an Essex wide meeting took place end April with Trusts, the Strategic (SCN) and the Cancer Registry. The aim was to reach agreement by end May but this timetable has slipped. The Trust anticipated date for completion, subject to external organisations is end July, Currently awaiting confirmation of date for teleconference from the SCN and Cancer Registry to finalise the policy. SCN agreed at Essex Cancer Forum (June 14) to bring the policy back to ECF October 14 for sign off. Timetable outside of CHUFT control. Establish regular failsafe monitoring programme to ensure all referrals are made by Day 42 and tracked appropriately 31 March 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. The deadline for completion to be reviewed. 10
Management of patients on a cancer pathway Summary of Urgent Actions Required Action Owner Timescale for Implementa tion 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 31 March Monitor Green 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 complete. Clarification relating to Consultant Upgrade discussed at Cancer Board Feb 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. Ensure that all recommendations from peer review are implemented Divisional s 31 December Strategic. Green 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. Timetable for peer review and requirements of each MDT team to be confirmed at June Cancer Board. Assessment of progress for all Immediate Risks and Serious Concerns is being undertaken and will be reported to Cancer Board in July 14. Ensure that the Anal Cancer Pathway is implemented and is IOG compliant 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 (upto 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. 11
Management of patients on a cancer pathway Summary of Urgent Actions Required Action Owner Timescale for Implementa tion Ensure Gynaecology MDT has cover for Consultant Oncologist 30 June Strategic Green Recruitment commenced December 13. Consultant Oncologist appointed commences June 14. Following induction, MDT cover will be in place by end June 14. Ensure Urology service has sufficient capacity to treat patients Chief Operating 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 commenced. Additional consultant commenced early March; additional nursing posts have been advertised and shortlisted. Interviews successful CNS post appointed to start date to be confirmed. Ensure Gynaecology MDT has cover for Consultant Oncologist 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. 12
Management of patients on a cancer pathway (continued) Summary of Urgent Actions Required Action Owner Timescale for Implementa tion We will Ensure there a re clear documented pathways for Urology (prostate and bladder) Multidisciplinary 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) confirmed pathways assured. No immediate risks or serious concerns identified. Ensure the Skin pathway is compliant with cancer waiting times guidance. 31 January Strategic Amber Pathway has been reviewed by visiting Consultant and compliance with Cancer Waiting Times guidance has been received. Pathway audit will be undertaken to ensure compliance. Awaiting date for revisit of pathway from Strategic. Ensure there is a clear documented pathway for suspicious lesions 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 Policy7. Discussed and agreed at Cancer Board March 14. pathway revisit (14 th April) confirmed process assured. Ensure there are robust tracking methods for Sarcoma patients 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) confirmed pathway assured. 13
Management of patients on a cancer pathway (continued) Summary of Urgent Actions Required Action Owner Timescale for Implement ation Progre ss Ensure there is a clear documented pathway for Brain/Central Nervous System patients 28 February Strategic Revised pathway completed 16 th December. at Cancer Board Feb 14. Pathway revisit took place 20 th May pathway assured. There is a clear MDT structure and pathway for Cancer of Unknown Primary 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. The external pathway revisit has confirmed assurance of the Cancer Unknown Primary pathway. Ensure all Cancer pathways are regularly audited. This is a failsafe process to ensure that patients are treated in line with agreed pathways. 31 December Strategic Green 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. Develop a continuous quality improvement programme for cancer specialties, to encompass clinical peer review visit recommendations Trust Cancer Lead 31 May Strategic Green 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 Safety Committee. The Royal Marsden is providing additional support to the hospital to develop a Strategy for Cancer. The Continuous Quality Improvement Programme to be submitted to Quality & Patient Safety Committee June 14. Programme ratified by Cancer Board June 14. Monitoring will be via Cancer Board. 14
Safeguarding Adults and Children Summary of Urgent Actions Required Action Owner Timescale for Implementation Revised deadline (if required) We will Confirm the Non-Executive lead and ensure all board members receive training of Nursing End December 2013 Monitor Non-Executive for Safeguarding confirmed. Safeguarding training completed. Ensure that there are policies and procedures in place to protect vulnerable adults and children 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 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). 31 July NHS England Green It has been agreed with NHS England that this will be incorporated into Retrospective Review programme timetable under Duty of Candour. 15
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 Safety 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. Effectiveness of the Group to be monitored throughout the year by the Quality & Patient Safety Committee Beg December 14 Sean MacDonnell, Cancer Programme took up post 2 nd December 13 Project Manager in post from 27 th February 16
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 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 Chief Operating 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 17