integrated cancer services action plan colchester hospital ... · blue daily report comparing...

Special Measures Action Plan

Colchester Hospital University NHS Foundation Trust

Cancer Action Plan 31st August 2014

KEY

Delivered

On Track to deliver

Some issues – narrative disclosure

Not on track to deliver

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Colchester Trust - Our improvement plan & 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, External 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 2014. 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 Clinical 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 Director and Project Manager to drive the required improvements reporting to a Cancer Steering Group

• A Project Management Office and Turnaround Director to oversee and give assurance to the delivery of the action plan.

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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 Director assigned to Colchester Hospitals NHS Foundation Trust is Mark Davies, who will be acting on behalf of Monitor and in concert with the relevant

Regional Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further information on

this role please contact [email protected]

• Ultimately, our success in implementing the recommendations of the Trust’s Cancer Action Plan will be assessed by the Chief Inspector of Hospitals, who will re-inspect our

Trust within 12 months after entering the Special Measures programme.

• If you have any questions about how we’re doing, contact Mark Prentice, Head of External Relations, [email protected] , 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: Dr Sally Irvine Signature: Date 11 Sept 2014

Chief Executive Name: Dr Lucy Moore

Signature:

Date: 11 Sept 2014

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mailto:[email protected]

mailto:[email protected]

Colchester Trust - Our improvement plan

Governance Structures and Processes for managing patients on a cancer pathway

Summary of Main Concerns

Summary of Urgent Actions Required

Action Owner

Agreed Timescale for Implementation

External Support/ Assurance

Progress Revised deadline (if required)

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 Director Director of Nursing

Lead Cancer Clinician/Executive Lead for Cancer – 31 Jan 2014 Lead Cancer Nurse by 28 Feb 2014

Monitor Clinical Commissioning Group

Green 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 2nd November 14. Letters defining roles have been sent to all MDT Clinical leads for signature/agreement to responsibilities. Draft letters have been prepared for all Clinical Nurse Specialists which sets out role description – being sent out by Director of Nursing w/c 1st September.

Responsive Effective

• Review of all MDTs to ensure they are effective (using National Cancer Action Team published "Characteristics of an Effective MDT" Feb 2010).

Medical Director

31 December 2014

Strategic Clinical Network

Green Review Programme is being developed using the National Cancer Action Team “Effectiveness 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.

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Governance Structures and Processes for managing patients on a cancer pathway



Action Owner




Well Led Responsive

• Ensure that the appropriate Governance Committees provide assurance to the Board of the quality of care delivered

Medical Director

31 March 2014

Monitor Blue Cancer Board meeting monthly, with clear Agenda and Minutes. Agreed Terms of Reference in place. Well attended by Clinical Leads. The work programme of the Cancer Board in 2014 is to monitor the delivery of the Cancer Remedial Action Plan. Quarterly update of progress to the Trust Quality & Patient Safety Committee in line with Terms of Reference.

Safe Effective

• Review the workload of all Cancer Services workforce

Medical Director (Clinicians) Director of Nursing (Nurses) Chief Operating Officer (Admin Staff)

31 March 2014

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. Clinical workload review is incorporated into annual joint planning cycle (commenced 1st April). Work on Medical workforce has commenced with risks identified in Lower GI, Head & Neck, and Dermatology. MDT Co-ordinator workload being assessed using IST Workload Tool. Clinical 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. 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 Director of Nursing. The outcome and recommendations of the review will be passed to the Lead Cancer Nurse to take forward.

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Data Collection and Data Governance



Action Owner




Safe Well Led Responsive

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 2014 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 has been incorporated into the Trust Access Policy, which is available on the Trust Intranet.

Responsive Effective

• Develop written protocols for the Multi-disciplinary data team setting out the application and recording of data relating to Cancer Waiting Times rules. This is a failsafe method of ensuring our staff have up to date and accurate guidance


28 February 2014 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 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. Diary sheets being collated and analysed.

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Data Collection and Data Governance


Summary of Urgent Actions Required Action Owner




Safe Effective

• Implement an electronic process for reviewing adjustments on Cancer Waiting Times database by hospital staff to enable review and monitoring by Information Team. This is a failsafe process to assure ourselves that any adjustments are consistent with national guidance.


31 January 2014

Clinical Commissioning Group

Blue 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.

Responsive Safe

• Implement a nationally recognised Information System to collate and report cancer waiting times data. The Somerset system being implemented has built in failsafe mechanisms to alert users when inaccurate data is input.

Cancer Programme Director

28 February 2014

Monitor Green Installation of Somerset system for collection of cancer waiting times data completed 6th March 2014. 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.

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Data Collection and Data Governance (continued)



Action Owner



Progress

Revised deadline (if required)

Safe Responsive

We will: • Make improvements

to our weekly cancer escalation processes ensuring there is a failsafe method for escalating patients treatment pathways.


31 January 2014 Clinical 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 at the weekly Performance and Activity Review meetings, led by the Chief Operating Officer.

Safe Effective

• Implement an electronic system of single point of receipt for GP Suspected Cancer Referrals, and referrals to and from other hospitals for cancer pathways. This is a failsafe method of capturing referrals which will replace paper referrals into the Trust.


31 March 2014 Clinical Commissioning Group

Green The Contact Centre commenced on 23rd December 13 for internal referrals. External (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 (led by the Strategic Clinical Network). 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 email accounts.

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Action Owner




Safe Caring Effective

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.


28 February 2014

Monitor Intensive Support Team

Blue 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 (7th & 14th 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.

Safe Responsive Caring

• Improve support and advice to MDT Co-ordinator Team including standard operating procedures to support MDTCs/Data Clerks roles/functions, including escalation processes This is a failsafe method of ensuring our staff are following consistent and accurate guidance.


28 February 2014


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 (anticipated to be in place by mid October) to complement the Standard Operational Policy.

Safe Effective Responsive

• Develop an electronic failsafe competency framework to ensure MDTC/Data Clerks knowledge and skills are maintained (similar to that used for IT Governance) which will be tested annually.

Cancer Programme Director

31 March 2014


Amber 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.

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Action Owner




Well Led Effective

• Implement Inter-Trust Referral policy (recommended by Midlands & East of England Strategic Clinical Network).

Medical Director

31 October 2014


Amber 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 Clinical Network (SCN) and the Cancer Registry. The Trust anticipated date for completion, subject to external organisations is October 2014. Strategic Clinical Network 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.


• Establish regular failsafe monitoring programme to ensure all referrals are made by Day 42 and tracked appropriately

Medical Director

31 October 2014


Amber Somerset implemented with data migration completed. Monitoring of incoming and outgoing tertiary referrals was expected to be monitored via Somerset from 1 April 2014. Release of Somerset module for Inter-Trust Referrals has slipped to Autumn 2014 by Somerset Cancer Registry and is outside of the control of the hospital. There is on-going 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.

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Management of patients on a cancer pathway



Action Owner Agreed Timescale for Implementation



Safe Caring Responsive

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


31 March 2014 Monitor Green 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 Safe Responsive

• Ensure that all recommendations from peer review are implemented

Divisional Clinical Directors

31 December 2014

Strategic Clinical Network .

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. Trust document confirming the annual cycle, process, timetable and requirements for each MDT presented to Cancer Board (July 14). Clinical Leads and MDTs have been given the opportunity to comment/provide feedback on the process document. To be 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.

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Management of patients on a cancer pathway






Effective Responsive

• Ensure that the Anal Cancer Pathway is implemented and is IOG compliant

Medical Director 30 September 2014 Specialised Commissioning Group

Blue Discussions are continuing with Specialised Commissioning and the Strategic Clinical Network 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. Essex wide meeting taking place 6th August 2014.

Effective Safe

• Ensure Gynaecology MDT has cover for Consultant Oncologist

Medical Director 30 June 2014 Strategic Clinical Network

Blue 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.

Effective Responsive Well Led

• Ensure Urology service has sufficient capacity to treat patients


31 March 2014 Monitor Amber 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 5th consultant who commenced early March 14 and a 6th consultant commences 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.

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Management of patients on a cancer pathway (continued)



Action Owner





We will • Ensure there are clear

documented pathways for Urology (prostate and bladder)

Multi-disciplinary Team Clinical Lead

30 December 13

External Visit Review Team

Blue Prostate and Bladder cancer pathways have been revised and assured by the visiting External Review Clinical Lead. The Clinical Team are regularly auditing this pathway and is part of the regular programme of pathway audits to be presented at Cancer Board. External revisit of prostate, bladder and renal pathways (28th April 14) confirmed pathways assured. No immediate risks or serious concerns identified.


• Ensure the Skin pathway is compliant with cancer waiting times guidance.

Medical Director 31 January 2014 Strategic Clinical Network

Red Pathway has been reviewed by visiting External Consultant and compliance with Cancer Waiting Times guidance has been received. Pathway audit has been deferred by agreement between the Clinical Commissioning Group, Local Area Team, and the Trust. Deadline for review of this pathway has been set for end December 14. An internal spot audit assessing the pathway against 2ww milestones has been conducted and will be reported to Cancer Board Sept 14.


• Ensure there is a clear documented pathway for suspicious lesions

Medical Director 31 January 2014 Strategic Clinical Network

Blue 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. External pathway revisit (14th April) confirmed process assured.

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Action Owner





• Ensure there are robust tracking methods for Sarcoma patients

Medical Director 31 March 2014 Strategic Clinical Network

Blue 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. External pathway revisit (14th April 14) confirmed pathway assured.


• Ensure there is a clear documented pathway for Brain/Central Nervous System patients

Medical Director 28 February 2014


Blue Revised pathway completed 16th December 13. Agreed at Cancer Board February 14. Pathway revisit took place 20th May 14 – pathway assured.


• There is clear MDT structure and pathway for Cancer of Unknown Primary

Medical Director 31st March 2014 Strategic Clinical Network

Blue 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.

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• Ensure all Cancer pathways are regularly audited . This is a failsafe process to ensure that patients are treated in line with agreed pathways.

Medical Director

31 December 2014


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).

Safe Effective Responsive Caring Well Led

• Develop a continuous quality improvement programme for cancer specialties, to encompass clinical peer review visit recommendations

Trust Clinical Cancer Lead

31 May 2014


Blue 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 Continuous Quality Improvement Programme to be submitted to Quality & Patient Safety Committee June 14. Programme ratified by Cancer Board June 14. Monitoring of all components of the programme will be via Cancer Board.

Safe Effective Responsive Caring Well Led

• NHS England – Follow up report on the Management of the above cancer pathways (published July 2014).

Medical Director

31 July 14

NHS England / Local Area Team

Blue 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.

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Safeguarding Adults and Children






Safe Responsive Well Led

We will • Confirm the Non-

Executive Director lead and ensure all board members receive training

Director of Nursing End December 2013

Monitor Blue Non-Executive Director for Safeguarding confirmed. Safeguarding training completed.

Safe Caring

• Ensure that there are policies and procedures in place to protect vulnerable adults and children

Director of Nursing End December 2013

Monitor Clinical Commissioning Group

Blue Policies and procedures completed and presented to Trust Board.

Safe Caring Responsive

• Ensure the internal Trust intranet has an e-training module

Director or Nursing End December 2013


Blue E-training module for Safeguarding In place mid December.

Safe Caring

• Develop a

communications plan for contacting all patients (to convey outcome) following clinical-notes review (duty of candour).

Medical Director 31 October 2014 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 External Assurance Panel (comprising LAT, CCG, Healthwatch representatives) and the completion date has been amended to reflect this.

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Colchester Trust - How our progress is being monitored and supported

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Oversight and improvement action Agreed Timescale for Implementation

Action owner Progress

Outline details of how the progress is being monitored and supported during the Special Measures programme. e.g. the appointment of an Improvement Director by Monitor; the identification of a Buddy Trust to help support the Special Measures Trust implement its Action Plan.

Confirm whether the action has been started – its due date or completed date (detail month and year.)

Confirm who is responsible for making sure each task is actioned.

Provide a brief summary of why the

RAG colour was picked for each particular

action

• There is a multidisciplinary led external review structure, which is overseeing the development and implementation of the Trust Cancer Action Plan, comprising a clinical oversight group, an operational group and an Executive Assurance Group. These groups encompass NHS England Clinical Commissioning Group, Trust representatives, Essex County Council , health regulators (Monitor) and Health Watch (which represents patients views).

Mid December 13 Chief Executive Blue The Trust is

represented with excellent attendance

on all groups

• In addition to the above, there are regular Clinical Commissioning Group oversight and assurance groups which meet weekly. These include :

a) Review of the weekly process for reviewing patients on the cancer waiting times database

b) Weekly unscheduled visits/walkabouts by the Commissioners

c) Weekly clinical scrutiny by GP partners –review of patient pathways

December 13 Cancer Programme Director Blue All groups are being regularly attended

• Trust Cancer Board has been reconstituted to include Multi-disciplinary Team Clinical Leads , Clinical 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.

Mid December 13

Clinical Lead for Cancer Services Blue Reconstituted Board

commenced mid December.

Effectiveness of the Group to be monitored throughout the year by the Quality & Patient

Safety Committee

• Appointment of Cancer Programme Director and Project Manager to drive the required improvements.

Beg December 14 Medical Director Blue Cancer Programme

Director took up post 2nd December 13

Project Manager in post from 27th February

2014


Colchester Trust - How our progress is being monitored and supported

Oversight and improvement action Agreed Timescale for Implementation

Action owner Progress

Outline details of how the progress is being monitored and supported during the Special Measures programme. e.g. the appointment of an Improvement Director by Monitor; the identification of a Buddy Trust to help support the Special Measures Trust implement its Action Plan.

Confirm whether the action has been started – its due date or completed date (detail month and year.)

Confirm who is responsible for making sure each task is actioned.

Provide a brief summary of why the

RAG colour was picked for each particular

action

• A Cancer 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 Safety Committee and the Trust Turnaround Board. The Steering Group monitors the progress of the Cancer Remedial Action Plan.

January 2014 Chief Operating Officer Blue Cancer Services

Steering Group has commenced and is

meeting weekly

• 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 2014 Chief Executive Blue Programme

Management Office commenced January 14

• Appointment of Improvement Director (by Monitor) to work with and support the Trust to deliver the Cancer Action Plan.

Completed 20th January 2014

Chief Executive Blue Improvement Director

took up post week commencing 20th

January

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integrated cancer services action plan colchester hospital ... · blue daily report comparing...

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