national cancer peer review programme louise wilson quality manager north zone
TRANSCRIPT
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National Cancer Peer Review ProgrammeLouise WilsonQuality ManagerNorth Zone
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Aims of TodayAims of Today
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The New Healthcare EnvironmentThe New Healthcare Environment
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Reducing the Burden of Peer Review on Reducing the Burden of Peer Review on the NHSthe NHS
The key actions are:
• Reducing the measures - To further reduce the number of measures within the manual for cancer services by 10%.
• Amalgamate Reports - Where possible amalgamate measures to reduce the number of reports required i.e. locality and MDT measures.
• Biennial Submission of Evidence - evidence for the annual SA should be submitted biennially, teams/services should instead complete a commentary in relation to the key questions each year along with the SA against compliance with the measures. The exception to this would be teams performing below 50% compliance or with unresolved immediate risks.
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Reducing the Burden of Peer Review on Reducing the Burden of Peer Review on the NHSthe NHS
• Targeted Peer Review Visits – Visits will only be undertaken where
a team/service: – Falls into the risk criteria– Where there is considered to be an opportunity for significant
learning – As part of a small stratified random sample to assure public
confidence in SA and IV.
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What is Cancer Peer Review?What is Cancer Peer Review?
• A quality assurance process for cancer services.
• An integral part of Improving Outcomes – A Strategy for Cancer
• Assesses compliance against IOG for NHS patients in England.
• A driver for service development and quality improvement
• Supported by a set of measures
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Aims of Cancer Peer ReviewAims of Cancer Peer Review
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Outcomes of Peer ReviewOutcomes of Peer Review
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The Peer Review ProgrammeThe Peer Review Programme
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The National ScheduleThe National Schedule
Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May
Notification of visit Programme
Prepare for visit complete Self Assessment
Peer Review VisitsFrom May to March
Complete Internally Validated Self Assessment
Targeted External
Verification
Feedback to teams
Notification of visit Programme
Complete Self AssessmentA team either has a peer review visit or completes a self assessment.
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Measures DevelopmentMeasures Development
• Developed by an expert group • Aimed to measure areas detailed in the National
documentation e.g. NICE Improving Outcomes Guidance and National reports such as NCAG and NRAG reports.
• 3 month consultation on new measures
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• The commissioning of services
• Inter-professional communication
• Co-ordination of care
• User Involvement
• User/carer experience
• Information
• Access to services
Focus for the MeasuresFocus for the Measures
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New MeasuresNew Measures
TopicSo
Consultation Closes
Publication Date
Commence Peer review
Comments
Brain&CNSImp
31st March Apr-11 2011 Out to Consultation
Sarcoma
Impr
16th May May-11 2011 Out to Consultation
Acute Oncology
Nati
NA Mar-11 2011 Waiting Gateway Approval
Chemotherapy
Nati
Closed Mar-11 2011 Editing Meeting 7th March
Patient Partnership MeasuresUser
NA Mar-11 2011 Awaiting Gateway Approval
TYAImp
5th April Apr-11 2011 Out to Consultation
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The Process
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The Self Assessment ProcessThe Self Assessment Process
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Self Assessment ReportSelf Assessment Report
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Self Assessment Report – Key ThemesSelf Assessment Report – Key Themes
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Self Assessment ReportSelf Assessment Report
• Will be a public document
• Will form basis of Annual Peer Review Report for those teams not subject to internal validation
• Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns
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Chemotherapy Service- Chemotherapy Service- Evidence Documents (only required Evidence Documents (only required every other year)every other year)
Operational Policy
Annual Report Work Programme
Describing how the service functions and how care is delivered across the patient pathway
Outlining policies/processes that govern safe / high quality care
Agreement to and demonstration of the clinical guidelines and treatment protocols for team.
Summary assessment of achievements & challenges
Demonstration that the service is using available information (including data) to assess its own service - Workload & Activity Data
-National Audits-Local Audits-Patient Feedback-Trial Recruitment-Work Programme Update
How the team is planning to address weaknesses and further develop its service.
Outline of the teams plans for service improvement & development over the coming year
-Audit Programme-Patient feedback-Trial Recruitment-Actions from Previous reviews
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Demonstrating Demonstrating AgreementAgreement
• Where agreement to guidelines and policies is required there should be a statement on the front cover of the document indicating the groups and individuals that have agreed the document and the date of agreement.
• Evidence Guides will indicate the groups and individuals that need to be documented as agreeing the key evidence documents.
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Evidence GuidesEvidence Guides
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Internal Validation Internal Validation – The Purpose– The Purpose
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Who Validates?Who Validates?
Service Responsibility for ValidationMDT Host Trust
Cross Cutting Service Host Trust
Locality Group Host Trust
NSSG Host Network Management Team
Network Cross Cutting Group Host Network Management Team
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Internal Validation – Internal Validation – What we ExpectWhat we Expect
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Internal Validation – Internal Validation – Suggested ApproachesSuggested Approaches
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Internal Validation – Internal Validation – The ProcessThe Process
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The Internal Validation The Internal Validation ReportReport
• Will be a public document
• Will form basis of Annual Peer Review Report for those teams not subject to external review
• Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns
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Using CQuINS V4Using CQuINS V4
Available via the web site at: www.cquins.nhs.uk
• Secure web based database supporting each stage of the cancer peer review process
• Records assessments, compliance with the measures and reports
• Provides information for national analysis and reporting
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Completing the Self AssessmentCompleting the Self Assessment
1. Upload Key Documents - (Alternate years only)
2. Enter Compliance on CQuINS
3. Complete Team Report
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Completing the Self AssessmentCompleting the Self Assessment
1
2
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1 Upload Key Documents1 Upload Key Documents
1
2
3
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Enter Compliance Enter Compliance
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Enter Compliance Enter Compliance 1
23
4
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Complete Overview ReportComplete Overview Report
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Self Assessment - EvidenceSelf Assessment - Evidence
Key Documents -teams/services should ensure the evidence requirement stated for each measure is included either in one of the key documents i.e. operational policy, annual report, work programme or if not in one of these key documents it should be included as an appendix.
Additional Evidence -If the actual evidence is not included in the upload documents on CQuINS then the team should include a statement which makes clear this evidence requirement has been checked by the team/service and would be available if a peer review team were to visit. Use of Internet Hyper-links - it is acceptable for teams/services to include internet hyperlinks but these links must have open access and not be on the closed section of the trust or organisation intranet system.
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Internal Validation - EvidenceInternal Validation - Evidence
• Key Documents - Ensure all the evidence required against the measures for a team/service has been checked and is available on the CQuINS database via the key documents.
• Additional Evidence - If any evidence is not available on the CQuINS system, the internal validation panel should confirm they have seen the evidence or give details of the spot checks they have undertaken.
• Confirmation - This should be made clear on the internal validation report form. It is not sufficient to give an overall statement that all evidence has been seen. Details of the specific evidence seen against measures should be identified and noted on the compliance spreadsheet.
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Peer Review Visit - EvidencePeer Review Visit - Evidence
• Key Documents - A full copy of all evidence uploaded onto CQuINS must be available to reviewers on the peer review visit. This can be either hard copy or electronic.
• Patient Records - Peer Review zonal teams will normally request 5 sets of patient notes in order to check compliance against the measures. Teams may sometimes require more than 5 set of patient notes but this should never exceed 10. Only clinical NHS staff will review patient notes.
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General PrinciplesGeneral Principles
Personal details / Patient information •It is essential that no identifiable patient data including hospital number should be uploaded on the CQuINS database.
•The personal details of individual staff in a team/service should not be uploaded e.g. certificates or job plans.
•Identification of individuals should not be made on reports uploaded onto CQuINS. Reports should refer to the roles they carry out.
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General PrinciplesGeneral Principles
Agreements•The role of the person indicated on the agreement should include any delegated role they are undertaking for others.
•The front cover of any document uploaded should show the date, version and planned review date.
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General PrinciplesGeneral Principles
Configuration of the Network•The configuration of the network is essential to the review of a particular tumour site and ensuring compliance against the Improving Outcomes Guidance. Details of PCT referral pathway and populations are essential.
Membership•When a measure asks for the membership of a group then the name, role and organisation the individual represents should be indicated on the evidence.
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General PrinciplesGeneral Principles
Patient Information•Does not require uploading on CQuINS
•Copies available for IV panel and Peer Review Team
•The IV report should confirm that the patient information has been seen and that it covers all the essential elements of the measure.
•At self assessment the team/service should list the patient information they have in the key documents uploaded on CQuINS.
Patient Experience Exercise•A summary of the exercise including the key points and action implemented is sufficient in the key documents.
•A copy of the patient exercise should be seen available for both peer review and IV
•IV assessment should confirm this has been seen.
•The national cancer patient survey would be acceptable for this measure.
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Specific Evidence Requirements
Working practice of a team/Spot checks•Where measures ask for reviewers to ask about working practice of teams/services or to undertake spot checks, they will do this when on a review. •IV should mirror this and include comments in the IV report. •For self assessment teams/services should state that they have completed a spot check and the results of the spot check or give details of the working practice.
Annual Meetings•It is only necessary to make a statement in the key documents to confirm the time/date of the meeting and that a record has been made. •IV should confirm this meeting has taken place. •If it is unclear that a meeting has taken place reviewers on a peer review visit may ask for minutes of the meeting.
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Specific Evidence RequirementsAttendance records /Meeting dates
This can often be satisfied by one clear piece of evidence showing:•Dates of the meetings•Name, role and organisation represented of those who have attended each meeting•The SA report form should comment about any roles not covered or attending appropriately. •Any summaries of attendance should demonstrate individual attendance at each meeting for all members as well as the summary.
Policies /Guidelines/Plans •The date and version should be shown on all policies/guidelines and plans. •These should be uploaded on CQuINS either as an internet hyperlink (see above) within the key documents or in the appendix. •National guidelines should have been adopted the local context should be explained. •Flow charts are an acceptable means to explain details within guidelines.•If it is unclear that a meeting has taken place to sign off the guidelines/policies and plans reviewers on a peer review visit may ask for minutes of the meeting.
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External VerificationExternal Verification– The Purpose– The Purpose
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External Verification External Verification – The Process– The Process
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Annual Meeting Annual Meeting with Networkwith Network
• December each year
• The purpose of the meeting will be to;– inform the Zonal team of key issues within the
Network such as implementation of Improving Outcomes Guidance, Service Configuration changes
– discuss the teams to be visited and schedule for the
following year.
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Peer Review Visit CriteriaPeer Review Visit Criteria
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Notification in January to teams to be
peer reviewed during May -
March
Deadline for submission of evidence for
all teams to be visited
Self Assessment evidence and compliance
matrix sent to reviewers and
copied to teams
Visits MAY-MARCH
Each Network is allocated one month. Can
take from 1 to 4 weeks to
complete a Network –
normally 1 day per Locality
Report published 8 weeks after last review
day
January- 2 Weeks- 4 WEEKS
The Peer Review Visit Plan
Preparation for review
+ 8 WEEKS
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Peer Review TeamsPeer Review Teams
• Between 2 and 5 reviewers per session
• Plus a member of the Zonal Quality Team
• Reviewers should normally include “Peers”
– people who are trained and working in the same discipline as those they are reviewing
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Outcomes Outcomes from the Processfrom the Process
• Annual Network Reports
• National “State of the Nation” Reports
• Joint Working between the Care Quality Commission (CQC) and the NCPR Programme
• Information for commissioners
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Outcomes of the Process – Network Outcomes of the Process – Network ReportsReports
• Published January and June each year
• Including IV, EV and PR Visit Assessments
• Executive Summary from Quality Director
• QD will discuss key issues with Network
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Next StepsNext Steps
• Revised measures published on CQuINS
• Revised Handbook
• Evidence guides
• Evidence documents
• Reports
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2011/12 (INTRODUCTION YEAR) 2012/13 (EVEN YEARS) 2013/14 (ODD YEARS)Acute Oncology
Breast Acute Oncology
Chemotherapy
Lung Chemotherapy
Teenage and Young Adults
Colorectal Teenagers and Young Adults
Sarcoma
Upper GI Sarcoma
Brain and CNS
Head and Neck Brain and CNS
Gynaecology
Skin Gynaecology
Urology Cancer Research Network Urology
Network Service User Partnership Group
Radiotherapy Network Service User Partnership Group
Rehabilitation
Children’s
Complementary Therapy Cancer of Unknown Primary
Psychology
Specialist Palliative Care
Haematology
Schedule of Teams for Schedule of Teams for Internal ValidationInternal Validation
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Thank YouThank You
Any Questions ?Any Questions ?