INTERNAL VALIDATION REPORT (MULTI-DISCIPLINARY TEAM)

Transcription

1 INTERNAL VALIDATION REPORT (MULTI-DISCIPLINARY TEAM) Network Trust MDT NTCN ROTHERHAM Rotherham Lcl UROL MDT (08-2G-1) /11 Date Self Assessment Completed 31st August 2010 Date of IV Review 14th September 2010 Lead Clinician Mr Z Abbasi Compliance LOCAL UROLOGY MDT Key Questions Self Assessment 100.0% (45/45) Internal Validation 97.8% (44/45) Does the team demonstrate that this is a properly constituted and functioning MDT? The Operational Policy clearly highlights the criteria and guidance for a functioning Urology MDT. There are clearly nominated core and extended members and agreed roles and responsibilities. MDT attendance is excellent. There is evident leadership from the MDT lead. Does the team demonstrate that it has effective systems for providing coordinated care to individual patients? The MDT is working to clearly defined network guidelines and the Lead Clinician is participating in the specialist MDT as a core member. There is a full range of patient information available. All patients with cancer diagnoses receive a copy of the letter to their GP, which also provides lay terms in brackets so that the patients can easily understand the content. This is exemplary The team are also working towards Information Prescriptions. Does the team demonstrate that it has adequate information to help improve service delivery? There is a need to start to introduce Holistic Need Assessment and information pathways for INTERNAL VALIDATION REPORT for Rotherham - Lcl UROL MDT (published: 30th September 2010) Page: 1/5

2 patients at a local level. The MDT would be encouraged to introduce information prescriptions. It has been recognised that the MDT core members waiting to complete the advanced communication course. Audit work is prioritised in line with Network agreed audits. The MDT participate in the national audit data set BAUS. The MDT is working with the NSSG to replicate the clinical lines of enquiry. Patient experience surveys are undertaken and the results discussed with agreed actions implemented. Does the team demonstrate that it is continuously improving its service including both clinical effectiveness and the patient experience? Patient experience survey has been undertaken. There is an active drive to aid recruitment to clinical trials however there have been some discrepancies in the way that Rotherham patients have been recorded in the clinical trials database prior to January This should be evident through the improved recruitment figures in future analysis. The team are encouraged to review this for 2010 to date for assurance that patients are accessing the trials, acknowledging difficulties in meeting the performance status for the trials, which should also be monitored. The planned recruitment of the research nurse should improve this. The team were enthusiastic about increasing locally delivered chemotherapy and believed this would support recruitment to clinical trials. Kim Fell, Network Director, will take this forward. There is evidence to demonstrate ongoing service improvement work. Notable achievements include establishing the one-stop prostate clinic Key Evidence Submitted Operational Policy Clear and well written operational policy Annual Report Good over view given in the Annual Report which is well constructed and the evidence provided is clear and accessible. Work Programme Work programme clearly sets out a continuous service improvement cycle. It is recommended that ongoing work programmes take forward some actions and recommendations from the audits and surveys being undertaken during INTERNAL VALIDATION REPORT for Rotherham - Lcl UROL MDT (published: 30th September 2010) Page: 2/5

3 Good Practice Good Practice/Significant Achievements It was noted that the Urology MDT have: Achieved all 14, 31 and 62 Cancer Waiting Times Directives and should be commended for this. The Nurse Consultant and Clinical Nurse Specialist have played a pivotal role in developing nurse-led services to improve the quality of care, establishment of a prostate support cancer group, telephone advice line and have acted as the main co-coordinators for the peer review process. It was also noted that a Lead Urology Nurse has been recruited. A one-stop Haematuria and early diagnosis clinic for bladder cancer has been established. As well as a one-stop prostate clinic. The theatre booking clerk also attends the MDTs so that patients are able to have a provisional surgery date immediately. All patients with cancer diagnoses receive a copy of the letter to their GP, which also provides lay terms in brackets so that the patients can easily understand the content. This is exemplary Concerns Immediate Risks: No Immediate Risks Identified Serious Concerns: IV panel discussion explored the differential approach to IOG implementation and where surgery is undertaken. Following the Panel Review Meeting Kim Fell, Network Director, has investigated current practice against IOG and has identified three key points for concern for Kidney Cancer practice across the North Trent Cancer Network: 1. All cases should be discussed by the Specialist MDT 2. Cases are operated on by member of the Specialist MDT 3. Surgery is undertaken at the host Trust of the Specialist MDT An urgent investigation will be initiated through the NSSG and the Rotherham Urology MDT will need to participate in this fully. Concerns: No further concerns identified. INTERNAL VALIDATION REPORT for Rotherham - Lcl UROL MDT (published: 30th September 2010) Page: 3/5

4 General Comments The IV panel commended the MDT on high compliance with the peer review measures. Effective systems in providing co-ordinated care for all patients are offered through support of the Clinical Nurse Specialist and Nurse Consultant from pre-diagnosis through the treatment care pathway. There may be a need to further review the patient pathways when vertical integration occurs with community services at a local level. The MDT should work to ensure that they meet the Psychology measures in 2011 for clinical supervision. The MDT is encouraged to explore ways in developing local chemotherapy services and accrual to clinical trials. The MDT raised concerns with the IV panel around the difficulties and waiting times for penile cancer referrals through supra network approach and this had led to a recent review of referral There was an in-depth discussion at IV panel regarding epidemiology and cancer data registry which demonstrates that Rotherham has a high incidence of prostate and bladder cancer. Rotherham has second highest incidence of bladder cancer. It was recognised that as a locality Public Health were further scoping the statistics alongside deprivation, occupational and geographic factors. Summary of validation process Internal Validation undertaken by Janine Birley (Macmillan Lead Cancer Nurse) 6th Sept 2010 Internal Validation checked by Nicki Doherty (Lead Cancer Manager) 6th Sept Internal Validation Panel 14th September 2010 Panel Members: Mike Pinkerton, Executive Lead Cancer, Chair Prof. John Lee, Cancer Director Rotherham Foundation Trust (RFT) Nicki Doherty, Lead Cancer Manager RFT Janine Birley, Lead Cancer Nurse RFT Nagpal Hoysal, NHS Rotherham Public Health Kim Fell, Director North Trent Cancer Network Shirley Harvey, Chair Cancer Action Rotherham Pat Fayboth, Member Cancer Action Rotherham INTERNAL VALIDATION REPORT for Rotherham - Lcl UROL MDT (published: 30th September 2010) Page: 4/5

5 Organisational Statement I, Mike Pinkerton (Executive Director of Cancer Sirvices) (Validation Chair) on behalf of ROTHERHAM agree this is an honest and accurate assessment of the Local Urology MDT. Agreed by Brian James (Chief Executive) on 14th Sep INTERNAL VALIDATION REPORT for Rotherham - Lcl UROL MDT (published: 30th September 2010) Page: 5/5