PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM)

Transcription

1 PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Network Trust NLCN BARNET AND CHASE FARM HOSPITALS Team Barnet And Chase Farm Hospitals Lcl SKIN MDT (08-2J-1) 2009/10 Peer Review Visit Date 4th February 2010 Compliance LOCAL SKIN MDT Peer Reviewer Team Self Assessment 88.2% (30/34) Peer Review 63.2% (24/38) Name (Print) Job Title Organisation Katherine Ackland Consultant Dermatologist Guy's & St Thomas' NHS Trust Saqib Bashir Consultant Dermatologist Kingâ s College Hospital NHS Foundation Trust Keith Foster User MVCN Donna McKenzie Quality Manager London Cancer Peer Review Team Zonal Statement Completed By Job Title Angela Hoyes Quality Manager Date Completed 3rd June 2010 Agreed By (Quality Director) Mike Bellamy Date 9th April 2010 Agreed By (Clinical Lead) John Bolton Date 9th April 2010 Meeting Attendance PEER REVIEW VISIT REPORT for Barnet And Chase Farm Hospitals - Lcl SKIN MDT (published: 3rd June 2010) Page: 1/7

2 Name (Print) Job Title Organisation Dr Stevens Consultant dermatologist Barnet & Chase Farm Hospitals Mr Peter McDemott Consultant maxillo facial surgeon Barnet & Chase Farm Hospitals Dr Penny Thomson Associate specialist dermatology Barnet & Chase Farm Hospitals Keryn Theobald CNS Barnet & Chase Farm Hospitals J Thiruchelvam Consultant maxillo facial surgeon Barnet & Chase Farm Hospitals J M Munro Consultant Pathologist Barnet & Chase Farm Hospitals Karen May Fergus Browne Barnet & Chase Farm Hospitals Barnet & Chase Farm Hospitals Dr Virginia Hill Consultant dermatologist Barnet & Chase Farm Hospitals Lizeth Cardona Skin MDT Coordinator Barnet & Chase Farm Hospitals Wanda Robles Consultant Dermatologist Barnet & Chase Farm Hospitals PEER REVIEW VISIT REPORT for Barnet And Chase Farm Hospitals - Lcl SKIN MDT (published: 3rd June 2010) Page: 2/7

3 Key Questions Does the team demonstrate that this is a properly constituted and functioning MDT? This local multidisciplinary team (MDT) had been existence for three years and had progressively developed its membership and improved the organisation of the MDT meetings. Seven consultants were listed as core members of whom two were locums. Other core team members included two maxillo-facial surgeons, a clinical nurse specialist (CNS), a coordinator and a histopathologist. The team had a large extended membership including a medical and a clinical oncologist and three plastic surgeons based at the Royal Free. The MDT had recently changed its working practices so that it discussed almost all basal cell carcinomas (BCCs), squamous cell carcinomas (SCCs) and malignant melanomas (MMs). The MDT felt that this had resulted in the better management of BCCs and an increase in the number of cases being discussed at each MDT. The team had moved to having weekly meetings which lasted approximately two to two and a half hours and some patients were discussed on multiple occasions. The MDT had well organized systems for listing patients for MDT discussion, recording decisions and communicating these to referring clinicians and for allocating patients a key worker. Simple BCC cases for patients who had had an excision in clinic at their first appointment were noted but not discussed at the MDT. Of the seven listed core team dermatologists only two, the clinical lead and an associate specialist, had attended over 66% of meetings and four others had attended less than 25% due to clashes with other clinical commitments. The lead histopathologist had an exceptionally high level of attendance. The two maxillo-facial surgeons, the coordinator and the CNS had compliant levels of attendance. The MDT meetings were however, non compliant as they only had clinical oncology input at alternate meetings. The lead histopathologist had an exceptionally heavy workload and there were inadequate cover arrangements for him. He did not have sufficient time to review all the slides prior to the meeting. The histopathology for complex cases was viewed by the specialist MDT histopathologist via video link but this was not of a particularly good image resolution. The specialist MDT histopathologist provided a double reporting service for all such cases. The operational policy was clearly laid out and well written. It provided a detailed description of the roles of the lead clinician, CNS and coordinator. However there appeared to be inconsistencies between the policy and clinical practice in relation to follow up. The policy stated a wide range of duties to be fulfilled by the CNS and given the large workload it needed to define the level of support provided by the CNS for the different types of skin cancer in a more discriminating way. The policy should identify which types of patients needed a key worker. Post operative follow up by the CNS should be restricted to patients who had had more complex surgery with her contact details being given to the other patients. The team needed to review that their working practices accurately reflected the local and the network guidelines. The trust received referrals from five primary care trusts (PCTs). The team managed a third of the network's total number of skin cancer referrals and was reported to have the highest number of such referrals of any of the 30 trusts in London. It had had 1,900 suspected skin cancer referrals in 2008 / 09 and had treated some 300 skin cancers. PEER REVIEW VISIT REPORT for Barnet And Chase Farm Hospitals - Lcl SKIN MDT (published: 3rd June 2010) Page: 3/7

4 Does the team demonstrate that it has effective systems for providing coordinated care to individual patients? The team had well organized patient pathways and had had 100% compliance with the 31 day target and had achieved the 62 day target in eleven of the twelve months in 2008 / 09 but the 14 day target had been breached in the last three months of the year. There were dedicated weekly clinics for suspected skin cancer cases at both Barnet and Chase Farm hospitals and at two other sites thereby providing local access to the service. Other skin referrals were reviewed and where necessary upgraded to suspected cancers. The patients considered by local team as suitable for Mohs surgery were referred to the St John's service at St Thomas's or to the Royal Free. It was unclear how this choice was made and there appeared to be inconsistencies within the team in this regard. It was planned to develop a local Mohs service. Communications with the specialist MDT at the Royal Free for cases needing discussion appeared good; however, referrals to other centres were sent by post, which was not regarded by reviewers as a sufficiently reliable or prompt way for cases to be passed to another MDT. The operational policy did not include the contact details of the specialist teams. The team had introduced changes in how communication with patients was organized in response to the patient feedback survey of The team was aiming to make further improvements to the information given to patients and had just introduced an MDT leaflet. Communication back from the specialist MDT at the Royal Free appeared to be poor. The CNS had a large work load and provided a high level of support to the patients often communicating with them by telephone. The links to the key worker at the Royal Free appeared to work well. The clinic arrangements for immuno-compromised patients needed to be better organized. The MDT reported capacity issues for follow up services and patients were discharged back to the care of their GP so the team were not able to follow the national and network clinical guidelines in this part of the pathway. The team had been represented by the clinical lead or deputy at all four meetings of the network site specific group (NSSG) held during Does the team demonstrate that it has adequate information to help improve service delivery? The MDT had adopted the network minimum data set (MDS) but it was unclear whether this had been fully implemented. Completion of the pathology MDS had significantly improved. There was a need for improved information technology (IT) systems and data collection capacity for the MDT. The annual report did not include any data about the different types of skin cancer the team had treated. The MDT had participated in the network-wide rapid access referral audit. A local audit covering patients being given their diagnosis by post had been published. The team had audited the reliability of its communications to general practitioners (GPs). There was a network wide Picker patient feedback survey which included a large number of patients from this MDT; although there was no written evidence that any actions had been implemented several improvements had been carried out. Five core team members had already attended an advanced communications course. Does the team demonstrate that it is continuously improving its service including both clinical effectiveness and the patient experience? The team had held an annual review meeting in November 2009 although the attendance had been poor. The work programme covered improving the speed of communications to ensure that all skin cancer cases were discussed at the MDT and referrals to other specialist teams made more reliable. The attendance at the MDT meeting should improve with the video link between the Barnet and Chase Farm sites and the proposed job plan changes. Recruitment to trials had been achieved by referring patients to the Royal Free but the MDT was not aware of the percentage of their patients being recruited. PEER REVIEW VISIT REPORT for Barnet And Chase Farm Hospitals - Lcl SKIN MDT (published: 3rd June 2010) Page: 4/7

5 Good Practice Good Practice/Significant Achievements - The extent to which the team provided local access to the service through holding clinics at four hospital sites. - The way in which the exceptionally large workload was managed by the team. - The well organized systems for organizing the MDT meetings and recording decisions. - The BCC GP referral form which had recently been introduced. - The effective communication systems to GPs. - User representation at the MDT annual meeting. Concerns Immediate Risks: The MDT had previously identified to the relevant PCT a GP who was inappropriately carrying out skin cancer excisions. He was still carrying excisions and had started to bypass the local histopathology department and was sending samples elsewhere. (Since the review the trust has responded that on 10th March the director of performance, planning and partnership was to raise this as an immediate concern with the PCTs. The actions that arise from this will be included in the final action plan.) The lack of evidence about how the five PCTs had implemented the requirements of the national guidance:- - There was no evidence that a baseline assessment had been carried out to identify the range and volume of skin cancer excisions taking place in the community and to identify the GPs concerned. - It was unclear how many GPs had minor surgery or dermatology contracts and whether these had been amended to ensure that they were not carrying out skin cancer excisions. - It was unclear whether excisions were still being carried out by GPs who were not authorized to do such procedures. (Since the review the trust has responded that on 10th March the director of performance, planning and partnership was to raise this as an immediate concern with the PCTs. The actions that arise from this will be included in the final action plan.) There was evidence from the case note review of at least one elderly patient who had had three attempts at an excision locally without referral on to the specialist MDT. (Since the review the trust has responded that the trust has recently undertaken audit of the rate of excision of skin cancers from the MDT which showed that 90% do not need to be excised again. However, as nationally the range of re-excision is four to seven percent this obviously is not satisfactory and so it was decided at the business meeting on 25th February 2010 that they would increase the number of referrals to Mohs micrographic surgery to improve the total number of complete excisions. A further audit would be undertaken to ensure that the rate of primary excisions improves.) Clinicians who were not core team members were excising skin cancers that needed discussion at an MDT. (Since the review the trust has responded that all skin cancers are discussed at the MDT and the decisions are made by the MDT. However, some clinicians who were not core members have been excising skin cancers. This has now been addressed and all clinicians who undertake excisions of skin cancers are now core members and will meet the requirements for attendance at MDT.) The team needs to ensure that all suitable cases are being brought to the MDT for discussion. (Since the review the trust has responded that they have recently changed the format of the MDT whereby the full membership discusses those cases suitable for the MDT. At the end of the MDT the cancer lead reviews the other BCCs and SCCs to ensure that their treatment plans are appropriate.) PEER REVIEW VISIT REPORT for Barnet And Chase Farm Hospitals - Lcl SKIN MDT (published: 3rd June 2010) Page: 5/7

6 Serious Concerns: The lack of clinical oncological support. (Since the review the trust has responded that this was an issue they had identified prior to peer review. They are in discussion with the radiotherapist at the Royal Free to provide a clinical oncologist who would be able to meet the MDT requirements in this regard and would also be able to provide a joint clinic.) Attendance at the MDT was non-compliant in a number of ways:- - the attendance of most of the named core dermatology members was less than 25%; - the lead clinician was the named cover for six other colleagues; - the core membership needed revision to ensure that all clinicians who regularly carry out excisions that require MDT discussion are core MDT members and attend meetings regularly; pathology slides were not sent to the specialist skin MDT and the MDT reported that the video link was not of sufficient quality for clinical discussion. (Since the review the trust responded that the job plans of all MDT members had been reviewed to free their time prior to 10am on Thursday mornings to ensure they are able to attend the MDT; it was decided at a business meeting on 25th February 2010 that the named cover for absent colleagues should be changed to improve the attendance figures and ensure that one individual is not covering too many people; the core membership of the MDT was being reviewed to ensure that those members of the department who are involved in the treatment of cancer patients are regularly attending the MDT; the trust has in its capital plan for this year to replace the video conferencing facilities to ensure improved image quality.) From the case notes and the patient survey it was evident that all treatment options were not discussed with the patients. The staffing of the team needed review as the workload was excessive, particularly:- - on the lead histopathologist; - on the CNS who could not fulfil the key worker role for all patients with more complex skin cancers; - on the coordinator as exemplified by the lack of data collection. (Since the review the trust responded that it is reviewing the workload of all the histopathologists to address the high workload and to improve the overall quality of reporting. The cancer lead has met with the pathologists to discuss specialist reporting. A business case for a further histopathologist to enable dermatology specialist reporting is being developed and will be confirmed by July 2010; the CNS has been discussed at the departmental team meeting, an assessment of the workload of the CNS will be completed by June 2010 to assess the need for additional CNS input; an additional MDT coordinator is in place providing some support to the skin MDT coordinator, the trust will continue to assess this through the departmental and MDT meetings.) PEER REVIEW VISIT REPORT for Barnet And Chase Farm Hospitals - Lcl SKIN MDT (published: 3rd June 2010) Page: 6/7

7 Concerns: The local pathways should be reviewed to ensure that a consistent service is being provided across both sites of the trust. The links with the specialist teams needed to be improved:- - the referral arrangements to various specialist teams needed to be made faster and more reliable; - the team members needed to follow the agreed referral pathways for Mohs surgery; - it was unclear if all level 5 and 6 patients including Kaposi's were being referred to the specialist MDT; - to address inconsistent feedback from the specialist teams; - to ensure arrangements for double reading of histopathology slides. The lack of data about the workload of the team. The team need to hold well attended service review meetings. The plans for creating a local Mohs service needed to be based on a clearer estimate of the likely workload against the minimum volumes defined in the guidance. There was no automated system for identifying skin cancers through histopathology. The lack of local patient support groups. Not all relevant members of the MDT have attended the advanced communications skills training. There was no action plan following the patient experience survey. PEER REVIEW VISIT REPORT for Barnet And Chase Farm Hospitals - Lcl SKIN MDT (published: 3rd June 2010) Page: 7/7