Consulted With Individual/Body Date. Last reviewed Mags Shaughnessy Director of Operations 16 August Operations

Transcription

1 Root Cause Analysis for Cancer Patients exceeding National Performance Standards Policy Register No: Status: Public Developed in response to: CWT Version 9 Going Further on Cancer Waits Achieving World Class Cancer Outcomes A strategy for England Inter Provider Transfer Policy East of England Strategic Clinical Network V.3 Contributes to CQC Outcome: 17 Consulted With Individual/Body Date Nicola Cottington Associate Director of Operations Last reviewed Mags Shaughnessy Director of Operations 16 August 2016 Effie Liakopoulou Clinical Director for Clinical 16 August 2016 Support Services and Cancer. Cancer Services Management Board Cancer Services Management 23 August 2016 Board Professionally Approved by: Trust Cancer Lead Clinician 03/03/17 Chief Executive Officer 03/03/17 Matt Riddleston Trust Lead Macmillan Cancer Nurse 03/03/17 Version Number 1.0 Issuing Directorate Cancer Services Ratified by: DRAG Chairmans Action Ratified on: 7 th March 2017 Trust Executive Board Date March/April 2017 Implementation Date 7 th March 2017 Next Review Date February 2020 Author/Contact for Information Karen Hull Cancer Service Manager Policy to be followed by (target staff) All MDT Staff Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) Cancer Access and Operational Policy Document Review History Version Author/Information Asset Administrator Active Date Number 1.0 Karen Hull Cancer Service Manager 7 March

2 Index 1. Purpose 2. Introduction 3. Scope 4. Roles and Responsibilities 5. Breach Management 6. RCA Patients >104 Days 7. Training Requirements 8. Implementation and Communication 9. References Appendix 1 Appendix 2 Equality Impact Assessment Process Flow chart for RCA 2

3 1.0 Purpose 1.1 The purpose of this policy is to provide guidance and outline the rules for the management of adult patients who have breached the national 62 day performance standard on a cancer pathway, to ensure learning is recorded and remedial actions implemented, to eliminate harm to patients and to avoid similar breaches in the future. 1.2 Patients with a confirmed cancer diagnosis who breach the 14, 31 day and 62 day pathway will have their pathway reviewed in accordance with the cancer standards relevant to their cancer pathway. The RCA will take into account that a patient may choose to wait longer or clinically be unable to be seen or treated within these time frames. 1.3 The policy will act as an operational guide for those staff involved in the management and investigation of patients who are not treated, including both those patients with and without a decision to treat within the national performance standard guidelines. 1.4 The policy sets out the roles and responsibilities, processes to be followed and establishes a number of good practice guidelines to assist staff with the effective analysis on patients with a confirmed cancer who have exceeded the national performance standards. 1.5 The outcomes and learning points from the RCA will feed through to the governance meetings of each division, to Divisional and Trust Governance, Senior Management Group and Cancer Management Board in view of improving services through a process of continuous improvement. 1.6 The policy will ensure that: Teams and individuals are aware of their responsibilities for moving patients along the agreed clinical pathway in accordance with the national Cancer Reform Strategy standards as set out in Going Further on Cancer Waits GFOCW 6.3 and Cancer Waiting Times Guide version 9 Clinical support departments adhere to and monitor performance against agreed maximum waiting times for tests/investigations in their department Everyone involved in the Cancer pathway has a clear understanding of their roles and responsibilities 2.0 Introduction This policy ensures that: There are robust processes and systems in place for all staff that clarifies all the essential cancer performance standards which are to be used to capture data in the analysis of an RCA An RCA is completed and recorded in line with the cancer performance standards to illustrate where a bottleneck has occurred, where it is clinically appropriate to delay a cancer pathway and where a patient chooses to delay their pathway, along with future remedial actions that can be taken to pull a patient through where a breach is deemed avoidable 3

4 There is a harm review following treatment and to assess the level of harm illustrating clear recommendations where harm has been identified. That each RCA must be signed off by the tumour site lead clinician and illustrate the outcome, identified bottlenecks and learning points from the individual cases. 3.0 Scope 3.1 This policy applies to patients on the 14, 31 & 62 day pathways for cancer. These cases require a root cause analysis (RCA) to identify any anomalies/actionable and correctable reasons that may have occurred during their pathway which has led to a breach of their pathway. 3.2 This policy excludes children s cancer 0-16 years and teenagers and young adults years old as these referrals are sent straight to principal treatment centres. 4.0 Roles and Responsibilities 4.1 Chief Operating Officer For implementing trust wide monitoring systems to ensure compliance with this policy, and where deemed possible to avoid breach of the 14, 31 and 62 day target. With Associate Director of Operations and Divisional Clinical Directors for managing any actual breaches in achieving targets. 4.2 Associate Director of Operations and Divisional Clinical Directors The Associate Director of Operations and Divisional Clinical Directors for each division have overall responsibility for implementing and adherence to this policy within their division Ensuring all staff that need to operate this policy are aware of this policy and receive training so that they can meet the policy requirements 4.3 MDT Coordinator MDT Co-ordinators are expected to objectively and factually complete the RCA forms electronically for each breached confirmed cancer patient case at Day 14, 31 or 62 days on the pathway if not treated within 10 working days of the breach occurring A Patient who remains on the pathway and reached day 80 who is either a confirmed cancer or suspected will be discussed with their responsible consultant. The MDT Coordinator will be responsible for completing an RCA form electronically and forward to the Clinician and Service Manager. Medical records should be located to enable the clinician to make an informed decision on the next steps. 4.4 MDT Waiting List/Manager Cancer Waiting List/MDT Managers will review cancer tracking and ensure all details are clear and entered on to Somerset Cancer Register; this will be the basis for any breach reporting. 4

5 4.5 Service Manager for Tumour site Service Manager for tumour sites are expected to review the RCA for each patient in the specialty to ensure it is a true and fair view of the patient journey within 10 working days of receiving the RCA form. Following review and sign off Service Managers will be expected to share the breach reports at their MDT meetings on a weekly basis to enable sign off by the respective tumour site lead clinician. 4.6 Lead Cancer Tumour Site Clinician The lead cancer tumour site clinician will be expected to sign off and confirm the following on the breach report at the MDT or within 10 working days if this is not possible: Was the breach avoidable/unavoidable What level of harm is associated with the breach, no harm, low harm, moderate harm, severe harm? Next steps to ensure patient is treated with minimal delay, taken into account patient clinical needs and patient choice On completion and sign off the clinician will be expected to discuss the findings of each case at the monthly directorate meetings A highlight report should be completed and through the lead cancer tumour site clinician discussed at the monthly divisional governance meetings, along with completed action plans where these are applicable and /or the breach was avoidable. In addition the highlight report will confirm the level of harm associated with each breach Tumour site clinical lead or deputy will be expected to present the breach highlight/summary report at the monthly Cancer Service Management Board. 4.7 Cancer Service Management Board Tumour site clinical lead or deputy will be expected to present the breach highlight/summary report at the monthly Cancer Service Management Board This policy will be professionally approved by the Cancer Services Management Board Alterations and amendments to this policy will be approved and endorsed by Cancer Services Management Board. 5.0 Breach Management 5.1 Following the directorate governance meeting for each specialty a report on the patients who have breached will be completed ready for presentation at the Divisional Governance meetings. 5.2 Breaches that may have led to patient harm will need to be reported as clinical incidents on the Trust Datix system for further investigation. 5.3 The information will be shared at Senior Management Group performance meetings and 5

6 Cancer Service Management Board. The themes/causes/actions will also be taken for discussion to Trust Governance Meeting and the Clinical Commissioning Quality Review Group. 6.0 RCA Patients >104 Days 6.1 On occasions a patient may exceed 104 days and these patients are usually due to a clinical or complex pathway and fall within the national performance tolerance range of 15% of patients being outside of the national performance standard 85%. 6.2 All patients >104 will be discussed at the >104 day monthly governance review panel which will be chaired by the Medical Director. 6.3 The panel will consist of: Medical Director (Chair) Cancer Clinical Lead (Deputy Chair) Head of Governance Associate Director of Cancer and Clinical Support Services Cancer Service Manager 6.4 The tumour site clinical lead will be expected to attend the panel to discuss the patient pathway, the reasons why the patient has breached and the harm review that was undertaken. 6.5 All breaches of more than 104 days must be recorded on an incident report form. 7.0 Training Requirements 7.1 All non/clinical staff involved in cancer pathways will have specific local training in relation to the implementation of this policy and Somerset Cancer Register training provided by Cancer Services, supported by the Cancer Waiting list/mdt Managers. Additional or remedial training will be provided as required. 8.0 Implementation and Communication 8.1 Corporate services will ensure that the Policy is available on the intranet and the Trust website together with supporting RCA procedures 8.2 The Cancer Service Manager is responsible for ensuring the policy is disseminated to all Divisions and cascaded. 9.0 References CWT Version 9 Going Further on Cancer Waits Achieving World Class Cancer Outcomes A strategy for England Inter Provider Transfer Policy East of England Strategic Clinical Network V.3 6

7 Appendix 1 Equality Impact Assessment (EIA) Root Cause Analysis for Cancer Patients exceeding National Performance Standards Equality or human rights concern. (see guidance notes below) Does this item have any differential impact on the equality groups listed? Brief description of impact. How is this impact being addressed? Gender All patients are treated equal and in chronological order. All Staff are treated equal. All Patients are tracked on the Somerset Cancer Register to ensure compliance with 14,31 and 62 day standards. Race and ethnicity Language may be a barrier for some patients. Interpreters are made available when required either face to face or via language line. Staff attend equality and diversity course in line with Trust Policy. Disability There may be patients, carers or staff considered to have a disability that use, visit or work within the service. The clinical areas are accessible by wheelchair. Sign language interpreters can be booked if required Staff encouraged to disclose disability to enable correct equipment where appropriate to be purchased for use. Learning Disabilities and Autism Religion, faith and belief There may be patients or carers who have been identified as meeting the specific needs of people with learning disabilities or autism that use cancer services. This would depend on individual patient, carers or staff needs and or requirements All patients identified with learning disabilities or autism are flagged and are accommodated at earlier or later appointment times to avoid excessive waits. If this is not possible or is not the patient s/carer s preference then all efforts will be made to ensure the patient is seen as close to their appointment time as possible, avoiding unnecessary anxiety and to achieve maximum benefit from the consultation. There is access to the chaplaincy team who can offer advice and support for staff, patients and relatives / carers. Written information is available in the clinical areas provided by the chaplaincy team There is a chapel available on the hospital site which can be used by patients, relatives / carers and staff It is possible to access multi-faith leaders when required 7

8 Sexual orientation Age Transgender people All people who use, visit or work within the service are treated the same. All Patients attending the cancer services are treated the same. All people who use, visit or work within the service are treated the same. Staff attend the course on equality and diversity in accordance with Trust Policy. All Patients are tracked on the Somerset Cancer Register to ensure compliance with 14, 31 and 62 day standard. Staff attend the course on equality and diversity in accordance with Trust Policy. Social class Carers. Some patients may have difficultly accessing the services at the Hub Hospital (Broomfield Hospital) due to financial reasons or transport problems. Some carers may have difficulty visiting anyone who requires admission to the Hub Hospital (Broomfield Hospital) due to the distance they may be required to travel to Chelmsford from where live. Provide information on public transport access to Broomfield Hospital for patients. Patients will only have hospital transport booked if they have a clinical need Staff to be made aware that when communicating information, both verbal and written, to patients and relatives / carers that they adapt the information to the needs and level of understanding of the individual Provide information on public transport access to Broomfield Hospital for carers. Date of assessment: 21 September 2016 Names of Assessor (s) Karen Hull 8

9 Appendix 2 Process flow chart for RCA 9

10 10