Breast Cancer MCN Work Plan /18 Objective Deliverables / Outcomes Lead 1. Manage the development/review of Breast Cancer Management Guideline and Guidance Documents. 1.1 Identify lead author/reviewer and communicate requirements of the development/review process in accordance with WoSCAN Standard Operating Procedures. Regional Guidance Documents circulated for implementation. Timely and consistent development/ review of Management Guidelines and Guidance Documents in accordance with WoSCAN Standard Operating Procedures. Documentation used to inform clinical practice will be developed and reviewed to ensure safe, equitable management of patients across the region and optimise effectiveness of treatment and care. Management Guideline: Breast Cancer c/f Guidance Documents: Breast Cancer Follow-up Guideline c/f Jun Prophylactic Mastectomy c/f Management of the Axilla following a Positive Sentinel Node Biopsy Recommended use of Mammograms after Pulmonary Thromboembolism Final Published Breast Cancer MCN Work Plan /18 v1.0 24/04/17 1
2. Participation in the West of Scotland rolling programme of regional and national education events; utilising the opportunity for learning and sharing of current best practice and innovation. Established managed clinical network educational events maximised to promote best practice and drive improvement in care delivery. Lead Sharing our best practice across the region should optimise the effectiveness of treatment and care and ensure equity of service provision. 2.1 Host regional tumour specific education event(s) which facilitate review of clinical audit data and shared learning of current best practice and innovation. Successful education event(s) which delivered a wide range of topics and achieved engagement with multi-professional groups. Lead May 2.2 Contribute to the programme development for national Breast Cancer meeting. 3. Support delivery of the National Cancer Quality Programme for /18, ensuring the regional/national governance process is adhered to. 3.1 Support the data verification process as defined by regional/local governance framework. 3.2 Input to the production of Annual Audit Report. Tripartite agreement of national programme across Networks. Programme delivered in line with agreed download schedule, Quality Performance Indicators (QPIs) and governance processes. and service issues are escalated and actioned appropriately. Audit data reports verified by NHS Boards. Board comments returned for inclusion in annual Audit Reports. Audit reports issued in line with agreed schedule. Report contains clearly defined regional/local actions to address areas where performance requires to be improved and status of unresolved actions highlighted and Final Published Breast Cancer MCN Work Plan /18 v1.0 24/04/17 Lead Information MDT Leads/ Effectiveness Leads Information /MCN Lead/ Aligned to event schedule for 17/18 Dec Dec QPI performance monitoring will ensure that quality improvement activity is focussed on those areas that are most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person centred cancer care. 2
escalated as appropriate. 3.3 Identify requirements for further data analysis to aid understanding of variance, and inform improvement work. 3.4 Monitor progress against agreed local/regional action/improvement plans, ensuring regional actions identified are progressed and outcomes documented and reported. Monitor progress with the recurrence data at the Advisory Board meetings Improved understanding of reasons for variance, enabling more targeted improvement work to be undertaken, ensuring service issues are addressed. Progress reported to the MCN Advisory Board. MCN Lead/MCN Lead/MCN / Board Effectiveness Leads Jan c/f 4. Update and further develop the regional service map for Breast Cancer service provision, detailing the points of service delivery and the connections between them. 4.1 Review the current high level service map for Breast Cancer MCN. 4.2 Agree and source additional information to populate new service map template. Breast Cancer service map updated to maintain a baseline position in support of use as an internal planning resource. Service map reviewed for Breast Cancer MCN. Regionally agreed high level service map for Breast Cancer which will be used to inform any detailed service planning work undertaken. s s / MDT Chairs s / MDT Chairs Feb To ensure equity of care for cancer patients in the West of Scotland by using information to improve quality and outcomes. 4.3 Finalise and publish service map for Breast Cancer, Annual update of the Service map completed to maintain a baseline position and published on intranet site. Lead / Feb Final Published Breast Cancer MCN Work Plan /18 v1.0 24/04/17 3
5. Continue to support the Transforming Care After Treatment (TCAT) programme of work, in particular, the roll out of the Breast Follow-up Guidelines utilising the learning from NHSAA and NE Glasgow 5.1 Access the costings of the NHS AA TCAT project Breast Follow-up Guidelines rolled out and adopted for use in the WoS. Information gathered and scale data to a WoS context. Lead Regional Lead for TCAT Lead May Change in clinical practice that is transformative with a cultural shift away from traditional models of follow-up care to more person centred models that focus on recovery and health and well being. 5.2 Access initial findings of the TrakCare and Repeat Waiting List/ Virtual Clinic model being trialled in NE Glasgow Initial findings noted, with the potential for wider implementation understood. Lead Jul 5.3 Utilise the data gathered on the TCAT projects to inform discussion with stakeholders in the WoS on the rollout of the Breast Follow-up Guidelines Roll out plan developed /agreed for each NHS Board. Lead/ Jul 5.4 Roll out plan implemented. Guidelines implemented in practice across the region. Lead/ 6. Utilise learning from the TCAT programme to determine applicability of HNA and treatment summaries, defining requirements for specific patient groups 6.1 Assess the learning and outcomes from all relevant TCAT projects and clearly define the application of suitable components to specific patient groups 6.2 Develop regional rollout and local implementation plans In collaboration with key stakeholders, develop an implementation plan to support regional rollout Convene a working partnership with key stakeholders to facilitate development of exemplar models of care utilising HNA and treatment summaries Produce detailed plans to facilitate regional rollout through local NHS Board implementation Final Published Breast Cancer MCN Work Plan /18 v1.0 24/04/17 Lead/ Lead for TCAT/ Lead/ Lead for TCAT/ Lead/ Lead for TCAT/ Develop person-centred models of care that focus on recovery and health and well being 4
Final Published Breast Cancer MCN Work Plan /18 v1.0 24/04/17 5