Upper GI Cancer MCN Work Plan /18 Objective Deliverables / Outcomes Lead 1. 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 1.1 Host the national meeting for Upper GI Cancer. Providing the opportunity for wide discussion and agreement on any areas where further work/targeted audit may be required to facilitate improvements. Successful meeting where nationally agreed quality performance indicators are reported and required actions agreed. Lead 2. Support delivery of the National Cancer Quality Programme for /18, ensuring the regional/national governance process is adhered to. 2.1 Support the data verification process as defined by regional/local governance framework. Programme delivered in line with agreed download schedule, Quality Performance Indicators (QPIs) and governance processes. Clinical and service issues are escalated and actioned appropriately. Audit data reports verified by NHS Boards. Board comments returned for inclusion in annual Audit Reports. Information MDT Leads/Clinical Effectiveness Leads Jun Aug 2.2 Input to the production of Annual Audit Report. 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 escalated as Upper GI Cancer MCN Work Plan /18 v1.0 25/04/ Information /MCN Clinical Lead/ Sept Sept 1
2.3 Identify requirements for further data analysis to aid understanding of variance, and inform improvement work. Improved understanding of reasons for variance, enabling more targeted improvement work to be undertaken, ensuring service issues are addressed. Aug 2.4 Monitor progress against agreed local/regional action/improvement plans, ensuring regional actions identified are progressed and outcomes documented and reported. 3. Update and further develop the regional service map for Upper GI Cancer service provision, detailing the points of service delivery and the connections between them. reported to the MCN Advisory Board. Upper GI Cancer service map updated to maintain a baseline position in support of use as an internal planning resource. / Board Clinical Effectiveness Leads s Nov 3.1 Review the current high level service map for Upper GI Cancer MCN. Service map reviewed for Upper GI Cancer MCN. s / MDT Chairs Sep 3.2 Agree and source additional information to populate new service map template. Regionally agreed high level service map for Upper GI Cancer which will be used to inform any detailed service planning work undertaken. s / MDT Chairs Feb 3.3 Finalise and publish service map for Upper GI cancer. Annual update of the Service map completed to maintain a baseline position and published on intranet site. Lead / MCN Feb 4. Utilise learning from the TCAT programme to determine the current use and future applicability of Holistic Needs Assessment (HNA) and treatment Upper GI Cancer MCN Work Plan /18 v1.0 25/04/ In collaboration with key stakeholders, develop an implementation plan to support regional rollout 2
summaries, defining requirements for specific patient groups 4.1 Undertake baseline analysis of current practice in relation to HNA across the region. Understanding of current practices across the region and identification of areas where learning can be shared. /CNSs July 4.2 Assess the learning and outcomes from all relevant TCAT projects to identify and define the application of suitable components within UGI practice in the Region. Potential identification and implementation of suitable models of care utilising HNA and treatment summaries in practice in the Region. Sep 4.3 Develop regional rollout and local implementation plans. 5. Working with the palliative care team, identify mechanism for inclusion of patients on the palliative care register as Facilitation of regional rollout of any suitable model identified, through local NHS Board implementation. In collaboration with key stakeholders, develop a sustainable communication plan to support inclusion of patients on the palliative care register. Clinical Lead / MDT Teams / Palliative Care / 5.1 Identify a sustainable process for notification to General Practitioners of patients who are eligible for inclusion in the palliative care register. Clear communication process in place to ensure patients are registered as required. Clinical Lead / MDT Teams / Palliative Care / 6. Following national discussion undertake targeted audit against the following areas of concern/interest noted in the 2015 QPI data analysis. Further in-depth analysis to identify potential areas of improvement, or areas where changes in practice could be beneficial. Lead / Clinicians TBD/Information Team Upper GI Cancer MCN Work Plan /18 v1.0 25/04/ 3
6.1 Conduct a retrospective audit of lymph node yield in oesophagectomies performed in WoS patients diagnosed in 2014 and 2015. Report of audit/review findings Clinicians TBD 6.2 Undertake retrospective audit to ascertain the status of patients who fell outside of the 90 day mortality QPI reporting due to data cut off dates. Report of audit/review findings Clinicians TBD 7. Work with ISD and the other Scottish Cancer Networks to improve the information available regards survival outcomes in UGI cancer. Meaningful survival and outcomes data for UGI cancer patients, which can be utilised further. Network Leads / ISD/ Information s 7.1 Utilise the audit data to undertake survival analysis in NHS Boards (NHS A&A and NHS Lanarkshire), utilising the methods previously applied in analysis undertaken by NHSGGC. Report of the audit findings NHS Board Leads / P Glen 7.2 Liaise with SCAN and NOSCAN to share the detail of the analysis and encourage similar is undertaken locally to provide national comparison. Presentation of survival outcomes in relation to the audit data in the national forum. Clinical Lead/ SCAN/ NOSCAN/ P Glen 7.3 Working regionally and nationally develop and agree a specification for future survival analysis. Agreed specification for future survival analysis submitted to ISD. Clinical Leads WoSCAN / SCAN / NOSCAN / Clinicians / ISD Upper GI Cancer MCN Work Plan /18 v1.0 25/04/ 4
8. Enhanced recovery following surgical procedures for gastric and oesophageal cancers. 8.1 Development of ERAS protocols in NHS GGC in first instance, for future roll out across the region. ERAS protocols suitable for management of UGI cancer patients in the West of Scotland. Regionally endorsed ERAS protocols. Lead / Dr A MacDonald (NHSGGC/HIS) Dr A MacDonald / il il Upper GI Cancer MCN Work Plan /18 v1.0 25/04/ 5