INTERNAL VALIDATION REPORT (MULTI-DISCIPLINARY TEAM) Network Trust MDT GMCCN SALFORD ROYAL Salford Pituitary MDT Neuroscience MDT (11-2K-4) - 2011/12 Date Self Assessment Completed 15th December 2011 Date of IV Review 15th June 2011 Lead Clinician Dr Tara Kearney Compliance NEUROSCIENCE MDT Key Themes Structure and function of the service Self Assessment 72.4% (21/29) Internal Validation 58.6% (17/29) SRFT provides specialist neurosurgical services to the North West of England and beyond, including the endocrine and surgical management of pituitary tumours, within a multi-disciplinary framework. The pituitary MDT is a collaboration working across Greater Manchester, with input from neuro-endocrinologists, neuro-surgeons, neuro-radiologists, histopathologists, pituitary specialist nurses and the MDT co-ordinator. Whilst there is a dedicated 'core team' who comprise the MDT, other interested individuals including trainees are invited to attend for educational purposes. The MDT was established approximately 10 years ago and arose out of clinical need rather then at the request of any external body and has evolved accordingly. The NICE guidance on CNS tumours and also on cancers recommends standardisation of cancer related MDTs and incorporates pituitary lesions in this recommendation, although in reality, pituitary carcinomas or metastases are exceptionally rare. We do aim however to work to these same accepted standards. The Pituitary MDT at SRFT aims to provide the best level of care and support to the patients that suffer from Pituitary Tumours. The MDT operates in an environment which has access to all patient data systems, on-line access to imaging and the latest information technology for video conferencing. Leadership and membership. The MDT meeting is lead by Dr. Tara Kearney and key members have been identified. The attendance is tabulated below. It is noted that there I at present no cover for Dr. Gattamaneni, Consultant radiotherapist. Meeting Arrangements The MDT is held on the second Thursday of the month from 8.00-10.30am at SRFT 12 months of the year. All radiological images are reviewed by the MDT neuro-radiologist on the day prior to the meeting and typed reports generated. These are circulated with the agenda at the beginning of the meeting, and the attendance record is completed by all MDT members. MDT minutes are posted to the GP by first-class post with a target dispatch time of 24-48hours after the MDT meeting, accompanied by a covering letter to explain that the patient and family may as yet be unaware of the diagnosis or prognosis. All patients to be discussed must be nominated to the MDT co-ordinator by the Friday before the Thursday meeting for the complete list to be circulated; in an emergency patients can be included at the last minute. It is the responsibility of the MDT coordinator to ensure that the relevant radiology is available. Patients referred to the MDT after the deadline will be discussed if the appropriate information is available and it will be the responsibility of the referring clinician to provide the information. Referrals can be made by clinical letter. INTERNAL VALIDATION REPORT for Salford Pituitary MDT - Neuroscience MDT (published: 19th December 2011) Page: 1/7
Workload involved in the MDT. In preparation for the MDT the following work is undertaken: - All Pituitary MDT members complete a pituitary MDT proforma providing information concerning the cases to be discussed and email this to the MDT co-ordinator, who compiles a list. This is then circulated to all members. - The Endocrinology Pituitary Clinical Fellow extracts all the necessary test results for each of the patients and prepares a case summary to present to the group. In the absence of the Endocrinology Clinical Fellow, a Consultant Endocrinologist will undertake this duty. - The Consultant Radiologist re-reports all scans to be discussed and his interpretation and opinion is typed by the Neuro-Oncology secretary. - The Histopathologist reviews the histology results for all the patients that are due to be discussed at the MDT. - The MDT co-ordinator prepares the Agenda that is to be discussed, retrieves the casenotes for the patients to be discussed and records all patient details onto the patient administration system. During the MDT The MDT lasts for approximately three to four hours and is held on a monthly basis. The time spent equates weekly to: - 0.25 PA's for eleven Consultants time - 1 hours of two Specialist Nurses time - 2 to 4 hours of administration time. Following the MDT - The outcomes of the discussion regarding each patient is recorded by one of the during the MDT - The MDT minutes are typed and sent for approval to the endocrinologist within 24hours - Once approved, letters are generated by the referring consultant to the patients GP, with a copy to the patient if deemed appropriate, within 24-48 hours. These letters are typed by the MDT co-ordinator and inserted in the patients records. - Appropriate actions are taken, often necessitating additional patient visits to discuss or explain the outcomes, or referral on for further treatments. - The workload involved here is considerable and is difficult to quantify. - With the exception of the MDT co-ordinator, all other MDT members are entirely unremunerated for this work. Sister Shashana Shalet is our Clinical Nurse Specialist and is supported by a team of clinical specialist nurses based both at SRFT and also at other trusts. Sister Shalet has recently completed a Masters of Sciences degree. Waiting time standards Two week wait targets are unusual for pituitary tumours since the majority do not come from primary care. 2WW patients are those patients who are referred from their GP with a suspected and previously undiagnosed cancer. We must either exclude a diagnosis of cancer, or treat the cancer, within 62 days of the referral. 31 Day patients are 'cancer' patients who are not referred urgently by the GP, and whose pathway starts once they have made a decision to treat. This scenario is more typical of pituitary patients. These can include subsequent treatments (e.g. repeat surgery or radiotherapy), and recurrent treatments. Certain adjustments can be taken, as a Decision To Treat has been made. We are 100% compliant with these targets. The table below describes the number of patients discussed at each MDT. Date of MDT Number of Patients Discussed 08.04.2010 16 13.05.2010 18 10.06.2010 13 08.07.2010 23 12.08.2010 20 09.09.2010 9 14.10.2010 17 11.11.2010 11 13.01.2011 18 10.02.2011 16 10.03.2011 23 This table below describes the number of patients undergoing pituitary surgery over the last five years. Gnanalingham Karabatsou 2005 23 0 2006 48 0 2007 66 0 2008 61 0 2009 52 9 2010 68 5 2011 11 7 To Date Coordination of care/patient pathways INTERNAL VALIDATION REPORT for Salford Pituitary MDT - Neuroscience MDT (published: 19th December 2011) Page: 2/7
Care and patient pathways are co-ordinated by various means: - MDT referral pathways have been agreed upon and are utilised by all parties using the service - The Inpatient pituitary pathway was devised by core MDT members and is used for all inpatients undergoing pituitary surgery - An agreed discharge co-ordination pathway is used to inform other care providers of the hospitalisation of pituitary patients and their ongoing care requirements - A pan-manchester endocrine group incorporating biochemists, scientist and endocrinologists meet three monthly to ensure that endocrine investigations are based on best practice and are co-ordinated across the region - Nationally agreed Patient information leaflets are provided on a wide range of pituitary conditions and their treatment - Locally agreed Patient information packs detailing the care that patients with pituitary disease should expect are provided - Patients are provided with written and verbal instructions on emergency contacts following surgery and the number of their locals teams is also often provided. - Patient education and support days are provided three times per year by local pituitary specialist, which are open to all interested parties. - An informal 'buddy service' is provided to add support for patients desiring this service. - Care is communicated both formally for patients undergoing pituitary surgery; Dr. Kearney and her team undertake a twice weekly ward round of all patients admitted to SRFT with pituitary related problems and is contactable through her mobile at all other times. Reviews of such patients frequently occurs out of hours as the request of the attending staff. Similar arrangements occur at other hospital sites. - Care related communication between care providers occurs daily through discussions/emails/mobiles/epr - Many of the MDT members are also chairs/committee members of National Specialist Groups and Patient Support Groups and will ensure that information and guidelines are disseminated and implemented These processes are monitored by the following means: - Cancer Services - Service Improvement Facilitator works closely with the MDT on an ad hoc basis to ensure local and national guidance is implemented within the operational policy and working practices. Dashboard monitoring of the MDT in meeting National Cancer Service Standards, of which the operational policy is one. - Peer Review Accreditation - Annually, the team will be assessed to ensure the effectiveness of the operational policy in meeting National Cancer Service Standards and from such review action plans will be produced should the operational policy fail to meet the standards. - Cancer Plan Implementation Meeting - This meeting is held monthly and requires feedback from the MDT about the effectiveness of their operational policies in meeting Local and National Guidelines and targets. The Local Multi-disciplinary Team at SRFT is responsible for implementing the policy and adopts its principles. The Peer Review assessment and accreditation process will review implementation of the policy and report to each team / Trust and Network on its progress. Patient experience Please see above for details on patient information and support. The Endocrine Medical and nursing team are the amin points of contact for all patients, families, GPs and non-specialists. The team are available through the department during office hours and patients are informed of this service verbally and in writing. A patient satisfaction questionnaire is being devised for both inpatient and outpatient care at SRFT and will be utilised fully on completion. At present there are no local or national patient experience surveys for pituitary patients Anecdotal feedback has always been very positive. Clinical outcomes/indicators Where available, the data from the Clinical Indicators should be used. You should comment separately on each indicator. Where national Clinical Indicators for the team's cancer site have not yet been agreed for the peer review, please identify and comment INTERNAL VALIDATION REPORT for Salford Pituitary MDT - Neuroscience MDT (published: 19th December 2011) Page: 3/7
on the top five clinical priority issues for your team. Teams should specifically comment on the following questions: - What are the major resection rates- - What are the mortality rates within 30 days of treatment- - What is your recruitment to trials- - Outcomes of any key audits projects- The major resection site is by definition the pituitary gland or tumours of the para-sellar region. Research. We are involved with some trials which are not directly linked to the MDT. Dr. Tara Kearney is the CRN lead in endocrinology and deputy National lead for the CLRN in Endocrinology and has built an active research team over the last two years. Some of the studies that are on the UK portfolio are listed in the evidence file. Many other MDT members undertake clinical and basic scientific work in their base unit which is not listed here but could be provided if necessary. Audit. - We are participating in a national audit looking at the prevalence of cardiac valvular disease in patient with pituitary disease taking cabergoline. - We have audited the success of surgical cure in patient with Acromegaly and this has improved considerable since the introduction of two dedicated pituitary surgeons (cure rates gone up from 22% to 67%) - With the appointment of the cancer data manager clinical outcomes will be audited and potential changes in clinical practices will be explored at this point (awaiting funding for the data input). - Compliance of administrative targets will also be audited and subsequent improvements made where necessary. Good Practice Good Practice/Significant Achievements Examples of good practice include: - The appointment of a Cancer Data Manager - Timely discussion of the majority of cases with subsequent timely treatment when required. - The appointment of an Endocrinology Pituitary Clinical Fellow - The appointment of a Neurosurgery Pituitary Clinical Fellow - The appointment of a Radiology Pituitary Clinical Fellow - Improved recording of MDT outcomes - Improved quality of MDT minutes that are distributed within 24hrs to the referring Clinicians. - Recruitment of 0.5 wte of a Co-ordinator - Ability to nominate a key worker to act as a point of contact for patients and their families through the existing Specialist Endocrinology Nurses. - Development of MDT referral proforma (Appendix 1) - Publications & presentations at local and national meetings (Appendix 2) - Facilitate communications with referring Clinicians: possible dedicated contact person or team at each hospital. - Development of a data base where all patients with a possible diagnosis of Pituitary Tumour are logged - Introduction of digital dictation to enable the turn around of all MDT minutes within 24hours. - Sr Shalet has completed her Master of Science degree please see evidence file Concerns Further Immediate Risks Identified? Not Identified INTERNAL VALIDATION REPORT for Salford Pituitary MDT - Neuroscience MDT (published: 19th December 2011) Page: 4/7
Immediate Risks Further Serious Concerns Identified? Not Identified Serious Concerns - Most members of the core team have not yet completed the advanced communication skills training - We are await National Guidance as to whether all Pituitary Tumours need MDT discussion or not. At present only a select few are discussed based on perceived clinical need - At present there is no cover for Dr Rao Gattamaneni, Consultant Oncologist - At present there is no cover for Dr David Hughes, Consultant Neuroradiologist - Most of the MDT members are not remuneration for this work - Funding required for data input into the database - Support required to undertake required research Concerns The team need to review the implementation of the Key Worker policy and include milestones SMART objectives are required in the work programme and this also needs to be more detailed. The lack of Radiology cross cover is a concern. General Comments INTERNAL VALIDATION REPORT for Salford Pituitary MDT - Neuroscience MDT (published: 19th December 2011) Page: 5/7
Generally this is a coherent, constructive, well developed MDT that works to a high standard, delivering the best evidenced based care. Its progress is limited by lack of resources at a time that demand is increasing. Structure and Function of the Service The Pituitary MDT has a heavy workload which has not been resourced fully, so there are cross cover issues in terms of Radiology and Oncology. This may be resolved later in the year. There is strong commitment in the team as the MDT is not actually within the job plans. There are two CNSs in place. The Waiting Times Standards doesn't really apply to this patient group. The compliance of patients which it does apply to is good. There is good leadership of this team. Co-ordination of care/patient pathways There are no Network Guidelines available. These have been written but need to be agreed nationally. The 'Buddy scheme' the team has in place is example of good practice Team dynamics, in terms of communication, need to be improved. Patient Experience The team informally gleam feedback from patients. The team are yet to complete a patient satisfaction survey. This is in work programme although needs to be prioritised within the next 12 months. Good Practice Embedded MDT The Lead Clinician is receptive to the panel's comments regarding developing the SHA wide CSG. General Comments There is no key worker identified in any of the patient notes/documentation. With the development of Christie at Salford, there is an opportunity for support from additional Clinical Oncologist Histopathologist - the Pituitary MDT is now confirmed in PA's Commitment is good from the Clinicians. The team have now got an MDT Co-ordinator. The team need to ensure that Minimum Data sets, which have been developed, now have data entry which will support the team reviewing clinical outcomes. Summary of validation process The team were internally validated in June 2011: 1 hour pre-meet for the Internal Validation Panel to review documents provided by team 1 hour face to face meeting with the Team 1 hour review of evidence, case note review and report completion by Panel Panel Joann Morse - ADNS/Lead Cancer Nurse Steph Gibson - Divisional Managing Director, Clinical Support Services and Tertiary Medicine Hilary Rothwell - Cancer Programme Manager Jane Campbell - Patient/Carer Representative Julie Bateson - PA, Cancer Services Following the receipt of the new Neuro measures after the IV, the team amended their documentation and were re-reviewed by Joann Morse and Julie Bateson in December 2011. INTERNAL VALIDATION REPORT for Salford Pituitary MDT - Neuroscience MDT (published: 19th December 2011) Page: 6/7
Organisational Statement I, Joann Morse (Validation Chair) on behalf of SALFORD ROYAL agree this is an honest and accurate assessment of the Neuroscience MDT. Agreed by Mr David Dalton (Chief Executive) on 15th Dec 2011. INTERNAL VALIDATION REPORT for Salford Pituitary MDT - Neuroscience MDT (published: 19th December 2011) Page: 7/7