INTERNAL VALIDATION REPORT (MULTI-DISCIPLINARY TEAM) Network Trust MDT GMCCN SALFORD ROYAL Salford Specialist Gynae MDT (11-2E-2) - 2011/12 Date Self Assessment Completed 30th June 2011 Date of IV Review 17th June 2011 Lead Clinician Mr Richard Slade Compliance SPECIALIST GYNAE MDT Key Themes Structure and function of the service Self Assessment 90.0% (27/30) Internal Validation 90.0% (27/30) The Gynae SMDT has been in place since 2006 and is a well established functional service. We are successful in maintaining compliance with the Cancer waiting times. The Gynae specialist team have a well established cover system which enable us to continue running the service during absent or sickness and this is well documented via MDT attendance records. Key Themes - National Patient Satisfaction Survey completed Gynaecology at SRFT was scored one of the best centres nationally and the hospital was in the top 20. - Achievement of the Cancer Waiting Times - Improved team working across the North West Sector by maintaining IOG Meetings. - Referrals from Bolton are now sent electronically as part of the introduction of a paper light system which will increase security of CaRP ad MDT documentation. A shared NHS net account to be established at Salford to allow referrals to be accessed electronically by the team. - All core members have completed the Advanced Communication Skills Training or are booked onto a course before the end of the year.. - QA visit for Colposcopy at SRFT very positive, full report is now available. - Mr Richard Slade and Mr Brett Winter-Roach have achieved publications in Peer Review Gynaecology Journals - Fostered links with surgical colleagues at SRFT to facilitate greater collaborative surgery at SRFT and changed theatre days to allow joint intervention of surgery - Mr Brett Winter-Roach has introduced Laparoscopic Hysterectomy for endometrial cancer as a surgery choice for women, as per NICE guidelines. Resulting in reduced hospital length of stay and benefits of this for the patient - Achieved full compliance of GP Notification of diagnosis within 24 hours across all 3 sites. - Better utilisation of beds to reduce length of stay through day of surgery admission and early patient discharge. Patients who meet the agreed critera are having bowel prep at home to further enhance use of the SAL lounge and reduce the number of patients requiring admission the day before their surgery. - Successfully appointed a research nurse Catherine Redshaw who will play a key part in ongoing gynaecological research and trials. - Successfully appointed a joint gynaecology / Urology ERAS Nurse who will become a key member of the team to further INTERNAL VALIDATION REPORT for Salford - Specialist Gynae MDT (published: 29th September 2011) Page: 1/5
reduce length of stay and enhanced recovery. - Bolton are piloting a 'information prescription' service enabling the team to provide specific information based on the individual needs and requirements of the patient, and also further enhancing GP notification of diagnosis. - Wigan are due to trial Information Prescriptions later this year. - CNS led study day increasing awareness of Vulval Cancer. - Planned CNS study day for Cervical Cancer - October 2011 - Communication meetings taking place between CNS at Bolton, Wigan and Salford. Key Challenges - Neo-adjuvant treatment resulting in patients attending the Christie and then remaining at the Christie for surgery - ongoing - Improve efficiency of SMDT meeting summaries: for example, through use of digital recording of meetings as piloted in other area's of SRFT and observation of other MDT's. - Minimum Data Set development and electronic upload - Continuing improvement to patient length of stay by: 1) Admitting to the surgical admissions lounge for the majority of patients 2) Improved discharge planning,, commencing at the pre-operative assessment. 3) Continued support of the high impact interventions policy for infection control in theatres and on the wards. - Establish a multi-site communication meeting with administration teams to ensure standardisation of documentation and correct processes. - Joint planning with surgical colleagues at SRFT to facilitate greater collaborative surgery at SRFT and changed theatre days to allow joint intervention of surgery - Introduction of a paper-light MDT including electronic referral for discussion. - Development of Oncology Dataset Coordination of care/patient pathways Gynae SMDT have well established guidelines and individual treatment pathways as outlined in the Operational Policy and these are reviewed as necessary. New guidelines regarding Ovarian Cancer have been released by NICE and these were discussed amongst the team at the recent IOG/AGM meeting. Enhanced recovery for Gynaecology patients is due to commence in June 2011 and will be reviewed at the next IOG meeting. Patient experience - Participation in the National Patient Experience Audit. Gynae was seen as being a 'very good' service by the patient group that participated although due to the number of patients who took part and individual breakdown for gynaecology was not given. Overall we scored one of the highest service groups in the Greater Manchester and Cheshire districts. The full audit can be seen within the Operational Policy. Clinical outcomes/indicators - Please see clinical lines of enquiry document INTERNAL VALIDATION REPORT for Salford - Specialist Gynae MDT (published: 29th September 2011) Page: 2/5
Good Practice Good Practice/Significant Achievements - Achieved overall compliance with GP fax notification for all 3 sites. - Sucessful recruitment of Enhanced Recovery Nurse - commences Enhanced Recovery Process for Gynae 13 June 2011 - Successfully recruited the help of an Audit Facilitator (Catherine Redshaw) - Implementation and upload of Oncology Dataset - Implementation of RAPA - multiple access within team to ensure all notifications are picked up within 24 hours. - Implementation of Pelvic MDT - Secured theatre availability for BWR - Strong communication channels within the team including dedicated service management input to assist the operational day to day management of the patient group. - Strong commitment to education in practice - Well established administrative communication links with Bolton, Wigan and the Christie Concerns Immediate Risks Serious Concerns We need a data management system for the MDT that allows for the prospective collection of data on tumour stage as well as operative morbidity, mortality and survival outcomes. We are not presently able to quickly audit our performance in these key domains and it is becoming necessary to be able to compare our practice at different time points and between different centres in the network. Concerns - Theatre capacity to maintain waiting times INTERNAL VALIDATION REPORT for Salford - Specialist Gynae MDT (published: 29th September 2011) Page: 3/5
- Data system inconsistencies with other Trusts - Funding issues around CNS specialist studies - Pelvic MDT support to facilitate collaborative surgical practice Whilst the team feel that the one hour SMDT is sufficient, the panel are concerned that giving the growing number of patients to be discussed and the teams concern regarding the lack of data, the one hour per week is insufficient and needs reviewing. Whilst the team are not concerned about pathology - the panel are concerned about lack of pathology support with particular reference to Wigan. Lack of real time valid data collection - this needs to be actioned as a priority for the team. General Comments The Gynaecology SMDT functions very well and has a consistent team approach. Identified concerns around isoft and its functionality in comparison to Somerset which is the commissioned data system at Wigan and The Christie, are being investigated by the Service Management team with a view to adapting our systems to generate the same data. Overall the Gynaecology SMDT is a successful and well established Service. Structure and Function of the Service This is a robust SMDT and operational policy in relation to the SMDT. Constitutes all core members with good attendance from individuals and compliance across all sites. The CNSs are in place, although single handed at RBH and WWL. There is clear evidence of strong leadership and this being a strong cohesive SMDT which core members contribute to. Co-ordination of care/patient pathways The Network Guidelines are being validated after this review to incorporate the latest guidance. There is good co-ordination between all 3 sites which is particularly led by the CNSs. There is joint working with Centre Consultants with Out Reach Clinics at RBH & WWL on a weekly basis. Patient Experience The National Patient Experience Survey has been completed, although with 19 responses, the team couldn't obtain a Gynae specific response. Overall, SRFT was in the top 20% Nationally which will also be attributed to the Gynae Team. The work programme needs to include actions from the survey. Patient support group - the panel would encourage the team to continue trying to establish this. Clinical Outcomes/Indicators The team has completed their Clinical Lines of Enquiry. There is variable achievement on targets for Cancer Waiting Times. Referral to first appointment within 14 days is 100% but the 31 days from Decision to Treat and First Definitive Treatment failed to reach the target in 5 consecutive months September to January ranging from 71% - 93%. 62 day target failed in 8 months ranging from 40% - 84%. Work is required to ensure onward referral meets the targets, especially to The Christie. The team expressed great concern that they do not have access to data resulting in the team has been unable to provide data in terms of outcomes. The data set has been developed with the Service Management Team. Support to Enhanced Recovery Patients, where appropriate, is identifying issues within the pathway though good progress has been made. The team were asked to consider the possibility of a third Surgeon who could support the services at RBH & WWL where they struggled during periods of leave and peaks in activity. Good Practice/Significant Achievements The Enhanced Recovery Programme, Referrals to the Fertility Service, The patient information pathways being implemented at Bolton, The vast majority of the team have attended the Advanced Communication Skills Training. INTERNAL VALIDATION REPORT for Salford - Specialist Gynae MDT (published: 29th September 2011) Page: 4/5
General Comments The team need to revisit the audit for diagnosis to GPs. The team, with the service management, are asked to review and consider the requirements of a third Gynae Oncologist to address the increasing capacity for surgery and cross cover for Wigan and Bolton clinics/service. The panel highlighted to the team that there is a forthcoming National Survey. The team have been advised to discuss this with patients in the next few months and ask them to complete the survey if received. This will then hopefully increase the number of patients participating, therefore ensure a more meaningful feedback to the team (only 19 patients replied which meant that didn't get a Gynae specific breakdown of data). Summary of validation process 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 Dr Gordon Armstrong - Lead Cancer Clinician Joann Morse - ADNS/Lead Cancer Nurse Jackie Elliott - Cancer Services Manager Hilary Rothwell - Cancer Programme Manager Dan Pearce - Acting Cancer Services Manager, WWL Helen Sewell - Acting Cancer Services Manager, RBH Julie Bateson - Personal Assistant, Cancer Services Patient/Carer - apologies given Organisational Statement I, Dr Gordon Armstrong (Validation Chair) on behalf of SALFORD ROYAL agree this is an honest and accurate assessment of the Specialist Gynae MDT. Agreed by David Dalton (Chief Executive) on 29th Sep 2011. INTERNAL VALIDATION REPORT for Salford - Specialist Gynae MDT (published: 29th September 2011) Page: 5/5