London Cardiovascular Project Cardiac Surgery Site Assessment Guidance The London Cardiac and Stroke Network teams have been working with local providers and commissioners to plan the implementation of the London Cardiovascular Project, in line with the Commissioning Support for London model of care 1. A panel of clinicians from across London met for four meetings between January and June 2011 to develop a set of quality standards and implementation timeframes, outlining the requirements that cardiac surgery centres need to meet to improve patient care, in line with the objectives of the London Cardiovascular Project. The standards have been shared with the Society for Cardiothoracic Surgeons (SCTS) for comment and have now been signed off by the pan London cardiac and stroke network Board (PLCSNB) and Cluster Chief Executives. The standards can be found in the London Cardiovascular Project Cardiac Surgery Service Specification 2. The intention is that the implementation of these standards be measured at regular intervals in metrics reports, which will be submitted regularly to the PLCSNB. These reports will form the majority of the performance monitoring process intended to quality assure centres delivering care to these groups of patients. Alongside the regular metrics reports, one-off site assessments will be scheduled to review the implementation of those standards considered of a more qualitative nature, at each centre in London undertaking cardiac surgery. This document outlines the process for these one-off site assessments, and includes checklists of evidence that should be provided by trusts during the site assessments, to ensure a thorough assessment can be undertaken. These site assessments will cover the non-elective and mitral valve surgery work areas only. Networks, providers and commissioners should work together to ensure a thorough assessment is undertaken, and a summary of the assessment is reported to the PLCSNB in November 2011. The acute aortic dissection work area will continue to be led by the London Specialised Commissioning Group. 1 Commissioning Support for London, August 2010. Cardiovascular Project Model of Care [online]. Available at <http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/cardiovascular-model-of-care.pdf> [Accessed 23.09.2011] 2 London Cardiac and Stroke Networks London cardiovascular Project, June 2011. Cardiac Surgery Service Specification [online]. Available at <http://www.slcsn.nhs.uk/lcv/cs/lcvp-cardiac-surgery-service-specification-072011.pdf> [Accessed 23.09.2011] London Cardiac and Stroke Networks 1
Site assessment guidelines Cardiac surgery centres are currently working with their local cardiac and stroke networks to prepare for implementation and the subsequent performance monitoring, and will have had the opportunity to review the quality standards and consider implications for their services. It is hoped the site visits will be undertaken during October, with a summary report being available for the PLCSNB in November 2011. Site assessments should be hosted by the lead consultant and operational management of the trust, and will be undertaken by a team that is likely to consist of a senior representative nominated by the director of the local cardiac and stroke network, a commissioner from the appropriate cluster, and an out of cluster clinical (surgical) colleague. A clinical assessor rotation for London has been suggested in Figure 1. Where delegated authority has been granted by the commissioners, the assessment will be undertaken on their behalf by the local network and out of cluster clinical colleague, and the results of the assessment reported to the commissioners. Figure 1 - Clinical Assessor Rotation Assessor Assessed centres within cluster SWL surgeon NCL providers NWL surgeon NEL providers SEL surgeon NWL providers NEL surgeon SWL providers NCL surgeon SEL providers Preparation for site assessments The cardiac surgery site assessment check lists (presented at the end of this document) have been prepared for cardiac surgery centres and outline all documentation required for the site assessments. It is strongly recommended that the information for the site assessments is compiled in advance of the assessment date, and in a format that is easy to navigate and use. On the day of the site assessment The schedule for the visit will include: An introduction to the service and walk-around of the facilities Documentation review this could be electronic or paper folders provided for each assessor with all evidence indicated in the checklist o This will be undertaken in conjunction with the trust leads to enable discussion and clarification where required. The assessing team will discuss the visit amongst themselves and then discuss the outcome and any further actions required with the trust leads. London Cardiac and Stroke Networks 2
Post-assessment The outcome of the site assessments will be communicated by email to the team following the assessment. This will then be followed up by more formal confirmation (letter to Chief Executive) and feedback forwarded to the team. Progress will be reported to the PLCSNB in November 2011. If a trust is unable to demonstrate full compliance with the implementation of the quality standards, the assessing team will discuss this with them at the assessment and will highlight the key actions required to achieve this. The network leads will then work with the trust as an urgent priority to support these actions. The assessing team will agree with the trust leads the method of monitoring these actions (i.e. paper exercise / data analysis). At all times progress on these actions will be reported to the PLCSNB via the regular highlight reports. If substantial actions are required, this may necessitate a review meeting to be scheduled two months after the site assessment. This will provide the opportunity for actions agreed at the initial assessment to be reviewed. Network leads will liaise with the original assessors for clarification about specific items following this meeting if required. Progress will be reported to the PLCSNB in January 2012. Inability to demonstrate compliance with the implementation of the quality standards at the aforementioned review meeting will require director level discussion and escalated to the appropriate bodies (the Cluster Chief Executives / NHS London Delivery Group). Content of remainder of performance monitoring The Network metrics reports will include the quantitative metrics for monitoring the cardiac surgery quality standards; such as the length of stay of non-elective cardiac surgery patients; and the number of mitral valve procedures undertaken by mitral valve specialist. The first metrics report is expected to be produced by local Network teams in collaboration with the Central Cardiac Audit Database team, and presented at the PLCSNB in November 2011. The metrics reports should also be shared with each trust, and where benchmarking agreements are in place, should be shared between trusts. London Cardiac and Stroke Networks 3
Assessment Criteria Non-elective cardiac surgery Where implementation has not yet begun, action plans and draft policies should be presented as evidence to demonstrate the intention of the provider to work towards implementing the work by the timeframes outlined by the cardiac surgery service specification. Item Evidence To be provided by Notes Evidence of London agreed non-elective pre-operative workup Assessment of 10 sets of notes (chosen at random criteria / referral criteria in place, as per service spec from a 3 month period) and policy Evidence of willingness to take part in regular audits, by giving Written confirmation of permission permissions for Network access to CCAD SCTS data Evidence of electronic non-elective referral system policy in Review of non-elective referral policy, risk place management and local pathways Evidence of using electronic non-elective referral system in IHT policy, staff training and schedule real time documentation. Record of last 20 referrals. Evidence of policy for including or excluding hot cases onto IHT policy including protocols for management of electronic non-elective referral system hot cases and data entry Evidence of % of non-elective (urgent) patients referred electronically Current metric, and action plan in place to deliver target (100% of non-elective urgent patients) by The % will be reported in the Evidence of % of patients with first time isolated CABG LOS within 21 days Evidence of submitting LOS data for London benchmarking March 2012 Current metric, and action plan in place to deliver target (90%) by March 2012 Written confirmation of permission to share LOS reports The % will be reported in the *Regular submission of the Metrics Reports, as previously outlined and produced by the Network in affiliation with the s, should demonstrate the continued improvements in performance of these items. The first Metrics Reports are expected to be presented at the PLCSNB in November 2011. London Cardiac and Stroke Networks 4
Mitral valve surgery Where implementation has not yet begun, action plans and draft policies should be presented to demonstrate the intention of the provider to work towards implementing the work by the timeframes outlined by the cardiac surgery service specification. Item Evidence To be provided by Notes Evidence of formally structured mitral valve team (mitral valve surgeons, mitral valve cardiologists, mitral valve echo/imaging specialist) as per service spec Assessment of 10 sets of MV MDT meeting notes, (chosen at random from a 3 month period) with patient outcome record, attendance lists and MDT Evidence of protocols for the management of MV patients by MV team Evidence of surgeons who will train to become designated mitral valve specialists, and those who will stop Evidence that surgeons who perform less than 6 operations per year on the mitral valve and who have no declared interest in mitral valve surgery should no longer accept nonemergency cases by 1 st October 2011 Evidence of surgeons working towards performing a minimum of 25 mitral valve operations per year Evidence of appropriate training and education of trainee surgeons Evidence of willingness to take part in regular audits, by giving permissions for Network access to CCAD SCTS data Evidence of ability to demonstrate increasing rate of repair, by giving permissions for Network access to CCAD SCTS data policy for attendance Review of protocols, and assessment of 10 sets of patient notes (chosen at random from a 3 month period) List of names, specialties and job plans, and training plans from previous year List of names, specialties and job plans, and plans for managing out-patients/theatres/referrals and policy for mitral valve patients and Network (These notes can be the same provided for the previous item) Supported by List of names and specialties and job plans and Network Supported by Review of trainee surgeons job plans / training schedule and training plans from previous year Written confirmation of permission Written confirmation of permission and Network Supported by *Regular submission of the Metrics Reports, as previously outlined and produced by the Network in affiliation with the s, should demonstrate the continued change in these items. The first Metrics Reports are expected to be presented at the PLCSNB in November 2011. London Cardiac and Stroke Networks 5