INTERNAL VALIDATION REPORT (MULTI-DISCIPLINARY TEAM) Network Trust MDT EMCN UNIVERSITY HOSPITALS OF LEICESTER Leicester General Hospital Specialist Urology MDT (11-2G-2) - 2011/12 Date Self Assessment Completed 30th June 2011 Date of IV Review 30th August 2011 Lead Clinician Mr Leyshon Griffiths Compliance SPECIALIST UROLOGY MDT Key Themes Structure and function of the service Self Assessment 90.5% (38/42) Internal Validation 92.9% (39/42) Refer to Operational Policy (OP) for reference This is a weekly well attended MDT. Attendance rates are also fully compliant and all specialties exceed the minimum rate of 67% attendance. The MDT Co-ordinator takes a proactive role in ensuring that all attendees sign the register. Effective team-working is evident when attending Urology MDTs, with discussions about treatment being balanced and focused. All disciplines have an opportunity to input their views, leading to informed treatment decisions. Sufficient time is spent discussing cases, considering the volume of patients and that the MDT can continue into the early evening. Urology MDT is committed and dedicated to providing high quality service to patients. The MDT Co-ordinator administers an efficient and effective meeting on a regular weekly basis. The outcomes are recorded by the MDT Co-ordinator during the meeting and are confirmed for accuracy by the Lead Clinician before being circulated to the rest of the team. The MDT Co-ordinator keeps records of MDT workload and Mr Griffiths' Secretary is responsible for updating the clinical to discuss a large volume of patients effectively. There is strong leadership and the chair of the MDT and the co-coordinator stay behind to ensure that all letters go out to GPs the evening of the MDT. The team works well together and informally discusses patients outside the MDT. There are 2 Urology Cancer Nurse Specialists and 1 Prostate Cancer Nurse Specialist working a total of 2.6 WTEs. Compliance with waiting times standards. Urology has struggled to comply with waiting time standards over the last year. A number of factors have contributed to this i) Closure of female Urology elective ward ii) Increased surgical subspecialisation amongst the Urological core members iii) Insufficient Consultant Urological Surgeons iv) Introduction of 31-day target for treatment of recurrent cancer and 18 week target for all patients (cancer or other) had an effect particularly on 62 day waiting times. Patient cancer pathways have been reviewed and the Planned Care Directorate is looking at ways of improving our compliance. See Annual Report for the following: - Urology CWT data - Testicular CWT data - How many patients by equality characteristics were diagnosed/treated in the previous year. INTERNAL VALIDATION REPORT for Leicester General Hospital - Specialist Urology MDT (published: 14th November 2011) Page: 1/7
Coordination of care/patient pathways This specialist Urology MDT demonstrates coordinated care to individual patients. There is prompt communication with GPs and other referrers to the Urology MDT. There is always an on-call consultant urological surgeon who can be consulted and is available to operate on the team's patients. The UHL/network Key Worker policy is adopted. The Lead CNS keeps her own database and gives her patients an efficient and supportive service. Patients are offered a copy of each consultation. Patient Information Leaflets for all the urological cancers are regularly updated and the Patient Information Pathways for each of the urological cancers are updated annually. The network-approved clinical referral and follow-up guidelines are adopted by this Urology MDT including network and supranetwork defined care. An annual Urology MDT Operational meeting is held to update issues concerning patient care and arrangements. The East Midlands Cancer Network Urology NSSG holds an annual general meeting and an educational event to further facilitate optimal coordinated patient care. Patient experience UHL participated in the 2010 National Survey. The patient survey included all adult patients (aged 16 and over) with a primary diagnosis of cancer who had been admitted to UHL as an inpatient or as a daycase patient, and had been discharged between 1st January 2010 and 31st March 2010. Postal surveys were sent to patients' home addresses following their discharge. The overall response rate was 67% for UHL Trust patients. There were 108 'Urological' respondents and 43 'prostate' respondents with separate tumour-site results. Many of the overall UHL results also apply to the Urology tumour-site. The results were initially discussed at our Urology MDT meeting on 9 June 2011 and then at the East Midlands Cancer Network Urology NSSG Meeting AGM on 10th June 2011. We agreed to work on action plans for scores <70%, review questions rated in the lowest 20% of Trusts and bring back a completed action plan to the Urology MDT by 15 August 2011. We agreed that Kate Moody (Urology Cancer Nurse Specialist), our lead for patient experience would take responsibility for this. Two action plans have already been agreed by the Urology MDT and implemented. 1) Questions 26 and 27: Action Plan - We have now added financial advice to the Urology Patient Information Leaflets. 2) Questions 51 and 52: Action Plan - We will raise awareness of the 'Orange booklet' (Lead Cancer Services booklet) on the Urology wards and outpatients. Scores <70% across UHL Trust Finding out what is wrong with you Q12: Patient told they could bring a friend when first told they had cancer (69%) Q15: Patient given written information about the type of cancer they had (68%) Deciding the best treatment for you Q19: Patient definitely involved in decisions about which treatment (65%) Support for people with cancer Q26: Hospital staff gave information on getting financial help (46%) Q27: Hospital staff told patient they could get free prescriptions (65%) Hospital doctors Q38: Patient's family definitely had opportunity to talk to doctor (59%) Ward nurses Q39: Got understandable answers to important questions all/most of the time (69%) Q40: Patient had confidence and trust in all ward nurses (63%) Q42: Always/nearly always enough nurses on duty (56%) Information given to you before leaving hospital and home support Q51: Family definitely given all information needed to help care at home (56%) Q52: Family definitely given enough care from health or social services (56%) Hospital care as a day patient/outpatient Q58: Hospital staff definitely gave patient enough emotional support (60%) Q60. Waited no longer than 30 minutes for OPD appointment to start (62%) UHL Questions rated lowest 20% of Trusts which are not already in the score <70% list Q10. Given complete explanation of test results in an understandable way (73%) Q14. Patient completely understood the explanation of what was wrong (70%) INTERNAL VALIDATION REPORT for Leicester General Hospital - Specialist Urology MDT (published: 14th November 2011) Page: 2/7
Q23. Get understandable answers to important questions all/most of the time (88%) Q36. Patient thought doctors knew enough about how to treat their cancer (86%) Q37. Doctors did not talk in front of patients as if they were not there (79%) Q56. Staff definitely did everything they could to help pain control (77%) Q65. Hospital staff and community staff always work well together (55%) Q67. Patients did not feel that they were treated as 'a set of cancer symptoms' (76%) Comment: Overall, the Urology MDT was disappointed by some of these results. The timing of the questionnaire after discharge from inpatient or daycase care may have had an influence on the performance of some of the questions. For example, 'Q15: Patient given written information about the type of cancer they had'. When patients attend outpatients, they are routinely seen by our Urology Clinical nurse specialists are routinely given patient information leaflets Clinical outcomes/indicators Urology MDT's data collection is comprehensive and noted for its quality. Urology MDT has agreed to collect the Minimum Dataset, in line with British Association of Urological Surgeons (BAUS) and Cancer Waits requirements. This database gives reliable outcome data. Outcomes are also submitted on all complex urological procedures (nephrectomy, radical cystectomy and radical prostatectomy) to the BAUS complex operations database. Currently this is filled in for all urological consultants by Mr Griffiths' PA under the supervision of Mr Griffiths. Top 5 clinical priority issues There is unanimous agreement from the Leicester Urologists that the following 5 quality cancer standards should be included in Urological cancer contracts. Generic 1. Enhanced Recovery Programme for radical cystectomy, prostatectomy and nephrectomy. 2. Cancer Service supported by Urology Oncology Cancer Nurse Specialists/Key Workers. Cancer-specific 1. Offering neoadjuvant systemic chemotherapy to patients prior to radical cystectomy or radiotherapy for muscle invasive transitional cell carcinoma of the bladder. 2. Offering bladder reconstruction to patients undergoing radical cystectomy for bladder cancer. 3. Offering the laparoscopic approach to patients undergoing radical nephrectomy for T1/T2 N0M0 renal cancer. See Annual Report for the following: - Major resection rates - Mortality rates - Recruitment to NCRN - adopted clinical trials Outcomes of any key audit projects Active surveillance of small renal tumours: Clinical outcomes Conclusion: Active short-term surveillance of small renal tumours appears to be a safe strategy. Validated FU imaging protocols and criteria defining the need to abandon surveillance are required. Audit of dynamic sentinel node biopsy (DSNB) in penile cancer in a new centre from 1/9/09 to 1/4/11 Summary: * 16 patients, 30 groins * Complication rate (16%); False negative rate (FN/TP + FN) = 1/1+1 = 50%; Sensitivity (50%); Specificity (100%) * Re-audit in 12 months' time after more DSNBs and a greater follow-up time to reassess false negative rate. Good Practice Good Practice/Significant Achievements INTERNAL VALIDATION REPORT for Leicester General Hospital - Specialist Urology MDT (published: 14th November 2011) Page: 3/7
* 100% of letters to GPs within 24 hours of MDT. * Appointment of a dedicated Consultant Uro-Pathologist to fill a vacant post * Rising numbers of patients recruited to Uro-oncological trials * Introduction of Enhanced Recovery Programme pathways for patients undergoing cystectomy, prostatectomy and nephrectomy * The laparoscopic approach to radical prostatectomy is increasingly being offered Increased experience of dynamic sentinel node biopsies for penile cancer * All currently working core members with clinical contact have attended the National Advanced Communication Skills training course * Mr Griffiths is now the Secretary and Mr Kockelbergh the Treasurer of the first national bladder cancer charity (Action on Bladder Cancer) which got charitable status last year. Concerns Immediate Risks Serious Concerns Concerns * Closure of the female urology elective ward at Leicester General Hospital last January 2011. These were the only dedicated female urological beds in Leicestershire. The reduced dedicated bed base for Urology has further contributed to our inability to meet Cancer Waiting Time targets in the last quarter. * The need for robotic surgery in Leicester. There are now 26 centres in the UK who routinely perform robotic urological surgery; there has already been a drift of some of Leicestershire's patients to these centres. National Cancer Intelligence are likely to recommend an increase in the number requirements for pelvic surgery in each centre in the near future and this will inevitably lead to robotic centres becoming the chosen centres for radical pelvic urological surgery in networks. * Non-compliant measures - 11-2G-202: Level 2 practitioners for psychological support - 11-2G-203: Support for Level 2 practitioners -11-2G-242 : >5 radical pelvic cystectomies/prostatectomies per surgeon INTERNAL VALIDATION REPORT for Leicester General Hospital - Specialist Urology MDT (published: 14th November 2011) Page: 4/7
* Waiting time targets Internal Validation Panels Comments: Closure of the female urology elective ward at Leicester General Hospital last January 2011. These were the only dedicated female urological beds in Leicestershire. The reduced dedicated bed base for Urology has further contributed to our inability to meet Cancer Waiting Time targets in the last quarter. Panel - to be discussed with the urology service manager. General Comments * Multiple examples of change in practice (including laparoscopoic prostatectomy and dynamic sentinel node biopsies) and good team working. * Enthusiastic team keen to participate in uro-oncological trials and adopt new technologies * A joint business case (Urology and Gynaecology) for robotic surgery is on-going Internal Validation Panels Comments: Multiple examples of change in practice (including laparoscopoic prostatectomy and dynamic sentinel node biopsies) and good team working. Panel comments - panel note achievements CWT - issue ongoing with local cancer waiting times meetings, urology manager, discussion to be had with MDT Co-ordinators about flagging up breaches at the MDT Robotic service - we note lack of progress for the robotic service when it has been adopted by 26 other centres, is there anything we can do as a cancer centre to help this business case. Support for level 2 practitioner - plans in place and noted within work programme. Patient information - small number of patient leaflets have expired, however within the work programme - good variety of information and leaflets. All patient information seen by IV panel. Spot check of 5 sets of Urology patients notes undertaken - suggest patient information checklist to be designed in-order to comply with Peer Review. If adopted this document could be in the patient notes highlighting the pt key worker name and contact details, this could also be a check about whether a patient wishes to receive a copy of letter as well as types of information. 223 Anonymised e.g of records given to patient, 228 - Anonymised e.g of records of meetings and individual treatment plans all seen at IV. Copy letter to patients, we note that a sentence is in new and follow-up letters, notice on walls in outpatient. Dr S Nicholson - opt out policy for all patients to receive a copy letter. Patient information also contains this information regarding copy letter to patients, in addition the patient information booklets have diagrams in order for the clinician to explain the location of the cancer. 242 - more than 5 procedures - we note the plan to ensue that all surgeons perform the requisite numbers of radical procedures and this is documented within the work programme. Communication skills training - the panel congratulate the Urology MDT team, as in Sept 11 they will be compliant with this measure. Evidence seen by panel. Urology are a dynamic MDT, with an effective chair and demonstrate good team working. Clinical Trials - good trial recruitment. INTERNAL VALIDATION REPORT for Leicester General Hospital - Specialist Urology MDT (published: 14th November 2011) Page: 5/7
Evidence seen during Internal Validation: 204, 207 - attendance at NSSG, agreed as compliant, EMCN Urology Constitution and Annual Report seen during IV. 205 - attendance a MDT meetings, agreed as compliant, paper evidence to support this measure seen by IV panel. 213 - Key worker policy, spot check of relevant patients case notes was undertaken and panel confirmed that this measure is compliant. 218 - participation in EQA, agreed compliant by panel. 219 - CNS study, agreed as compliant, certification seen by panel. 223 & 228 - paper evidence seen and in addition spot check of 5 sets of patients notes undertaken and panel confirmed compliant. 224 - Trust and local level results seen by panel. Trust and MDT action plan contained within the Annual report. 201, 226 & 227 - Job plans of consultants and CNS seen by IV panel. 229 to 237 panel received hyperlinks prior to IV, and evidence seen by IV panel. 238 - MDS - agreed as compliant and evidence seen at IV. Post meeting note, Level 2 practitioner is now compliant, evidence seen by Jane Pickard, Lead Nurse, member of the Peer Review Internal Validation Panel. This was also endorsed by Validation Chair. Summary of validation process Summary of validation process University Hospitals of Leicester NHS Trust's Approach to the Validation Process for 2011: Option 1 - For teams that are above 85% compliant and an old team who have already been IV'd, however, without immediate risks or serious concerns. Our Trust Approach: MDT Self Assessments, clinicians Self Assessment Report and electronic evidence to be submitted. A small panel to undertake a desk top review and prior to review, the panel will receive highlighted comments, queries to alert them to issues that need to be clarified or explored in advance of desk top review. If panel request, a face to face meeting can be arranged. Option 2 - Old teams below 85% compliant and new teams Our Trust Approach: MDT's to self assess and complete Self Assessment Report and electronic evidence this will be submitted to panel members 2 weeks prior. Panel are able to request further members to attend their face to face Internal Validation. Prior to IV, panel are sent highlighted comments, queries to alert them to issues that need to be clarified or explored in advance of desk top review & face to face discussion. The above approach was agreed by The Trust has adopted the above approach for MDT/services and was agreed by: Carole Ribbins - Director of Nursing/Deputy DiPaC Elspeth Macdonald - East Midlands Cancer Network Director Nicky Rudd - Trust Cancer Lead Clinician As Urology MDT were Internally Validated in 2010 with a face to face interview and achieved 95.8%, it was agreed that Option 1 approach would be adopted. Panel Members in attendance at the Internal Validation: Nicky Rudd, Lead Cancer Clinician Michael Nattrass, CBU Manager Jane Pickard, Lead Nurse - Apologies received. Anna Follows - Network manager Anthony Locke - Patient /Carer representation Sam Holmes - Peer Review Project Lead INTERNAL VALIDATION REPORT for Leicester General Hospital - Specialist Urology MDT (published: 14th November 2011) Page: 6/7
Organisational Statement I, Dr Nicky Rudd (Validation Chair) on behalf of UNIVERSITY HOSPITALS OF LEICESTER agree this is an honest and accurate assessment of the Specialist Urology MDT. Agreed by Malcolm Lowe-Lauri (Chief Executive) on 23rd Sep 2011. INTERNAL VALIDATION REPORT for Leicester General Hospital - Specialist Urology MDT (published: 14th November 2011) Page: 7/7