INTERNAL VALIDATION REPORT (MULTI-DISCIPLINARY TEAM) Network Trust MDT EMCN UNIVERSITY HOSPITALS OF LEICESTER Leicester Royal Infirmary Acute Oncology MDT (11-3Y-1) - 2011/12 Date Self Assessment Completed 30th June 2011 Date of IV Review 13th September 2011 Lead Clinician Dr Irene Peat Compliance ACUTE ONCOLOGY MDT GENERAL ACUTE ONCOLOGY MDT ACUTE ONCOLOGY IN-PATIENT MDT Key Themes Structure and function of the service Self Assessment 100.0% (4/4) Self Assessment 63.6% (7/11) Self Assessment 50.0% (1/2) Internal Validation 33.3% (2/6) Internal Validation 18.2% (2/11) Internal Validation 0.0% (0/3) There is a long history at UHL of cooperation between the oncology service, A and E, and the admissions unit, with senior medical staff available 24/7 for advice, and a liaison nurse in post to support outlyers. The majority of Acute Oncology patients are admitted via the Osborne assessment unit with a large proportion self-referring. The formalised Acute Oncology team had its inaugural meeting in July 2011. All key core members are in place, with a vacancy for the MSCC rehab lead. A separate MSCC MDT is planned. The AOT will meet 6 monthly, but with vigorous and frequent communication and liaison in between. Operational policies and work programme have been agreed. Coordination of care/patient pathways INTERNAL VALIDATION REPORT for Leicester Royal Infirmary - Acute Oncology MDT (published: 14th November 2011) Page: 1/7
UHL is unique in that patients receive cancer management and emergency management in the same Trust. Formation of the Acute Oncology team is welcomed as a means of strengthening the normal lines of communication between clinical staff, and of achieving excellent care wherever the patient is admitted on site. Presently available management guidelines are being reviewed and amended, to ensure that all patients receive an equally high standard of care whatever their portal of entry into UHL, and these will be supplemented by agreed Network guidelines as they become available. Patient experience This is a new 'specialty' and there has not yet been chance to survey locally. I am not aware of any national surveys, outside the UHL/Network provision. Clinical outcomes/indicators This is a new 'specialty' and I am not aware of any trials available for recruitment or of any key audits outside mandatory NCAG/A and E audits. Good Practice Good Practice/Significant Achievements We have made a good start and volunteers have come forward to offer review of protocols (307). Concerns Immediate Risks Internal Validation Comments Serious Concerns INTERNAL VALIDATION REPORT for Leicester Royal Infirmary - Acute Oncology MDT (published: 14th November 2011) Page: 2/7
Internal Validation Comments Concerns I wish to see a UHL MSCC MDT formally instituted. Internal Validation Comments General Comments This is a new team for UHL, but the participants are willing and enthusiastic, and keen to improve patient care. Internal Validation Comments The Panel reviewed the following measures to determine compliance: - 101 - Compliant The MSSC team are awaiting formation, discussion ongoing regarding the Lead for the MSSC, work is in progress and to be formulised. AOT team are unable to identify an orthopaedic link, IV panel suggested that the team liaise with the Cancer Centre Clinical Lead and the Network groups, and needs to be explored further. Named members are in place, terms of reference agreed. The evidence seen at IV, i.e. Secretary, Job Description & person spec, Chemotherapy Handbook, meeting minutes and attendance. - 102 - Non compliant The Panel noted that a member of staff had received training, evidence seen at IV, however, all outstanding members to received training to be listed in the Work programme. Staff to be included: A&E Consultants, NCCG medical staff in the A&E department. Contracted Nurses of band 6 and above in the A&E department. ED & AMU - list of staff needed in relation to the above. Panel has noted that nursing induction training has been feedback to matrons on the units and to be filtered down to staff and is currently work in progress. Panel suggested that the AOS Acute admission and review policy Aug 2011 requires more content to comply with Peer Review Measures, to be in a Trust style/font and Quality assured (Q-pulse). - 103 - Non Complaint The panel note the list of staff that have currently received induction training, evidence seen at IV, however all outstanding members to receive training to be listed in the Work programme. Staff to be included: Consultant Physicians and any NCCG medical staff on the acute medical take rota of the hospital in INTERNAL VALIDATION REPORT for Leicester Royal Infirmary - Acute Oncology MDT (published: 14th November 2011) Page: 3/7
addition contracted nurses of band 6 and above in the medical admission unit. Panel has noted that nursing induction training has been feedback to matrons on the units and to be filter down to staff and is currently work in progress. 104 -Non Compliant. Fast track referral protocol. Chemotherapy treatment & patient information card seen at IV. LOCAL WORKING PRACTICE IP informed the panel that the trust has a local arrangement. Only a small proportion of patient come through the A&E department, most come through AOT unit. A Central fax number has been set up which will activate an out patient appt or fast track clinic appointment immediately. For an acute oncology patient where a diagnosis of malignancy and its likely primary site is known, or judged to have been made in the Emergency Department, where clinically indicated, the patient should be referred via fax to: Oncology Administration Office - FAX: 0116 258 5942 Fax location: Osborne Building, Level One, Oncology Medical Secretaries & Clinic Co-ordinators office. The named office is open Monday am to Friday 5 pm, all urgent faxes are actioned as below. Out of Hours - for immediate advice or urgent admission that require fast tract, contact the consultant on call or SpR on call via switchboard. SWITCHBOARD: 0 Working practice: When a referral from A&E is received via fax to the Oncology Administration Office, this is given directly to the appropriate Consultants Medical Secretary, who then brings this to the urgent attention of the Consultant. All oncology patient notes are situated within the Medical Secretaries and Clinic Co-ordinators office. The Consultants Secretary may already be familiar with the patient and therefore can pull the patients notes and book an out patients appointment or fast track clinic slot immediately. The patient will be seen within one week in receipt of the faxed referral. Further clinical engagement with haematologists required regarding their working practices, and evidence of haematology local policies. - 105 - Non compliant - Acute Oncology Fast Track The process is in place as guidance, and team has confirmed booking rules. Through the local policy, the service doesn't have any waiting lists as patients are seen within time. Further clinical engagement with haematologists required regarding their working practices, and evidence of haematology local policies. - 106 - Compliant The panel asked if a patient was seen or admitted outside of the normal working hours, in the Emergency Department over the weekend, would this patient be picked up on a Monday am by a consultant oncologist. AOT lead agreed. There is evidence of a protocol, however, the panel would recommend that the content needs to be expanded to give more detail i.e Haematology. Work Programme. - 301 - Agreed compliant. Evidence seen at IV - Job plan and job description. - 302 - Non Compliant - patient flagging system Currently non compliant due to not having an electronic system. It is Unknown as yet what the plan is as further discussions are needed. Very little info is getting to the AMU and ED unit due to this. 7% of patients are presented to ED. There are questions that need to be explored regarding the cost of the system for the small number of patients that present to A&E and AMU. Further question been asked if something could be put into place Trust wide. - 303 - Agreed Compliant Agreement to Network Consultant Oncologist and haematologist Telephone On call Service "minimum specification" Evidence seen at IV, on call rotas. - 304 - Non Compliant - MSCC coordinator service AOT Lead confirmed that discussion is still ongoing. Orthopaedic cover is the problem as there are only 4 consultants that do spinal work. Further discussion and consultation is needed. ADD TO WP - 305 -Currently non compliant - AO induction training. The Panel note that a member of staff that has received training, evidence seen at IV, however, all outstanding members to INTERNAL VALIDATION REPORT for Leicester Royal Infirmary - Acute Oncology MDT (published: 14th November 2011) Page: 4/7
received training to be listed in the Work programme. Staff to be included: Consultant Oncologist 24/7 on call rota and the 24/7 chemotherapy advice service rota. - 306 - Currently Non Compliant - communication protocol The review team acknowledge that this is work in progress pending further ratification of the policy. - 307 - Non Compliant Panel reviewed submitted evidence. AO Lead agreed that the information is stored on the Trust Document Management System (DMS), and Q-pulse system which is the Cancer and Haematology Quality Management System, and within Junior Dr Handbook. These policies can be accessed by all areas via the staff member logging on a UHL PC. Panel agreed that a more central location is required and to be added to the work programme. AO Lead added that they are thinking of producing a handbook of up to date information and have this on the DMS system. The panel suggested that organisation of documentation and storage needs to be explored and in addition which areas require which policy. e.g. The Emergency Department need the sepsis policy and AMU will require different things. Paper evidence seen as detailed in the electronic evidence contents page. The review team note again that this is work in progress and suggest that there needs to be a more robust process in relation to equitable accessibility to the protocols across the organisation. - 308 - Currently non Compliant - one hour to antibiotic Pathway AO Lead currently looking at with Chemotherapy Services Lead as this may cross referenced with regard to what information is given to a patient i.e. chemo card and chemo Leaflet. To be added to the work programme. Evidence seen at IV. Confirmation of the pathway to be verified with the chemotherapy leads. - 309 -Non Compliant - one hour audit Chemotherapy Services Lead is currently collecting data. Unfortunately the audit want ready in time for Peer Review. To be added to the Work programme. - 310 - Non Compliant - MSCC Service Panel note that this is currently non compliant due to awaiting formation of the service. - 311 - Non Compliant - Network agreed patient information leaflet Panel note that this was agreed at network meeting, AO Lead informed that they have produced a local leaflet and will continue to use. The review team saw evidence of a locally adapted patient information leaflet, however this was only in draft form, therefore, and needs completion along with evidence with distribution. To be added to WP. - 401 - Non Compliant - Assessment oncologists Senior opinion is available for patients, however, cant guarantee a consultant currently. If need to cover module we will need a case of need for this. If on Monday morning, consultant would take a call or not necessarily see the patient in am. Panel note that there is a trust grade post out to advert to provide day time cover for the assessment unit. AO Lead confirmed that currently we have 1 full and 3 part time medical oncologists. Paper evidence seen as detailed in the electronic evidence contents page. Whilst it is acknowledge in the operational policy the arrangements for staffing, there was no evidence of job plans agreed by the acute oncology lead and clinical director. - 402 -Non Compliant - Assessment by specialist nurse Panel note that the assessment unit has a shortfall in the nursing establishment. The service does not have an acute oncology nurse specialists and a bid is in progress for Macmillan funding to support this post. - 403 - Not applicable - this measure is a duplication of measure 305. - 404 -Non Compliant - Oncology assessment Policy AO Lead confirmed that if a Patient admitted over weekend they should be seen by an Oncologist on the following Monday morning, but could not confirm that this was in place. The panel acknowledged that the SpR's do review the patient on a Monday morning. Consideration will need to be given on how this will be addressed. Add to WP. AO Lead confirmed their top 5 clinical priority or clinical issues - MSCC - Manual of protocols - central point - Out of hour - Audit is a concern - Specialist nurse support - Clincial Medial Oncologist. The panel congratulated the service and in a short period of time they have worked hard with Peer Review timeline scales and acknowledged that this is a very complex service within a large organisation. The panel acknowledges that whilst that there is a significant element of non compliance, there are robust plans in place to INTERNAL VALIDATION REPORT for Leicester Royal Infirmary - Acute Oncology MDT (published: 14th November 2011) Page: 5/7
address these as evidenced in the work programme and significant number of the measures are almost compliant with the current work to date. It is evident that the acute oncology team have established a good communication network within the organisation, to further support the development of this service 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 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 Acute Oncology Service are newly established, the trust approach was option 2, desk top exercise and face to face interview with members of the servcie. Panel Members: Michael Nattrass - CBU Manager Jane Pickard - Lead Nurse Anthony Locke - Patient Representative Andy Williamson - Service Improvement Lead (Network Representative) Sam Holmes - Peer Review Project Lead Acute Oncology Service Members in attendance: Irene Peat, Lead for Service Helena Gleeson - Physician Jo Hyde - Matron Petronilla Mukuzvazva - deputy sister Judy Kilby, Haematology Chemotherapy Specialist Sister INTERNAL VALIDATION REPORT for Leicester Royal Infirmary - Acute Oncology MDT (published: 14th November 2011) Page: 6/7
Organisational Statement I, Mr Michael Nattrass (Validation Chair) on behalf of UNIVERSITY HOSPITALS OF LEICESTER agree this is an honest and accurate assessment of the Acute Oncology MDT. Agreed by Malcolm Lowe-Lauri (Chief Executive) on 30th Sep 2011. INTERNAL VALIDATION REPORT for Leicester Royal Infirmary - Acute Oncology MDT (published: 14th November 2011) Page: 7/7