National Cancer Action Team National Cancer Peer Review Programme FOR: Version 1
Introduction This evidence guide has been formulated to assist Networks and their constituent teams in preparing for peer review. The contents of this guide are not exhaustive and organisations should continue to tailor their policies to reflect activity of the respective team, whilst demonstrating compliance with the key questions. Networks and their constituent teams during the review process will be required to demonstrate ownership of all policies, and assure visiting Review Teams that policy is reflective of practice. Agreement Where agreement to guidelines, policies etc is required this should be stated clearly on the cover sheet of the three key documents including date and version. Similarly, evidence of guidelines, policies etc requires written evidence unless otherwise specified. The agreement by a person representing a group or team (chair or lead, etc) implies that their agreement is not personal, but that they are representing the consensus opinion of that group. Confirmation of Compliance Compliance against certain measures will be the subject of spot checks or further enquires by peer reviewers when a peer review visit is undertaken. When self assessing against these measures a statement of confirmation of compliance contained within the relevant key evidence document will be sufficient. 2
Key Questions for an MDT Question 1 Can you demonstrate that you have a properly constituted and functioning MDT? This can be demonstrated through compliance to those measures that relate to MDT Leadership, MDT Structure (membership) and MDT Meeting Arrangements (including attendance). In addition, measures within the operational policies section regarding ensuring all new patients are reviewed by the MDT, % time MDT Core members devote to this cancer type, training requirements of MDT members and responsibilities of nurse MDT Members also help demonstrate this. MDT Workload data and surgical workload data is also important here. Question 2 Can you demonstrate that you have effective systems for providing coordinated care to individual patients? This can be demonstrated through compliance to those measures that relate to the existence of a coordinated and patient centred pathway of care. For example, measures relating to communication with patients, key worker and principal clinician policies, communication with GPs, gaining feedback from patients, recording of treatment planning decisions, and agreement of Network Clinical Guidelines. Demonstration of coordinated referral pathways between specialist and local teams is also an important part of this. In addition, teams may demonstrate within their evidence other aspects of service delivery not covered by the existing measures that fit in here (for example, the provision of streamlined diagnostic pathways, enhanced recovery programmes or other patient support initiatives). Demonstrating that there are robust referral arrangements to and from specialist teams is also important here. Question 3 Can you demonstrate that your team has adequate information to help it improve service delivery? The term information is used in its broadest sense to cover data, audit, feedback from patients and feedback from service improvement initiatives such as process mapping and capacity and demand analysis. Compliance to measures relating to data-collection (collection of agreed minimum data-sets for example), participation in agreed Network Audits, service improvement initiatives and gaining feedback from patients help demonstrate this question. In addition, teams may demonstrate within their evidence other initiatives, over and above the existing measures, that give further assurance against this question. For example, audit activity, other initiatives to learn from the patients experience and innovative use of data. Access to accurate information about the teams workload is also important here. Question 4 Can you demonstrate how you are continuously improving your service (including clinical effectiveness and the patient experience)? This follows on from the previous question. It relates to the implementation of improvements to the delivery of services on an ongoing basis. Demonstration of the outcomes from audit activity, implementation of actual measured improvements to services delivery and implementation of improvements to the patients experience of those services will give assurance that this question is met. It is important to demonstrate the outcome or measurement of the improvement (whether it is related to the patients experience, clinical outcome, waiting times, or other quality indicators) within your evidence. 3
MDT Operational Policy - Agreement Cover Sheet This Operational Policy has been agreed by: Position MDT Lead Clinician Name Organisation Date Agreed Position Trust Lead Clinician for MDT Leadership(10-1D-101 & 10-2D-101 ) Name Organisation Date Agreed The MDT Policy agreed on Date Agreed Operational Policy Review Date 4
MDT Evidence Guide - Operational Policy Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Introduction Confirm locality which MDT is part of and population served. Declare the cancer types the team deals with, e.g. does the team treat early rectal cancer or anal cancer? Attach your team s patient pathways. Purpose of MDT Describe the aims & objectives of the MDT. MDT s objectives may include - implementation of IOG, working to agreed NSSG guidance, undertaking service improvement, participating in audit, including agreed NSSG audits. Leadership Arrangements & Responsibilities 10-2D-101 State name of MDT clinical lead and detail agreed responsibilities of clinical lead. The agreement is between the MDT lead clinician and the lead clinician of the host trust. Membership Arrangements 10-2D-102 State names and professional roles of each core team member. State the name of individual responsible for integrating recruitment of patients into clinical trials and person responsible for patient information and patient / carer issues. Useful to describe any division of oncologists role and responsibilities. The colonoscopist can be one of the core members but does need to be specifically named. 10-2D-108 State the cover arrangements for each core member. 5
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) 10-2D-122 State names and professional roles of each extended team member. The list may include other optional members such as bowel screening team members. Extended members need not carry the regular patient workload from the MDT but should be a communication conduit between the service specialty and the colorectal MDT. Useful to describe in operational policy if extended members are invited to the operational meetings and how the MDT communicates policy decisions. The extended membership for a team specialising in anal cancer should include; gynaecologist with a surgical practice in the treatment of vulval cancer; Please refer to annual report for the core membership list of the liver resection MDT and the network list of people judged competent in lower intestinal stenting. plastic surgeon. 10-2D-118 Detail of core nurse members specialist study. Summarise specialist qualifications, these should include accreditation of at least 20 credits at first degree level. 10-2D-119 10-2D-120 Detail the agreed responsibilities for core nurse members. If agreement not demonstrated through attendance at the meeting where the operational policy was agreed, then further agreement needs to be shown. 10-2D-121 State the expectation that core members of the team who have direct clinical contact with patients should have attended the national advanced communications skills training. Please refer to annual report for progress against this. Consider all members that have direct contact, e.g. this may include interventionalist radiologists. Diagnostic Services 10-2D-114 Provide confirmation that core histopathological members are taking part in a general histopathology EQA and detail whether this includes colorectal pathology. 10-2D-133 State agreement to network investigation protocol for colorectal cancer. 6
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) The MDT Meeting 10-2D-107 10-2D-109 Confirm frequency, time and duration of MDT meetings and arrangements for recording attendance. Detail policy for dealing with patients that require a treatment decision before next scheduled meeting. 10-2D-111 Detail policy whereby it is intended that all new cancer patients will be reviewed by the MDT. 10-2D-127 Include details of the system used for recording MDT decisions and for circulating these. 10-2D-113 Outline the policy for allocation of the key worker. 10-2D-112 Outline policy whereby after a patient is given a diagnosis of cancer, the patient's general practitioner (GP) is informed of the diagnosis by the end of the following working day. Please refer to annual report for full compliance where a summary of attendance should be given. Useful to describe procedure for reviewing and feeding back MDT attendance. Outline requirements for attendance (e.g. in person, via video link) Useful to also include details of which patients are routinely discussed at MDT, how list for discussion is compiled and arrangements for identifying patients suitable for clinical trials. Useful to describe any governance policy that provides assurance that all patients are discussed. Attach a template to show an example of a meeting record. Do not upload any potentially patient identifiable information onto CQuINS. When patients are referred to other teams e.g. anal cancer then this MDT should be specifically stated. If the team receives referrals from other MDTs it should describe the process for the communication of the MDT outcome. For full compliance refer to annual report for summary of patient notes audit of this policy. Useful to include details of handover arrangements when patients are transferred between teams. Describe audit plans. Details of the audit of this to be included on annual report. 7
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) 10-2D-110 Outline arrangements for the MDT operational policy meeting. Referral Arrangements 10-2D-116 State agreement to network secondary to secondary referral policy. Patient and Carer Information, Feedback & Involvement 10-2D-123 Outline arrangements for patients to be offered permanent record of consultations. 10-2D-124 10-2D-125 State the arrangements for the undertaking and reporting of the patient experience exercise. 10-2D-126 Details of the type of information offered to patients. Relationship with NSSG 10-2D-106 Confirm arrangements for the lead clinician or nominated MDT representative to attend the NSSG meetings. This meeting should be at least annually. Useful to keep a record of who was invited and attended. Include date, version number and links to the policy where appropriate. Also see section on network guidelines including anal cancer and laparoscopic colorectal cancer surgery. This may differ in different parts of the pathway, e.g. letters in some areas and taped consultations in another. This could be in the form of a survey, interview or focus group. Participation in the national cancer patient survey will be accepted for these measures. Refer to annual report for the results. Useful to state if the intention is to perform across an organisation or network. Ensure that the four elements described in the measure are covered. Examples of information should be available for internal validation and peer review visits. Please refer to annual report for full compliance where a summary of attendance should be given. Useful to describe communication arrangements between the MDT and the NSSG. If referral pathways cross network boundaries state whether policy communication is undertaken between the NSSGs or via the MDT to each NSSG. 8
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Data Collection 10-2D-134 Define and state agreement to the NSSG minimum dataset. Attach/link to the NSSG MDS 10-2D-135 Provide anonymised example or a template of the data proforma. Network Referral and Treatment Guidelines (including palliative care) 10-2D-115 10-2D-117 State agreement to NSSG agreed guidelines (attach or link to the full network guidelines) Management of surgical emergencies. Network list of named personnel judged competent for colorectal stenting. 10-2D-128 Network colorectal clinical guidelines. 10-2D-129 Network anal clinical guidelines. 10-2D-130 Network liver resection clinical guidelines. 10-2D-131 Network anal referral guidelines. 10-2D-132 Network liver resection referral guidelines. Network Audit 10-2D-136 Define and state agreement to the network audit project. 10-2D-137 Describe the arrangements for the MDT to review the progress or present the results of the network audit to an MDT meeting. Research 10-2D-138 Define and state agreement to the NSSG approved list of clinical trials and other well designed studies. 10-2D-139 Agree to produce a remedial action plan with the agreement of the NSSG. Do not upload any potentially patient identifiable information onto CQuINS. Reference should be made to version and date of the guidelines. This must include details on management of surgical emergencies, secondary to secondary referral. It may be considered acceptable to refer to some national or international guidelines. If these are considered appropriate then details should also be provided of a local context demonstrating how a patient moves through the pathway specifically naming MDT teams where appropriate. Refer to annual report for results of this. Refer to annual report for results of this. Each trial on the list should be reflected upon by the MDT. 9
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Workload 10-2D-140 Outline the arrangements for evaluating the workload of the annual number of new cancer case discussions at the MDT. 10-2D-141 Outline the arrangements for evaluating the workload of the individual core surgical members. Anal Cancer MDTs 10-2D-105 State if the MDT is formally nominated in the network agreement to receive referrals and to treat anal cancer. 10-2D-103 State which surgical core members under whose care all operations for anal cancer are performed for the MDT. 10-2D-104 State which consultant clinical oncology core members under whose care all curative chemotherapy and or radiotherapy for anal cancer are performed for the MDT. 10-2D-142 Designated anal cancer MDTs should state the arrangements that radiotherapy practice should be restricted to no more than two clinical oncologists. Refer to annual report for results of this. Refer to annual report for results of this. If the MDT is not formally designated by the network and does not treat anal cancer with curative intent then this measure should be assessed N/A. The list of core members of the MDT should be provided. It is expected this will be no more than two surgeons. Operations refers to perineal salvage surgery and not the simply the formation of stoma which other surgeons will also do. If the MDT is not formally designated by the network and does not treat anal cancer with curative intent then this measure should be assessed N/A. The list of core members of the MDT should be provided. If the MDT is not formally designated by the network and does not treat anal cancer with curative intent then this measure should be assessed N/A. The list of core members of the MDT should be provided. If the MDT is not formally designated by the network and does not treat anal cancer with curative intent then this measure should be assessed N/A. 10
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Laparoscopic Colorectal Cancer Surgery 10-2D-143 Outline the policy for the MDT whereby all patients who fulfill the agreed network criteria should be offered the option of laparoscopic surgery as an alternative to open surgery for the surgical treatment of their cancer. 10-2D-144 Indicate whether the MDT has a core colorectal cancer surgeon trained on the national laparoscopic colorectal cancer surgery programme or if any members are exempt. 10-2D-145 State agreement to abide by the network policy and referral guidelines on laparoscopic colorectal cancer surgery. Agreements Include the date that this policy was agreed by the MDT. Confirm agreement by all core team members and trust s lead cancer clinician. Appendices 1. Patient pathway 2. List of clinical trials & studies (or electronic link to these) 3. All NSSG Agreed Clinical Guidelines (or electronic link to these) 4. Example record of MDT Meeting 5. NSSG Agreed Minimum Dataset (or electronic link to these) Please refer to annual report for further evidence. This applies to all colorectal MDTs even if they do not have trained or exempt members. These can be found on the cover sheet of the evidence guide. 11
Work Programme - Agreement Cover Sheet This Work Programme has been agreed by: Position MDT Lead Clinician Name Organisation Date Agreed The MDT members agreed this Work Programme on Date Agreed Work Programme Review Date 12
MDT Evidence Guide - Work Programme Category Link to Measure Guidance for Compliance (please also refer to full details of the measure) Each area of the work programme should include dates for review, implementation and a named lead. It should principally include things that need working on. Any areas identified as deficient in the measures should be considered for inclusion in the MDT s work programme. Service Improvement & Development Outline the MDT s agreed service improvement action plan. Include details of how the team is planning to address any weaknesses in service delivery and/or the constitution & function of the MDT. It is important that the service improvement aspects of this work programme are aligned with the relevant national and local service improvement priorities. Patient and Carer Feedback & Involvement 10-2D-102 10-2D-126 10-2D-124 10-2D-125 Include details of planned work regarding learning from and acting on patient feedback. Conduct, present and make recommendations from a patient experience exercise. Consider including summary of report from the core member responsible for patient information and user issues. This could be in the form of a survey, interview or focus group. Participation in the national cancer patient survey will be accepted for these measures. The MDT Meeting 10-2D-107 Record and evaluate MDT attendance. 10-2D-108 10-2D-109 10-2D-110 Hold operational policy meeting at least annually to agree and record at least some operational policies. 10-2D-127 Review MDT documentation. 10-2D-113 10-2D-123 13
Category Link to Measure Guidance for Compliance (please also refer to full details of the measure) Relationship with NSSG with NSSGRelationship with NSSG 10-2D-106 Attendance at NSSG. Lead Clinician or nominated representative. 10-2D-115 10-2D-116 10-2D-128 10-2D-129 10-2D-130 10-2D-131 10-2D-132 10-2D-133 Contribution to the review of Network referral and clinical guidelines. Training Needs of MDT Members 10-2D-117 Consider if any other following skills are required; stenting; 10-2D-144 laparoscopic colorectal cancer surgery; 10-2D-118 nursing qualifications; 10-2D-121 advanced communications course; 10-2D-114 EQA participation. Data Collection 10-2D-135 Collect the network agreed minimum dataset. Consider participation in the national bowel cancer audit. Audit 10-2D-112 Conduct an audit of the MDT s policy to notify the GP of the communication of a cancer diagnosis to the patient. Include details of the MDT s audit programme / outstanding actions from previous audits 10-2D-136 10-2D-137 Consider MDTs contribution to the Network audit project. Discuss the progress or results at an MDT meeting. Include details of planned actions in relation to any relevant national audit programmes. Consider any equity or governance issues. 14
Category Link to Measure Guidance for Compliance (please also refer to full details of the measure) Research 10-2D-138 Agree to a NSSG approved list of trials. 10-2D-139 Outline of any agreed actions arising from MDT s recruitment results. Annual Report Produce an MDT annual report. Reflect on all measures and also include workload and performance data. 10-2D-140 Include details of the number of confirmed new colorectal cancer cases discussed by the MDT per year. 10-2D-138 Workload by named surgeon. Actions from Previous Peer Review Assessments Include any agreed actions arising from previous peer review, external verification or internal validation of self-assessment. Agreements Confirm date when work programme was agreed by MDT. Comment on each trial. 15
MDT Annual Report - Agreement Cover Sheet This Annual Report has been agreed by: Position MDT Lead Clinician Name Organisation Date Agreed The MDT members agreed this Annual Report on Date Agreed Annual Report Review Date 16
MDT Evidence Guide - Annual Report Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) The Annual Report needs to reflect things that have changed in the previous year, not re-affirm what has already occurred. For example, the nurse s qualifications. If he/she got a new one in the year it should be included, it is there is no need to re-affirm previously achieved qualifications of this has already featured in the evidence. Introductions and Purpose of the MDT Include short narrative giving a summary assessment of the team s achievements and challenges faced over the previous year. Define period report relates to (i.e. state year covered). This period of time should be the same across the network to allow comparisons to be drawn. Membership Arrangements 10-2D-102 10-2D-108 10-2D-122 Reflect on any gaps in the core, cover and extended MDT membership. Describe the impact of any gaps and any remedial action plan, link to work programme if appropriate. Include the core membership list of the liver resection MDT and the network list of people judged competent in lower intestinal stenting. 10-2D-118 Detail core nurse member s specialist study. Summarise specialist qualifications. Evidence required that the 20 credits were attained at level 3. If the course has not yet been completed then it is useful to describe enrolment and progress. Certificates should be available to view at the visit. 10-2D-121 Provide evidence that each core member of the team who has direct clinical contact with patients has attended the national advanced communications skills training. Provide name, role and date of the course for those members that have attended. Also provide list of eligible members who have not yet attended and indicate if they have a planned date for attendance. Certificates should be available to view at peer review visits. 17
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Diagnostic Services 10-2D-114 Detail each core histopathologist s participation with the EQA scheme with dates. The MDT Meeting 10-2D-107 10-2D-108 10-2D-109 MDT attendance - Include a breakdown of attendance by named core member and by specialism for MDT meetings over the previous year. 10-2D-111 Policy for all new patients to be discussed by the MDT - describe any review of a governance policy that provides assurance that all patients are discussed. 10-2D-113 Key worker - if an audit has been done to evaluate the policy of key worker allocation this should be included. 10-2D-112 Audit of timeliness of diagnosis notification to GPs. Provide the results of the audit that has been performed to assess whereby after a patient is given a diagnosis of cancer, the patient's general practitioner (GP) is informed of the diagnosis by the end of the following working day. 10-2D-111 Include details of meetings of the MDT over the previous year, used to discuss, review, agree and record at least some operational policies. If the course has not yet been completed then it is useful to describe enrolment and progress. Certificates should be available to view at the visit. The summary also needs to be displayed by meeting date so that group role, personal attendance and cover arrangements are demonstrated. If video-conferencing technology is being used then comment if this has worked well, or indicate any problems encountered. Reviewers will need to spot check the patient s case notes at the peer review visit. Include audit methodology. Useful to show agenda, attendance and outcomes. 18
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Patient and Carer Information, Feedback & Involvement 10-2D-123 Reflect on the arrangement for the provision of an opportunity of a permanent record or summary of at least a consultation between the patient and the doctor. 10-2D-124 10-2D-125 Include details of the work that this MDT has undertaken to gain feedback from its patients. Include details of the outcome of this work and what changes have taken place to service delivery as a result. 10-2D-126 Useful to include a report from the core member responsible for user issues and patient information. Relationship with NSSG 10-2D-106 Include details of the team s attendance over (at least) the last years NSSG meetings. Network IOG Action Plan (where relevant) Reviewers will need to see examples at peer review visit. This could be in the form of a survey, interview or focus group. Participation in the national cancer patient survey will be accepted for these measures. Useful to state if this was undertaken across an organisation or network. Consider including update on development and whether the information prescription is in use. Reviewers will need to check the patient information at the peer review visit. Provide the NSSG attendance record highlighting the MDT representation. If referral pathways cross network boundaries and if the MDT deals with other NSSGs out of their network (rather than NSSG to NSSG communication) then details should be provided. Include summary (if relevant) of implementation of changes to service delivery in line with agreed network IOG plans. 19
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Network Referral and Treatment Guidelines (including palliative care) 10-2D-115 10-2D-117 NSSG agreed guidelines. Management of surgical emergencies. Network list of named personnel judged competent for colorectal stenting. 10-2D-128 Network colorectal clinical guidelines. 10-2D-129 Network anal clinical guidelines. 10-2D-130 Network liver resection clinical guidelines. 10-2D-131 Network anal referral guidelines. 10-2D-132 Network liver resection referral guidelines. Data Collection 10-2D-134 Report on completeness of data of agreed NSSG minimum dataset. Network Audit 10-2D-136 10-2D-137 Include details of the audit projects the MDT had participated in over the previous year, indicating which ones are agreed NSSG audits. Give date when results of NSSG audit where presented by this MDT to the NSSG (if this has happened). Research 10-2D-138 10-2D-139 Include details of recruitment into each of the agreed NSSG clinical trials and remedial actions agreed with NSSG arising from the MDTs recruitment results. Reference should be made to version and date of the guidelines. Include details of plans for revision of the guidelines and state how the MDT will contribute to the update. If any audits have been undertaken to show adherence to the guidelines include these. Although not a specific requirement it would be useful to include details of progress with the national bowel cancer audit. Include update on the team s participation in any established national audit programme. Report on data completeness and specified clinical outcomes. It is useful to also provide summary details of the outcomes of completed audit projects, and what changes to service delivery have taken place as a result. Consider equity issues for this MDT compared to others in the network. 20
Category Link to Measure Guidance for Compliance* (please refer to full details of the measure) Workload of MDT / Cases Discussed 10-2D-140 Include details of the number of confirmed new colorectal cancer cases discussed by the MDT per year. 10-2D-141 Anal Cancer MDTs 10-2D-103 10-2D-104 10-2D-105 The list of the core members of the MDT should be provided indicating which oncologists and surgeons treat the patients with anal cancer. Laparoscopic Colorectal Cancer Surgery 10-2D-142 10-2D-143 10-2D-144 Reflect on the availability and development of laparoscopic colorectal cancer surgery. 10-2D-145 Agreements Confirm date when MDT agreed this report. Include details of the number of patients treated (over previous year) by treatment type. This should be calculated and averaged over two complete years. The summative figure is required for compliance but ideally this should documented by the number of; rectal cancers; colon cancers; anal cancers. Although not a specific requirement it would be useful to include details from bowel screening and also cancer waiting times performance. Include surgical workload by named surgeon. 21
Appendix 1 - Internal Validation Report () Network Trust MDT Date Self Assessment Date of IV Review Lead Clinician Compliance MDT Self Assessment % Internal Validation Key Questions With reference to the guidance on answering the key questions, provide comments including details of strengths and areas for development and overall effectiveness of the team. Any specific issues of concern or good practice should also be noted in the following section. Does the team demonstrate that this is a properly constituted and functioning MDT? (Consider leadership, membership, attendance, operational policies, workload etc...) % Does the team demonstrate that it has effective systems for providing coordinated care to individual patients? (Consider patient pathways, communication, clinical guidelines etc...) Does the team demonstrate that it has adequate information to help improve service delivery? (Consider data collection, audit activity, how feedback from patients is obtained etc...) Does the team demonstrate that it is continuously improving its service including both clinical effectiveness and the patient experience? (Consider outcomes from audit activity and patient feedback, include any recent achievements/developments etc...) Key Evidence Submitted Provide comments and details of strengths and areas for development Operational Policy Annual Report Work Programme 22
Good Practice Identify any areas of good practice. Good Practice/Significant Achievements Concerns Refer to the guidance on identifying concerns. Any immediate risks or serious concerns must be brought directly to the attention of the zonal team. Immediate Risks: Serious Concerns: Concerns: General Comments: Summary of validation process: Provide details of the method used to validate the Self Assessment together with names of panel members if appropriate. Organisational Statement I (insert name of validation chair) on behalf of (insert name of organisation) agree this is an honest and accurate assessment of the (insert name of team) MDT/Service. Agreed by Chief Executive Date 23
Designed and produced by Cynergy 01642 713211 www.cynergy.co.uk All rights reserved Crown Copyright 2008 National Cancer Action Team