National Cancer Peer Review Programme Evidence … · National Cancer Peer Review Programme Evidence Guide for: Breast MDT Intelligence National Cancer Action Team Part of the National

National Cancer Peer Review Programme

Evidence Guide for: Breast MDT

Intelligence

National Cancer Action TeamPart of the National Cancer Programme

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National Cancer Peer Review Programme | Evidence Guide | Breast MDT

This evidence guide has been formulated toassist Networks and their constituent cancerservice teams in preparing supportingevidence for peer review. The contents of thisguide are not exhaustive and organisationsshould continue to tailor their policies toreflect activity of the respective team, whilstdemonstrating compliance with the qualitymeasures. Networks and their constituentteams during the review process will berequired to demonstrate ownership of allpolicies, and assure visiting Review Teamsthat policy is reflective of practice.

Agreement

Where agreement to guidelines, policies etcis required this should be stated clearly onthe cover of the relevant evidence documentincluding date and version. Similarly,evidence of guidelines, policies etc requireswritten evidence unless otherwise specified.The agreement by a person representing agroup or team (chair or lead, etc) implies thattheir agreement is not personal, but thatthey are representing the consensus opinionof that group.

Confirmation of Compliance

Compliance against certain measures will bethe subject of spot checks or furtherenquiries by peer reviewers when a peerreview visit is undertaken. When self assessing against these measures astatement of confirmation of compliancecontained within the relevant key evidencedocument will be sufficient.

Foreword

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1. Rationale

In 2008 the SHAs review of theNational Cancer Peer Review(NCPR) programme concludedthat there should be a strongerfocus on clinical issues in order tomake the reviews clinicallyrelevant and to sustain thecontinued support andinvolvement of clinical staff. Itwas therefore decided tointroduce clinical lines of enquiryinto the review process in order tofacilitate this focus.

The introduction of these lines ofenquiry is also important in orderto align Peer Review with furtherdevelopments since thepublication of the measures, forexample the increase in the rangeof possible diagnostic andtreatment interventions;subsequent guidance issued byNICE; to support the overall aimsof Improving Outcomes: AStrategy for Cancer and keep instep with the commissioningfunction of cancer services.

2. Clinical Indicators

NB: Please note that theindicators for 2011 - 2012 remainthe same as those for the previousyear pending the evaluation ofthe 2010 – 2011 pilot for BreastClinical Lines of Enquiry.

Discussions with the Site SpecificClinical Reference Group (SSCRG)Chair, members of the SSCRG,National Cancer IntelligenceNetwork (NCIN) and NCPRresulted in the development ofindicators relating to thefollowing areas:

Nationally available data

• Percentage of women offeredaccess to immediatereconstruction surgery by MDTor by referral onto anotherteam and rate of uptake

• Ratio of mastectomy to BreastConserving Surgery (BCS)

• Each surgeon managing at least30 new cases per year

• Average length of stay forbreast cancer with any surgicalprocedure

• The one-, two- and five-yearsurvival rates

Local data

• Proportion of women tested forHER2 prior to commencementof drug treatment (ifundergoing resectional surgeryand receiving adjuvant or neo-adjuvant chemotherapy)

• Availability of Screening andestimated impact on workload

• Availability of Digitalmammography

3. Data

Information relating to the abovewill be completed by NHS Truststhrough existing monitoringsystems, with national dataprovided where available andrelevant to discussions by theNational Cancer StatisticalAnalysis Team (NATCANSAT), theNational Cancer IntelligenceNetwork (NCIN) and CancerRegistries. The National data hasbeen refreshed where available.Although the indicators for 2011 -2012 remain the same as those forthe previous year pending the

evaluation of the 2010 – 2011pilot for Breast Clinical Lines ofEnquiry, teams should makecommentary on their current datain relation to 2010 – 2011 for eachof the national and localindicators.

4. Clinical Lines of Enquiry

A briefing sheet on the relevanceof these headline indicators willbe available both to the ZonalNational Cancer Peer Reviewteams and to MDTs and NSSGs.This will structure the discussionson the data on a Peer Review visitwhich will take place at the timeof the formal review against theManual for Cancer Services andalso acts as a guide for thoseteams completing self-assessmentreports.

As part of self-assessment, MDTsand NSSGs should include acommentary on the clinicalindicators in their Annual Report,and in the self assessment reportunder the Key Theme ‘Clinicaloutcomes/indicators’. Acommentary on the clinical linesof enquiry will also be included inthe Peer Review reports.

Where national data is availablethis will be provided to both thereview teams and the servicebeing reviewed to enablediscussion against the clinicalindicators. If local data is requiredto enable discussion against theclinical indicators this may beuploaded, where relevant, as anappendix in the Key EvidenceDocument section (‘Clinicaloutcomes/indicators’) on theCancer Quality ImprovementNetwork Systemwww.cquins.nhs.uk (CQuINS).

Clinical Lines of Enquiry

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Introduction

With reference to theguidance on Key Themes,when completing a report,please provide commentsincluding details of strengths,areas for development andoverall effectiveness of theteam. Any specific issues ofconcern or good practiceshould also be noted. It isimportant to demonstrateany measurable change inperformance compared toprevious assessments.

Breast MDT Key Themes:

1. Structure and function of theservice

Comment in relation toleadership, membership,attendance and meetingarrangements, MDT and surgicalworkload. In addition, anymeasures within the operationalpolicies section regarding patientswhich are reviewed by the MDT,percentage of time MDT coremembers devote to this cancertype, training requirements ofMDT members and responsibilitiesof nurse MDT members also helpdemonstrate this. MDT workloaddata and surgical activity is alsoimportant here.

Teams should specificallycomment with regard to thefollowing questions:

• Are all the key core members inplace?

• Does the MDT have a clinicalnurse specialist?

• What is the compliance withwaiting time standards?

• How many patients by equalitycharacteristic (race, age andgender) were diagnosed /treated in the previous year?

2. Coordination of care/ patientpathways

Comment on coordination andpatient centred pathways of care,network guidelines andcommunication. For example, anymeasures relating to agreementof network guidelines and patientpathways, recording of treatmentplanning decisions, key workerand principal clinician policies andcommunication with GPs.

3. Patient experience

Comment on information on andachievement of improvements toservice delivery, patientexperience and gaining feedbackon patients’ experience,communication with andinformation for patients andother patient support initiatives.

It may include informationassociated with enhancedrecovery programmes, 23hr breastsurgery, communication with andinformation for patients andother patient support initiativesand service improvementinitiatives such as processmapping and capacity anddemand analysis.

Information from the NationalCancer Patient Experience Survey

should be included here. It isimportant to demonstrate anymeasurable change inperformance regarding theseparameters, compared to previousassessments. This section of thereport requires specific answersto:

• What are the national patientexperience survey results

• What are the local patientexperience exercise feedbackresults

4. Clinical outcomes/ indicators

Where available, the data fromthe clinical indicators should beused. You should commentseparately on each indicator. It isimportant to demonstrate anymeasurable change inperformance regarding theseparameters, compared to previousassessments.

Comment on any relevantmeasures including any relatingto data collection, relevantnetwork audits and researchactivity.

This section of the report requiresspecific answers to:

• What are the major resectionrates?

• What are the mortality rateswithin 30 days of treatment?

• What is your recruitment totrials?

• Outcomes of any key auditprojects?

Key themes for a Breast MDT

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MDT Operational Policy - Agreement Cover Sheet

The Operational Policy has been agreed by:

Position: MDT Lead Clinician (on behalf of MDT members)

Name:

Organisation:

Date Agreed:

The MDT Operational Policy Agreed on:

Date Agreed:

Position: Trust Lead Clinician for MDT Leadership (08-2B-101)

Name:

Organisation:

Date Agreed:

Operational Policy Review Date:

5

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Category Link toMeasure

Guidance for Compliance* (Please refer to full details of the measure)

Additional Guidance

Introduction Confirm locality which MDT is part ofand Population Served.

Attach team’s patient pathway.

Purpose of MDT Describe the aims & objectives of theMDT

MDTs objectives may include -implementation of IOG, workingto agreed NSSG guidance,undertaking service improvement,participating in audit, includingagreed NSSG audits.

LeadershipArrangements &Responsibilities

11-2B-101 State name of MDT clinical lead anddetail agreed responsibilities of clinicallead

MembershipArrangements

11-2B-101 State names and professional roles ofeach core team member

State the name of individualresponsible for integratingrecruitment of patients intoclinical trials and personresponsible for Patient / Carerissues

11-2B-106 State the cover arrangements for eachcore member

11-2B-118 State names and professional roles ofeach extended team member

11-2B-115

11-2B-116

Details of core nurse members specialiststudy

Detail the agreed responsibilities for corenurse members

11-2B-102 Details of level 2 psychology teammember training

11-2B-112

11-2B-113

For each of the consultant core membersof the MDT state the % of direct patientcare sessions dedicated to this tumoursite.

Provide confirmation that nurse coreMDT members provide at least 50% oftheir time dedicated to breast cancer

MDT Evidence Guide - Breast MDT Operational Policy

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Additional Guidance

DiagnosticServices

11-2B-114 Provide confirmation that corehistopathological members are takingpart in a general histopathology EQAthat includes breast pathology.

The MDTMeeting

11-2B-105

11-2B-109

Confirm frequency, time and duration ofMDT meetings and arrangements forrecording attendance.

Detail policy for dealing with patientsthat require a treatment decision beforenext scheduled meeting.

Detail policy whereby it is intended thatall new cancer patients will be reviewedby the MDT.

Please refer to ANNUAL REPORTfor full compliance where asummary of attendance should begiven.

Outline Requirements forattendance (e.g. in person, viavideo link)

Useful to also include details ofwhich patients are routinelydiscussed at MDT, how list fordiscussion is compiled andarrangements for identifying ptssuitable for clinical trials.

11-2B-122 Include details of the system used forrecording MDT decisions and forcirculating these.

11-2B-111 Outline ‘key worker’ policy For full compliance refer to annualreport for summary of patientnotes audit of this policy.

11-2B-110 Outline policy whereby after a patient isgiven a diagnosis of cancer, the patient'sgeneral practitioner (GP) is informed ofthe diagnosis by the end of the followingworking day.

Details of the audit of this to beincluded on ANNUAL REPORT

Data Collection 11-2B-128 State agreement to the NSSG minimumdataset.

Attach/link to the NSSG MDS

PatientInformation

11-2B-119 Outline arrangements for patients to beoffered permanent record ofconsultations.

11-2B-121 Details of the type of informationoffered to patients.

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Additional Guidance

Treatment(includingpalliative care)

11-2B-123

11-2B-124

11-2B-125

11-2B-126

11-2B-127

State agreement to NSSG agreedguidelines (attach or link to the fullnetwork guidelines)

Agreements Include the date that this policy wasagreed by the MDT / confirm agreementby all core team members and Trust’sLead Cancer Clinician.

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MDT Work Programme - Agreement Cover Sheet

This Work Programme has been agreed by:


Name:

Organisation:

Date Agreed:

The MDT Work Programme Agreed on:

Date Agreed:

Work Programme Review Date:

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Additional Guidance

Each area of the work-programme should include dates for implementation and a named lead.

ServiceImprovement &Development

Outline the MDT’s agreed serviceimprovement action plan

Include details of how the team isplanning to address anyweaknesses in service deliveryand/or the constitution & functionof the MDT.

It is important that the serviceimprovement aspects of this workprogramme are aligned with therelevant national and local serviceimprovement priorities

Patient andCarer Feedback& Involvement

Include details of planned workregarding learning from andacting on patient feedback.

Audit Include details of the MDT’s auditprogramme / outstanding actionsfrom previous audits

Include details of planned actionsin relation to any relevantnational audit programmes

Research 11-2B-130 Outline of any agreed actions arisingfrom MDT’s recruitment results

Actions fromPrevious PeerReviewAssessments

Include any agreed actions arisingfrom previous peer review,external verification or validationof self-assessment

Agreements Confirm date when work-programmewas agreed by MDT.

MDT Evidence Guide - Breast MDT Work Programme

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MDT Annual Report - Agreement Cover Sheet

This Annual Report has been agreed by:


Name:

Organisation:

Date Agreed:

The MDT Annual Report Agreed on:

Date Agreed:

Annual Report Review Date:

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Additional Guidance

Introduction Define period report relates to (i.e.state year covered)

Include short narrative giving asummary assessment of the teamsachievements and challenges facedover the previous year.

Workload ofMDT / CasesDiscussed

11-2B-131 Include details of the number of newcases discussed by the MDT over theprevious year.

Include details of the number ofpatients treated (over previousyear) by treatment type.

Include surgical workload bynamed surgeon.

% and/or numbers of patientsoffered immediate reconstruction

TeamAttendance atNetwork NSSGMeetings

11-2B-104 Include details of the team’s attendanceover (at least) the last years NSSGmeetings.

MDT MeetingAttendance

11-2B-107 Include a breakdown of attendance bynamed member and by “specialism” forMDT meetings over the previous year.

Meetings todiscussOperationalPolicies

11-2B-108 Include details of meetings of the MDTover the previous year, used to discuss,review, agree and record at least someoperational policies.

Training 11-2B-117 Advanced communication skills training Please note the measures differ foreach team in terms of core teammembers who should haveattended the training. Pleaseprovide detail for relevant teammembers regardless of whentraining was undertaken.

11-2B-103 Psychology clinical supervision provision

Network IOGAction Plan

(where relevant)

Include summary (if relevant) ofimplementation of changes toservice delivery in line with agreednetwork IOG plans

Data Collection 11-2B-128 Report on completeness of data ofagreed NSSG minimum dataset

MDT Evidence Guide - Breast MDT Annual Report

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Additional Guidance

National/LocalAudits

11-2B-129 Include details of the audit projects theMDT had participated in over theprevious year, indicating which ones areagreed NSSG audits.

Give date when results of NSSG auditwhere presented by this MDT to theNSSG (if this has happened).

Include update on the team’sparticipation in any establishednational audit programme. Reporton data completeness andspecified clinical outcomes.

It is useful to also providesummary details of the outcomesof completed audit projects, andwhat changes to service deliveryhave taken place as a result.

Audit oftimeliness ofdiagnosisnotification toGPs.

11-2B-110 Include the results of the audit of theoperational policy whereby after apatient is given a diagnosis of cancer, thepatient’s GP is informed of the diagnosisby the end of the following working day.

Patient andCarer Feedback& Involvement

11-2B-120 Include details of the work that this MDThas undertaken to gain feedback from itspatients . Include details of the outcomeof this work and what changes havetaken place to service delivery as a result.

Research 11-2B-130 Include details of recruitment into eachof the agreed NSSG clinical trials andremedial actions agreed with NSSGarising from the MDTs recruitmentresults.

Agreements Confirm date when MDT agreed thisreport

NCAT

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National Cancer Peer Review Programme Evidence … · National Cancer Peer Review Programme Evidence Guide for: Breast MDT Intelligence National Cancer Action Team Part of the National