National Cancer Peer Review ProgrammeLouise WilsonQuality ManagerNorth Zone

Aims of TodayAims of Today

The New Healthcare EnvironmentThe New Healthcare Environment

Reducing the Burden of Peer Review on Reducing the Burden of Peer Review on the NHSthe NHS

The key actions are:

• Reducing the measures - To further reduce the number of measures within the manual for cancer services by 10%.

• Amalgamate Reports - Where possible amalgamate measures to reduce the number of reports required i.e. locality and MDT measures.

• Biennial Submission of Evidence - evidence for the annual SA should be submitted biennially, teams/services should instead complete a commentary in relation to the key questions each year along with the SA against compliance with the measures. The exception to this would be teams performing below 50% compliance or with unresolved immediate risks.

Reducing the Burden of Peer Review on Reducing the Burden of Peer Review on the NHSthe NHS

 • Targeted Peer Review Visits – Visits will only be undertaken where

a team/service: – Falls into the risk criteria– Where there is considered to be an opportunity for significant

learning – As part of a small stratified random sample to assure public

confidence in SA and IV.

What is Cancer Peer Review?What is Cancer Peer Review?

• A quality assurance process for cancer services.

• An integral part of Improving Outcomes – A Strategy for Cancer

• Assesses compliance against IOG for NHS patients in England.

• A driver for service development and quality improvement

• Supported by a set of measures

Aims of Cancer Peer ReviewAims of Cancer Peer Review

Outcomes of Peer ReviewOutcomes of Peer Review

The Peer Review ProgrammeThe Peer Review Programme

The National ScheduleThe National Schedule

Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May

Notification of visit Programme

Prepare for visit complete Self Assessment

Peer Review VisitsFrom May to March

Complete Internally Validated Self Assessment

Targeted External

Verification

Feedback to teams

Notification of visit Programme

Complete Self AssessmentA team either has a peer review visit or completes a self assessment.

Measures DevelopmentMeasures Development

• Developed by an expert group • Aimed to measure areas detailed in the National

documentation e.g. NICE Improving Outcomes Guidance and National reports such as NCAG and NRAG reports.

• 3 month consultation on new measures

• The commissioning of services

• Inter-professional communication

• Co-ordination of care

• User Involvement

• User/carer experience

• Information

• Access to services

Focus for the MeasuresFocus for the Measures

New MeasuresNew Measures

TopicSo

Consultation Closes

Publication Date

Commence Peer review

Comments

Brain&CNSImp

31st March Apr-11 2011 Out to Consultation

Sarcoma

Impr

16th May May-11 2011 Out to Consultation

Acute Oncology

Nati

NA Mar-11 2011 Waiting Gateway Approval

Chemotherapy

Nati

Closed Mar-11 2011 Editing Meeting 7th March

Patient Partnership MeasuresUser

NA Mar-11 2011 Awaiting Gateway Approval

TYAImp

5th April Apr-11 2011 Out to Consultation

The Process

The Self Assessment ProcessThe Self Assessment Process

Self Assessment ReportSelf Assessment Report

Self Assessment Report – Key ThemesSelf Assessment Report – Key Themes

Self Assessment ReportSelf Assessment Report

• Will be a public document

• Will form basis of Annual Peer Review Report for those teams not subject to internal validation

• Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns

Chemotherapy Service- Chemotherapy Service- Evidence Documents (only required Evidence Documents (only required every other year)every other year)

Operational Policy

Annual Report Work Programme

Describing how the service functions and how care is delivered across the patient pathway

Outlining policies/processes that govern safe / high quality care

Agreement to and demonstration of the clinical guidelines and treatment protocols for team.

Summary assessment of achievements & challenges

Demonstration that the service is using available information (including data) to assess its own service - Workload & Activity Data

-National Audits-Local Audits-Patient Feedback-Trial Recruitment-Work Programme Update

How the team is planning to address weaknesses and further develop its service.

Outline of the teams plans for service improvement & development over the coming year

-Audit Programme-Patient feedback-Trial Recruitment-Actions from Previous reviews

Demonstrating Demonstrating AgreementAgreement

• Where agreement to guidelines and policies is required there should be a statement on the front cover of the document indicating the groups and individuals that have agreed the document and the date of agreement.

• Evidence Guides will indicate the groups and individuals that need to be documented as agreeing the key evidence documents.

Evidence GuidesEvidence Guides

Internal Validation Internal Validation – The Purpose– The Purpose

Who Validates?Who Validates?

Service Responsibility for ValidationMDT Host Trust

Cross Cutting Service Host Trust

Locality Group Host Trust

NSSG Host Network Management Team

Network Cross Cutting Group Host Network Management Team

Internal Validation – Internal Validation – What we ExpectWhat we Expect

Internal Validation – Internal Validation – Suggested ApproachesSuggested Approaches

Internal Validation – Internal Validation – The ProcessThe Process

The Internal Validation The Internal Validation ReportReport

• Will be a public document

• Will form basis of Annual Peer Review Report for those teams not subject to external review

• Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns

Using CQuINS V4Using CQuINS V4

Available via the web site at: www.cquins.nhs.uk

• Secure web based database supporting each stage of the cancer peer review process

• Records assessments, compliance with the measures and reports

• Provides information for national analysis and reporting

Completing the Self AssessmentCompleting the Self Assessment

1. Upload Key Documents - (Alternate years only)

2. Enter Compliance on CQuINS

3. Complete Team Report

Completing the Self AssessmentCompleting the Self Assessment

1

2

1 Upload Key Documents1 Upload Key Documents

1

2

3

Enter Compliance Enter Compliance

Enter Compliance Enter Compliance 1

23

4

Complete Overview ReportComplete Overview Report

Self Assessment - EvidenceSelf Assessment - Evidence

Key Documents -teams/services should ensure the evidence requirement stated for each measure is included either in one of the key documents i.e. operational policy, annual report, work programme or if not in one of these key documents it should be included as an appendix.

Additional Evidence -If the actual evidence is not included in the upload documents on CQuINS then the team should include a statement which makes clear this evidence requirement has been checked by the team/service and would be available if a peer review team were to visit. Use of Internet Hyper-links - it is acceptable for teams/services to include internet hyperlinks but these links must have open access and not be on the closed section of the trust or organisation intranet system.

Internal Validation - EvidenceInternal Validation - Evidence

• Key Documents - Ensure all the evidence required against the measures for a team/service has been checked and is available on the CQuINS database via the key documents.

• Additional Evidence - If any evidence is not available on the CQuINS system, the internal validation panel should confirm they have seen the evidence or give details of the spot checks they have undertaken.

• Confirmation - This should be made clear on the internal validation report form. It is not sufficient to give an overall statement that all evidence has been seen. Details of the specific evidence seen against measures should be identified and noted on the compliance spreadsheet.

Peer Review Visit - EvidencePeer Review Visit - Evidence

• Key Documents - A full copy of all evidence uploaded onto CQuINS must be available to reviewers on the peer review visit. This can be either hard copy or electronic.

• Patient Records - Peer Review zonal teams will normally request 5 sets of patient notes in order to check compliance against the measures. Teams may sometimes require more than 5 set of patient notes but this should never exceed 10. Only clinical NHS staff will review patient notes.

General PrinciplesGeneral Principles

Personal details / Patient information •It is essential that no identifiable patient data including hospital number should be uploaded on the CQuINS database.

 •The personal details of individual staff in a team/service should not be uploaded e.g. certificates or job plans.

•Identification of individuals should not be made on reports uploaded onto CQuINS. Reports should refer to the roles they carry out.  

General PrinciplesGeneral Principles

Agreements•The role of the person indicated on the agreement should include any delegated role they are undertaking for others.

•The front cover of any document uploaded should show the date, version and planned review date.

 

General PrinciplesGeneral Principles

Configuration of the Network•The configuration of the network is essential to the review of a particular tumour site and ensuring compliance against the Improving Outcomes Guidance. Details of PCT referral pathway and populations are essential.

 

Membership•When a measure asks for the membership of a group then the name, role and organisation the individual represents should be indicated on the evidence.

General PrinciplesGeneral Principles

Patient Information•Does not require uploading on CQuINS

•Copies available for IV panel and Peer Review Team 

•The IV report should confirm that the patient information has been seen and that it covers all the essential elements of the measure.

•At self assessment the team/service should list the patient information they have in the key documents uploaded on CQuINS. 

Patient Experience Exercise•A summary of the exercise including the key points and action implemented is sufficient in the key documents.

•A copy of the patient exercise should be seen available for both peer review and IV

•IV assessment should confirm this has been seen.

•The national cancer patient survey would be acceptable for this measure. 

Specific Evidence Requirements

Working practice of a team/Spot checks•Where measures ask for reviewers to ask about working practice of teams/services or to undertake spot checks, they will do this when on a review. •IV should mirror this and include comments in the IV report. •For self assessment teams/services should state that they have completed a spot check and the results of the spot check or give details of the working practice.

 

Annual Meetings•It is only necessary to make a statement in the key documents to confirm the time/date of the meeting and that a record has been made. •IV should confirm this meeting has taken place. •If it is unclear that a meeting has taken place reviewers on a peer review visit may ask for minutes of the meeting.

 

Specific Evidence RequirementsAttendance records /Meeting dates

This can often be satisfied by one clear piece of evidence showing:•Dates of the meetings•Name, role and organisation represented of those who have attended each meeting•The SA report form should comment about any roles not covered or attending appropriately. •Any summaries of attendance should demonstrate individual attendance at each meeting for all members as well as the summary.

Policies /Guidelines/Plans •The date and version should be shown on all policies/guidelines and plans. •These should be uploaded on CQuINS either as an internet hyperlink (see above) within the key documents or in the appendix. •National guidelines should have been adopted the local context should be explained. •Flow charts are an acceptable means to explain details within guidelines.•If it is unclear that a meeting has taken place to sign off the guidelines/policies and plans reviewers on a peer review visit may ask for minutes of the meeting.

 

 

External VerificationExternal Verification– The Purpose– The Purpose

External Verification External Verification – The Process– The Process

Annual Meeting Annual Meeting with Networkwith Network

• December each year

• The purpose of the meeting will be to;– inform the Zonal team of key issues within the

Network such as implementation of Improving Outcomes Guidance, Service Configuration changes

– discuss the teams to be visited and schedule for the

following year.

Peer Review Visit CriteriaPeer Review Visit Criteria

Notification in January to teams to be

peer reviewed during May -

March

Deadline for submission of evidence for

all teams to be visited

Self Assessment evidence and compliance

matrix sent to reviewers and

copied to teams

Visits MAY-MARCH

Each Network is allocated one month. Can

take from 1 to 4 weeks to

complete a Network –

normally 1 day per Locality

Report published 8 weeks after last review

day

January- 2 Weeks- 4 WEEKS

The Peer Review Visit Plan

Preparation for review

+ 8 WEEKS

Peer Review TeamsPeer Review Teams

• Between 2 and 5 reviewers per session

• Plus a member of the Zonal Quality Team

• Reviewers should normally include “Peers”

– people who are trained and working in the same discipline as those they are reviewing

Outcomes Outcomes from the Processfrom the Process

• Annual Network Reports

• National “State of the Nation” Reports

• Joint Working between the Care Quality Commission (CQC) and the NCPR Programme

• Information for commissioners

Outcomes of the Process – Network Outcomes of the Process – Network ReportsReports

• Published January and June each year

• Including IV, EV and PR Visit Assessments

• Executive Summary from Quality Director

• QD will discuss key issues with Network

Next StepsNext Steps

• Revised measures published on CQuINS

• Revised Handbook

• Evidence guides

• Evidence documents

• Reports

2011/12 (INTRODUCTION YEAR) 2012/13 (EVEN YEARS) 2013/14 (ODD YEARS)Acute Oncology

Breast Acute Oncology

Chemotherapy

Lung Chemotherapy

Teenage and Young Adults

Colorectal Teenagers and Young Adults

Sarcoma

Upper GI Sarcoma

Brain and CNS

Head and Neck Brain and CNS

Gynaecology

Skin Gynaecology

Urology Cancer Research Network Urology

Network Service User Partnership Group

Radiotherapy Network Service User Partnership Group

Rehabilitation

Children’s

Complementary Therapy Cancer of Unknown Primary

Psychology

Specialist Palliative Care

Haematology

Schedule of Teams for Schedule of Teams for Internal ValidationInternal Validation

Thank YouThank You

Any Questions ?Any Questions ?