Presentation to CMO MDs in June 09

Safety and Quality inNI Chemotherapy Service

Regional Review and NCEPOD29th June 2009

Working Towards the Continuous Improvement in the Quality of Cancer Care and Cancer Survival

Aims of presentation

To present initial findings from the Regional Chemotherapy Review baseline assessment and NCEPOD self assessment

To raise awareness of quality issues and major risks in the system and consider necessary leadership responses


Background Decentralisation of chemo 1998 Safe guards, systems and processes RPA Loss of organisational memory Variations in practice Increasing workload New therapies and technologies Patient expectations


Drivers for change NICaN Chemotherapy Group

Patient and professional feedback and audit Need for review and reform of services identified

DHSSPS Cancer Control Programme DHSSPS Cancer Service Framework Standards

Recent National Reports NCEPOD (2008) National Chemotherapy Advisory Group (NCAG)


Regional Chemotherapy Service Review


Regional Chemotherapy Review

The aim is to develop a safe, clinical and cost effective, patient centred, integrated chemotherapy service in line with regional policy, patient and carer expectations and best practice


Key elements of Review Identifying safety and quality issues Appropriateness of treatment

location Current activity levels Workforce review Capacity planning tool Accrual to clinical trials New models of chemotherapy

delivery Cost benefit analysis


Mandate & Process Limited capacity to meet exponential

demand – Cancer Reform Strategy Meet provider and commissioner

needs Project endorsed by NICaN Board Macmillan funded project manager

appointed Jan 09 Steering group established* Baseline assessment underway


Baseline assessment process NCEPOD

Self Assessment (complete)

Stakeholder engagement (Until end of July)


Patient experience feedback Patient metaphors

Its like being on a conveyor belt I’m just a number Its like a cattle market At end of treatment it feels like the bike

stabilisers are removed and you’re pushed off Going through A/E is a nightmare

Lack of systematic information giving and sign posting to other services It’s the luck of the draw – find things out from

other patients


Different groups of patients Patients with chemotherapy

complications Patients who have received

chemotherapy but have other apparently unrelated health issues

Patients with cancer who previously had chemotherapy / radiotherapy who have comorbidites


NI Risk Management Issues Poorly defined acute oncology arrangements *

Timeliness and location of assessment Absence of joint protocols Lack of clarity of roles and responsibilities Strained relationships between A/E and oncology

Weak system for managing chemotherapy complications

Reported Adverse Incidents – learning? Neutropenic sepsis – recognition of and delays in AE Pathways poorly defined – variation in where pt

admitted between centre and units during hours and out of hours


Acute Oncology Defined

Involves clinicians working in AE, acute medicine as well as oncology and related disciplines


NI Risk Management Issues Workforce issues

Limited oncology cover Lack of shared care arrangements Unit with very limited medical cover Lack of Knowledge, communication

arrangements and feedback loops to oncology

Lack of robust system/ shared care arrangement for patients with cancer and co morbidities Orphan patients Patient expectations


NI Risk Management issues: Telephone arrangements

During hours and out of hours Variation in staff knowledge, advice and

protocols Prescriber competencies

Lacks formal process Audit

Ad hoc and limited Morbidity and mortality

No formal or systematic mechanism to discuss Information System inadequate


Cancer Reform Concerns (Prof. M

Richards)

NPSA rapid response alert on oral chemotherapy 3 deaths, 400 incidents over 4 yrs (England)

Cancer Peer Review Concerns regarding leadership for emergency

arrangements and standards of safety NCEPOD report

Need to get basics right, consent, performance status, investigations, recording of toxicities, prescribing

Need to focus on management of complications


What needs to be done? Draw on recommendations

contained in NCEPOD and NCAG Strategic ownership and steer Trusts understanding and

prioritisation of integrated response Knowledge of and support for work-

strands underway


National Chemo Advisory Group

Focus on safety and quality (aligned with NCEPOD)

Highlights need to improve both elective chemotherapy services and acute oncology services Involves A&E and acute medicine as

well as oncology


NCAG: Acute Oncology All hospitals with an A&E should

establish an ‘acute oncology service’ Local policies and procedures (agreed

with the network) Training of junior doctors and other staff 24 hour access to specialist oncological

advice Routine audit of emergency admissions

with cancer


NCAG: areas of focus Assessment, decision to treat and

consent Prescribing and dispensing Delivery (CPORT) Information, Education, Support

and Advice Helpline 24 and appropriate access to

emergency care


NCAG areas of focus

Urgent assessment of chemotherapy complications Know which hospital to go to Out of hours arrangements Clear policies agreed across network 24 advice from oncologist If admitted to hospital acute oncology

team informed within 24hours


NCAG areas of focus

Knowledge and recording of toxicity

End of treatment record Subsequent care plan drawn up and

communicated to relevant health care professionals

Models of service delivery


Collaboration needed NICaN Chemotherapy Network Work

Program Policies, guidance, telephone standards, clinical

management guidelines, training packages Chemotherapy Service Review Steering

Group Synthesis of issues, capacity planning tool, new

models of review, recommendations, inform commissioning

HSCT Trusts Robust chemotherapy risk management

arrangements required


In particular - Acute Oncology

All hospitals with an A&E should establish an ‘acute oncology service’ Local policies and procedures (agreed

with the network) Training of junior doctors and other staff 24 hour access to specialist oncological

advice Routine audit of emergency admissions

with cancer


Relevance to HSC Trusts Medical Directors influence within Trusts and

strategically Development of acute oncology teams and protocols Supportive infrastructure (eg rapid turn around

bloods etc) Audit agenda – challenge of morbidity/mortality Medical training

Future A&E arrangements / location of assessment

Systems for communication and feedback for patients and professionals

Documents

Presentation to CMO MDs in June 09