Transcript Peer Review and the New Political Environment

National Cancer
Peer Review
Programme
Louise Wilson
Quality Manager
North Zone
Aims of Today
To promote an
understanding of the
Revised National Cancer
Peer Review Process
The New Healthcare Environment
Reducing the Burden of Peer Review on
the 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
the 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?
• 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 Review
To ensure services are as safe as possible
To improve the quality and effectiveness of care
To improve the patient and carer experience
To undertake independent, fair reviews of services
To provide development and learning for all involved
To encourage the dissemination of good practice
Outcomes of Peer Review
Speedy identification of major
Confirmation of the quality of
cancer services
shortcomings in the quality of
cancer services where they
occur so that rectification can
Published reports that
provide accessible public
information about the quality
take place
of cancer services
Timely information for local
commissioning as well as for
Validated information which
specialised commissioners in
is available to other
the designation of cancer
stakeholders
services
The Peer Review Programme
Peer Review
Visits
Targeted
External Verification
of Self AssessmentsA sample each year
Internal Validation of Self
Assessments
Every other year
(Half of the topics covered each year)
Annual Self Assessment
All teams/services
The National Schedule
Dec
Jan
Feb
Mar
April
A team either has a peer
review visit or completes a
self assessment.
May
June
July
Aug
Sept
Oct
Nov
Jan
Complete Self Assessment
Complete Internally Validated Self
Assessment
Targeted
External
Verification
Feedback
to teams
Notification
of visit
Programme
Notification
of visit
Programme
Prepare for visit complete Self
Assessment
Dec
Peer Review Visits
From May to March
Feb
Mar
April
May
Measures 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
Focus for the Measures
• The commissioning of services
• Inter-professional communication
• Co-ordination of care
• User Involvement
• User/carer experience
• Information
• Access to services
New Measures
Topic
Consultation
Closes
Publication Commence Peer
Date
review
Brain&CNS
31st March
Apr-11
2011
Out to Consultation
Sarcoma
16th May
May-11
2011
Out to Consultation
Acute Oncology
NA
Mar-11
2011
Waiting Gateway Approval
Chemotherapy
Closed
Mar-11
2011
Editing Meeting 7th March
Patient Partnership Measures
NA
Mar-11
2011
Awaiting Gateway Approval
TYA
5th April
Apr-11
2011
Out to Consultation
Comments
The Process
The Self Assessment Process
SA Report
Evidence
Documents
Quality Measures
Self Assessment Report
Forms part of the self assessment
Short summary report completed by the lead
clinician
Commentary that reflects the level of compliance
with the measures, patient experience and clinical
outcomes. Includes development and
achievements over the past year.
Self Assessment Report – Key Themes
Structure and Function
Co-ordination of Care/Pathways
Patient experience
Clinical Outcomes/Indicators
Self 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 ServiceEvidence Documents (only required
every other year)
Operational
Policy
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.
Annual Report
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
Work
Programme
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
Agreement
• 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 Guides
Guidance to help you structure your
evidence documents
Guidance for Compliance
Always refer to the full measure in
making assessments against measures
Internal Validation
– The Purpose
to ensure accountability for the self assessment within organisations
and to provide a level of internal assurance
to develop a process whereby internal governance rather than external
peer review is the catalyst for change
to confirm that, to the best of the organisation’s knowledge, the
assessments are accurate and therefore fit for publication and sharing
with stakeholders
to identify and share areas of good practice
Who Validates?
Service
Responsibility for Validation
MDT
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 –
What we Expect
the process is agreed within the organisation
the process adopted has agreement with the commissioners
within the locality and the cancer network
accountability for the self assessments is confirmed by
agreement of the chief executive of the organisation
there is commissioner and patient / carer involvement within
the process
the process and outcome of the validation is reported on the
nationally agreed proforma.
Internal Validation –
Suggested Approaches
Desk-Top
Review
Small panel review
and validate
assessment
Panel
Review
Small panel review
assessment
Meet with
representatives of the
MDT/NSSG to
discuss key issues
and finalise validation
Internal Validation –
The Process
Agreed Validation Process takes place
Further clarification may be sought on some issues / opportunity
of re-submission of specific evidence
Validation report agreed
Validated compliance recorded on CQuINS
Validation report uploaded
The Internal Validation
Report
• 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 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 Assessment
1. Upload Key Documents - (Alternate
years only)
2. Enter Compliance on CQuINS
3. Complete Team Report
Completing the Self Assessment
1
2
1 Upload Key Documents
1
2
3
Enter Compliance
Enter Compliance
1
4
3
2
Complete Overview Report
Self 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 - 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 - 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 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 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 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 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 Requirements
Attendance 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 Verification
– The Purpose
Verify that self-assessments are accurate
Check consistency across organisations
Ensure that a robust process of self-assessment and internal
validation has taken place
Provide a report on performance against the measures and
associates issues relating to IOG implementation
Identify teams or services who will receive an external peer
review visit in accordance with the selection criteria.
External Verification
– The Process
Desk top review of validated assessment
undertaken by Zonal Quality Team
Review of accuracy of self-assessment
Zonal Team may request further information
Zonal Team will have access to specialist clinical
input and patient/carer input
Annual Meeting
with 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 Criteria
Milestones not met for implementation of an IOG as agreed with CAT
Immediate Risks identified at previous peer review visits that have not yet
been resolved
Requests from organisations i.e. SHAs, local and specialist commissioners,
PCTs, Networks, Acute Trusts
% compliance with measures within lowest performance grouping
Concerns regarding rigor of Internal Validation
Stratified random sample based on % compliance (if available capacity)
The Peer Review
Visit Plan
January
Notification in
January to
teams to be
peer reviewed
during May March
Preparation for
review
- 4 WEEKS
Deadline for
submission of
evidence for
all teams to be
visited
- 2 Weeks
Self
Assessment
evidence and
compliance
matrix sent to
reviewers and
copied to
teams
+ 8 WEEKS
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
Peer 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
from 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
Reports
• 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 Steps
•
•
•
•
•
Revised measures published on CQuINS
Revised Handbook
Evidence guides
Evidence documents
Reports
Schedule of Teams for
Internal Validation
2011/12 (INTRODUCTION YEAR)
Acute Oncology
2012/13 (EVEN YEARS)
Breast
2013/14 (ODD YEARS)
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
Thank You
Any Questions ?