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Safety and Quality in NI Chemotherapy Service Regional Review and NCEPOD 29 th June 2009

Safety and Quality in NI Chemotherapy Service Regional Review and NCEPOD 29 th June 2009. Aims of presentation. To present initial findings from the Regional Chemotherapy Review baseline assessment and NCEPOD self assessment

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Safety and Quality in NI Chemotherapy Service Regional Review and NCEPOD 29 th June 2009

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  1. Safety and Quality in NI Chemotherapy Service Regional Review and NCEPOD 29th June 2009

  2. 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

  3. 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

  4. 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)

  5. Regional Chemotherapy Service Review

  6. 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

  7. 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

  8. 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

  9. NCEPOD Self Assessment (complete) Stakeholder engagement (Until end of July) Baseline assessment process

  10. 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

  11. 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

  12. 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

  13. Acute Oncology Defined • Involves clinicians working in AE, acute medicine as well as oncology and related disciplines

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

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