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Comprehensive Cancer Quality Surveillance Programme

Improve clinical service quality and outcomes with integrated surveillance system. Annual assessments, quality profiles, and feedback for continuous improvement and compliance. National and regional visits. Rapid response for patient safety.

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Comprehensive Cancer Quality Surveillance Programme

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  1. Quality Surveillance Programme Ed Nicolle, Cancer Services Manager, RUH

  2. Quality Surveillance Programme • Aims: • To improve the quality and outcomes of clinical services • To embed a quality surveillance programme across all specialised and cancer services • Establish and maintain an integrated quality assurance system for all cancer services • QST governed by the National Specialised Commissioning Team, NHSE • Quality Surveillance visit programme determined by local and specialised commissioners

  3. Programme • Quality indictors for each service developed by CRGs • Annual self-declaration (QSIS) • Annual assessment • Quality profile • Annual meeting with specialised commissioners • Notification to organisations • Service review visits • Feedback to CRGs

  4. Data sources • Quality dashboards (provider and service level) • COSD • Clinical Health Indicators • National Cancer Registration and Analysis Service • CWT • Serious incidents • Complaints • NCPES • Annual self-declaration • Other reports i.e. CQC inspection

  5. Annual Self-Declaration • Compliance response required including reasons for non-compliance • No upload of evidence • Annual declaration endorsed by CEO or delegated authority • Internal validation process – determined by Trust • Quality profile generated • Upload by June

  6. Self-Declaration Questions • Named lead clinician • MDT which meets service specification requirements • Weekly MDT held • Agreed clinical guidelines • Agreed patient pathways • Pathology timelines achieved

  7. Annual QST Assessment • Automated report generated and sent to regional QSTs (July) • Annual assessment of quality profiles (September) • Findings recorded on QSIS and reported to: • Specialised Commissioning Hub • Chair of relevant network • Annual meeting with regional specialised commissioning (October) • National and regional visit programme agreed • Outcomes of annual assessments recorded on QSIS: • Routine surveillance • Enhanced surveillance – additional information gathered before agreeing further action • Quality Surveillance visit

  8. Annual QST Assessment • National report published (Autumn) • Trusts notified of visit schedule (November) • Visit cycle (January to July) • My Cancer Treatment website/NHS Choices

  9. Rapid Response Visits • Small number requested by commissioners • Criteria for visits based on patient safety concerns: • Serious provider failings • Single/material events • Providers given minimum 4 weeks notice

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