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Quality Surveillance Programme

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

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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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