Aims Improve the quality and outcomes of clinical services Embed a quality surveillance programme across all specialised services and all cancer services Reduce duplication of effort sharing good practice ID: 807150
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Slide1
The Quality Surveillance Team / Programme
Slide2Aims:
Improve
the quality and outcomes of clinical services Embed a quality surveillance programme across all specialised services and all cancer servicesReduce duplication of effort / sharing good practiceQuality Surveillance Team is now governed by the National Specialised Commissioning Team, NHS EnglandQuality Surveillance Visit Programme to be determined by local and specialised commissioners
Quality Surveillance
Programme
Slide3Role of the QST
The establishment & maintenance of an integrated quality assurance system for specialised services and all of cancer
Providing a responsive and flexible review visit programme in line with national and regional priorities
Alignment to the specialist services quality dashboards / NCIN CHI for shared data sourcesBuilding a quality profile for each specialised serviceProviding a national & regional reporting function
Slide4Key Stages in Quality Surveillance Programme:
Quality indicator development for each specialised service/cancer service by Clinical Reference Group (CRGs)
Data collection from national data sources
Quality Service Information System portal development (QSIS)Annual self-declarationAnnual AssessmentQuality profile Annual meeting with specialised commissionersNotification to organisationsService review visits Feedback to CRGs
Slide5Quality Indicators will be developed from the service specification:
Structure and process
Patient experience
Clinical outcomesData will be collected on the QST portal Data sourcesAnnual self-
de
claration
Quality i
ndicators
Slide6Acute and specialised quality dashboards (provider level)Specialised services quality dashboards (service level
)
Cancer Outcomes and Services Dataset (COSD)
Clinical Health Indicators (CHI)National Cancer Registration and Analysis Service (NCRAS) Cancer Waiting Times Serious incidentsComplaintsPatient experience (CPES)Annual self-declarationInformation relevant from other service review reports, such as CQC Inspection, etc
Data Sources
Slide7Annual Self-Declaration – Trust Requirements:
Teams/services
to complete self declaration against a small set of essential structure and function
indicators Annual declaration completed on quality portal by end of July 2016 (June for 2017)Yes or No compliance required and reason for non complianceNo evidence upload required at this stage of processNo self assessment report required but teams required to identify any significant issues and general comments sectionAnnual declaration endorsed by CEO or delegated authority(s)Internal validation process to be determined by TrustInformation fed into quality profile
Slide8Alert criteria to be developed
according to an agreed set of pre-determined rules and national parameters
Automated report sent to regional QST early July each year
QST annual assessment of quality profiles to understand the reasons behind either services being identified as a national outlier or non-compliance with quality indicators - by end of September each yearFindings recorded on QSIS
Annual Assessment - completed by Regional QST
Slide9Findings reported to:
Specialised Commissioning Hub
Nurse Director of Local Commissioning Operations
Chair of Relevant NetworkAnnual meeting with regional specialised commissioning October each yearFinal visit programme agreed regionally and nationally
Annual Assessment - completed by Regional QST
Slide10Outcomes of annual assessment recorded on QSIS portal:
Routine surveillance through local contracting meetings - services are required to update the self-declaration as part of the annual cycle
Enhanced surveillance undertaken by local commissioners
Increased surveillance – additional data/information required and to be reviewed by QST prior to agreeing further actionPeer review visit – undertaken by QSTNational report published late Autumn each yearAnnual Assessment - completed by Regional QST
Slide11In Summary:Annual self-declaration – completed by teams/services Annual Assessment – completed by regional QSTOutcome
Information recorded on QSIS
Annual Surveillance Programme
Slide12Peer review visits will be either risk based or comprehensive:National Priorities
Regional Priorities
Rapid Response
ReviewsTrusts notified of visit schedule November Visit cycle January to July 2017Review Visit Cycle
Slide13Review Visit Cycle for 2016
National comprehensive visits
for
:Cancer of Unknown PrimaryTransplant Services (incl Scotalnd & Wales)CardiothoracicRenal/Pancreatic Liver Spinal InjuriesRegional visit programme:
South - Specialist Urological & Anal Cancer
Renal Dialysis rapid response visits
Vascular Review Visits
Slide14Review Visit Process
No change in visit process
Services to be reviewed against quality indicators that underpin the national service specification
CQuINS system used for peer review visits for 2016Evidence to be uploaded to CQuINS to demonstrate compliance 4 weeks prior to visitRegional Team to analyse evidence and to notify organisations/reviewers of preliminary findings 2 weeks prior to visitClinically led / peer on peer review visits
Slide15Rapid Response Visits
Small number of rapid response reviews requested by commissioners
Criteria for visit based on patient safety concerns:
Serious failings within a providerNeed to react rapidly to protect patients and/or staffA single, material eventNotification and scope of review by commissionersProvider organisations will be given at least 4 weeks noticeVisits undertaken by QST, peer on peer review
Slide16IR/SC Process
Letter to CEO within one week notifying them of immediate risk or serious concern cc cancer management team and relevant commissioners
Action plan in 2 weeks to address immediate risk to QST
Action plan in 4 weeks to address serious concern to QSTOnce action plan ratified by QST, ongoing monitoring of implementation by relevant commissioner
Slide17Reports published on CQuINS approximately 8 weeks following the review visit (2016)2017 – QSIS portal for peer review visitsMy Cancer Treatment Website - discussions taking place with NHS
Choices
Peer Review Visit Reports
Slide18QSIS (
Quality Surveillance and Information System)
Portal
Single web-based portalHolds information from a range of sourcesEnables comparison and calibrationEnables shared use of dataAllows input from range of stakeholdersAutomatic production of
service specific quality profiles
User Permissions
Slide19https://
nqp.dev.methodsdigital.co.uk
Live Demonstration of QSIS Portal
Slide20Support Available
National Workshops – Specialised Services
Standard Operating Procedure for QST
On-line training guidance on use of quality portalRegional QM and AQM support
Slide21Any Other Questions?
Thank
You
Lucy.evans11@nhs.net
Fiona.fitzpatrick@nhs.net
.
Lorraine.sime@nhs.net
Paul.wickens@nhs.net