1. National Cancer Peer Review Programme Louise Wilson Quality Manager North Zone

2. Aims of Today To promote an understanding of the Revised National Cancer Peer Review Process

3. The New Healthcare Environment

5. 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.

6. 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.

7. 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

8. Aims of Cancer Peer Review To ensure services are as safe as possibleTo improve the quality and effectiveness of careTo improve the patient and carer experienceTo undertake independent, fair reviews of services To provide development and learning for all involved To encourage the dissemination of good practice

9. Outcomes of Peer Review Confirmation of the quality of cancer services Speedy identification of major shortcomings in the quality of cancer services where they occur so that rectification can take place Published reports that provide accessible public information about the quality of cancer services Timely information for local commissioning as well as for specialised commissioners in the designation of cancer services Validated information which is available to other stakeholders

10. The Peer Review Programme Peer Review Visits Targeted External Verification of Self Assessments- A sample each year Internal Validation of Self Assessments Every other year (Half of the topics covered each year) Annual Self Assessment All teams/services

11. The National Schedule

12. 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

13. The commissioning of services Inter-professional communication Co-ordination of care User Involvement User/carer experience Information Access to services Focus for the Measures

14. New Measures

15. The Process

16. The Self Assessment Process Quality Measures Evidence Documents SA Report

17. 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.

18. Self Assessment Report – Key Themes Structure and FunctionCo-ordination of Care/PathwaysPatient experienceClinical Outcomes/Indicators

19. 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

20. Chemotherapy Service- Evidence Documents (only required every other year) Operational Policy Annual Report Work Programme 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. 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 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

21. 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.

22. Evidence Guides Guidance to help you structure your evidence documents Guidance for Compliance Always refer to the full measure in making assessments against measures

23. 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

24. Who Validates? ServiceResponsibility for Validation MDTHost Trust Cross Cutting ServiceHost Trust Locality GroupHost Trust NSSGHost Network Management Team Network Cross Cutting GroupHost Network Management Team

25. 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.

26. 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

27. 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 agreedValidated compliance recorded on CQuINSValidation report uploaded

28. 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

29. Using CQuINS V4 Using CQuINS V4 Available via the web site at: www.cquins.nhs.ukwww.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

30. Completing the Self Assessment 1.Upload Key Documents - (Alternate years only) 2.Enter Compliance on CQuINS 3.Complete Team Report

31. Completing the Self Assessment 1 2

32. 1 Upload Key Documents 1 2 3

33. Enter Compliance

34. 1 23 4

35. Complete Overview Report

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. 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.

44. 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.

45. External Verification – The Purpose Verify that self-assessments are accurateCheck 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.

46. External Verification – The Process Desk top review of validated assessment undertaken by Zonal Quality Team Review of accuracy of self-assessmentZonal Team may request further information Zonal Team will have access to specialist clinical input and patient/carer input

47. 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.

48. 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 groupingConcerns regarding rigor of Internal ValidationStratified random sample based on % compliance (if available capacity)

49. Notification in January to teams to be peer reviewed during May - March Deadline for submission of evidence for all teams to be visited Self Assessment evidence and compliance matrix sent to reviewers and copied to teams 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 January - 2 Weeks - 4 WEEKS The Peer Review Visit Plan Preparation for review + 8 WEEKS

50. 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

51. 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

52. 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

53. Next Steps Revised measures published on CQuINS Revised Handbook Evidence guides Evidence documents Reports

54. 2011/12 (INTRODUCTION YEAR)2012/13 (EVEN YEARS)2013/14 (ODD YEARS) Acute Oncology BreastAcute Oncology Chemotherapy LungChemotherapy Teenage and Young Adults ColorectalTeenagers and Young Adults Sarcoma Upper GISarcoma Brain and CNS Head and NeckBrain and CNS Gynaecology SkinGynaecology UrologyCancer Research NetworkUrology Network Service User Partnership Group RadiotherapyNetwork Service User Partnership Group Rehabilitation Children’s Complementary Therapy Cancer of Unknown Primary Psychology Specialist Palliative Care Haematology Schedule of Teams for Internal Validation

55. Thank You Any Questions ?