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