The Quality Surveillance Team / Programme

Quality Surveillance Programme 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 Quality Surveillance Team is now governed by the National Specialised Commissioning Team, NHS England Quality Surveillance Visit Programme to be determined by local and specialised commissioners

Role 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 sources Building a quality profile for each specialised service Providing a national & regional reporting function

Key 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-declaration Annual Assessment Quality profile Annual meeting with specialised commissioners Notification to organisations Service review visits Feedback to CRGs

Quality indicators Quality Indicators will be developed from the service specification: Structure and process Patient experience Clinical outcomes Data will be collected on the QST portal Data sources Annual self-declaration

Data Sources Acute 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 incidents Complaints Patient experience (CPES) Annual self-declaration Information relevant from other service review reports, such as CQC Inspection, etc

Annual 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 compliance No evidence upload required at this stage of process No self assessment report required but teams required to identify any significant issues and general comments section Annual declaration endorsed by CEO or delegated authority(s) Internal validation process to be determined by Trust Information fed into quality profile

Annual Assessment - completed by Regional QST Alert 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 year Findings recorded on QSIS

Annual Assessment - completed by Regional QST Findings reported to: Specialised Commissioning Hub Nurse Director of Local Commissioning Operations Chair of Relevant Network Annual meeting with regional specialised commissioning October each year Final visit programme agreed regionally and nationally

Annual Assessment - completed by Regional QST Outcomes 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 action Peer review visit – undertaken by QST National report published late Autumn each year

Annual Surveillance Programme In Summary: Annual self-declaration – completed by teams/services Annual Assessment – completed by regional QST Outcome Information recorded on QSIS

Review Visit Cycle Peer review visits will be either risk based or comprehensive: National Priorities Regional Priorities Rapid Response Reviews Trusts notified of visit schedule November Visit cycle January to July 2017

Review Visit Cycle for 2016 National comprehensive visits for : Cancer of Unknown Primary Transplant Services (incl Scotalnd & Wales) Cardiothoracic Renal/Pancreatic Liver Spinal Injuries Regional visit programme: South - Specialist Urological & Anal Cancer Renal Dialysis rapid response visits Vascular Review Visits

Review 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 2016 Evidence to be uploaded to CQuINS to demonstrate compliance 4 weeks prior to visit Regional Team to analyse evidence and to notify organisations/reviewers of preliminary findings 2 weeks prior to visit Clinically led / peer on peer review visits

Rapid Response Visits Small number of rapid response reviews requested by commissioners Criteria for visit based on patient safety concerns: Serious failings within a provider Need to react rapidly to protect patients and/or staff A single, material event Notification and scope of review by commissioners Provider organisations will be given at least 4 weeks notice Visits undertaken by QST, peer on peer review

IR/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 QST Once action plan ratified by QST, ongoing monitoring of implementation by relevant commissioner

Peer Review Visit Reports Reports published on CQuINS approximately 8 weeks following the review visit (2016) 2017 – QSIS portal for peer review visits My Cancer Treatment Website - discussions taking place with NHS Choices

QSIS (Quality Surveillance and Information System) Portal Single web-based portal Holds information from a range of sources Enables comparison and calibration Enables shared use of data Allows input from range of stakeholders Automatic production of service specific quality profiles User Permissions

Live Demonstration of QSIS Portal https://nqp.dev.methodsdigital.co.uk

Support Available National Workshops – Specialised Services Standard Operating Procedure for QST On-line training guidance on use of quality portal Regional QM and AQM support

Any Other Questions? Thank You Fiona.fitzpatrick@nhs.net. Lucy.evans11@nhs.net Fiona.fitzpatrick@nhs.net. Lorraine.sime@nhs.net Paul.wickens@nhs.net