1. The Quality Surveillance Team / Programme

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Live Demonstration of QSIS Portal

20. 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

21. Any Other Questions? Thank You Fiona.fitzpatrick@nhs.net.