The New National Cancer Peer Review Programme

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The New National Cancer Peer Review
Programme Preparing to Go Live
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Welcome and Introductions
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Aims of Today
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Learning Outcomes

• Understanding of the new process and the national
  schedule
• Understand the new self-assessment requirements
• Understand how to validate self-assessments
• Be familiar with the new version of CQuINS
• Understand the external verification and peer
  review visit processes
• Have knowledge of the outcomes from NCPR
  Programme
• Have confidence to train others in their
  organisations and know where to access support
  and advice

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Session 1Introduction to the New Process
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Why Have we Changed?
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Why Have we Changed?
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The New Process
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The National Schedule
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Session 2 Completing a Self Assessment
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The New Self Assessment Process
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What are Key Questions?
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MDT Key Questions
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NSSG Key Questions
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MDT- Evidence Documents
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Network GroupEvidence Documents
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Other Topics

• Similar approach will be adopted for other topic
  areas
• Evidence requirements will be released alongside
  the updated measures e.g. Locality Groups, Chemo
  Teams, Network User Groups
• Some areas will require an extensive review of
  the measures e.g. Network Boards and
  Commissioning groups, Specialist Palliative Care

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Demonstrating Agreement

• Where agreement to guidelines and policies is
  required this should be stated clearly on the
  cover sheet of the relevant evidence document.
• Evidence Guides will indicate the groups and
  individuals that need to be documented as
  agreeing the key evidence documents.
• See Examples within Lung Evidence Guides

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Using our Evidence Guides
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Group Work A Fictional Lung MDT

• You are a Lung MDT and need to complete the
  self-assessment for your team. Using the
  spreadsheet, complete the self-assessment for
  those measures highlighted in YELLOW.
• You will need to identify in which of the key
  documents the evidence is found and which page
  and record this on your spreadsheet.
• 20 Minutes

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Group Work Documents

• Operational Policy, Annual Report and Work
  Programme
• Part Completed Self-Assessment
• Lung MDT Evidence Guides
• Lung MDT Measures

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Key Points from Group Work

• How did you self-assess your compliance? Where
  was the Evidence?
• 2C-110, 2C-111, 2C-114, 2C-116, 2C-119

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Self-Assessment Key Tips
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Session 3Validating Self-Assessments
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Validation The Purpose
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Who Validates?
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Validation What we Expect
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Validation Suggested Approaches
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Validation The Process
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Advice on Involving Patient/Carers
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The Validation Proforma

• 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

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Group Work A Fictional Lung MDT

• You are the Cancer Management team for the Trust
  and are required to validate the Lung MDT
  Self-Assessment.
• You will need to review the teams evidence for
  the measures highlighted in BLUE on the
  spreadsheet, identify whether you agree with the
  self-assessment or not.

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Group Work A Fictional Lung MDT

• Consider whether you have sufficient information
  or whether you would need to see any supporting
  documents or ask questions of the team?
• Then look at the validation proforma based on
  your review of the evidence focus on one of the
  4 key questions....and also think about whether
  there are any areas of concern?
• 40 Minutes

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Key Points from Group Work

• Did you change compliance of any measures?
• What questions would you like to ask this MDT?
• How did you complete the key questions?
• What are the Key Concerns

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Key Points from Group Work

• Answering the Key Questions for the Balamory Lung
  MDT
• Thinking About Areas of Concern

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Validation Key Tips
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Session 4Using CQuINS V4
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CQuINS V4 Why do we Need a New Version?

• Response to feedback from 2004-07 Programme
• New NCPR Process requires
• changes to the CQuINS functionality

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Recording Internally Validated Assessment
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CQUINS V4

• Front end Website
• Resources for Teams
• Measure Manuals
• Published Reports
• Public Information About NCPR.
• NCPR News
• Login Access to the Database
• (which wont be publicly accessible)

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CQUINS V4

• Live from 1 Jan 2009
• Skin
• UGI
• Urology
• Gynae
• Lung
• Breast
• Further Support and Guidance will be made
  available

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Session 5External Verification Peer Review
Visits
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External Verification The Purpose
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When does External Verification Take Place?

• Nationally Selected topics each year within which
  all teams self-assessments will be externally
  verified
• In addition, random selection
• From 2010 in any year, any teams assessment may
• be externally verified
• Every team will be externally verified at
• least once every 5 years

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External Verification The Process
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External Verification The Outcome
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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
• agree the teams to be visited and schedule for
  the following year.

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Selecting Teams for a Peer Review Visit
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The Peer Review Visits
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The Peer Review Visit Plan
December

- 4 Weeks
- 6 WEEKS
Preparation for review
8 WEEKS

Notification by 31st December to teams to be peer
reviewed during May - March
Deadline for submission of evidence for all teams
to be visited
Pre-visit meeting for NEW TEAMS with the Zonal
Team or Zonal Team Pre-assessment circulated
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
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The Visit Day

• Max of 3 concurrent sessions am pm
• Max of 6 teams will be reviewed in 1 day
• E.g. Session

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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

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Peer Review Teams May Include
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Which Team Members should attend the Review?

• MDT Review
• Lead Clinician and CNS
• with other core members (e.g. Surgeon,
  Oncologist, Radiologist, Pathologist, Palliative
  Care)
• Not the whole extended team we need to have a
  discussion not a seminar
• NSSG Review
• Chair of NSSG
• Small group of other key NSSG Members

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Session 6Outcomes from the Process
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Outcomes from the Process

• Interface with
• Care Quality Commission,
• Cancer Commissioning Toolkit,
• NHS Choices
• Department of Health
• Annual Network Reports
• National State of the Nation Reports
• IV/EV and PR Assessments - public

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Outcomes of the Process Network Reports

• Published June each year
• Including IV, EV and PR Visit Assessments
• Executive Summary from Quality Director
• QD will discuss key issues with Network

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Post Review Actions

• Recommendations from IV, EV or PR Visits
• Picked up within Work-Programmes / Reported on in
  Annual Reports
• Separate process for actions regarding
• Immediate Risks and Serious Concerns
• Written notification and written response

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Session 7Cascading the new Approach to Others in
your Organisations
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Resources Availablewww.cquins.nhs.uk
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Session 8 Next Steps and Close
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First Year Calendar Peer Review Visit Cycle
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First Year Calendar Self Assessment Cycle
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Next Steps and Close

• Support 1st wave teams in preparation for
  self-assessments
• Plan and phase Self-Assessment
• Think about the validation approach for Lung and
  Breast Self-Assessments

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Close

• Thank You
• Please Complete your Evaluation form
• Have a Safe Journey Home....