SALFORD

INTERNAL VALIDATION REPORT

(Multi-Disciplinary Team)

Network / GMCCN
Trust / Salford Royal NHS Foundation Trust
MDT / Specialist Upper GI SMDT
MDT Lead Clinician / Miss Laura Formela
Date Self Assessment Completed / 21 May 2012
Date of IV Review / 2 July 2012
Compliance / Self Assessment / Internal Validation
Specialist Upper GISMDT / 94.1% / 97.1%
Key Themes
With reference to the guidance on Key Themes in the evidence guides, please provide comments including details of strengths, areas for development and overall effectiveness of the team. Any specific issues of concern or good practice should also be noted in the following sections. It is important to demonstrate any measurable change in performance compared to previous assessments.
Structure and Function of the Service
Comment in relation to leadership, membership, attendance and meeting arrangements, operational policies and workload. Teams should specifically comment with regard to the following questions:
  • Are all the key core members in place?
  • Does the MDT have a Clinical Nurse Specialist?
  • What is the compliance with waiting time standards?
  • How many patients by equality characteristic were diagnosed/treated in the previous year?
This is a really strong and cohesive team.
In the last 12 months, the team has doubled in size and still really positive about moving forward.
The team has completed a large amount of work to ensure extremely high compliance with the Peer Review measures including work on Waiting Times compliance and holding monthly breach analysis meetings.
The CNSs work well together. They are proactive in communication regarding patients transferring between sites.
Co-ordination of care/patient pathways
Comment on co-ordination and patient centred pathways of care, network guidelines and communication.
Patients are tracked to move through the pathway quicker with fewer breaches.
The team are planning for MDT discussions to start earlier in the next few months in order to bring the finish time earlier.
The team are piloting electronic onward referrals via proformas live during the SMDT
All surgery for RBH and WWL is performed at SRFT.
The team always provide 24 hour post operative care. Now the team have 6 Surgeons, there is a formal rota for 24 hour care in place.
The CNSs meet every couple of months to review and discuss where improvements can be made to patient care/communication.
Patient Experience
Comment on patient experience and gaining feedback on patient’s experience, communication with and information for patients and other patient support initiatives. Teams should comment specifically with regard to:
  • What are the national patient experience survey results/local patient experience exercise feedback results?
The team were part of the National Survey and are expecting the results in July/August 2012 when they will then complete an action plan from the results.
With the size of the team now, numbers are much larger. There is a good mix of patients who attend the Patient Support Group.
All Patient Information Leaflets are in place. The team ensure they tailor their information for the variety of needs which are required.
The team hold ‘best interest meetings’ for patients with Learning Disabilities. These are held prior to surgery to ensure all needs are taken care of.
Clinical Outcomes/Indicators
Where available, the data from the Clinical Indicators should be used. You should comment separately on each indicator. Where national Clinical Indicators for the team’s cancer site have not yet been agreed for the peer review, please identify and comment on the top five clinical priority issues for your team. Teams should specifically comment on the following questions:
  • What are the major resection rates?
  • What are the mortality rates within 30 days of treatment?
  • What is your recruitment to trials?
  • Outcomes of any key audits projects?
Resection rates are good.
Recruitment to trials – Salford patients in trials are classed as being recruited by The Christie.
The panel found it difficult to interpret why this team were able to put some patients through to trials and not others – we need to understand more about the problems with recruiting.
Overall, mortality rates for this tumour specific group are decreasing and this appears to be in line with the development of the wider working.
Clinical Lines of Enquiry – large number of patients and procedures – standardised good practice across the North section of Manchester.
Good Practice
Identify any areas of good practice
Good Practice/Significant Achievements
The team work well together and are keen to provide the best care for patients.
The team have good working relationship with colleagues.
The team hold monthly breach analysis meetings. The panel would be keen to see in the Annual Report how these meetings have affected results.
The team are developing EHR
There is a full range of endoscopic treatments offered
There are more Surgeons in the team who are newly qualified – education and mentoring will have a positive impact on the team.
Outreach to Pennine – all Surgeons hosted by host Trust.
Quarterly Upper GI away days taking place for the team to discuss further improvements and enhance team working.
The team are working in conjunction with Liverpool to share working practices e.g. patient engagement and data collection
Concerns
Any immediate risks or serious concerns must be brought to the attention of the Zonal Team.
Immediate Risks Identified? Yes/No
Specify Immediate Risks
None
Serious Concerns Identified? Yes/No
Specify Serious Concerns
None
Concerns
None
General Comments
The SUGI team have requested Senior Trust support regarding enormous amount of data collection and the need for enhanced resources.
The team appear robust and cohesive, although the panel would have liked to have seen a greater representation from all sites and all disciplines at the Internal Validation meeting.
2012 NOGCA Annual Report out today –no Oncology treatments submitted for this Trust as The Christie hadn’t submitted the data for us.
Congratulations to the team for the excellent level of compliance achieved for the Cancer Peer Review measures.
Summary of Validation Process
Provide details of the method used to validate the Self Assessment together with names of panel members if appropriate
1 hour pre-meet for the Internal Validation Panel to review documents provided by team
1 hour face to face meeting with the Team
1 hour review of evidence, case note review and report completion by Panel
Panel
Cancer Manager (Chair)
Head of Commissioning -Cancer & End of Life
Divisional Director of Nursing
Cancer Manager (RBH)
Patient Representative (WWL)
Peer Review Co-ordinator and PA for Cancer Services (WWL)
PA for Cancer Services
Organisational Statement
I (Validation Chair) / Leah Robins
On behalf of (host organisation) / Salford Royal
Agree this is an honest and accurate assessment of the (service) / Specialist Upper GI SMDT
Agreed by (Chief Executive) / David Dalton
On (Date Agreed) / 2 July 2012