Cancer Services Operational Policy (Patient Access) V2.1
Cancer Services Operational Policy
(Patient Access)
Version number 2.1
Lead executive Chief Operating Officer
Name / title of author: Karen Blackburn, Lead Manager Cancer Services
Date reviewed:
September
2015 Date ratified: 19/10/2015
Ratifying
Committee: Cancer Board
Target audience:
Cancer Services Team
Directorate Management Teams; Waiting List Teams
Out Patient teams Clinical Teams;
Performance and Information Team Cancer Analysts
Policy Summary:
This document sets out how UHSM will manage the pathway of patients who are waiting for an out-patient appointment, diagnostic investigation, in-patient or day-case admission on a cancer pathway including data entry and validation.
Equality Impact Statement:
University Hospital of South Manchester NHS Foundation Trust (‘UHSM’) strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of health care, UHSM aims to ensure that none are placed at a disadvantage as a result of its policies and procedures.
This document has therefore had an initial assessment, in accordance with the equality impact proforma incorporated in ‘the Checklist for Review and Ratification of UHSM-wide Documents’, to ensure fairness and consistency for all those covered by it regardless of their individuality.
This initial impact assessment indicated that the potential discriminatory impact is nil (see Appendix C
Training impact and plan
summary:
Training on the cancer section of the Patient Access Policy and the Cancer Services Operational Policy is required by the Cancer Services core team and Performance and Information Team Cancer Analysts. This will be delivered via dedicated training
sessions to be led by the Lead Manager Cancer Services. Out Patient and Waiting List staff will be trained by their local managers, to include both initial and refresher training
Outline plan for
dissemination: Please see Appendix B
Dissemination lead: name / title / ext no
Karen Blackburn, Lead Manager Cancer Services, extension number 2969
University Hospital of South Manchester NHS Foundation Trust
VERSION CONTROL SCHEDULE
Version number
Issue / Review Date
Amendments from previous issue Date of
Ratification by Committee
V2.0
Addition: Section 5 Duties &
Responsibilities:The Lead Manager Cancer Services will undertake on going review of the cancer services team staffing resources to ensure the team is fit for purpose
Endoscopy booking team
The endoscopy booking team have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the GP on referral straight to test, in order that patients can be tracked within the relevant national cancer time frame
Amendment: 6.3.1 Out Patient Capacity escalation:
The CPCs will query any outpatient appointment delays or 2WW target breaches with the
outpatient call-centre clerical team in the first instance.
The call-centre team will raise the capacity issue with the relevant Assistant Directorate Manager who should action any capacity issues.
The CPCs will query any endoscopy straight to test 2ww target breaches with the endoscopy clerical team in the first instance.
If not resolved the endoscopy clerical team will escalate to the Assistant Directorate Manager Medical Specialties.
Amendment: Capacity issues diagnostic Section 6.3.2:The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the relevant Deputy Directors of Operations and finally via the weekly Patient Access board
Amendment: 6.3.3Capacity issues treatment: The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the Deputy Directors of Operations and finally via the weekly Patient Access Board.
The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate firstly to the relevant departmental manager as identified by radiology and pathology and then via the weekly escalation report to the relevant Directorate Manager and Deputy Directors of Operations and finally via the weekly Patient Access Board.
6.3.5 Clinical or patient choice delays amendment:
The CPCs will notify the Lead Manager Cancer Services/Deputy Manager Cancer Services of any patient-choice or clinical delays to the pathway and note the issue within the tracking comments section on SCR.
6.3.9 Step Downs Administrative SECTION DELETED
8.1 Peformance Monitoring addition:
Root Cause Analysis forms will be completed by the relevant CPC for each breach of the 62 day target. This will be shared with commissioners and also with Directorate Management Teams who will be required to review and ensure action is undertaken to maintain and improve cancer performance and patient experience General:
Throughout the document, Associate Director of Operations has been changed to Deputy Director of Operations, Director of Performance and Information has been changed to Chief
Information officer. Escalation previously to Chief Information Officer and Chief Operating Officer has been changed to “via the weekly Patient Access Board”
Document Control Summary of consultation process
Draft policy circulated to Cancer Board members, Cancer Information Analyst, Deputy Manager Cancer Services, Cancer Tracking Coordinator, Directorate Managers (including Out Patients) Elective Access Manager, MDT Lead Clinicians and Chief Operating Officer, Chief Information Officer, Deputy Directors of Operation for comment. Publication on the trust intranet for a 3 week period of consultant and comment
Control arrangements
[Reviews shall generally be undertaken every 2-3 years or more frequently to take account of organisational learning]
This policy will be subject to review by the Lead Manager for Cancer Services every 2 years, or, more frequently if external bodies eg NHS England issue updates on current Cancer Waiting Times Guidance in the meantime.
Associated documentation and references
Cancer Waiting Times Guidance v 8.1 Date July 2015 UHSM Patient Access Policy (2015)
Policy for the Upgrade (‘Step Up’) & Downgrade (‘Step Down’) of Patients to and from the Fast Track, 62 day Cancer Pathway – July 2015
References COSD - Cancer Outcomes and Services Dataset CPC – Cancer Pathway Coordinator
CaRP –Communication and Referral Proforma CWT – Cancer Waiting Times
DoH – Department of Health GP – General Practioner
GDP – General Dental Practitioner
SCR – Somerset Cancer Register Database TCI – To Come In (Admission)
PAS – Patient Administration System PPI – Patient Pathway identifier MDT – Multi-Disciplinary Team PCA – Patient Choice Adjustment
PTL – Primary Target List (chronological list of patients being tracked against national standards)
2WW – GP Two week wait referrals
Cellular pathology: diagnosis by microscopic examination of tissue sections (histopathology) or cytological preparations (cytopathology)
DOCUMENT COMPLIANCE MONITORING ARRANGEMENTS
Minimum requirement to be monitored
Compliance with national and local cancer waiting time targets
Process for monitoring e.g. audit Review of patient pathways and achievement of waiting times targets at weekly PTL meetings
Bi-annual audit of application of policy guidance via PAS, ensuring relevant information has been entered on to PAS and resulting adjustments have been applied to patient pathways on SCR. This will be undertaken via random selection of patients from a ‘live’ PTL.
Responsible individual / group/
committee Lead Manager Cancer Services Frequency of monitoring Weekly via PTL
Biannually via PAS and SCR Individual responsible for
preparation / approval of
compliance report and action plan
Lead Manager Cancer Services
Individual / group / committee that is responsible for review of results / approval of action plan
Cancer Board
Individual / group / committee that is responsible for monitoring of action plan
CONTENTS
Page
1 Introduction and Purpose 6
2. Policy Statement 6
3. Relevant Access Standards 6
4. Scope 7
5. Duties and responsibilities 7
6. Access Policy Standards 9
7. Escalation outside the Team 14
8. Quality and Performance Monitoring 15
9. Training/ Communication Plan 16
10. Relevant Performance Reports 17
Appendices
A
Flowchart for dealing with repeated patient non-compliance 18
B
Plan for Dissemination
19
1. Introduction and Purpose
This document sets out University Hospital of South Manchester NHS Foundation Trust’s (UHSM) Operational Policy for the Cancer Services Team. It details how UHSM will approach the management of patients against national cancer waiting time targets. It has been developed using current guidance from the Department of Health, including Cancer Waiting Times (CWT) guidance, and other sources of best-practice.
The overall purpose of the document is to establish a consistent approach to the management of cancer waiting times across the organisation and robust validation of the same.
2. Policy Statement
To ensure all staff involved in cancer waiting times management are aware of and follow the processes outlined in this document in order to provide equitable access for patients through effective cancer tracking, to enable the Trust to achieve the required access standards, taking into account national rules and guidelines.
The key principles of this policy are:
improve the patient experience as they move through the clinical pathways, minimising unnecessary delays where possible;
ensure patients receive treatment according to clinical priority in the first instance, followed by actual waiting time;
escalate bottlenecks in cancer-waiting-time pathways at an early stage to directorate management teams;
provide timely, consistent and accurate data-recording for patients on cancer waiting-time pathways.
3. Relevant Access Standards a) Maximum 2 weeks from:
i) receipt of urgent GP/GDP referral for suspected cancer to first outpatient attendance [Operational Standard of 93%];
ii) receipt of referral of any patient with breast symptoms (where cancer not suspected) to first hospital assessment [Operational Standard of 93%].
b) Maximum 31 days from:
i) decision to treat to first definitive treatment [Operational Standard of 96%]; ii) decision to treat/earliest clinically appropriate date to start of second or
subsequent treatment(s) for all cancer patients including those diagnosed with a recurrence where the subsequent treatment is:
(1) surgery [Operational Standard of 94%]
(2) drug treatment [Operational Standard of 98%] (3) radiotherapy [Operational Standard of 94%]. c) Maximum 62 days from:
(i) receipt of urgent GP/GDP referral for suspected cancer to first treatment [Operational Standard of 85%];
(ii) receipt of urgent referral from NHS Cancer Screening Programmes (breast, cervical and bowel) for suspected cancer to first treatment [Operational Standard of 90%];
(iii) date of consultant upgrade of urgency of a referral to first treatment [No Operational Standard as yet].
d) Maximum 31 days from receipt of urgent GP referral to first treatment for children’s cancer, testicular cancer, and acute leukaemia [No separate Operational Standard – Monitored within 62-day standard].
4 Scope
This document has been designed to be a reference guide for all staff involved with cancer-pathway management and sets out the standards required.
5. Duties and Responsibilities
Lead Manager Cancer Services
The Lead Manager Cancer Services will ensure that all cancer services core team staff involved in cancer-pathway tracking are aware of this policy and the importance of following the procedures. Training will be provided to the cancer services core team on this policy together with the Trust’s Access Policy. Training will also be provided to new members of the team at induction.
The Lead Manager Cancer Services will undertake on going review of the cancer services team staffing resources to ensure the team is fit for purpose
The Lead Manager Cancer Services is responsible for reviewing this policy.
Deputy Cancer Services Manager, Project Support Manager and Cancer
Tracking Coordinator
The Deputy Cancer Services Manager and Cancer Tracking Coordinator will ensure that the processes outlined in this document are implemented and adhered to, without deviation by the cancer pathway coordinating team, on a day-to-day basis. The Deputy Cancer Services Manager will ensure that refresher training on this policy and the Trust’s Access Policy is included within the cancer services core team annual training programme, in order to maintain skills and knowledge.
Cancer Pathway Coordinators
The Cancer Pathway Coordinators will ensure the accuracy of information for all patients managed against national cancer waiting time targets on the Somerset Cancer Registry Database, using information received from multi-disciplinary and Trust IT systems.
All Cancer Pathway Coordinators have a responsibility to ensure that they comply with the guidance in this operational policy.
Clinicians
All clinicians must ensure that before adding a patient to the waiting list for a cancer treatment, the patient is fit, ready and able to come into hospital for their procedure. Clinicians must complete an ‘upgrade’ form if they wish to upgrade patients to the national 62-day target or alternatively request the patient is upgraded via Sunquest ICE.
Clinicians must sign a ‘step down’ form, if they believe it is clinically appropriate to step the patient off a national cancer 62-day pathway, or alternatively request the patient is stepped down via Sunquest ICE.
The directorate management teams have a responsibility to ensure that adequate capacity is available for all patients added to all waiting lists to enable the Trust to achieve the required local and national cancer standards.
The Directorate management teams have a responsibility to ensure that their respective clinical teams have robust processes in place in order to enable cancer patients are added to the waiting list in a timely and consistent manner.
Out-patient Call Centre Team
The outpatient administrative clerks / receptionists have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the GP on referral, in order that patients can be tracked within the relevant national cancer standard time frame.
Out Patient Clerks/Receptionists
The outpatient administrative clerks / receptionists have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the clinical teams on the clinic-outcome proforma.
Endoscopy booking team
The endoscopy booking team have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the GP on referral straight to test, in order that patients can be tracked within the relevant national cancer standard time frame
Performance & Information Team
The Performance & Information team has a responsibility to comply with all quality and performance monitoring duties described in section 8.2 of this document.
Waiting List Teams
Have a responsibility to ensure that patient data entered onto IPM/PAS is accurate and reflects the information provided by the clinician at listing. They also have responsibility to ensure that patients are dated within relevant waiting time standards and escalate to the relevant directorate manager where there are capacity issues.
6. Access Policy Standards 6.1 General Principles
All patients with suspected or diagnosed cancer will be managed in line with national cancer waiting time standards.
All relevant patients will be added to the Somerset Cancer Registry Database (SCR) which will hold full and comprehensive records for each patient. Patient records will include MDT discussion and a full Cancer Outcomes and Services Dataset (COSD) and where relevant National Audit data.
Patients will be tracked against the appropriate local and national standards and any bottlenecks or pathway breaches will be actioned and / or escalated as appropriate.
Compliance/ breaches of target will be reported in line with national reporting guidance. Data quality checks will be undertaken.
Cancer team members will receive comprehensive induction and refresher training to allow them to undertake their duties.
6.2 Operational Process
6.2.1 Adding patients to SCR
Referral details for all patients referred to UHSM for treatment by their GP/GDP as a suspected cancer (all tumour groups) and all symptomatic breast referrals will automatically transfer from PAS to SCR as part of an overnight extract from the Trust’s data warehouse.
Organisations across Greater Manchester and Cheshire Cancer Network have agreed a communication and referral process, which requires that a Communication and Referral Proforma (CaRP) includes accurate demographic and pathway data with each referral between hospital trusts.
The Cancer Tracking Coordinator and Cancer Services Central Office team will check the generic email account at regular intervals during each working day and will immediately add any CaRPed referrals received on to SCR, to include accurate demographic and patient pathway data.
The Cancer Tracking Coordinator and Cancer Services Central Office team will add any faxed CaRPed referrals immediately upon receipt on to SCR, to include accurate demographic and patient pathway data (having reviewed to ensure patient is not already on an existing 62 day pathway).
The Cancer Tracking Coordinator and Cancer Services Central Office team will add any faxed Upgrade referrals immediately upon receipt on to SCR, to include accurate demographic and patient-pathway data.
The Cancer Services Central Office or Breast CPC will add any screening referrals to SCR immediately upon receipt, to include accurate demographic and
patient-pathway data.
The Cancer Services Central Office team will add to SCR any upgrade referrals received via the generic cancer services email account from the ICE electronic
referrals will be added immediately following a triage of tumour group and referral details from GP where those are required.
The tumour specific Cancer Pathway Coordinator (CPC) will check any new additions to the elective waiting list daily to ensure all appropriate patients have been added to SCR, all records added to include accurate demographic and patient-pathway data.
6.2.3 Pathway Management
The Cancer Tracking Coordinator will produce a full cancer PTL each Monday and distribute to CPCs, waiting-list team and directorate teams.
Cancer Pathway coordinator duties
Check the full PTL for their specialty daily to ensure patient pathways are expedited. Check agreed, timely next steps are in place for all patients, chase outcome of outpatient appointments, diagnostic tests and treatments and update information for all patients on SCR. Escalate as necessary (see section 6.3 for details).
Meet with the relevant Booking & Scheduling Clerk from the waiting-list team on (at least) a weekly basis, to ensure patients are given a TCI date within the required timescale.
Check the daily pathology report to identify incidental cancer diagnoses not known to SCR and update SCR for all relevant patients.
Ensure real-time, accurate, comprehensive tracking comments exist on SCR, for each event/relevant patient within their specialty. NB each patient should have an SCR record which includes:
Full demographic detail and PPI
Standard recorded (31, 62, 2nd/subsequent, screening & upgrade)
Diagnosis where known (primary, recurrence, mets etc)
ICD10 diagnosis code
Tests and treatments booked in accordance with agreed pathway so as to avoid unnecessary breaches
Cancer registration dataset completed in the relevant field on the diagnosis screen
All relevant staging
Complete COSD dataset
National audit data where relevant
Ensure the outcome from each patient discussed at the MDT meeting is entered onto SCR, preferably during the MDT meeting, but no later than 24 hours following the meeting.
Ensure ‘Step Down’ proformas are collected and actioned daily.
Ensure Patient Choice Adjustment (PCA) forms are completed for all relevant patients (as indicated by DoH Cancer Waiting Times guidance and Trust’s Access Policy) and signed by the relevant Directorate/Assistant Directorate Manager.
Check the PAS record for patients who have DNA(d) their first appointment on the 62 day pathway, to ensure there is an auditable trail prior to adding the adjustment in days to SCR.
Produce an updated cancer PTL for all standards (31, 62, 2nd/subsequent, screening & upgrades) for the weekly PTL meeting.
Complete the breach-analysis template for all pathway breaches.
6.2.4 Communications
The Cancer Tracking Coordinator will maintain a ‘shadow list’ of UHSM patients CaRPed to other trusts for diagnostics or treatments, ensuring tracking comments are updated on SCR and breaches notified to Lead /Deputy Manager Cancer Services.
The Cancer Service Tracking Coordinator will ensure that a full update is provided, to each referring organisation, on a weekly basis, of their patients who are on ‘live’ tracking on the UHSM PTL.
The CPCs will ensure inter-provider CaRPs, generated from SCR,are sent for all patients within their specialty for all cancer standards (31, 62, 2nd/subsequent, screening & upgrades) immediately, with the referral letter being sent within 24
hours.
The CPCs will ensure inter-provider CaRP information is entered into SCR.
The CPCs will maintain a ‘CaRPs Out List’ for all patients who are transferred out of UHSM where the initial management plan is chemotherapy and /or XRT
(radiotherapy) followed by Surgery or chemotherapy at UHSM. These patients should be monitored for their 2nd / subsequent treatment at UHSM.
6.3 Escalation Procedure
6.3.1 Capacity Issues – Out Patient Appointments
The CPCs will query any outpatient appointment delays or 2WW target breaches with the outpatient call-centre clerical team in the first instance.
The call-centre team will raise any capacity issue with the relevant Assistant Directorate Manager who should take necessary action to prevent a breach of target. The CPCs will query any endoscopy straight to test 2ww target breaches with the endoscopy clerical team in the first instance.
If not resolved the endoscopy clerical team will escalate to the Assistant Directorate Manager Medical Specialties.
6.3.2 Capacity Issues – Diagnostics
The CPCs will discuss any diagnostic appointment delays or target breaches with the relevant departmental booking clerk.
If the delay is not resolved within a maximum 48 hours the CPCs will raise the issue with the relevant Assistant Directorate Manager and, if still not resolved within a further 24 hours, with the Lead Manager Cancer Services/Deputy Manager Cancer Services.
The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report,
to the relevant Deputy Directors of Operations and finally via the weekly Patient Access Board.
6.3.3 Capacity Issues – First Treatment
The CPCs will discuss any booked definitive treatment appointment delays or target breaches with the relevant waiting list clerical team (for in-patient surgical treatments), waiting list clerical team, secretary, administrative team (for day case/out patient treatments eg chemotherapy) in the first instance.
If the delay is not resolved within a maximum 48 hours the CPCs will raise the issue with the relevant Assistant Directorate Manager and, if still not resolved within a further 24 hours, with the Lead Manager Cancer Services/ Deputy Manager Cancer Services.
The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the Deputy Directors of Operations and finally via the weekly Patient Access Board.
6.3.4 Delays to diagnostic reporting
If histopathology diagnostic biopsies remain unreported after 5 working days from procurement (where the report is not requested via ICE/ requesting clinician does not write the date on the request card, this will be date of receipt of specimen within pathology laboratory), the CPCs will flag the outstanding reporting to the pathology cancer pathway coordinator.
If radiology remains unreported after 2 working days, the CPCs will flag the outstanding reporting to the radiology cancer pathway coordinator.
If tests remain unreported within a further 48 hours the CPCs will escalate to Lead Manager Cancer Services/ Deputy Manager Cancer Services.
The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate firstly to the relevant departmental manager as identified by radiology and pathology and then via the weekly escalation report to the relevant Directorate Manager and Deputy Directors of Operations and finally via the weekly Patient Access Board.
6.3.5 Clinical or patient choice delays
The CPCs will notify the Lead Manager Cancer Services/Deputy Manager Cancer Services of any patient-choice or clinical delays to the pathway and note the issue within the tracking comments section on SCR.
6.3.6 Step Downs (Clinical)
For all suspected cancer patients with the exception of those referred to breast, where diagnostic results/clinical correspondence appears to indicate that the patient does not have a malignancy and this has been communicated to the patient, the CPC will complete a step-down proforma, attach all relevant diagnostics results and clinical correspondence and where available, the patient case notes. The step down will be passed to the relevant medical secretary to request clinician sign off. It is the responsibility of the clinician removing the patient from the pathway to complete the step-down proforma promptly. If the proforma is not signed within 48 hours, the CPC will escalate to the relevant Assistant Directorate Manager and, if still not resolved,
The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the relevant Deputy Director of Operations and finally via the weekly Patient Access Board.
NB for those areas with a high volume of weekly step downs a weekly step down
report will be produced for all patients with outstanding step down requests. This will be attached to the PTL produced by the CPCs for the weekly PTL meetings.
If the clinician signs the step down proforma the patient’s record will be closed on SCR and no further tracking undertaken.
The relevant member of the Central Office team /CPC inputting the step down is also responsible for updating the Somerset cancer tracking system and changing the status of the patient. This can be done in the ‘patient diagnosis screen’. The patient status must be changed to ‘no new cancer diagnosis identified’, the tumour status must be amended to ‘non-cancer’, and the date of non-cancer should be completed with the date on the step-down proforma or clinic letter. The non-cancer details section should be completed with the reason for removing the patient eg stepdown proforma received, removed as per clinic letter etc.
Should any patient initially stepped down from the 62 day pathway later be diagnosed with cancer, this will be treated as an incidental finding and their pathway will be tracked against the 31 day target (‘Date of Decision to Treat’ to ‘First Definitive Treatment’). Patient may also be placed on an Upgrade 62 day pathway.
The date of clinical decision to remove the patient from cancer 62 day tracking marks the end of the 62 day pathway.
If the clinician declines to sign the patient off the pathway due to clinical reasons, the patient will continue to be managed within national targets and tracked accordingly.
A copy of the signed step down must be filed within the relevant file within the Cancer Services Central Office.
6.3.7 Step Down at receipt of referral
Only GPs and GDPs are able to downgrade referrals from the HSC 2ww referral pathway, at the point of receipt. Where a consultant believes that a referral does not meet the criteria for HSC205, 2ww referral prior to first appointment, the consultant
must discuss the referral with the referring GP/GDP and the GP/GDP must agree to
down grade the referral. Consultant must inform the outpatient schedulers they have spoken to the GP/GDP. Without this confirmation the downgrade will not take place.
6.3.8 Step Downs (Breast Referrals)
For breast patients, a number of conditions or treatment plans have been identified locally by the clinical team in the clinic letter as acceptable
evidence that the patient has received a formal non malignant diagnosis and can be removed from the pathway. In these circumstances a step down proforma is unnecessary. These have been reviewed in October 2015 by the Lead Breast MDT Clinician.
The conditions triggering removal from the pathway are fibroadenoma, gynaecomastia, lipoma, sebaceous cyst, abscess, benign phylloides and Eczema.
The treatment plans are:
Discharge pending results (such as blood tests for gynaecomastia when we have benign cytology)
Write to with results of 2nd FNA (when the 1st FNA is benign)
MRI for implant rupture
Reconstruction/Reduction/Augmentation/Symmerisation procedures
Nipple Eversion
By local agreement, other breast patients to be removed from the 62 day pathway include those:
attending the lymphoedema clinic
where a pathology report from a surgical specimen is benign
where a patient has been given a FU of 4 weeks/1month or more and is not undergoing any sort of treatment/trial
The clinic letter may therefore be used in place of a Step Down proforma as evidence of a patient being removed from the 62 day pathway.
The Cancer Pathway Coordinator (CPC) responsible for the tumour site has responsibility for ensuring the Step Down proforma is filled out, signed and returned to the cancer office fax by liaising closely with the clinician. The Breast CPC is responsible for checking clinic letters.
The CPC is also responsible for updating the Somerset cancer tracking system and changing the status of the patient. This can be done in the patient diagnosis screen. The patient status must be changed to ‘No new cancer diagnosis identified’, the tumour status must be amended to ‘Non-cancer’, and the date of non-cancer should be completed with the date on the stepdown proforma or clinic letter. The non cancer details section should be completed with the reason for removing the patient eg stepdown
proforma received, removed as per clinic letter etc.
Should any patient initially stepped down from the 62 day pathway later be diagnosed with cancer, this will be treated as an incidental finding and their pathway will be tracked against the 31 day target (‘Date of Decision to Treat’ to ‘First Definitive Treatment’). Such patients can also be upgraded to a 62 day pathway.
The date of clinical decision/ adherence to protocol described above, to remove the patient from cancer 62 day tracking, marks the end of the 62 day pathway.
7. Escalation outside the Team
7.1.1 Capacity Issues and diagnostic reporting
The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the relevant Deputy Director of Operations and finally via the weekly Patient
In addition, the Lead Manager Cancer Services/Deputy Manager Cancer Services will advise the Elective Access Manager of any surgical diagnostic or treatment capacity issues to facilitate dialogue with the relevant directorate management team regarding capacity planning at the weekly Theatre Management Meeting.
7.1.2 Clinical or patient-choice delays
The Lead Manager Cancer Services/Deputy Manager Cancer Services will note any relevant breaches and advise the Chief Operating Officer, Chief Information Officer, Head of Performance and the Senior Information analyst (Cancer) accordingly. The Senior Information Analyst (Cancer) will include breaches in both internal and external cancer waiting times for reporting purposes.
8. Quality & Performance Monitoring
8.1 Lead Manager Cancer Services/Deputy Manager Cancer Services
The Lead Manager Cancer Services/Deputy Manager Cancer Services chairs weekly Cancer PTL meetings, attended by the relevant tumour specific CPC and directorate management representative. Every patient on the Cancer PTL will be reviewed at the meeting, to ensure compliance with national and local cancer targets. Any gaps in tracking comments, identified from the PTL, will be discussed with the CPC at this meeting.
Root Cause Analysis forms will be completed by the relevant CPC for each breach of the 62 day target. This will be shared with commissioners and also with Directorate Management Teams, to include diagnostic services, who will be required to review and ensure action is undertaken to maintain and improve cancer performance and patient experience.
Breach trends and resulting action to improve cancer performance will be discussed at the Patient Access Board.
8.2
Performance & Information Team
The Performance & Information team has a responsibility to ensure that
validation checks are carried out prior to upload to the national cancer waiting
times database. These are in the form of identifying missing treatments,
missing mandatory data items and breach validation. Any inaccuracies
identified should be reported to the Lead Manager Cancer Services/Deputy
Manager Cancer Services for resolution prior to upload.
The Performance & Information team has a responsibility to ensure that
UHSM reports all cancer waiting time treatments and breaches in line with
national reporting deadlines. Any individual within the Performance &
Information team with responsibility for a submission must notify their Line
Manager and the Lead Manager Cancer Services/Deputy Manager Cancer
Services of any issues relating to compliance with reporting deadlines.
8.3 Cancer Pathway Coordinator
The CPCs have a responsibility to undertake a number of data-quality checks each week:
check records on SCR for patients with a treatment start date where there is no ICD10 code (N.B. when entering the ICD10 code, a 4-digit code is required e.g. C509, C342 etc);
when entering a diagnosis on SCR ensure tumour laterality is recorded;
check records on SCR for patients with a treatment start date where there is no TCI (to come in) date;
ensure the Lead Manager Cancer Services/Deputy Manager Cancer Services are aware of any breaches of national target, prior to entering the treatment details on SCR
ensure breach comments are entered on SCR for all relevant patients;
check the SCR checklist weekly to ensure that any data issues highlighted in
RED are resolved;
check the COSD (Cancer Outcomes and Services Dataset) checklist to ensure that any data issues highlighted in RED are resolved;
when entering treatment records on SCR ensure that ‘Clinical Trial’ details are entered (Yes / No / Unknown).
9. Training/ Communication Plan
The Access Policy and Cancer Services Operational Policy will be communicated to all members of the cancer services core team via team meetings and dedicated training sessions and to new members of the team at induction
The cancer pathway coordinating team will participate in an annual training programme and this will include refresher training on the Trust’s Patient Access Policy and the Cancer Services Operational Policy
A copy of the Patient Access Policy and the Cancer Services Operational Policy will be provided to all cancer pathway coordinators.
10. Relevant Performance Reports
Report
description
Location Frequency Actions
Responsibility
for Monitoring
Addition to Waiting List report
Intranet Daily CPC to check the addition to waiting lists daily and add relevant patients to SCR and / or ensure patients are treated within national/local cancer targets Cancer Tracking Coordinator Cancer Services Pathology Reports
ICE Daily Check for any outstanding pathology reporting (patients who are already on tracking)
CPC
Cancer Services Pathology Reports
ICE Daily Check for incidental cancer diagnosis and add any previously unknown cancer patients to SCR
CPC
Radiology Reports
ICE Daily Check for radiology reports CPC Endoscopy
Reports
Unisoft Daily Check for scope reports CPC Cancer PTL SCR/
Intranet
Daily Reviewed patient pathways daily
CPC Cancer PTL Intranet Weekly Full PTL to be reviewed at
weekly PTL meeting Lead/Deputy Manager Cancer Services National Cancer Waiting Times Checklist
SCR Weekly CPC to review on weekly basis to ensure complete records uploaded to CWT, compliant with national and local cancer targets
Lead/Deputy Manager
Cancels DNA
Re-book appointment
DNA/Cancellations
Diagnostic phase of pathway
Attends Pathway Continues
No – refer
back to
managing
clinician
DNA/cancels Consultant or delegate contacts pt byphone
Pt agrees to be
discharged
No response
within 48
hours pt sent
letter
Pt re-books
Pt discharged
back to GP
1 week no
response
Discharged to
GP
Contact GP by letter, in
agreement with the
managing clinician. “Pt is
now discharged back to
your care for re-referral if
required”
Clerk asks if patient wishes to be referred back to GP Yes – clerk to discharge and advise consultant team for clinical review ofpatient’s decision
Appendix B
PLAN FOR DISSEMINATION: of Cancer Services Operational Policy (Patient Access)
Title of document Cancer Services Operational Policy (Patient Access)
Date finalised Dissemination Lead Karen Blackburn
Lead Manager Cancer Services Previous document
already being used?
Yes If yes in what format
and where
Word document stored on the Trust intranet Policies page and also on the S Drive within cancer services
Proposed action to retrieve out of date copies of the document
Policy Administrator to remove from intranet. Deputy Cancer Manager to remove from S Drive
Describe the plans for dissemination of the document to the specific people/groups in specified formats and if appropriate with relevant training
Policy to be circulated to core cancer services team, directorate managers, waiting list team, out-patient team, MDT lead clinicians, Cancer Information Analyst.
All cancer core team members to be given training on the contents of the policy and implementation, both induction and refresher training.
Dissemination Record – to be used once document is ratified
Date put out on
register/library of
policy or procedural
documents
Date due to be
reviewed
Appendix C
EQUALITY IMPACT ASSESSMENT Cancer Services Operational Policy (Patient
Access)
Yes/No
Comments
1. Does the policy/guidance affect one group less or more favourably than another on the basis of
No
Race No
Ethnic origins (including gypsies and travellers)
No
Nationality No
Gender No
Culture No
Religion or belief No
Sexual orientation including lesbian, gay, bisexual and transgender people
No
Age No
Disability No
2. Is there any evidence that some groups are affected differently?
No 3. If you have identified potential
discrimination, are any exceptions valid, legal and/or justifiable?
N/A
4. Is the impact of the policy/guidance likely to be negative?
No 5. If so can the impact be avoided N/A 6. What alternatives are there to
achieving the policy/guidance without the impact
N/A
7. Can we reduce the impact by taking different action
