Systemic Anti-Cancer Therapy Governance Framework and Audit Tool March 2013

Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

© Healthcare Improvement Scotland 2013 First published March 2013 The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document’s date and title specified. www.healthcareimprovementscotland.org 2

Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

Contents 1

Introduction

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2

Governance framework for Systemic Anti-Cancer Therapy services

5

3

Systemic Anti-Cancer Therapy Audit Tool

7

Appendix 1: Patient record review

24

Appendix 2: Healthcare Improvement Scotland escalation algorithm

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Appendix 3: Membership of the SACT working group

28

Appendix 4: References

30

Appendix 5: About Healthcare Improvement Scotland

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

1

Introduction

Systemic Anti-Cancer Therapy (SACT) encompasses both biological therapy * and cytotoxic chemotherapy †. CEL 30 (2012), [Revised] Guidance for the Safe Delivery of Systemic Anti-Cancer Therapy1 was published by the Scottish Government in July 2012. It stated that “cytotoxic chemotherapy is known to be potentially carcinogenic, mutagenic and is hazardous as defined by the Control of Substances Hazardous to Health Regulations 2002 (COSHH)” and provided updated guidance on its safe delivery. The guidance was endorsed by the Scottish Cancer Taskforce. The Scottish Cancer Taskforce is leading a programme developing quality performance indicators (QPIs) to drive continuous quality improvement in cancer care across NHSScotland, within which small sets of cancer-specific indicators will be underpinned by core generic QPIs. This programme is outlined in CEL 6 (2012), National Cancer Quality Programme2. Following the publication of CEL 30 (2012), and with acknowledgement that indicators related to SACT are contained within some of the cancer-specific indicators, the Scottish Cancer Taskforce agreed that generic SACT QPIs should be considered for development alongside an audit tool and governance framework for CEL 30 (2012) aligned to the QPI framework. In September 2012, Healthcare Improvement Scotland convened the SACT working group to consider and develop these outputs. Membership was drawn from the regional cancer advisory groups (RCAGs) with support provided by Healthcare Improvement Scotland and Scottish Government staff. The group’s membership is given in Appendix 3. This document contains the national governance framework for SACT, linked to CEL 30 (2012), and the national SACT audit tool. National generic QPIs for SACT, building on elements of existing cancer-specific indicators, will be re-considered for development subject to the collection of baseline data from the audit allowing identification of suitable targets for measures. Status of this advice

The status of Healthcare Improvement Scotland advice and guidance is defined as one of the following three categories: 'mandatory', 'required to consider', or 'for information only'. The governance framework and audit tool have been endorsed by the Scottish Cancer Taskforce, and completion of audit of SACT services using the audit tool and in line with the governance framework is mandatory.

*

Biological therapies include medicines that block the growth and spread of cancer by interfering with specific molecules involved in tumour growth and progression, and medicines that use the body’s immune system to fight the cancer. † A group of medicines that contain chemicals which are directly toxic to cells, preventing their replication or growth, and so are active against cancer.

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

2

Governance framework for Systemic Anti-Cancer Therapy services

The governance framework for CEL 30 (2012), which is aligned to the governance framework outlined in CEL 6 (2012), presents the process NHS boards must follow when undertaking mandatory audit of SACT services. Figure 1 on page 7 shows each stage of the governance framework. Key stages are outlined below. Self-assessment

Self-assessment of SACT services, using the audit tool must be undertaken for all SACT services by the end of September 2013. These self-assessments should contribute to an NHS board level exception report for SACT services to address any areas of non-compliance with the audit tool. Peer review

NHS boards will be peer reviewed through intra-regional assessment to inform Board-level and regional action/improvement plans every 3 years. The peer review process will be arranged by the RCAGs. It will involve identifying the schedule of peer review visits, ensuring all sites are visited at least every 3 years, and inviting external reviewers from other regions to select and participate on one regional audit each year. Following an audit, if there is potential cause for concern the external review team must inform the NHS Board involved, the appropriate RCAG and Healthcare Improvement Scotland ‡. Any issues raised will be subject to the Healthcare Improvement Scotland escalation algorithm (included as Appendix 2). All SACT units within a region should be audited as soon as practical, recognising that this will be dependent on the number of individual units within the region. The maximum completion time of a full round of audits is 3 years. Following peer review, NHS board approved exception reports and action/improvement plans must be submitted to the appropriate RCAG. Expert review group

NHS board-level exception reports and action/improvement plans must be submitted to the expert review group, which will be convened following the initial round of self-assessment. This group will be hosted by Healthcare Improvement Scotland‡, with medical, pharmacy, nursing and management membership from each of the three RCAGs, plus patient representatives and data expertise (ISD). The expert review group will meet annually and produce a review of the exception reporting and submit it to the Scottish Cancer Taskforce.

‡

Contact: Laura McIver, Chief Pharmacist: [email protected], 0131 227 3285

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

Figure 1: Governance framework for Systemic Anti-Cancer Therapy services

Development of national audit framework

Self-assessment of compliance with CEL 30 (2012) undertaken by NHS Boards Peer review of compliance with CEL 30 (2012) undertaken by NHS Boards

If progress acceptable

Annual expert review group convened to review exception reports and improvement plans

Improvement support (where required) Monitoring

Escalation: action if failure to progress improvement

1. Development stage • National audit framework developed to support review of compliance with CEL 30 (2012). Development group includes medical, pharmacy, nursing and manager representation from Regional Cancer Networks, Healthcare Improvement Scotland, ISD, Scottish Government, patient representatives and the Cancer Coalition. 2. Self-assessment • NHS boards undertake self-assessment using audit tool within 6 months of the governance framework being issued. • NHS boards prepare board-level exception report and action/ improvement plan to address any areas of non-compliance. 3. Peer review • NHS boards are peer reviewed through intra-regional assessment to inform board-level and regional action/improvement plans every 3 years. • Each region will include an external peer reviewer in one intraregional audit each year. • NHS board approved exception reports and action/improvement plans submitted to RCAGs after peer review assessment. • Healthcare Improvement Scotland notified of any potential cause for concern, and issue subject to Healthcare Improvement Scotland escalation algorithm (Appendix 2). 4. Expert review group • The expert review group, hosted by Healthcare Improvement Scotland, reviews Board-level exception reports and action/improvement plans. • Expert group will include medical, pharmacy, nursing and management representatives from each regional cancer network, Healthcare Improvement Scotland, patient representatives and data expertise (ISD). • Expert review group will produce a report on the review of exception reporting for submission to the Scottish Cancer Taskforce. 5. Improvement support • Improvement approaches are considered.

6. Monitoring • RCAGs work with NHS boards to progress outstanding actions, monitor action/improvement plans. • Healthcare Improvement Scotland reports to Scottish Cancer Taskforce at annual expert review. 7. Escalation • If progress not acceptable, Healthcare Improvement Scotland will establish dialogue with the service concerned, visit if necessary and work with the NHS board and RCAG to address issues. See Healthcare Improvement Scotland escalation algorithm (Appendix 2). • Report submitted to Scottish Cancer Taskforce through the Scottish Government Health and Social Care Directorates.

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

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Systemic Anti-Cancer Therapy Audit Tool

The purpose of this audit tool is to record compliance with CEL 30 (2012) [Revised] Guidance for the Safe Delivery of Systemic Anti-Cancer Therapy1,3,4. CEL 30 (2012) provides NHS boards with a framework for safe practice in the prescribing, preparation, administration and disposal of systemic anti-cancer therapy (SACT), and NHS boards are required to demonstrate compliance with it. The audit tool should be used by SACT services to complete self-assessment by the end of September 2013, and thereafter in line with the governance framework for Systemic Anti-Cancer Therapy services. Audit should be conducted by a multi-professional (nurse, pharmacist, and medical staff) team involved in the delivery of SACT. The NHS board lead clinician for SACT should report compliance with CEL 30 (2012) to the NHS board Chief Executive as part of their clinical governance procedures. The SACT working group would like to acknowledge the work of Kathryn Brechin (Clinical Nurse Manager, Cancer & Palliative Care, Edinburgh Cancer Centre) and Heather Dalrymple (Lead Cancer Care Pharmacist, Edinburgh Cancer Centre) in piloting the audit tool. Please see our website (www.healthcareimprovementscotland.org) to download a Word version of this audit tool to save and use electronically, or print to use by hand.

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

1. The NHS board has identified a Lead Clinician for SACT services (a consultant oncologist or haematologist) and documented their roles and responsibilities. They are supported by a senior pharmacist and a senior nurse EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Minutes from NHS Board Clinical Governance Committee (or equivalent) which names the responsible individuals. b. Reporting Structure c. Lead Clinician’s job description including details of roles and responsibilities. d. Cooperative governance arrangement where Lead Clinician is outside the NHS Board area

Signature:

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

2. There are clinical management guidelines (CMGs), SACT protocols and associated supportive treatment guidelines (STGs) in place which are in line with CEL 30 (2012) and are readily available to all clinical staff involved in the delivery of SACT EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Accessibility to all clinical staff of; i. CMGs ii. SACT protocols - cross-section sample of SACT protocols comply with the framework outlined in Appendix 1 of CEL 30 (2012) (see over) iii. Supportive treatment guidelines - STGs comply with the minimum list of guidelines outlined in Appendix 5 of CEL 30 (2012) (see over) iv. Protocols for the management of complications of SACT, in particular, neutropenic sepsis, are accessible to all relevant staff across the NHS Board area e.g. AAUs b. System in place for development, approval and review of the above, including document control c. Availability of contingency plan when system failure (e.g. computer system failure)

Signature:

Date: 9

Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

CEL 30 (2012) Appendix 1

CEL 30 (2012) Appendix 5

“SACT Protocol Framework

“Supportive Treatments

• • • • • • • • • • • • • • • • • • • • • •

the sole use of an acronym to identify a protocol is minimised definition of the clinical condition being treated including line of therapy treatment intent all SACT medicines by full generic name and, if appropriate by formulation and proprietary name dosing schedule for each medicine route, method and duration of administration maximum cumulative doses where applicable any pre-medication required diluents and appropriate infusion volumes hydration schedules (if required) supportive therapy including, where appropriate, prophylaxis for the prevention of neutropenic sepsis concomitant radiotherapy & scheduling where relevant relevant haematology and biochemistry parameters any other tests that need to be performed before SACT starts and during treatment special precautions and contraindications to treatment potential medicines and food interactions expected toxicities extravasation risk recommendations for treatment delays or dose reductions based on relevant toxicities and/or haematology and biochemistry parameters where relevant, reference should be made to policies for the management of toxicities decision points including response assessment and advice on when patients should be referred for review reference source(s).”

Protocols for the following conditions are developed locally and endorsed by local or regional governance groups. The detail of the content will reflect local practice. • neutropenic sepsis in line with the Best Practice statement for Assessment, Diagnosis and Management of Neutropenic Sepsis: Scottish Government September 2011 • nausea and vomiting • diarrhoea and constipation • mucositis • skin toxicity • tumour lysis syndrome • hypersensitivity reactions.”

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

3. The decision to initiate a new course of SACT is taken by a consultant oncologist / haematologist and the patient has provided written informed consent to receive SACT EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. NHS Board policy for consent to receive SACT b. Availability of standardised documentation for consent to treatment c. Completion of individual patient record review questions 1 – 8 (see Appendix 1) for 6 patients by cross-section review to include 4 oncology and 2 haematology patients

Signature:

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

4. The performance status of the patient is documented EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Completion of individual patient record review question 9 (see Appendix 1) for 6 patients by cross-section review to include 4 oncology and 2 haematology patients

Date:

Signature:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

5. SACT is prescribed, verified, prepared and administered correctly EVIDENCE

COMPLIANCE Yes

No

COMMENTS

Partial

a. SACT prescribing policy b. List of practitioners appropriately qualified and trained to prescribe SACT (medical and non-medical prescribers) is available to all staff c. Local policy/protocol for key pharmaceutical checks (see CEL 30 (2012) Appendix 3, provided overleaf) d. Completion of individual patient record review question 10 (see Appendix 1) for 6 patients by cross-section review to include 4 oncology and 2 haematology patients in accordance with local identified policy and protocols e. Procedures for the safe dispensing and release of SACT from a pharmacy controlled facility f.

Aseptic facility has undergone external audit within the last 2 years and an action plan is in place to achieve full compliance with standards where relevant

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ACTION PLAN

Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

5. SACT is prescribed, verified, prepared and administered correctly EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

g. Policies/procedures for SACT administration (including oral) h. Areas used for SACT administration are safe and appropriate

Signature:

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

CEL 30 (2012) Appendix 3 “Key Pharmaceutical Checks This list of pharmaceutical checks is not exhaustive but forms the basis of local policy and practice. For specific SACT regimens additional checks may be necessary or, conversely, some checks may not be relevant. In both these scenarios a risk assessment is completed and documented to determine which checks are required to maintain patient safety and quality of care. • prescriber details and signature are present and confirm they are authorised to prescribe SACT • ensure protocol has been through local approval processes • for the first cycle, the protocol is the intended treatment as documented in the patient specific treatment plan and is appropriate for the indication • the protocol is appropriate for the patient’s diagnosis, medical history, performance status and SACT history • there are no known medicine or food interactions or conflicts with patient allergies or previous adverse reactions • the timing of administration is appropriate in relation to interval since last treatment • patient demographics including age, height and weight are correctly recorded on prescription • body surface area (BSA) is correctly calculated, taking into account recent weight • all dose calculations and dose units are correct and have been calculated correctly according to the protocol and any other relevant local guidance • cumulative dose and maximum individual dose as appropriate • reason for any dose adjustment is documented and the dose adjustment is appropriate • method of administration is appropriate • relevant laboratory values are within accepted limits as defined in the SACT protocol • other essential tests have been undertaken where appropriate • doses are appropriate with respect to renal and hepatic function, performance status and co-morbidities and any experienced toxicities • supportive care is prescribed and it is appropriate for the patient and SACT protocol

•

requirement for dose adjustment and/or prophylaxis, to minimise risk of neutropenic sepsis, as specified in the SACT protocol.”

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

6. The patient is assessed for adverse effects at appropriate intervals using a recognised toxicity grading system, and adverse effects are being managed EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Completion of individual patient record review question 11 (see Appendix 1) for 6 patients by cross-section review to include 4 oncology and 2 haematology patients

Signature:

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

7. All clinical incidents relating to SACT of avoidable harm and near miss events are documented, reviewed, and learning shared EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. NHS Board incident management policy and investigation process b. System(s) for: i. documenting and reviewing clinical incidents of avoidable harm and near miss events (e.g. DATIX) ii. documenting actions taken / changes made as a result of incident reports iii. Clinical Governance Committee review of clinical incidents c. Local / regional / national shared learning

Signature:

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

8. Administration of intravenous SACT includes techniques to minimise risk of extravasation § and procedures for management of the suspected or actual extravasation EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Extravasation policies / procedures for: i. prevention ii. treatment iii. follow-up management b. i. Review an extravasation event identified on an incident reporting system (e.g. DATIX) ii. Examine the relevant patient’s record for; - appropriate documentation of the incident along with a completed clinical incident report - evidence of communication with the patient’s GP iii. Collated reports and learning

Signature:

§

Leakage of an intravenous medicine from the vein into surrounding tissues.

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

9. Intrathecal cytotoxic chemotherapy is administered safely EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Intrathecal register held by the Chief Executive and copies held by the designated lead for the NHS board, Medical Director, Director of Pharmacy and Director of Nursing b. Review 2 intrathecal prescriptions Check that all personnel involved with the process are listed on the intrathecal register i.e. prescriber, pharmacist, personnel issuing, receiving and administering the intrathecal

Signature:

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

10. Death within 30 days is reported and reviewed EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Procedures/protocols for documenting, reporting and reviewing all deaths occurring within 30 days of SACT administration b. Minutes of clinical governance meetings where reports are discussed

Date:

Signature:

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11. All staff have the appropriate skills, knowledge and training EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

a. Education and training programme (see CEL 30 (2012) 1.2.3, provided overleaf) including competencies and methods of assessments b. Cross section of staff training records to ensure practice remains up to date and relevant (i.e. select from medical, pharmacy and nursing) and review: i. Details of training received, specialist clinical updates etc ii. competency assessments if appropriate

Signature:

Date:

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Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

CEL 30 (2012) 1.2.3 “The education and training programme includes: • principles of safe use and relevant national guidance • local policy and procedures on safe use • principles of SACT • CMGs and SACT protocols relevant to area of clinical practice • consent and information giving • holistic assessment of patients receiving SACT • prevention and management of adverse effects • selection and use of equipment • safe handling of cytotoxic chemotherapy”

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12. Delivery of SACT outwith Cancer Centres/Units is compliant with CEL 30 (2012) EVIDENCE

COMPLIANCE Yes

No

COMMENTS

ACTION PLAN

Partial

A shared care framework for delivery of SACT outwith the Cancer Centre/Unit which has been developed and approved by the NHS Board and Clinical Governance committee

Signature:

Date:

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Appendix 1: Patient record review Patient initials:

CHI number:

Diagnosis: Treatment intent: EVIDENCE

COMPLIANCE Yes

1. Decision to initiate a new course of SACT is taken by a consultant oncologist/haematologist 2. Multidisciplinary discussion for consideration of cancer treatment, where appropriate 3. Decision on initiation of first line treatment 4. Patient specific management plan 5. Communication of treatment decision, treatment intent, and plan to GP within 14 days 6. Treatment decisions and subsequent changes are clearly documented 7. Patient’s written consent to treatment 8. Verbal and written information has been given to patient (see CEL 30 (2012) section 2.2.1, provided overleaf, for minimum information) 9. WHO performance status 10. Prescription documents patient specific information and SACT details, including prescriber and pharmaceutical verification and record of administration (see CEL 30 (2012) Appendix 2, provided overleaf) 11. Adverse effects are being assessed at appropriate intervals, and managed.

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No

Partial

COMMENTS

Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

Excerpt from CEL 30 (2012) section 2.2 “2.2 Information for Patients 2.2.1

There is provision of written and verbal information to patients receiving SACT and as a minimum patients receiving treatment are made aware of the following: •

SACT protocol specific toxicities

•

signs and symptoms of extravasation

•

information on what to do in the event of developing a toxicity including when, who and how to contact the appropriate services

•

safe handling and disposal of patient waste.

2.2.2

Additional information is provided to support safe self management for patients self administering SACT outwith a healthcare setting, for example, oral treatment.

2.2.3

A record of the information given to patients is documented.”

Excerpt from CEL 30 (2012) Appendix 2 “SACT Prescriptions The following patient specific information is documented: • • • • • • • •

name, date of birth, CHI number height, weight and body surface area where relevant diagnosis performance status relevant haematology and biochemistry results any other relevant tests calculated doses to be administered indication of any dose modifications made.

Prescriptions are clear and unambiguous and include: • the name of the SACT protocol • all SACT medicines to be given including protocol doses • the full generic name of each medicine and, where appropriate, the specific formulation and its proprietary name • intervals between cycles • maximum cumulative doses where applicable • route, method and duration of administration • where appropriate, diluents and infusion volumes • hydration schedules if required • pre-medication if required • appropriate supportive therapy • indication of concomitant radiotherapy where applicable • cycle number and date of administration • for oral SACT, the start date and duration of each treatment cycle • name of prescriber, signature and date prescribed • pharmaceutical verification signature and date • administration signatures, date and time where relevant.”

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Appendix 2: Healthcare Improvement Scotland escalation algorithm Figure 2 on page 27 is the Healthcare Improvement Scotland escalation algorithm. Initiation of the algorithm starts with identification of an adverse event, routine analysis or interpretation of healthcare data (for example. HSMR, quality indicators), review of compliance or inspection activities [box top left]. The initial assessment results in a decision to: a) take no further action, b) escalate to an appropriate external agency, or c) instigate further interactions with the NHS board concerned, including inspection visit, diagnostic visit, improvement support, request for further information or improvement plan, and regulatory activities. A second round of assessment generates reporting and/or learning activities if satisfactory, and a further round of Healthcare Improvement Scotland activity or escalation to external agencies as appropriate if not satisfactory.

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Figure 2: Healthcare Improvement Scotland Escalation Algorithm Potential cause for concern eg • Adverse event • Adverse scrutiny report • Routine review of data raises concerns • Request for assistance from NHS Board • Request for input from SGHD

Action: Situation needs assessment – review situation-specific data and contextual data [individual unit to define who does this and how] Urgent action: Immediate escalation to SGHD. No

Urgent external escalation?

Assessment satisfactory?

No action required. Update records or risk profile; inform relevant persons/ agencies Yes

No

Urgent action: Emergency enforcement Urgent action: Refer to other external agency

Action: Inspection/scrutiny visit by HIS

Action: Diagnostic visit/implementation support from HIS

Action: Request further information including improvement plan/feedback

Action: Independent Healthcare – follow regulatory framework

Output: Inspection report & improvement action plan

Output: diagnostic report/ implementation action plan

Output: Additional information or feedback submitted to HIS [agreed timescale]

Output: Inspection report, condition notice, improvement notice

Action: NHS Board to report on progress [agreed timescale]

Action: NHS Board to report on progress [agreed timescale]

Urgent Action: Escalate failure to act/ progress to satisfactory level to SGHD

Action: Organisation to report on progress in line with statutory timescales

Action: Assess & review results of intervention

Action: Provide feedback to board/provider

Action: Refer to external agency including Procurator Fiscal Action: Refer board to HIS team for implementation support Action: Review situation & action further round of input/scrutiny/escalation

No

Response/ improvement 27 satisfactory?

Yes

Action: Publish findings within defined timescale if appropriate

Update organisational profile; inform relevant persons/ agencies. Review progress at defined interval(s)

Systemic Anti-Cancer Therapy - Governance Framework and Audit Tool

Appendix 3: Membership of the SACT working group Name

Title

Organisation

Paul Baughan

Chair

Scottish Primary Care Cancer Group

Moray Baylis

Project Officer

Healthcare Improvement Scotland

Shelagh BonnerShand

Manager

NOSCAN

Angela Bowman

Medical Oncologist, Edinburgh Cancer Centre

SCAN

Kathryn Brechin

Clinical Nurse Manager, Cancer & SCAN Palliative Care, Edinburgh Cancer Centre

Heather Dalrymple

Lead Cancer Care Pharmacist, Edinburgh Cancer Centre

SCAN

David Dunlop (Chair)

Clinical Director, Beatson West of Scotland Cancer Centre

WOSCAN

Keith Farrer

Macmillan Lead Cancer & Palliative Care Nurse, North of Scotland Planning Group

NOSCAN

Cathy Hutchinson

Consultant Nurse, Beatson West of Scotland Cancer Centre

WOSCAN

Lesley Kidd

Patient representative

SCAN Patient Network

Kate MacDonald

Network Manager

SCAN

Laura McIver

Chief Pharmacist

Healthcare Improvement Scotland

Mary Maclean

Regional Cancer Care Pharmacist (West of Scotland)

WOSCAN

Stella Macpherson

Patient representative

SCAN Patient Network

Ewan Morrison

Associate Director of Pharmacy - Acute services, NHS Lothian

SCAN

Joy Nicholson

Consultant Pharmacist

Healthcare Improvement Scotland

Mark Parsons

Macmillan Regional Cancer Pharmacist North of Scotland

NOSCAN

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Karen Ritchie

Head of Knowledge and Information

Healthcare Improvement Scotland

Judith Smith

Nurse Consultant, Cancer / Palliative Care, Borders General Hospital

SCAN

Scott Taylor

Programme Manager – Cancer Team, QuEST, Directorate for Health Workforce and Performance

SGHD

Evelyn Thomson

Regional Manager (Cancer)

WOSCAN

Jane Tighe

Head of Service for Clinical Haematology, NHS Grampian

NOSCAN

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Appendix 4: References 1. Scottish Government. CEL 30 (2012), Guidance for the Safe Delivery of Systemic AntiCancer Therapy. July 2012. [cited 2013 February 07]; Available from: http://www.sehd.scot.nhs.uk/mels/CEL2012_30.pdf 2. Scottish Government. CEL 6 (2012), National Cancer Quality Programme. March 2012. [cited 2013 February 07]; Available from: http://www.sehd.scot.nhs.uk/mels/CEL2012_06.pdf 3. Scottish Government. CEL 21 (2009), Safe Administration of Intrathecal Cytotoxic Chemotherapy. June 2009. [cited 2013 February 07]; Available from: http://www.sehd.scot.nhs.uk/mels/CEL2009_21.pdf 4. NHS Scotland. Assessment, Diagnosis and Management of Neutropenic Sepsis, Best Practice Statement. September 2011. [cited 2013 February 07]; Available from: http://www.scotland.gov.uk/Topics/Health/Services/Cancer/Neutropenic-Sepsis-BestPractice 5. Scottish Parliament. Primary Medical Services (Scotland) Act 2004. Edinburgh. HMSO. 2004 [cited 2013 February 07]; Available from: http://www.legislation.gov.uk/asp/2004/1/pdfs/asp_20040001_en.pdf 6. Scottish Government. The Healthcare Quality Strategy for NHSScotland. May 2010. [cited 2013 February 07]; Available from: http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf

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Appendix 5: About Healthcare Improvement Scotland Healthcare Improvement Scotland was launched on 1 April 2011. This health body was created by the Public Services Reform (Scotland) Act 20105 and marks a change in the way the quality of healthcare across Scotland will be supported nationally. Our vision

Our vision is to deliver excellence in improving the quality of the care and experience of every person in Scotland every time they access healthcare. Our purpose

Our organisation has key responsibility to help NHSScotland and independent healthcare providers to: • •

deliver high quality, evidence-based, safe, effective and person-centred care, and scrutinise services to provide public assurance about the quality and safety of that care.

What we do

We are building on work previously done by NHS Quality Improvement Scotland and the Care Commission, and our organisation includes: • • • •

Healthcare Environment Inspectorate Scottish Health Council Scottish Health Technologies Group, and Scottish Intercollegiate Guidelines Network (SIGN).

Our work programme supports Scottish Government priorities, in particular those arising from the Healthcare Quality Strategy for NHSScotland6. Our work encompasses all three areas of the integrated cycle of improvement (see Figure 3) with patient focus and public involvement at the heart of all that we do. The integrated cycle of improvement involves: • • •

developing evidence-based advice, guidance and standards for effective clinical practice driving and supporting improvement of healthcare practice, and providing assurance about the quality and safety of healthcare through scrutiny and reporting on performance.

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Figure 3: Integrated cycle of improvement

Visit our website: www.healthcareimprovementscotland.org for further information.

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www.healthcareimprovementscotland.org

Edinburgh Office | Gyle Square | 1 South Gyle Crescent | Edinburgh | EH12 9EB Telephone 0131 623 4300

Glasgow Office | Delta House | 50 West Nile Street | Glasgow | G1 2NP Telephone 0141 225 6999

The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group and the Scottish Intercollegiate Guidelines Network (SIGN) are part of our organisation.