Quality Improvement and Learning Strategy

About The Clatterbridge Cancer Centre

The Clatterbridge Cancer Centre (CCC) is one of three specialist cancer centres in the UK. We have a unique multi-site care model – we provide radiotherapy at our three main hub sites, systemic anti-cancer therapy at six sites and outpatient care at 13 centres. We serve a population of 2.4 million across Cheshire and Merseyside.

With almost 1,800 specialist staff we are one of the largest NHS providers of non-surgical cancer treatment and we are consistently rated as one of the best performing hospitals in the Care Quality Commission’s national inpatient survey. 

Our Five‑Year Strategic Plan 2021 – 2025

Launched in 2021, the Trust’s Five Year Strategic Plan outlines six priorities:

Be Outstanding - deliver safe, high-quality care and outstanding operational and financial performance

Be Collaborative - Drive better outcomes for cancer patients, working with our partners across our unique network of care

Be a Great Place to Work - Attract, develop and retain a highly-skilled, motivated and inclusive workforce to deliver the best care

Be Research Leaders - Be leaders in cancer research to improve outcomes for patients now and in the future

Be Digital - Deliver digitally-transformed services, empowering patients and staff

Be Innovative - Be enterprising and innovative, exploring opportunities that improve or support patient care

National context

As set out in the NHS Long Term Plan, there is a clear focus on the provision of integrated care systems, which provide the platform to establish and encourage partnership working to ensure that services are coordinated to support and improve the health of the population we serve and reduce health inequalities. 

The Clatterbridge Cancer Centre NHS Foundation Trust already drives collaborative working across the region in many ways, including hosting the Cheshire and Merseyside Cancer Alliance. We are committed to ensuring that we work with colleagues across the healthcare economy to drive transform of the delivery of cancer services, address health inequality gaps and increase the years of life that people live in good health. 

Quality definition

The common and enduring definition of quality care is that of Darzi (2008) who stated that: “High quality care should be as safe and effective as possible, with patients treated with compassion, dignity and respect. As well as clinical quality and safety, quality means care that is personal to each individual.”

This Quality Improvement and Learning Strategy is written within the context of this definition whilst also acknowledging the contributions of the Francis, Cavendish, Berwick and Keogh Reports alongside the introduction of the Patient Safety Incident Response Framework (PSIRF) as major drivers for quality, change and learning across the NHS. 

This strategy is not a stand-alone document; it is aligned to existing strategies and work streams to ensure a united approach to meeting this commitment.

These include transformation, leadership, workforce, organisational culture and staff behaviours. The Digital Strategy, People Plan and the Patient Safety Incident Response Framework provide greater detail on the organisation’s approach to these elements.

Our Quality Improvement and Learning Strategy 

Our quality improvement and learning strategy has been designed, not only around national principles but also to build on our strengths by equipping our staff with the skills and tools to deliver quality patient care, every day. This will contribute to the delivery of our strategic goals. 

Improving quality and achieving our aims will take a consistent approach to improvement and learning taking account of a number of different factors. 

This new strategy builds upon previous successes and is intended to set the direction for the future quality improvement and learning processes. 

It has been informed by engagement with a wide range of stakeholders who have provided very helpful input. Early planning meetings with key individuals in the organisation and responses to consultations with patient, staff and visitors have contributed greatly to its contents. 

Our Quality ambitions

1. To widely share learning, success and excellence to improve patient safety culture and staff experience
2. To use digital real-time data and system-wide collaboration to drive outstanding care
3. To discover and implement new knowledge in order to achieve the best outcomes for patients
4. To promote and reward innovation and continuous quality improvement initiatives to build safer systems and improve patient experience

Objective 1

To widely share learning, success and excellence to improve patient safety culture and staff experience.

Current position

• CEO’s monthly video message for staff 
• Presentation at Quality Committee
• Established ward safety huddles 
• Monthly executive director quality and safety walk-round 
• Screensavers providing regular updates and important information for staff
• Schwartz Rounds to provide an open forum for learning and sharing of staff experience and support
• SRG* Lead Forum enabling regular discussion of learning opportunities, changes affecting the organisation and feedback from clinical teams
• Staff awards recognising outstanding contributions to quality and care from staff and teams
• Six-monthly audit presentation events recognising excellence in audit and quality improvement activities 

* SRG - site reference group. Our site reference groups look at treatment and care for people with cancers affecting that part (site) in the body e.g. gynaecological cancers, lung cancers. 

Short-term deliverables 2023-2024

• Undertake a patient safety culture questionnaire in order to establish a baseline data set 
• To establish improvements required to enhance the quality, effectiveness and experience of patients through the inpatient, outpatient and Trust-wide transformation programmes 
• To embed a single quality improvement (QI) process and documentation across the organisation 
• To undertake quarterly multi-professional CQC style inspection programmes based on the new methodology
• To engage in peer to peer ‘mock’ inspections to ensure a continuous focus on learning 
• To create a mechanism for sharing critical alerts to all staff in a timely manner  

Long-term aspirations 2024-2025

• To establish a ward quality accreditation framework on inpatient wards 
• To develop an interactive centrally located tool for sharing learning
• To establish a Trustwide network of improvement practitioners with access to training on quality improvement, linked with the NHS England Impact Framework

Objective 2

To use digital real-time data and system-wide collaboration to drive outstanding care.

Current position

• Established dedicated Business Intelligence Team focused on making the best use of real-time data
• Multiple live dashboards to inform clinically relevant decision making in real time
• Hosting the Cheshire and Merseyside Cancer Alliance since 2017 to facilitate collaboration between all services in Cheshire and Merseyside
• Supra-regional and a range of specialist and metastatic multidisciplinary teams (MDTs) to enable access to specialists between organisations
• Launch of the Digital Strategy which sets new standards for use of digital resources to drive improvements in care
• Metastatic spinal cord compression (MSCC) service covering Cheshire and Merseyside

Short-term deliverables 2023-2024

• To roll out ward specific patient-level dashboards to minimise risk 
• Encourage use of all wards and department dashboards to ensure that contemporaneous high quality data is captured and drives improvement 
• To actively participate in Cheshire and Merseyside regional falls prevention collaborative 
• To drive collaboration and benchmarking of standardised data between the three oncology centre infection prevention and control (IPC) teams 
• To ensure use of electronic systems for all data capture and analysis

Long-term aspirations 2024-2025

• To collaborate with the Cancer Academy to support the education agenda 
• To embed the use of live dashboards within our committee structure 
• To identify opportunities for peer to peer review of key areas of service 
• Develop digital resources to enable remote monitoring and patient reported outcome measures in real-time across multiple SRGs

Objective 3

To discover and implement new knowledge in order to achieve the best outcomes for patients.

• Published the outcomes of our mortality reviews in the quality accounts with benchmarking against peer organisations
• 30-day SACT mortality process and other related projects fully embedded, driving detailed reviews of care by clinical teams and identification of changes to minimise treatment related mortality alongside best possible care
• Full internal clinical audit programme with administrative and statistical support
• Participants in national audit programme for all tumour types
• Launched a Trustwide innovation strategy to drive innovations within the trust which improve patient experience and quality of care
• All new patient data has been made available to all consultants using an interactive format
• Launch of the Trust Research Strategy
• Active recruitment of patients into clinical trials
• The Clatterbridge Cancer Centre (CCC) research grant scheme

Short-term deliverables 2023-2024

• Establishment by clinicians of defined measures of ‘clinical excellence’ for each disease site that can be measured and continuously monitored to ensure that any changes are immediately apparent
• Continue the improvement in comprehensive new patient data collection so that more than 90% of all new patients are included
• Continue to work with clinical staff to improve access to and direct use of available data and to encourage ‘ownership’ of their data to improve data quality
• To continue to use the Safer Nursing Care Tool (SNCT) model of patient acuity to inform on-going workforce succession planning 
• To lead on the national drive to fully integrate clinical audit methodology alongside other quality improvement initiatives so that the focus is on improvement rather than measurement only

Longer-term aspirations 2024-2025

• Access to clear and concise outcome and population data that will inform best practice.
• Having a portfolio of clinical measures of excellence for all disease groups published on the website
• Clinical staff have the confidence to access clinical data that is both meaningful and enhances their work activities

Objective 4

To promote and reward innovation and continuous quality improvement initiatives to build safer systems and improve patient experience.  

Current position

• Established Bright Ideas scheme in 2021, enabling clinical teams to make the changes they feel will make the biggest difference
• Big Ideas scheme for larger initiatives was launched in 2023
• Quality improvement projects monitored via Quality Improvement and Clinical Audit Committee
• NICE assurance monitored in the Clinical Effectiveness Committee and linked to SRGs as appropriate

Short-term deliverables 2023-2024

• To pilot smart hydration system 
• To undertake quarterly multi-professional CQC style inspection programme based on the new methodology
• Provide a patient centred and patient led approach to care that includes keeping patients informed and involved in decisions about their care

Long-term aspirations 2024-2025

• Co-design and develop a ward accreditation programme to celebrate excellence in care 
• To embed Quality Improvement in the appraisal process to ensure that staff who work for us understand their role in improving patient care and experience
• Look at new and innovative ways to recruit and retain the best staff
• To retain a workforce that continually strives for excellence as demonstrated through their performance, attitudes and behaviours  and on-going commitment to the organisation
• Support people who have led quality improvement to attend conferences to present their work and project outcomes 
• Establish a CCC Improvement hub for access training and resources to support our staff leading quality improvement as well as sharing examples of excellence from within the organisation

This document has outlined our strategic ambitions with regards to quality improvement and key objectives to achieve in delivering those ambitions. As an organisation we need to know when those objectives are met and when we have successfully implemented an improvement. 

Implementing and sharing what we have learnt in a rigorous, measurable and demonstrable way is vital. However sharing what we have learnt from an event, project or investigation is broader than telling people and delivering training.

Making a sustained system-wide change shows we have learnt as a whole organisation: training everyone not to use a broken system is not as good as fixing it. Our strategy for handling lessons therefore needs to reflect that whilst some lessons need to be widely disseminated and form the basis of further education, others need to be definitively addressed using system-based approaches. 

The below model describes a tiered approach to managing lessons which emerge in the organisation through existing governance routes. 

Step 1 - How lessons are generated

The lessons we learn in our organisation are generated in a number of ways. These can include audits and quality improvement initiatives, feedback from patients, staff or external agencies, lessons picked up through standing governance processes or external lessons e.g. national alerts which are fed into the organisation.

Whilst there needs to be a central oversight of lessons and decisions taken about how to act upon them, different lessons will require different responses.

Additionally, in line with the national patient safety strategy, The Clatterbridge Cancer Centre will adopt the national framework for identifying local areas of focus and improvement and adopt a risk-based approach to incident investigations to ensure that the lessons we learn are based around local needs, risks and priorities and do not expend excessive resource on areas which are already the subject of improvement or where further actions and lessons would not improve the outcome further.

These priorities will be formalised in the organisation’s Patient Safety Incident Response Policy.

Step 2 - Who decides what to do with the lessons we learn?

Oversight of lessons and decisions of how these should be acted upon and disseminated should fall within the scope of work of the three governance domains:

• Patient safety
• Patient experience, and
• Clinical effectiveness

Each of these streams has a governing committee with a reporting structure into and out of the committee and should have oversight of all lessons in these domains.

It will be the responsibility of these committees to determine what level of action is required (see step 3 for guide), or if an alternative approach is needed.

As the central point for overseeing lessons these committees will also be responsible for monitoring trends as multiple lessons relating to the same process, department, clinic etc. may require further in depth quality assessment. 

Step 3 - How do we act on lessons?

The action required for the lessons to be learnt may be stratified. Not every lesson requires an organisation-wide response although some will. Not all lessons need to be restricted to staff, some will.

Therefore the hierarchy described here enables different actions to be assigned to each lesson. Of note, this hierarchy is not exhaustive and committees can opt to pursue a difference avenue for learning a lesson and each lesson may have more than one tier of action assigned to it.

1:1 text

The five levels are:

• Emergency major incident response
• Safety guardianship / cognitive aids for critical processes
• Process review: can it be simplified, automated or digitised?
• Widespread communication, education and including patients in maintaining safety
• Make a specific change once and re-audit 

Make a specific change once and re-audit 

This action relates to when a lesson learnt relates to a specific and rapidly amendable process or procedure such as a faulty piece of equipment or estates. The whole organisation does not need to be involved in the lesson if it can be dealt with more efficiently by a focused and immediate intervention which ensures a faulty process cannot recur. 

Widespread communication, education and including patients in maintaining safety

This action relates to lessons which are a matter of getting knowledge to the right people, including patients where appropriate to ensure mistakes are not made in routine practice which could foreseeably occur if the information does not reach the right people.

This should include disseminating information where people cannot miss it, e.g. in common thoroughfares in the organisation and by using technology to enhance the transfer of information. Using mass email or banners on computer screen savers are unlikely to stand out enough for the information to be received – a bolder approach which is not over-used should be considered.

The involvement of patients in receiving this information should be considered when there is a lesson relating to the general population over which The Clatterbridge Cancer Centre has no oversight but which they may need to act upon. 

Process review: can it be simplified, automated or digitised?

This action relates to when lessons are learnt about processes which are complex, error prone or have resulted in human error. The event of human error in a process may be addressed by removing as many of the human steps in that process as possible, so an in-depth review of the process considering which elements can be automated or digitised removes that risk.

Safety guardianship / cognitive aids for critical processes

This action relates to lessons which emerge from complex processes which can only be done by humans, and errors in that process have led to learning events. The process cannot be automated and one-time (or limited) (re)training is unlikely to have lasting impact or address the complexity of the process in action.

This action therefore requires a subject expert be released to supervise the process as it occurs, offering corrective feedback in real time and constructing cognitive aids to challenge people at key points in the process where common mistakes are made to ensure longer term change in practice. 

Clinical emergency major incident communications

This action relates to a major event which requires high level senior oversight of actions. It requires members of the Trust executive team to meet at short notice and create a bespoke action plan, delegate actions appropriately and hold responsibility for overseeing completion. 

An example might be a breach of the law occurring on the organisation’s premises where patient care and/or staff safety are impacted. 

What about Trustwide communications?

The Trust intranet and a learning for improvement bulletin should still be used to disseminate learning across the whole organisation. However, these tools should be issued quarterly as a record of the actions in step three which have already been undertaken that quarter. This way it serves as a reminder to be vigilant rather than the first or only response to a lesson learnt.

Monitoring arrangements

Progress against the objectives set out in this plan will be monitored annually by the Quality Committee.

However the specific actions and progress of each workstream will be captured on a more regular basis through the well-established governance committees (Patient Safety, Patient Experience and Clinical Effectiveness) and the Transformation Boards.  

Quality improvement is everyone's business...

...but there are some specific ways that you can get involved:

• Join a quality and improvement session where we will look at how to identify an improvement project and how you can use tools to measure deliverable improvements
• Sign up for a training session which will offer frontline teams a variety of training on how to develop improvement skills that apply in a real life work context
• Gather a team together an apply for an improvement collaborative  to focus on a specific issue
• Support one of the established pathway improvement boards or join an improvement collaborative 

Quality Improvement Hub

• Let’s create an improvement movement – look out for the opening of the Improvement Hub 
• Promoting good practice across the Trust –celebrating and learning from the great things staff are doing

• NHS Impact Framework (2023)
• NHS England (2016) National Quality Board NHS Outcomes Framework 
• Berwick D. (2013) A promise to learn– a commitment to act: Improving the Safety of Patients in England
• Cavendish C. (2013) An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings
• Francis R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry
• Keogh B. (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England