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Report finds safety flaws in breast care
[Posted: Thu 25/02/2010 by Niall Hunter, Editor www.irishhealth.com]
A major review of the eight designated hospital breast cancer centres has found that the centres still do not have all the proper processes in place aimed at minimising missed or delayed diagnoses.
The review found that in spite of the recent breast cancer scandals, which helped prompt the reorganisation of services into the eight centres, there is as yet no national definition of a delayed diagnosis, or a consistent approach across the eight centres for doctors to audit and report these clinical incidents and share information.
The Health Information and Quality Authority (HIQA) report on quality and safety standards in the centres says that while delayed diagnoses in breast cancer are rare, they will occur in the best centres in the world.
"When this happens, it is important that it is detected early and the patient is treated appropriately and promptly. An analysis of how it has happened, in order to minimise the likelihood of it happening again, is essential in any service."
However, the report indicates that this type of analysis is not yet in place across the eight centres. It says there should be a nationally-agreed definition of delayed diagnosis and a consistent approach across the eight centres in reporting these incidents, including discussion with patients.
"These will allow the centres to develop improvement strategies to reduce the risk of these rare incidents which have profound consequences for patients, and to put in place processes and behaviours to openly and effectively communicate with patients and their families."
The report found there is still no sharing of treatment outcome data between the eight designated breast cancer centres to enable them to compare their clinical performance and maximise patient safety.
However, the absence of this data is not peculiar to the breast cancer centres, as there is no comparative audit data on clinical performance between hospitals throughout the health service.
The HIQA report effectively admits that in spite of the reorganisation and improvements in breast cancer services, we still do not know for certain how safe the centres are.
The report shows that the level of clinical audit within individual hospitals is varied.
It said there was no comparative clinical audit done between centres to drive improvements nationally.
The review also found has been a large increase in patients at a low risk of breast cancer being referred to the new designated cancer centres.
The HIQA report recommends that the HSE should develop a national clinical audit programme for breast cancer services that includes, as a minimum, patients triaged as non-urgent and subsequently diagnosed with breast cancer, delayed diagnoses, longer-term clinical outcome and survival data.
It recommends that the HSE with the designated cancer centres should put in place arrangements to begin publicly reporting performance against the NCCP key performance indicators during 2010.
The HSE's National Cancer Control Programme (NCCP), in reponse, said such audit programmes "will in future" be the key driver of quality improvement in the service.
Interim Director of the NCCP Tony O'Brien said it is currently building on recently-introduced key performance indicators allowing it to measure its performance across a range of areas. "And will use these and the data processes developed to support them to audit performance in defined cycles/periods of time on a long-term basis."
It said the NCCP will consult on how best to reflect performance indicator data in an annual report on the performance of the breast cancer service for 2010.
The designated breast care centres are in Beaumont Hospital, Cork University Hospital, Limerick Regional Hospital, the Mater, St James's, St Vincent's, University Hospital Galway and Waterford Regional Hospital.
The HIQA review found that four of the eight centres were not ensuring that patients who needed surgery were having their operations within 20 working days of diagnosis, in accordance with the quality standards for the units.
The report also says all centres have faced challenges in offering an appointment within 12 weeks in non-urgent cases. There has been a large increase in the number of low-risk patients being referred to the breast centres.
HIQA notes that the profile of patients being seen in the eight centres translates into large numbers of patients with benign disease being seen in a service oriented primarily to managing patients with confirmed cancer.
The report noted that during 2009, some centres were falling below the required performance on offering appointments for 95% of patients with suspected breast cancer triaged as "urgent" within two weeks.
HIQA says while it is not acceptable for these standards not to be met, remedial action was being taken.
The report also reveals that flaws in the system in 2008 meant that patients have to convey vital clinical in information from one consultant to another when they have to get treatment outside a designated centre.
"For example, being asked to let their surgeon know when radiotherapy had been completed. This is unacceptable."
It expresses concern about the absence of processes to effectively manage the move of patients from one part of the service to another. There were weak mechanisms for the transfer of patient information or data between doctors, especially when they were practising within different centres, the report says.
Referring to care at the centres in 2009, the report states that the flow of some data and information between centres needs strengthening and even within some centres, not all patient information is accessible in one place.
It expresses concern about the absence of processes to effectively manage the move of patients from one part of the service to another. There were weak mechanisms for the transfer of patient information or data between doctors, especially when they were practising within different centres.
Service users surveyed by HIQA said their experience of aspects of their care delivered by departments or institutions outside the designated centres was variable.
The report recommends that centres put measures in place to ensure that all relevant information about a patient is available irrespective of where the care is provided.
The report says, however, patients reported very high levels of satisfaction and confidence in the care the had experienced or were experiencing in the centres.
HIQA says it will be carrying out further reviews on governance and information systems in Cork, Limerick and Waterford hospitals.
The report makes 18 recommendations for further improvements in breast cancer services at the eight hospitals in areas such as clinical management and governance, contingency plans for when key staff are absent; imnproving continuity of care; sharing of patient information between doctors;improving GP referral processes and on auditing performance.
It says there needs to be a coherent response to the group of patients waiting for treatment longer than they should be.
The report also says there remains work to do in many of the eight centres on monitoring performance quality.
The HIQA report says a recurrent theme from examining the centres has been the weakness of governance outside the designated site.
This, the report indicates, can affect access to services such as radiotherapy and imaging services when these are not provided in the centres.
The report says the absence of adequate specification of these relationships, for example through a service level agreement, is a significant cause for concern and could have adverse consequences for patients.
This needs to be addressed both in local arrangements and nationally by the National Cancer Control Programme (NCCP).
The report says the NCCP has been unable yet to fully develop the national systems and processes that will help drive the long-term benefits of creating designated centres.
HIQA says, however, the eight centres now have clear arrangements in place for the multidisciplinary care of all breast cancer patients.
The absence of effective multidisciplinary review, where different specialists work together on the care of patients, and triple review of tests was cited as a key factor in previous breast cancer misdiagnosis controversies.
The report notes that all of the eight centres now have the core specialist staff to deliver evidence-based breast disease care.
HIQA says it will be carrying out further reviews on governance and information systems in Cork, Limerick and Waterford hospitals.
The NCCP, in response to the report, said since it was written, 98% of women deemed urgent cases attending the centres were now being seen within two weeks. Ninety-six per cent of non-urgent cases are now being within a 12-week period, it said.
Commenting on its quality review, HIQA said that overall, the eight centres meet key requirements of national quality assurance standards for breast cancer services. and that significant progress has been made in the physical establishment of the eight centres.
"This represents a major shift in the capabilty and capacity of the health system to deliver better and safer care for people with symptomatic breast disease, compared to the position in the autumn of 2007."
It said some centres need time and support to establish successfully if patient safety and service quality are to be maintained and delivered on a stable and sustainable basis.
The NCCP said the HIQA report recognises the significant development and progress that has taken place over the past two years in breast cancer services.
View the full report here
february Posted:
26/02/2010 20:45 |
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I am experiencing a mild pain on my left breast for the past number of months, from underneath my arm to centre of breast. the pain comes ands goes at random, lasts for approx 10-15 mins and goes then. i have done breast check and nothing abnormal found. i have been to doctor they have ruled out cancer but no explanation for it i am scared as to what to do next? |
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Anna Posted:
27/02/2010 10:01 |
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I went for a routine Mammogram last October in the Merrion Centre and was called back to an accessment clinic within two working days. I cannot speak highly enough of the care and consideration given to me by the entire staff from the consultant down to reception, a wonderful group of people. There was no mention of money or health insurance until it came to my radiotherapy and I was asked would I like to go public or private. As I have insurance cover I opted for private, however it is the same consultant public or private and same timescale. Again here I am being looked after by a super team and they have where ever possible given me early appointments as I go into work after my treatment. My experience of Breastcheck, the Merrion Centre and St. Vincent's both Public and Private as excellent during these past months and I feel one must give credit where credit is due.
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Anonymous Posted:
01/03/2010 15:31 |
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February, you don't mention your age but aside from obvious things like an incorrectly fitting bra or muscle spasm, breast pain can result from hormonal changes. |
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CATHY Posted:
01/03/2010 23:27 |
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HIQA report on quality and safety standards in the centres says that while delayed diagnoses in breast cancer are rare, they will occur in the best centres in the world.-- wonder why they didn't say anything when the "scandals" around the country spent millions of euros? |
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JamesH Posted:
02/03/2010 13:22 |
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Cathy, You wonder why they didn't say anything before. Where have you been for the last ten years. Prof Niall O'Higgins report of 2000 was advocating specialist centres way back then. However it took the likes of Portlaoise & Barringtons & Rebecca O'Malley to happen for the public to finally be able to accept that there might be a better way. Even then the last 3 or 4 years have not been a smooth ride, with much resistance to the concept of specialist high volume centres and people wanting a world-class cancer centre at every crossroads on the flimsy basis that they did not want to travle to save their lives. |
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CATHY Posted:
02/03/2010 21:49 |
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Prof or no prof mistakes happen even in the best centres , happened few years ago and there is no guarantee it will not happen again. Stats in some Centres of Excellence have recently shown that can cope with only 50% of the cases and there has been a huge number of "normal" cases--- scary So, it was{and is }wrong to blame anyone hospital or any system. The hospitals that happened were the "fall guys" and an excuse for cover ups of huge magnitude. The likes which no one will ever accept. Likes that will always blame these hospitals! |
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JamesH Posted:
03/03/2010 08:57 |
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Cathy, Everyone would agree with you that mistakes will always happen no matter how good the system. The whole point is that in a specialist cancer centre with high volume of cases and a well functioning multidisciplinary team, the risk is minimised (never eliminated). Errors are less likely and it is more likely to detect them. Do you accept this basic fundamental? The “normal” cases that you refer to I assume are the large influx of low risk women who are being referred to the cancer centres and are being found to have no cancer. These “worried-well” women naturally have concerns after the Portlaoise, Barringtons & Rebecca O’Malley cases. Again everyone in the area would agree with you that this is worrying. In fact it was Prof Keane himself who has highlighted this issue and has called for a methodology to deal with safely. Cathy nobody is out to blame anybody. What has happened is that it is well recognised that cancer care in Ireland was not up to international standards. The cancer strategy is an attempt to improve a poor situation, using methods that are supported by sound logic and international evidence. |
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CATHY Posted:
03/03/2010 22:29 |
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A major review of the eight designated hospital breast cancer centres has found that the centres still do not have all the proper processes in place aimed at minimising missed or delayed diagnoses.-- that was the opening sentence of this feature-- so why should we believe that these centres are the excellent ones? Ireland is supposedly a developed country, yet the medical system is primitive and everything is soooooo slooooooow, even snails make better progress |
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JamesH Posted:
04/03/2010 19:15 |
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Cathy,
You haven’t answered my question. Do you accept that in a specialist cancer centre with high volume of cases and a well functioning multidisciplinary team, the risk is minimised ; i.e. errors are less likely and it is more likely to detect them.
The general message of the HIQA report is that the NCCP (under the leadership of Prof Keane) has made huge progress in the last 2 years by reducing from 33 hospitals delivering cancer care to 8 specialist centres. The other main achievement is that the 8 centres all have functioning multidisciplinary teams. This is in marked contrast to the situation where the service in many cases was being delivered in an ad hoc basis with no multidisciplinary team. In addition NCCP has withstood the local resistance to the whole concept of centralisation and the public largely accept the logic now. That is quite an achievement for two years. That is a sea-change in attitude.
Yes the HIQA report does highlight many areas that need to improve. Nobody is disputing this with you. Any quality orientated organisation will always acknowledge that you never get to the end, there is always room to improve. |
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CATHY Posted:
10/03/2010 00:09 |
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HIQA or NCCP or anyone highlighted these facts when scandals occurred around the country- instead there was general blame game-- pointed fingers and spate of well cooked reports -protecting the people ACTUALLY responsible ??!! Well functioning MDTeams-- are they? really? do you believe that? The headline of this article:Report finds safety flaws in breast care followed by----- A major review of the eight designated hospital breast cancer centres has found that the centres still do not have all the proper processes in place aimed at minimising missed or delayed diagnoses. One would expect things will improve and be better in these so called COEs |
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JamesH Posted:
10/03/2010 12:01 |
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Cathy, There is nobody engaged in the blame game but you. The indisputable fact is that cancer care in Ireland was not up to international standards and the NCCP cancer strategy is a sound logical reasoned attempt to address that based on international best practice. That is not the blame game, that is simply acknowledging the reality of the situation and coming up with a strategy to improve. It is not me talking about well functioning MDT; it is HIQAs report. Do I believe it? I have no reason not to. Have you any evidence that HIQA is lying to us? I understood that you were in support of the HIQA report; which is it? Re the heading on this article; there is nobody saying that the 8 specialist centres are perfect. Everyone would acknowledge that they have a long way to go and true that is one of the central messages of the HIQA report. However another central message is that in 2 years there have been huge improvements in moving all breast cancer care to 8 centres from 33 hospitals, and also in establishing functioning MDTs. Finally for the third time; do you accept that in a specialist cancer centre with high volume of cases and a well functioning multidisciplinary team, the risk is minimised ; i.e. errors are less likely and it is more likely to detect them. (Even in theory) (Yes or No will suffice) |
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JamesH Posted:
29/03/2010 10:27 |
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Cathy I take your lack of response to my third attempt to ask you the same question as a tacit Yes. i.e Yes you do accept that in a specialist cancer centre with high volume of cases and a well functioning multidisciplinary team, the risk is minimised ; i.e. errors are less likely and it is more likely to detect them. You should not be afraid to accept that the health sector at least has the correct approach to something (and still with dignity hold your position that they have a lot more improvements to actually achieve that approach) |
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