Report finds safety flaws in breast care

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

[Posted: Thu 25/02/2010]