Quality Account 2010/11 - Royal Marsden Hospital

The Royal Marsden NHS Foundation Trust
16 Snapshot audit of recording of treatment
planning on multidisciplinary team (MDT)
proforma: agree and record individual
patient treatment plans on Electronic Patient
Record (EPR), Sutton site, BRPR09-3
17 Snapshot audit of recording of treatment
planning on multidisciplinary team (MDT)
proforma: agree and record individual
patient treatment plans on Electronic Patient
Record (EPR), Chelsea site, BRPR09-5
18 What proportion of women are tested for
HER2 gene prior to commencement of
drug treatment (if undergoing resectional
surgery and receiving adjuvant or neoadjuvant
chemotherapy), BRCLE1
19 South West London Cancer Network
(SWLCN) – Patient Survey 2009:
The Royal Marsden NHS Foundation
Trust, March 2009, SWLCNPS1
20 Complications associated with
gastrostomy tube insertion in head
and neck cancer patients, HAN7
21 Re-audit of effectiveness of aroma sticks
for symptom management (REHAB7)
22 Snap-shot audit of compliance to The
Royal Marsden Venous Thromboembolism
(VTE) Prevention and Management Antiembolic
Stockings Policy (Adult Inpatient):
Nursing documentation (NAR223b)
23 Implementation of Red Serviette initiative
on the wards – red serviette audit (NAR240)
Results confirmed compliance to
measure. Operational policy reviewed
and updated. Re-audit planned.
Results confirmed compliance to measure.
Re-audit planned. Operational policy reviewed
and updated. Repeat audit planned.
Results confirmed availability of HER2
receptor information at the time of treatment
planning for all patients. Re-audit planned.
Local patient surveys identified and undertaken.
Use of a proforma introduced.
Clinic forms modified to improve data collection.
A VTE Working Group has been established
to ensure implementation and monitoring
of the Trust’s comprehensive action plan
to improve compliance to policy.
Successful implementation confirmed of
the red serviette initiative which identifies
patients requiring help with eating.
24 Protected Mealtimes (REHAB10) Policy reviewed, pre-meal checklist
for staff developed and the initiatives
covered in induction training.
25 Repeat radiotherapy patient
survey 2010 (RT17)
26 Patient evaluation of breast radiotherapy
information session (BRIS); repeat
patient survey (REHAB05)
Areas prioritised for improvement.
Improved referral of patients to the sessions,
information sheet reviewed, further information
provided and introduction of standardised
information across the cancer network.
30