| Domain |
KPI |
Minimal Standard |
Aspirational Standard |
Score |
Comments for markers |
| Process |
Information giving |
Patient information sheets for all major procedures
-SNS
-LVMR
-Sphincter repair
-STARR
-Posterior repair
as well as conservative management eg
-Diet
-biofeedback
-irrigation
|
Website based information
|
5 |
4 marks for core
1 for aspirational
|
| |
|
Unit protocol algorithm for
1.Constipation management
2.Incontinence management
3.Pelvic pain management
|
|
5 |
2 for constipation
2 for incontinence
1 for pain
|
| |
|
History and examination proforma
|
|
|
|
| |
Information gathering
|
Quality of life assessment for all patients undergoing intervention
|
|
5 |
4 marks for assessment of all new
1 for follow up
|
| |
|
|
Evidence of follow up QoL assessment |
5 |
|
| |
MDT
Representation
(SEE website for guidance)
|
Colorectal Surgeon (>1)
Urogynaecologist
Radiologist
Clinical Scientist and/or nurse specialist
Trainees
|
Additionally:
Physiotherapist
Gastroenterologist
Psychologist
Pain specialist
Research fellow/nurses
|
10 |
8 marks for core
2 for others
|
| |
|
Some membership of TPFS
|
All enrolled in TPFS
More frequently
|
5 |
2 marks for 1 member. 5 for all |
| |
Frequency |
Monthly |
More frequently
|
5 |
4 for monthly
1 for more frequently
|
| |
Selection |
Discussion of ALL
- Patients considering surgery, including SNS (and other continence procedures), rectal prolapse (IRP&ERP), defunctioning stomas, colectomy, STARR.
|
|
15
|
Fail if not provided
|
| |
|
Evidence of conversion rate to surgery [from annual nos of new patients seen in OPD for
1) Constipation/ODS
2) Continence]
|
|
10
|
Fail if not provided
|
| |
|
Register of attendees |
|
|
|
| |
Administration |
|
annual AGM (review of process)
|
5 |
4 for evidence of register
1 mark for AGM
|
| |
Regional/multi Trust MDM
|
2 or more Trust MDM’s
|
Regional
|
10
|
8 for multi-trust
2 for regional
|
| Personnel |
Lead |
-CV to include training, CPD etc
-Job plan to include at least 1 PA per week
- Evidence of an average of at least 1 major pelvic floor op per week (SNS, rectopexy, sphincter repair, etc)
- Evidence of referrals from colleagues
|
-National or international involvement in pelvic floor topics
(leadership, quality improvement etc)
|
10
|
4 marks for >1PA
2 mark for op evidence
1 mark for CPD
1 mark for national involvement
2 marks for training
|
| |
Other consultants with interest |
-CV to include training, CPD etc
-Job plan
- Evidence of pelvic floor work
- Evidence of referrals from general colleagues
Summary of numbers
|
National or international involvement in pelvic floor issues
(leadership, quality improvement etc)
Details of CPD
|
5 |
2 marks for >1PA
1 mark for op evidence
1 mark for CPD
1 mark for national
|
| |
Allied health professional support (eg, continence nurse, GI physiologist, physiotherapist) |
|
|
5 |
1 mark for evidence CPD
4 marks for evidence of AHP attendance
|
|
Procedures
|
Unit throughput data
|
12 month data kept for:
- New OPD referrals
- Biofeedback
- Surgical activity
|
- Physiology investigation
- Physiotherapy
|
5 |
1 mark for each of these
|
| |
Auditable Outcomes
|
Morbidity recording and monitoring
for 12 months, including reporting any mesh related complications to MHRA
|
Patient reported outcome measures
- Severity scores
- QofL scores
|
15
|
10 marks for M&M
5 for aspirational (PROM’s)
Fail if mesh related complications not reported
|
| |
|
Evidence of use of TPFS audit database for LVMR (if done) |
|
5 |
Fail if no evidence (if LVMR done) |
| |
|
Recurrence data for external rectal prolapse (12 month period)
|
Recurrence data for >12 months
|
|
|
| |
|
Local audit |
|
5 |
|
| |
Engagement in R&D
|
|
Recruitment to national portfolio study
|
|
Up to 3 for local audit, full 5 if national recruitment
|
| Research |
|
|
|
5 |
|
|
PF Training
|
Evidence of training core trainees/AHCP’s
|
For surgical trainees, logbook evidence.
AHCP’s annual appraisal evidence of training
|
PF fellow
|
15
|
10 for minimum standard, 5 for PF fellow
|