SA Health Terms of Reference South Australian Chemotherapy Prescribing Governance Committee
Version control and change history
Version Date from Date to Amendment 01 21/6/2016 Original Document ID: Chairperson Executive Officer Replaces: New
Appendices Document ID: Meeting Schedule
Official Use Only – I#-A# SA Health Terms of Reference South Australian Chemotherapy Prescribing Governance Committee
Scope The South Australian Chemotherapy Prescribing Governance Committee is a state wide committee with representation from: Central Adelaide Local Health Network (CALHN) Southern Adelaide Local Health Network (SALHN) Northern Adelaide Local Health Network (NALHN) Country Health South Australia Local Health Network (CHSALHN) Women’s and Children’s Health Network (WCHN) That will provide clinical governance in the management of chemotherapy prescribing for patients with malignant or non-malignant disorders.
Role The South Australian Chemotherapy Prescribing Governance Committee is responsible to the South Australian Medicines Advisory Committee for the quality use of chemotherapeutic medicines. This is achieved by ensuring that the chemotherapy prescription templates, their source protocols and decision support tools are regularly reviewed and supported by current evidence.
Responsibilities The South Australian Chemotherapy Prescribing Governance Committee will undertake a rolling review of all new and existing prescription templates and source protocols based on a register of existing and required prescription templates identify from the register the treatments appropriate for CHSALHN administration establish as required a rotating subgroup to review new or revised source protocols, prescription templates, and support tools. provide final review and endorsement of the prescription template, source protocols and support tools following the subgroup review recommendations. The Chair (or deputy) will provide final approval enable an emergency review in the event that treatment without an endorsed source protocol is required before the next committee meeting with a minimum of two members of the subgroup (involving a pharmacist/ oncologist or haematologist) conducting a review and providing their recommendation to the Chair (or deputy) for final sign off out of session. submit any non eviQ protocol to eviQ for consideration of submission to the National Protocol Database monitor and arrange document updates based on eviQ revisions or new protocols coordinate the transition of all prescription templates (EPAS Transition Script), source protocols and support tools (including bone marrow transplantation and clinical trials) to eCentral following the review and endorsement process ( CALHN Representative to manage access for NALHN and CHSALHN). SALHN will maintain their current separate process until they transition to ePAS) develop the competency and supervisory requirements including an education module in the learning management system for a senior registrar to be approved to order chemotherapy prescriptions develop SA Health guidelines for the assessment, ordering authorising and administration of chemotherapy
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Reporting The South Australian Chemotherapy Prescribing Governance Committee Relationships reports to SAMAC (SA Medicines Advisory Committee) and has the mandate to determine governance of chemotherapy prescribing practice on behalf of the state. (to be endorsed by SA Health Portfolio Executive)
Selection of Membership will be selected to ensure representation across the Local Health Advisory Group Networks. Additional members may be co-opted if required to provide specific input. The committee will: Members elect a chair for a three year tenure. The selection of the chair will be determined on a rotation of LHN representation ensuring each LHN takes their turn at chairing. election of the chair will include the selection of their proxy for the three year tenure. ensure authors of documents are excluded from the approval process if they are a member of the committee or a member of the subgroup and that this is minuted ensure that all members have a three year tenure, but can be reappointed to the committee if the relevant LHN makes this determination Operating Quorum Procedures A minimum of half of the members of the South Australian Chemotherapy Prescribing Governance Committee plus one for issues requiring vote.
Proxies The Chair must be notified in advance of the meeting if a proxy will be present at a meeting. Frequency of Meetings Meetings will be scheduled every month (3rd Tuesday) The South Australian Chemotherapy Prescribing Governance Committee Chair may convene additional meetings to consider business which may require urgent consideration The rotating subgroup will meet out of session to progress review of documents Meeting Papers The Chairperson will set the agenda. The agenda and supporting papers will be circulated to members 1 week prior to each meeting. A register of documents for rolling review, action plan and program schedule will drive the proceedings of each meeting. There will be funding for the function of the secretariat provided by SA Health Committee Process Within 7 days of the Committee meeting the minutes will be approved by the Chair including the list of approved source protocols, support tools and prescription templates circulate the list of approved documents via a distribution list of relevant staff. The approved prescription / protocol will be submitted to the agreed location that provides documentation governance within 14 days of the meeting assign a member of the committee to the role of receiving email
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updates from eviQ to monitor for any revisions or new protocols from eviQ and to notify the author of the need to update their prescription template, source protocol or support tools and then to resubmit for endorsement. The committee member assigned will be responsible for tracking that the review has occurred and the updated documents provided to the committee within 14 days provide an emergency review of treatment and prescription actioned and approved within an hour. In circumstances where this is not possible (for example after hours) then the consultant orders the treatment submitting the prescription and source protocol to the subgroup the following day. The documentation is provided to the committee at the next meeting for discussion and endorsement Undertake an annual review of committee process and function and progress against the register and action plan. Provide an annual report based on the following Key Performance Indicators are: o Percentage of documents reviewed and approved according to the schedule o Percentage of new prescription templates created from the register of source protocols o Percentage of emergency reviews conducted and approved within the one hour time frame ( rare events) o Percentage of prescription templates created from eviQ source protocols
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Appendix 1 Membership & Meeting Schedule
South Australian Chemotherapy Prescribing Governance Committee
Sponsor:
Chair: As elected by the Committee for a three year tenure
Executive Officer/Project Officer: To be advised –EO Safety, Quality and Risk Management Coordinator – Pam Selim Cancer Services temporary until 30 June 2016.
Membership: Deputy Chair – ( rotating position through LHN) Haematologist – CALHN Haematologist – SALHN Haematologist – NALHN/CHSALHN Haematologist/Oncologist – WCHN Oncologist - CALHN Oncologist - SALHN Oncologist – NALHN/CHSALHN Pharmacologist / Pharmacist– SALHN Pharmacologist/Pharmacist – CALHN Pharmacologist/Pharmacist – NALHN Nurse Practitioner – SALHN Nurse Practitioner –CALHN Clinical Nurse Consultant – Cancer Services - NALHN Clinical Nurse Consultant – Cancer Services WCHN State-wide pharmacy representative EPAS representative Consumer representative
Meeting Schedule: 2016 Date Date Date Date Date Date END OF APPENDIX 1