The Screening Division Quality Framework Dr Rosemary Fox

The Screening Division Quality Framework Dr Rosemary Fox, Director, Screening Division

Background • Division delivers four (current) national screening programmes, and is developing two more • Quality Assurance is integral to each programme • Framework is the same in each programme, though operational details vary Quality Framework

External Systems • Standards for Health Services • CPA/UKAS • Ionising radiation regulations 1999 • Audit programmes • EQA schemes for clinicians • Links to performance standards and targets of other UK screening programmes Quality Framework

QA Advisers • Advise the Head of Programme (managerial Lead) on Quality Issues – Programme specific clinical advisers eg • QA radiologist (breast) • QA colonoscopist (bowel) • QA colposcopist (cervical) – Divisional Leads eg • Head of Administration • Head of Nursing Quality Framework

Management Groups • Governance for each programme held by its All-Wales Management Group (AWMG), – Chaired by Director/Deputy – QA advisers as members – Approves operational policy changes – Monitors performance • Underpinned by operational groups within each programme. Quality Framework

Quality manuals • Programme-specific • Set out policies, standards and processes • Regularly reviewed and updated • Available on-line to all staff within programme Quality Framework

Using BSW as an example • QA advisers for colonoscopy, pathology, radiology, surgery • Emerging evidence/ guidelines discussed at BSW QA meeting • AWMG approves changes to Quality manual • Users notified by email, reinforced at local and professional meetings Quality Framework

Performance Management • Programmes – Performance monitored against National (UK) and Wales standards – SPAR reports – level of detail and frequency determined by intended audience, eg BTW • AWMG quarterly, all-Wales figures • SMG monthly, regional performance stats Quality Framework

Performance Management • Individuals – Data comparing performance against peers and standards fed back to individuals, eg • BTW film readers – Number of films read – Number women recalled for assessment – Cancers detected (sensitivity) – Cancers missed and picked up by second reader (specificity) – Proportion of women recalled diagnosed with cancer (PPV) Quality Framework

Individual and programme audits • Focus is on individual and programme learning- acknowledged that screening not 100% sensitive • Single call cancers (breast) • Interval cancers (all programmes) – Can allow targeted training- to individuals or groups Quality Framework

National Audits (UK) • Sloane • BASO • Interval Cancer (breast) • PT 1 cancers (bowel) Quality Framework

Partners • BTW (and AAA) delivered in-house • Other programmes rely on Health Boards to deliver part of the service eg smear taking, colposcopy, colonoscopy • Must be delivered to specified quality standards (premises and practitioners) • Smear taking in primary care Quality Framework

User Feedback • All invitation leaflets contain contact details for complaints and queries • Websites have ‘contact us’ facility • BTW invites women to fill in feedback forms at the time of screening • NBHSW has carried out extensive surveys of mothers of screened and assessed babiesuses responses in staff training • Screening Engagement Team run focus groups and ‘virtual panels’ Quality Framework

Concerns and Incidents • ‘Putting things right’ • May be reported by – Division staff – Service users – Staff in Health Boards • Reported to relevant AWMG and RMG • RIDDOR, NPSA, radiation incidents reported externally • SUIs reported to WG. Quality Framework

Using BSW as an example • BSW lab and admin staff, SSPs and colonoscopists all report incidents or concerns – ‘First Alert’ process has increased reporting rates from HBs x 5 • Entered on to datix, discussed at BSW QA meeting, recommendations fed back to HBs • Requests to deviate from BSW QM also considered by QA group and fed back to HB Quality Framework

Risk Management • Programmes and projects have individual risk registers – Feed in to Division’s risk register • Risk Management group meets quarterly- discusses SUIs and reviews the risk register • Feeds in to Trust risk register Quality Framework

Summary • Quality Framework embedded in programme design • Incorporates EQA and internal processes, feedback and audit at programme and individual level Quality Framework

Questions? Quality Framework

Data Quality • Screening depends on high quality data to deliver and evaluate the programmes • Data warehouse receives downloads from each programme- verified against several sources – Used to produce management reports, audit and research • Audited by WAO in 2012 Quality Framework