Screening quality assurance

service update

• Review of recent QA changes

• Programme Specific Operating Model

Screening Quality Assurance update

Regional Structure for Cervical SQAS

Screening Quality Assurance update

Jan YatesHead of Regional Quality Assurance, Screening QA

Service - London

National Screening QA Data and Intelligence Lead

Sonya Narine

Senior QA Advisor

Olive Moynihan

QA Advisor

Reena Patel

QA Facilitator

David Jeansoulé-Ruiz

Jorge Marin

QA Audit Staff

Mai Dang

Noosheen Bashir

QA Officers Pro

fessio

nal &

Clin

ical

Advis

ors

(P

CA

s)

Professional Clinical Advisors

Screening Quality Assurance update

• Deirdre Lyons - Lead Colposcopist

• Anne Jackson - Lead Colposcopist

• Anna Parberry - Nurse Colposcopist

• Dr Mary Falzon - Lead Cytolopathologist

• Parmjit Chana - Lead BMS

• Mark Terry - Lead BMS

• Theresa Freeman-Wang - Chair for QA visits

• Vacant PCA Histology

Liaison with SQAS

What do we expect from Screening Services?

Tell us immediately of any concerns, issues, potential problems, threats to the

service etc etc

Too trivial to tell the SQAS? if in doubt - tell us!

What can Screening Services expect from us:

Timely communication of issues

Explain any data that we’ve produced

Help in the interpretation of national guidance

Share good practice

Support in pursuing difficulties; performance, culture etc

Act as a conduit to queries for our PCAs

Screening Quality Assurance update

• Programme Specific Operating Model

Screening Quality Assurance update

Programme Specific Operating Model

Cervical Screening• Establishment of a QA project group

• Purpose:

• to design an optimal and consistent quality assurance process for the

cervical screening programme

• Building on existing good practice and external review findings

Members:

• National QA Portfolio Leads

• Senior Cervical QA staff

• Screening Programme Manager

• 2 PCAs from each professional discipline

Screening Quality Assurance update

Screening Pathway for QA

Screening Quality Assurance update

“cervical screening QA begins with the

identification of eligible women and includes

sample taking, cytology, colposcopy and

histopathology. It ends with the diagnosis of

cancer, completion of the screening programme

at 65 years of age, or the ending of a

surveillance period, whichever is later”

Ref: QA Operating Model

Professional QA networks• Key element of Regional QA process

• Sharing of issues and good practice

• Key to communications throughout the programme

• Geography-dependent so different models to ensure facilitate good

attendance and engagement

• Not separate from the QA process – activities will be part of the overall QA

work programme

• No “regional” guidance now – issues raised for wider consideration within

PHE Screening Division

• Clarifications/updates will move to being national now

Screening Quality Assurance update

QA Visit Process

Screening Quality Assurance update

Principles for QA Visits

• Just one aspect of the overall QA process

• Prioritisation-based approach with a maximum interval of 5 years

• Annual QA data review – detailed review of performance of all services

• Detailed data review and key question proforma for services to complete

and return

• Service assessment matrix

• Informs visit schedule

• Focused visits if indicated by service assessment/service change

Screening Quality Assurance update

QA Visits – what will they cover?• Sample taker registers/training arrangements/governance – Primary Care

• Call/recall (separate visit); linkages where necessary to local visits

• Hospital-based programme co-ordination (management & governance)

• Cytopathology

• Biomedical Science (Cytology)

• HPV testing

• Colposcopy

• Colposcopy Nursing and Administration

• Cervical Histopathology

• Includes private providers undertaking any part of NHS screening work

Screening Quality Assurance update

Recommendations• QA will recommend issues are addressed, not how to address them

• Timescale and priority are separate indicators against recommendations

• Areas identified that are, for example:

• Practice identified that is outside national guidance

• Performance does not meet national standards

• Inadequate governance

• Types of recommendations:

• Immediate recommendations

• Three-month recommendations

• Longer-term recommendations

• Follow up

• SQAS role in reviewing evidence and advising on completeness

• Trust responsible for implementing

• NHSE responsible for ensuring action is taken (performance board meetings)

Screening Quality Assurance update

Incidents Update

Public Health England leads the NHS Screening Programmes

To be covered

Managing the SIAF

Why do an RCA

Themes and learnings from incidents

15 Incident Update

Overview Managing Safety Incidents in NHS Screening Programmes

(MSI in NSP)

https://www.gov.uk/government/publications/managing-safety-incidents-in-

nhs-screening-programmes

(October 2015)

NHS England Serious Incident Framework (SIF)

https://www.england.nhs.uk/patientsafety/serious-incident

(March 2015)

16 Incident Update

Duty of Candour

• The statutory duty of openness and transparency applies to

notifiable incidents where death, severe and moderate harm or

prolonged psychological harm has occurred or could occur.

• A provider responsibility – undertaken with “due diligence”.

• Individuals should be told the facts; the further enquires being

carried out and receive an apology in person which is confirmed in

writing

• It is not the remit of PHE Screening to advise on this duty beyond

signposting providers to published guidance

17 Incident Update

What is Screening?

Screening is ………

“an organised programme of identifying

apparently healthy people in a defined

population who may be at increased risk

of a disease or condition in order to offer

information, further tests or appropriate

treatment to reduce risk or complications

arising from the disease or condition”.

18 Incident Update

Screening safety incident

Screening safety incidents include:

• any unintended or unexpected incident(s), acts of

commission or acts of omission that occur in the delivery

of an NHS screening programme that could have or did

lead to harm to one or more persons participating in the

screening programme, or to staff working in the

screening programme

• harm or a risk of harm because one or more persons

eligible for screening are not offered screening.

Incident Update

Screening Serious Incident

In distinguishing between a screening safety incident and a serious

incident, consideration should be given:

- whether individuals, the public or staff would suffer avoidable severe

harm or death if the root cause is unresolved

- the likelihood of significant damage to the reputation of the

organisations involved

This means that a “near miss” can be a serious incident where there is

a significant existing risk of a system failing.

20 Incident Update

Characteristics

Incident Update

Screening Safety

Incident

Individual error or

systematic failure

Particular part of pathway or at interfaces

Affect individuals

and populations

Risk to individual low

but large number of

people

Learning from incidents can reduce risk to future users

Systematic failure to

comply with nationals guidelines

Adverse media

coverage resulting in high public

concern

Can do

harm

Screening incident assessment form

The screening incident assessment form (SIAF) is to be used for all

suspected safety incidents and serious incidents in NHS screening

programmes

Completed by all parties within 5 days of the incident being identified

Achieved through early reporting, sharing of information and open

discussion by all parties

The form should be accessed from the DH.gov.uk website at

https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-

screening-programmes

22 Incident Update

SIAF - screening incident assessment form

Key components of the SIAF

Organisation/department where incident has happened

Screening programme involved

Date of incident and date QA notified

Summary of incident

Action taken so far

Classification of incident

23 Incident Update

SIAF - screening incident assessment form

24 Incident Update

SIAF - screening incident assessment form

25 Incident Update

Safety Incident reports by SIAF classification

• No concern – no further action required

• Problem still suspected, cause not yet identified, further investigation required

• Safety incidents for internal investigation – no further QA action –

Provider decides format in line with its governance process

Screening and immunisation team may want to review

Recorded on SQAS and SIT monitoring systems

• Safety incidents internal investigation and RCA

SQAS advise that a one page report is produced – suggested template available SIAF

included as an appendix, e.g 5 whys

• Safety incident (multi-organisation/disciplinary, investigation panel and

RCASQAS advise that NPSA concise report with SIAF included as an appendix

26 Incident Update

Safety Incident reports by SIAF

classification

Finally:

This should be managed as a Serious Incident

(declaration, concise or comprehensive or

independent investigation)

27 Incident Update

Incident team

Immediate actions –patient focus

Produce / implement Action plan

RCA –depth varies

Oversee implement

actions

Identify and share lessons learnt

Agree timescales for closure

Incident Update

Managing incidents

29 Incident Update

Incident team

RASCI – Why do we need it?

Good communication tool; helps setting up the proper expectations among team

members and hence reduces future misunderstandings; identifies key contacts in the

organisations

Roles and responsibilities of members of the incident panel (functions covering

contributions, chair, independent advice and chair’s remit in decision making outside

panel meetings avoids duplication).

Identifies the owner of a task clearly and assigns accountability to that role

By ensuring that the correct people are involved, RASCI helps in avoiding wrong

decisions

Methodology for RCA agreed and adopted including content and process for sign-off

30 Incident Update

RASCI – What is it?RASCI ensures that each person is responsible only for the task assigned to

them and will not need to interfere with another person's task, unless asked

to do so

Responsible – person who performs the work. If a role has too many or too few

responsibilities the work load can be adjusted

Accountable – person who has the final authority and accountability to a given task.

Only one role/person accountable.

Supported – Supported’ are the roles/groups/departments that provide the resources

and hence support that task

Consulted – people/roles who are consulted and taken advice from before and during

the task. Too many ‘consulted’ roles = increased time to perform task. Not enough

‘consulted’ roles = task may be under performed

Informed – people/roles who are informed after the task is completed. Right

people/roles need to be informed to avoid miscommunication and delays

31 Incident Update

RASCI

R RESPONSIBLE "The doer"

A ACCOUNTABLE "The buck stops here"

S SUPPORT "Helper"

C CONSULT "In the loop"

I INFORM "Tell me after"

32 Incident Update

RASCI Template

Task Responsible Accountable Support Consult Inform

Establish the panel (if required,

where multiple stakeholders are

required to support decision

making)

If panel required - Responsibility for

developing panel documentation

e.g. TOR, agendas, meeting invites

Immediate actions to understand

current position and mitigate further

risk in the programme e.g. audits

Investigation – review of risk/harm;

interviews and submit RCA

Consideration of RCA and action

plan for closure of incident

Delivery of action plan

Monitoring action plan

Incident Update33

Root cause analysis

What is it?

• The systematic process to identify the factor that, if resolved, would

remove the chance of recurrence. It is often not immediately apparent.

• A root cause is usually management or system failures of one kind or

another - identify corrective actions to “cut off the root”.

34 Incident Update

RCA= thinking

35 Incident Update

Why bother to find the root cause?

A) come up with a quick fix, tell your staff and just try to fix the error when it

recurs;

and

B) Do A) and also identify why the error has occurred and fix what has caused it, as

the error could be the result of a much wider problem

National Patient Safety Agency:

http://www.npsa.nhs.uk/

Incident Update

Fishbone Diagram - Tool

37 Incident Update

Patient

factors:Clinical condition

Physical factors

Social factors

Psychological/

mental factors

Interpersonal

relationships

Individual

(staff) factors:Physical issues

Psychological

Social/domestic

Personality

Cognitive factors

Task

factors:Guidelines/

procedures/

protocols

Decision aids

Task design

Communication

factors:Verbal

Written

Non-verbal

Management

Team factors:Role congruence

Leadership

Support + cultural factors

Education +

Training Factors:Competence

Supervision

Availability /

Accessibility

Appropriateness

Equipment +

resources:Displays

Integrity

Positioning

Usability

Working condition

factors:Administrative

Design of physical

environment

Environment

Staffing

Workload and hours

Time

Organisational +

strategic factors:Organisational structure

Priorities

Externally imported risks

Safety culture

Problem

or issue

(CDP/SDP)

Root Cause Analysis Using Five Ways

How to complete the 5 ways:

1) Write down the specific problem. Writing it down helps you formalise the

problem and describe it accurately. It also helps a team focus on the same

problem

2) Use brainstorming to ask why the problem occurs then, write the answer

down below

3) If this answer doesn't identify the source of the problem, ask ‘why?' again

and write that answer down

4) Loop back to step three until the team agrees that they have identified the

problem's root cause. Again, this may take fewer or more than five ‘whys?'

Source:

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_

and_service_improvement_tools/identifying_problems_-

_root_cause_analysis_using5_whys.html

38 Incident Update

Link cause and action

39 Incident Update

Reporting formats for serious incidents

NPSA

40 Incident Update

• Concise and comprehensive-independent report templates

• most serious incidents in a screening will require a comprehensive report

• http://www.nrls.npsa.nhs.uk/resources/?entryid45=75419

41 Incident Update

Critique of a report - what should the report

contain?

• a summary of the incident, including details (eg: injury, damage etc)

• recommendations, including time scales for completion

• an outline of the event itself, including details of injury, illness and damage

• the immediate causes, errors made, etc.

• the root cause(s) and contributing factors

• risk alerts and lessons learnt where appropriate

• Governance arrangements for review of actions (where needed)

• distribution

Is the level of detail appropriate to the incident?

42 Incident Update

Closing safety incidents & serious incidents

SQAS advise on:

• Commissioner satisfied with the content/style of the report and its fit to

the incident classifications

• Actions planned match root causes

• Report reviewed/signed through the provider’s governance structures

• NHSE sign off through programme board or alternative governance

• Provider monitor action plan with NHSE oversight

43 Incident Update

Dissemination of learnings

• Detailed quarterly reports

• Blogs

• Regional forums

• Programme boards

44 Incident Update