SPAN Networking and the National Picture: Where are We and Where are We Going? Dr. Lee B. Jordan...

SPAN

Networking and the National Picture: Where are We and

Where are We Going?Dr. Lee B. Jordan

Lead Clinician for SPANConsultant Pathologist, NHS Tayside

Scottish Pathology Network

SPAN

Networking, Quality and All That Jazz…

SPAN

Just what is Networking and who is this Barnes chap

anyway?

SPAN

Overview• What is SPAN?

– Context, History, Structure.• What have WE done?

– Achievements to date.• What are WE doing?

– Current and future objectives.• Quality & Performance

– Kings Mill, Barnes, etc.

SPAN

Mission StatementTo improve pathology services by creating and developing a Scotland wide Managed Diagnostic Network (MDN) which will steer modernisation, including service change and redesign, improve quality, ensure provision of an effective pathology service which anticipates and responds to user needs, future requirements, national guidelines and meets Clinical Pathology Accreditation Standards'

SPAN

What is SPAN?

10 Boards supplying cellular pathology servicesacross 12 laboratory sites.

SPAN

Achievements• Benchmarking• Re-design of Cervical Cytology • Implementation of Molecular Pathology as a National

Service• Review of Electron Microscopy• Workforce Planning• Quality Agenda• Digital Imaging• Site Visits• Facilitating cross Board communication and support

SPAN

Cervical Snippets• Managed Service Contract• Imager• Consortia Model• Workload distribution• Workforce modelling• Screening Programme changes• Primary HR-HPV testing?

– Tim Palmer’s talk…

SPAN

Molecular Pathology Snippets• NSD adminstered, centrally funded service

– Boards top-sliced• Four core centres

– Aberdeen, Dundee, Edinburgh, Glasgow • Known repertoire• ‘Free’ at the point of use• Structure for evaluation and introduction of new

tests– MPEP & MPCSG

http://www.nsd.scot.nhs.uk/services/specserv/molpath.html

SPAN

Benchmarking Snippets

SPAN

2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13300,000

350,000

400,000

450,000

500,000

550,000

SPAN Benchmarking: TOTAL Histo Requests & Specimens 2005/6 to 2012/13

Requests (TOTAL) Linear (Requests (TOTAL))Specimens (TOTAL, data incomplete) Linear (Specimens (TOTAL, data incomplete))

Requ

est/

Spec

imen

Num

ber

SPAN

2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13500,000

700,000

900,000

1,100,000

1,300,000

1,500,000

1,700,000

1,900,000

2,100,000

2,300,000

2,500,000

SPAN Benchmarking: TOTAL Histo Blocks & Slides 2005/6 to 2012/13

Blocks (Total) Slides (Total)

Bloc

k/Sl

ide

Num

bers

SPAN

2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13350,000

370,000

390,000

410,000

430,000

450,000

470,000

SPAN Benchmarking: TOTAL Cervical Cyto Requests (2005/6 to 2012/13)

Cervical Cytology Requests

Requ

est N

umbe

r

Note these are SPAN figures not SCSP figures

SPAN

2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/1350,000

55,000

60,000

65,000

70,000

75,000

80,000

SPAN Benchmarking: TOTAL Non-Cervical Cyto Requests (2005/6 to 2012/13)

Non-Cervical Cyto

Requ

est N

umbe

r

SPAN

2009/10 2010/11 2011/12 2012/130.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

SPAN Benchmarking:% Histo Requests Reported in 168hrs (7 Calendar Days)

% Requests Reported in 168hrs (7 Calendar Days)

Perc

enta

ge

49%

76%

SPAN

2009/10 2010/11 2011/12 2012/130.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

SPAN Benchmarking:% Histo Requests Reported in 72hrs (3 Calendar Days)

% Requests Reported in 72hrs (3 Calendar Days)

Perc

enta

ge

34%

12%

SPAN

RCPath KPI 6.4• Cellular Pathology Reporting Turnaround

Times

– Reported, confirmed and authorised within 7 and 10 calendar days of the procedure

– 80% (7 Days)– 90% (10 Days)

– [Cases requiring prolonged decalcification (not bone marrow trephines) are excluded, as are cases requiring molecular tests.]

SPAN

2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/130.00

50.00

100.00

150.00

200.00

250.00

300.00

350.00

400.00

SPAN Benchmarking: Scottish BMS and HCSW Staffing (2006/7 to 2012/13)

Overall BMS Staffing (Scotland) Linear (Overall BMS Staffing (Scotland))Overall HCSW Staffing (Scotland) Linear (Overall HCSW Staffing (Scotland))

WTE

SPAN

2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/130.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

SPAN Benchmarking: Scottish BMS AfC Band Splits (2006/7 to 2012/13)

8d 8c 8b 8a 7 6 5 Trainee

WTE

SPAN

2007/8 2008/9 2009/10 2010/11 2011/12 2012/130.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

SPAN Benchmarking: Medical Consultant Vacancy Rate (2007/8 to 2012/13)

Medical Consultant Vacancy Rate

SPAN

[Excluding Capital Charges, Whole Sample Mean]

2008/9 2009/10 2010/11 2011/12£0.00

£10.00

£20.00

£30.00

£40.00

£50.00

£60.00

Keele Benchmarking: Cost per Request (Histo & Cyto) 2008/9 to 2011/12

England & NI (All) Scotland (All)

Cost

(£)

SPAN

2008/9 2009/10 2010/11 2011/120

200

400

600

800

1000

1200

1400

Keele Benchmarking: Requests per WTE (Histo & Cyto) 2008/9 to 2011/12

England & NI (All) Scotland (All)

Requ

ests

per

WTE

SPAN

NHSA&A

NHSD&G

NHSF

NHSGG&C

NHSGram

NHSFV

NHSH

NHSLan

NHSLoth

NHST

All UK

£0.00 £20.00 £40.00 £60.00 £80.00 £100.00 £120.00

Keele Benchmarking: Cost per Request (Histo & Cyto) for 2012/13

Cost per Request

[Excluding Capital Charges, Whole Sample Mean]

SPAN

NHSA&A

NHSD&G

NHSF

NHSGG&C

NHSGram

NHSFV

NHSH

NHSLan

NHSLoth

NHST

All UK

0 200 400 600 800 1000 1200 1400 1600

Keele Benchmarking: Requests per TOTAL WTE (Histo & Cyto) for 2012/13

Request per WTE

SPAN

Key Objectives• Appoint a Network Scientific Manager• Consolidating/reinforcing existing activity

– Cervical Cytology – Molecular Pathology

• New activity– Paediatric & Perinatal Pathology Services Review– Quality & Performance

SPAN

Quality & Performance• IQA• QMS• UKAS/CPA –> ISO 15189• RCPath KPI• SPAN Benchmarking• Keele Benchmarking• QPIs (Cancer Specific)• Targets (Cancer & General)• Pathology Quality Assurance Review (Barnes)

SPAN

Barnes Report…• England!• 28th January 2014

To understand BarnesOne must understandKings Mill!

(Not the loaf)

SPAN

Kings Mill

SPAN

Kings Mill (1)• “inadequate assurance processes at Sherwood

Forest Hospitals NHS Foundation Trust, which subsequently resulted in inappropriate care for a number of women with breast cancer”.

• What happened?• ER +ve breast cancers were called negative

denying patients treatment.

SPAN

Kings Mill (2)• CQC found:

– Histopathology services had poor communication and feedback with the local trust board.

– Equipment in use at the time had been outdated.– Recruitment issues around medical staffing and

medical leadership.– No robust internal quality audit programme in

place.

SPAN

Kings Mill (3)• RCPath found:

– Kings Mill was NOT an outlier on ER results as the sample size was too small for statistical analysis.

– Samples were NOT misreported, there was no medical/interpretative error.

– There were problems with IHC service, these were flagged and the service outsourced.

– Issues around governance and culture – finance had overridden service planning and provision

SPAN

Kings Mill (4)• RCPath found:

– EQA scheme for ER did NOT identify any problems.– EQA scheme did NOT provide any benchmark

comparison for the Kings Mill histopathology service to relate to.

– External monitoring, peer review, accreditation and QA systems did NOT identify any problem.

SPAN

Kings Mill (5)• In summary:

– Specific local issues had been found at Kings Mill:• small screening centre• small workload • behind in technological terms

– National issues • Quality assurance • Communication• Monitoring of quality • Applicable beyond Kings Mill…

SPAN

Pathology QA Review (1)• Key positives:

– Underwrites 80% of patient interactions.– Compare favourably with Europe and others.– High quality services.– High clinician confidence.– Skilled workforce.– Good IQA and QMS.– Mature EQA.– Forefront of QA (in the world).– Overall = safe, reliable and effective.

SPAN

Pathology QA Review (2)• Key negatives:

– Relies almost entirely on professionalism and goodwill.

– Setup to provide assurance to laboratories and not public or patients.

– Systems focussed on minimal acceptable standards.– No identification, incentivisation or reward for

excellence.– Little sanction or support if performance falls below

acceptable standards.

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Recommendation 1“A systematic approach should be taken to educating, training and developing the skills of the pathology workforce in quality management systems and quality improvement methodology, in ways appropriate to professional group, role and grade. This process should be led by HEE [Higher Education England].”

“HEE should work with the professional bodies and regulators to ensure that quality management and assurance can be recognised as an essential requirement in CPD [Continuing Professional Development], and in individual appraisal requirements.”

SPAN

Implication – R1• If Scotland were to adopt:

– NHS Education for Scotland (NES) would be the surrogate for HEE ?

– Medical deaneries and other parties?– Educational mechanisms (appraisal, PDRs, CPD,

eKSF, etc.).– Could be beneficial for ALL of the Pathology Team.

SPAN

Recommendation 2 (1)“The membership, role and function of the JWGQA [Joint Working Group for Quality Assurance] should be revised and expanded. It should set consistent standards and performance criteria for all schemes across pathology and work with UKAS [UK Accreditation Service] to ensure their implementation in the scheme accreditation process. The JWGQA should advise on publication of performance data. The National Medical Director has confirmed that he will ask the RCPath to lead this work.”

SPAN

Recommendation 2 (2)“Further consideration must be given to the ways in which individual performance can be assessed, monitored and competence-assured. The National Medical Director will ask the professional bodies, led by RCPath, to review these issues and report back within twelve months on their findings.”

SPAN

Implication – R2 (1)• Scottish impact (1):

– JWGQA is UK wide.• ?devolved nation representation.

– Laboratory (technique) EQA:• Little/no objection in Scotland for transparency.• Output unlikely to be informative to the public.• Unlikely to be understandable without review.

SPAN

Implication – R2 (2)• Scottish impact:

– Interpretative EQA (individual performance):• Much more concern here.• Developed from informal slide clubs, internal learning

and professional development perspective.• Currently (mostly) voluntary, performance output is

linked anonymised.• Each scheme differs – own

scoring/exclusion/answering/marking/analysis/result reporting processes.

• Not all are CPA accredited.

SPAN

Implication – R2 (3)• Scottish impact:

– Interpretative EQA (individual performance):• Not reflective of practice or in-service performance.• Schemes prohibit consultation and consensus, which

are key aspects to service delivery and QA in labs.• Review states that attempts at collusion should be a

matter of professional probity.• EQA responses are a matter of opinion.• English use for commissioning.• Current EQA is not fit for R2 purpose?

SPAN

Recommendation 3“The quality and governance systems of pathology providers must be integrated with trust governance and quality structures. This should include the measurement of appropriate quality assurance indicators and the identification of an accountable board member within the organisation. CQC and the Chief Inspector of Hospitals have indicated that robust information on the quality of pathology services could contribute to the overall assessment of quality under the new hospital inspection model.”

SPAN

Implication – R3• For Scotland:

– There should be some input into any development of KPIs or KAIs that may impact Scotland.

– How to achieve that?– Should we develop our own?– Should we simplify matters?

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Recommendation 4“Existing guidance on the standardisation and transparent reporting of errors from pathology services must be rigorously followed, including the reporting of all incidents that could have, or did lead to patient harm, to the NRLS [National Reporting and Learning System]. Pathology services should be encouraged to share information and data about clinical risks, ‘lessons learnt’ and good practice, in order to contribute to education and quality improvements nationally. The Trust Development Agency (TDA) and Monitor/CQC should encourage trusts to improve their adherence to existing guidance.”

SPAN


– Already have local mechanisms for reporting.– Part of QMS and Board mechanisms.– Part of UKAS/CPA review.– Should there be sharing beyond host

organisations?– Do we need another system?

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Recommendation 5“The continued development of the NLMC [National Laboratory Medicines Catalogue] to ensure consistency of data and information across the NHS in England should remain a priority. Ministers and NHS England have confirmed that this task, undertaken by HSCIC [Health & Social Care Information Centre], with support from professional bodies and others, must continue at scale and pace. The professional bodies, the IVD [in vitro Diagnostics] manufacturers and others should work towards minimising the differences between analytical processes, requesting and reporting.”

SPAN


– Already committed for NLMC.• More impact for non-Cell Path labs.

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Recommendation 6“In order that patients and clinicians can rely on accreditation status as shorthand for a quality assured service, the accreditation of pathology services must be updated showing clearly which laboratories are meeting minimum requirements, and which are excelling to provide first-rate service quality. UKAS has agreed to undertake this work.”

SPAN

Implication – R6 (1)• For Scotland:

– Particular risks for Scotland:• CPA/UKAS is often a struggle and a rush.• ISO 15189 is proving challenging, esp. Test Validation.• May see labs accredited minus aspects of their current

repertoire.• Introduction of random, unannounced visits.

– Does inspection improve standards?• Too late? • Need to embed Continuous Quality Improvement.

SPAN

Implication – R6 (2)• For Scotland:

– Overlap with R2 and EQA elements.– “4.80 - UKAS should work with the professional

bodies and JWGQA to facilitate an assessment of the minimum number of specimens per annum required to quality assure an individual test.”

• Kings Mill reports suggest minimum numbers of ER tests at any one site.

• Minimum limits on reporting size and duties for reporters.

SPAN

Recommendation 7“In order to support commissioners in the next planning round, the PSCT [Pathology Commissioning Services Toolkit] should be updated. The National Clinical Director (NCD) for Pathology, with the NCD for Diagnostics and the Chief Scientific Officer, will lead this project, working in conjunction with local commissioners and professional bodies. When the NICE QS is published, it should be included in the PSCT. Commissioners should follow the MHRA guidelines when commissioning POCT.”

SPAN


– No impact?• Commissioning has no role in NHS Scotland at present.

– Monitoring tools suggested could be of use?• Kent & Medway tools covered in the QA Review

document.

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Recommendation 8“A high level, system-wide Oversight Group should be created with responsibility for steering the improvements in quality assurance frameworks and governance mechanisms outlined in this report. NHS England has confirmed that it will facilitate this group.”

“The Oversight Group should also develop a Pathology Quality Assurance Dashboard, which draws transparent and meaningful information from existing data sources to provide a national picture of quality improvement across England, to enable trend analysis and the identification of opportunities for development of the system.”

SPAN


– Concept of a live Dashboard could be useful in the Scottish context.

• How to feed in to the process?

SPAN

Quality & Performance• IQA• QMS• UKAS/CPA –> ISO 15189• RCPath KPI• SPAN Benchmarking• Keele Benchmarking• QPIs (Cancer Specific)• Targets (Cancer & General)• Pathology Quality Assurance Review (Barnes)

SPAN

Quality & Performance

Is there a simpler way forward?

(September)

SPAN Networking and the National Picture: Where are We and Where are We Going? Dr. Lee B. Jordan...

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Transcript of SPAN Networking and the National Picture: Where are We and Where are We Going? Dr. Lee B. Jordan...