This document summarizes the key themes and common recommendations from the ANNB QA visits conducted in London in 2016-17. It discusses the visit process and provides data on the number of visits conducted. The main themes identified relate to governance, including strategic oversight, leadership, risk management, and quality improvement. Common recommendations include revising terms of reference, defining roles and responsibilities, improving communication of governance structures, ensuring risk management processes are robust, and monitoring quality.

1. ANNB QA Visits 2015/16
Key Themes and Common
Recommendations
Public Health England leads the NHS Screening Programmes
London Local Screening Coordinators & IDPS Midwives
9th December 2016
Presented by Allison Thompson

2. The Process
• 26 weeks notification
• Minimum evidence request (usually past 1-2 years data)
• Desktop review and decision on next steps
• KLOEs
• Visit day
• Report – factual accuracy (6 weeks), and final report (4weeks later)
• Action Plan
• Completion and signoff
2 ANNB QA Visits - Key Themes and Common Recommendations

3. Visit Breakdown – 2016/17
(April 2016 – March 2017)
3 ANNB QA Visits - Key Themes and Common Recommendations
Visits National London
Total 18 2
Regional
laboratory
2 1

4. London Recommendations – 2016/17
4 ANNB QA Visits - Key Themes and Common Recommendations
Priority Number
Immediate
(1 week)
1
High
(12 weeks)
18
Medium
(24 weeks)
41
Low
(52 weeks)
0

5. London themes - Governance
• This theme is concerned with ensuring that governance is demonstrated by
clear accountability for the strategic and operational oversight of the
delivery, performance, quality and risk across the screening pathways.
There should be evidence of senior leadership, governance structures.
• The theme is concerned with ensuring the screening programmes are
provided by a trained and skilled workforce with capacity to deliver
programmes to national standards as described in the national service
specifications
• The theme covers the use of appropriate IT systems to support both the
screening pathway and any audit.
5 ANNB QA Visits - Key Themes and Common Recommendations

6. London Themes – Governance 2
6 ANNB QA Visits - Key Themes and Common Recommendations
Themes Recommendation
Strategic and
Operational
Oversight
Revise Terms of Reference for the TSSG and implement a
process to monitor completion of actions from the TSSG
Define and document roles and responsibilities within the
newborn infant physical examination (NIPE) and newborn
bloodspot (NBS) programmes
Senior
Leadership
Governance
structure and
accountability
Communicate the senior management and governance
structure supporting the 6 ANNB screening programmes
to all relevant staff and stakeholders –
Identify lead/s for newborn screening programmes for the
neonatal units

7. London Themes – Governance 3
7 ANNB QA Visits - Key Themes and Common Recommendations
Themes Recommendation
Risk
Management
Ensure there is a robust process in place for the follow up
of outstanding actions after an incident is closed.
Ensure all departments involved in screening are aware of
their responsibilities to report screening incidents to QA
and NHS England.
Ensure all screening patient safety incidents are managed
in accordance with ‘Managing Safety Incidents in NHS
Screening Programmes’

8. London Themes – Governance 4
Themes Recommendations
Risk
Management
Complete a risk assessment for the transfer of on site
pathology services to the xxxxxxxx London Pathology
Services consortium
Quality
Improvement
plan
The trust should consolidate their quality improvement
activities into a single quality improvement plan. NHS
England should monitor this and consider escalated
contractual levers if agreed targets are not achieved
8 ANNB QA Visits - Key Themes and Common Recommendations

9. London Themes – Governance 5
9 ANNB QA Visits - Key Themes and Common Recommendations
Themes Recommendation
IT & Data Ensure all bookings are placed on the maternity IT
system within an appropriate time frame to ensure
correct and timely identification and reporting of the
cohort.
Enable access to maternity IT systems for
community midwives.
FASP Use a Down’s syndrome risk cut off and implement a
quadruple test policy which conforms to national
requirements.
Monitor the quality of all sonographers

10. London Themes – Governance
10 ANNB QA Visits - Key Themes and Common Recommendations
Themes Recommendations
FASP Address the risk of calculating Down’s, Edwards’ and Patau’s
syndromes risk calculations within Astraia from nuchal
translucency alone
Implement a tracking system to ensure all quadruple screening
samples are confirmed as received
Monitor the fetal anomaly ultrasound pathway to ensure women
who accept the offer complete the scan within the required
timeframe
Complete a risk assessment to establish whether prenatal
testing can be retained in house

11. 5 minutes reflection:
Assess your maternity services against these
recommendations - would they be the same for
you if you were visited tomorrow
11 ANNB QA Visits - Key Themes and Common Recommendations