NHS CSP Screening Quality Assurance Service update

NHS CSP Screening Quality Assurance Service update

• 1.
  Screening quality assurance serviceupdate
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  • Review ofrecent QA changes • Programme Specific Operating Model Screening Quality Assurance update
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  Regional Structure forCervical SQAS Screening Quality Assurance update Jan Yates Head 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 Professional&Clinical Advisors(PCAs)
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  Professional ClinicalAdvisors Screening QualityAssurance 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
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  Liaison with SQAS Whatdo 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
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  • Programme SpecificOperating Model Screening Quality Assurance update
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  Programme Specific OperatingModel 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
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  Screening Pathway forQA 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
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  Professional QAnetworks • Keyelement 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
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  QA Visit Process ScreeningQuality Assurance update
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  Principles for QAVisits •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
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  QAVisits – whatwill 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
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  Recommendations • QA willrecommend 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
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  Incidents Update Public HealthEngland leads the NHS Screening Programmes
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  To be covered Managingthe SIAF Why do an RCA Themes and learnings from incidents 15 Incident Update
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  Overview Managing Safety Incidentsin 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
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  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
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  What is Screening? Screeningis ……… “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
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  Screening safety incident Screeningsafety 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
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  Screening Serious Incident Indistinguishing 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
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  Characteristics Incident Update Screening Safety Incident Individual error or systematic failure Particularpart 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
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  Screening incident assessmentform  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
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  SIAF - screeningincident 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
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  SIAF - screeningincident assessment form 24 Incident Update
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  SIAF - screeningincident assessment form 25 Incident Update
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  Safety Incident reportsby 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
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  Safety Incident reportsby SIAF classification Finally: This should be managed as a Serious Incident (declaration, concise or comprehensive or independent investigation) 27 Incident Update
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  Incident team Immediate actions – patient focus Produce / implement Actionplan RCA – depth varies Oversee implement actions Identify and share lessons learnt Agree timescales for closure Incident Update Managing incidents
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  29 Incident Update Incident team
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  RASCI – Whydo 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
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  RASCI – Whatis 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
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  RASCI R RESPONSIBLE "Thedoer" A ACCOUNTABLE "The buck stops here" S SUPPORT "Helper" C CONSULT "In the loop" I INFORM "Tell me after" 32 Incident Update
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  RASCI Template Task ResponsibleAccountable 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
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  Root cause analysis Whatis 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
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  RCA= thinking 35 IncidentUpdate
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  Why bother tofind 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
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  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)
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  Root CauseAnalysis UsingFive 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
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  Link cause andaction 39 Incident Update
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  Reporting formats forserious 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
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  41 Incident Update
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  Critique of areport - 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
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  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
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  Dissemination of learnings •Detailed quarterly reports • Blogs • Regional forums • Programme boards 44 Incident Update