1 / 19

The Screening Division Quality Framework

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

armani
Download Presentation

The Screening Division Quality Framework

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. 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

  3. 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

  4. 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

  5. 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

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

  7. 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

  8. 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

  9. 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

  10. 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

  11. National Audits (UK) • Sloane • BASO • Interval Cancer (breast) • PT1 cancers (bowel) Quality Framework

  12. 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

  13. 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 babies- uses responses in staff training • Screening Engagement Team run focus groups and ‘virtual panels’ Quality Framework

  14. 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

  15. 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 x5 • 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

  16. 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

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

  18. Questions? Quality Framework

  19. 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

More Related