Breast Screening Programme Policy 1.1 24 Jun 13

Transcription

Breast Screening Programme Policy
1.1
24 Jun 13
Page 1 of 15
Table of Contents
1. Introduction ................................................................................................................... 3 2. Purpose of this Policy ................................................................................................... 3 3. Scope ........................................................................................................................... 3 4. Definitions / Glossary .................................................................................................... 3 5. Ownership and Responsibilities .................................................................................... 4 5.2. Duties within the organisation ................................................................................ 5 5.3. Duties external to the Organisation ....................................................................... 5 6. Standards and Practice ................................................................................................ 6 6.2. Duties .................................................................................................................... 6 6.3. Process for Requesting Screening Procedures identifying and calling
women/consent ................................................................................................................ 7 6.4. Process for the Receipt of the Results of a Screening Test .................................. 7 6.6. Process for Taking Action on Screening Results ................................................... 8 6.7. Process for Documentation of Screening Results ................................................. 9 6.8. Process for the Communication of Screening Results........................................... 9 7. Dissemination and Implementation ............................................................................... 9 8. Monitoring compliance and effectiveness ..................................................................... 9 9. Updating and Review.................................................................................................. 10 10. Equality and Diversity.............................................................................................. 10 10.2. Equality Impact Assessment ............................................................................ 10 Appendix 1. Governance Information ................................................................................ 11 Appendix 2.Initial Equality Impact Assessment Screening Form ....................................... 13 Appendix 3. Screening Round Plan Flow Chart ................................................................. 15 Breast Screening Programme Policy
Page 2 of 15
1. Introduction
1.1. The NHSBSP began in 1988.At present it aims to invite all women aged 5070 years for mammographic screening once every three years. The programme
now screens 1.3 million women each year of which about 75% attend, and the
programme diagnoses about 10,000 breast cancers annually (NHSBSP
publication no.61)
1.2. This document has been produced to support the National Breast
Screening Standard Operating Procedures which can be found on the National
Health Service National Breast Screening Programme (NHSBSP) website in
numerous publications and within the Cornwall Breast Screening Centre in the
Quality Management System
1.3. Cornwall Breast Screening invites around 65,000 women over the course of
three years for mammographic screening. Around 7% of these ladies are
recalled for assessment and approximately 140 cancers are diagnosed annually.
The programme adheres to the national guidelines set out by the NHSBSP in
publication no.60.
2. Purpose of this Policy
2.1. Breast Screening is a process of identifying well women between the ages
of 50 and 70 who may be at increased risk of/in the early stages of Breast
Cancer. They can then be offered information, further tests and appropriate
treatment.
2.2. The purpose of this document is to ensure that all risks associated with the
RCHT Breast Screening programme are managed and compliant with NHSLA
standards.
2.3. All procedures before, during and after Breast Screening are stored in an
electronic shared folder and a paper master copy, (Quality Management System
QMS) situated in the Radiographer Team Lead office.
3. Scope
This policy applies to all those involved in Breast Screening procedures and Quality
Assurance in the organisation.
4. Definitions / Glossary
NSC
National Screening Committee
The UK National Screening Committee (UK NSC) is chaired by
the Chief Medical Officer for Scotland, advises Ministers and the NHS
in the four UK countries about all aspects of screening and supports
implementation of screening programmes. Using research evidence,
pilot programmes and economic evaluation, it assesses the evidence
for programmes against a set of internationally recognised criteria
covering the condition, the test, the treatment options and the
effectiveness and acceptability of the screening programme.
Assessing programmes in this way is intended to ensure that they do
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more good than harm at a reasonable cost. The UK NSC also sets up
practical mechanisms to oversee the introduction of new programmes
in the English NHS and monitors effectiveness and quality of these
programmes.
Screening
Screening is a process of identifying apparently healthy people who
may be at increased risk of a disease or condition
QMS
Quality Management Systems
A clear, step-by-step working instruction of how to carry out agreed
actions that promote uniformity to help clarify and augment processes.
QMS documents the way activities are to be performed to facilitate
consistent conformance to requirements and to support data quality.
QMS provides individuals with the information needed to perform a job
properly and consistently.
SOP
Standard Operating Procedures
Document the way activities are to be performed to facilitate
consistent conformance to requirements and to support data quality.
SOPs provide individuals with the information needed to perform a job
properly and consistently.
WI
Working Instructions
This indicates the reference number where the protocol for the
procedures followed can be found in the QMS file
QA
Quality Assurance
Quality assurance (QA) has been an integral part of the NHSBSP
since it was introduced in 1988. This is to ensure that all women have
access to a high quality breast screening service, wherever they live
in the UK.
QARC
Quality Assurance Reference Centres
There are minimum QA standards that all of the disciplines in the
NHSBSPs have to meet and maintain. These standards are monitored
by regional Quality Assurance Reference Centres (QARCs), which
also act to promote the sharing of good practice between BSPs.
There are eight regional QARCs which cover the whole of England,
with Scotland, Wales and Northern Ireland each having their own
QARCs. Each QARC is headed by a Director of QA who heads a
team typically comprising of a QA Co-ordinator, Professional QA Coordinators for each of the breast screening disciplines, Audit staff and
Administration staff. The Director of QA is directly accountable to the
Regional Director of Public Health
5. Ownership and Responsibilities
5.1. This section gives a detailed overview of the strategic and operational roles
responsible for the development, management and implementation of the policy.
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5.2. Duties within the organisation
The duties of the directors, committees, clinicians, healthcare and administrative
staff with responsibility for managing the processes surrounding screening
procedures are outlined below:

Chief Executive - The Chief Executive has ultimate responsibility for ensuring
that suitable structures, resources and monitoring arrangements are in place to
ensure that screening procedures are carried out in a safe and effective way.

Trust Boards - The Trust Board must seek assurance that screening
procedures are carried out in a safe and effective way.

Divisional Quality Group - The Divisional Quality Group (DQG) will receive a
quarterly summary of all adverse incident reports related to screening
procedures and analyse the annual audit tool kit returns. This group is
responsible for the overview of screening procedures within the Trust and
adherence to organisational and local standards.

Director of Breast Screening is responsible for the management and
performance of the Breast Screening programme (NHSBSP Publication No 52)

Breast Screening Supervisor – Programme Administrator and
Superintendent Radiographers The Breast Screening Lead will liaise with
screening staff and the National Breast Screening Office to produce the annual
required results and audits,

Lead Clinician/Director - The Trust’s Medical Director plays a lead role in the
development of organisation-wide and local procedural documents to manage
the risks associated with screening procedures. This includes ensuring that all
tests and procedures are undertaken by authorised staff following training
where necessary; developing standing operating procedures or equivalent
protocols to an agreed organisational or national standard.

Screening Staff - The screening pathway begins when an individual is
identified as meeting the criteria to be offered the opportunity of Breast
screening. Should the offer of screening be taken up, the relevant protocol
will be followed. Accurate records will be kept in the event that screening is
declined. Various healthcare staff may be involved in this pathway including
Doctors, Nurses, Healthcare Assistants/Support workers and Professions Allied
to Medicine. Responsibilities include adherence to standard operating
procedures or equivalent protocols; undertaking training as required and
agreed.

Administrative Staff - Administrative staff have an important role in ensuring
that, for paper based and electronic systems, all records are kept up to date and
that administrative protocols are followed.
5.3. Duties external to the Organisation
External bodies have a role in providing external quality assurance and protocol
guidance and where relevant programme management of the screening service
provided. Such bodies include:
Page 5 of 15





National Screening Committee/NHS Screening Programme Committees
External Quality Assessment/Assurance schemes (Regional and National)
Synertec
PCT
QARC
6. Standards and Practice
6.1. Standards for Breast Screening comply with the National Health Service
Breast Screening Programme (NHSBSP) guidelines and procedures and are set
out in the numerous relevant NHSBSP Publications, All screening procedures
are undertaken by authorised healthcare staff that have been trained and
accredited by approved Breast Screening Courses
6.2. Duties

The undertaking and outcome of Breast Screening will be documented on the
dedicated National Breast Screening Computer System (NBSS)

The result, the interpretation and the subsequent surveillance plan will be
managed by Breast Clinicians, Breast Radiologists, Consultant Radiographers,
Advanced Radiographers.

Routine Recall results are communicated to the women by letter within a three
week target deadline and their GP will be informed by a bulk report produced by
the local breast screening office.

the continuous performance management and monitoring of the screening
procedures is provided by a three yearly QA visit and National Audit of results

Line managers are responsible for ensuring that staff follow those processes
and procedures described in the Standards and Practice (QMS) relevant to the
part they play in the screening procedure;

The Trust Screening Lead is responsible for the development, approval,
communication of this policy and monitoring compliance with it by use of the
Annual Audit Tool.

All staff members are responsible for being aware of the policy and any
documents referred to within it pertaining to their part in the screening pathway;
adhering to any requirements described within the policy and documents
described in the standards and practice section pertaining to their role in the
diagnostic pathway.

Clinical Directors and the Breast Screening Centre programme administrator
are responsible for completion of the annual audit tool and for screening
governance which includes the reporting of any deviation or errors arising from
the screening procedures using the RCHT Trust reporting system and
governance processes.

The continuous performance management and monitoring of the screening
procedures are provided via Crystal reports to QARC generated both monthly
and quarterly, KC62 which is an annual report and three yearly QA inspection.
Page 6 of 15
6.3. Process for Requesting Screening Procedures
and calling women/consent
identifying

The Screening office requests all eligible women’s details from the Primary
Care Support Agency by GP practice.

All GPs are informed 8 weeks in advance of ladies from their practice being
screened.

GPs are advised to update ladies details and to provide the details of any ladies
not to be called for screening (deceased, bi-lateral mastectomy) to the
screening office.

Valid consent must be given prior to a screening test being undertaken, in line
with RCHT Consent Policy or, if the patient does not have the mental capacity
to decide whether to have the test, a best interest’s decision should be made on
their behalf, as described in The Mental Capacity Act 2005.

Women over the age for routine call for screening may self refer see QMS WI
3.7.
6.4. Process for the Receipt of the Results of a Screening Test
6.5. The process for the recording and dissemination of the results adheres to
local protocols (QMS) in line with NHSBSP Publication No 55 Right Results
Audit and includes the following:

the process for recording of the result;
o QMS WI
6.1 Preparation of Screening Clinics for Film reading
6.2 Film Reading
8.2 Updating Arbitration
6.4. Partial mammography

the interpretation of the result;
o QMS WI
6.2 Film Reading
7.2 Admin for Technical recalls
7.3 TR booking Procedure
8.1 Routine Results
8.2 Updating Arbitration
9.1 Recalls To Assessment
Page 7 of 15
9.2 Booking assessments

that the management plan is recorded in the designated media;
o QMS WI
6.1Preparation of Clinics for Bulk Updating
8.1 Routine results
9.1Recalls to Assessment
7.2 Admin for Technical Recalls
DNA letter

‘fail safe’ measures to ensure that results are not inadvertently missed. Regular
audits
o QMS WI
10.6 Regular audits (daily)/weekly/monthly)
10.4 Missing results report (weekly)
3.5 Synertec Audits for results letters(definition of codes)
Form 1- Breast screening tracking form
6.6. Process for Taking Action on Screening Results

that identified actions are documented;
o QMS WI
7.3 Technical Recall booking procedure
8.1 Routine results
9.2 Booking assessments

Initial screening results are communicated by letter, assessment results are
given face to face with a follow up letter.

Routine results are communicated within 3 weeks this is checked on a monthly
basis reports are run from Crystal monitoring QARC run checks every month
from our computers to audit the process

Missed or incorrect diagnosis must be reported using the Trust incident
reporting system. Missed or incorrect diagnosis is also reviewed by QARC.

Technical repeat audits are run monthly locally and by QARC.( folder of results
in Team Lead Office)
Page 8 of 15
6.7. Process for Documentation of Screening Results

audits are performed monthly
o WI 106

all screening results are recorded on the NHSBSP computer system
6.8. Process for the Communication of Screening Results

Initial screening results are communicated by letter, assessment results are
given face to face with a follow up letter.
o Results will then be confirmed in writing to the womens’ home address and
GP
o Reports to GP
o WI 8.4
7. Dissemination and Implementation
The document will be placed on the Cornwall & Isles of Scilly Health Community
Documents Library. It will also appear on Screening Testing A-Z of Services Intranet
pages as well as a link on the individual screening programme intranet pages. A
global email will be sent to all Service Users.
8. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Tool
Frequency
Reporting
arrangements
Target/breaches
Audit repeats
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
Routine Results sent within 2 weeks >90%
Date of first offered assessment appointment to be within 3 weeks
>90%
Date of first attended assessment appointment to be within 3
weeks >90%
Technical repeat and recall rate to be <3%
Dr Donna Christensen Director of Cornwall Breast Screening
Crystal Reports KC62 Audit / Performance Monitoring
Monthly/Annually / Quarterly
The Trust Screening Lead will circulate and collect the Annual
Audit Tool for submission to the Divisional Quality Group for
analysis.
Monthly/Quarterly Performance Monitoring will be prepared and
presented to QARC/Trust
The Division which encompasses the service provided will
undertake subsequent recommendations and action planning for
any or all deficiencies and recommendations within reasonable
timeframes.
Required changes to practice will be identified and actioned within
three months (where reasonable). A lead member of the team will
be identified to take each change forward where appropriate.
Lessons will be shared with all relevant stakeholders.
Page 9 of 15
9. Updating and Review
9.1. This policy will be reviewed every two years or sooner if circumstances
suggest this may be necessary.
9.2. Where the revisions are significant and the overall policy is changed, the
author will ensure the revised document is taken through the standard
consultation, approval and dissemination processes.
9.3. Where the revisions are minor, e.g. amended job titles or changes in the
organizational structure, approval can be sought from the Executive Director
responsible for signatory approval, and can be re-published accordingly without
having gone through the full consultation and ratification process.
9.4. Any Revision activity will be recorded in the Version Control Table as part
of the document control process.
10. Equality and Diversity
10.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement.
10.2. Equality Impact Assessment
10.3. The Initial Equality Impact Assessment Screening Form is at Appendix 1.
Page 10 of 15
Appendix 1. Governance Information
Document Title
Date Issued/Approved:
24 Jun 13
Date Valid From:
24 Jun 13
Date Valid To:
24 Jun 16
Directorate / Department responsible
(author/owner):
Breast Screening Programme
Administrator/Lead Radiographers
[email protected] or
[email protected]
This organisation-wide policy for the
Management of Breast Screening outlines
the documented process for managing the
risks associated with screening procedures
and that those risks are managed through
locally approved policies that are
implemented and monitored.
Contact details:
Brief summary of contents
Suggested Keywords:
RCHT

Target Audience
PCT
CFT
Executive Director responsible for
Policy:
Chief Operating Officer
Date revised:
24 Jun 13
This document replaces (exact title of
previous version):
Approval route (names of
committees)/consultation:
Diagnostics Lead
Divisional Manager confirming
approval processes
Emma Spouse Diagnostics Lead
Name and Post Title of additional
signatories
Not Required
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
{Original Copy Signed}
Internet & Intranet
 Intranet Only
Document Library Folder/Sub Folder
Clinical/Breast
Links to key external standards
NHSLA Standards
National Breast Screening Programme
Page 11 of 15
Standards
Related Documents:
 The 2011 NHSLA Risk Management
Standards Handbook
 NHSLA Standards 2011-2012
 NHSBSP Publication No. 60
Training Need Identified?
No
Version Control Table
Date
Version
No
Summary of Changes
May 12
V1.0
Initial Issue
Jun 13
V1.1
Correct para numbering
Changes Made by
(Name and Job Title)
Diana Williams,
Senior Radiographer
Diana Williams,
Senior Radiographer
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Page 12 of 15
Appendix 2.Initial Equality Impact Assessment Screening Form
Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: Breast Screening Procedure Policy
Directorate and service area: Human
Is this a new or existing Procedure? New
Resources
Name of individual completing
Telephone: 2884
assessment: Catherine Rule
1. Procedure Aim*
Sets out an approved documented process whereby the
risks associated with Breast screening procedures are
managed through the provision of local policies which
are implemented and monitored.
2. Procedure
The risks associated with Breast screening procedures
Objectives*
are minimised; compliance with NHSLA Standard 4 –
Criterion 3: Screening Procedures is achieved.
3. Procedure – intended To ensure that the Breast screening procedures provided by
Outcomes*
the organisation have developed, documented local
processes and that screening is offered as appropriate,
records are accurate and risks are minimised.
4. How will you
As described in section 8
measure the outcome?
5. Who is intended to
All individuals being screened
benefit from the
Procedure?
6a. Is consultation
No
required with the
workforce, equality
groups etc. around this
procedure?
b. If yes, have these
groups been consulted?
c. Please list any
groups who have been
consulted about this
procedure.
*Please see Glossary
7. The Impact
Please complete the following table using ticks. You should refer to the EIA guidance
notes for areas of possible impact and also the Glossary if needed.


Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
Page 13 of 15

Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Equality
Group
Age
Positive
Impact
Disability
Religion or
Belief
Gender
Transgender
Negative
Impact
No
Reasons for decision
Impact

Breast Screening is targeted at women
from 50 to 70 years as research screening
of women in the 40-50 age group is less
effective. Women over the age of 70 can
self refer for a mammogram with their
Local Breast Screening service

Breast Screening is aimed at a target
population and condition

population and condition.

Breast Screening is targeted at women
from the age of 50.

Pregnancy/
Maternity
Race

Sexual
Orientation
Marriage /
Civil
Partnership



You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
 A negative impact and
 No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that the policy
promotes equality, equal opportunities or
improved relations - could it be adapted so
that it does? How?
Full statement of commitment to policy of
equal opportunities is included in the
policy
Please sign and date this form.
Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean
House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
A summary of the results will be published on the Trust’s web site.
Signed ________________________________________
Date _________________________________________
Page 14 of 15
Appendix 3. Screening Round Plan Flow Chart
Page 15 of 15

Breast Screening Programme Policy 1.1 24 Jun 13

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