NW Region Breast Screening Quality Assurance Reference Centre
Breast Screening Programme Management
Quality Assurance Visit Questionnaire
Date of QA Visit: ………………………………………………………………………………………
Breast Screening Service: ………………………………………………………………………………………
Name of person performing audit: ………………………………………………………………………………
Signature:
______Screening Service
(Persons completing questionnaire)
Data is required for the screening period
1st April 2013 – 31st March 2014
The information provided in this questionnaire will be reviewed in confidence by members of staff from the QA Reference Centre and the regional QA Team, including deputies if they are required. Information supplied will form the basis of the final QA Team Visit report. For clarification purposes, some of the information obtained from this questionnaire and used in the final report may be referenced to the reporting member of staff. As part of the pre-publication validation process, a copy of the draft report will be sent to the Director of Breast Screening to check for accuracy. At this point any concerns regarding named information may be made in writing to the QA Director at the QA Reference Centre. The QA Reference Centre will store all completed questionnaires indefinitely; paper copies will be transferred to electronic versions and stored on a secure server.
SECTION ONE – PROGRAMME MANAGEMENT
Assessment of Programme Management
Areas Discussed / Comments / Evidence to be provided to QARC1.0 / Management Arrangements
1.1 / Role of Director / Job description programme director
No. of PA’s for role in job plan.
1.2 / Role of programme manager and screening office manager. / Job description(s) for PM and SOM and Head of Department/Superintendent.
1.3 / Lines of accountability & division of responsibility. Access to senior management. Integration into host trust management structure / Organisational chart showing all BSP groups of staff and directorate or divisional links from Prog director upto CEO.
Evidence of directorate/divisional management meetings eg minutes x 3
Evidence of breast board meetings
Annual report of the local screening programme and detail of circulation.
1.4 / Service level agreement and service specification / SLA / Service specification
1.5 / Service costs / Evidence demonstrating that screening budget is clearly identifiable
1.6 / Relationship with symptomatic services and breast care services / For discussion
2.0 / Service Review
2.1 / Staffing levels and workload
· Division of responsibilities
· Professional relationships
· Staff changes
· Vacancies
· Recruitment
· Training / Evidence of budgeted WTE for each discipline and in post WTE.
Records of staff meetings, sickness & staff turnover.( to be viewed at pre-visit)
Training/CPD files (at pre-visit)
2.2 / Equipment (X-ray, film processing, ultrasound, offices). Plans for maintenance & replacement.
Long term ability to accommodate growing population / For discussion :
Are there any breast screening issues currently on the Trust Risk Register?
Is there an asset register?
Are there lease agreements in place?
Maintenance contracts. / Evidence that risk assessments have taken place.
Copy of Trust risk register showing any breast screening issue
Capital plans/asset register for mx equipment.
2.3 / Facilities (patient areas and staff accommodation)
· Availability of suitable sites for mobile units
· Reception and waiting areas for women
· Environment for staff, including film viewing
· Storage facilities
· Facilities for special needs / Discuss any accommodation issue at pre visit. / Evidence of customer care surveys undertaken within the last round.
Detail any specific mobile site issues.
2.4 / Clinical practice
· One view/two views
· Single reading/double reading
· Assessment
· Localisation
· Waiting times for assessment
· Waiting times for treatment
· Multidisciplinary meetings
· Case reviews
· Interval cancer reviews
· Participation in trials / Discuss any areas of non achievement at pre visit.
Discuss any issues with the MDT meetings / Local assessment protocol
Detail any issues with non achievement of waiting times and recovery plans if any.
MDM records. 3/12 attendance to be provided.
Protocol for review of interval cancers.
2.5 / Screening Practice
· Population served
· Population forecasts
· Progress of screening rounds
· Numbers screened (including over 65’s)
· Coverage and uptake
· Failsafe
· Round length
· Cross border flows
· Screening of non-batch women
· Links with GP’s
· Screening non batch women / QA admin to review these issues and 3 year screening round plan. / Detailed population split by 50-70, 47-49, 71-73 and 47-73 with projections to 2018.
2.6 / Professional performance
· radiology
· radiology
· pathology
· surgery
· breast care nursing
· medical physics
· administration / Discuss any non achievement of NHSBSP standards at Programme Management pre visit and note plans to address.
QA coordinators to discuss individual areas at pre visits. / Performance statistics to be discussed.
2.7 / Data collection / QA Admin to discuss any KC62/3 issues. / Job description for breast screening data manager or coordinator if applicable.
2.8 / Compliance with NHSBSP guidance on Organising a Screening Programme and NHS England Breast Screening Specification April 2013 / Discuss any areas of non compliance
3.0 / The NHS Cancer Plan
3.1 / Skill mix / Discuss any skill mix issues.
Development of 4 tier radiographic structure.
Future plans? / Annual report
3.2 / Effects on planning programme and workforce
(i) Age extension
(ii) Population increase / Three year round plan
3.3 / Plans to take high risk women into NHSBSP and onto NBSS / Discuss progress
4.0 / Risk management
4.1 / Implementation of QMS
Funding for QMS
Right Results Review
Quality review meetings / How far has QMS been developed?
Is further work required?
Have all the previous recommendations
been achieved since the last QA audit? / QMS work instructions (view at previsit).
Evidence of completion of RRP recommendations
Quality review meeting records (view)
4.2 / Complaints since last audit / Complaints & compliments files – view at visit.
Evidence of customer surveys, complaints/compliments data
4.3 / Reported incidents / Incident book. Discuss local policy on reporting incidents.
4.4 / Use of Early Warning Protocol
For incidents, near misses. / Is there a local/Trust early warning protocol in place?
4.5 / Involvement in local clinical governance programme development / How is the programme integrated into Trust clinical governance structures?
Who attends CG meetings from BSP? / Framework of Trust clinical governance structure(s).
Minutes from Clinical Gov’ce meetings
4.6 / Service approach to QA
· Data collection and review
· Responsibility for quality control
· Systematic management of quality
· Professional relationships
· Time for quality assurance
· Collection of interval cancer data / How is QA embedded in the programme/team?
Is there a local audit plan for the BSP/breast unit?
Is there a backlog of interval classifications? / Discuss QMS – progress,
Audit of QMS,
Attendance at NW QA meetings
Evidence of local audit
5.0 / Outstanding Recommendations From Previous Audits
6.0 / Points of Good Practice
North West Breast Screening QARC Page 2 of 10
Section 1 - Programme Management