Internal Quality Assurance Guidance and Best Practice Toolkit · Internal Quality Assurance Guidance and Best Practice Toolkit Version 1.2 23 January 2012 Payal Patel and Philippa

Internal Quality Assurance Guidance and Best Practice Toolkit

Version 1.2 23 January 2012

Payal Patel and Philippa Castell

Diabetic Eye Screening Programme Internal Quality Assurance, Release 1.2

Release 1.2 23 January 2012

Page 2 of 15

Project/Category Internal Quality Assurance

Document title Internal Quality Assurance Guidance and Best Practice Toolkit

Version and date Version 1.2, 23 January 2012

Release status Final

Author Philippa Castell, Regional Quality Assurance Manager, NHS DESP

Owner Sue Cohen, QA Director, NHS DESP

Type Toolkit

Authorised By NHS DESP Quality Assurance Committee (QAC)

Valid from 14 November 2012

Review Date 14 November 2012

Audience NHS DESP Local Programmes and Programme Boards; Ophthalmology providers of medical retina services; Commissioners

Distribution

Name / group Responsibility

All programmes & programme

boards

National Programme Centre (NPC)

QA Team NPC

Ophthalmology Providers of

medical retina services

NPC

Commissioners NPC

SHA Screening Leads NPC

QA Committee members NPC

Amendment history

Version Date Author Description

0.2 6/9/11 Comments from Val Armstrong and Helen King incorporated

0.3 12/9/11 Comments from Philippa Castell incorporated


Release 1.2 23 January 2012

Page 3 of 15

0.4 5/10/11 Comments from QAC incorporated

1.0 14/11/11 Final

1.1 18/11/11 Embedded documents removed

1.2 13/01/12 JR Updated name and logo

Review / approval

Version Date Requirement Signed


Release 1.2 23 January 2012 Page 4 of 15

Introduction

This document has been produced to provide an overview of the processes within the retinal screening programme that link the national quality

standards to internal quality assurance processes and the external QA review. A number of resources are identified to support these quality

and failsafe processes.

This document will be updated in line with developments in the screening programme and any changes to the quality standards. The latest

version will be available on line at the NHS DESP website.

Who should use this document?

Why or how it might it be useful?

Providers of retinal screening services To identify which processes can be put in place to keep the programme on track in relation to providing quality care and meeting the standards. A number of the internal quality processes could be assigned to various staff members and usefully integrated in staff work plans and job descriptions. Reports on the processes could be reviewed at staff meetings. Summaries of reports and actions may be usefully presented to the screening programme board. The output of these processes will provide useful evidence for the external QA review.

Ophthalmology care providers for medical retinal services

To be informed of the role of the internal processes within screening providers held to assure quality. To demonstrate how information from ophthalmology care of referred patients contributes to screening programme quality

Programme boards This document identifies important internal quality assurance processes which should be an integral part of the whole programme. A number of the processes cross the boundaries of service provision and the programme board need to be assured that these are in place and working well.

Commissioners of screening programmes

Commissioners can refer to this document in service specification.

A number of the areas are cross referenced to the self assessment questionnaire (denoted by (SAxx) to show how they can contribute to this

process. However it is important to note that this is not the only source of evidence for these self assessment questions.



Abbreviations

SLB Slit Lamp Biomicroscopy

VA Visual Acuity

SI / SSI Sight impairment/ Serious sight impairment

HES Hospital Eye Services

DNA/DNR Did Not Attend/ Did Not Respond

C&G City and Guilds (qualification)

DR Diabetic retinopathy

STTT Screening to Treatment Timeline

KPI Key Performance Indicators

MDT Multi Disciplinary Team

NPL No perception of light



AN

NU

AL

SCR

EEN

ING

Invitation

Grading

Screening

Visual Acuity, dilation and image

capture

Results

Positive

GO

VER

NA

NC

E

AFE

AN

D E

QA

LIST

CLE

AN

SIN

G A

ND

VA

LID

ATI

ON

Did Not Respond/

Attend: Failsafe, list cleansing

and validation

Negative

Referral

Treatment

Slit Lamp

Biomicroscopy

AU

DIT

an

d F

AIL

SAFE

AFE

AN

D E

QA



Contents

Process One

Invitation

Process Two

Screening

Process Three

Grading

Process Four

Slit Lamp Biomicroscopy

Process Five

Results

Process Six

Referral and Treatment

Process Seven

Outcomes

Process Eight

Recall

KEY

Quality

Measure

Subject Actions and

Evidence



Process One: Invitation

Objective: Ensure that the entire eligible population is sent an invitation for screening with appropriate information given after screening

QA standards: Objective 1: Ensure the database is accurate Objective 2: To invite all eligible persons with known diabetes to attend for the DR screening test Objective 3: To maximise the number of invited persons receiving the test

Excluded patients Post Office Returns Inappropriate invitations

Excluded patients to be discussed at

Programme Board (SA39)

Adherence to programme exclusion

policy/protocol (SA38)

Provisions for translation services if

required (SA8)

Ensure patients receive the

appropriate information to

understand the importance of

screening on an annual basis (SA7)

Ensure database accuracy

Ensure excluded patients are

accurately recorded with

auditable evidence


Ensure Post Office returns are

investigated

Database accuracy

(SA36)

Adherence to local

policy/protocol for

deceased and excluded

patients (SA39)

Ongoing engagement

with GPs and Hospital

Eye Services

Use of GP2DRS


Ensure invitations to deceased

and NPL patients are

investigated

Database accuracy

Adherence to the guidance

in the QA standards.

(requirement to check post

office returned invitations as

per) (SA36)

Maximise Number of invited

persons screened

Maximise uptake of

invitations

National Templates

Ensure invitation letter and

accompanying documents

adhere to national guidance

Review of invitation letters

(SA 45 and 46)

Health Equity Audit/ Review of uptake

(SA8)

Project reports

Health promotion initiatives (SA7)

DNA and DNR audit (SA7)

Database accuracy

Ongoing engagement with GPs and

Hospital eye services

Patient Education (SA7)

Provision of ‘out of hours’ appointments

(SA7)

Review of screening locations and

accessibility issues i.e. transport (SA7)

Discussion at programme board or sub-

group

Submission of KPI’s (DR1)

Invitation letter Uptake



Process Two: Screening

Objective: Ensure a high quality service for patients attending a screening appointment and encourage re-attendance for the next invitation

QA standards: Objective 4: To ensure image are of adequate quality Objective 14: To ensure that screening and grading of retinal images are provided by a trained and competent workforce

Workforce Annual Review of sites Surveys Monitoring of programme and

individual grader rates and feedback

Annual Review

Annual review of screening sites

Competent Workforce

Ensure an accredited screening

workforce

User Views

Patient Satisfaction survey

Adherence to policy and

protocols

Review of acceptability of

screening sites for screeners and

their patients

Report on results of survey

and actions implemented.

Implications discussed at

Programme Board (SA2)

C&G completion (SA35)

Staff Continuous Professional

Development and training plans

(SA33)

Adherence to policy and protocols

including those for image capture

and grading process

Evidence of discussion at MDT meetings

Ensuring prompt rectification of

technical issues

Feedback on individual grader rates

Policy for management of patients

whose screening results may always be

ungradeable

Ensuring adequate images

Monitor ungradeable images



Process Three: Grading

Objective: Ensure a high quality service of reliable image grading results for patients

QA standards: Objective 5: To ensure grading is accurate Objective 14: To ensure that screening and grading of retinal images are provided by a trained and competent workforce Objective 15: To ensure optimum workload for all graders in order to maintain expertise

Workforce Grading quality Grading queue

C&G completion (SA32)

Staff Personal Development

(SA33)

Training plans (SA31)

Adherence to policy and

protocols

Monitoring of grading queues (SA10)

Monitoring of time taken to grade images

Monitoring of monthly cumulative numbers graded

Contingency plan for breaches in timescales

Participation in the test and training set

(SA35)

Evidenced feedback on results (SA35)

Review of intergrader reports

10% QA sample completion

Participation in MDT meetings

Staff grade minimum numbers

Grading Accuracy

Maximise grading accuracy

Staff workload

Ensure images are graded in a

timely manner

Competent Workforce

Ensure an accredited grading

workforce

Grading Environment

Ensure image grading takes place

in a suitable environment

Grading quality

Monitoring of grading

workstations, light levels and

noise/disruption (SA21)



Process Four: SLB

Objective: Ensure that all patients with ungradeable images receive an SLB assessment of their retina

QA standards: Objective 1: Ensure the database is accurate Objective 10: To ensure timely biomicroscopy assessment of patients recorded as ungradeable

SLB results SLB initial and ongoing

assessment

Data returns

Ensure results for SLB referrals

are being collected

Ensure timely referral

Ensure SLBs are referred in a

timely manner

Completed Annual Report (SA37)

Tracking of all results/outcomes

Monitoring of SLB referrals

(SA11)


Ensure patients are in the

appropriate exclusions category

Annual recall and exclusions

Database validation (SA36)

Process for management of

recall within SLB clinics in place



Process Five: Results

Objective: Ensure that all patients invited for screening receive their results within the appropriate timescale

QA standards: Objective 1: Ensure the database is accurate Objective 6: To ensure GP and patient are informed of all test results

Results letters Results Waiting times for results letters

Evidence of results being sent to

patient and GP

Ensure failsafe processes are in

place to ensure all patients have a

screening outcome

Protocol for ensuring that the

correct results are sent to the

correct patients

Review of results letter (SA 45

and 46)

Review of user feedback/

queries on results letter

Monitoring of times to results

letters

Submission of KPIs (DR2)

Contingency plan in place for

breaches

Discussion at Programme Board

(SA2)

Right Results

Ensure that all patients screened

receive the right result

National Templates

Ensure the results letter and

accompanying documents

adhere to national guidance

Ensure timely result

Ensure results are issued in a

timely manner



Process Six: Referral and treatment

Objective: Ensure that any patient requiring a referral is referred and treated in a timely manner (urgent and routine)

QA standards: Objective 7: Ensure timely referral of patients with R3 screening results Objective 8: To ensure timely consultation for all screen-positive patients Objective 9: To follow up screen-positive patients Objective 11: To ensure timely treatment of those listed by ophthalmologist Objective 12: To minimise overall delay between screening event and first laser treatment

i

Waiting times Results Appointment Laser treatment Audit Appointment

Laser treatment tracking

Ensure all patients receiving

laser treatment are known to

the screening programme

Ensure timely treatment

Ensure any patient requiring

treatment are listed in a timely

manner

Tracking

Ensure all referrals are

acknowledged by HES

Data returns

Ensure results for referral and

treatment are collected

Ensure timely referral

Ensure any patient requiring a

referral is referred in a timely

manner

Completion of laser audit

(when available) SA28

Case note review (SA28)

Completion of STTT

analysis

Report of breaches

Logging of date of first

offer of appointment

may assist in analysis

of breaches

Record of annual RxMx

(SA30)

Tracking of results and

outcomes

Annual Report

Completion of STTT

analysis

Completion of STTT analysis (SA12 and 14)

Record of Hospital Eye Services

acknowledgement

Review of ‘referrals’ discharged by Hospital

Eye Services

Monitoring of ‘urgent’ referral

times (SA12)

Monitoring of ‘routine’ referral

times (SA12)

Contingency plan in place for

breaches

Reporting system in place for

identifying actual and potential

breaches



Data returns

Ensure collection of new

blindness due to diabetic

retinopathy

Process Seven: Outcomes

Objective: Ensure regular collection and review of data indicating levels of new blindness due to diabetic retinopathy

QA standards: Objective 13: To ensure regular collection of data indicating levels of new blindness due to diabetic retinopathy Objective 16: To optimise programme efficiency and ensure ability to assure quality of service Objective 18: To ensure the public and health care professionals are informed of performance of the screening programme at regular intervals Objective 19: To ensure the service participates in quality assurance

SI/SSI

Discussion at programme board (SA2)

Case note review

Collection of VA data

Secure process for data collection



Process Eight: Recall

Objective: Ensure an annual screening interval for the eligible population

QA standards: Objective 17: To ensure that the screening interval is annual

Annual Recall

Annual Recall

Ensure a 12 month recall

interval for all patients

Monitoring of recall interval (SA9)

Report timeline breaches

Capacity/demand analysis (SA 9,10,11 and 12)

Contingency plan for breaches

Discussion at programme board (SA2)

Documents

Internal Quality Assurance Guidance and Best Practice Toolkit · Internal Quality Assurance Guidance and Best Practice Toolkit Version 1.2 23 January 2012 Payal Patel and Philippa