nhsp quality assurance programme: what are the outcomes?

Hosted by the Royal Free Hampstead NHS Trust hearing.screening.nhs.uk

NHS Newborn Hearing Screening ProgrammeNHS Newborn Hearing Screening Programme

NHSP Quality Assurance Programme:NHSP Quality Assurance Programme:

What are the outcomes?What are the outcomes?

Christine Cameron MSc CSChristine Cameron MSc CS

Head of NHSP QA ProgrammeHead of NHSP QA Programme

BAPA Conference January 2013BAPA Conference January 2013

Hosted by the Royal Free Hampstead NHS Trust 2

NHS Newborn Hearing Screening Programme

hearing.screening.nhs.uk

Setting the scene

English newborn hearing screen has been fully implemented since 2006

Recently celebrated screening of the 5 millionth baby

115 local screening programmes in England

Local screening programme incorporates the whole care pathway of the hearing screen

33 clearly defined quality standards relating to activity across the care pathway

QA Programme started in 2006




Some questions to begin with

• How does quality assurance work?

• Does quality assurance have an effect on improving services?

• How do the professionals feel about an external audit?

• Is there a benefit for the families?

• What is the real value of quality assurance?




Quality Assurance is an external audit of local performance against the quality standard




Quality Assurance in practice

• Collect information from all services in each local programme

– Self assessment questionnaires

– Supporting evidence

– Visit to the service to look at clinic resources, case notes, interviews, observations

• Expert Peer Review team who review the information and assess performance against the quality standards

• Final Report– Recognition of good practice and gives recommendations for quality improvement

– Report circulated to managers and commissioners, and public domain

– Improvement Plan




Quality Assurance in practice

• Action Plan lists all the recommendations in a convenient table

• It takes 18 months to complete one QA cycle of all 115 local programmes

• In the next QA cycle we repeat the process– look at the previous Action Plan

– reassess performance against the standards

– can determine progress and quality improvement

• We have now reviewed all the local screening programmes four times so, have we any evidence that the QA programme is necessary or has improved services?




QA programme: an iterative process

• First cycle Nov2006 - March2008– Word documents for self assessment– Peer review visits

• Second cycle April2008 – Oct2009– Electronic self assessment questionnaires QAF– Peer review visits incl case studies and ABR

• Third cycle June2010 – Sept2011– Self assessment questionnaires; triggered recommendations– ABR review– Targeted peer reviews to services

• Fourth cycle April2012 – March2013– Self assessment questionnaires; triggered recommendations– Case studies – audiology/medical/early intervention– ABR review– Targeted peer reviews to services




Does quality assurance have an effect on improving services?

Evidence from;

• comparison between QA cycles

• recommendations addressed in Implementation Plan

Screening

Audiology

Education

Medical

CHSWG




Screening: Quality Standard 7 : 95% screens completed in 4 weeks

Screen complete in 4 weeks: across the QA cycles

50

60

70

80

90

100

SouthWest

SouthCentral

SouthEast

Coast

London East ofEngland

WestMidlands

EastMidlands

Yorkshire& Humber

NorthWest

NorthEast

perc

enta

ge QA1

QA2

QA3




Screening Quality Standard 15: all screen referral to audiological assessment offered within 4 weeks

Screen referral to assessment within 4 weeks: across the QA cycles

0

20

40

60

80

100

SouthWest

SouthCentral

SouthEast

Coast

London East ofEngland

WestMidlands

EastMidlands

Yorkshire& Humber

NorthWest

NorthEast

perc

enta

ge QA1

QA2

QA3




Screening: case study

QA1

• screen coverage 55.8 % by 4 weeks of age

• no effective leadership

• no robust procedure for referral to audiology

Local working group set up to address issues following QA report and possible suspension of screening

When would this situation have been identified without QA

QA2

• turned the service around

• Overall rating in top five of country




Case study

Screening activity over the QA cycles

0

20

40

60

80

100

QA1 Revisit QA2 QA3

QA cycle

per

cen

tag

e

completed by 4 w eeks

screen decline

screen complete by 3months

audiol assess w ithin 4w eeks

screen incomplete




impact on Audiology services

• Diagnostic testing

• Behavioural testing – use of VRA

• Habilitation –RECD; appointment time; staffing

• Facilities – test accommodation

• Test results given on same day

• Team working

• Community audiology – VRA, staffing, facilities





Recommendation QA1 QA3to perform frequency specific tone

pips and bone conduction ABR 31* audiology

servicesnone

to measure RECD before fitting hearing aids

28* audiology services

2 audiology services

to introduce insert and bone conduction VRA

27* audiology services

none




Impact on Audiology: behavioural testing

testing in targeted follow up clinics

020406080

100120140160

bone VRA distraction soundfield VRA insert VRA

QA2

QA3

QA4





• Eastbourne & Hastings – lone paediatric audiologist

• Highlighted in 2 QA reports as a risk

• As a direct result of the QA reports the new team looks like:

• 1 wte head of service

• 0.4wte senior paediatric audiologist

• 1.0wte paediatric audiologist

• 0.4wte health visitor specialist (with Audiology training)




Impact on Audiology services

QA2 QA3 QA4

Results given on same day

112 135 135

Course attended79 119 132

Education present 42 50 43




Impact on Audiology: ABR

• QA1 identified issues with ABR traces. Poor use of BC and tone pip

• QA2 ABR traces included in peer review

– Training update courses

– External review groups encouraged

– Pilot of regional review groups

– serious incident and suspension

• QA3 ABR review (5 cases) by external experts. All using BC and tone pip

– Followed up with phone call to ensure QI

• QA4 ABR review (4 cases) by external experts with requested ID




Impact on Audiology: ABR Review

• 13 incidents

• Additional 20 audiology departments requiring regular external review & training

• External expert reviewers

• PC expert reviewer

• Setting up of regional peer reviews




Impact on Audiology: ABR Review

• QA3 42% category 1 or 2

• QA4 48% category 1or 2

ABR Review QA3 and QA4

0

10

20

30

40

50

60

1 2 3 4 5

category

pe

rce

nta

ge

QA3

QA4




Impact on Medical services

• Improved adherence to the aetiological investigation guidelines

• Inclusion of all PCHI – mild & unilateral

• Attendance at aetiological investigation course

• Raised concerns over succession planning

• Supportive evidence for genetic testing




Impact on Early Intervention services

• Early Intervention services have improved their year round cover to respond and visit families referred from audiology

• Improved sharing of information between education and audiology colleagues

• An increased number of parents are now involved in the local Children Hearing Services Working groups




Is there a benefit for the families?

• ‘Sharing the news’ courses

• Results discussed on day of test

• Informed choice

• Parent satisfaction surveys

• Representation at CHSWG

• Quality improvement to services

• Improved equity of services

• QA reports in public domain




impact of QA programme: CHSWG QA3

• 78% QA3 groups report they are now ‘effective’ : 54% in QA2

• 81% in QA3 as being both strategic and operational : 78% in QA2.

• 74% QA3 groups meet every 3-4 months : 53% in QA2

• Improved representation – see next slide




Stakeholder representation in CHSWG

QA2 QA3

Audiology 29 120

Medical 17 109

Education 29 119

Parents 28 109

Social care 20 90




Patient satisfaction survey: impact on service provision

Integral part of the QA programme is to recommend services ask families for their view of the service and we have asked what changes they have made as a result of such a surveyo Wax removal was improved and a fast track care pathway was implemented

o Appointment slots altered to give greater parental choice of time and date

o Improved parking and waiting room facilities

o Ensure that all staff introduce themselves and their role when first seeing a patient

o Establishing hearing aid maintenance sessions at satellite clinics

o Ear moulds sent directly to families from manufacturers




Why did the improvement happen?

• QA Reports were taken seriously and acted on– Wide circulation of reports

– Respect for the QA programme

– External Peer Review audit against Quality Standards

– Local ownership for improvement

– Suspension of services

• Repeated QA cycles – Came back to check on progress

• Working with professionals to improve practice with offering training courses, networking, peer review groups (ABR)

• Parent surveys




Quality improvement culture developed

• Courses– ABR Update

– Sharing the News

– Infant Hearing Aid fitting

– VRA

• Forum to discuss late identified cases

• Peer review – internal & external

• Audit embedded in services




How do professionals feel about the QA programme? QA3

• 96% valued the QA programme as a means to maintain and improve quality

• 96.9% reported that changes have been made to their service as a result of QA programme

ABR review QA3

• 86% aid to quality improvement

• 78% necessary to assure quality across services

• 75% reassuring exercise

• 69% change in their clinical practice




Quality Assurance : the value

• Identifying poorly performing services and services performing well

• Driver for quality improvement

• Provide commissioners with either assurance that they are paying for a good service or encouragement to improve

• Provide professionals with an external review of practice

• Offer families a view of services – informed choice

• Inclusion of the complete care pathway was vital to ensure no ‘gaps’

Most importantly families and babies benefit – the Quality Assurance Programme ensures they will receive a quality service wherever they live in England




Summary

• Demonstrated power of QA cycles in bringing about QI and maintaining high level of service provision – across the care pathway

• QA programme is now established and respected

• The future of NHSP QA




Acknowledgements & thanks to

• All the leads of screening, audiology, medical and early intervention services in England that have participated in the QA programme over the past 6 years

• The expert peer review Quality Assurance team of experienced professionals who undertook the review visits

• Colleagues at the national Programme Centre

nhsp quality assurance programme: what are the outcomes?

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