SCOTLAND and NORTHERN IRELAND EQA SCHEME in GENERAL HISTOPATHOLOGY ANNUAL REPORT 2015/2016 NHS TAYSIDE

Transcription

1 SCOTLAND and NORTHERN IRELAND EQA SCHEME in GENERAL HISTOPATHOLOGY ANNUAL REPORT 2015/2016 NHS TAYSIDE H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 1 of 9

2 CONTENTS Section A: Service/Programme.4 A2 Aim / Purpose / Mission Statement / Date of Designation... 4 A3 Description of Patient Pathway... 4 A3 a) Target Group for Service or Programme... 4 A3 b) Abbreviated Care Pathway for Service or Programme... 4 Section B: Quality Domains.4 B1 Efficient... 4 B1 a) Report of Actual v Planned activity... 4 B1 b) Resource use... 5 B1 c) Finance and Workforce... 5 B1 d) Key Performance Indicators (KPIs) and HEAT targets... 5 B2 Effective... 6 B2 a) Clinical Audit Programme... 6 B2 b) Clinical Outcomes/ complication rates / external benchmarking... 6 B2 c) Service Improvement... 6 B2 d) Research... 6 B3 Safe... 6 B3 a) Risk Register... 6 B3 b) Clinical Governance... 7 B3 c) H.A.I. and Scottish Patient Safety Programme (SPSP)... 7 B 3 d) Adverse Events... 7 B 3 e) Complaints / Compliments... 7 B4 Timely (Access)... 8 B4 a) Waiting / Response Times... 8 B4 b) Review of Clinical Pathway... 8 B5 Person Centred... 8 B5 a) Patient/Carer/Public Involvement....8 B5 b) Better Together Programme Involvement...8 B5 c) User Surveys...8 B6 Equitable... 8 B6 a) Fair For All: Equality and Diversity...8 B6 b) Geographical Access...8 Section C: Looking Ahead/Expected Change/Developments...8 Section D: Summary of Highlights (Celebration and Risk)..9 H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 2 of 9

3 The completed Annual Report should be sent electronically by 31 May to: Isabel Zaman Senior Programme Manager National Services Division Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone Mobile Phone to NSS.nsd-reports@nhs.net Phone: Fax: H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 3 of 9

4 Section A: Service/Programme A2 Aim / Purpose / Mission Statement / Date of Designation The scheme was inaugurated in 1994 and Consultant Pathologists from departments in Scotland and Northern Ireland are assessed bi-annually on their diagnoses of 10 general histopathology slides. Four optional additional cases of special educational interest are also circulated, but not marked. The slides are provided for each circulation by two members of the scheme's Management Committee on a rotational basis. The cases are chosen to emulate general histopathology in routine practice. The aims of the General Histopathology EQA Scheme are to: Promote consistency in reporting across the country and contribute to the establishment of minimum national standards Contribute to continuing medical education Enhance confidence of participants in their reporting practice. Following the Service Reviews carried out in the Scheme has aimed throughout 2015/16 to: Increase participation levels throughout all centres. Continue to review the governance issues for the scheme so these are more robust throughout. Submit any proposed changes to the current staffing arrangements for consideration by NSD. Maintain full accreditation with UKAS. Initiate participant charges for those outwith Scotland. A3 Description of Patient Pathway A3 a) Target Group for Service or Programme The Scheme is available to those who report surgical pathology cases and have the authority to report independently on material which is part of the Scheme i.e. consultants and specialty trainees post MRCPath who have achieved their CCT and are reporting independently. N/A A3 b) Abbreviated Care Pathway for Service or Programme Section B: Quality Domains B1 Efficient B1 a) Report of Actual v Planned activity The scheme continues to plan and carry out 2 runs per year. The agreed indicative level of activity for this service is: Number of consultants participating Number of Centres participating 20 The number of registered participants who submitted returns were 130 for Run 40 and 131 for Run 41. In 2015/16 there were 9 new participants enrolled and 17 withdrawals, the majority of which were retirals and a few opting to concentrate on specialised reporting. An active recruiting drive will continue in 2016/17 and has proved fairly successful over the last 4 years. H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 4 of 9

5 B1 b) Resource use The scheme continues to operate within the financial budget provided by NSD. B1 c) Finance and Workforce NATIONAL SERVICES DIVISION CONTRACT EQA HISTOPATHOLOGY (TCH013) FINANCIAL YEAR 2015/ MONTH REPORT TO MARCH /2016 CONTRACT VALUES ANNUAL WTE BUDGET BUDGET TO MAR 12 MONTH REPORT EXP TO MAR VARIANCE TO MAR STAFF COSTS Admin Band ,846 11,846 14,184 2,338 Quality Manager - Band 8C 1,681 1,681 7,139 5,458 Data Manager - Band 8A 1,503 1,503 1,044 (459) TOTAL STAFF COSTS 15,030 15,030 22,367 7,337 SERVICE COSTS Postages, Stationery, Sundries 2,631 2,631 1,658 (973) Equipment Committee Meeting & Travel 3,276 3, (3,205) Travel/Training 3,503 3,503 2,027 (1,476) National Meetings 1,948 1,948 0 (1,948) Overheads 1,293 1,293 1,293 0 Capital Charges UKAS Accreditation 5,650 5,650 5, Income from Non Scottish Participants 0 0 (10,000) (10,000) TOTAL SERVICE COSTS 18,868 18,868 1,498 (17,370) TOTAL COSTS 33,898 33,898 23,865 (10,033) Whilst every effort is made to curtail unnecessary expense the increasing costs of consumables (e.g. postage) and travel will continue to increase. The increasing use of and fax for communication with participants and transfer of results helps to offset the increasing costs. The costs of UKAS accreditation compared to CPA accreditation have increased significantly, but have been offset by the introduction of fees for non-scottish participants in 2015/16. B1 d) Key Performance Indicators (KPIs) and HEAT targets Key Performance Indicators include: Activity (see B1 a) Turnaround Times (see B4 a) Results Number of participants in bottom 2.5%:- H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 5 of 9

6 In run 40, one participant was in the bottom 2.5%, which triggered a First Action Point notification letter. In run 41 two participants triggered a 2.5% notification letter and no other action points were triggered. B2 Effective B2 a) Clinical Audit Programme Internal audit of quality management system Fourteen horizontal audits were carried out during 2015/16, against all sections of ISO and giving rise to 3 non conformances. These were mainly for overdue reviews and audits. All of these have now been completed and signed off. Internal audit of EQA Scheme operation Two vertical audits were carried out during 2015/16, on runs 40 and 41, resulting in five non conformances: two of them for the website not being up to date. This has been an ongoing concern for the scheme over the last nine months, but hopefully the issues have now been resolved. The others were for lapses of reviews and procedures. Corrective and preventive measures have been signed off. Seven examination audits were carried out during 2016/17, none of which gave rise to any non conformances. The final of these audits was against all the corrective actions put in place during 2015, which highlighted one main area of concern ongoing problems with the scheme website, which is administered by NSD. B2 b) Clinical Outcomes/ complication rates / external benchmarking The last review by National Services Division of National Services Scotland occurred on 18/11/2015 with continuation of our core funding. A service level agreement is also in place, the current version covering July 2015 saw a full external assessment visit of the scheme by UKAS. This resulted in 13 improvement actions, evidences for which were submitted to UKAS and full accreditation under ISO 17043:2010 was granted in October B2 c) Service Improvement Further items for improving the service delivered by the scheme include: Continue to explore further possibilities of utilising the Scheme Web page to communicate with participants. Continue to actively invite all new consultant appointments to join the scheme. Continue to review mode of assessment and evaluation of performance. Maintain UKAS accreditation. B2 d) Research Continuing investigation of the possible use and benefits of participants being able to access scanned images remotely. Whilst we remain open to the provision of cases in electronic formats our previous experiments in this direction have not been very successful and there has been minimal demand from the membership for such innovations. B3 Safe B3 a) Risk Register NHS Tayside operates a risk management system called the DATIX system. This is an electronic web-based system which enables staff to record and monitor incidents that occur within their department. The DATIX system produces a high level of accuracy and automatically links to the Root Cause Analysis (RCA), Executive Summaries and External Reporting. Our EQA scheme has not had H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 6 of 9

7 to record any incidents on the AIM system over the past 8 years. Critical Incidents are recorded within our Qpulse database; see section B3 d). B3 b) Clinical Governance Clinical Governance is discussed at Executive Team meetings. The Clinical Governance structure has altered within NHS Tayside since the last directorate restructuring 5 years ago and a new group within the Surgery Directorate meets regularly to discuss all aspects of clinical governance. This gives our EQA scheme a defined route in which to take forward any clinical governance issues relevant to NHS Tayside, our host site. B3 c) Healthcare Associated Infection (HAI) and Scottish Patient Safety Programme (SPSP) The pathology department takes an active part in departmental and site Health and Safety meetings, which gives the scheme a communication for any HAI issues. The SPSP is not relevant to this scheme. B 3 d) Adverse Events The scheme Quality Management System is also used to record any critical incidents which take place directly relevant to the Scheme activities. Two critical incidents were recorded during 2015/16: The first was based on an appeal in reference to diagnostic interpretation of a particular case. This incident led to minor corrective and preventive procedural changes within the scheme. The second incident was a failure of secure document control and appropriate checks being in place, resulting in a submitted copy of a participants answers inadvertently being circulated to all participants. A full root cause analysis took place and appropriate corrective and preventive measures have been actioned. Final resolution and closure should take place next month, following the next participants meeting. All critical incidents are discussed at executive meetings and also at the annual management review. Two minor errors were also recorded and these are also discussed at executive meetings. B 3 e) Complaints / Compliments No complaints have been received by the scheme during 2015/16. Participants of the scheme can also provide feedback about the scheme at the ACP meetings held twice a year. The most recent participants User Survey was carried out in 2015 using Survey Monkey with approximately 35% of participants responding. The final analysis of the results has been discussed at executive and management meetings. Comments given by participants included: Investigate further the possibility of video linking into the participants meetings The website was not used regularly by participants Communication within the scheme was highly praised Concerns that some of the submitted cases were specialist in nature and could not safely be diagnosed on a single H&E Increasing number of problems in ability to attend the participants meetings Concerns with EQA results being used as a marker of professional proficiency All respondents who identified themselves were given direct feedback from the Executive Team. The next participants Users Survey will take place in autumn H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 7 of 9

8 B4 Timely (Access) B4 a) Waiting / Response Times Although not relevant to patient care, the scheme does have clearly defined turn around times laid out in the quality manual in respect of receiving pro-formas, issuing of participant results etc. The scheme has no control over the timing of the participants meeting, which can sometimes lead to a delay in the dispatch of final results. Slippage Any slippage against these turn around times would be recorded as a critical incident in the schemes quality management system and discussed at the executive committee. No slippages have been recorded in the last 12 months. Exceptional Circumstances Affecting Targets Any exceptional circumstances affecting targets would be recorded as a minor error in the schemes quality management system and discussed at the executive committee. One such incident has been recorded in the last 12 months. B4 b) Review of Clinical Pathway (i) Review and Changes to Clinical Pathway Not relevant to our scheme. (ii) Improvements to Local Delivery of Care Not relevant to our scheme. B5 Person Centred B5 a) Patient Carer/Public Involvement Not relevant to our scheme. B5 b) Better Together Programme Involvement Not relevant to our scheme. B5 c) User Surveys Discussed under B3 e) B6 Equitable B6 a) Fair for all: Equality & Diversity Whilst the scheme has not undertaken a formal Equality and Diversity Impact Assessment, we do strive to make the scheme accessible to all relevant Pathology Consultant staff. Our ongoing informal recruiting initiative regularly results in new participants. B6 b) Geographical access The scheme is available to all relevant centres across Scotland and Northern Ireland. Section C: Looking Ahead/Expected Change/Developments Relevance of a general histopathology EQA scheme at a time of increasing specialisation remains an active issue. Occasional participants continue to withdraw from the Scheme, or from selected areas of specialisation within the terms of the Scheme s protocols, in response to changes in their own practice. Nevertheless, continuing support from many participants does suggest that the Scheme is relevant to the professional practice of many diagnostic Histopathologists in Scotland and Northern Ireland. H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 8 of 9

9 The Scheme continues to be based on the circulation of glass slides, and while this remains overwhelmingly the format in which as diagnostic pathologists we undertake our diagnostic duties, this is considered appropriate. We remain open to the provision of cases in electronic formats but so far there had been little demand or indeed success with such innovations. The scheme will need to ensure data management continuity with the impending retirement of our current data manager in the summer of Section D: Summary of Highlights (Celebration and Risk) The Scheme remains committed to its established model of selecting assessment cases regarded as definitively diagnosable from a single H and E section, with relevant core clinical history and occasionally (but rarely) supplementary data, e.g. immunohistochemistry results. From time to time the acceptability of differential diagnoses being offered is discussed but the problems which would be caused for scorers by moving away from the model of a single preferred consensus diagnosis are considered to outweigh any likely advantages. Where a consensus diagnosis does not emerge clearly, the Scheme s protocols provide for the removal of such a case, if there is less than 80% agreement with the consensus diagnosis, which does occasionally happen. Participant numbers continue to remain above our established baseline of 120. Results of provisional marking continue to be presented at Participant s Review Meetings, hosted by the Caledonian Branch of the Association of Clinical Pathologists. Quorate meetings are still not regularly achieved and when not quorate our procedure is that participants are circulated with a minute of the meeting and its conclusions by and are asked to vote on the marking. On those occasions when this has been necessary a quorum has been achieved without difficulty. During 2014/15 the run 40 meeting failed to achieve a quorum. The comments received in response to the Participants Survey in 2015 gave the Executive Team a clear indication that the scheme is well respected and is still a worthwhile educational and professional development opportunity. In 2014 our scheme was encouraged to investigate the possibility of charging a fee to Irish participants as NSD should only be funding Scottish based participation. Initial discussions took place and participant fees for non Scottish participants were successfully introduced in April In 2015 the scheme successfully achieved full accreditation under ISO: H:\EQA\sops\CurrentSOPS\EQAM07.doc Page 9 of 9