Introduction to External Quality Assurance

1
Introduction to External Quality Assurance

• Dr Linda Garvican
• National QA Director
• English Screening Programme for Diabetic
  Retinopathy,
• QA Director
• Breast and Cervical Screening, South East Coast

2
Aim of QA

• Reduce the probability of error and risk
• Ensure that errors are dealt with competently and
  sensitively
• Help professionals and organisations improve year
  on year

3
Why the need for QA?

• All screening involves potential harms as well as
  benefits
• Different ethical position from usual clinical
  care
• Onus on programme to ensure that benefits
  outweigh harms
• Poor quality screening is worse than no screening
  at all.

4
Why is all this necessary?

• Incidents in other screening programmes have
  cost the NHS millions
• Photo/sample never processed
• Mix-up of photos/sample and paperwork
• Wrong grading result
• Right grading, but not acted upon
• Patients not followed up
• Treatment delays/failures

5
Deming and the car industry

• Develop clarity of purpose
• Build quality into the whole process from the
  outset
• Involve all the staff
• Make it right first time

6
Donabedian

• Identified 7 components of quality in health care
• Efficacy trial conditions
• Effectiveness real world
• Efficiency value for money
• Optimality balancing improvements with costs
• Acceptability to patients and families
• Legitimacy ethical issues - follow through to
  treatment
• Equity access, fairness, appropriateness
• Structure, process, outcome

7
QA in screening programmes

• Integral to the programme, built in from the
  beginning
• Cultural part of what people do daily,
• Covers all aspects of the programme/stages of the
  pathway
• All staff/professional groups
• Monitored at regional or national level

8
Components of QA

• Ongoing monitoring of key programme statistics
  for each local service
• Monitoring of performance against a set of
  quality assurance standards and criteria
• Internal quality control schemes, including
  double checking of grading
• External quality assessment by proficiency
  testing of all graders
• Evidence of initial training, accreditation, and
  ongoing development programmes for staff.
• Audit of screening history of screening
  failures/managing Serious Untoward Incidents
• Peer-review through a system of QA visits
• Support mechanisms for overseeing quality and
  assisting local programmes with quality
  improvement

9
Purpose of a QA visit

• See the whole programme, as a unit, in local
  context
• Providers - screening, grading, admin,
  ophthalmology
• Commissioners and Public Health at PCT
• Look at facilities, meet staff, observe elements
  of screening pathway, consider resources,
  governance and IT
• Identify and celebrate good practice
• Provide recommendations on how to improve the
  service, and aid communication between
  constituent parts

10
A QA visit is not

• A formal inspection with pass/fail
• Just about picking holes in a service
• It is meant to be
• Constructive
• Facilitative
• Educational

11
Visiting team

• Common membership Local RQAM, public health,
  ophthalmology, administration
• Tailored to provide peers who are running
  similar service models
• Appropriate visiting clinical leadership
  diabetologist, optometrist, etc
• Optometrist if optometry-based programme
• Retinal screener/grader if mobile/fixed site
  programme

12
Outputs

• Feedback on the day
• Detailed report to provider and PCT with
• Areas of good practice highlighted
• Recommendations with timescales and suggested
  action lead

13
Already achieved as a result of visits

• Increased PCT recognition of complexity of
  programme and responsibility to provide accurate
  and timely data on people with diabetes
• Increased investment into screening programme
• Better communication between PCT and service
• Development of Service Level Agreements
• Engagement of SHA screening leads