REGIONAL QUALITY ASSURANCE VISITS TO

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					PROTOCOL FOR MULTI-DISCIPLINARY

      QUALITY ASSURANCE

           VISITS TO

       EAST OF ENGLAND

    BREAST SCREENING UNITS
REGIONAL QUALITY ASSURANCE VISITS TO
EAST OF ENGLAND BREAST SCREENING UNITS




INTRODUCTION

The East of England Quality Assurance Evaluation Group agreed that all units should have a
multi-disciplinary assessment from the QA Team at least every 36 months.

Breast Screening personnel can discuss working practices and demonstrate their achievements. It
is an ideal opportunity for raising awareness of problems in a multi-disciplinary environment.

In the future these visits may become part of an accreditation process.

QA GROUP MEMBERSHIP

QA Director
QA Radiologist
QA Surgeon
QA Administrator
QA Physicist
QA Pathologist
QA Radiographer
QA Breast Care Nurse


Where team members are visiting their own unit they would be expected to advise the rest of the
team of an appropriate replacement.


UNIT PREPARATION

Policy and procedure manuals should be sent to QA Reference Centre one month before visit.

Check lists from the QA team members have been devised on subject areas that will be covered
during the visit. Check lists will be distributed prior to the meeting so that any statistics or other
information may be prepared in advance. (Appendix 1 – 8 shows checklists)

Units should produce statistics to compare against National standards (previous financial year) at
least one month prior to the meeting.)

It is advisable that the home team meet prior to the visit to ensure that important issues are raised
and the time of the visit is used constructively.

Units should ensure that individual rooms are available for discussions to take place by each
group.

The Chief Executive and Purchasers will be informed of the date of the visit and approximately
when to expect the final report
.
Any recommendations made in previous reports will be followed-up.

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Recommendations made in the report will have set time scales to which the Unit will be expected
to adhere. The QA Director will follow up all recommendations.


PROGRAMME FOR VISIT

The visit will be an all day visit.

The QA Director will chair the meeting.

The programme will normally follow this format:

VISIT

Time approx. (this may be subject to amendment)

10 min             -         Introductions

60 min             -         Split into groups and discuss topics on check lists.

45 min             -         QA Team meet to discuss findings, and recommendations.

30 - 60 min                  QA Team and home team meet together and chairman summarises
                             findings and recommendations.

REPORTS:

Individual reports should be ready with 3 weeks of the visit.

QA Members will produce reports which will be collated and sent to the home team for comment
within 5 weeks of the visit.

Any changes to the report will be made prior to sending a copy to the purchasers and the Chief
Executive within 8 weeks.


FOLLOW UP ACTION

Recommendations may be made with time scales for implementation. These will be followed up
by the relevant QA team member.

If recommendations are not instituted, then communication with Purchasers and/or Chief
Executive may follow.




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                                                                       Appendix 1

                                     QUALITY ASSURANCE VISIT

GENERAL CHECKLIST

Possible areas to be covered during general discussion:

1. Eligible population

2. Managerial structure/division of responsibilities

3. Level of workload

4. Distribution of workload

5. Are regular Breast Screening team meetings held?

6. Do all team members attend assessment?

7. Degree of involvement of different professional groups in case management

8. Quality Assurance

        Time allocated for QA duties

        Knowledge of QA measures

        Designated individual responsible for data collection

9. Procedures

10. Evidence of performance against National Standards




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                                                                                           Appendix 2

                                     QUALITY ASSURANCE VISIT

RADIOLOGY CHECKLIST

QA Radiologist – Dr Geoff Hunnam/Dr Sue Barter

A Peer Review of Screening Cases

The QA Radiologist will review at least 25 screening cases with the home team radiologist.

These cases should include:

1.       Films and records of the last 5 localisation excision cases.

2.       Films and records of women diagnosed with cancer on early recall (for the last two years).

3.       Films and records of any woman placed on early recall for a second time (in the last two
         years).

4.       Films and records of women placed on early recall during the last screening year.

5.       Films and records of results of interval cancer routine review of all interval cancers
         reviewed in the last year.

Interval cancers should be placed in order with false negative and minimal sign cases first and
true intervals and occult cases last. Dr Jenny McCann’s analysis of the interval cancer peer
review days may help with classification.

B        Items for discussion at Standard Multidisciplinary Quality Assurance Visit

1.       Data from the previous year’s KC62 return will be discussed ie visits after 1 October of
         each year will review the previous screening year’s figures.

2.       Timetable
         Fill in the attached radiologists timetable detailing each radiologists (by initials) breast
         commitments. This should include both screening and symptomatic work eg

         Monday am           9-10                 multidisciplinary meeting      (AB,CD,EF)
                             10-11                screening reading              (EF)
         Monday pm           14.00 hrs-17.30      breast clinic                  (AB)
                             8 assessments, 12 symptomatics plus 2 localisations

3.       Screen reading (for each of the radiologists)

         a)        Viewing conditions

         b)        Protected time/interruptions

         c)        How many read at one session

         d)        Aids to reading used

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         e)        Double reading (estimate of percentage double read)

         f)        Mechanism of recall if discrepancy between two readers

         g)        Process of recall/failsafe mechanisms. Who removes films from roller viewer?

         h)        Previous films. Availability and are previous films on the roller viewer at the
                   time of reading.

4.       Assessment Clinics

         The number of assessment sessions and the number of patients and radiologists present at
         each assessment clinic should be on the timetable.

         a)        Who are the other members of staff present (eg breast care nurse specialists,
                   surgeons etc).

         b)        What ultrasound machine is used and how old is it?

         c)        Needle biopsy – what guidance methods used?

         d)        FNAC or Core biopsy?

         e)        Needle biopsy audit undertaken?

5.       Multidisciplinary meetings

         How often? (This should be listed on the timetable).

         Who attends the multidisciplinary meetings?

6.       Education

         Review of continuous training and education

         a)        Recent courses attended

         b)        Regional Interval Cancer Peer Review Meetings attended




Regional QA Visit Protocol Sept 98                                                                   6
Breast Screening Radiologists Timetable


                                     Am   pm




Monday


Tuesday


Wednesday


Thursday


Friday




Regional QA Visit Protocol Sept 98             7
                                                                                  Appendix 3

                                     QUALITY ASSURANCE VISIT

PATHOLOGY CHECKLIST

QA Pathologist - Dr Lynda Bobrow/Dr Salam Al-Sam

Possible areas to be covered during discussion:

1. Does all breast screening pathology go to a single pathology department?

2. Names of Pathologists (including non-consultants) who report breast screening histology

    a) Reporting times

3. Review of difficult/interesting cases

4. Participation in National QA Scheme

5. Quality of cytology preparations

6. Quality of histology preparations

7. Liaison and relations with radiologists and surgeons

8. Are regular multi-disciplinary meetings held?

9. Is there sufficient medical and MLSO support?

10. Is an FNA service provided?

11. Standard of facilities and equipment

12. Secretarial support

13. Workload

14. Turnover




Regional QA Visit Protocol Sept 98                                                           8
                                                                       Appendix 4
                                     QUALITY ASSURANCE VISIT

SURGERY CHECKLIST

QA Surgeon - Mr Neil Rothnie/Miss Fiona MacNeill

Possible areas to be covered during discussion:

1. How many surgeons are involved in the breast screening programme?

2. Do you have a breast clinic?

3. Do you have a breast care nurse(s)/counselling?

4. Are there facilities for FNA (including sterotaxis)?

5. Biopsy rate

6. Accuracy of localisation biopsies

7. Time for specimen x-ray result

8. Weight of benign biopsies

9. Benign:malignant ratio

10. Carcinomas detected – methods of treatment

11. Times:

    a) Mammography to assessment

    b) Patient notification to assessment

    c) Admission after assessment

12. Multidisciplinary meetings with Radiologists and Pathologists

13. Data retrieval

14. Participation in national trials

15. Follow up

16. Standard of working facilities




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                                                                                     Appendix 5
                                     QUALITY ASSURANCE VISIT

RADIOGRAPHY CHECKLIST

QA Radiographer – Sue Jones/Monica Dale

This is a guide on topics that could be covered. This meeting will provide you with the

opportunity to discuss your Unit’s strengths and weaknesses. If you have anything specific that

you wish to raise please add to the list.

1. Staffing

    a) Compliance with Pritchard

    b) Sufficient to cover workloadd

    c) Training needs

    d) Sickness in past twelve months

2. Workload

    a) Number of weeks screening/year

    b) Number invited to van clinics

    c) Number invited to assessment clinics

    d) Number of sessions of screening/week

    e) Number of symptomatic women/week

3. Quality

    a) Monitoring of complaints/comments

    b) Communication with the Unit

    c) Team work

    d) Appraisal

    e) QC records

    f) Tests as per QC Manual

    g) Technical recall/repeat rate

    h) Equipment maintenance
                                                                                     Appendix 6

Regional QA Visit Protocol Sept 98                                                            10
                                     QUALITY ASSURANCE VISIT

TECHNICAL CHECKLIST

QA Physicist – Mr David Goodman/Dr Jane Shekhdar

Possible areas to be covered during discussions:

1. Equipment problems

    a) Mammography Units

    b) Processing System

    c) QA equipment

    d) Screen/film system

    e) Mobile trailer

2. Number of service visits per year

3. Response time and technical competence of equipment service engineers – in-house and

    manufacturers representatives.

4. Fault report forms – are these up to date?

5. Name of designated QA Radiographer

6. Sensitometry and routine QA measurements, please provide

    a) Recent examples of sensitometry and perspex block measurements of density and mAs

    b) Time of the day when image quality phantom films are obtained

7. Image quality problems

8. Physics services – ie: are these satisfactory?

    a) Understanding of tests and survey reports

    b) Response time to requests for assistance or ad hoc surveys

    c) Level of adequacy

9. Visit to Radiation Protection Service (this forms part of the Quality Assurance Reference

    Centre for East Anglia)

10. Lecture/Seminar subjects required to be presented by physics personnel

11. Attendance at a routine xray unit QA survey

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12. Radiation Protection

13. Mean Glandular Breast Dose




Regional QA Visit Protocol Sept 98   12
                                                                                     Appendix 7

                                     QUALITY ASSURANCE VISIT

ADMINISTRATIVE CHECKLIST

QA Administrator – Judith Fatibene/Linda Birch

Areas to be covered during discussion:

Staffing

1.   Numbers and grades
2.   Responsibilities
3.   Morale
4.   Training needs

Workload

1.   Screening coverage
2.   Self referrals – numbers
3.   Uptake
4.   Screening schedule – on target?

Information

1. Health Authority

     a) Integrity checks
     b) Transfer of screening history – Early Rescreens
     c) ZZZ batches

2. Institutions and Armed Forces

3. Adequate information to GPs

     a)   Results
     b)   Staging information – at assessment and outcomes
     c)   Screening schedules
     d)   Mobile/Static information for surgeries

4. Screening Office Procedures Manual

5. Regional Admin & Clerical Manual

Monitoring Standards

1.   Interval between initial appointment. letter and appointment - 2-4 weeks
2.   Interval between screen and result – less than 2 weeks
3.   Interval between screen and assessment – less than 3 weeks
4.   Interval between screen and assessment appointment letter – less than 2 weeks



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Computer

1.   HCSS/NBSS problems
2.   Hardware support
3.   KC62
4.   Data entry/problems/IPH download

Fail safe procedure

1. Results
2. Recalls – procedure for handling
3. Routine administrative procedural checks




Regional QA Visit Protocol Sept 98            14
                                                                              Appendix 8

                                     QUALITY ASSURANCE VISIT

QA BREAST CARE NURSE CHECKLIST

QA Breast Care Nurse - Hilary Harte/Jane Wood

Possible areas to be covered during discussion:

1. Audit of standards for Breast Care Nurse

    (guidelines for Nurses in Breast Cancer Screening NHS Breast Screening)

2. Discussion of involvement with screening women:

    a) Assessment Clinics

    b) Follow up for patients with screen detected cancers

    c) Patient information literature

3. Education – need and opportunities for course, etc

4. Unresolved difficulties to take to the QA Group




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