RECOMMENDATIONS FROM HULL PCT CERVICAL SCREENING INCIDENT

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RECOMMENDATIONS FROM HULL PCT CERVICAL SCREENING INCIDENT Powered By Docstoc
					                  ACTION PLAN FROM RECOMMENDATIONS FROM HULL PCT CERVICAL SCREENING INCIDENT
                                                                       Compiled by John Rodriguez. 25th July 2008

                          Recommendation                                     Kent and Medway Practice                        Action Required

                                    1.
GP Practices who employ nurses to take cervical samples should             Yvonne Carne-Ross provides                GPs should be reminded of the
ensure that they are competent to do so. This should be by assessment      Certificates of Competence for            need to ensure competence and
through the Regional Cervical Screening Nurse Training Programme.          practice staff. (GPS, hospital            keep personal records.
They should hold a copy of the Certificate of Competence in the nurse’s    doctors and community staff are
personnel and training records.                                            outside this system).                     Action: John Rodriguez to write
                                                                           Once updated a Certificate of             to Practice Managers.
                                                                           Assessment will be issued which
                                                                           together with the original Certificate    Other staff groups should be
                                                                           of Competence (which otherwise            reminded of the need for training
                                                                           expires) is sufficient to assure of       and updating.
                                                                           competence. Laboratories no
                                                                           longer issue certificates but do issue    Action: John Rodriguez to write
                                                                           numbers if asked to by Consultants.       to GPs, Postgraduate Tutors for
                                                                           Yvonne Carne-Ross requests ST             Primary and Secondary Care and
                                                                           numbers with a “T” suffix for use         Hospital Based Screening
                                                                           only during training from QA. Once        Coordinators.
                                                                           trained the “T” is removed. It is valid
                                                                           only for 9 months as training should
                                                                           be faster than this.
                                    2.
The Regional Cervical Screening Nurse Training Scheme should               Yvonne Carne-Ross emphasises              This can be reinforced in the letter
continue to emphasise to local training providers, students and their      this and also says 20 samples must        to Practice Managers.
employers the limitation on the number of samples to be taken prior to     be taken together with completing         Yvonne Carne-Ross will supply
“signing off” as competent.                                                course requirements prior to receipt      precise details of the system.
                                                                           of a Certificate of Competence.
                                                                           Additional supervised samples             Action: Yvonne Carne-Ross and
                                                                           about 3 around samples 10-15 are          John Rodriguez
                                                                           required to ensure learning is
                                                                           maintained.
                                     3.
Each GP practice should identify a named cervical screening lead to act    Leads can be Practice Nurses so           Carol Barber has a list of Leads
as the point of contact for matters relating to cervical screening. This   the knowledge may be variably             and will supply to John Rodriguez.
person should be knowledgeable about relevant aspects of the working       clinical or administrative.

                                                                                                                                                            1
                  ACTION PLAN FROM RECOMMENDATIONS FROM HULL PCT CERVICAL SCREENING INCIDENT
                                                                       Compiled by John Rodriguez. 25th July 2008

of the Cervical Screening Programme and be an experienced and                                                  Action: Carol Barber
competent sample taker.
                                    4.
In any incident involving under-performance by a health care worker,        We would do this.                  No action needed.
that worker’s own professional and emotional needs should be
supported in order to enable them to develop their knowledge and skills
to meet the required standards.

                                     5.
The points awarded for cervical screening provision in the Quality and      Has already been proposed by Kent No action needed locally.
Outcomes Framework should be reviewed to further incentivise high           and Medway but requested so far by
quality provision and improved uptake of cervical screening in primary      the GP advisory committee.
care, and/or local incentivisation schemes should be developed.

                                   6.
The Regional Cervical Screening Nurse Training Scheme should include        K&M training scheme is alert to    No action required.
advice and training for CSNMs in the management of “failing” students       failing students eg. via record
and interpersonal management.                                               keeping.

                                    7.
The Regional Cervical Screening Nurse Training Scheme should include        It already does.                   No action required but Yvonne
aspects of ethical professional practice in the student training                                               Carne-Ross to provide evidence.
programme to emphasise the importance of self-regulation.
                                                                                                               Action: Yvonne Carne-Ross
                                    8.
Students should be issued at “signing off” with a Certificate of            Unsure of K&M practice.            This will be emphasised in letters to
Completion of Training and Competence” and employers should require                                            Practice Managers.
this before allowing their employee to take further samples.

                                     9.
The CSNMs in the RCSNTP and the University are jointly accountable          Does not apply here as we have a   No action required.
for assessing candidates as competent to take cervical samples. In          different organisation.
addition the employer is vicariously liable for the acts and omissions of
the staff. Therefore appropriate communication between the university,
CSNM, student and her employer should be maintained throughout
training.

                                                                                                                                                  2
                   ACTION PLAN FROM RECOMMENDATIONS FROM HULL PCT CERVICAL SCREENING INCIDENT
                                                                        Compiled by John Rodriguez. 25th July 2008

                                    10.
It should be a requirement for continued certification of competence that    Updates being arranged. TZ cells      No action required.
all sample takers undergo 3-yearly update training including an              not reported in K&M in line with
assessment of their laboratory results profile (e.g. detection of high and   national guidance. Results profiles
low grade abnormalities and TZ cells sampling rate) and an independent       will not be linked to updates. But
review of their cervical sampling technique.                                 see recommendation 15 which will
                                                                             offer more value.
                                     11.
Links between CSNMs and the local PCT should be strengthened to              Links are poor apart from with        To identify key links.
develop local ownership of the training and that it is an integral part of   Clinical Governance.
the running of the local cervical screening programme. The CSNM must                                               Action: Paula McLachlan
understand recognise their clinical Governance responsibilities in this
respect.

                                     12.
It is suggested that the National Office for Cervical Cancer Screening       It is already mandatory.              No action required.
considers the implications of this incident and strengthens the guidance
on training to make updating every three years mandatory.

                                   13.
The Commissioning arrangements for the RCSNTS should be                      A meeting on the 8th July 2008 was    Clarification of arrangements
strengthened and enhanced. One approach would be to include                  arranged to review this.              needed.
representatives from the QARC, SHA screening leads and PCT’s in the
discussion of the Service Level Agreement. Alternatively, NESHA may                                                Action: Carol Barber
wish to consider developing Commissioning arrangements similar to that
for the East Pennine Cytology Training Centre.

                                    14.
The Regional Cervical Screening Nurse Training Scheme should                 No protocol exists.                   Produce a protocol.
develop a protocol for dealing with underperforming sample takers.
Cervical Screening Nurse Mentors should be given training to assist                                                Action: Yvonne Carne-Ross
them in identifying and dealing with underperforming sample takers.

                                    15.
Consideration should be given to laboratories providing regular and          Each lab provides feedback but in     To standardise feedback to use a
timely feedback to individual cervical sample takers. If possible this       different ways.                       time-based and cumulative number

                                                                                                                                                   3
                   ACTION PLAN FROM RECOMMENDATIONS FROM HULL PCT CERVICAL SCREENING INCIDENT
                                                                        Compiled by John Rodriguez. 25th July 2008

should be monthly for three months for newly trained sample takers and                                                  based system. Also low numbers
twice a year for all others. Sample takers should keep a log of their                                                   should be considered. Trigger
results.                                                                                                                points are difficult to identify without
                                                                                                                        TZ cell reporting.

                                                                                                                        Action: HBSC
                                    16.
The roles and responsibilities of GP Practices for the provision of           We do not have local guidelines but       No action required.
cervical sampling services as part of the NCSP should be made clear to        there is a relevant policy on the
them by the PCT in their local NCSP Guidelines. This includes the             LMC website that has been
training and updating of staff as well as the necessary equipment and         published.
facilities.

                                     17.
PCTs should require the training and certification of competence of           National contracts limit the ability to   No local action required.
cervical sample takers in their local contracts with GP practices to          enforce this.
provide cervical screening services

                                    16a.
Hull PCT should produce a report on this incident including the               Not applicable.                           No action required.
outcomes for all the women who met the case definition for the recall
exercise, the difficulties encountered in the management of the incident
and its application to the running of the local cervical screening
programme

                                   17a.
PCTs should ensure that they report Serious Untoward Incidents in a           Should be compliance locally.             No action required.
timely way in line with SHA requirements.

                                    18.
The roles and accountability of the various “key players” in local cervical   Roles and responsibilities would          A list of key players is needed
screening programmes – including those of service providers, the local        take time to document and we follow       including:
PCT, the District Cervical Screening Programme Coordinator, and the           national guidelines.                      HBSC
DPH – be clarified. This piece of work could be undertaken within the                                                   QA
Regional Cervical Screening Coordinators Group.                                                                         Lead Colposcopists
                                                                                                                        KPCA

                                                                                                                                                              4
                  ACTION PLAN FROM RECOMMENDATIONS FROM HULL PCT CERVICAL SCREENING INCIDENT
                                                                       Compiled by John Rodriguez. 25th July 2008

                                                                                                                PH Lead and PCT contracts
                                                                                                                Commissioners
                                                                                                                Training Providers
                                                                                                                Action: Paula McLachlan
                                     19.
Each PCT should appoint a named person to act as the PCT’s internal         We have different arrangements.     No action required.
lead on cervical screening, liaising closely with the District Cervical     Medway PCT DPH, Angela Barnett
Screening Coordinator, being a member of the District Cervical              is one contact and Assistant DPH,
Screening Coordinating Committee and being the first point of contact       Declan O’Neill is the contact for
on cervical screening issues for the PCT’s GP practices. We suggest         West Kent. John Rodriguez
that this person be within the clinical governance or public health arena   doubles up for ECK PCT.
in order to be able to address particularly the quality of cervical
screening by the PCT’s contracted service providers.

                                 20.
National guidance be updated or produced to provide guidance on the         Not applicable.                     No action required.
management of a screening incident in primary care, and a protocol on
the organisation and management of a lookback and recall exercise.

                                     21.
The potential of TZ cells as a quality indicator of sample taker            TZ cells not reported have but      K&M Committee asks the NCSP to
performance should be explored urgently with a view to establishing a       laboratories warned that it was a   urgently consider guidance on
consistent approach across the North East, and Yorkshire and the            quality marker. Inadequate rates    reporting of TZ cells.
Humber Regions. Then cervical sample takers should be provided with         are no longer of use.
timely feedback from the laboratory including their TZ sampling rate and                                        Action: Carol Barber
this should be provided monthly for three months for newly trained staff
(and reviewed with their Nurse Mentor) and annually for all sample
takers. The laboratories should monitor TZ rates for each individual
sample taker.

                                     22.
Consideration should be given to other indicators of good practice in the   Already considered as part of       No action required as in hand.
role of the cervical sample taker in the Screening Programme, including     update training.
basic and update training, and the standard equipment and facilities
available.


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