Cervical Screening Wales
This folder contains the Cervical Screening Wales Colposcopy Quality Manual. The manual
contains the Standard Operating Policies and Procedures (SOPPs) for colposcopy services
working within the Cervical Screening Programme in Wales. Where specified ‘Trust’ refers
to Velindre NHS Trust and not the host trust for the local colposcopy service.


Manual Holders

Each copy of the Quality Manual is identified individually, by number, and is the
responsibility of the specified member of staff named as the manual holder.

Manual Identification

The manual number, manual holder and manual location is recorded at the front of each copy
of the manual.

Updates to the Quality Manual

The Quality Manual is subject to continuous ongoing review; additions and amendments will
be issued periodically, following approval by the Cervical Screening Wales All Wales
Management Group (AWMG).

Updates will be issued to all manual holders by the document controller. It is essential that
the filing instructions accompanying each update are followed precisely by manual holders,
so that all copies of the Quality Manual remain identical and up to date.

Approved Procedures

These are SOPPs that have been approved for implementation by the AWMG.

Draft Procedures

These are SOPPs that have been proposed by the Policy and Procedure Group (PPG) and
have been circulated to the service for comment before submission to the AWMG.

Working Draft Procedures

These are SOPPs that have been agreed by the PPG for trial implementation. Colposcopy
services may be asked to implement the SOPP in the department and feed back comments, so
that amendments may be made before submission to the AWMG for final approval.

Colposcopy Quality Manual                  Cervical Screening Wales   Introduction : Page 1 of 2
V4 - Final Working Draft - Issued to Service 1st June 2009
Colposcopy is in part a subjective procedure, designed to visualise and assess pre-malignant
lesions that have been identified in the primary screening process; it is an integral part of the
cervical screening programme in Wales and has a central role in the management of these
pre-malignant conditions. It enables directed biopsies to be taken to confirm the clinical
diagnosis and enable local treatment to be performed which meet the needs of the individual

A National Service Framework (NSF) for the Cervical Screening Programme in Wales has
been introduced to ensure that cervical screening is delivered in a consistent manner across
Wales; this includes the management of screen detected non-invasive disease.

The aim of the NSF is that all women should receive the same level of service and quality of
care for the same level of need, regardless of location. The NSF covers not only what should
be provided, but also how the programme, and each of its elements, should be organised and
managed. Standard Operating Policies and Procedures, accepted throughout the service are,
therefore, essential if this aim is to be achieved.

Colposcopy offers a second screening strategy as a diagnostic procedure for the woman
identified as having an abnormal cervical sample. It enables an accurate diagnosis of the
patient’s condition and a decision to be made on arrangements for the subsequent local
delivery of the appropriate treatment, depending on the severity of the underlying
pathological changes identified.

    Diagnosis is confirmed by the histopathological examination of directed biopsies taken
    during the colposcopic examination.

    The aim of treatment is to reduce the level of morbidity and mortality from cervical

    The success of treatment is indicated by the return of the woman to normal cytology and
    her subsequent reinstatement to normal recall within the cervical screening programme.

    The quality of a colposcopy service is measured by a high level of success in the
    eradication or removal of cervical intra-epithelial neoplasia (CIN) following treatment.

Patient satisfaction is also identified as a crucial element in measuring the success of
treatment. Treatment is relatively straightforward and usually highly effective. A high level
of compliance following referral to colposcopy will, therefore, have a major impact on the
success of the cervical screening programme in Wales. The degree of compliance will depend
very much on the acceptability of the process to women, their experience of colposcopy and
the underlying satisfaction with the service whilst undergoing investigation.

Maintenance of quality in colposcopy is an essential part of the framework of clinical
governance. The responsibility for clinical governance within the screening programme for
all elements of the programme lies with Cervical Screening Wales.

Colposcopy Quality Manual                  Cervical Screening Wales      Introduction : Page 2 of 2
V4 - Final Working Draft - Issued to Service 1st June 2009

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