governance and general administration manual...act health – cancer, ambulatory and community...

Governance and General

Administration Manual

BreastScreen ACT

Version 5.2

2017

ACT Health – Cancer, Ambulatory and Community Health Support – BreastScreen ACT Governance and General Administration Manual of 72

CONTENTS 1 VERSION CONTROL ...................................................................................................................................... 4

2 INTRODUCTION ........................................................................................................................................... 5

2.1 BREASTSCREEN AUSTRALIA .......................................................................................................................... 5 2.2 QUALITY .................................................................................................................................................. 5 2.3 MONITORING AND EVALUATION .................................................................................................................. 6 2.4 OBJECTIVES OF BREASTSCREEN AUSTRALIA ..................................................................................................... 6 2.5 BREASTSCREEN AUSTRALIA PROGRAM FEATURES ............................................................................................. 6 3.1 INTRODUCTION ......................................................................................................................................... 8 3.2 OVERVIEW OF BREASTSCREEN ACT............................................................................................................... 8 3.3 SERVICE PROVISION ................................................................................................................................... 8 3.4 ORGANISATION AND COMMITTEE STRUCTURE ................................................................................................ 9

3.4.1 Management Structure .................................................................................................................... 9 3.4.2 Staffing/Employment ....................................................................................................................... 9 3.4.3 Internal Planning, Management and Review Meetings ................................................................... 9 3.4.4 Advisory Structures ......................................................................................................................... 11

4 QUALITY IMPROVEMENT FRAMEWORK .................................................................................................... 12

5.1 POLICY AND PROCEDURE FRAMEWORK ........................................................................................................ 13 5.2 BREASTSCREEN ACT POLICY AND PROCEDURES MANUAL ............................................................................... 14 5.3 BREASTSCREEN ACT MANAGEMENT POLICIES .............................................................................................. 16 5.4 BREASTSCREEN ACT OPERATIONAL POLICIES ................................................................................................ 16 6.1 INTRODUCTION ....................................................................................................................................... 17 6.2 RISK MANAGEMENT FRAMEWORK .............................................................................................................. 17 6.3 INCIDENT MANAGEMENT .......................................................................................................................... 17

6.3.1 BreastScreen ACT Incident Management ....................................................................................... 17 7.1 DELEGATION OF AUTHORITY ...................................................................................................................... 18

7.1.1 Financial Delegation Schedule ........................................................................................................ 18 7.1.2 Human Resource Delegation Schedule ........................................................................................... 18

7.2 PURCHASING OF GOODS AND SERVICES ...................................................................................................... 18 7.3 USE OF GOVERNMENT OR PRIVATE VEHICLES AND TAXI.................................................................................. 19 7.4 CONTACT WITH MEDIA ............................................................................................................................. 19 8.1 CLINICAL GOVERNANCE ............................................................................................................................ 19 8.2 CONSUMER ENGAGEMENT AND FEEDBACK ................................................................................................... 19 8.3 CLINICAL EFFECTIVENESS ........................................................................................................................... 20 8.4 INFECTION PREVENTION & CONTROL .......................................................................................................... 20 8.5 EFFECTIVE WORKFORCE ........................................................................................................................... 21 8.6 QUALITY IMPROVEMENT ........................................................................................................................... 22 8.7 ACCREDITATION ...................................................................................................................................... 22

8.7.1 BreastScreen Australia Accreditation ............................................................................................. 22 8.7.2 BreastScreen ACT Quality Committee (SQC) ................................................................................... 23 8.7.3 ACT Health Accreditation ................................................................................................................ 23

9.1 CLINICAL RECORDS AND CONFIDENTIALITY ................................................................................................... 24 9.2 CONSENT ............................................................................................................................................... 24

9.2.1 Documenting written consent ........................................................................................................ 25 9.2.2 Consent for Screening ..................................................................................................................... 26 9.2.3 Consent for Assessment .................................................................................................................. 27 9.2.4 Consent for Invasive Procedures - Fine Needle biopsy, Core Biopsy or Mammotome .................... 27 9.2.5 Refusal to Sign Consent for Assessment Procedures ...................................................................... 27

9.3 PROTOCOL FOR PROVIDING FILM AND FILE COPIES ........................................................................................ 27 10.1 RECRUITMENT ........................................................................................................................................ 28

10.1.1 Recruitment aims ............................................................................................................................ 28 10.1.2 Recruitment principles .................................................................................................................... 28 10.1.3 Recruitment Planning ..................................................................................................................... 29 10.1.4 Approaches to Recruitment ............................................................................................................ 29


10.2 PROFESSIONAL REFERRALS ........................................................................................................................ 30 10.2.1 General Practitioners ...................................................................................................................... 30 10.2.2 Community Health Workers ........................................................................................................... 30 10.2.3 Other Health Personnel/Services .................................................................................................... 30

10.3 COMMUNITY BASED RECRUITMENT, EDUCATION AND LIAISON STRATEGIES ........................................................ 31 10.3.1 Media .............................................................................................................................................. 31 10.3.2 Community Education & Promotion ............................................................................................... 31

10.4 SOURCES OF INFORMATION ....................................................................................................................... 32 10.5 ENLISTING WOMEN TO RECRUIT FRIENDS, FAMILY AND COLLEAGUES ................................................................ 32 10.6 BREASTSCREEN STAFF .............................................................................................................................. 32 10.7 STRATEGIES FOR UNDER SCREENED WOMEN ................................................................................................ 33

10.7.1 Women of Culturally And Linguistically Diverse Backgrounds ........................................................ 33 10.7.2 Aboriginal and Torres Strait Islander Women ................................................................................ 33 10.7.3 Women of Low Socio Economic Status ........................................................................................... 33 10.7.4 Women with Disabilities ................................................................................................................. 33

10.8 INFORMATION PROVISION ......................................................................................................................... 34 10.8.1 Review of Existing Resources .......................................................................................................... 34 10.8.2 Guidelines for Review Of Resources ................................................................................................ 35 10.8.3 New Resource Development ........................................................................................................... 35

12.1 DATA QUALITY ....................................................................................................................................... 36 12.2 DATA RELEASE ........................................................................................................................................ 36 12.3 ACCEPTABLE USE OF ICT RESOURCES .......................................................................................................... 37 13.1 APPENDIX 1 – BREASTSCREEN ACT ORGANISATIONAL CHART.......................................................................... 38 13.2 APPENDIX 2 – ACCURATE INFORMATION AND RESOURCES POLICY .................................................................... 39 13.3 APPENDIX 3 – RECRUITMENT POLICY .......................................................................................................... 41 13.4 APPENDIX 4 - EXTENDED WAIT TIMES FOR RESULTS POLICY ............................................................................ 43 13.5 APPENDIX 5 – OUT OF TARGET WOMEN POLICY ........................................................................................... 45 13.6 APPENDIX 6 – ELIGIBLE WOMEN WITHOUT A MEDICARE NUMBER POLICY .......................................................... 47 13.7 APPENDIX 7 – CLIENT RECORDS ARCHIVE POLICY .......................................................................................... 49 13.8 APPENDIX 8 – ACCESS TO SCREENING MAMMOGRAPHY AREAS ......................................................................... 53 13.9 APPENDIX 9 – CONTACTING CLIENTS........................................................................................................... 56 13.10 APPENDIX 10 – WOMEN WITH DISABILITIES POLICY....................................................................................... 57 13.11 APPENDIX 11 – CONSUMER FEEDBACK FLOWCHART ...................................................................................... 59 13.12 APPENDIX 12 – CONFIDENTIALITY AGREEMENT ............................................................................................. 60 13.13 APPENDIX 13 - EECTORAL ROLL INVITATION LETTER EXAMPLE .......................................................................... 62 13.14 APPENDIX 14 – BREASTSCREEN CONSENT FORM ........................................................................................... 63 13.15 APPENDIX 15 – INFORMATION – HAVING A BIOPSY ....................................................................................... 64 13.16 APPENDIX 16 – PROMOTIONAL MATERIALS ................................................................................................. 67 13.17 APPENDIX 17 – RESOURCES PROCEDURES – NAMING, LOCATION, REVIEWING AND ARCHIVING ............................... 68 13.18 APPENDIX 18 – BREASTSCREEN ACT RESOURCES TRACKING CHANGES .............................................................. 70 13.19 APPENDIX 19 – BREASTSCREEN ACT RESOURCE ORDER FORM ........................................................................ 71


1 VERSION CONTROL

Version Effective From Effective To Change Summary

1.0 June 2002 June 2004

2.0 June 2005 June 2006

3.0 June 2006 September 2009

4.0 September 2009

September 2012

5.0

October 2012

July 2013

Updated old Policy and Procedure Manual V4.3 to new format including revision of existing content and addition of new content.

5.1

July 2013

July 2014

Update to electoral roll letter (Appendix 27). Draft letter endorsed by the Consumer Reference Group.

5.2 March 2017 May 2019 Updated to align with ACT Health Directorate policy and procedure guidelines.

BREASTSCREEN ACT

GOVERNANCE AND GENERAL ADMINISTRATION

MANUAL

Effective Date: Approval Authority: Executive Director, Cancer, Ambulatory and Community Health Support

Next Review Date: May 2018 Approval Sponsor: Director, BreastScreen ACT

Last Updated: July 2013 Version: 5.2


2 INTRODUCTION

2.1 Breastscreen Australia The BreastScreen Australia Program aims to reduce morbidity and mortality from breast cancer through an organised systematic approach to the early detection of breast cancer using screening mammography.

Screening mammography detects unsuspected cancer at an early stage so that early treatment can reduce illness and death from breast cancer.

This population based approach encourages asymptomatic women in the target population to have regular screening mammograms. It is distinctly different from the use of mammography to investigate symptoms in an individual woman, which is a diagnostic procedure. A central tenet of the success of BreastScreen Australia is to maximise the benefits of early breast cancer detection while minimising potential harm to women.

Women with symptoms of breast cancer or at high risk of breast cancer may need individualised care and services that are different from those provided through the screening program.

BreastScreen Australia’s accreditation system intends to drive continuous quality improvement in the delivery of breast screening services to ensure women receive safe, effective and high quality care.

BreastScreen Australia has a target age group of 50-69 years. In 2014 additional funding was provided to services to extend the target age group to 74 years.

BreastScreen Australia is a clearly identifiable, integrated, systematic and coordinated Program consisting of a network of accredited and dedicated Screening and Assessment Services within each State and Territory. The National Program is coordinated through the Cancer Screening Section of the Department of Health and Ageing.

The State & Territory Governments have primary responsibility for the implementation of the Program at their local level. The Australian Government provides overall coordination of policy formulation, national data collection, quality control, monitoring and evaluation. There are two components within the Program: Screening & Assessment Services and Co-ordination Units at State & Territory levels.

The Screening & Assessment Services provide all services from the initial mammogram to any follow up diagnostic procedures required. The initial mammogram is performed in a screening unit. If a woman needs further investigation, she is recalled to the assessment centre where the screen detected abnormality is assessed by a multidisciplinary team.

The State Coordination Units (SCUs) have responsibility for implementation of the National Program within the State or Territory. In BreastScreen ACT (BSACT), the management team takes on the responsibilities of the SCU.

Further information can be found on the Program on the BreastScreen Australia website in the BreastScreen Australia Accreditation Handbook and National Accreditation Standards Commentary.

2.2 Quality The National Quality Management Committee (NQMC) oversees the accreditation process for breast screening programs.


The accreditation process aims to strengthen and sustain the quality of service provision to ensure women receive breast screening services that keep pace with best practice standards and are safe, effective and of a high quality.

All BreastScreen Australia services are regularly reviewed to ensure they are providing a high quality service. The performance of every service is measured against a set of nationally agreed standards, the National Accreditation Standards (NAS). The accreditation system includes checking that each service meets the standards through a process of self-assessment, site visits and annual reporting to the accrediting body.

2.3 Monitoring and Evaluation The collection of data is a high priority, as it enables the monitoring of the Services efficiency and performance.

The Australian Institute of Health & Welfare (AIHW) also produces reports on BreastScreen Australia activity, performance and outcomes to monitor achievements.

2.4 Objectives of Breastscreen Australia

The objectives of the BreastScreen Australia program are to:

• Reduce the mortality and morbidity attributable to breast cancer. • Maximise early detection of breast cancer in the target population. • Maximise the proportion of women in the target population who are screened every two years. • Provide high quality services that are equitable, acceptable and appropriate to the needs of the

population and equally accessible to all women in the target age group. • Provide screening and assessment services in accredited Screening and Assessment Services as

part of the BreastScreen Australia program. • Provide high standards of program management, service delivery, monitoring, evaluation and

accountability.

BSACT adheres the above objectives.

2.5 BreastScreen Australia Program features BSACT services are delivered in accordance with the following national program features.

2.5.1 Access and participation Appropriate levels of access and participation in the target and eligible populations: • women are eligible and invited for screening on the basis of age alone. That is, women aged 40

years and above are eligible to participate and recruitment strategies are targeted at women aged 50−74 years;

• the screening interval is every two years; • screening is provided at minimal or no cost to the women, and free of charge to eligible women

who would not attend if there were a charge; and • patterns of participation should be representative of the socioeconomic, ethnic and cultural

profiles of the target population.

2.5.1.1 Cancer detection


Breast cancer detection is maximised and harm is minimised: • screening employs mammography as the primary screening method; • all women are screened with two view mammography. Reasons for any variation from this

policy are documented; • all mammograms are taken by a radiographer appropriately trained in screening mammography; • all mammographic images are read and reported independently, in a blind relationship, by two

or more readers, at least one of whom shall be a radiologist; and • all mammography results are combined into a single recommendation, which indicates whether

or not further assessment for the presence of breast cancer is required.

2.5.1.2 Assessment Assessment and diagnosis of breast cancer is appropriate, safe and effective: • a comprehensive approach is employed in the assessment of breast abnormalities; • a multidisciplinary team is involved in the assessment of women recalled from screening; • the pre-operative diagnosis of breast cancer is maximised, and recommendations for surgery for

benign lesions are minimised; • the outcomes for all women recommended for surgery are collected, reviewed and utilised in

continuing professional education for members of the multidisciplinary team; and • women’s general practitioners are kept informed of the results of screening and assessment,

unless a woman requests otherwise.

2.5.1.3 Timeliness Screening and assessment services are provided to women in a timely and efficient manner: • women have timely access to screening; • the time from screening to assessment is minimised; and • the results of screening and assessment are provided promptly and directly to the woman

concerned in ways which are sensitive to her possible anxiety.

2.5.1.4 Data management and information systems Effective data and information management systems: • data are collected, stored and managed using secure, quality, contemporary data management

and communication systems that comply with relevant state and national standards, and that enable valid, reliable system and service performance analysis and evaluation;

• data are used for strategic purposes, quality improvement of services and for clinical and service management;

• data are collected in line with the requirements of the BreastScreen Australia Data Dictionary; and

• data are to be submitted annually to the Australian Institute of Health and Welfare, for use in a national program monitoring report, and annual performance data reports for review by the National Quality Management Committee.

2.5.1.5 Client focus Services are of high quality and client focused:


• high quality information is provided to inform women, and women feel appropriately engaged and supported;

• screening services are provided in a manner which is acceptable to women in accessible, non-threatening and comfortable environments;

• women and health care providers are given comprehensive and easily understood information about the Program, from screening up to and including diagnosis of breast cancer;

• counselling and information are an integral part of the Program; • women are advised of the benefits and risks of mammography; and • women are provided with written information and actively involved in decisions about their

management, particularly in relation to further assessment and treatment.

2.5.1.6 Governance and management Effective structures and processes are in place to ensure high quality governance and management: • screening and assessment are carried out at BreastScreen Australia accredited services; and • key stakeholders and stakeholder groups participate in the monitoring and management of the

Program.

3 SERVICE PROVISION, ORGANISATION AND COMMITTEE STRUCTURE

3.1 Introduction BSACT is the BreastScreen Australia service in the Australian Capital Territory (ACT). The broad aim of the program is to reduce mortality and morbidity from breast cancer in the target population of women aged 50 to 69 years, by providing free screening mammograms at two-year intervals.

Screening mammography is currently the most effective tool available for the early detection of breast cancer. Screening is primarily recommended for all women aged 50 to 69. Women aged 40 to 49 and over 69 are eligible for screening, and are welcome to phone for an appointment if they wish to attend.

3.2 Overview of Breastscreen ACT In 1991, the Commonwealth Government funded a feasibility study of the viability of establishing a mammography screening program in the ACT. From this study, the ACT Government decided to establish a single centre for undertaking breast screening and follow up assessments.

BSACT commenced screening on 1 February 1993. In September 1995, with agreement from BreastScreen NSW, the service was extended to include mammography screening in the SE NSW region.

In 1 July 2011, BSACT became a new entity with a focus on servicing women residing in the ACT only. The Murrumbidgee and Southern Local Area Health Network of BreastScreen NSW, then screened clients in the SE NSW region.

3.3 Service Provision BSACT has three screening sites with one including provision for assessment clinics. Screening and assessments are carried out at the Canberra City Clinic. This site is also the administrative centre of BSACT. A screening site was established in November 2008 at the Phillip Community Health Centre


in Woden and a third site was established in December 2015 at the Belconnen Community Health Centre.

3.4 Organisation and Committee Structure

3.4.1 Management Structure BSACT is a Program within the Cancer, Ambulatory and Community Health Support Division of the ACT Government Health Directorate. The Organisation Chart for BSACT is at Appendix 1 and the ACT Health Directorate organisational chart is available on the ACT Health Intranet site.

3.4.2 Staffing/Employment All staff are employed under the provisions of the ACT Public Service and the Public Sector Management Standards.

Every position has a documented position description which is stored and available electronically.

All staff attend an orientation program that includes ACT Health Orientation and Cancer, Ambulatory and Community Health Support Division Orientation. New employees to BSACT are welcomed by the Program Director, introduced to staff, and the rationale of the Program is explained. The BSACT orientation Manual provides guidance to Managers when orientating new staff.

3.4.3 Internal Planning, Management and Review Meetings

Meeting Frequency Membership Purpose

BSACT Administrative Meeting

Fortnightly Senior Administration Manager (chair)

Office Coordinator

Administrative Staff

Provides a forum to discuss administration issues and provide feedback between management and staff.

BSACT Managers and Quality Meeting

6 weekly Promotion & Quality Manager (chair)

BreastScreen Director

Clinical Coordinator

Senior Radiographer

PACS Administrator (e-Health and Clinical Records)

BIS Administrator (e-Health and Clinical Records)

Nurse Counsellor rep

Senior Administration Manager

Data Manager (Business Intelligence Unit)

To provide leadership in the development and monitoring of quality and safety across the BSACT, performance reporting, management issues and promotional activities.

BreastScreen ACT Data Management

fortnightly BreastScreen Director (chair)

Data Manager (Business

Provides a forum to discuss data


Meeting Intelligence Unit)

Promotion & Quality Manager


Senior Radiographer



Nurse Counsellor


management and reporting requirements and issues.

BIS go-live every 3 weeks




Data Manager (Business Intelligence Unit)



Senior Radiographer


Nurse Counsellor

To discuss and progress BIS issues.

BSACT Clinical Meeting

6 weekly Clinical Coordinator (chair)

Nurse Counsellor

Senior Radiographer




To discuss any clinical matters that require input from the management team and to review, propose and endorse clinical processes and policies.

BSACT Radiographers Meeting

Every 2-3 months

Senior Radiographer (chair)

Radiographers

To distribute information between the mammography staff regarding all clinical issues associated with BSACT

BSACT Clinical Audit Meeting

Monthly Clinical Coordinator (chair) Nurse Counsellor Senior Radiographer Pathologists

A forum for the multidisciplinary clinical team to review complex client cases and recommend


Radiologists

Surgeons

treatment plans/ options.

BSACT Village Meeting

Every 2-3 months

BreastScreen Director (chair)

All BreastScreen staff

A forum for all BSACT staff to meet, discuss the service performance and receive updates and training/ presentations on pertinent issues.

3.4.4 Advisory Structures

3.4.4.1 BreastScreen ACT Advisory Committee BSACT reports to an advisory committee. This committee provides a forum for stakeholders in the ACT region to discuss issues and provide feedback and advice to BSACT. The Terms of reference outline the role and tasks of this committee. The meeting is held quarterly and membership comprises of:

Executive Director, Cancer, Ambulatory and Community Health Support Division (Chair)

Promotion and Quality Manager (Secretariat)

Representatives of the following agencies/ disciplines:

Cancer Council Radiography

Women’s Health Service Breast Surgery

ACT Medicare Local – General Practice Culturally and Linguistically Diverse community

Epidemiology Aboriginal and Torres Strait Islander community

Pathology Bosom Buddies

Breast Cancer Network Australia Breast Cancer Network Australia

BreastScreen ACT Program Director General Practice

3.4.4.2 BreastScreen ACT Community Reference Group The Community Reference Group is made up of representatives of women’s' organisations and consumer representatives. The Committee provides a forum for the members to discuss issues and provide feedback on BSACT, in particular on promotional resources. Meetings are bi-annually or as required.

Promotion and Quality Manager (Chair & Secretariat)

Health Care Consumers Association

Cancer Council


Women’s Health Service

Winnunga Nimmityjah Aboriginal Health Service

Bosom Buddies

Canberra Multicultural Community Forum

Country Women’s Association

Council on the Ageing (COTA)

HCCA and Women with Disabilities ACT

Breast Cancer Network Australia

4 QUALITY IMPROVEMENT FRAMEWORK The ACT Health Directorate has a Quality and Clinical Governance Framework which details the structure, process and systems that support continuous quality improvement across the organisation.

Refer to ACT Health Directorate Quality and Clinical Governance Framework 2015-2018 available on the ACT Health Policy Register.

The framework covers:

• Patient centred care (experience) • Patient Safety • Clinical Effectiveness • Culture of Quality • Continuous Improvement • Clinical Governance • National Safety and Quality Standards

Roles and Responsibilities:

• ACT Health engages Australian Council on Healthcare Standards (ACHS) to survey our systems and processes against a set of national standards.

• The Corporate Plan has a list of indicators that each of the service areas will report on annually. The indicator for BreastScreen ACT is screening rates.

• Measuring quality is achieved through a range of qualitative and quantitative evaluation methods including:

o performance indicators o accreditation o benchmarking o professional certification and recertification o peer review o clinical review o policy and clinical guideline review and revision o incident and complaints trends o audits & surveys.


o ACT Health uses the following management systems and resources for quality improvement and to meet ACHS standards.

o Divisional quality or clinical governance committees o Recording and tracking QI activities and projects o Incident and complaint management systems o Clinical review committees o Standardised policy development and review o Risk management systems o Clinical indicator reporting o Health Round Table benchmarking partnerships o Quality and Accreditation education and training o ACHS Evaluation and Quality Improvement Program (EQuIP) o Structured consumer participation o Clinical credentialing and scope of practice review o Competency assessment and training o Participation in national quality and patient safety projects.

5 POLICY, PROCEDURES AND GUIDELINES FRAMEWORK

5.1 Policy and Procedure Framework ACT Health policies and procedures are informed by evidence, consulted on, soundly governed, and appropriately evaluated and reviewed.

BreastScreen ACT are informed by various levels of policy and procedure. This includes:

• Whole of Government Policy: addressing issues across all government agencies. • ACT Health Directorate policy: addressing issues of relevance across the health

directorate. • Divisional policy: addressing issues of relevance to the Cancer, Ambulatory and

Community Health Support Division. These policies are informed by directorate level policy.

• Program policy: addressing issues of relevance across service areas within the team that is not applicable to service areas in the broader organisation.

All levels of Policy and Procedures can be found via the Policy Register on the Health Intranet.

To locate the ACT Health Policy Register. See below.


Policy development must follow the directions outlined in the ACT Health Policy Management Policy for ACT Health wide policies/procedures and the Canberra Hospital and Health Services (CHHS) Policy Development Guideline for policies/procedures applicable to CHHS areas. Refer to the ACT health Policy Register for these documents.

All polices, guidelines and standard operating procedures are reviewed by the CACHS policy officer and must be approved by managers, and approved by the CACHS Clinical Governance Committee.

5.2 BreastScreen ACT Policy and Procedures Manual The BreastScreen Policy & Procedures Manual is divided into Corporate and Support and Clinical Practice. All manuals are available on the ACT Health Policy register.

Each manual has a sponsor who retains overall responsibility for the manual. Managers must ensure relevant staff are aware of, have access to and where applicable, are provided with appropriate instructions/training, for the policy, procedure and/or guideline.


Clinical Practice

(Clinical Coordinator)

Corporate & Support

(Director)

Clinical Services

(Clinical Coordinator)

Radiographer Procedures

(Senior Radiographer)

Governance & General Administration

(Promotion & Quality)

Administrative Services

(Senior Admin Manager &

Office Coordinator)

Safe Practice & Environment

(Office Coordinator)

Data, Information & Reporting

(Data Manager)

Information Systems

(BIS Administrator &

PACS Administrator)

Digital Image Management

(PACS Administrator)

BreastScreen ACT –Procedures Manual

(Executive Director – Cancer, Ambulatory and Community Support)


Each staff member must familiarise themselves with their requirements under each of the Manuals and must they comply with them.

If an employee has any questions or is uncertain about any aspect of the requirements set out in the Manuals, it is their responsibility to seek clarification and guidance from their Manager in the first instance.

The Quality & Promotion Manager will be responsible for the archiving of BSACT policies and procedure documents including any electronic and hard copy system. All requests to archive must go through the Policy Officer within CACHS who will submit it to the process outlined in the CHHS Policy Development Guideline.

The current versions of the BSACT Manuals will be stored electronically, however a printed version will be located in the bookshelf outside the Program Directors office. The most recent version will be the electronic version.

All sections of the manual will include identification, document control, approval authority and version control information.

5.3 BreastScreen ACT Management Policies The following BSACT management policies provide direction and guidance specifically for the management of BS ACT.

The following management policies are attachments.

Appendix 2 – Accurate Information and Resources Policy Appendix 3 – Recruitment Policy Appendix 4 – Extended Wait Times for Results Policy Appendix 5 – Out Of Target Women Policy Appendix 6 – Eligible Women without a Medicare Number Policy Appendix 7 – Client Records Archive Policy Appendix 8 – Access to screening mammography areas Appendix 9 – Contacting Clients Appendix 10 – Women with a Disability Policy

Appendix 17 – Resources – Naming, location, reviewing and archiving

5.4 BreastScreen ACT Operational Policies BreastScreen ACT has operational processes to provide direction and guidance for staff that cover a wide a range of specific work functions and scenarios. These operational processes are in the related Manuals.


6 RISK AND INCIDENT MANAGEMENT

6.1 Introduction Risk management facilitates informed decisionmaking based on evidence and implementation of treatment options with measureable outcomes.

The management of risk enables BSACT to:

• Plan, in a consistent manner, to minimise risks to our organisational objectives • Improve stakeholder confidence and trust • Improve operational effectiveness and efficiency • Minimise incidents and prevent loss • Establish transparency in decision making and to prioritise • Improve organizational learning and resilience • Comply with relevant legal and regulatory responsibilities.

6.2 Risk Management Framework ACT Health is guided by the International Risk Management Standard AS/NZS ISO 31000:2009.

BreastScreen ACT adhere to the ACT Health Risk Management Policy, Framework and Guidelines. These documents are located on the ACT Health Policy Register and provide detailed information regarding roles and responsibilities that apply across the organisation.

6.3 Incident Management An incident is defined as “An event or circumstance which could have resulted, or did, result in unintended harm to a person and/or a complaint, loss or damage” (ISO 31000:2009).

All ACT Health staff are required to comply with the Incident Management Policy and Standard Operating Procedures located on the ACT Health Policy Register.

All staff are responsible for:

• identifying and notifying incidents to their immediate supervisor, including all adverse events, near misses and hazards through the Riskman incident notification and reporting module (Riskman)

• ensuring the security of passwords and the correct assigning of managers when using Riskman

• cooperating in the investigation of incidents • participating in the implementation, monitoring and evaluation of actions from

recommendations and subsequent learning opportunities • encouraging colleagues to notify identified incidents.

ACT Health uses the Riskman incident notification and reporting module to document the notification of incidents. Staff should also notify their immediate supervisor when an incident occurs. Managers are required to review incidents lodged by their staff to ensure appropriate action is taken.

6.3.1 BreastScreen ACT Incident Management All BreastScreen ACT incidents are reviewed and action identified at the Managers and Quality meeting.


Incidents involving clients will be recorded in the client’s clinical record in BIS and entered into RiskMan.

Staff accidents/incidents/work safety issues are also reported online using the Staff Accident Incident reporting module of Riskman. Further information on staff incident reporting can be found in the Safe Practice & Environment Manual.

7 ADMINISTRATION AND FINANCE

7.1 Delegation of Authority Delegation of Authority assists managers to carry out their roles whilst meeting their responsibilities under legislation and policies that apply to BSACT.

Staff that are required to exercise delegated authority are encouraged to seek advice and assistance from the Director, BSACT if they are uncertain of their powers or jurisdiction in any matters.

ACT Health Finance Delegations and Chief Executive Instructions ensure staff have the appropriate legal authority to exercise powers and carry out certain actions for which they are personally accountable. Refer to the ACT Policy register for this policy.

Staff with delegations have a responsibility when using a delegation to ensure:

• the action is within the power and conditions of their delegation; and • they have followed all relevant Directorate policies, procedures and guidelines, e.g.

procurement, asset management.

7.1.1 Financial Delegation Schedule ACT Health has a Register of Delegations available at Finance Matters Online on the intranet site. This register sets out in a table the position details, power and conditions applicable for each delegation.

The Chief Finance Officer is responsible for the establishment, maintenance and review of this register. The Directorate has eight (8) types of financial delegations:

• Commitment to Expenditure and Contract Execution Authorisation • Expenditure and Payment; • Asset Write-off and Disposal; • Cash Advances; • Debt Write-off and Deferral; • Finance Leases (ACT Fleet Vehicles with Rhodium only) • Investment of Surplus Monies; and • Trust finds and Administered funds.

7.1.2 Human Resource Delegation Schedule Human Resources Delegations can be exercised by the occupants of positions that have been granted the power to exercise authority on behalf of the Director General.

A copy of the Human Resources Delegations can be viewed in the PSS Delegations Manual on the HR Delegations webpage of the ACT Health Intranet site.

7.2 Purchasing Of Goods And Services


BreastScreen ACT staff are required to adhere to the ACT Government Procurement Policy and ACT Health Procurement Guidelines for the procurement of goods and services. These are available on the ACT Health Intranet site under procurement.

The procurement policy and guidelines are based on the requirements of the Government Procurement Act, 2001 (GPA 2001).

7.3 Use Of Government or Private Vehicles and Taxi When using government or private vehicles and taxis, BreastScreen ACT staff are required to adhere to the ACT Government Travel Policy and Director General Financial Instructions accessible through the ACT health Intranet site.

7.4 Contact with Media ACT Health’s Communications and Engagement Team is the point of contact for all media inquiries and responses. This team liaises and coordinates media activity with the Minister's Office.

All requests by the media are to be directed to the Communications and Engagement Team. Only staff members authorised by the Director General can speak to the media regarding ACT Health issues or on behalf of the ACT Health. Further information is available in the ACT Health’s Media Policy located on the ACT Health Policy Register.

8 QUALITY AND PERFORMANCE IMPROVEMENT

8.1 Clinical Governance Clinical governance is underpinned by effective corporate governance: further information can be found in ACT Health Directorate’s Corporate Governance Statement and Quality & Clinical Governance Framework 2015-2018 located on the ACT Health Policy Register.

BSACT operates within a Clinical Governance framework through which the managers and clinicians share responsibility and are held accountable for continuously improving the quality of services.

8.2 Consumer Engagement and Feedback BreastScreen ACT adheres to the Australian Charter of Healthcare Rights and ACT Health’s suite of policies, procedures and guidelines relating to consumer engagement and feedback.

The Consumer and Carer Participation Policy, Consumer Feedback Standards, Consumer Feedback Management in the Health Directorate and Procedure and Consumer Feedback Management Policy are available on the ACT Health Policy Register and ACT Health Intranet under Consumer Feedback and Engagement.

BreastScreen ACT has a systematic approach to managing client feedback and encourages feedback from women at each stage of the screening and assessment process.

Client feedback is recognised as providing valuable information on service quality and the effectiveness of programs and policies. Complaints, compliments and comments about the Service are made through a variety of mechanisms including written and verbal communication to staff and, occasionally through the ACT Minister of Health. Complaints are investigated and handled in a fair, confidential and responsive manner, free from repercussion or prejudice. All complaints are monitored and the nature and pattern of complaints recorded and analysed.

Processes by which consumers can register complaints, concerns or compliments in BSACT are:

• Informal:


• A book is provided in the main waiting room in Moore St, Phillip and Belconnen clinics.

• Any staff member receiving an informal complaint or compliment need to document it, in the form of an email, which is directed to the Program Director, the Promotions and Quality Manager in BreastScreen, and the Senior Administration Manager. The Promotions and Quality Manager is responsible for follow-up and management of any action arising from the compliment or complaint and prepares monthly reports to the ACT Health Feedback team, the Managers and Quality meeting and BreastScreen Advisory Committee.

• Formal: • ACT aims to resolve all complaints as readily as possible. If a resolution is not

achieved the supervisor will bring the matter to the Program Director who will resolve the issue in consultation with the staff involved and client or stakeholder.

See Appendix - BreastScreen ACT Feedback Flowchart.

8.3 Clinical Effectiveness BSACT staff are directed by the ACT Health Clinical Audit Activities policy in relation to the expectations of their involvement in clinical audit. This policy is available on the ACT Health Policy Register.

Clinical audit activities are part of BreastScreen ACT’s quality management system for continual improvement.

Reporting processes for clinical audit activity outcomes and the implementation and monitoring of actions are managed through BreastScreen ACT’s Clinical meetings.

8.4 Infection Prevention & Control The ACT Health Infection Prevention & Control (IPC) Policy outlines the systems and processes to ensure effective organisation-wide infection surveillance, prevention and control and to promote infection prevention and control best practice.

The best practice systems and processes include:

• Monitoring of hand-hygiene techniques and rates of compliance. • Monitoring the prevalence of multi-resistant organisms. • Blood infection and surgical site surveillance. • To describe recommended IPC education and training requirements. • Creation and management of policy documents that reflect contemporary Evidence-

Based IPC practice. • Management of internal IPC committees and participation on external and

professional IPC committees. • Monitor uptake by Health Care Workers (HCW) of vaccine preventable diseases. • Monitor and detail audit cleaning requirements for hospital cleaning standards. • Undertake/advise-on relevant IPC projects and research. • Facilitate effective communication of matters relating to IPC. • Oversee reporting responsibilities of matters relating to IPC. • Advise on renovation and building projects. • Advise on and influence the procurement of medical supplies and equipment

effected by IPC considerations in compliance with AS4187. Reduction or elimination of risk brought about by compliance to best IPC practice.


• Achieve optimum outcomes for inpatients and out patients alike as well as visitors, and all staff who work for ACT Health.

• Maintaining a safe and healthy work environment and workforce. • To advise ACT Health on infection prevention and control matters. • To detail mechanisms to report/escalate/advise-on breeches of IPC policy/ practices. • To undertake surveillance on infections diagnosed and queried. • To support the antimicrobial stewardship program managed by pharmacy. • To deliver reporting on infection prevention and control matters to the Healthcare

Associated Infection Standard Group. • To promote collaboration with Occupational Medicine Unit. • To minimise the risk of acquiring a healthcare associated infection by patients,

visitors or staff. In order to comply with the Policy, BSACT staff undertake:

• initial orientation training; • annual IPC update education utilising either;

o face to face educational opportunities; o online e-learning packages through 'Capabiliti';

• Ensure that they are familiar with the procedures relating to: o their work practices; o patient safety; o Ensure that procedures are followed; o Report, in a timely manner, any breaches to IPC best practice or exposure to an

infectious agent; o Incorporate IPC into; o workplace specific orientation; o staff credentialing and clinical practice assessment and; o patient care planning and service provision.

Further information and access to Infection Prevention Control processes can be found in the Clinical Services Manual.

8.5 Effective Workforce BSACT staff adhere to the ACT Health Essential Education Policy and Guidelines. ACT Health essential education programs are based on the following criteria:

• Legislation, regulations and personal liability potentials (e.g. Dangerous Substances, Food Act)

• Professional registration requirements • Major or catastrophic risks to patient safety and/or other identified

major/catastrophic organisational risks • Accreditation (mandatory criteria only) • National Council of Australian Governments (COAG) Partnership Agreements

BSACT complies with ACT Health’s Annual Renewal of Professional Registration Policy and SOPs to ensure it meets our legal obligation to employ registered health practitioners and demonstrates its shared responsibility in maintaining a safe and competent workforce by ensuring that health professional employees hold a current registration.


Performance Management Plans are a compulsory requirement for all ACT Health staff. Refer to the ACT Public Service Performance Management Framework available on the ACT Health Performance Framework section of the ACT Health Intranet.

All training is managed and recorded electronically on Capabiliti and the Promotion & Quality Manager maintains a spreadsheet of all mandatory training that has occurred or is due for BreastScreen ACT staff.

8.6 Quality Improvement Continuous Quality Improvement is an ongoing part of the BSACT service. It is facilitated through ongoing monitoring of the Program’s performance against the National Accreditation Standards (NAS) and National Safety and Quality Health Service Standards (NSQHSS).

The Managers and Quality Committee review and monitor program performance. Tools used for assessment include:

• BSACT Quality Plan • Review of performance in Annual Data Reports against the National Accreditation

Standards. • Review of performance against screening targets and wait times to assessment • Consumer feedback – compliments and complaints • Clinical audits • Clinical and Administration services health and safety audits • Staff feedback • Visiting Medical Officer’s feedback • Review of incidents entered into RiskMan • Project evaluation • Client satisfaction surveys • Research

All areas of BSACT are involved in quality improvement and quality assurance activities.

The Managers and Quality Committee of BSACT reports to the BreastScreen Advisory Committee. BSACT report quality activities and consumer feedback to the HealthCare Improvement area of Act Health.

BSACT’s Quality Improvement Plan supports BreastScreen Australia’s commitment to quality improvement.

The Promotion & Quality Manager is responsible for supporting quality improvement activities.

8.7 Accreditation

8.7.1 BreastScreen Australia Accreditation BSACT undergoes a rigorous accreditation process whereby all aspects of the service are measured against nationally recognised and accepted data standards. These BreastScreen Australia National Accreditation Standards are:

1 Access and Participation 2 Cancer detection 3 Assessment 4 Timeliness 5 Data management


6 Client Focus 7 Governance and Management

The Managers and Quality Committee directs preparation for accreditation. The Service generates and reviews a Data Report against the NAS, which is submitted to the NQMC annually. A self-assessment of the Program’s performance is reviewed at the Quality Committee at least two-yearly and when necessary as issues arise.

8.7.2 BreastScreen ACT Quality Committee (SQC) The role of the BSACT – State Quality Committee (SQC) is to drive quality improvement by monitoring performance, advising on best practice principles, learning from adverse incidents, systematically addressing areas of risk and recommending strategies that will achieve continuous enhancement of breast screening services provided to women.

The key areas of responsibility and membership are outlined in the Terms of Reference.

This Committee reports to the National Quality Management Committee (NQMC) through the State Coordination Unit (SCU) (BSACT Management).

8.7.3 ACT Health Accreditation BSACT complies with ACT Health accreditation requirements.

ACT Health undertakes mandatory accreditation against the 10 National Safety and Quality Health Service Standards using the Australian Council for Healthcare Standards (ACHS) as the accrediting agency.

The Standards require that ACT Health reviews and acts on safety and quality risks and is compliant with all legislative requirements and relevant industry standards.

The 10 Standards are:

• Governance for Safety and Quality in Health Service Organisations • Partnering with Consumers • Preventing and Controlling Healthcare Associated Infections • Medication Safety • Patient Identification and Procedure Matching • Clinical Handover • Blood and Blood Products • Preventing and Managing Pressure Injuries • Recognising and Responding to Clinical Deterioration in Acute Health Care • Preventing Falls and Harm from Falls

Further information can be found at http://www.safetyandquality.gov.au/

9 CLIENT RIGHTS ACT Health and BSACT have a strong commitment to recognising client rights and respecting them in the operation of the service. Clients’ rights are set out in the Australian Charter of Health Care Rights and these rights relate to access, safety, respect, communication, participation, privacy and comment.

BSACT clients are provided information on their rights via information provided in the Australian Charter of Health Care Rights Brochure which is available from the ACT Health Website or in hard copy in the BreastScreen waiting room.

http://www.safetyandquality.gov.au/


9.1 Clinical Records and Confidentiality The ACT Health Clinical Records Management Program is supported by a number of documents which detail the way in which all staff will make, modify, use, handle and care for records, the length the records will be retained and how access to records will be provided, these include:

• Clinical Records Management Policy • Clinical Record Documentation Procedure • Clinical Records Management Manual • Clinical Records Release or Sharing of Clinical Records or Personal Health Information • Essential Clinical Record Documentation Audit Policy

The ACT Health Clinical Records Management Policy outlines the Records Management Program for the Directorate and details how the Directorate will adhere to the requirements of records management legislation. The Clinical Record Documentation standard operating procedure (SOP) provides information for staff to ensure clinical record documentation complies with ACT Health policy, legislative requirements and best practice standards.

The Essential Clinical Record Documentation Audit standard operating procedure (SOP) provides a framework for a systematic approach to essential clinical record documentation audit activity across ACT Health.

BSACT staff are governed by the ACT Health Clinical Record Policies and Procedures to ensure that all personal health information, clinical records, and clinical information systems are protected against loss, misuse, modification, unauthorised access or disclosure.

The Health Records (Privacy and Access) Act 1997 requires ACT Health & BSACT to create and keep health records in a manner that ensures the privacy of health information. Further information is available on the ACT Health Website or in hard copy in the BreastScreen waiting room.

BreastScreen clients can expect to have their information treated in a confidential manner.

Confidentiality is maintained by following these general protocols:

• Telephone calls that involve discussion of information about clients are made in private.

• Women are interviewed and undergo procedures in rooms that ensure visual and auditory privacy.

• Access to clients’ records and information is minimised and restricted to those who ‘need to know’.

• All BreastScreen ACT staff sign a standard confidentiality agreement yearly which is included at in the Appendices.

Relevant policies and procedures are available on the ACT Health Policy Register.

9.2 Consent The ACT Health Consent & Treatment Policy provides clarification on the requirements and documentation required for informed consent. Consumers have the right to decide whether or not they wish to receive health care and must be actively involved in the decision making process.

The Policy outlines the processes to gain informed consent prior to any clinical activity, treatments and/or procedures.

The ACT Health Patient Identification and Procedure Matching Clinical Procedure and Release or Sharing of Clinical Records or Personal Health Information procedure relate to consent procedures in BSACT .


9.2.1 Requirements and documenting consent As stated in the ACT Health Consent & Treatment Policy, ACT Health staff are required to use a form endorsed for use by ACT Health, signed by the consumer and included in the clinical record. Consent involves a number of interconnected processes, and requires health professionals to:

• provide people with information that will assist them to reach an informed decision about whether or not to consent to the proposed treatment. This must include:

• a description of the proposed treatment and any potential benefits or any material risks inherent in that procedure, including the possibility that the treatment may be unsuccessful, and of any risks of not undergoing the proposed treatment or procedure.

• consideration and provision of information in relation to what a reasonable person would want to know and what the particular person being treated would want to know (both subjective and objective).

• ensure the person: • understands and retains the information • believes the information (i.e. is not divorced from reality or is unable to comprehend

what is being said) • understands that a choice can be made, and • is able to reason, make a choice, and convey their decision.

• seek a decision from the person about the proposed treatment. Subject to some specific, it is always the person’s right to determine whether or not to consent to receiving the treatment recommended by the health professional.

• record in the patient’s health care record if the person refuses to agree to the proposed treatment, and the circumstances in which consent was refused.

• thoroughly and accurately record and document the consent process and the person’s decision on the consent form and their health care record, including:

• the person’s core identifiers (full name, date of birth and ACT Health medical record number or if no record number, the person’s address – please see Patient Identification and Procedure Matching Clinical Procedure). To avoid transcription errors, an ACT Health approved patient identification label must be used to document core identifiers where possible. If the information is hand written, it must be clear and include all of the core identifiers,

• how any communication barriers were addressed, • any substitute decision maker used if the person doesn’t have the capacity to

consent, • the presence of any legal document/s relevant or revocation, e.g. enduring power of

attorney, health direction, guardianship order, advance consent direction, etc • relevant risks, benefits and alternatives of the treatment or procedure, • any tools used to support decision-making that have been provided e.g. information

sheets, • any specific wishes or concerns the person may have regarding the proposed clinical

activity, treatment or procedure, • date and time when the consent was given, • the full name, title and signature of the health professional obtaining the consent.

• obtain the person’s signature on the consent form as this formalises the process and should be done in all cases, where practicable.


Abbreviations are not to be used on consent documents due to the potential for misinterpretation or misunderstanding.

A person should be informed that his or her consent can be withdrawn at any time during a course of treatment. Consent is considered valid until a person’s clinical condition has changed, they withdraw their consent or a different procedure is recommended.

All staff are responsible for ensuring people are aware that information relating to their care will be kept by ACT Health and may be shared with members of the persons treating team as necessary, including their nominated General Practitioner (GP). People have the right to decline to have their information shared at any time. For more information, refer to the Release or Sharing of Clinical Records or Personal Health Information procedure.

In alignment with the ACT Health policy, when gaining informed consent BSACT staff:

• Encourage and support women to make their own decisions about procedures and/or treatments.

• Provide women with adequate information on which to base their decisions. • Present information in an accessible plain language format aimed at assisting the

client to understand procedures and processes. • Provide translated materials and access to trained interpreters. • Provides information regarding investigation, diagnosis and treatment to clients.

Women undergoing any procedure in the BreastScreen Clinic give written consent. This includes consent to:

• undergo screening, • undergo assessment procedures, • allow the BreastScreen Program to obtain follow-up of any treatment post

assessment, and • allow data collection for monitoring and evaluation.

9.2.2 Consent for Screening BreastScreen ACT gain consent for screening, an understanding of breast screening processes and sharing of information, including with GPs, prior to the procedure commencing.

It is the responsibility of the Admin staff to check the personal details on the form as well as ensuring the consent has been signed when the woman reports for screening. If the woman has any concerns relating to a consent issue, she is referred to the nurse counsellor or radiographer who provides further advice on procedures and, if needed, explanation of reasons for seeking such things as additional data.

Routine consent allows for:

• mammographic screening • collection of personal information for data entry • information to be sent to the woman’s GP, if woman wishes.

Minimum requirements for consent include the woman’s consent to supply her demographic details and her consent for the procedure. Women who do not give consent for all aspects covered by the consent will be advised that screening cannot proceed.


Women who do not wish to give consent for their details to be entered into the database are to be referred to a nurse counsellor for further discussion. If they still do not wish to give consent at this stage, they are advised that the screening cannot proceed.

9.2.3 Consent for Assessment All women recalled to the assessment clinic are initially seen by a nurse counsellor, who explains the reason for the assessment and anticipated procedures. At this time, the woman is encouraged to ask questions to ensure she has a clear understanding of the process and procedures before giving written consent. If a woman expresses any doubt about her readiness to proceed, she is offered more time to seek further information, which may include information and/or opinion outside BSACT.

Every effort is made to ensure that women, including those from non-English speaking backgrounds who may have difficulty understanding the information, will have that difficulty addressed and resolved. If required Nurse counsellors organise an interpreter when making an appointment. If a woman signs the consent with an interpreter, the interpreter is asked to co-sign the consent form.

The Nurse Counsellor is responsible for obtaining the woman’s general consent for assessment.

BreastScreen use the ACT Health Consent for Treatment form located on the Clinical Forms register.

9.2.4 Consent for Invasive Procedures - Fine Needle biopsy, Core Biopsy or Mammotome

A woman undergoing any invasive procedure is given a full explanation of the procedure, including the benefits and risks, by the clinician performing the procedure before signing the ACT Health Consent for Treatment form. It is the responsibility of the clinician to ensure a valid consent has been signed and that any concerns or remaining questions are addressed before the procedure begins.

Explanatory Information is provided to clients on any invasive procedures.

See Appendices for - INFORMATION – Having a Biopsy

9.2.5 Refusal to Sign Consent for Assessment Procedures If a woman does not wish to give consent for assessment, the assessment will not continue. The woman is then strongly advised to consult her GP. The clinical coordinator will relay all relevant information to the woman’s GP. The woman will then be discharged from the BSACT, but is able to return, provided she can produce evidence of an “all clear” result, if assessed elsewhere. If she, as a result of assessment elsewhere, is diagnosed with breast cancer, she is discharged from the Program. See the ACT Health Policy register for the Consent to Treatment Policy.

9.3 Protocol for Providing Film and File Copies Clients have a right to view their files and are entitled to copies of their films and clinical notes. Copies of films and pathology results are provided to women who are diagnosed with breast cancer. They are given to the woman at the time she is given her results.

Copies of films for other reasons are given to women at their request.

Women who request copies within the timeframe of their current round (within 1 year for annual recalls and 2 years for 2 yearly recalls) will be provided with copies at no cost.


Women who request copies outside the timeframe of their current round (over 1 year for annual recalls and 2 years for 2 yearly recalls) will be charged for the copies.

Women requesting copies of their files are encouraged to view them with a clinical coordinator before taking copies away. All requests for film and file copies are referred to the senior radiographer with the client’s file.

All original films are kept, along with the file.

Copies of films and pathology results are provided to women with a diagnosis of breast cancer free of charge. They are given to the client at the time her results are given. If a woman for the SE NSW area is receiving her results from her local GP or surgeon, nursing staff will contact the woman to find out if she would prefer copies to be sent to her nominated surgeon or GP, or to herself.

Clients relocating to another area and hence another BreastScreen Clinic within the National BreastScreen Program are provided with copies of films and clinical file on written request. Copies of films will be sent by mail to the receiving service (at no charge). Client consent is obtained at the new service and a copy faxed through to the clinic before films are provided. Original files are retained in the record folder at BSACT.

If an existing client develops an interval symptom, or wishes to seek an opinion outside of BSACT, copies will be made available to the client. These will be made available to the client or to their designated medical practitioner after written request by a client, but no report of the x-rays is available.

When copies are requested, the senior radiographer (or delegate) will document this on the progress chart. The staff member handing over the films will notate this on the front sheet of the file. If films cannot be collected in person, written requests for them to be posted or collected by a designated person should be made.

10 RECRUITMENT AND EDUCATION

10.1 Recruitment Recruitment principles and strategies are guided by the aims and objectives of the National BreastScreen Program and BSACT’s Communication and Recruitment Plan.

10.1.1 Recruitment aims • To motivate women aged 50 - 69 to attend for regular screening at two-yearly

intervals to increase detection of breast cancers at an early stage; • To facilitate informed choice to participate in the Program through the provision of

accurate, consistent, honest and sensitive information to women; • To inform women aged 40 - 49 and over 74 years that screening mammography is

available on request.

10.1.2 Recruitment principles The Recruitment of women is conducted within the framework outlined by the following principles:

• Respect for women’s rights to make informed decisions about their participation in the program,

• Recognition of the population health basis of the Program and the importance of maximising the participation of women between the ages of 50-74,

• Acknowledgment of the diversity of women who utilise the program and a commitment to addressing the diverse needs of women,


• Utilisation of a holistic view of women’s health and recognising that breast health and breast care are just one aspect of this,

• Recognition of the importance of partnerships with GPs and health professionals in recruiting women to the program,

• Commitment to accountability and taking a planned approach to the recruitment of women while being responsive to unexpected opportunities, and

• Actively seeking consumer involvement and stakeholder feedback on strategies and products.

10.1.3 Recruitment Planning The communications and recruitment plan outlines specific activities that happen throughout the year and is reviewed in conjunction with an analysis of service performance against the National Accreditation Standards and the Source of Referral Report.

These activities are focused on meeting the following objectives:

• To aim towards screening 70% of women in the target group (50-69 years) in ACT. • To encourage participation in the screening program of Aboriginal and Torres Strait

Islander women, Culturally and Linguistically Diverse women, and vulnerable women. • To increase participation rates for rescreening to National Accreditation Standards. • To provide high quality resources and education to General Practitioners. • To provide women, health professionals and community workers with high quality

resources and education regarding the program. • To work with community groups and key stakeholders to promote and improve the

BSACT.

10.1.4 Approaches to Recruitment A multi-faceted recruitment strategy is required for the Program including both personal and non-personal approaches to individuals, health professionals, and the general public and community groups.

Provision of information and education to individual women is a continuous process throughout the screening and assessment pathway, and involves all staff, with contact with the women.

10.1.4.1 Letters to women Letters are the primary method of inviting woman into the Program or to remind them to attend. Letters include:

• Personalised letters of invitation using Electoral Roll or Medicare information. • Personal re-screen reminder letters/cards to women aged 50 – 73. • Reminder letters/cards. • Following a first screening mammogram, women in the target age 50-74 years, are

recalled for screening at the recommended interval via a reminder to rescreen letter. Rescreen reminder letters are generated by BIS, by review date and postcode.

• First reminder letters are sent 4 weeks before the appointment is due. A second letter is sent 4 weeks after the first if there has been no response. A further letter is sent in 12 months from the due date if there has been no response from the two previous letters.

The letter of invitation strategy assists BreastScreen ACT to:

• Recruit women in the numbers required to fill available appointment times.


• Maximise the number of women who attend for rescreen within the recommended time frame.

Electoral roll or Medicare invitation letters

• Personal invitation letters based on information from the Electoral Roll or Medicare are an effective, practical and acceptable means of recruiting women to mammographic screening. The Electoral Roll or Medicare data is relatively accurate, crosses all social-economic boundaries and allows screening to take place in a planned, controlled manner. See appendices for example Electoral Roll/ Medicare Invitation Letter.

Follow-up Electoral roll or Medicare letters

These can be sent if no response from initial invitation. The use of these letters is dependent on capacity for screening.

10.2 Professional Referrals Research and anecdotal evidence show that women respond very positively from a recommendation from their GP or community health nurse to book a mammogram. Links with the medical community are important so they are knowledgeable about current BSACT policy and practice.

Strategies for the various professional groups are as follows:

10.2.1 General Practitioners GPs provide advice to women about breast cancer and screening Services. Studies have shown that a referral or encouragement by a GP is a primary reason for a woman to attend BreastScreen.

Professional education is offered to GPs to ensure they are aware of the value of mammographic screening, of issues involved in the diagnosis and management of impalpable lesions, and of the organisational aspects of the service. Invitations to information seminars are offered to GPs and run by the clinical coordinator.

GP practices are provided with promotional material and a resource order form. The reception staff at each practice and practice nurses are an important resource as they have the opportunity to encourage a wide range of women to participate.

Relationships with the Capital Health Network also assist in connecting with GPs.

10.2.2 Community Health Workers Community and women’s health nurses often have special expertise in women's health and in a well women's health approach. This professional group can play a critical role in recruiting women to the Service, particularly women in under screened groups.

A range of other health workers, community development workers and health educators are also important contacts for recruiting women to the Service.

Strategies include liaison with community health and women's health worker/educator networks to determine their information and education requirements and preferences, to seek their cooperation with the Service, and identify possible joint recruitment initiatives.

10.2.3 Other Health Personnel/Services


A range of other health personnel have a potentially important role to play in the screening Service, e.g. pharmacists, staff of nursing homes, hostels, local hospitals, etc. They can be supplied with brochures and other promotional materials for distribution as appropriate.

10.3 Community Based Recruitment, education and Liaison Strategies Education and liaison requires continual effort and reinforcement in order to inform the community about the Program and recruit eligible women to attend for screening mammography.

The Program can enlist the cooperation of professional and community groups, e.g. assistance with distribution of promotional resources, use of their networks and contacts to promote the involvement of other groups.

The following education and liaison strategies have been used in combination to inform the community about the Service and facilitate recruitment of eligible women.

10.3.1 Media BreastScreen ACT uses mass media carefully to ensure a targeted approach to recruitment or information delivery is achieved. Radio, newspapers and newsletters provide an invaluable, pre-existing local vehicle for educational material and promotion. The media is used widely to develop a general awareness, and to announce the service to the community.

National or state based advertising campaigns have resulted in an increased awareness of screening as an issue and enhanced local efforts.

Local strategies include:

• Features and advertisements in local media, restricted where possible to the geographically defined target area, e.g. local papers, public radio community announcements, interviews and talkback.

• Articles in publications and newsletters, e.g. local government service directories, CWA newsletters, older women's network and ethnic community newsletters.

All media material must be approved by the Program Director and Executive Director, CACHS, and must convey the philosophy and all other details of the Program, especially eligibility.

Directions can be found in the ACT Health Media Policy & Guidelines which is available on the ACT Health website.

10.3.2 Community Education & Promotion Contact with as many eligible women as possible spreads the message. Any waiting room, counter or notice board where eligible women or their families may see BreastScreen posters is considered appropriate. This may include coffee shops and women’s fashion store dressing rooms.

10.3.2.1 Public Displays and Events Public displays have been established at suitable venues and in conjunction with community events and festivals. Each event opportunity is assessed on an individual basis. There are also opportunities for other organisations to display BreastScreen information at events.

At community events BreastScreen signage can be placed in a prominent position as an adjunct to other promotional methods.

Events organised by BreastScreen in the ACT will need approval from ACT Health. If the ACT Minister is required to attend an event, contact the Executive Officer, CACHS or Communications and Engagement Team of ACT Health for assistance.


10.3.2.2 Community talks Community groups and women's organisations offer a unique opportunity to speak to large numbers of women who in turn have contact with many other women.

Working in a community engagement framework means that other agencies may be more appropriate to deliver community education than BreastScreen staff. Local community health workers in some locations offer talks on reproductive and breast health and will include BreastScreen information.

Breast Cancer support groups who already deliver community education usually give BreastScreen information and encourage the participation of women in the Program. There may also be opportunities to do joint education sessions.

Community education sessions offer the opportunity to talk about the process, effectiveness and risks of mammography, the risk of breast cancer and the maintenance of a regime of breast care, e.g. awareness of breast changes and an annual breast check with an appropriate health professional.

10.3.2.3 Network meetings In order to reach disadvantaged clients, attending meetings of networks of providers to talk about BreastScreen is useful.

10.3.2.4 Community champions Identifying individuals or groups who may be a key in promoting the BreastScreen Program is beneficial. A community champion is usually someone who is passionate about either decreasing deaths from breast cancer or women’s health generally. They may offer or be asked to distribute promotional material, organise talks or suggest promotional ideas in their area.

10.4 Sources of Information Telephone books and community directories are sources of information concerning women's and community organisations. Community Health Centres and Neighbourhood Centres are also an invaluable source of information.

Some Government Departments may be able to provide information concerning ethnic organisations and registered clubs. Advertising in Government Departments will also reach the target age group.

10.5 Enlisting Women to Recruit Friends, Family and Colleagues Evaluations of BSACT show that women respond positively to the recommendations of friends and family. At the ACT Clinic, posters can be left in a prominent place with a notice asking women to help promote the Service by putting posters at their workplace or other venues.

10.6 BreastScreen Staff All staff are considered part of the recruitment, education and liaison Service. Reception staff, for example, are the ones called upon to respond to women's most asked questions, and will be involved in monitoring responses following promotions. They also play a first line role in public relations, and can encourage women to recommend the service to others.

It is therefore essential that recruitment and information provision is to be included as an item of staff training on all levels and in all orientation sessions.


10.7 Strategies for Under Screened Women Under screened women are usually women from cultural and linguistically diverse backgrounds (CALD), Aboriginal and Torres Strait Islander women, women of low socio-economic status, women with disabilities and rural women. While fewer in number, women residents of institutions and homeless women also face barriers to accessing the Service.

BreastScreen ACT has a strong commitment to access and equity. Recruitment strategies tailored to specific groups of women and areas are applied.

Liaison with workers across the region and other areas of ACT Health with expertise with disadvantaged groups and knowledge of their communities is useful.

10.7.1 Women of Culturally And Linguistically Diverse Backgrounds To develop a service which is relevant and accessible to CALD women it is necessary to develop strategies to inform ethnic communities about the service which take account of language barriers, cultural values, and the low levels of awareness in some communities about the health system.

Strategies can be developed in conjunction with community personnel who work with women of various communities.

10.7.2 Aboriginal and Torres Strait Islander Women Consultation with the Aboriginal and Torres Strait Islander communities is essential in the design and delivery of a mammographic screening service to provide a relevant and accessible service.

The Service refers to the Engaging and Consulting with the Aboriginal and Torres Strait Islander Communities in the ACT document for guidance and explores options with the Aboriginal and Torres Strait Islander communities as follows:

10.7.2.1 Liaison and consultation Aboriginal and Torres Strait Islander health workers are consulted regarding the appropriate approach to encourage women to attend. Connections with the Winnunga Nimmityjah Aboriginal Health Service and the Aboriginal and Torres Strait Islander Health Policy Unit are important to reach this group.

The Service routinely monitors attendance rates of Aboriginal and Torres Strait Islander women, and review recruitment strategies.

10.7.2.2 Education and training The Service provides information on mammographic screening to Aboriginal health personnel where required.

10.7.3 Women of Low Socio Economic Status In the absence of data, the Service ensures that all reasonable steps are taken to recruit women of low SES, and to provide a service, which is sensitive and appropriate to their needs.

In many instances, strategies adopted for women in general are acceptable e.g. easily understandable promotional materials, accessible hours of service etc. Where possible educating workers who work with women from low socio-economic groups is appropriate.

10.7.4 Women with Disabilities As with other groups of women it is important to work closely with groups who work with women with disabilities. In the ACT this includes the Home and Community Care (HACC) network and Women with Disabilities ACT.


Other areas of the BreastScreen ACT manuals give direction for ensuring women with disabilities have the information required to make an informed decision about whether the Service can meet their breast care needs.

10.8 Information Provision BSACT has a policy of providing evidence based information to women about the screening program that reflects the national program policies. A key goal of the BreastScreen Program is to share information with women, health care providers and the community about breast cancer, the effectiveness of screening mammography and the advantages of early management of screen-detected abnormalities. Information is monitored and reviewed through the Managers and Quality Committee.

Information is supplied by BSACT to:

• Ongoing clients of BreastScreen • Potential clients of BreastScreen • General Practitioners • Health Professionals • Community groups

Information provided includes:

• Information about the program • Information about breast cancer • Information about benign abnormalities of the breast • Information on breast health

Principles governing information provision:

• It recognises and considers the diverse range of women using the service in terms of culture, age, education, language, education and socio-economic status when preparing resource materials

• It is timely • It is accurate and evidence-based • It is appropriate to the target group • It is written in plain English and other languages

Considerations:

• Does the publication or resource meet the ACT Government and ACT Health mandatory requirements?

• Does it meet the BSACT Design and Style Guide? • Does the material fit corporate layout and requirements? • Does the material fit within the National BreastScreen guidelines and Information

Statements? • Is it evidence based? • Storage of materials • Cost • Quantity • Review

10.8.1 Review of Existing Resources


All resources are reviewed regularly by the Promotions and Quality Manager, in consultation with staff and the Managers and Quality Committee.

Guidelines for Review of Resources The resource review should be consumer tested by the Community Reference Group or another relevant consumer group before printing.

Resources not requiring changes can be reprinted after being approved by the BSACT Managers and Quality Committee.

Resources requiring changes to clinical information, or for a clinical audience, must be approved by the Clinical Committee before being printed.

10.8.2 New Resource Development Develop a ‘plan’ for the development of the resource and include:

• why it is needed • investigate whether other BreastScreen services have a similar resource that could

be copied • who will be responsible for progressing the resource through the plan and ensuring

appropriate procedures are followed, developing the drafts and making changes • who are the major stakeholders who may need to have input into the resource draft,

and • what is the time frame for completion.

Draft the publication considering clinical accuracy, language (plain English) and design features.

Circulate the draft for review of content.

Seek feedback from the Community Reference Group and gain approval from the Managers and Quality Committee or Clinical Committee.

Send draft resource to graphic designer. In most instances this should be ACT Health graphic design team. The time frame for the graphic design is usually 1 – 2 weeks.

Seek consumer feedback into resources. In most instances this should include Community Reference Group, Advisory Committees and other key stakeholders.

Incorporate feedback into resource with graphic design team. Inform the focus group of outcome of the focus group feedback.

Once final draft in design has been approved by the Program Director and any changes made, apply for quote for printing of the resource with ACT Government Publishing Services.

Include a copy of resource into appendices of Policy & Procedure Manual.

Add resource to Resource Order Form if appropriate. See appendices – BreastScreen ACT Resource Order Form.

Also see Procedure for naming, location, reviewing and archiving resources. See Appendices – Resources Procedures – naming, location, reviewing and archiving.

The range of promotional materials used by BSACT is included in hard copies at Appendix 20 – Promotional Materials

11 INTRODUCTION OF NEW TECHNOLOGIES


The ACT Health Introduction of New Technology Policy states that all technologies that are new to the public health services in the ACT, or existing technologies that are to be reviewed, will have an electronic application submitted and be assessed by the Health Technology Assessment Committee.

The policy identifies and describes the common and comprehensive approach to the adoption of new health technologies to the public health services in the ACT.

Health technologies are defined as “Therapeutic devices, medical or surgical procedures used in medical care and the organisational and supportive systems with which such care is provided” (Introduction of New Health Technology ACT Health 2007).

The process for introducing new technologies in BSACT follow BreastScreen Australia requirements and comply with the ACT Health “Introduction of New Health Technology” Policy; and includes the following principles:

• The Program will be guided by policies set out by National and State and Territory bodies.

• Advice about new technology will be sought from relevant and appropriate information sources including local, national and/or international agencies.

• A thorough evaluation of the technology, taking into consideration a number of factors such as cost, need, benefits, limitations and expected outcomes, will be undertaken prior to the purchase and introduction of any new technology.

• Consultation with all staff involved in the use of the technology will be undertaken and feedback analysed prior to the purchase and introduction of any new technology.

• A program for staff training and documentation of quality control procedures will be developed prior to the introduction of a new technology, and

• An evaluation of the effectiveness of the introduction of the new technology will be undertaken as part of the BreastScreen Quality program.

Refer to the ACT Health Policy Register for the New Technologies policy.

12 INFORMATION MANAGEMENT The ACT Health Information Management Framework provides principles for the management of information.

12.1 Data Quality The purpose of the ACT Health Data Quality Framework is to ensure that quality data is available to inform and support policy and program delivery with the aim to provide highest quality of care and safety of clients.

The policy states that all staff, contractors and external agencies with responsibility for creation, capture and recording of data in formal or informal clinical or non-clinical systems are charged with ensuring the quality of that data. Data must be collected promptly and in accordance with standards, it must accurately reflect the status at the time it is collected, and must be updated to reflect changes.

12.2 Data Release The ACT Health Data Release Policy sets out the framework by which all ACT Health employees must comply regarding the release and disclosure (both internally and externally) of all data held by ACT Health.


12.3 Acceptable Use of ICT Resources All ACT Health staff are required to comply with the Information and Communication Technology Resources – Acceptable Use Policy which outlines the acceptable use of Information and Communications Technology (ICT) resources for all ACT Government employees.

The Policy is available on the ACT Health Policy Register.


13 APPENDICES

13.1 Appendix 1 – BreastScreen ACT Organisational Chart

Cancer Ambulatory and

Community Health Support Division

Executive Director

Program Director

SOGA (1FTE)

Nurse Counsellors RN (2.4FTE)

Clinical Coordinator SMO (1FTE)

BIS System Admin SOGC

(0.5FTE)

PACS System Administrator SOGC (1FTE)

Senior Radiographer HP4 (1FTE)

Promotion & Quality

Manager SOGC (1FTE)

Snr Administration Manager ASO6 (1FTE)

Radiographers HP3 (6FTE)

Office Coordinator ASO5 (1FTE)

PA/ Clinical Administrati

on ASO3 (1FTE)

Client Support

ASO2 (4.8FTE)

Clinical Administrati

on ASO3 (2FTE)

Data Manager

SOGC (0.5FTE)


13.2 Appendix 2 – Accurate Information and Resources Policy

CHHSXX/XXX (number will be allocated by Policy Register Manager after final

endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Accurate Information and Resource

All staff are to provide appropriate and accurate information about BreastScreen ACT to women who participate in the Program and those interested in the Program.

Information on mammographic screening and the BreastScreen Australia Program will be easily comprehensible and in appropriate forms for a variety of forums, and to women and healthcare providers. This will assist women make an informed choice about participating in the Program.

The information should include:

• benefits

• risks

• limitations

• rationale behind the National Breast Screening program, and where relevant

• specific procedures undertaken during screening and assessment.

Information materials should be consistent with National Health and Medical Research Council (NHMRC) guidelines and the BreastScreen Australia policy of providing accurate, consistent, honest and sensitive information to women. It should be presented in a manner, language and format which women can understand.

POLICY STATEMENT

PURPOSE

SCOPE

ROLES & RESPONSIBILITIES


All staff members who have contact with clients, potential clients or people interested in the program are expected to provide up to date, relevant information, either verbally or written.

Information provided is reviewed regularly and endorsed by the Managers and Quality Committee. Any clinical information is reviewed and endorsed by the BreastScreen ACT Clinical meeting.

ACT Health Publication Policy & Guidelines Policy

BSA National Accreditation Standards

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed.

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services, Cancer Ambulatory and Community Health Support Division specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By

18 March 2017 reformatted

Doc Number Version Issued Review Date Area Responsible Page <xxxxx/xxx> X <XX/XX/XXXX> <XX/XX/XXXX

(> or = 3 yrs) XXXX 40 of 72

RELATED POLICIES, PROCEDURES, GUIDELINES AND LEGISLATION

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13.3 Appendix 3 – Recruitment Policy


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Recruitment of Women

BreastScreen ACT complies with the national program by inviting and encouraging women in the target age group of 50-69 year olds to participate in the program.

To achieve a 70 per cent participation rate in the BreastScreen Australia program of women in the target group (50- 69) and access to the program for women aged 40-49 years and 70-79 years through planned recruitment strategies

To meet participation rates in the program which are representative of the socioeconomic, ethnic and cultural profiles of the target population through targeted strategies to these groups.

The Program’s Recruitment Plan identifies recruitment principles and strategies that are consistent with the aims and objectives of the National BreastScreen Program.

The Promotions and Quality Manager is responsible for coordinating the Recruitment Plan, carrying out strategies, and evaluating outcomes.

BSA National Accreditation Standards Hand Book.

POLICY STATEMENT

PURPOSE

SCOPE




Recruitment: Process by which women in the target age group of 50-69 years are invited and encouraged to participate in the BreastScreen Program.

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, recruitment.





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DEFINITION OF TERMS

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13.4 Appendix 4 - Extended Wait Times for Results Policy


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Extended Wait Times for Results

Where required, BreastScreen ACT actively manages extended wait times.

Extended wait times occur when the service is temporarily unable to provide results to women who have attended for screening in the time frame outlined by the National Accreditation Standards. This includes women who have normal results as well as those needing assessment appointments.

BreastScreen ACT will actively manage wait times to ensure that women receive timely results to if required, progress to the next stages of their care.

Where wait times for results become extended, the Program will introduce strategies to reduce the wait time for women participating in the service.

The Director of BreastScreen ACT will escalate any wait time concerns to the Executive Director of CACHS and ACT Health Executives.

BSA National Accreditation Standards.

POLICY STATEMENT

PURPOSE

SCOPE




BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, wait times, extended wait times, target age group.





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13.5 Appendix 5 – Out Of Target Women Policy


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Out of Target Women

BreastScreen Australia screen women over 40 years, with a target age group of 50-69 years. And women 70-74 years.

The Program prioritises screening for women in the target age group of 50-69 years and aims to screen 70% of these women.

‘Out of target’ women are women aged 40-49 and those over 74 years.

Women under 40 years of age are not eligible for screening.

Women aged between 40-49 years and over 74 years are eligible for screening by request, but are not actively recruited or sent reminder letters.

Women outside the target age group with family history or previous history of breast cancer may be eligible for yearly screening at their request. Women in the 40-49 year age group will be sent reminder letters once they turn 50.

The applies to all women attending BreastScreen ACT.

BreastScreen staff actively recruit and send reminder letters to women in the 50-74 age group only.

Women under 40 years are declined to use the service.

POLICY STATEMENT

PURPOSE

SCOPE



This policy follows the National Policy Statement of BreastScreen Australia, developed in consultation with the National Advisory Committee to BreastScreen Australia June 2000. It is based on consideration of:

• Currently available research evidence

• Harms and benefits to women

• Relative costs and benefits in undertaking a population based screening approach

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, recruitment, target age group, target age, reminder letters, out of target.





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13.6 Appendix 6 – Eligible women without a Medicare Number Policy


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Eligible Women without a Medicare Number

BreastScreen Australia screen women over 40 years, with a target age group of 50-69 years, and women 70-74 years. Where a woman meets all eligibility criteria, does not have a Medicare number and is not associated with the diplomatic corps, they are able to access free breast screening at BreastScreen ACT.

To outline BreastScreen ACT’s policy on providing services to women without a Medicare number.

All Australian citizens are issued with a Medicare number.

Where a person is in Australia temporarily, such as a Diplomat, they are not issued with a Medicare number.

This applies to all women wanting to access BreastScreen ACT services. All women are expected to be available 6 weeks after their screening appointment to receive results and attend any follow up appointments as required.

Administrative staff are responsible for reviewing Medicare information at the time of appointment.

Women that are not Australian citizens and are therefore without a Medicare card or number are able to access free breast screening unless the women is associated with the diplomatic corps.

POLICY STATEMENT

PURPOSE

SCOPE



In the case of a woman associated with the diplomatic corps their ‘home’ country is required to pay for screening and assessment (if required).

Where a woman requires further services/ treatment after their breast screen, they are require to pay for the service as per any other public health service without a Medicare card.

BreastScreen ACT will provide free screening to women who do not have a Medicare Number as per instructions from Chief Executive of ACT Health (February 2007).

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, recruitment, target age group, target age, reminder letters, out of target, eligible, Medicare, Medicare Card, Diplomat, Medicare Number.





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13.7 Appendix 7 – Client Records Archive Policy


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Client Records Archive

The archiving of inactive BreastScreen ACT client files complies with the Health Directorate’s Records Management Program which is in accordance with legislation and the client’s rights to privacy and confidentiality.

To maximise storage space for active client records, hard copy files of clients who no longer use the service will be removed from the file storage area and archived.

To ensure the archive of inactive hardcopy client records and documents are accurately catalogued and recorded in ACTPAS and BIS using the document tracking function, enabling record identification, tracking and retrieval as required.

This policy applies to:

All inactive clinical records in any format (hard copy or electronic) created and stored by BreastScreen ACT.

Health Directorate policy does not allow for the disposal of any client files who have accessed any service within ACT Health within 7 years. As it is difficult for BreastScreen to determine which clients have accessed any other ACT Health services, the Program will not destroy any files, but will put the files of clients who meet the criteria as set out in the Evaluation into archived storage.

Managers and Supervisors

POLICY STATEMENT

PURPOSE

SCOPE



Managers and Supervisors are responsible for ensuring that the Clinical Records Management Policy and Procedures set out in the Health Directorate’s Clinical Record Management Program are implemented in their area of responsibility, for both Paper and electronic records. This includes:

Maintaining adequate recordkeeping systems that underpin and support the unit’s business processes including the creation, keeping, maintaining and disposal of clinical records within privacy and confidentiality obligations.

BreastScreen’s Administration staff is responsible for:

Complying with the Health Directorate’s record keeping policies and SOPs

Ensuring that privacy and confidentiality are maintained at all times by observing relevant policies.

Legislation

Administrative Appeals Tribunal Act 19889

Administrative Decision (Judicial Review) Act 1989

Copyright Act 1996 (Commonwealth)

Coroners Act 1997

Crimes Act 1900

Electronic Transactions Act 2001

Evidence Act 1971

Financial Management Act 1996

Freedom of Information (FOI) Act 1989

Health Records (Privacy and Access) Act 1997

Human Rights Act 2004

Ombudsman Act 1989

Privacy Sector Management Act 1994

Territory records Act 2002

Policies & Standard Operating Procedures

Abbreviations and Symbols Policy

Clinical Record Digitisation Plan

Clinical Record Documentation SOP

Clinical Record Form Design and Approval Policy

Clinical Record Management Manual

Community Based Clinical Records – Order of filing SOP

Confidentiality, Privacy and Release of Information Policy



Managing Clinical Records transferred through the internal mail process

Records Disposal Schedule – Health Directorate Clinical Records

Records Disposal Schedule for Source Records

Release or Sharing of Clinical Records or Personal Health Information SOP

Retrieving Archived (Community-Based) Clinical Records from Mitchell Storage Facility

Standards

Australian Standard (AS2828-1999) Paper-based health records

Australian Standard (AS ISO 15489) – Records Management

the Territory Records Office Standards for Records Management;

Archiving

Removing files from the filing area and storing in archive boxes.

Confidentiality

The assurance that written and spoken information is protected from access and use by unauthorised persons. With respect to confidentiality, Health Directorate staff members are to refer to the Public Sector Management Act 1994 (ACT) and are to note that disclosure or misuse of confidential information held in official records is illegal.

Health Record

Any record or part of a record:

held by a health service provider and containing personal information; or

containing personal health information

May also be known as clinical record, client file, clinical record or medical record

Hard Copy

The hard copy file consists of all written records and letters of communication as well as all x-ray films taken for screening and assessment purposes.

Health Service Provider

An entity that provides a health service in the ACT

Privacy

The freedom from intrusion and public attention

Records Management

The discipline and organisational function of managing records to meet operational business needs, accountability requirements and community expectations. Records Management covers

DEFINITION OF TERMS


but is not limited to the creation, keeping, protecting, preservation, storage and disposal of, and access to records of the agency.

ACTPAS

ACT Patient Administration System

BIS

BreastScreen Information System

ACT Health Records (Privacy and Access) Act 1997.

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, recruitment, target age group, target age, reminder letters, out of target, eligible, client record, archive client record,





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REFERENCES

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13.8 Appendix 8 – Access to screening mammography areas


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Access to Screening Mammography Areas

BreastScreen ACT is committed to providing a safe and healthy work environment for its employees, contractors, patients and visitors. This includes taking measures to prevent injury and ill health from radiation used in the healthcare environment and to protect people for any unnecessary exposure to radiation.

BreastScreen ACT adheres to the ACT Health Radiation Management Policy and Standard 1.5 of the AIR Professional Practice Standards.

While radiation levels are considered to be low in mammography and well attenuated by the shielding provided, to limit any unnecessary risk of radiation exposure in a mammography screening room the areas are considered ‘controlled’ work areas with restricted access.

Access to all mammography screening areas in BreastScreen ACT is restricted to the person receiving the mammogram, a designated carer and/or translator (if deemed required) and staff with a current ACT radiation licence.

A support person or children under the age of 18 are not permitted in mammography screening areas. This restriction is in place to protect against unnecessary radiation exposure and to reduce the possibility of a child distracting the person receiving the mammogram or radiographer, which may result in injury or in the need for repeat exposure and the potential of an additional radiation dose.

BreastScreen ACT staff do not have appropriate training or vulnerable persons approval to provide child minding during mammogram screenings or assessment clinics.

The BreastScreen ACT website, informs women of BreastScreen ACT’s limitations of access to screening areas and women should identify this issue at the time of booking an appointment.

BreastScreen ACT adheres to radiation safety and restricts access to ensure any risk of radiation exposure for people accessing mammography screening areas in BreastScreen ACT is as low as reasonably achievable (ALARA).

POLICY STATEMENT


The purpose of this policy is to define BreastScreen ACT’s position on restricted access to mammography screening areas and to provide relevant information and direction in circumstances where support people or children may have the intention of accompany a person having a mammogram.

This policy applies to all BreastScreen ACT staff and contractors and relates to restricted access of adults and children in mammography screening areas.

Support Person

Where a woman arrives for an appointment with a support person, Admin staff will inform the Radiographer. The Radiographer will advise the woman of the restrictions of access to mammography screening areas for their support person. The Radiographer will recommend both having the screen without the support person or offer the woman an opportunity to reschedule.

Children

Where a woman arrives for an appointment with children, Admin staff will inform the Radiographer. The Radiographer will advise the woman of the restrictions to screening areas for safety reasons and that BreastScreen ACT staff are not qualified to provide child minding. The Radiographer will recommend bringing an adult to mind the children while the woman is having a mammogram and offer the woman an opportunity to reschedule.

Continue or reschedule

The overall decision to continue or cancel the appointment is at the discretion of the Radiographer. When making the decision to continue or reschedule the appointment the following need to be considered, the:

• woman’s capacity to reschedule and attend with another adult to mind the children or without the children,

• impact on BreastScreen ACT core business, • impact and comfort of others, • facilities available to accommodate children, especially if in the waiting room, and

For the safety of the child, under no circumstances can a child accompany a woman in the mammography screening room.

Policies

ACT Health Radiation Safety Management Policy

PURPOSE

SCOPE




Standards

Standard 1.5 of the AIR Professional Practice Standards.

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, target age group, target age, reminder letters, out of target, eligible, client record, screening, mammography.





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13.9 Appendix 9 – Contacting Clients


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Contacting Clients

BreastScreen ACT is committed to maintaining client’s privacy.

This policy refers to guidelines to be adopted when BreastScreen staff telephone a client and need to identify themselves when speaking to a person other than the client.

When contacting a client and speaking to a clients family members or work colleague of BreastScreen ACT should not identify their place of work.

If the client has indicated that they consent to having a message left with family members or at work, then the procedure would be to identify yourself and also that you are from BreastScreen .

If they do not want a message left, then it is appropriate only to leave your first name and contact number. If the other person presses any further, it is appropriate to say that the woman has not given permission to speak with anyone other than her.

If you are unsure about whether the client would give consent, then it would be appropriate to state your name and number, if the person presses further say that you need to speak directly to the woman as you don’t, at this time, have the consent of the woman to leave a message with anyone else.

POLICY STATEMENT

PURPOSE

SCOPE



The procedure applies to Administrative and Clinical staff within BreastScreen ACT.

Privacy Act.

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, target age group, target age, reminder letters, out of target, eligible, client record, screening, mammography, privacy.





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13.10 Appendix 10 – Women with Disabilities Policy


SEARCH TERMS



endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Policy Women with Disabilities

BreastScreen ACT aims to provide access to all women including those with disabilities.

Women with disabilities represent a diverse group who, for one reason or another, have particular needs when accessing health services. A disability may be physical, sensory, intellectual, neurological and/or psychological.

The Program acknowledges that some women with disabilities have unique needs and aims to provide a service that meets the needs of all women using the service.

This policy guides protocols and procedures that provide a safe and appropriate environment for booking, screening and assessment processes within the BreastScreen clinic.

All staff must treat all women with equity and privacy and be as flexible and accommodating as possible to meet client needs.

Privacy Act

POLICY STATEMENT

PURPOSE

SCOPE



SEARCH TERMS


BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, target age group, target age, reminder letters, out of target, eligible, client record, screening, mammography, privacy.





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13.11 Appendix 11 – Consumer Feedback FlowChart


13.12 Appendix 12 – Confidentiality Agreement


BREASTSCREEN ACT

CONFIDENTIALITY AGREEMENT

The disclosure or misuse of confidential information held in official records is illegal (Public Sector Management Act 1994, ACT). Women who are clients of the BreastScreen ACT screening and assessment service should feel secure that all matters concerning them are strictly confidential. The following principles and practices should be adopted.

Staff must not use their position to obtain or disclose confidential information

Details about clients should not be discussed in corridors, reception areas or outside of work, with staff members outside the treating team or with any unauthorised person

Only staff involved in clinical management or clinical review should have access to clinical information about women

Only staff or visitors under the supervision of BreastScreen staff should be permitted in areas where women’s records are stored

Access to a woman’s records (outside the treating team) shall only be granted with the woman’s permission in writing or when required by a subpoena

All records should be securely kept out of public view

Should circumstances arise where files are removed for use in other facilities the files should be transported securely and not left unattended or visible in vehicles

Disciplinary action, termination of employment or legal action may occur for staff who do not maintain confidentiality.

I have read, fully understood and agree to comply with requirements to maintain confidentiality.

Signature …………………………………. Date ……………………

Staff Member’s or Visitor’s Name: …………………………………………………


13.13 Appendix 13 - Electoral Roll Invitation Letter example <letterhead>

Welcome!

BreastScreen ACT would like to invite you to join our program and make an appointment today to have a FREE screening mammogram (breast x-ray).

Having a breast screen every two years is the most effective way to detect breast cancer early – well before you or your doctor can see or feel anything.

BreastScreen ACT is part of the national breast cancer screening program, BreastScreen Australia.

We offer FREE breast screening to women over 40 at three convenient locations, in Canberra City, Belconnen and Phillip.

If you have any unusual changes in your breasts such as a lump, pain or nipple discharge, rather than attend BreastScreen ACT, we encourage you to see your GP for a clinical examination and diagnostic imaging such as an ultrasound or MRI.

We encourage you to call our friendly team TODAY on 13 20 50 to book your FREE breast screen. Please quote reference number ER2015.

For interpreter assistance, please call the Translating and Interpreting Service (TIS) on 13 14 50 and ask to be connected to the BreastScreen ACT booking service on 13 20 50.

We have enclosed an information brochure and magnet to remind you how important it is to look after your breast health.

We look forward to hearing from you.

Kind Regards

Yvonne Epping

Program Director

BreastScreen ACT

<date>

The ACT Electoral Commission has provided name, address and date of birth information to assist us in increasing participation in breast cancer screening. BreastScreen ACT do not use your information for any purpose other than sending you this invitation letter, and will not disclose your information to any other party. Your information is protected by Territory and Australian privacy legislation.

If you do not wish to receive information from BreastScreen in the future, please advise us and we will update our records accordingly.


13.14 Appendix 14 – BreastScreen Consent Form


13.15 Appendix 15 – Information – Having a Biopsy

Things to watch out for:

Bleeding

• Superficial: It is important to inspect your wound every 20 minutes for the first 2-3 hours. If you are concerned with the amount of bleeding, please contact BreastScreen ACT or your GP for a dressing change.

• • Deep: If you notice a swelling in the area of the biopsy, it may indicate bleeding. If

this occurs, apply firm pressure with the palm of your hand to the area for 20 minutes. If the area continues to swell, maintain the pressure and contact BreastScreen ACT during business hours, or report to the emergency department of your nearest hospital.

Bruising

Bruising after a biopsy is expected.

Reaction to the dressing

Some women may have sensitivity to the waterproof dressing. This skin may become itchy and reddened around the edges of the dressing. If this occurs, BreastScreen ACT or your GP can apply an alternative dressing.

Infection

An infection is unlikely, but as you have had an incision in your skin, it is a possibility. If you notice any signs of infection such as redness, swelling, increased pain in the area or discharge from the biopsy site, please contact BreastScreen ACT or your GP.

INFORMATION - After your biopsy

YOUR APPOINTMENT FOR RESULTS IS

Dr

Day/Date

Time

Location: Ground Floor, 1 Moore St Canberra City.

Care after your biopsy

Please leave the dressing on for five days. As the dressing is waterproof, you may shower.

Please use the ice pack supplied for 24 hours. Change the ice pack every 20-30 minutes during waking hours.

Your 24hr period ends _____

Heavy lifting, stretching or pulling involving the chest should be avoided for 24 hours following the procedure.

You may take Panadol for pain if necessary. DO NOT use Aspirin or Ibuprofen or Nurofen as these may cause bleeding.

CONTACT DETAILS

Contact nursing staff at BreastScreen ACT if you have any questions or concerns.

Phone: 6205 5053 during office hours.

OR contact your GP.


The BreastScreen ACT team of doctors have recommended you undergo a biopsy. The doctor will go through the following information with you prior to the procedure.

About the Procedure A biopsy is a procedure used to remove several pieces of tissue from an area of abnormality for testing and identification by the pathologist. This procedure is performed using local anaesthetic. A small incision is made in the skin through which a needle is inserted into the breast and several small biopsies are taken. This biopsy is guided by using either ultrasound or mammogram. There may be a need for the placing of a small metal marker into the biopsy site at completion of the biopsy. This marker remains in the area and will not be removed within the BreastScreen Program. The marker would only be removed if surgical treatment were required.

The specific biopsy type recommended to test the abnormality identified in your breast is:

(Initialled by treating doctor)

Ultrasound Guided Core Biopsy

Stereotactic (mammogram guided) Vacuum Assisted Biopsy (VAB)

With Marker Insertion

Alternatively, a simpler type of biopsy – Fine Needle Aspiration (FNA) biopsy under ultrasound guidance may be recommended which does not require local anaesthetic or marker insertion. This procedure is used to take a only few cells from an area of abnormality or to drain a cyst, for testing by the pathologist.

Fine Needle Aspiration (FNA) Biopsy

What are the risks? As with any medical procedure there are risks. (Initialled by treating doctor)

Bruising Some bruising in the area can be expected. Rarely, more extensive bruising may be experienced.

INFORMATION – Having a biopsy


Infection As with any interruption to the skin an infection is possible, however with the technique used this risk is minimal.

Bleeding Some bleeding in the area can be expected. Rarely, more extensive bleeding may be experienced.

Other important information

(Initialled by treating doctor)

You may request to defer this procedure to a later date if you need to make suitable personal arrangements.

You have the right to withdraw from the procedure at any time.

If you have any questions at any time please ask the doctor


13.16 Appendix 16 – Promotional Materials

See plastic sleeve in hard copy manual


13.17 Appendix 17 – Resources Procedures – naming, location, reviewing and archiving


endorsement

Canberra Hospital and Health Services BreastScreen ACT Operational Procedure Resources – naming, location reviewing and archiving

To provide a consistent process for developing, naming, storing reviewing and archiving resources.

These procedures apply to all BreastScreen ACT staff and relate to the ACT Health Consumer Handouts Policy and toolkit, available in on the ACT Health Intranet.

Naming of resources

• Resources must named in soft copy in a way that it is obvious what it is referring to and when it was created.

For example posters should be named after their message line. The poster with the woman in the green t-shirt is named ‘green woman’ which is not necessarily obvious to any new worker. The message line says ‘9 out of 10 women who get breast cancer don’t have a family history of the disease’ but could be shortened to ‘9 out of 10 women’ poster 2007’.

• Where a resource is created by ACT Health Communications and Marketing Unit, BreastScreen staff should tell graphics staff the name of the resource.

Location of resources on Q: Drive

Resources should be saved in one place only.

• Resources, such as letters, forms, and information sent regularly to clients are kept in Q:Drive/CH/CY&W/BScreen/Forms & Letters – current/ or Q:/CH/CY&W/BScreen/Publications, and Resources, and

PURPOSE

SCOPE



• In hard copy with this section of the BreastScreen ACT manual.

Bulk copies of resources are kept in two locations:

• the first floor resources room, or • the stuffer room.

Archiving resources

All resource must be kept in case a complaint is made based on information in the resource. The Archive file on Q drive is Q:\CH\CY&W\BScreen\Archive - Forms, Labels and Letters.

Reviewing resources

All existing resources will be reviewed every 2 years or earlier if appropriate by the Managers and Quality Committee or by a Working Group Review team identified by the Managers and Quality Committee.

ACT Health Consumer Handout Policy provides guidance on review processes.

All new or reprinted documents need to have a ‘date produced’ or ‘Created (date)’ so it is clear it is the latest version.

ACT Health Consumer Handout Policy

BreastScreen, BreastScreen ACT, BSACT, Participate, participation, participating, informed, target age group, target age, reminder letters, out of target, eligible, client record, screening, mammography, privacy, consumer resources.





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13.18 Appendix 18 – BreastScreen ACT Resources Tracking changes

This form can be placed at the front of the resource with any other relevant documentation behind.

Name of Resource: …………………………………………………………………

When created:

When reviewed:

Reviewed by:

Summary of reasons for changes:


13.19 Appendix 19 – BreastScreen ACT Resource Order Form

Health Care Worker Resource Order Form – Free resources and delivery Contact Name:

Practice/Organisation:

Postal Address:

GP Referral Pad (A5 sized pad containing 50 leaflets) Tear away leaflets to provide to eligible patients recommending them to make an appointment with BreastScreen ACT. Leaflets contain a space for GP contact and information for patients.

BreastScreen ACT Brochure (also available in other languages. Contact BreastScreen ACT) - Overview of BreastScreen ACT Program.

BreastScreen and You Brochure BreastScreen Australia Resource providing an overview of breast screening.

Breast Pain Brochure BreastScreen ACT resource providing general information on breast pain for women.

Breast Changes Brochure BreastScreen ACT resource providing general information on breast changes for women.

After 75 leaflet Information about breast and cervical screening for older women.

Assessment Clinic brochure Information for women recalled for assessment following a recent screening mammogram.

BreastScreen ACT Poster A4 (Please circle) 1.Promote two yearly screening

2.General BreastScreen ACT 3.Open in Belconnen 4.Call to action -image of woman on phone

BreastScreen ACT Poster A3


Appointment Reminder Cards Business cards including dates to remind woman of next screening date.

BreastScreen ACT Fridge Magnet

BreastScreen ACT Pen (limit 10 per order) * Available only while stocks last.

BreastScreen ACT Bookmarks (limit 50 per order)

Please e-mail completed order form to [email protected]

mailto:[email protected]

governance and general administration manual...act health – cancer, ambulatory and community...

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