span networking and the national picture: where are we and where are we going? dr. lee b. jordan...
TRANSCRIPT
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SPAN
Networking and the National Picture: Where are We and
Where are We Going?Dr. Lee B. Jordan
Lead Clinician for SPANConsultant Pathologist, NHS Tayside
Scottish Pathology Network
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SPAN
Networking, Quality and All That Jazz…
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SPAN
Just what is Networking and who is this Barnes chap
anyway?
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SPAN
Overview• What is SPAN?
– Context, History, Structure.• What have WE done?
– Achievements to date.• What are WE doing?
– Current and future objectives.• Quality & Performance
– Kings Mill, Barnes, etc.
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SPAN
Mission StatementTo improve pathology services by creating and developing a Scotland wide Managed Diagnostic Network (MDN) which will steer modernisation, including service change and redesign, improve quality, ensure provision of an effective pathology service which anticipates and responds to user needs, future requirements, national guidelines and meets Clinical Pathology Accreditation Standards'
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SPAN
What is SPAN?
10 Boards supplying cellular pathology servicesacross 12 laboratory sites.
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SPAN
Achievements• Benchmarking• Re-design of Cervical Cytology • Implementation of Molecular Pathology as a National
Service• Review of Electron Microscopy• Workforce Planning• Quality Agenda• Digital Imaging• Site Visits• Facilitating cross Board communication and support
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SPAN
Cervical Snippets• Managed Service Contract• Imager• Consortia Model• Workload distribution• Workforce modelling• Screening Programme changes• Primary HR-HPV testing?
– Tim Palmer’s talk…
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SPAN
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SPAN
Molecular Pathology Snippets• NSD adminstered, centrally funded service
– Boards top-sliced• Four core centres
– Aberdeen, Dundee, Edinburgh, Glasgow • Known repertoire• ‘Free’ at the point of use• Structure for evaluation and introduction of new
tests– MPEP & MPCSG
http://www.nsd.scot.nhs.uk/services/specserv/molpath.html
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SPAN
Benchmarking Snippets
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SPAN
2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13300,000
350,000
400,000
450,000
500,000
550,000
SPAN Benchmarking: TOTAL Histo Requests & Specimens 2005/6 to 2012/13
Requests (TOTAL) Linear (Requests (TOTAL))Specimens (TOTAL, data incomplete) Linear (Specimens (TOTAL, data incomplete))
Requ
est/
Spec
imen
Num
ber
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SPAN
2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13500,000
700,000
900,000
1,100,000
1,300,000
1,500,000
1,700,000
1,900,000
2,100,000
2,300,000
2,500,000
SPAN Benchmarking: TOTAL Histo Blocks & Slides 2005/6 to 2012/13
Blocks (Total) Slides (Total)
Bloc
k/Sl
ide
Num
bers
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SPAN
2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13350,000
370,000
390,000
410,000
430,000
450,000
470,000
SPAN Benchmarking: TOTAL Cervical Cyto Requests (2005/6 to 2012/13)
Cervical Cytology Requests
Requ
est N
umbe
r
Note these are SPAN figures not SCSP figures
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SPAN
2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/1350,000
55,000
60,000
65,000
70,000
75,000
80,000
SPAN Benchmarking: TOTAL Non-Cervical Cyto Requests (2005/6 to 2012/13)
Non-Cervical Cyto
Requ
est N
umbe
r
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SPAN
2009/10 2010/11 2011/12 2012/130.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
SPAN Benchmarking:% Histo Requests Reported in 168hrs (7 Calendar Days)
% Requests Reported in 168hrs (7 Calendar Days)
Perc
enta
ge
49%
76%
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SPAN
2009/10 2010/11 2011/12 2012/130.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
SPAN Benchmarking:% Histo Requests Reported in 72hrs (3 Calendar Days)
% Requests Reported in 72hrs (3 Calendar Days)
Perc
enta
ge
34%
12%
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SPAN
RCPath KPI 6.4• Cellular Pathology Reporting Turnaround
Times
– Reported, confirmed and authorised within 7 and 10 calendar days of the procedure
– 80% (7 Days)– 90% (10 Days)
– [Cases requiring prolonged decalcification (not bone marrow trephines) are excluded, as are cases requiring molecular tests.]
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SPAN
2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/130.00
50.00
100.00
150.00
200.00
250.00
300.00
350.00
400.00
SPAN Benchmarking: Scottish BMS and HCSW Staffing (2006/7 to 2012/13)
Overall BMS Staffing (Scotland) Linear (Overall BMS Staffing (Scotland))Overall HCSW Staffing (Scotland) Linear (Overall HCSW Staffing (Scotland))
WTE
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SPAN
2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/130.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
180.00
SPAN Benchmarking: Scottish BMS AfC Band Splits (2006/7 to 2012/13)
8d 8c 8b 8a 7 6 5 Trainee
WTE
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SPAN
2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/130.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
180.00
SPAN Benchmarking: Scottish BMS AfC Band Splits (2006/7 to 2012/13)
8d 8c 8b 8a 7 6 5 Trainee
WTE
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SPAN
2007/8 2008/9 2009/10 2010/11 2011/12 2012/130.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
SPAN Benchmarking: Medical Consultant Vacancy Rate (2007/8 to 2012/13)
Medical Consultant Vacancy Rate
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SPAN
[Excluding Capital Charges, Whole Sample Mean]
2008/9 2009/10 2010/11 2011/12£0.00
£10.00
£20.00
£30.00
£40.00
£50.00
£60.00
Keele Benchmarking: Cost per Request (Histo & Cyto) 2008/9 to 2011/12
England & NI (All) Scotland (All)
Cost
(£)
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SPAN
2008/9 2009/10 2010/11 2011/120
200
400
600
800
1000
1200
1400
Keele Benchmarking: Requests per WTE (Histo & Cyto) 2008/9 to 2011/12
England & NI (All) Scotland (All)
Requ
ests
per
WTE
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SPAN
NHSA&A
NHSD&G
NHSF
NHSGG&C
NHSGram
NHSFV
NHSH
NHSLan
NHSLoth
NHST
All UK
£0.00 £20.00 £40.00 £60.00 £80.00 £100.00 £120.00
Keele Benchmarking: Cost per Request (Histo & Cyto) for 2012/13
Cost per Request
[Excluding Capital Charges, Whole Sample Mean]
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SPAN
NHSA&A
NHSD&G
NHSF
NHSGG&C
NHSGram
NHSFV
NHSH
NHSLan
NHSLoth
NHST
All UK
0 200 400 600 800 1000 1200 1400 1600
Keele Benchmarking: Requests per TOTAL WTE (Histo & Cyto) for 2012/13
Request per WTE
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SPAN
Key Objectives• Appoint a Network Scientific Manager• Consolidating/reinforcing existing activity
– Cervical Cytology – Molecular Pathology
• New activity– Paediatric & Perinatal Pathology Services Review– Quality & Performance
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SPAN
Key Objectives• Appoint a Network Scientific Manager• Consolidating/reinforcing existing activity
– Cervical Cytology – Molecular Pathology
• New activity– Paediatric & Perinatal Pathology Services Review– Quality & Performance
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SPAN
Quality & Performance• IQA• QMS• UKAS/CPA –> ISO 15189• RCPath KPI• SPAN Benchmarking• Keele Benchmarking• QPIs (Cancer Specific)• Targets (Cancer & General)• Pathology Quality Assurance Review (Barnes)
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SPAN
Quality & Performance• IQA• QMS• UKAS/CPA –> ISO 15189• RCPath KPI• SPAN Benchmarking• Keele Benchmarking• QPIs (Cancer Specific)• Targets (Cancer & General)• Pathology Quality Assurance Review (Barnes)
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SPAN
Barnes Report…• England!• 28th January 2014
To understand BarnesOne must understandKings Mill!
(Not the loaf)
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SPAN
Kings Mill
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SPAN
Kings Mill (1)• “inadequate assurance processes at Sherwood
Forest Hospitals NHS Foundation Trust, which subsequently resulted in inappropriate care for a number of women with breast cancer”.
• What happened?• ER +ve breast cancers were called negative
denying patients treatment.
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SPAN
Kings Mill (2)• CQC found:
– Histopathology services had poor communication and feedback with the local trust board.
– Equipment in use at the time had been outdated.– Recruitment issues around medical staffing and
medical leadership.– No robust internal quality audit programme in
place.
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SPAN
Kings Mill (3)• RCPath found:
– Kings Mill was NOT an outlier on ER results as the sample size was too small for statistical analysis.
– Samples were NOT misreported, there was no medical/interpretative error.
– There were problems with IHC service, these were flagged and the service outsourced.
– Issues around governance and culture – finance had overridden service planning and provision
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SPAN
Kings Mill (4)• RCPath found:
– EQA scheme for ER did NOT identify any problems.– EQA scheme did NOT provide any benchmark
comparison for the Kings Mill histopathology service to relate to.
– External monitoring, peer review, accreditation and QA systems did NOT identify any problem.
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SPAN
Kings Mill (5)• In summary:
– Specific local issues had been found at Kings Mill:• small screening centre• small workload • behind in technological terms
– National issues • Quality assurance • Communication• Monitoring of quality • Applicable beyond Kings Mill…
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SPAN
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SPAN
Pathology QA Review (1)• Key positives:
– Underwrites 80% of patient interactions.– Compare favourably with Europe and others.– High quality services.– High clinician confidence.– Skilled workforce.– Good IQA and QMS.– Mature EQA.– Forefront of QA (in the world).– Overall = safe, reliable and effective.
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SPAN
Pathology QA Review (2)• Key negatives:
– Relies almost entirely on professionalism and goodwill.
– Setup to provide assurance to laboratories and not public or patients.
– Systems focussed on minimal acceptable standards.– No identification, incentivisation or reward for
excellence.– Little sanction or support if performance falls below
acceptable standards.
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SPAN
Recommendation 1“A systematic approach should be taken to educating, training and developing the skills of the pathology workforce in quality management systems and quality improvement methodology, in ways appropriate to professional group, role and grade. This process should be led by HEE [Higher Education England].”
“HEE should work with the professional bodies and regulators to ensure that quality management and assurance can be recognised as an essential requirement in CPD [Continuing Professional Development], and in individual appraisal requirements.”
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SPAN
Implication – R1• If Scotland were to adopt:
– NHS Education for Scotland (NES) would be the surrogate for HEE ?
– Medical deaneries and other parties?– Educational mechanisms (appraisal, PDRs, CPD,
eKSF, etc.).– Could be beneficial for ALL of the Pathology Team.
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SPAN
Recommendation 2 (1)“The membership, role and function of the JWGQA [Joint Working Group for Quality Assurance] should be revised and expanded. It should set consistent standards and performance criteria for all schemes across pathology and work with UKAS [UK Accreditation Service] to ensure their implementation in the scheme accreditation process. The JWGQA should advise on publication of performance data. The National Medical Director has confirmed that he will ask the RCPath to lead this work.”
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SPAN
Recommendation 2 (2)“Further consideration must be given to the ways in which individual performance can be assessed, monitored and competence-assured. The National Medical Director will ask the professional bodies, led by RCPath, to review these issues and report back within twelve months on their findings.”
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SPAN
Implication – R2 (1)• Scottish impact (1):
– JWGQA is UK wide.• ?devolved nation representation.
– Laboratory (technique) EQA:• Little/no objection in Scotland for transparency.• Output unlikely to be informative to the public.• Unlikely to be understandable without review.
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SPAN
Implication – R2 (2)• Scottish impact:
– Interpretative EQA (individual performance):• Much more concern here.• Developed from informal slide clubs, internal learning
and professional development perspective.• Currently (mostly) voluntary, performance output is
linked anonymised.• Each scheme differs – own
scoring/exclusion/answering/marking/analysis/result reporting processes.
• Not all are CPA accredited.
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SPAN
Implication – R2 (3)• Scottish impact:
– Interpretative EQA (individual performance):• Not reflective of practice or in-service performance.• Schemes prohibit consultation and consensus, which
are key aspects to service delivery and QA in labs.• Review states that attempts at collusion should be a
matter of professional probity.• EQA responses are a matter of opinion.• English use for commissioning.• Current EQA is not fit for R2 purpose?
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SPAN
Recommendation 3“The quality and governance systems of pathology providers must be integrated with trust governance and quality structures. This should include the measurement of appropriate quality assurance indicators and the identification of an accountable board member within the organisation. CQC and the Chief Inspector of Hospitals have indicated that robust information on the quality of pathology services could contribute to the overall assessment of quality under the new hospital inspection model.”
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Implication – R3• For Scotland:
– There should be some input into any development of KPIs or KAIs that may impact Scotland.
– How to achieve that?– Should we develop our own?– Should we simplify matters?
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Recommendation 4“Existing guidance on the standardisation and transparent reporting of errors from pathology services must be rigorously followed, including the reporting of all incidents that could have, or did lead to patient harm, to the NRLS [National Reporting and Learning System]. Pathology services should be encouraged to share information and data about clinical risks, ‘lessons learnt’ and good practice, in order to contribute to education and quality improvements nationally. The Trust Development Agency (TDA) and Monitor/CQC should encourage trusts to improve their adherence to existing guidance.”
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Implication – R4• For Scotland:
– Already have local mechanisms for reporting.– Part of QMS and Board mechanisms.– Part of UKAS/CPA review.– Should there be sharing beyond host
organisations?– Do we need another system?
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Recommendation 5“The continued development of the NLMC [National Laboratory Medicines Catalogue] to ensure consistency of data and information across the NHS in England should remain a priority. Ministers and NHS England have confirmed that this task, undertaken by HSCIC [Health & Social Care Information Centre], with support from professional bodies and others, must continue at scale and pace. The professional bodies, the IVD [in vitro Diagnostics] manufacturers and others should work towards minimising the differences between analytical processes, requesting and reporting.”
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Implication – R5• For Scotland:
– Already committed for NLMC.• More impact for non-Cell Path labs.
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Recommendation 6“In order that patients and clinicians can rely on accreditation status as shorthand for a quality assured service, the accreditation of pathology services must be updated showing clearly which laboratories are meeting minimum requirements, and which are excelling to provide first-rate service quality. UKAS has agreed to undertake this work.”
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Implication – R6 (1)• For Scotland:
– Particular risks for Scotland:• CPA/UKAS is often a struggle and a rush.• ISO 15189 is proving challenging, esp. Test Validation.• May see labs accredited minus aspects of their current
repertoire.• Introduction of random, unannounced visits.
– Does inspection improve standards?• Too late? • Need to embed Continuous Quality Improvement.
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Implication – R6 (2)• For Scotland:
– Overlap with R2 and EQA elements.– “4.80 - UKAS should work with the professional
bodies and JWGQA to facilitate an assessment of the minimum number of specimens per annum required to quality assure an individual test.”
• Kings Mill reports suggest minimum numbers of ER tests at any one site.
• Minimum limits on reporting size and duties for reporters.
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Recommendation 7“In order to support commissioners in the next planning round, the PSCT [Pathology Commissioning Services Toolkit] should be updated. The National Clinical Director (NCD) for Pathology, with the NCD for Diagnostics and the Chief Scientific Officer, will lead this project, working in conjunction with local commissioners and professional bodies. When the NICE QS is published, it should be included in the PSCT. Commissioners should follow the MHRA guidelines when commissioning POCT.”
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Implication – R7• For Scotland:
– No impact?• Commissioning has no role in NHS Scotland at present.
– Monitoring tools suggested could be of use?• Kent & Medway tools covered in the QA Review
document.
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Recommendation 8“A high level, system-wide Oversight Group should be created with responsibility for steering the improvements in quality assurance frameworks and governance mechanisms outlined in this report. NHS England has confirmed that it will facilitate this group.”
“The Oversight Group should also develop a Pathology Quality Assurance Dashboard, which draws transparent and meaningful information from existing data sources to provide a national picture of quality improvement across England, to enable trend analysis and the identification of opportunities for development of the system.”
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Implication – R8• For Scotland:
– Concept of a live Dashboard could be useful in the Scottish context.
• How to feed in to the process?
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Quality & Performance• IQA• QMS• UKAS/CPA –> ISO 15189• RCPath KPI• SPAN Benchmarking• Keele Benchmarking• QPIs (Cancer Specific)• Targets (Cancer & General)• Pathology Quality Assurance Review (Barnes)
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Quality & Performance
Is there a simpler way forward?
(September)