Siobhan O'callaghan findings from QA activities

1. Findings from QA activities
Siobhan O’Callaghan
Senior QA Advisor

2. Methodology
• 30 QA visits reports
• 786 QA recommendations
• September 2017 to 4 July 2018
2
QA visits
by region

3. All recommendations by theme – 786
3
259
96
56
27
34
53
69
63
41 42 44
2
0
50
100
150
200
250
300
numberofrecommendations

4. Infectious diseases in pregnancy
4
218
51
40
26 22
61
93
111
42
57
63
0
50
100
150
200
250
governance
infrastructure
invitation
cohort-
antenatal
cohort-
newborn
IDPS
SCT
FASP
NBS
NHSP
NIPE
numberofrecommendations

5. Infectious diseases in pregnancy – priority
3
1
1
15
9
5
41
24
13
5
15
10
10
45
48
46
37
67
68
48
17
10
30
41
172
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Blank
NIPE
NHSP
NBS
FASP
SCT
IDPS
cohort - newborn
cohort - antenatal
invitation
infrastructure
governance
immediate high standard low blank
5

6. Infectious diseases in pregnancy – 61
6
12
8
7
1 1
7
6
5
3 3
2 2 2
1 1
0
2
4
6
8
10
12
14
numberofrecommendations
17
34
2
8
Timescales
3 months 6 months 9 months 12 months

7. Laboratory (29/61 recommendations)
• ability to identify antenatal samples as distinct from other pathology
samples
• samples to the laboratory or reference laboratory to be
tracked/booking to result tracking system
• laboratory to notify the screening team/maternity services directly of
rejected or untested samples or screen positive results
• weekly failsafe of screen positive results
• wording on reports – remove ambiguity
• do not release screening results until confirmed
• update standard operating procedures to reflect current processes
• remove reference to rubella from local documents
7

8. Laboratory (29/61 recommendations)
• store national documents on quality management systems
• commissioner to identify risks and issues in the laboratory
• UKAS accreditation
• risk assessment of screening sample in the lab
• laboratory to schedule regular audits specific to the screening
pathways (vertical audits)
• implement electronic requesting
8

9. Generic recommendations– under other themes
• formalise governance arrangements (programme boards)
• terms of reference to ensure operational oversight and
representation for all key stakeholders
• management of incidents in NHS screening programmes
https://www.gov.uk/government/publications/managing-safety-
incidents-in-nhs-screening-programmes
• staffing and job descriptions – named laboratory lead
• training and competency assessments
• standards and key performance indicators – standard 4: turn around
times
9