NHSP Quality Assurance Programme: What are the outcomes?

1. NHSP Quality Assurance Programme:What are the outcomes? Christine Cameron MSc CS Head of NHSP QA Programme BAPA Conference January 2013

2. Setting the scene English newborn hearing screen has been fully implemented since 2006 Recently celebrated screening of the 5 millionth baby 115 local screening programmes in England Local screening programme incorporates the whole care pathway of the hearing screen 33 clearly defined quality standards relating to activity across the care pathway QA Programme started in 2006

3. Some questions to begin with • How does quality assurance work? • Does quality assurance have an effect on improving services? • How do the professionals feel about an external audit? • Is there a benefit for the families? • What is the real value of quality assurance?

4. Quality Assurance is an external audit of local performance against the quality standard

5. Quality Assurance in practice • Collect information from all services in each local programme • Self assessment questionnaires • Supporting evidence • Visit to the service to look at clinic resources, case notes, interviews, observations • Expert Peer Review team who review the information and assess performance against the quality standards • Final Report • Recognition of good practice and gives recommendations for quality improvement • Report circulated to managers and commissioners, and public domain • Improvement Plan

6. Quality Assurance in practice • Action Plan lists all the recommendations in a convenient table • It takes 18 months to complete one QA cycle of all 115 local programmes • In the next QA cycle we repeat the process • look at the previous Action Plan • reassess performance against the standards • can determine progress and quality improvement • We have now reviewed all the local screening programmes four times so, have we any evidence that the QA programme is necessary or has improved services?

7. QA programme: an iterative process • First cycle Nov2006 - March2008 • Word documents for self assessment • Peer review visits • Second cycle April2008 – Oct2009 • Electronic self assessment questionnaires QAF • Peer review visits incl case studies and ABR • Third cycle June2010 – Sept2011 • Self assessment questionnaires; triggered recommendations • ABR review • Targeted peer reviews to services • Fourth cycle April2012 – March2013 • Self assessment questionnaires; triggered recommendations • Case studies – audiology/medical/early intervention • ABR review • Targeted peer reviews to services

8. Does quality assurance have an effect on improving services? Evidence from; • comparison between QA cycles • recommendations addressed in Implementation Plan Screening Audiology Education Medical CHSWG

9. Screening: Quality Standard 7 : 95% screens completed in 4 weeks

10. Screening Quality Standard 15: all screen referral to audiological assessment offered within 4 weeks

11. Screening: case study QA1 • screen coverage 55.8 % by 4 weeks of age • no effective leadership • no robust procedure for referral to audiology Local working group set up to address issues following QA report and possible suspension of screening When would this situation have been identified without QA QA2 • turned the service around • Overall rating in top five of country

12. Case study

13. impact on Audiology services • Diagnostic testing • Behavioural testing – use of VRA • Habilitation –RECD; appointment time; staffing • Facilities – test accommodation • Test results given on same day • Team working • Community audiology – VRA, staffing, facilities

14. impact on Audiology services

15. Impact on Audiology: behavioural testing

16. impact on Audiology services • Eastbourne & Hastings – lone paediatric audiologist • Highlighted in 2 QA reports as a risk • As a direct result of the QA reports the new team looks like: • 1 wte head of service • 0.4wte senior paediatric audiologist • 1.0wte paediatric audiologist • 0.4wte health visitor specialist (with Audiology training)

17. Impact on Audiology services

18. Impact on Audiology: ABR • QA1 identified issues with ABR traces. Poor use of BC and tone pip • QA2 ABR traces included in peer review • Training update courses • External review groups encouraged • Pilot of regional review groups • serious incident and suspension • QA3 ABR review (5 cases) by external experts. All using BC and tone pip • Followed up with phone call to ensure QI • QA4 ABR review (4 cases) by external experts with requested ID

19. 13 incidents Additional 20 audiology departments requiring regular external review & training External expert reviewers PC expert reviewer Setting up of regional peer reviews Impact on Audiology: ABR Review

20. QA3 42% category 1 or 2 QA4 48% category 1or 2 Impact on Audiology: ABR Review

21. Improved adherence to the aetiological investigation guidelines Inclusion of all PCHI – mild & unilateral Attendance at aetiological investigation course Raised concerns over succession planning Supportive evidence for genetic testing Impact on Medical services

22. Impact on Early Intervention services • Early Intervention services have improved their year round cover to respond and visit families referred from audiology • Improved sharing of information between education and audiology colleagues • An increased number of parents are now involved in the local Children Hearing Services Working groups

23. ‘Sharing the news’ courses Results discussed on day of test Informed choice Parent satisfaction surveys Representation at CHSWG Quality improvement to services Improved equity of services QA reports in public domain Is there a benefit for the families?

24. impact of QA programme: CHSWG QA3 • 78% QA3 groups report they are now ‘effective’ : 54% in QA2 • 81% in QA3 as being both strategic and operational : 78% in QA2. • 74% QA3 groups meet every 3-4 months : 53% in QA2 • Improved representation – see next slide

25. Stakeholder representation in CHSWG

26. Patient satisfaction survey: impact on service provision Integral part of the QA programme is to recommend services ask families for their view of the service and we have asked what changes they have made as a result of such a survey • Wax removal was improved and a fast track care pathway was implemented • Appointment slots altered to give greater parental choice of time and date • Improved parking and waiting room facilities • Ensure that all staff introduce themselves and their role when first seeing a patient • Establishing hearing aid maintenance sessions at satellite clinics • Ear moulds sent directly to families from manufacturers

27. Why did the improvement happen? • QA Reports were taken seriously and acted on • Wide circulation of reports • Respect for the QA programme • External Peer Review audit against Quality Standards • Local ownership for improvement • Suspension of services • Repeated QA cycles • Came back to check on progress • Working withprofessionals to improve practice with offering training courses, networking, peer review groups (ABR) • Parent surveys

28. Quality improvement culture developed • Courses • ABR Update • Sharing the News • Infant Hearing Aid fitting • VRA • Forum to discuss late identified cases • Peer review – internal & external • Audit embedded in services

29. How do professionals feel about the QA programme? QA3 • 96% valued the QA programme as a means to maintain and improve quality • 96.9% reported that changes have been made to their service as a result of QA programme ABR review QA3 • 86% aid to quality improvement • 78% necessary to assure quality across services • 75% reassuring exercise • 69% change in their clinical practice

30. Quality Assurance : the value • Identifying poorly performing services and services performing well • Driver for quality improvement • Provide commissioners with either assurance that they are paying for a good service or encouragement to improve • Provide professionals with an external review of practice • Offer families a view of services – informed choice • Inclusion of the complete care pathway was vital to ensure no ‘gaps’ Most importantly families and babies benefit – the Quality Assurance Programme ensures they will receive a quality service wherever they live in England

31. Summary • Demonstrated power of QA cycles in bringing about QI and maintaining high level of service provision – across the care pathway • QA programme is now established and respected • The future of NHSP QA

32. Acknowledgements & thanks to • All the leads of screening, audiology, medical and early intervention services in England that have participated in the QA programme over the past 6 years • The expert peer review Quality Assurance team of experienced professionals who undertook the review visits • Colleagues at the national Programme Centre