Networking and the National Picture: Where are We and Where are We Going?

1. Scottish Pathology Network Networking and the National Picture: Where are We and Where are We Going? Dr. Lee B. Jordan Lead Clinician for SPAN Consultant Pathologist, NHS Tayside

2. Networking, Quality and All That Jazz…

3. Just what is Networking and who is this Barnes chap anyway?

4. 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.

5. Mission Statement To 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'

6. What is SPAN? 10 Boards supplying cellular pathology services across 12 laboratory sites.

7. 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

8. Cervical Snippets • Managed Service Contract • Imager • Consortia Model • Workload distribution • Workforce modelling • Screening Programme changes • Primary HR-HPV testing? • Tim Palmer’s talk…

10. 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

11. Benchmarking Snippets

14. Note these are SPAN figures not SCSP figures

16. 76% 49%

17. 34% 12%

18. RCPath KPI 6.4 • Cellular Pathology Reporting Turnaround Times • Reported, confirmed and authorisedwithin 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.]

23. [Excluding Capital Charges, Whole Sample Mean]

25. [Excluding Capital Charges, Whole Sample Mean]

27. Key Objectives • Appoint a Network Scientific Manager • Consolidating/reinforcing existing activity • Cervical Cytology • Molecular Pathology • New activity • Paediatric & Perinatal Pathology Services Review • Quality & Performance

28. Key Objectives • Appoint a Network Scientific Manager • Consolidating/reinforcing existing activity • Cervical Cytology • Molecular Pathology • New activity • Paediatric & Perinatal Pathology Services Review • Quality & Performance

29. 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)

30. 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)

31. Barnes Report… • England! • 28th January 2014 To understand Barnes One must understand Kings Mill! (Not the loaf)

32. Kings Mill

33. 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.

34. 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.

35. 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

36. 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.

37. 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…

39. 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.

40. 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.

41. 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.”

42. 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.

43. 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 criteriafor 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.”

44. 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.”

45. 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.

46. 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.

47. 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?

48. 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.”

49. 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?

50. Recommendation 4 “Existing guidance on the standardisation and transparent reporting of errorsfrom 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.”