COLLECTING, MONITORING AND REPORTING REPEAT
EXAMINATIONS
Good Practice Guide No 4
Version 2
November 2006
Published by:
NHS Cancer Screening Programmes
Fulwood House
Old Fulwood Road
Sheffield
S10 3TH
Tel: 0114 271 1060
Fax: 0114 271 1089
Email: info@cancerscreening.nhs.uk
Web site: www.cancerscreening.nhs.uk
© NHS Cancer Screening Programmes 2006
The contents of this document may be copied for use by staff working in the public sector but may
not be copied for any other purpose without prior permission from the NHS Cancer Screening
Programmes.
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Printed by Charlesworth
Collecting, Monitoring and Reporting Repeat Examinations
CONTENTS
Page No
Preface
iv
1.
INTRODUCTION
1
1.1
1.2
1.3
1.4
Purpose
Responsibilities
Definitions
NHSBSP standard
1
1
1
2
2.
RECORDING REPEAT EXAMINATIONS
3
2.1
2.2
2.3
2.4
2.5
2.6
2.7
Data requirements
Inputting technical repeats without using the NBSS daybook
Inputting technical repeats using the NBSS daybook and SMDE
Inputting technical recalls by manual entry
Inputting technical recalls by direct barcode entry
Technical recall and assessment
Women who fail to attend for technical recall appointments
3
4
5
6
8
9
9
3.
COLLECTING, MONITORING AND REPORTING
10
3.1
3.2
3.3
3.4
3.5
3.6
Local protocols
Information to be collected locally
Regional reporting and monitoring
National reporting and monitoring
Equipment faults
Crystal reports
10
10
10
11
11
12
REFERENCES
12
NHSBSP November 2006
iii
Collecting, Monitoring and Reporting Repeat Examinations
Preface
This Good Practice Guide was originally prepared for the NHS Breast Screening Programme (NHSBSP)
by a working party consisting of members of the National Quality Assurance (QA) Coordinating Group for
Radiography and the National Administration and Clerical QA Coordinating Group. The guide has now been
updated by Sarah Cush and Margot Wheaton with the help of current members of the national coordinating
groups, and reflects the changes in working practices following implementation of the redeveloped national
breast screening computer system (NBSS). The NBSS User Guide, which gives a detailed explanation of the
functionality of the system, can be found on the NBSS website at http://www.nbss.nhs.uk.
NHSBSP November 2006
iv
Collecting, Monitoring and Reporting Repeat Examinations
1. INTRODUCTION
1.1
Purpose
The purpose of this document is to clarify and standardise the recording of data on repeat mammographic
examinations in order to monitor performance against the national standard. The aim is to produce standard
reports for local, regional and national monitoring.
1.2
Responsibilities
Mammographers have specific responsibilities under the Ionising Radiation (Medical Exposure) Regulations
2000 (IR(ME)R2000) for justifying repeat mammographic examinations. These should be clearly set out in
work instructions. The appropriate circumstances for the repeat must be specified and always applied.1
All breast screening programmes are responsible for recording, collecting and monitoring repeat examination
data. The data should be reported regionally and nationally. All mammographers have a responsibility for
regular audit of the number of repeat examinations and review of their performance against personal, unit,
regional and national standards.2
1.3
Definitions
Repeat examinations can be divided into two categories: technical recalls and technical repeats.
A technical repeat (TP) is when the mammographer makes the decision to repeat the same projection(s)
after identifying an error.
A technical recall (TC) is when a woman is asked to reattend for the same projection(s) to be repeated,
whether oblique or craniocaudal, because the current screening examination is technically inadequate for
reporting (or is missing).
For the purpose of this document, the NBSS abbreviations TC and TP are used. The term repeat examinations
(TR) refers to the total number of technical repeats (TPs) and technical recalls (TCs).
Supplementary projections may occasionally be required to complete the mammographic screening examination. This is while the woman is still present either on the mobile unit or at the static unit and is based on
the professional judgement of the mammographer. These are not classed as repeat examinations.
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Collecting, Monitoring and Reporting Repeat Examinations
1.4
NHSBSP standard
Objective 6 in the NHSBSP national standards table is ‘to minimise the number of women undergoing repeat
examinations’.3 The minimum standard is that less than 3% of total examinations should be repeated, and the
target is less than 2%.3
Objective
6. To minimise the number of women
undergoing repeat examinations
Criteria
The number of repeat
examinations
Minimum standard Target
< 3% of total
< 2% of total
examinations
examinations
It is important that breast screening programmes accurately and consistently record repeat examination data
to ensure that this standard is monitored. Repeat examinations should be minimised to keep radiation dose to
the minimum necessary and, particularly when second appointments are needed, to minimise anxiety caused
to women.
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Collecting, Monitoring and Reporting Repeat Examinations
2. RECORDING REPEAT EXAMINATIONS
2.1
Data requirements
The following data must be collected in order to be able to monitor repeat examination rates:
•
•
•
name and screening number of the woman
code of the mammography practitioner performing the original examination
repeat reason code.
In order to calculate the rates, the number of women screened must also be known.
Training centres and breast screening services that have mammographers in training should identify them
separately on NBSS with an individual code. The calculation of the repeat examination rate for a department
should include all mammography practitioners, but the calculation of the repeat examination rate for an individual mammography practitioner should take account of their training status.
The categories of repeat examinations and associated reason codes are shown in Table 1.
Table 1 Categories of repeat examinations and reason codes
Category
Mammographer
Equipment
Reason code
R1A
Reason
Inadequate position
R2
R3
Inadequate compression
Incorrect exposure
R4
R5
Incorrect processing
Artefacts obscuring image Overlapping anatomy
E1
X-ray machine
malfunction
Film processing system
fault
Film handling fault
Identification marker
Cassette
Film manufacturing fault
E2
E3
E4
E5
E6
Client
R1B
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Inadequate position
– client
Example(s)
The mammographer had not imaged all of the breast
tissue, nipple not in profile or obscuring breast tissue
Blur
Too light or too dark or automatic exposure control
(AEC) not over dense area of the breast
AEC failure
Scratches obscuring breast tissue
Fogging, double loading, not loading
No name
Light leakage, screen artefacts
Cutting artefacts
Physical difficulties experienced in getting adequate
images
Collecting, Monitoring and Reporting Repeat Examinations
2.2
Inputting technical repeats without using the NBSS daybook
The Screening Film Record for a right sided technical repeat is shown below. This screening record is now
complete and the episode can be closed.
2.2.2 Inputting technical repeats using the NBSS daybook and SMDE
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Collecting, Monitoring and Reporting Repeat Examinations
2.3
Inputting technical repeats using the NBSS daybook and SMDE
Using the NBSS daybook is an alternative way of inputting technical repeats.
2.2.3 Inputting technical recalls (manual entry)
The screening film record for a technical recall is shown below. Note that:
•
•
•
•
the overall opinion shows films not reported
only one film reader is required; this could be a film reader or an appropriately experienced
radiographer who decides that the film is inadequate
both sides must be recorded as TR irrespective of whether one or both sides are affected
the repeat reason must be documented on this first screening film record so that it is recorded
against the correct mammography practitioner’s name.
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Collecting, Monitoring and Reporting Repeat Examinations
2.4
Inputting technical recalls by manual entry
The Screening Film Record for a technical recall is shown below. Note that:
the Overall Opinion shows films not reported
only one Film Reader is required; this could be a film reader or an appropriately experienced radiographer
who decides that the film is inadequate
both sides must be recorded as TR irrespective of whether one or both sides are affected
the Repeat Reason must be documented on this first screening film record so that it is recorded against
the correct mammography practitioner’s name.
•
•
•
•
A new screen film record is now created to enter the details of the technical recall visit. In this
example, films were repeated on the right side, but none was taken on the left side:
•
•
N must be entered in the view(s)/procedure(s) field to signify that no films were taken on the left
side
this case was reported as RR by two readers.
The screening record is now complete and the episode can be closed.
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Collecting, Monitoring and Reporting Repeat Examinations
A new Screen Film Record is now created to enter the details of the technical recall visit. In this example,
films were repeated on the right side, but none was taken on the left side:
•
•
N must be entered in the View(s)/Procedure(s) field to signify that no films were taken on the left side
this case was reported as RR by two readers.
The screening record is now complete and the episode can be closed.
2.2.4 Technical recall by direct barcode entry
The SIRE film results screen is shown below. Note that:
•
•
•
•
•
only one reader is required; this could be a film reader or an appropriately experienced
radiographer who decides that the film is inadequate
a tech recall outcome should be entered onto each side irrespective of whether one or both sides
are affected
the save & unload button should be pressed in order that the woman can be recalled for her TR
appointment
the films can then be taken off the viewer
the repeat reason should be entered on the first SIBX film results screen so that it is recorded
against the correct mammographer’s name.
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Collecting, Monitoring and Reporting Repeat Examinations
2.5
Inputting technical recalls by direct barcode entry
The SIRE film results screen is shown below. Note that:
•
•
•
•
•
only one Reader is required; this could be a film reader or an appropriately experienced radiographer who
decides that the film is inadequate
a Tech Recall outcome should be entered onto each side irrespective of whether one or both sides are
affected
the Save & Unload button should be pressed in order that the woman can be recalled for her TR
appointment
the films can then be taken off the viewer
the repeat reason should be entered on the first SIBX Film Results screen so that it is recorded against
the correct mammographer’s name.
A new screen film record is created automatically to enter the details of the technical recall visit.
A new Screen Film Record is created automatically to enter the details of the technical recall visit.
2.3
Technical recall and assessment
Women requiring technical recall for one side and assessment recall for the other side should be
recalled for assessment in the normal way. The letter sent to the woman should be the recall to
assessment letter (FVRC).
A screening film record should be created and completed for the TR side in the normal way. It is
important that the screening film records are completed with an outcome of recall to assessment (FV
or RC) before the assessment film record is completed.
It should be noted that, when women are recalled for a repeat examination and for assessment, the two
processes should be recorded separately. Local protocols must be drawn up to allow separate
NHSBSPand
November
2006
recording
monitoring
to take place. Mammographic
images repeated during assessment
procedures (eg repeated stereo images) should not be counted in the calculation of repeat examination
rates, but should be monitored separately.
Collecting, Monitoring and Reporting Repeat Examinations
2.6
Technical recall and assessment
Women requiring technical recall for one side and assessment recall for the other side should be recalled
for assessment in the normal way. The letter sent to the woman should be the recall to assessment letter
(FVRC).
A Screening Film Record should be created and completed for the TR side in the normal way. It is important
that the screening film records are completed with an outcome of recall to assessment (FV or RC) before the
assessment film record is completed.
It should be noted that, when women are recalled for a repeat examination and for assessment, the two processes
should be recorded separately. Local protocols must be drawn up to allow separate recording and monitoring to
take place. Mammographic images repeated during assessment procedures (eg repeated stereo images) should
not be counted in the calculation of repeat examination rates, but should be monitored separately.
If images are repeated as part of the assessment process, these should be recorded on NBSS, but are not part
of the standard. The national minimum standard and target apply only to repeat examinations undertaken on
screening mammography. Each breast screening unit should have in place clear protocols for collecting and
monitoring the repeat images carried out in the assessment clinics.
2.7
Women who fail to attend for technical recall appointments
Each breast screening unit should have a protocol in place for when women fail to attend for their TR appointment. This should include documentation for recording the outcome. The protocol usually involves the unit
director writing to the woman and to the woman’s GP to explain the importance of attending for a technically
adequate screening examination.
A woman may decide not to attend her appointment for repeat imaging despite having all the relevant information. This needs to be recorded on the client record as Opted Out (OT) as she has not had a full diagnostic
screen. These women will be identified on the annual Department of Health KC62 returns as lost to follow
up.
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Collecting, Monitoring and Reporting Repeat Examinations
3. COLLECTING, MONITORING AND REPORTING
3.1
Local protocols
Each breast screening unit should have work instructions and protocols to cover the process for collecting,
recording, monitoring and reporting TRs at local and regional level. It is important that radiographers and
administration and clerical staff are fully informed about the need for, and the process of, collecting these data.
It is the responsibility of the radiography manager and the office manager in conjunction with the regional QA
reference centre to ensure that suitable and appropriate training is given to all staff.
3.2
Information to be collected locally
The local radiography manager should collect the following information (which should be based on the number
of women rather than on the number of films):
•
•
•
the number and percentage of TRs, number and percentage of TCs and number and percentage of TPs for
each mammographer in the screening unit
the number and percentage of TRs, number and percentage of TCs and number and percentage of TPs by
reason code
the number and percentage of TRs, number and percentage of TCs and number and percentage of TPs by
mammographer and by reason.
The data should be monitored locally by the radiography manager in conjunction with the unit QA radiographer
and all the mammographers. Audit should be carried out on a regular basis (quarterly as a minimum), and
the outcome of the audit should be available for discussion and feedback to the mammographers. The data
may indicate equipment problems, mammographer underperformance or trends indicating a training need. If
a problem is identified, investigations should be initiated and may cover such areas as accuracy of data. Once
data accuracy has been confirmed, a clear action plan with timescales should be agreed.
3.3
Regional reporting and monitoring
The breast screening unit should report the following information quarterly to the regional QA reference centre
for the breast screening unit:
•
•
the number and percentage of TRs, number and percentage of TCs and number and percentage of TPs
the number and percentage of TRs, number and percentage of TCs and number and percentage of TPs by
reason code.
The radiography manager and the mammographers together with the regional QA radiographer should discuss
the data at regular intervals. The data should be available for discussion at the formal and interim QA visits
by the regional QA radiographer.
The quality assurance reference centre (QARC) should summarise this information and report the following
annually:
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Collecting, Monitoring and Reporting Repeat Examinations
•
•
•
a summary of regional performance
individual programme performance compared with regional averages and national standards
exceptions – where programmes have not met the national standard, an explanation of the reasons and
plans to address the issues.
The regional report should be submitted to the national office one month after the end of each financial
year.
3.4
National reporting and monitoring
The regional QA radiographer should report the following regional data at the twice yearly meeting of the
national coordinating group for radiographic quality assurance:
•
•
•
number and percentage of repeat examinations (TRs)
number and percentage of technical recalls (TCs)
number and percentage of technical repeats (TPs).
The national office will collate this information and provide an annual summary of the regional data. This will
be available on the NBSS website and through QARCs.
3.5
Equipment faults
Every breast screening service must ensure that any equipment failure is reported via the national equipment
fault reporting system and the relevant people/organisations informed.
The Equipment field (arrow) on NBSS is available for recording the equipment used and will enable specific
equipment within a unit to be monitored. These fields are user definable.
REFERENCES
NHSBSP November 200611
1.Quality Assurance Guidelines for Mammographers including Radiographic Quality Control. NHS Breast Screening
Programme, 2006 (NHSBSP Publication No 63).
2.Guidance Notes for the Implementation of the Ionising Radiation (Medical Exposure) Regulations 2000 in the NHSBSP.
Collecting, Monitoring and Reporting Repeat Examinations
3.6
Crystal reports
A standard Crystal report for monitoring technical recalls and technical repeats against the national standard is
available on the NBSS website at http//www.nbss.nhs.uk, under the Crystal reports section. The NBSS website
is password protected and for NHS staff only. The reference for the relevant Crystal report is SR0011. Other
Crystal reports with different data items are available for local use.
REFERENCES
1. Guidance Notes for the Implementation of the Ionising Radiation (Medical Exposure) Regulations 2000 in the NHSBSP. NHS
Breast Screening Programme, 2000 (Occasional report, unnumbered).
2. Quality Assurance Guidelines for Mammographers including Radiographic Quality Control. NHS Breast Screening
Programme, 2006 (NHSBSP Publication No 63).
3. Consolidated Guidance on Standards for the NHS Breast Screening Programme. NHS Breast Screening Programme, 2005
(NHSBSP Publication No 60, Version 2).
NHSBSP November 200612