NHS Newborn Hearing Screening Programme
NHSP Quality Assurance Programme:
What are the outcomes?
Christine Cameron MSc CS
Head of NHSP QA Programme
BAPA Conference January 2013
Hosted by the Royal Free Hampstead NHS Trust
hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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?
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Quality Assurance is an external audit of local
performance against the quality standard
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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?
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
QA programme: an iterative process
•
First cycle Nov2006 - March2008
–
–
•
Second cycle April2008 – Oct2009
–
–
•
Electronic self assessment questionnaires QAF
Peer review visits incl case studies and ABR
Third cycle June2010 – Sept2011
–
–
–
•
Word documents for self assessment
Peer review visits
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Screening: Quality Standard 7 : 95% screens completed in 4 weeks
percentage
Screen complete in 4 weeks: across the QA cycles
100
90
80
70
60
50
QA1
QA2
QA3
South
West
South
Central
South
East
Coast
London
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East of
England
West
Midlands
East
Yorkshire
Midlands & Humber
9
North
West
North
East
hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Screening Quality Standard 15: all screen referral to audiological assessment
offered within 4 weeks
Screen referral to assessment within 4 weeks: across the QA cycles
percentage
100
80
QA1
60
QA2
40
QA3
20
0
South
West
South
Central
South
East
Coast
London
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East of
England
West
East
Yorkshire
Midlands Midlands & Humber
10
North
West
North
East
hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Case study
Screening activity over the QA cycles
percentage
100
completed by 4 w eeks
80
screen decline
60
40
screen complete by 3
months
20
0
QA1
Revisit
QA2
QA3
audiol assess w ithin 4
w eeks
screen incomplete
QA cycle
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
impact on Audiology services
Recommendation
QA1
QA3
to perform frequency specific tone
pips and bone conduction ABR
31* audiology
services
none
to measure RECD before fitting
hearing aids
28* audiology
services
2 audiology
services
to introduce insert and bone
conduction VRA
27* audiology
services
none
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Impact on Audiology: behavioural testing
testing in targeted follow up clinics
160
140
120
100
80
60
40
20
0
QA2
QA3
QA4
bone VRA
distraction
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soundfield VRA
15
insert VRA
hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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)
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Impact on Audiology services
Results given on
same day
QA2
QA3
QA4
112
135
135
79
119
132
42
50
43
Course attended
Education present
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Impact on Audiology: ABR Review
• 13 incidents
• Additional 20 audiology
departments requiring regular
external review & training
• External expert reviewers
• PC expert reviewer
• Setting up of regional peer
reviews
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Impact on Audiology: ABR Review
ABR Review QA3 and QA4
percentage
60
50
40
QA3
30
QA4
20
10
0
1
2
3
4
5
category
• QA3 42% category 1 or 2
• QA4 48% category 1or 2
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Impact on Medical services
• 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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Is there a benefit for the families?
• ‘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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
Stakeholder representation in CHSWG
QA2
QA3
Audiology
29
120
Medical
17
109
Education
29
119
Parents
28
109
Social care
20
90
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
o Wax removal was improved and a fast track care pathway was implemented
o Appointment slots altered to give greater parental choice of time and date
o Improved parking and waiting room facilities
o Ensure that all staff introduce themselves and
their role when first seeing a patient
o Establishing hearing aid maintenance sessions
at satellite clinics
o Ear moulds sent directly to families
from manufacturers
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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 with professionals to improve practice with offering training
courses, networking, peer review groups (ABR)
• Parent surveys
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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
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hearing.screening.nhs.uk
NHS Newborn Hearing Screening Programme
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