Guidance

NHSP Local Services Management Tasks appendix

Updated 29 May 2024

Applies to England

Newborn Hearing Screening Programme (NHSP)local services management tasks

This document is intended to supplement the NHSP operational guidance and provides more detailed guidance for local NHSP service providers. It lists the management tasks that services are responsible for undertaking on a daily, weekly, monthly, quarterly, or annual basis and or as required. Including how they need to work with internal and external stakeholders.

Details of how to undertake the tasks can be found within the NHSP national IT system’s Generic, Audiology and Advanced user guides and the Reports user guidance documents, held on the Resources tile of the NHSP national IT system and in the Bitesize videos on the NHSP national IT TRAINING system.

Adherence will ensure the delivery of a high quality, reliable, supportive, and effective service. Local NHSP services should identify the individual(s) responsible for making sure the tasks are carried out appropriately and in a timely way.

It is essential local managers engage with governance screening boards, local Children’s Hearing Services Working Group (CHSWG) and regional local manager meetings whenever they are scheduled. This will ensure programme performance is reported against standards and KPI’s, and that local services are working to current guidelines and can access the support that is available to them through these groups.

Completion of the tasks in this guidance will provide commissioners, screening and immunisation teams and screening quality assurance services (SQAS), with reassurance that the service being provided to the families is using the correct protocols, procedures and equipment, in a family friendly safe way. Local NHSP services will be able to identify any gaps or risks within their service and make plans to address these, making sure any additional local guidelines are in place.

Any screening incidents must be reported locally in line with local procedures, and regionally to SQAS and screening and immunisation teams following the managing safety incidents in NHS screening programmes guidance. Contact details for SQAS can be found here

Working with internal and external stakeholders

Communicating regularly and effectively with internal and external stakeholders encourages good working relationships, accurate data and reliable failsafe mechanisms.

Work together with:

Midwifery, NICU/SCBU/PICU and children’s wards to review and validate local guidelines for:

• antenatal provision of information on screening

• NHSP updates and awareness

• NHSP information for staff training

• NHSP information for medical teams, paediatricians and neonatologist induction on rotations

To raise awareness and prepare the family to expect to be offered a hearing screen.

Midwifery, Audiology, NICU/SCBU/PICU, children’s wards, Neonatal infant physical exam (NIPE) leads and child health to review and validate notifications and local guidelines for:

• deceased babies

• births (hospital / home)

• baby location / change of address

• baby discharge from hospital

• declined / incomplete screen

• babies moved into area

This should:

• avoid the risk or incidence of offering a deceased baby’s family a hearing screening appointment

• avoid a baby missing their hearing screen

• identify babies that need further screening or follow up hearing assessment

• ensure babies records on all the newborn screening national IT system shared database are managed correctly

Midwifery, Audiology, NICU/SCBU/PICU, children’s wards, medical teams, paediatricians and neonatologist to review and validate local guidelines for:

• identifying babies that are contraindicated for screening and needing immediate referral to audiology

• ascertaining and recording risk factors

• referrals for targeted follow-up

To help make sure babies whose hearing has been at risk and need further hearing assessment are managed through the pathway appropriately and within the appropriate timescales for referral attendance and diagnosis.

Communication within local NHSP team

Hold regular meetings with the screening team and NHSP team leader to review local service activity, escalate concerns and formulate improvement plans.

See roles and responsibilities and regional SQAS

Disseminate information about the local services performance

In consultation with your provider communication team, distribute information to local stakeholders, including:

• ANNB screening team

• midwives

• health visitors

• NICU/SCBU/PICU teams

• medical teams caring for babies

• paediatricians

• audiologists

• aetiologists

• early intervention teams

See roles and responsibilities, clinical governance,  audiology and aetiology

Establish and maintain good communication with your local audiology service(s).

Local managers should:

• conduct joint audits to ensure accurate data is held in the NHSP national IT system

• ensure data reflects the local services yield of babies found with:

    * a hearing loss from the screen

    * a later identified permanent childhood hearing impairment (PCHI)

• attend relevant meetings

• share and present performance data

See roles and responsibilities, clinical governance,  audiology. There is additional guidance and training in the S4H Audiology user guide, available on the Resource tile in the NHSP national IT system.

Recording and reporting later identified PCHIs

Make sure audiology update records for later identified PCHIs on the NHSP national IT system, where the child was discharged with a clear response or incomplete screen, or initial diagnostic audiology assessment was satisfactory. As a minimum, data should be entered for all children identified by 5 years of age, but local services can record information for older children on the NHSP national IT system to be included in their total PCHI yield.

For actions see audiology, and the S4H Audiology user guide on the NHSP national IT system Resources tile.

Make sure reports of later identified hearing loss are completed and submitted if required, following the  Review of case of PCHI not identified by the newborn hearing screen guide on the NHSP national IT system Resources tile.

Establish and maintain good communication with your local aetiology service(s)

Attend meetings, present performance data, conduct joint audits to ensure accurate data is held in the NHSP national IT system, to ensure the cause of a PCHI is investigated and the minimum dataset of nine data items are recorded.

See roles and responsibilities , clinical governance and aetiology.

Daily

Reconcile cohort data and birth data population into the NHSP national IT system

Make sure that details for every birth that is registered by the birthing site maternity unit(s) has reached the NHSP national IT system, with accurate data and in a timely way.

Investigate with maternity unit any delays or errors in birth notifications and report missing records to the NHSP national IT system helpdesk

Follow up with incident reports when required.

See patient journey from screen to referral, NHSP national IT system and non-availability of national IT system and birth notification

Locate and share records where you have become the temporary hearing screening provider or are providing audiological assessment

Make sure records on the NHSP national IT system are shared with the appropriate screening or audiology locations, especially for babies in NICU/PICU or children’s wards. Always remembering to communicate with the other NHSP local services when you have joint responsibility for a babies ongoing care.

Guidance on this can be found in Transfer and Share in the S4H Advanced user guide on the Resources tile within the NHSP national IT system.

Monitor transfer and share in/out lists

Review lists and process all records. Move records to the correct location within the local NHSP national IT system site for ongoing record/patient management.

Check why a record is shared in or out and whether the share can be stopped or needs to continue. Always communicate with the NHSP screening or audiology service the record is being shared with.

Stop shares when they are no longer appropriate.

Guidance can be found in Transfer and Share in the S4H Advanced user guide on the Resources tile within the NHSP national IT system.

Check babies are moving through the screening pathway

Review records in the NHSP national IT system ‘my searches’ search results to identify:

• inpatient well babies with incomplete screen

• inpatient NICU babies with incomplete screen

• well babies who are waiting for outpatient appointments

• NICU babies who are waiting for outpatient appointments

• completed screens with no screening outcome set

Process all records.

Investigate why screening administrators or screeners have not set outcomes.

Arrange outpatient appointments if baby is no longer an inpatient.

Reconcile NHSP national IT system NICU protocol list with hospital NICU in-patient list.

See how to add ‘saved searches’ to ‘my searches’ in the S4H Generic user guide on the Resources tile within the NHSP national IT system.

Monitor outstanding imported test results

Review the NHSP national IT system imported files to make sure all results are correct, and none are unresolved or unmatched.

Guidance on reconciling results, setting and deferring outcomes can be found in the S4H Generic user guide on the Resources tile within the NHSP national IT system.

Review user case notes

Review NHSP national IT system case notes created by users for accuracy and make sure all relevant actions have been completed and recorded appropriately.

Weekly

QA equipment checks

Make sure equipment is safe to use and that staff are performing and recording QA checks. 

Checking QA checks are completed correctly avoids recalling babies for a repeat screen where faulty equipment has been used or inaccurate results have been recorded.

Guidance is available in the Monitoring QA test results section of the S4H Advanced user guide on the Resources tile in the NHSP national IT system. 

Local managers must know and educate screeners what actions should be taken if an unexpected clear response is recorded during a Cavity QA 1 check.

Guidance is provided by equipment suppliers in user manuals and technical guides to enable NHSP local services and their managers to:

• operate the devices

• undertake manufacturer and QA checks

• troubleshoot when unexpected results are recorded 

See equipment.

Identify movers in

Develop local mechanisms to receive information from Child Health departments for any babies who move into the area from outside England.

Work with midwifery, health visitors, NICU / PICU / SCBU and Child Health to identify babies moved into your area who require:

• screening at less than 3 months (12 weeks) of age

• audiological assessment immediately

• targeted follow-up at 7-9 months

See patient journey from screen to referral, and ongoing surveillance guidelines.

Check for duplicate records

Identify and update records with no NHS number, merge duplicate records on the NHSP national IT system and check for merge conflicts on their patient summary. It is important to liaise with the neonatal infant physical examination (NIPE) team as the records are shared by both national IT systems.

Guidance can be found in the S4H Advanced user guide on the Resources tile in the NHSP national IT system. 

Advanced searches of the NHSP national IT system can be used to quality assure local services and their data

A list of available advanced searches can be found in the S4H Advanced user guide on the Resources tile in the NHSP national IT system. 

DECEASED BABIES

Work with Midwifery, NICU / PICU / SCBU and Child Health to routinely obtain and share details of any deceased baby to make sure the NHSP national IT system is up to date to avoid offering a screen or audiology assessment to the family of a deceased baby.

Inform other screening services locally such as NIPE and newborn bloodspot (NBS) who share data with NHSP on their national IT systems.

Share information with audiology services, and make sure hospital patient management systems are up to date.

Run status override searches

Identify records where the screening outcome differs from the NHSP national IT systems suggested screening outcome.

Approve these overrides or challenge the decision with the screening team. Overriding a suggested system outcome could indicate an incident has occurred that needs to be investigating.

Search for all records without a screening outcome set

To make sure all babies can be screened within the expected timeframe, local services should look for patterns or challenges in meeting programme standards and key performance indicators (KPI’s)

This could also identify inequalities that need to be addressed. A health equity audit guide for screening providers and commissioners.

Guidance on exporting data from the NHSP national IT system, importing and pivoting data into Excel, can be found in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the Resources tile of the NHSP national IT system.

Search for records with a dummy or no GP

Add missing GP details to records as soon as possible so records are mapped to the correct local services.

Guidance on adding a dummy GP practice when needed, can be found in the S4H Advanced user guide held on the Resources tile of the NHSP national IT system.

Use audiology predefined searches

To:

• monitor the service with the audiology team

• search for all records awaiting audiological assessment

• share information with audiology to appoint for follow up

• check all screen referrals and contra-indicated outcomes have audiological appointments within target time

• check offered audiology appointments are attended within target time

A list of S4H predefined Audiology searches can be found in the S4H Audiology users guide on the Resources tile. Videos on exporting data from the NHSP national IT system, importing and pivoting data into Excel, can be found in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the LIVE systems Resources tile.

Monthly

Sharing screening results with Child Health

Good relationships with Child Health will aid accuracy of screening result data and help identify any baby who has missed a screen.

Make sure screening results are shared with local child health information systems (CHIS). This can be by various methods including sharing:

• via IT interfaces

• data exported from the NHSP national IT system

• via National Events Management Service (NEMS)

• PCHR duplicate pages

CHIS staff can also be given direct READ ONLY access to the NHSP national IT system.

Guidance on providing CHIS access to and exporting data from the NHSP national IT system can be found on the Resources tile within the NHSP national IT system. Access can only be granted by the NHSP local manager or team lead by using the S4H User authorisation form in the Tools and Forms section of the Resources tile.

For actions, see NHSP national IT system

Reports

Including:

• highlights

• activity

• outcomes

• screening and audiology data quality

Available from the Reports tile on the NHSP national IT system. Local services are responsible for saving and reviewing their reports and taking appropriate action where necessary. They should be stored locally for audit and QA evidence, including reports with no entries.

Local managers have responsibility for the screening and audiology data in the national IT system.  It is important they work with Audiology to ensure they are actioning data quality reports and provide feedback regularly.

For actions, see Data and Reports , and S4H Audiology user and Reports guidance on the NHSP national IT system Resources tile. There is also useful guidance on using the reports to quality assure a service in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the Resources tile.

Audit screening test results

Using Highlight report 14, you can audit screener activity to identify any records where NCR has been recorded after a CR on AOAE or AABR screening test protocol and the system has suggested a Clear response outcome which the user has accepted.

For actions, see Data and Reports , and S4H Reports guidance on the NHSP national IT system Resources tile. There is also more useful guidance on using the reports to quality assure a service in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the Resources tile.

Audit records with an incomplete screening outcome

Check that any incomplete outcome has been used appropriately by auditing the reasons given.

For actions, see the Screening outcomes and Patient status - additional guidance tables in the Generic user guide on the NHSP national IT system Resources tile.

Risk factors and screen outcome check

Check that all records with:

• appropriate risk factors have targeted follow-up outcome set, unless they are immediate referrals

• targeted follow up outcome set have risk factors that require follow up

Check all NICU babies with AOAE bilateral ‘no clear response’ and AABR bilateral clear response have targeted follow-up outcome set.

See guidance on risk factors and ongoing surveillance

Using audiology predefined searches

Audit quality and completeness of assessment data on the NHSP national IT system by working with Audiology teams to ensure attendance and assessment data is recorded for babies:

• with immediate referrals

• with risk factors that require targeted follow up

• identified with permanent childhood hearing impairment (PCHI) annually until the child is 5 years of age

Guidance on how to use the predefined searches, how to enter data, when to deactivate records and a recorded training session for Audiologists can be found in the S4H Audiology guide on the NHSP national IT systems Resources tile.

Quarterly

Reports

Including:

• performance

• activity

Available from the Reports tile on the NHSP national IT system. Local services are responsible for saving and reviewing their reports and taking appropriate action where necessary. They should be stored locally for audit and QA evidence, including reports with no entries.

For actions, see Data and Reports, S4H Audiology user and Reports guidance on the NHSP national IT system Resources tile. Local services should use the NHSP Performance and KPI reporting template, available on the NHSP national IT system Resources tile. There is guidance on how to complete the template and using the reports to quality assure a service in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the Resources tile of the NHSP national IT system.

Monitor supplies of equipment consumables

Complete stock checks to make sure:

• sufficient supplies to sustain screening

• stock has good use by dates

• stock supply issues are reported

Insufficient supplies could result in an incident of delayed or missed screening.

Annually

Reports

Including:

• performance

• activity

Available from the Reports tile on the NHSP national IT system. Local services are responsible for saving and reviewing their reports and taking appropriate action where necessary. They should be stored locally for audit and QA evidence, including reports with no entries.

For actions, see Data and Reports S4H Audiology user and Reports guidance on the NHSP national IT system Resources tile. There is also useful guidance on using the reports to quality assure a service in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the S4H Resources tile.

Existing local manager and screener competency

Organise update training and mentorship for local manager and existing screeners to include:

• using the NHSP national IT system reports to monitor screening activity on a monthly basis

• repeating eLearning modules

• completing screener competency assessments

A review, at least annually, will ensure NHSP screening pathway knowledge, screening skill expertise and competency to screen are of a high quality in your local service.

See education and training, Data and Reports  and guidance on S4H Reports can be found on the Resources tile of the NHSP national IT system.

There is also useful guidance on using the reports to quality assure a service in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the S4H Resources tile.

ANNB screening report

Submit a written report about your local NHSP service to promote, support and evidence NHSP performance.

This can be included in your provider organisations annual ANNB screening report or use the NHSP Performance and KPI reporting template, available on the NHSP national IT system Resources tile to create an annual version. There is guidance on how to complete the template in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the Resources tile.

See clinical governance.

Parental satisfaction

Complete a parental satisfaction survey to make sure the service meets the needs of families and to help identify inequalities. You could also complete a health equity audit using the audit guide for screening providers and commissioners.

See clinical governance and either use your provider organisation parental satisfaction survey, or an approved survey from a regional peer.

Archive data and paperwork as required

Make sure NHSP reports, results data or other paperwork such as proformas or letters are stored appropriately in line with provider organisation records management requirements.

Ensure you have the appropriate intermediate software to be able to download screening results from the NHSP national IT system should you be required to review the data. See S4H Advanced user guide, held on the Resources tile of the NHSP national IT system and equipment.

As required local manager tasks

New screener training and competency

Organise training and mentorship for new screeners to ensure NHSP screening pathway knowledge, screening skill expertise and competency to screen independently.

All screeners should have a NHSP national IT system user account created as soon as they start.

Make sure all screeners who are required to do so have registered for and complete the Health Screener Diploma (HSD) as the recommended training for new screeners or those returning to practice after a break of 3 years. This includes fixed term contracts, such as maternity cover.

See education and training and guidance on user access to the NHSP National IT system can be found in the S4H Advanced user guide held on the Resources tile of the NHSP national IT system.

Maintain appropriate user access to the NHSP national IT system

Keeping appropriate access to local service and patient data via the NHSP national IT system is imperative to maintain patient confidentiality, avoid a breach of information governance and potential data protection risks.

When a user leaves their NHSP role and are therefore no longer authorised to access the NHSP national IT system, you must submit a request to the NHSP national IT system helpdesk to deactivate and remove their access.

See guidance on user access to the NHSP National IT system in the S4H Advanced user guide held on the Resources tile of the NHSP national IT system. 

Mentoring new local managers

It is important that new local managers receive support and mentorship from experienced peers and neighbours.

The mentorship guidance appendix provides information for experienced local managers in a mentorship role.

Meet accessibility needs when providing screening information

Make sure information is available in:

• digital leaflets and checklists, in available language translations

• paper copies (for those with limited or no access to digital information)

• letters with QR codes linking to national digital information

• videos and alternative versions of the information that meet accessibility needs

See Newborn screening: information and the auto translate functionality in the information videos where needed.

Equipment

Arrange:

• repairs

• software and firmware installation and updates

• calibration of leads and equipment according to supplier recommendations

• local safety testing

Follow local procurement and provider organisation procedures. Report equipment incidents and inform the Newborn hearing screening programme so they understand what is happening nationally, can discuss with equipment suppliers and share any relevant learning.

Timely arrangement of safety testing and calibration visits in advance of their due date, mitigates risks of screening with faulty or inaccurately calibrated equipment and makes sure equipment is safe to use.

Refer to local clinical engineering guidance and equipment supplier manuals and recommendations and see the equipment

Screening websites and blogs

Check the GOV.UK website for any NHSP updates and encourage all NHSP staff to do the same for updates on all antenatal and newborn screening programmes. Subscribe to receive Screening blogs, produced by the UK national screening committee (UKNSC) and sign up to NHS Futures screening updates

See the [NHS screening programmes] (https://www.gov.uk/government/organisations/uk-national-screening-committee) for more information on all screening programmes)

Review local guidance

Including:

• policies

• protocols

• standard operating procedures

• business continuity plan

• failsafe mechanisms

• governance arrangements

To make sure:

• all are up-to-date

• there are up to date versions of parental information and NHSP agreed letters are in use

• normal working practices have not changed

• failsafe mechanisms are still in place

See checks and audits

Prepare for ANNB cross programme screening quality assurance (QA)

Gather supporting evidence for your QA such as :

• records of local manager and screener:

  * training

  * eLearning updates

  * competency assessments

  * activity and performance reviews

  * job descriptions

  * staffing whole time equivalents

• attendance or representation at:

  * provider organisation screening boards

  * children’s hearing working groups

  * local manager regional meetings

• standards and KPI data, quality and performance adherence from quarterly NHSP standards and KPI reporting templates

• audiology data:

  * quality from reports

  * PCHI yield

  * later identified cases of PCHI

• equipment calibrations, QA check audits

• incident reports

• risk register logs for any NHSP items

Review your local NHSP service against QA report recommendations

Make sure actions have been completed and continued improvements are achieved.

SQAS are able to support local NHSP services through any QA process. But also, any service challenges a local manager needs to manage, such as working outside business as usual (BAU) or using continuity plans.

Ad hoc audits

Complete relevant provider organisation audits to evidence family friendliness and good working practices for the local NHSP service.

Example audits could include:

• screener training needs analysis

• infection control

• health inequality

• non-attendance at clinics, declines

• reasons for the use of the Incomplete

  * screening outcomes

  * audiology follow up status

• lost to follow up after audiology assessment

Refer to provider organisation checks and audit policies. Guidance can be found on the NHSP national IT system Resources tile and in the Bitesize videos on the NHSP national IT TRAINING system. A guide for accessing the training system is available on the Resources tile.

Resources

SMaRT4 Hearing (S4H) is the national IT system for the Newborn Hearing Screening Programme (NHSP).

Information and guidance documents are provided on the ‘Resource’ tile to help all users of S4H to manage and become familiar with the system.

Acronym list:

• BAU: business as usual

• NHSP: Newborn Hearing Screening Programme

• SQAS: Screening Quality Assurance Service

• NICU: Neonatal Intensive Care Unit

• PICU: Paediatric Intensive Care Unit

• QA: Quality Assurance

• NIPE: Newborn Infant Physical Examination

• NBS: Newborn Blood spot

• PCHR: Personal Child Health Record (red book)

• AOAE: Automated Otoacoustic Emissions

• AABR: Automated Auditory Brainstem Response