Guidance

National external quality assessment (EQA) scheme for Bowel Cancer Screening Histopathology

Published 6 October 2025

Applies to England

Bowel Cancer Screening Histopathology EQA Scheme

The NHS Bowel Cancer Screening Programme (BCSP) is committed to maintaining its internationally recognised track record in innovation, service quality, use and development of evidence and data, education and public information.

Achieving high quality outputs across all cancer screening activities underpins every aspect of the programme. A clear professional accountability and governance structure supports this philosophy.

One way the programme achieves this is through the external quality assessment (EQA) scheme for Bowel Cancer Screening Histopathology.

The requirements of ISO/IEC 17043 influence the scheme’s approach to quality management.

This document provides guidance on the:

• design of the scheme
• interpretation of results
• general requirements and responsibilities for laboratories and participants
• principles and methodology of operation for a consistent delivery across the nation

It applies to NHS bowel cancer screening laboratories in England, Wales, Scotland,

Northern Ireland and laboratories outside the UK which have signed up to the EQA agreement.

This document is approved by the Bowel Cancer Screening Programme (BCSP) Histopathology External Quality Assessment (EQA) Steering Group.

1. The EQA scheme

The scheme centres on the assessment of slide sets by all staff who report bowel cancer screening histopathology on behalf of the NHS BCSP. It compares individual reporting to consensus reporting to determine if a participant’s performance falls within an acceptable range.

There are 2 rounds (2 circulations of slide sets) in each EQA year. An EQA year runs from 1 April to 31 March.

There are 10 slides in each slide set per round used for performance analysis. The set may include up to 2 additional ‘special interest’ slides. These are for educational interest and are not included in the calculation of final assessment results.

1.1 Quality Assurance in Pathology Committee

The Quality Assurance in Pathology Committee (QAPC) is a multidisciplinary group accountable to the Royal College of Pathologists (RCPath) for:

• the oversight of performance in EQA schemes
• monitoring of the EQA performance of reporting histopathologists in the United Kingdom (UK)

The QAPC achieves this via discipline-specific panels which report to them. In turn, the QAPC will work with failing histopathologists and is also bound to report persistent substandard performance to the Care Quality Commission (CQC).

Cellular pathology national quality assurance advisory panel (NQAAP)

The cellular pathology NQAAP oversees the running of EQA schemes in histopathology and cytopathology. The panel oversees the annual activities of each scheme registered with RCPath, including the investigation of persistent substandard performance by individual pathologists or laboratories.

The panel promotes a uniform standard of EQA across the country. This is important to ensure the work of cellular pathology laboratories and their contribution to clinical services is of a uniformly high standard.

1.2 Aims of the scheme

The scheme aims to provide an acceptable degree of reliability and consistency by educating, advising and supporting all participants.

The scheme is committed to:

• upholding professional standards, good professional practice and conduct
• providing direction, leadership and guidance for the overall operation and management of the scheme
• complying with all data security legislation including the General Data Protection Regulations (GDPR) and Caldicott principles
• complying with all relevant health and safety legislation to warrant the safety and welfare of all staff on site and visitors
• providing equal access, within the limits of reasonable adjustment, to all eligible participants, taking into consideration their needs and requirements to promote continual improvement of the scheme
• meeting the needs of all stakeholders by delivering an acceptable degree of reliability and consistency between laboratories through education, advice and support for all participants
• enabling inter-laboratory monitoring and review of ongoing participation and performance
• providing a service to the highest levels of quality, safety and efficiency
• making sure the scheme is run by high calibre staff who are competent in their EQA roles on the basis of appropriate education, experience, skills and expertise
• treating participants fairly, sensitively, without prejudice and maintain confidentiality within the limits of the scheme
• providing an established and maintained framework for the QMS to integrate the organisation, procedures, processes and resources needed to meet (and exceed) the needs of participants
• setting measurable quality objectives which are taken into account as part of the reviews undertaken by the scheme’s EQA steering group

1.3 Enquiries

For any enquiries about the bowel cancer screening EQA scheme, please contact:

National EQA Team

Screening Quality Assurance Service23 Stephenson Street

Birmingham B2 4BH

Email: england.eqa@nhs.net

Support is available during normal office hours (9am to 5pm).

2. Scheme management: roles

2.1 EQA facilitator

A dedicated EQA facilitator and administrative team are responsible for the day-to- day running of the scheme.

The EQA facilitator is also responsible for:

• development and maintenance of local administrative and quality systems in line with published protocols and quality procedures
• undertaking the role of scheme quality manager
• overseeing arrangements for providing participants with appropriate notice of EQA requirements
• identifying and highlighting actual or potential issues in relation to the scheme’s operation and bringing these to the attention of the appropriate manager
• maintaining all aspects of confidentiality and for the safe storage, recording and tracking of samples submitted for use in EQA
• working closely with the local support team to identify areas for development in relation to the EQA Online reporting system
• preparing the audit strategy and internal audit programme and making sure findings are recorded and completed appropriately
• preparing for external audits and maintenance of routine activities in line with United Kingdom Accreditation Service (UKAS) requirements
• producing accurate reports as requested, for steering group and operational review meetings
• taking action in the event of substandard performance as documented in this protocol, and act as the scheme secretary as required

2.2 Scheme organiser and deputy scheme organiser

NHS England’s Screening QA Service (SQAS) subcontracts the scheme organiser role.

The scheme organiser must:

• be a consultant histopathologist with an interest in bowel cancer screening histopathology
• be professionally regulated through their registration body
• be a participant in the scheme and has experience of selecting and reviewing slides for EQA
• hold a substantive consultant post in a laboratory providing histopathology reporting for the NHS BCSP
• participate in an appropriate continuing professional development (CPD) scheme, and fulfils NHS BCSP and pre-existing professional body requirements for CPD
• act as the chair of the scheme’s EQA steering group
• collaborate with the provider in setting annual objectives for the EQA scheme and its strategic direction
• receive and consider advice from the EQA steering group on the practical aspects of scheme design and operation
• be responsible for the oversight of substandard performance and liaises with NQAAP in the event of persistent substandard performance
• oversee difficult and sensitive situations associated with participant substandard performance, complaints and appeals
• approve the scheme’s annual report(s) for service users and management
• promote the value of the EQA scheme and its activities at relevant professional meetings
• promote and provides advice on the educational elements of the scheme
• respond urgently to any situation arising during the EQA round which has the potential to adversely affect a patient’s management

A deputy is appointed from the membership of the steering group, who fulfils the same requirements as the scheme organiser and will deputise as necessary.

The deputy scheme organiser must:

• be a consultant histopathologist with an interest in bowel cancer screening histopathology and be professionally regulated through their registration body
• be a participant in the scheme and have experience of selecting and reviewing slides for EQA
• hold a substantive consultant post in a laboratory providing histopathology reporting for the NHS BCSP
• participate in an appropriate continuing medical education (CME) or CPD scheme
• fulfil NHS BCSP and pre-existing professional body requirements for CPD
• have some knowledge of quality management systems and accreditation requirements
• be an active member of the EQA steering group and contribute to setting annual objectives for the scheme and its strategic direction
• promote the value of the scheme and associated activities at relevant professional meetings, and contribute to the annual EQA participant workshop
• proactively highlight areas where improvements can be made

The deputy provides operational cover in the scheme organiser’s absence. This includes:

• chairing the EQA steering group
• taking responsibility for the oversight of substandard performance and communicating with the NQAAP chair of RCPath in the event of persistent substandard performance
• overseeing difficult and sensitive situations associated with participant substandard performance, complaints and appeals
• promoting and providing advice on the educational elements of the scheme
• responding urgently to any situation during EQA rounds which has the potential to adversely affect a person’s management
• providing advice and contributing as necessary to United Kingdom Accreditation Service (UKAS) visits to the scheme’s operations centre and the scheme’s continuing accreditation
• providing ongoing, ad hoc clinical and professional advice to the National EQA Team

2.3 National EQA lead

The Consultant in Public Health/National EQA Lead has national responsibility for EQA as part of their national portfolio role. This includes:

• day-to-day support and advice to the SQAS National EQA Team
• line management for the EQA facilitator and administrative function
• responsibility for EQA Online through the line management of the SQAS staff who develop and maintain the system
• joint authorisation, with the EQA facilitator, of individual end of round reports
• review and authorisation of all operational work instructions and associated documentation
• chairing the EQA operational group meetings

The National EQA Team is comprised of staff with defined responsibilities to support the EQA facilitator as well as responsibilities for management, IT and data

support. The Consultant in Public Health/National EQA Lead arranges appropriate cover in the absence of these staff.

3. Governance

3.1 Operational group

The operational group:

• is chaired by the Consultant in Public Health/National EQA Lead
• includes the national EQA administration team and staff responsible for the maintenance of EQA Online
• may be attended by the scheme organiser or deputy organiser
• discusses all operational activity
• meets in accordance with the requirements and frequency expressed in the group’s terms of reference
• is administered by the National EQA Team

3.2 EQA steering group

The EQA steering group:

• is chaired by the scheme organiser
• conducts the twice yearly management review
• provides a review and governance mechanism for the scheme
• is responsible for the strategic direction, planning and development of the scheme
• provides a supporting and advisory role
• meets in accordance with the requirements and frequency described in the terms of reference
• includes individuals from laboratories to make sure the requirements and interests of participants are represented
• provides technical advice and assistance on scheme design and operational issues (its role does not extend to involvement in performance issues unless these relate to the scheme’s design and performance monitoring systems)
• is administered by the National EQA Team
• can escalate any major concerns about the scheme to the NHS England (NHSE) Senior Quality Assurance Delivery (SQAD) group

3.3 National oversight

The EQA steering group is accountable to the NHSE SQAD group  which is chaired by the Deputy Director of Screening. The Deputy Director of Screening is accountable to the NHS England Director of Screening.

The EQA annual report is shared with the NHSE bowel screening pathology network. 

3.4 EQA Online

EQA Online is a secure website accessed via an N3 or Health and Social Care Network (HSCN) connection. It provides a secure facility for existing participants to enter their results for the current round and to view, download and print their individual reports.

4. Laboratory participation

An agreement to participate in the EQA scheme exists between SQAS, NHS bowel screening centres and their staff who report histopathology for the NHS BCSP.

The agreement also applies to private laboratories and those from outside the UK who participate in the scheme. The agreement describes the general terms and conditions of participation for all parties. This is subject to periodic review.

4.1 General terms and conditions of participation

Participation in the EQA scheme is mandated for all staff who independently report histopathology specimens for NHS BCSP. These pathologists are usually in substantive consultant posts but also include:

• consultant histopathologists in long term locum posts
• pathologists in non-consultant career grade posts
• stage D histopathology trainees who report gastrointestinal histopathology independently
• advanced practitioners holding the Advanced Specialist Diploma in Histopathology Reporting – gastrointestinal tract pathology

Participation is mandated for all staff whether employed on a full-time, part- time, permanent or temporary basis.

Participation in relevant accredited EQA schemes is a prerequisite for laboratories registered with UKAS and seeking accreditation to ISO 15189:2022 .

Local lead BCSP Pathologists are responsible for notifying the National EQA Team of any changes in service provision, and changes in staffing (whether permanent or temporary) including new recruits, leavers and locums.

Where possible, the National EQA Team will make reasonable adjustments to facilitate access to the scheme for all potential participants. Laboratories are responsible for notifying the National EQA Team if a member of staff has any particular needs which may require an adjustment as to how they participate in EQA.

Screening Centres must confirm their acceptance of all terms and conditions described in the EQA agreement in order that their staff can enrol on the scheme. There is no requirement for annual re-enrolment as this is managed through periodic review and renewal of the Scheme Agreement.

All data entry and result reports are managed via the BCSP EQA website.

4.2 Sanctions for non-compliance with the EQA agreement

Participants who do not conform to the protocol requirements are in breach of the EQA agreement and may be removed from the scheme. The scheme has established a clear escalation policy. Removal from the scheme presents a risk to a laboratory achieving or maintaining ISO 15189:2022 accreditation.

4.3 Eligibility requirements

Trainees

Trainees not reporting independently who are working in an NHS BCSP  screening laboratory or a screening laboratory under contract to the NHS, are eligible to participate in the scheme for educational purposes only. Scores are excluded from the performance analysis. Lead Pathologists must make sure that this staff group discusses results with the relevant training officer/supervisor.

Locum staff

Locum staff participate in the national scheme and comply fully with all conditions and arrangements if they work:

• in an NHS BCSP screening laboratory
• in a private screening laboratory under contract to the NHS

Note that production of a satisfactory report and/or evidence of participation in EQA does not guarantee eligibility for employment in an NHS BCSP screening laboratory or a BCSP screening laboratory under contract to the NHS.

Ineligible staff

Individuals are not eligible to participate in the EQA scheme if they are not currently reporting BCSP histopathology.

4.4 Enrolment

On enrolment, participants are directed to the secure EQA website for general guidance and instructions on how to set up and manage their EQA account.

Participants must use an employer issued email address to set up and operate an EQA account. Access to the online system is only permitted via the secure NHS network.

Participants will be asked to confirm they have read and understood this document prior to each round of the Scheme.

Participants who are unsure about any EQA website content or a scheme operational matter should contact the National EQA Team for guidance.

4.5 Participant responsibilities

Non-participation

Participants need to be aware of the consequences of non-participation in EQA. An individual who does not participate without a legitimate reason, is classed as a non-participant without a valid reason. This may lead to a result of substandard performance being recorded.

If an individual fails to participate in 2 out of 3 rounds without legitimate reasons, this information is passed to the:

• scheme organiser
• Consultant in Public Health/National EQA Lead who alerts the Consultant in Public Health/Senior Clinical Lead for Bowel Screening (who alerts the commissioners of the service)
• chair of NQAAP

Legitimate reasons for non-participation include:

• short or long-term authorised absence
• maternity/paternity leave
• an extended period of sabbatical leave
• pre-arranged annual leave

4.6 Confidentiality

Information disclosure liabilities, responsibilities and procedures are communicated to and followed by all EQA staff. This includes staff employed directly by and/or under contract to NHS England .

All participant data is confidential. All electronic data is stored in password protected files or in areas accessible only to authorised EQA staff. Paper based data is stored in a secure, locked cabinet and access is restricted and limited to only authorised EQA staff.

The scheme is confidential under the conditions of participation in EQA schemes determined by the professional bodies through the Quality Assurance in Pathology Committee (QAPC).

Participants may choose to waive confidentiality for the purposes of discussion and mutual assistance. They can also choose to waive confidentiality for regulatory or recognition purposes.

The identities of participants are not made available except under circumstances stated in the terms and conditions of participation. The EQA facilitator will only provide participant names and corresponding codes:

• when a participant is enrolled on the scheme
• when a participant has requested a reminder of his or her code number either in writing or e-mail or via the facility provided in their online EQA account
• when circumstances dictate that the chair of the QAPC on quality assurance is notified of a member of medical staff or a consultant biomedical scientist who has reached the second action point (see section 15.5.2). The chair of the QAPC may request that confidentiality is not broken in these circumstances

The scheme requires Screening Centre Lead Pathologists/Local Lead BCSP Pathologists to monitor and review on-going staff participation in EQA.

At present, it is considered extremely unlikely that any ‘interested parties’ or government regulatory authorities require participants’ results to be provided directly to them.

If in the unlikely event the provider organisation receives a third party request from a regulatory authority requiring EQA results, the source will be investigated and verified by the National EQA Team. The provider organisation will comply with a valid and verified request, and notify the affected participants of this action in writing within 5 working days.

4.7 Subcontracted services

Laboratories

The SQAS National EQA Team subcontracts with NHS BCSP laboratories toprovide assessment materials. The provision of these materials for digitisation and use is critical to the success and integrity of the scheme.

NHS BCSP screening laboratories or those under contract to the NHS are accredited by or registered for accreditation with United Kingdom Accreditation Service (UKAS). Laboratories that are not accredited to ISO 15189:2022 should make sure that only qualified and competent staff undertake slide selection and submission activities for the scheme.

Staff are deemed competent on the basis of:

• qualification
• experience
• satisfactory participation in the scheme
• employment by a laboratory which is contracted to provide a histopathology service to the NHS BCSP

4.8 Source of cases

All NHS BCSP screening laboratories (or screening laboratories under contract to the NHS) are required to submit slides under the terms and conditions of the EQA agreement in accordance with the slide request schedule prepared by the scheme’s administrators. An equitable number of cases will be requested from participating laboratories in accordance with the scheme’s operational needs. Requests will be restricted to a maximum of once per laboratory for each 24 month period. The provision of special interest slides is optional.

Laboratories must keep a record of the slides and supporting documents submitted for EQA purposes.

The National EQA Team returns all slides to the submitting laboratory immediately following successful digitisation and the completion of the 2 year retention period.

The National EQA Team provides feedback to submitting laboratories on the outcome of slides used in EQA rounds and laboratories are required to consider this information during their review and EQA performance monitoring processes.

4.9 Slides selected for EQA

Laboratories should provide good (not necessarily easy) examples for potential use in EQA. A minimum of 2 of each classification must be provided. Slides provided for each case should be in the form of a “recut”, with one good “level” of the material represented within the slide. Physical slides will be retained for a minimum of 2 years. Thereafter the National EQA Team will return the slides to the originating laboratory. Digital images will be accessible for a minimum of 2 years and for a maximum of 8 years.

The slides selected for EQA range across the diagnostic classifications outlined in the NHS BCSP guidance on reporting lesions document (2024). The following classifications are covered:

• adenoma with low grade dysplasia
• adenoma with high grade dysplasia
• invasive adenocarcinoma
• other

4.10 Slides agreed for submission

Slides should be selected either by the lead pathologist or by a pathologist selected by the lead pathologist. These individuals are responsible for assessing the diagnostic suitability and technical quality of slides for potential use in EQA.

Submitted slides should have achieved an in-house consensus opinion with the submitted diagnosis agreed by the screening centre lead pathologist (or nominated deputy) and a second BCSP accredited pathologist. Slides submitted should be accompanied by a fully completed EQA slide submission form.

No patient identifiable information should be included with or on the recut slides prior to submission. The laboratory should make sure that the slides are sufficiently labelled to allow the EQA facilitator to match slides to the relevant accompanying information.

4.11 Professional code of conduct

The scheme relies on each participant’s professional honesty to make sure that discussion of cases does not occur until after all staff (excluding absentees) have completed the EQA and submitted their responses.

Any evaluation of personal performance is meaningless if prior case discussions take place. It reduces the value of the EQA scheme, and gives rise to the risk of false responses which could adversely affect individual performance.

The scheme expects underperforming staff to avail themselves of the support offered to them.

These measures are in the interests of all participants, with the aim of avoiding adverse effects on individual performance.

If it becomes necessary to bring a suspected case of malpractice to the attention of the scheme organiser, the procedure for doing so is set out in section 12.

4.12 EQA financial levy

The BCSP histopathology EQA scheme may be subject to a levy that is defined in an addendum to the Scheme: Laboratory agreement.

Appropriate notice will be given to laboratories in relation to changes in this levy.

5. Preparation for the EQA round

5.1 Management of submitted materials

Cases submitted for inclusion in the scheme will be stored in NHSE SQAS offices in a manner consistent with the requirements of ISO17043:2023.

Each case received by the National EQA Team through the routine case submission process will be logged before dispatch to the supplier approved by the steering group to provide digitising and image hosting services.

The approved supplier will confirm receipt of cases selected for digitisation and following the digitisation process, will return all cases to the National EQA Team. Upon receipt the log will be updated to reflect the return of the cases to NHSE SQAS premises.

The National EQA Team will retain the slides in accordance with the schedule stated in section 4.7.

5.2 Case digitising criteria

Slides submitted for use in the BCSP EQA Scheme will be scanned to produce a bank of digital images at a single plane of focus. Cases will be drawn from this bank to compile digital slide sets; the screening of a slide set forms the basis of BCSP EQA assessments.

The guidance below provides detailed criteria for laboratories to ensure that their slide preparations are suitable for scanning:

• standard 25 x 50mm slides should be used
• tissue should be undamaged and of uniform thickness between 3 and 5 microns
• keep a minimum 5mm gap between the tissue and the label area
• tissue should be flat and without folds.
• to minimise scan time, strips of tissue should be orientated either across or along the slides, not diagonally.
• 15% of the slide area should bear no tissue (this is required as a reference for correct tissue detection)
• small coverslips should be avoided. Rectangular coverslips should be fitted squarely on the slide, without overhang, and without protruding mountant.
• slides must be submitted to the scheme clean and dry, without fingerprints, annotations or other marks.

5.3 Assembly of slide sets

The EQA facilitator is responsible for making sure the required combination of slides is selected for digitisation.

5.4 Composition of slide sets

Each slide set contains 10 EQA slide images (plus up to 2 special interest slides) that have been digitised in accordance with criteria specified in section 5.2. The special interest slides are clearly labelled as such, and do not form part of the assessment. The EQA facilitator determines the final composition of the slide sets using the following criteria:

• a minimum of 2 examples of each classification must be included in each year (covering 2 assessments)
• special interest slides will be reviewed by a minimum of 2 members of the steering group prior to inclusion in any round

5.5   Supporting information

Participants receive supporting information and instructions for use prior to the start of an EQA round. The EQA facilitator instructs participants on where and how to access the relevant information online.

Supporting information includes:

1. participant instructions for recording and submitting responses
2. relevant information for special interest slides

5.6 Response form

Responses are to be entered via an electronic form within the EQA Online platform. User accounts for the website will be set up as part of the participant enrolment process. This will be managed through communications with the nominated contact(s) for each participating organisation.

6. Conditions for examining EQA slides

Digital pathology is not in use at present for routine reporting in bowel cancer screening. It is recognised that a digital EQA scheme does not replicate routine practice exactly but the EQA will be the same for all participants. The scoring system of peer consensus and criteria used to determine substandard performance is well established and designed to make sure that individuals are assessed fairly and consistently with their peers. Participants do not undertake the assessment in an examination setting. Participants must not discuss the slides in any way before all participants (excluding absentees) have viewed them and recorded and submitted their results.

7. The assessment

7.1 Recording responses

All participants are to record their opinion online. Their diagnosis will be limited to one of the following categories:

• adenoma with low grade dysplasia
• adenoma with high grade dysplasia
• invasive adenocarcinoma
• other

All participants are advised to keep paper/separate electronic records of their submitted responses until the final results are issued by the scheme. This is to mitigate against potential loss of EQA data in the event of catastrophic IT system failure.

7.2 Feedback to participants

The scheme provides confidential final feedback to each participant at the end of the EQA round. This is in a report (or series of reports) and includes an overall score of performance in the scheme. Verbal feedback on individual performance is not available.

7.3   Reports

Participant reports

The Consultant in Public Health/National EQA Lead and the EQA facilitator have joint authorisation to issue reports to individuals at the end of each completed round. Participant reports are issued within the 6 month period allocated for each round (no later than 30 September for the first round, and no later than 31 March for the second round). Participants should keep their own records of performance in EQA, including the outcomes of investigations of any unsatisfactory results.

Performance results are a useful record for participants, however there are limitations on using them to determine competence. Successful performance may represent evidence of competency for a particular round but may not reflect ongoing competence. Similarly, unsatisfactory performance in a particular round may reflect a random departure from a participant’s normal competence.

Annual report

The annual report includes an anonymised summary of participant results and is widely distributed within the programme and to key stakeholders

7.4 Certificates of participation

All participants completing EQA will receive a certificate of participation once the final reports have been validated and issued.

7.5 Continuing Professional Development

For the purposes of continuing professional development, participants may claim 2 hours CPD credit per completed EQA round.

8. Slide consensus

8.1   Consensus opinion

Final analysis of participants’ performance is based on consensus agreement. The correct classification of a slide is based on consensus opinion determined at the end of the round and is based on an 80% consensus of participant results. In addition, at least 80% of the participants will have to have agreed in their classification of that slide in order for it to be used to analyse performance. Such calculations only take into account EQA responses from participants who report histopathology for the NHS BCSP (ref: section 8).

If a participant fails to provide a response for a slide, or provides multiple responses for a slide, they are excluded from the consensus calculations for that slide and scored according to the guidance.

8.2 Data handling and calculations

To simplify data handling and calculations, the EQA facilitator keeps a record of responses by participant number (not name) for each EQA slide.

Automatic electronic calculation of consensus scoring will be performed; these calculations have been previously audited and validated.

8.3 Consensus on diagnostic category

Consensus agreement on low grade dysplasia, high grade dysplasia, invasive carcinoma and “other” is based on all valid participant responses for the particular case.

8.4 Cases not reaching consensus

Cases that have not been reported with 80% consensus are removed from any performance analysis. This means that participants are scored only against the remaining cases in the set that reach consensus. To achieve statistical validity, a minimum of 6 cases within any set has to reach consensus.

Discordant Opinions

If the final consensus opinion (ref: section 12) differs from the submitted opinion and would result in the patient being managed differently, the EQA facilitator notifies the originating laboratory. For example, the final consensus opinion may be an adenoma with high-grade dysplasia or worse, whereas the laboratory may have reported the slide as an adenoma with low grade dysplasia.

It is the responsibility of the lead pathologist of the submitting laboratory to take any necessary follow up action in the event of such notification.

9. Scoring

9.1 Consensus slides

Participants are only scored on cases in their EQA slide set that reach 80% consensus. Cases reaching consensus do not necessarily mean the consensus classification is correct.

9.2   Scoring

Participants are scored on their ability to distinguish between the four diagnostic classifications:

• adenoma with low grade dysplasia
• adenoma with high grade dysplasia
• invasive adenocarcinoma
• other

See the scoring matrix

9.3 Transcription errors

If a participant fails to enter a response for a case no mark is allocated.

9.4 Final scores

In order to make sure that scores are comparable the total score for each participant is converted into a percentage of the possible score for the particular slide set that was used (after any non-consensus slides have been removed).

score = participant’s score ÷ maximum possible score for the slide set x 100

Percentage scores are expressed to 2 decimal places. Values below 4 in the third decimal place are rounded down. Values of 5 or above are rounded up.

10. Assessment of performance

Personal performance is assessed on an individual’s ability to distinguish between adenoma with low grade dysplasia, adenoma with high grade dysplasia, invasive adenocarcinoma and other.

10.1 Identification of substandard performance

Substandard performance is specified as a score that falls below the bottom

2.5 percentile point when percentage scores are placed in rank order for the slide circulation

10.2 Calculation of the bottom 2.5 percentile point

It is possible to calculate the bottom 2.5 percentile point in Excel by using the inbuilt function key (fx) on the tool bar. The percentile function can be found in the statistical function category. The ‘array’ of data is all percentage scores in the rank and the ‘K’ value is the percentile value sought, expressed as a decimal (such as 0.025). The value obtained is the bottom

2.5 percentile point of all the results. Results falling beneath this value are identified as substandard for the purposes of EQA performance assessment.

Automatic electronic calculation of the bottom 2.5 percentile point is acceptable, provided that these calculations have been previously audited and validated.

It is also possible to calculate the score at the 2.5 percentile manually, as shown in the following example:

The calculation is based on an EQA round consisting of 68 percentage scores that range from 100% at the upper level to 60% at the lower level. The score of the second lowest participant (R2) was 66%; that of the third lowest participant (R3) was 72%.

The formula used is

1 + P(N – 1) = a + b

where a is the integer of the result indicating the ranked position of the score, b is the fraction indicating the proportion of the difference between scores at (a) and (a + 1), P is the percentile (0.025), and N is the number of participants (68).

1 + 0.025(68 – 1) = a + b

1 + (0.025 x 67) = a + b

1 + 1.675 = a + b a + b = 2.675

a = 2

b = 0.675

Since a = 2, the score of the second lowest participant is taken as the baseline; if the calculation resulted in a = 1 then the score of the lowest participant would be used as the baseline, or the third lowest participant if the result was a = 3 and so on. With a = 2, the value of b, 0.675, relates to the proportion of the difference between the scores of the second and third lowest participants (if the calculation resulted in a = 1 then the value of b would relate to the difference between the scores of the lowest and second lowest participant and so on).

The proportional difference between the 2 figures is calculated as follows

(R3 – R2) x 0.675

(72 – 66) x 0.675

6 x 0.675 = 4.05

The desired percentile is then calculated by adding this difference to the score of the second lowest participant (as a = 2 in the first part of the calculation) as follows:

66 + 4.05 = 70.05%

Any scores below 70.05 are below the 2.5 percentile point and considered to be substandard performance.

Owing to the nature of the scoring system, on some occasions there may be individuals whose scores equal the 2.5 percentile point with no scores falling below the value. In such cases, the scheme does not consider these individuals to have shown substandard performance.

Substandard performance is identified by placing the scores for each peer group in rank order for each circulation. Individuals with scores below the 2.5 percentile point are classed as having substandard performance for that EQA round.

10.3 Notification of substandard performance

If a participant scores below the 2.5 percentile this is deemed to be a single instance of substandard performance for that round.

Any participant with substandard performance receives a confidential letter notifying them of this, and offering support from the scheme organiser.

Although this does not constitute persistent substandard performance, participants are encouraged to discuss a result of this nature with their BCSP lead pathologist or clinical line manager

10.4 Persistent substandard performance

Persistent substandard performance is defined as scoring below the 2.5 percentile point in 2 out of 3 consecutive EQA rounds.

After each round, results are analysed to identify persistent substandard performance. This is based on the participant’s EQA results for the 3 most recent rounds. The BCSP EQA Online system keeps a record of participants’ previous scores so that persistent substandard performance can be easily identified.

###Action points for persistent substandard performance

Action points, and the remedial measures taken when they are reached, are defined by the NQAAP (histopathology and cytopathology).

First action point

The first action point is reached when persistent substandard performance is first identified (as defined in section 10.2).

Second action point

The second action point is reached when a participant’s performance continues to be substandard in 1 out of 2 consecutive rounds. Persistent substandard performance is determined on a ‘rolling’ basis (using the results of the last 3 consecutive rounds). Substandard performance in either of the next 2 rounds after triggering the first action point means that the participant has reached the second action point.

A table which demonstrates the various combinations of results that can lead to the first and second action points, depending on an individual’s pattern of persistent substandard performance is in section 15.

10.5 Participant responsibilities in cases of persistent substandard performance

Participants identified as persistent substandard performers will be provided with a checklist (via email) which encourages reflection on circumstances which may have contributed to reaching this action point. These checklists must be completed and returned. The participant will submit the checklist and declaration to the scheme organiser (via the National EQA Team) to confirm and evidence that appropriate reflection and action has been taken.

Areas participants will wish to consider when reflecting on performance include (but are not limited to):

• overall personal workloadworkload for BCSP histopathology
• departmental staffing
• equipment and accommodation
• routine performance data (where available)
• CPD records and attendance at educational events as required by BCSP (have attended an educational event relevant to their screening work in at least 1 of the past 3 years)
• personal circumstances

11. Communication to and from the EQA scheme provider

11.1 Comments or concerns

The EQA scheme provider for BCSP histopathology considers any concern or negative comment relating to any aspect of its operation or management to be a complaint. Scheme participants are welcome to express concerns or suggest improvements via email, telephone or letter. The EQA service actively seeks feedback (both positive and negative) through a national annual survey.

All communications are logged and acted on as needed. The scheme maintains records of comments to help identify system improvements.

11.2 Complaints

Complaints go directly to the EQA facilitator in the first instance. In the event of failure to resolve a complaint, the individual in question can complain directly to the scheme organiser. The matter will be escalated to the steering group who will collectively adjudicate the issue and determine the final response.

The complaints procedure (section 13) describes how participants can lodge a complaint regarding any aspect of scheme operation or management.

11.3 Appeals

If EQA participants wish to appeal regarding their performance assessment or results, they should contact the EQA facilitator in the first instance. In the event of escalation, the individual in question can complain directly to the scheme organiser. Ultimately, the participant can refer their appeal to the chair of NQAAP. The NQAAP decision is final.

The appeals procedure (section 14) describes how participants can lodge a formal appeal against an evaluation of their EQA performance.

11.4 Change requests

The scheme protocol may undergo changes when improvement opportunities are identified, or when non-conformity within a process has been identified and requires corrective and/or preventive action.

All changes to the protocol are communicated to participants in advance of the next round. The changes are listed in the revision history at the beginning of the protocol. The revised protocol will be uploaded to BCSP EQA online. All participants are required to confirm, via BCSP EQA online, they have read and accept the terms specified in the protocol.

Changes may also arise as a consequence of participant feedback, or direct request from the operational group or steering group

The scheme uses a change control procedure to prioritise and manage all changes.

11.5 Participant feedback forum

The scheme runs an annual participants’ forum where staff can discuss general performance data and educational aspects of the scheme. These meetings are open to all participants. Laboratories are encouraged to send at least 1 participant who can then cascade information to colleagues.

11.6 Surveys

Short surveys are used periodically to obtain feedback or views from participants on actual or proposed scheme activity.

There is an annual survey which all participants are encouraged to complete, either to register their satisfaction with the EQA service or use as an opportunity to voice concerns, comments and/or suggestions for improvement.

11.7 Annual report

The scheme produces an annual report for:

• participating laboratories and participants
• members of the EQA steering group and operational group
• NHSE bowel screening professional pathology network
• Consultant in Public Health/National EQA Lead Consultant in Public Health/Senior Clinical Lead for Bowel Screening (for cascade to bowel screening QA staff)
• RCPath
• UKAS

The annual report includes a summary of participant results and is widely distributed within the programme and to key stakeholders. The EQA facilitator distributes the annual report by the end of the second quarter of each financial year.

12. Procedure for investigating alleged malpractice

12.1 Purpose

To provide a procedure for investigating any behaviour witnessed or strongly suspected, whether deliberate or not, which has the potential to compromise the validity of results and consequently damage the integrity of the scheme.

12.2 Scope

This procedure applies to all scheme participants and EQA staff.

12.3 Policy

This policy assumes that collusion is the likely trigger of any rare event of suspected malpractice. Any behaviour that threatens the integrity of the scheme is taken seriously.

The scheme defines collusion as supporting malpractice by the passing on of information by a participant during the EQA round, thus allowing his or her opinions to be submitted by another. Such action may result in a participant (or participants) gaining an unfair advantage, or conversely, result in a serious disadvantage to their performance records.

12.4 Responsibilities and authorities

All participants and EQA staff have a responsibility for reporting any behaviour which could potentially damage the integrity of the scheme. Anyone suspecting malpractice should notify the EQA facilitator or a local laboratory manager.

12.5 Procedure

In the first instance, any witnessed or strongly suspected case of malpractice should be notified in writing to the EQA facilitator. The EQA facilitator refers the information to the scheme organiser for action. The scheme organiser convenes a national panel to conduct an investigation. The chair of the investigation panel corresponds with the participants involved via the EQA facilitator.

The procedure for individuals who are facing allegations of malpractice is set out below.

12.6 Participants

The scheme organiser writes to individuals separately and anonymously via the EQA facilitator within 7 days of receiving notice of the allegation.

The recipients are asked to respond within 14 days and offer an explanation for the allegation of malpractice. An investigation panel is convened and the correspondence forwarded to the chair.

If no acknowledgement is forthcoming by 21 days then a reminder is sent. If no reply is received after a further 7 days, the scheme organiser notifies the chair of NQAAP.

If malpractice is admitted, the EQA round of each individual concerned is invalidated and counted as sub-standard performance. The matter is referred back to the scheme organiser who provides appropriate feedback and guidance to the individuals concerned.

12.7 Repeated malpractice

In the unlikely event of a number of separate allegations, the EQA round of the individuals concerned is invalidated and counted as sub-standard performance.

The chair of the QAPC is notified of the participant identities and will refer the matter to the Professional Performance Panel of The Royal College of Pathologists and to the medical director of the appropriate trust.

13. Complaints procedure

13.1 Purpose

This guidance provides a procedure for dealing with complaints from any individual in the event of dissatisfaction with any aspect of scheme operation or management.

13.2 Scope

This procedure applies to all participants and EQA staff.

13.3 Responsibilities and authorities

Individuals are responsible for following the procedure if making a complaint. EQA staff are responsible for taking appropriate action and offering a solution within the required timeframes.

Individuals and EQA staff are responsible for keeping complaints confidential between the complainant and the scheme. The scheme will handle all concerns that could infer a complaint as an official complaint and treat these as confidential.

13.4 Procedure

If an individual wishes to make a formal complaint, then they must do so by writing to the EQA facilitator.

1. The EQA facilitator sends a holding response within 3 working days of receiving the complaint.

2. The EQA facilitator logs the complaint together with a summary of the communication and subsequent discussions that may involve other EQA staff including the scheme organiser.

3. The complainant can expect to receive a response offering a solution within 20 working days.

4. If the matter is not resolved to the satisfaction of the complainant then the EQA facilitator will refer the matter to the scheme organiser. The scheme organiser will provide a response within 28 working days.

5. If the matter is still not resolved then the scheme organiser will escalate it to the EQA steering group The EQA steering group decision is final. The complainant can expect to receive a final response within 28 working days.

14. Appeals procedure

14.1 Purpose

This guidance provides a procedure for dealing with participants in the event of an appeal against an evaluation of their EQA performance.

14.2 Scope

This procedure applies to all participants.

14.3 Responsibilities and authorities

Participants are responsible for making a timely appeal against an evaluation of their EQA performance. EQA staff are responsible for taking appropriate action and offering a solution within the required timeframes.

14.4 Procedure

If a participant wishes to appeal against an evaluation of their EQA performance, then he or she may do so by writing to the EQA facilitator within 28 working days upon receipt of their final results report.

The EQA facilitator sends a holding response within three working days of receiving the appeal.

The appeal is logged together with a summary of the communication and subsequent discussions that may involve other EQA staff including the scheme organiser.

The appellant can expect to receive a response offering a solution within 28 working days.

If the matter is not resolved to the satisfaction of the appellant then the matter is referred to the scheme organiser. A response is provided within 28 working days.

If the matter is still not resolved then it will be escalated to the EQA steering group The EQA steering group decision is final. A final response can be expected within 28 working days.

If the appellant remains dissatisfied with the outcome, or the matter becomes intractable then they can self-refer the matter directly to NQAAP.

15. Performance examples with action points