Guidance

NHSP: local programme management tasks

Updated 9 April 2024

Applies to England and Wales

This document is intended to supplement the NHSP operational guidance and provide more detailed guidance for local NHSP programmes to ensure the delivery of a high quality, reliable, supportive and effective service.

It lists the management tasks that local programmes are responsible for undertaking on a daily, weekly, monthly, quarterly or annual basis and as appropriate.

Local programmes are responsible for the identification of individual(s) responsible for ensuring the tasks are carried out appropriately and in a timely way.

Completion of these tasks will provide commissioners, PHE screening and immunisation teams and screening quality assurance services (SQAS), assurance that the service being provided to the patients is using the correct protocols, procedures and equipment, in a family friendly safe way.

Through completion of the tasks, local programmes will be able to identify any gaps or risks within their service and formulate plans to address these.

Daily

Reconcile cohort data and birth data population into the hearing screening IT system

Ensure every birth that is registered by the birthing site maternity unit(s) reaches the hearing screening IT system, with accurate data and in a timely way.

Investigate with maternity unit any breaches and report if minor data errors become a regular occurrence. Report breaches to the national IT system helpdesk.

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

Locate and share records where you have become the temporarily responsible hearing screening facility or temporarily responsible audiology facility

Ensure records on the national IT system are shared to the appropriate facility to enable screening or audiology assessment. Particularly relevant for babies in NICU/PICU or children’s wards.

See national IT system.

Monitor transfer in list

Review list and process all records. Move records to the correct facility within programme for ongoing record or patient management.

See national IT system.

Run patient journey searches:

• with completed screen but no screen outcome set
• for in-patient well babies with incomplete screen – are they still in hospital and should you appoint?
• for in-patient NICU babies with incomplete screen
• for babies who are waiting for outpatient appointments

Review lists and process all records. Check why administrators or screeners are not setting their outcomes. Is baby still an inpatient should you appoint?

Reconcile national IT system list with NICU in-patient list. Do they all have appointments pending or do they need re-appointing or incomplete outcome set?

See patient journey from screen to referral, national IT system.

Monitor outstanding imported test results

Review outstanding import files and resolve to ensure all results are correctly matched to records.

See national IT system.

Weekly

QA equipment checks

Avoid recalling babies for another screen where faulty equipment has been used or inaccurate results have been recorded, by regularly checking QA tests are being completed.

See equipment and national IT system.

Obtain data for babies born outside of England less than 3 months old

Arrange appointment for babies less than 3 months of age born outside of England.

Child health departments can provide data for babies born outside of England and moved in.

Monitor candidate transfer in list

Liaise with other programmes to ensure births your responsible for are offered screening within the target time, by whichever programme can offer in the most family friendly way.

See national IT system.

Monitor share lists

Regularly check why a record is shared in or out and whether the share can be ended or needs to continue. For shares out liaise with the programme sharing your baby.

See national IT system.

Check for duplicate records

Identify and rectify records with no NHS number. Identify and merge duplicate records.

See national IT system.

Check deceased babies records

Liaise with Midwifery, NICU and SCBU and Child Health to routinely obtain details of any deceased baby to ensure the national IT system is up to date in order to avoid offering a screen or an audiology assessment to the family of a deceased baby. Inform other screening programmes locally (NIPE and NBS) who share common national IT system data

See patient journey from screen to referral, national IT system.

Status override search

Identify records where the screen outcome differs from the screening IT system suggested outcome. Authorise these overrides or challenge the administrator or screener’s decision.

See patient journey from screen to referral, national IT system.

Search for all records without a screening outcome set

Ensure all babies can be screened within the NH1 target time. Export and investigation of data into an excel spreadsheet can show patterns and help to improve NH1 statistics.

See patient journey from screen to referral, national IT system.

Search for all records with a screening outcome set to ‘referral for audiological assessment’ (pre-defined Audiology search 7)

Liaise 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. Export and investigation of data into an excel spreadsheet can show patterns and help to improve NH2 statistics.

See patient journey from screen to referral, national IT system and audiology.

Monthly

Update Child Health (or do this as regularly as child health require)

Ensure data is shared with local Child Health Record Department. This can be by PCHR duplicate pages, IT interface or data export from the NHSP national IT system.

See national IT system.

Identify babies moved into your NHSP area

Liaise with Midwifery, Health visitors, NICU and SCBU and Child Health to identify babies moved into your area that require:

• audiological assessment
• targeted follow-up

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

Monthly national reports

Reports must include:

• highlights
• activity
• outcomes
• data quality

See data and reports.

Review national highlight reports

Follow the national reports guidance notes for the highlight reports which should be reconciled to local logs and investigated with the outcome added to the excel spreadsheet for audit and evidence purposes.

Any screening incidents must be reported.

See data and reports.

Review national screener activity report and screening outcome by screener report

Follow the national reports guidance notes for the screener performance activity reports to monitor individual’s performance, protocol adherence and numbers of attempts (can be used to evidence screener competency during annual observations and review or 2 yearly reviews for Health Visitors).

See data and reports.

Review national activity reports

Follow the national reports guidance notes to review monthly activity reports, which can be used to evidence the total screening activity of your service including screening completed for other NHSP providers.

See data and reports.

Review national audiology data quality reports

Follow the national reports guidance notes and pass these reports to the relevant audiologists to action.

See data and reports.

Review national outcome reports

Follow the national reports guidance notes to review the outcome reports which should be used to monitor accumulative cohort data and report on your services yield and false negatives locally and to ANNB regional PHE groups.

Any screening incidents must be reported.

See data and reports.

Audit records with incomplete outcomes set

Check appropriateness of records with an incomplete screen outcome. Note that ‘Incomplete screening out of coverage’ is only used in 2 scenarios:

• babies born and screened in a private hospital
• babies born at your hospital, screen not completed, moved outside England

See patient journey from screen to referral, national IT system.

Missing audiological assessment data

Work with your audiology teams to audit quality and completeness of assessment data on the national IT system. The national screen referral and yield report shows records with missing audiology data.

See patient journey from screen to referral, data and reports, national IT system, audiology.

Risk factors and screen outcome check

Check all records that have:

• appropriate risk factors set have targeted follow-up outcome set unless they are immediate referrals
• targeted follow up 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 patient journey from screen to referral, national IT system.

Ensure babies with targeted follow up are assessed (predefined audiology search)

Liaise with audiology to ensure babies with risk factors who require targeted follow up are offered assessment appointment.

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

Quarterly

Quarterly national reports

Reports must include:

• performance
• highlights
• activity

See data and reports.

Review programme performance against standards

Follow the national reports guidance notes to download and review the performance against programme standards. Use the information to report to your organisation, ANNB board and other stakeholders.

See data and reports.

Audit records that did not meet NH1 target

Follow the national reports guidance notes to download the list and investigate each one. Agree improvement plan if required.

See data and reports.

Audit records that did not meet NH2 targets

Follow the national reports guidance notes to download the list and investigate each one. Agree improvement plan if required.

See data and reports.

Review the other quarterly reports

Follow the national reports guidance notes to download the quarterly activity reports for transfers in, out, discharge and protocol adherence. Review these reports, address any issues identified and report on them when required.

See data and reports.

Annually

Annual national reports

Reports must include:

• performance
• activity

This data can be used for annual reports or comparison to previous year’s annual position.

See data and reports.

Annual ANNB screening report

Submit a written report on your local NHSP service for inclusion in the trust annual ANNB screening report (available from Screening QA team). To promote, support and evidence NHSP performance locally.

See clinical governance.

Archive data and paperwork as required

Ensure NHSP reports or results data or decline forms are stored appropriately in line with Trust requirements.

Refer to your local medical record storage protocols and procedures.

Arrange:

• screening equipment calibration
• local safety testing

Timely arrangement of safety testing and calibration mitigates risks of screening with faulty or inaccurately calibrated equipment and ensures equipment is safe to use.

See equipment. Refer to local clinical engineering guidance.

Liaison with internal and external stakeholders

Regular and effective liaison with internal and external stakeholders will ensure good working relationship between services, accurate data and robust fail safes.

Liaise with Midwifery and NICU or SCBU to review and validate:

• antenatal provision of parental information
• NHSP updates and awareness
• NHSP input to antenatal parent classes
• NHSP input to student midwife training

This prepares the family to expect to be offered a hearing screen.

See clinical governance and patient journey from screen to referral.

Liaise with Midwifery, NICU or SCBU and child health to review and validate notification processes for:

• deceased babies
• births
• baby location (change of address)
• baby discharge (hospital sites)
• declined or incomplete screen
• babies moved into area

This helps:

• avoid the risk or incidence of offering a deceased babies family a hearing screening appointment
• avoid a baby missing their hearing screen
• identify babies that need further screening or follow up hearing assessment

See clinical governance and patient journey from screen to referral.

Liaise with Midwifery, NICU or SCBU and paediatricians to review and validate processes for:

• ascertainment of risk factors
• referrals for targeted follow-up

This helps identify babies who have been at risk for their hearing and needs further hearing assessment.

See clinical governance and patient journey from screen to referral.

As appropriate

New screener training, competency and performance monitoring

Organise training and mentorship for new screeners to ensure competency and performance regarding: Ensure new screeners have:

• undertaken and successfully completed eLearning units in a timely manner
• completed statutory and mandatory induction for training requirements specific to their NHSP role
• undertaken an OSCE (communication and clinical competence workshop including observation)
• all other NHSP required training and assessments as per the NHSP Screener Competency Framework

See education and training.

Existing screener training, competency and performance monitoring (this should be at least annually for non-professional screeners and every 2 years for professionally registered screeners (such as Health Visitors))

Mentor or assess existing screeners competency and performance regarding:

• screening technique, communication and hearing screening IT system skills
• adherence to protocol
• information governance
• appropriate use of documentation
• adherence to local infection control protocols
• clear or no clear response rates
• number of screen attempts
• equipment QA checks and logs are completed

Ensure existing screeners e-learning units are completed annually to refresh. Ensure completion of statutory and mandatory induction or training requirements specific to their NHSP role.

See education and training.

Inform NHSP IT system helpdesk when a team member leaves NHSP role and therefore is no longer authorised to access the NHSP IT system

Keeping access to service and patient data via the national IT system is imperative to avoid a breach in patient confidentiality and potential data protection risks.

See clinical governance.

Monitor supplies of consumables and parent information booklets

Complete stock checks to ensure:

• sufficient supplies to sustain screening
• stock has good use by dates
• sufficient supplies of all relevant booklets

See introduction and contacts, equipment and patient journey from screen to referral.

Arrange equipment:

• repairs
• probe out of calibration
• software update installation

Follow local procurement and trust procedures. Report equipment incidents. Inform NHSP national programme if appropriate.

See equipment.

Contacts database maintenance

Check your information on the NHSP national IT system contacts database and amend as appropriate. Remove all contacts no longer relevant. Add new contacts.

Screening websites and blogs

Check the websites and encourage all NHSP staff to do same for updates on all antenatal and newborn screening programmes.

You can subscribe to the blog by clicking on the email link under “sign up for updates” on the right hand side of the blog. Select “NHS Newborn Hearing Screening Programme” from the category list to just see blog posts relating to NHSP.

See NHS Screening Programmes and PHE Screening blog.

Meetings

Meetings you should attend to represent and report on your service and to escalate concerns:

• AN and NB Regional and Local Co-ordinators and PHE screening leads
• Provider:
  • Clinical Governance
  • Finance

Meetings you should have regularly to gather feedback, and formulate improvement plans and escalate concerns:

• With your screening team
• With your team lead

See regional SQAS.

Parent satisfaction

Ensure your programme meets the needs of families using the service by organising parental satisfaction survey.

See clinical governance.

Review NHSP local paperwork

Ensure standards letters and templates are up to date and fit for purpose.

See local policies and guidance.

Review practice and failsafe mechanisms

Ensure normal working practices have not changed and failsafe mechanisms are still in place.

See guidance for checks and audits.

Review local policies, protocols and procedures

Ensure all are up-to-date and evidenced and audited.

Refer to local standards on policy review.

Review your service against quality assurance (QA) report recommendations

Ensure actions have been taken and continuous improvements are achieved.

Refer to your QA report.

Disseminate information about programme performance locally via newsletter

Distribute to local stakeholders – midwives, health visitors, NICU/SCBU staff, paediatricians, audiology, early intervention.

Consult provider communication team.

Ensure good liaison with your local audiology service(s)

Attend meetings, present performance data, joint audits.

See roles and responsibilities, clinical governance, audiology.

Recording and reporting later identified PCHIs

Ensure audiology are aware of need to update records when a PCHI identified in a child that was previously discharged with clear responses or had an incomplete screen.

See patient journey from screen to referral, audiology, report of later identified PCHI.

Ensure good liaison with your local aetiology service(s)

Attend meetings, present performance data, joint audits.

See roles and responsibilities, clinical governance, aetiology.

Prepare for cross programme QA visit

Gather supporting evidence for your QA visit:

• audits
• protocol, procedure and policy updates
• HR records of competency reviews
• appropriate meeting attendance and agenda or action items
• data, quality and performance adherence

See clinical governance, patient journey from screen to referral and aetiology.

Adhoc audits

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

• infection control
• equality and diversity
• use of interpreters
• non-attendance at clinics, declines
• lost to follow up post audiology assessment
• notification of late onset or progressive losses

See local policies and guidance.

Useful searches and exports

Any of the following searches and exports can provide local programmes with detailed audit data should they need it.

Data quality extracts

To ensure patient data on the national IT system has been recorded accurately check records:

• with family history parents and siblings set have wide family history set
• with risk factor NICU > 48 hours set have:
  • NICU protocol set
  • gestational age entered
  • been screened using the NICU protocol
• with no GP Practice code are investigated and rectified and correctly assigned to their responsible NHSP programme
• whose consent is set to full have verbal as consent type
• whose consent is set to not given has verbal as consent type and an appropriate outcome set
• where consent signatory is set have a translator and language type been set appropriately

Data can be exported from the national IT system into excel spreadsheets to provide audits/evidence locally.

See patient journey from screen to referral, national IT system.

Test results data extract

Searching and exporting patient data into excel including test results, will enable programmes to use excel to pivot tables to:

• sort records by screening protocol
• sort by screener
• tally numbers of attempts for individual Community Information Data Sets or NHS numbers by screener

This audit can be used to monitor screener performance in a detailed way or as evidence of screener competency during annual observations and review or 2 yearly reviews for health visitors.

See patient journey from screen to referral, national IT system.