Screening standards
Principles for developing, reviewing and publishing screening standards.
Screening standards are indicators that measure parts of the screening pathway to assess the screening process and support continuous improvement. When defined, used and applied properly they enable screening service providers, national screening programme teams, quality assurance teams and commissioners to identify where improvements are needed and support assessment of effectiveness.
Screening standards support a consistent approach to service delivery across screening programmes and can make sure that data collection is proportionate and measures important aspects of the pathway.
They:
- provide reliable and timely information about the quality of the screening programme at multiple geographical or sub-population levels
- support a focus on quality across the screening pathway
They can be used for:
- quality improvement and assurance of screening services by national and regional quality assurance teams
- performance management by commissioning or purchasing bodies
- national reporting to support the development of screening programmes, including national policy
- transparency and public accountability
- identification and reduction of inequalities
- assessment of screening programmes’ effectiveness
Development of screening standards is resource intensive and we recommend they are developed at a programme level (for example, nationally). This also supports consistent use across a large population and avoids duplication of effort.
This chapter:
- describes an approach and framework for developing, reviewing and publishing screening standards
- provides a clear, consistent and auditable approach to producing screening standards
- describes how standards can be used to underpin continuous quality improvement to deliver a screening programme’s aims
- proposes the development of standards that are specific, measurable, achievable, realistic and timely (SMART)
The expected audiences for this information are:
- screening programme teams
- commissioning or purchasing bodies
- screening quality assurance teams
- screening service providers
- clinical networks
- academics
- government departments responsible for public health
- international screening policy makers and service deliverers
- the public
Following the Donabedian model for examining health services and evaluating quality [footnote 1], we can categorise screening standards as follows.
Process standards
Process standards assess actions that make up the screening pathway and allow for continuous improvement. These actions commonly include selection of the eligible cohort, testing and referrals. For example, coverage (the proportion of the eligible population who receive a screening result) is often one of the process standards.
Structural standards
Structural standards describe the structure of the screening programme and the factors that affect how it is delivered. This includes the physical facility, equipment and human resources. The availability of trained staff to provide the screening service in line with guidelines and national policy, and good quality imaging equipment are examples of structural standards.
Outcome standards
Outcome standards describe the effect of screening programmes at a population level, including eligible and ineligible individuals. This includes changes to health status, behaviour, patient satisfaction, health related quality of life and mortality rates linked to a particular condition. Outcomes are important measures of quality and effectiveness of services but they are generally most difficult to accurately measure in relation to a specific healthcare service and possible biases. Consider outcomes where a screened individual lives to the same age as one who was diagnosed symptomatically, but the screened individual appears to have a longer survival time because they were diagnosed earlier. Changes in behaviour such as smoking cessation and survival rates are examples of outcome standards.
Only process standards are in scope of this guidance. However, it is important to note that many of the principles and processes can be applied to the development of structural and outcome standards. Information from all 3 categories is important to feed into quality assurance and improvement of screening services, commissioning, analyses of the clinical effectiveness and cost-effectiveness of a screening programme.
The Good Indicators Guide [footnote 2], published by the NHS Institute for Innovation and Improvement and The Association of Public Health Observatories, identified the following principles.
A good standard should:
- be described using plain language
- address an important issue
- be supported by clear definitions
- be SMART
- prompt or promote action to maintain or improve the quality of the screening service
- be understood and supported by screening service providers
- not disadvantage any group or groups of people (as described in the reducing health inequalities section below)
- not be too burdensome for providers to collect and report on
Consideration should be given to the number of screening standards. Often IT systems are not adequate for easy data extraction and data provision is an additional burden for screening service providers. The focus should be on important parts of the pathway where there may be risk to the participant or where there is potential for improvement with minimum burden.
Reducing health inequalities is a priority for an effective, good quality screening programme. One way of doing this is to develop standards focusing on areas for possible improvement so they can be continuously monitored and used to develop and evaluate interventions aimed at reducing inequalities. Inequality standards can relate to any point along the screening pathway and can directly or indirectly relate to characteristics, such as those protected in the UK by the Equality Act 2010. These will depend on the programme pathways, data availability and the demographics of the population eligible for screening.
You should:
- aim to develop at least one standard that will help identify and address inequalities as well as respecting an individual’s right to make a personal informed choice about having screening
- consider the potential impact of any new or existing standards (this may be positive or negative)
Examples of standards that focus on inequalities include:
- coverage of screening in the most deprived proportion of the eligible population
- the difference in standard values between most deprived and least deprived quantiles of the eligible population
- repeat non-attenders for screening or referral appointments by one or more inequality dimensions
- coverage, uptake or screen positivity by ethnic groups
- local or regional differences by one or more inequality dimensions
Consider if the required data:
- is available
- can be extracted from IT systems or be locally collected
- needs to be or can be linked to any other available dataset(s)
- can be reported and in what format
- will place an undue burden on the providers to collect
See the inequalities chapter for more information about health inequalities in screening.
Reviewing screening standards is a considerable undertaking that requires careful planning, good communication, engagement from all stakeholders and a significant staff resource.
Reviews can be:
- regular (for example, every 3 years)
- triggered by a change in the screening pathway (for example, changing criteria for the selection of the eligible population)
- triggered by some other reason
Both regular and ad-hoc reviews can result in major or minor changes to screening standards. Regular reviews should be undertaken even if no changes to standards are expected.
For a standards review, you should:
- ensure adequate resources are provided (for example, set as an organisational objective)
- consider how complex or sensitive your standards are and how long it will take to complete the process (it may take over a year)
- engage with relevant stakeholders
- consult an indicator review group (see the Review of standards by an independent indicator review group (IIRG) section below)
- follow the appropriate sign-off process and governance
- plan the publication of revised standards definitions to allow time for providers, quality assurance teams, commissioners and other stakeholders to understand and prepare for their implementation
- consider the timeliness and availability of data, as some data may only be available after a screening episode closes (for example 6 months after the initial invitation, or after delivery of babies for antenatal screening programmes)
- be open to feedback on existing standards and proposed changes
- consider the effect your standards have on health inequalities
You should hold a consultation with the relevant stakeholders and public if changes to standards are considered major. This could be, for example, changing thresholds, introducing a new standard, removing an old standard or significantly changing definitions.
There should be a streamlined process for making minor changes to standards such as small wording changes to clarify definitions.
Review group
Coordinating the review of standards should be the responsibility of one person, for example a national screening programme lead. You should convene a task and finish group and consider representation from people who understand the programme and know what is feasible to measure to develop standards that are supported by good quality data. By involving all stakeholders early you can ensure the acceptability of standards by those who provide and use the data. Contributions from all stakeholders will allow you to prioritise the most important parts of the pathway to measure and assure consistent use of standards for multiple purposes.
Representation on the group can include experts in:
- project management
- screening quality assurance
- data and intelligence
- publication and information
- IT (linking to software suppliers if required)
- clinical advisor roles
- screening commissioners or purchasers
- government departments responsible for policy and public health
- lay member representation, such as service users and/or charities
- different screening programme teams to support the process and share experience
No stakeholder group should be surprised by the development and publication of new standards. It is very important to take on board comments and concerns by engaging with stakeholders throughout the process.
Coding
To manage the publication of standards and data, it is helpful for each indicator to have a unique and easy to interpret public facing code. A consistent coding convention helps provide clarity and should be used for all screening programmes implemented in your country.
You may choose to prefix standards by the acronym of the relevant screening programme, followed by ‘S’ (for ‘standard’) and a unique number. For example, for a cervical screening programme, standard number one could be coded ‘CSP-S01’. No matter how you code your standards, you should be consistent across the screening programme, and explain to your audience how the codes work.
Consider how a potential introduction of a new standard, retirement of an existing standard, changes to thresholds or definitions are reflected in your codes.
As well as public facing codes, internal computer-generated codes (which may not be user friendly) can be used in IT systems to precisely identify a standard for a given reporting period.
We do not recommend grouping different indicators as one standard under one code, especially if they have different definitions and thresholds.
Standard themes
It is good practice to link your standards with themes that support the standardised use of indicators for quality assurance, effectiveness or commissioning and delivery of screening services. Standards should fall under at least one theme but there may not be a standard for every programme under every theme. Where a standard could fit under more than one theme, choose the most appropriate one.
You may consider the following 8 themes (listed with an example standard in brackets):
- population (identify eligible population, such as all ex-smokers)
- coverage (proportion of tested individuals from all eligible)
- uptake (proportion of tested individuals from those eligible offered)
- test (positive predictive value, test turnaround time)
- diagnosis/intervention (time to first clinical assessment)
- referral (time to intervention, attendance at specialist assessment appointments)
- intervention/treatment (timely entry to care)
- outcome (rate of invasive interval cancers)
As a principle of consistency, consider which parts of the screening pathway the numerator and denominator sit in and which theme covers that part of the pathway.
For purposes like quality assurance there may be additional themes which apply to structural standards, for example education and training, governance, leadership and minimising harm.
How to describe standards (metadata)
You should use the same template for all standards definitions. This type of information is often referred to as ‘metadata’ and allows for clear and explicit definitions.
A metadata template[footnote 2] should include the:
- standard name
- standard code
- description (what is being measured)
- rationale (why it is being measured)
- definition (detailed description of terms such as numerators, denominators, timescales, exclusions and units of measure such as rates, percentages and ranges)
- performance thresholds – consider using 2 thresholds: for example acceptable and achievable (these should be set using published evidence or existing data, and should use consistent precision, such as to one decimal point)
- caveats (describe where there are known and expected reasons why providers might not be able to reach set thresholds, for example a high number of babies in tertiary care could result in delayed newborn screening)
- data collection requirements (the data source, reporting and publishing geography, who is responsible for data quality, completeness and submission)
- reporting period (for example, 1 April to 31 March)
- review dates (date standard introduced and/or updated)
The standards should be reviewed by a group of screening and data experts independent to those developing the standards. We recommend having standardised forms or checklists to support the review of the standards.
An IIRG can help you:
- check that the agreed process is followed when developing the standards
- make sure there is consistency across screening programmes
- discuss retirement, amendment or introduction of new standards
- make sure the proposed standards meet the principles set out in this guidance
- scrutinise the interpretation of the standards
- provide advice to senior management teams for updates to screening standards
- consider the issues with using standards where the reported numbers are about sensitive topics and / or are potentially identifiable (for example continuously reported numbers less than 5)
- consider if and how to pilot standards
- consider introducing a shadow standard (collecting data for a specific period of time to test the feasibility and definition of the standard, and/or not setting thresholds for the first year of collection)
- review standards data in order to make decisions about publishing it
The IIRG should provide feedback, which you should review and then record any actions taken.
Engaging with stakeholders is vital in gathering feedback on whether the standards meet the set development principles and to obtain support from those who participate in the programme, collect and use the data. Consultation methods include, but are not limited to:
- workshops
- face to face meetings
- online surveys
- internal and/or public consultations, for example focus groups
- any process used to arrive at a group opinion or decision by surveying a panel of experts
There may be a team within your organisation that will help and support consultations with members of the public. You may want to consider using a trained facilitator to help. If you open a consultation survey to the public, it is good practice to publicly publish a summary of the responses (as described below).
Ideally, record responses to and actions arising from consultations for audit purposes. Record reasons for accepting or rejecting consultation feedback. You should produce a report that outlines a summary of the responses with conclusions or actions and a thematic analysis of the comments received.
Once standards are finalised, communicate any changes and updates to all stakeholders. All communications should highlight new, retired and revised screening standards to make it easier to focus on changes from previous versions. Consider if any additional guidance or supporting documents are required.
Ensure there is a reasonable time period between the publication of new standards and when they will be implemented. For example, if your reporting year starts in April it is good practice to publish standards and notify stakeholders by December the previous year.
Clearly define all technical and programme-specific terms so the standards are easy to understand.
To develop consistent, well defined standards you should:
- have project management support
- record your actions and decisions for audit purposes
- engage often with stakeholders
- follow an agreed approval and sign-off process
- commit to publishing standards definitions and standards data to agreed timescales
- assess resources needed to implement a standard, including data availability, burden and collection
- not underestimate the time required for the development, modification and implementation of a standard
- consider piloting a standard before full implementation
- respect the right of individuals to make a personal informed choice about screening attendance (this may influence the setting of thresholds)