Guidance

IQA framework and competence assessments

Published 1 May 2016

1. Background

To ensure a safe and effective service, it is a requirement that all screening staff who perform abdominal aortic aneurysm (AAA) ultrasound scans as part of the NHS Abdominal Aortic Aneurysm Screening Programme are trained to the highest standard and are competent in their work. They must maintain a high level of competence through ongoing development and regular monitoring of their skills and the ultrasound images they capture.

The internal quality assurance (IQA) processes provide detailed guidance for local internal quality assurance (IQA) leads/clinical skills trainers (CSTs) and screeners, including screening nurses and locum screeners. The document includes resources for IQA leads and CSTs to enable them to record and provide feedback on the quality images captured by screening technicians and for feedback when undertaking clinical observations and annual competency assessments. Local services must adhere to these processes, to ensure staff competency and quality.

2. Overview of screening technician quality assurance

Continuing IQA aims to identify omissions and inconsistencies in technique and training to ensure quality and standards are maintained, these include:

• local support, monitoring and mentoring by the clinical skills trainer/IQA lead
• random sampling of aortic images recorded by screening technicians
• QA of images when a man enters surveillance and at point of referral
• direct clinical observation of screening technicians
• providing support and recovery plans if screener performance is below acceptable standard

Only a trained CST or IQA lead can assess images for IQA, undertake clinical observations and competency assessments.

3. Quality assurance framework for screening technician

To maintain their competency to deliver screening, screening technicians must:

• successfully complete the NHS AAA Screening Programme approved qualification for screening technicians
• perform a minimum of 200 scans per year spread over a 12-month period
• have a minimum of 8 random scans reviewed by the IQA lead/CST once a month (the IQA lead/CST will assess the images for quality using the NHSE AAA image quality assurance guidance as reference (hyper-link). For newly qualified or appointed screeners, the process for random imaging sampling must be activated on the SMaRT system by local programmes. Appendix 1 and 2 provide templates to support recording IQA activity for screening technicians.
• have all abnormal scans reviewed by the IQA lead/CST within 21 days following the man’s initial screening event (to maintain best clinical practice programmes should attempt to review abnormal images within 7 days)
• be clinically observed during one clinic by a CST at least once every 6 months (a minimum of 4 men needs to be observed having screening, which must include at least one surveillance scan); a standardised proforma is available to record outcomes and evidence continuing professional development (CPD) (Appendix 3).
• undertake and successfully complete an annual competence assessment. This will be carried out locally by the service’s own CST as one of the clinical observations that the CST is required to carry out every 6 months. A standard national template for the annual competence assessments is available in this document to guide the process (Appendix 4)
• If the CST/IQA lead decides a screener’s performance does not meet expected standards of practice a recovery action plan must be implemented and once satisfactorily completed, observation should recommence initially to 3 monthly. Appendix 5 and 6 provide resources to support recovery plans. Once the screener has demonstrated they meet acceptable standards, clinical observation can be decreased to 6 monthly.

3.1 Feedback

Feedback to screening technicians is an integral component of the IQA process and should always be undertaken by the CST or IQA lead.

Feedback should be as soon as possible (ideally within a week) following any IQA of images to enable technicians to effectively alter their practice when an issue is highlighted. Screening technicians should be advised by the programme co-ordinator/manager in the event of an alert providing feedback from IQA.

Feedback should ideally be face-face following clinical observation review with clear and defined mechanisms to record feedback given and monitor any actions agreed.

If a screening technician fails to meet any of the standards after a 6-monthly clinical observation visit, or there are concerns related to the quality of captured image during random image review, then appropriate factual feedback should be provided with a recovery training plan. This can include:

• close mentoring, supervision, and a period of training
• review of all images for a period defined by the IQA lead or CST
• review of past images and possible recall of men.

Note, recovery training plans following annual competency assessments are more detailed and included within the annual competency assessment process.

Guidance and prompts for completing trainee screening technician clinical observation assessments can be found at: Guidance and example prompts for completing trainee screening technician clinical observations - GOV.UK (www.gov.uk).

3.2 Screeners returning to work after a period of absence and the IQA process

If a screening technician returns to work following a period of absence of more than 6 months since their previous annual competency assessment, they must, after a period of reorientation:

• participate in an update and refresher session with a CST
• undertake the e-learning modules, achieving a minimum score of 80% in both units
• undertake the annual competency assessment before being able to screen independently.

The CST can also increase the number of monthly random images to review to ensure consistency in practice.

3.3 Reporting

CST/IQA leads must be able to access the SMaRT IT system. The QA resource page can be used to manage the image QA process. In addition, resources have been developed to provide services with proformas that can be used as evidence of ongoing training, education, CPD and IQA mechanisms within local screening services. A suggested IQA reporting form is available as resource Appendix 1 to enable services to record IQA activity for screening technicians and report to programme board meeting where required. It can be submitted as evidence as part of any quality assurance visit by the screening quality assurance service (SQAS).

If a potential incident or serious incident is identified during any of these QA processes the regional SQAS should be informed, and a screening incident assessment form completed.

4. IQA processes for CST’s/IQA leads

4.1 Process 1 - achievement of semi-independent scanning or qualified screeners new in post

This process should be used to monitor and provide feedback to the screening technicians to ensure all scans are undertaken and reported in line with the NHS AAA Screening Programme protocol, see Appendix 1.

The review of the first 100 scans needs to take place after the screening technician has completed the technician portfolio and approved/authorised by the CST/IQA lead before they can begin to scan semi-independently. Appendix 2 provides an optional template to support this.

Screening technicians who have achieved semi-independent scanning status or qualified screeners who are new in post but have not undertaken any scanning in the previous six months, must have their first 100 scans reviewed by the IQA lead/CST to build upon the initial training and ensure that technicians receive ongoing support and guidance.

Existing local AAA screening services may have developed their own proformas or tools for the QA of technician images, however they must include all the requirements outlined in this document.

4.2 Process 2 - image quality assurance

To ensure standards are maintained and to help identify omissions and inconsistencies in technique, accredited screening technicians must have their images quality assured by the CST/IQA lead. Each screening technician must have a minimum of 8 random or surveillance scans reviewed every month. In addition, the following scans must be reviewed within 21 days and ideally within 7 days to ensure best practice):

• all abnormal initial screening scans (aortic diameter ³3cm diameter or threshold set by services if this is <3cm).
• all referrals to vascular surgery including men whose aneurysm has grown by 1cm or more within 12 months.

The process must check for accuracy and appropriateness of the care pathway for all men including screened positive individuals. The information can be entered and managed on the QA section of the SMaRT IT system and includes:

• gain
• depth
• focus
• calliper placement
• correct NHS number
• correct measurement of aortic diameter

The CST or IQA lead should provide documented feedback to screening technicians when there are:

• any comments regarding image quality or calliper placement and orientation
• scanner control settings
• technical set up of the scanner as displayed on the image
• requests for image QA by the screener. Feedback should be provided in all cases
• instances when the aorta is considered non-visualised
• incidental findings
• any other features that are important to feedback to screening technicians

Local services can increase the number of monthly random scans if there are any reasons why an individual screener images should be selected for monitoring more closely. This can be changed by selecting this in the QA admin section of SMaRT.

If there are concerns related to the images captured by screening technicians an action and recovery plan should be put into place.

The minimum diameter measurement at which a screening result is automatically referred for image quality assurance review can be adjusted on the SMaRT system, for example to 2.7cm to enable images of the aorta to be checked close to the threshold for abdominal aortic aneurysms.

4.3 Process 3 – clinical observation

Each screener should be observed during one clinic by the CST at least every 6 months. A minimum of 4 men needs to be observed, which must include at least one surveillance scan and the resource proforma should be used (Appendix 3). It covers the following elements:

• introduction, explanation, and consent, including verifying patient ID
• communication and interpersonal skills
• correct patient NHS number and input of information and results
• correct use of equipment
• image optimization
• appropriate sonographic technique
• identification of the aorta and landmarks
• correct calliper placement
• giving appropriate outcome to man
• screening technician performance
• reflective practice
• suggested areas to concentrate on.

If screening technicians fail to meet a standard deemed acceptable to the CST or IQA lead, an action and recovery plan should be instigated as outlined in the feedback and recovery section.

4.4 Process 4 – annual screening technician scanning competence assessment

4.4.1  Overview

The annual scanning competence assessment aims to ensure that screening technicians have the knowledge and practical skills to perform to the standards required to work within the NHS AAA Screening Programme. The assessment is through direct observation of performance in clinic.

Assessments are carried out by CSTs who have completed CST training as required by the NHS AAA Screening Programme and who have maintained continuing professional development. 

4.4.2  Preparation for assessments

The local service should co-ordinate and plan to carry out the assessment in a clinic where the screening technician will screen invited individuals. This must be a clinic that includes at least one individual on surveillance pathways.

Enough time should be set aside for the assessing CST to give verbal feedback to the screening technician immediately after the assessment.

The assessing CST must check and confirm that the screening technician has completed the knowledge assessment every two years and achieved a minimum score of 80% in both e-learning units. It should be completed no more than 4 weeks before that year’s annual scanning competence assessment.

4.4.3  Completing the assessment form

The assessing CST must observe the screening technician screening a minimum of 4 individuals, 1 of whom must have an aneurysm.

A single assessment form can be completed for each observed clinic (Appendix 4).

The assessment is made up of several assessment criteria, some relating to knowledge and others to performance, and are described within the screening technician scope of practice.

The CST/IQA lead should award a grade for each of the criteria which is an average of the screening technician’s performance across the minimum of 4 individuals screened unless otherwise stated (see section 2.4.5).

The assessment form only needs to be completed once. This can be done after the minimum of 4 scans have been observed and assessed.

4.4.4  Grading the assessment criteria

There are 2 possible grades for each assessment criteria. These are:

• satisfactory (S)
• unsatisfactory (US)

 Satisfactory

This means the screener performs or explains the skill or procedure competently, independently, and safely.

Unsatisfactory

This means the screener demonstrates limited knowledge and understanding of the skill/procedure, does not recognise own limitations and requires assistance.

4.4.5  Assessment outcomes

There are 2 possible outcomes. These are:

• competent
• conditional

Competent

This means the screening technician has reached the satisfactory NHS AAA Screening Programme standard for all elements assessed.

This is awarded where the screening technician has no US grades in any of the assessment criteria.

If a screening technician exceeds the satisfactory standard, CSTs are encouraged to include this as part of the feedback to them.

Conditional

This means the screening technician has not reached a satisfactory standard in one or more of the assessment criteria.

For example, a conditional outcome will be triggered if the screening technician:

• scores 1 or more US grades in the assessment criteria
• does any of the following in any of the observations:
• fails to correctly identify the individual to be screened
• uses the colour function of the ultrasound scanner
• uses coronal scanning
• fails to identify the aorta when it is visible within the image
• incorrectly positions the callipers which would result in the individual being assigned to the wrong screen result pathway.

To ensure the safety of the individual being screened, the assessing CST must step in and assist the screener when necessary.

4.4.6  Next steps following assessment

The CST is required to inform the local service manager/coordinator and clinical lead of the outcome of the assessment by the next working day. This should be done by email. The local programme co-ordinator/ manager should confirm receipt of the email.

4.4.7  Next steps: competent outcome

The assessment should be repeated every 12 months. Internal quality assurance processes must be followed to ensure the ongoing quality of the screening technician’s work.

Where the CST identifies areas for development, this must be documented in the feedback and an action plan agreed. The actions identified should be completed within 12 weeks of the assessment date, see Recovery Training section.

The screening technician should continue to demonstrate and maintain improvement. This can be assessed through the internal quality assurance processes.

The screening technician and their line manager (usually the programme co-ordinator/manager) should keep copies of the assessment and action plan documentation.

5. Recovery training

Completion of the recovery training portfolio is a requirement for AAA screening technicians who receive a ‘conditional’ outcome from their annual scanning competence assessment.

A conditional outcome means the screening technician did not reach the satisfactory NHS AAA Screening Programme standard in one or more of the assessment criteria.

The screening technician must complete the recovery training portfolio and a scanning competence reassessment within 12 weeks of receiving the conditional outcome.

The CST/IQA lead, in discussion with the programme co-ordinator/ manager and clinical lead should decide if the screening technician can continue to actively screen. This should be documented along with recovery training requirements.

If the screening technician continues actively screening, their subsequent scans must be quality assured within 7 days of the screen until the screening technician has had a scanning competence reassessment and been awarded an assessment outcome of ‘competent’.

There may be a requirement to provide screening technicians extra training or supervision, because of issues identified during image QA. These may not be identified during a supervised assessment. Sections of the recovery training requirements may be useful in this scenario.

5.1 Recovery training requirements

The minimum requirements, which local services can add to depending on the needs of the screening technician, are:

• 10 hours of directly supervised training with the CST
• a minimum of 20 documented scans where the screener is directly supervised by the CST, with a minimum of 5 of these scans having an abdominal aortic aneurysm
• completion of a recovery training portfolio which includes an action plan that addresses all the specific elements of the assessment where the screening technician scored US and any additional areas for development identified
• reflection on learning from the directly supervised training

The recovery training portfolio is designed to be a supportive, not punitive, process. The process assists the screening technician in improving their knowledge and skills and demonstrating learning that meets the required standards for their role.

It is important to set specific, measurable, achievable, relevant, and timely (SMART) objectives when action planning.

The screening technician and the local screening service are advised to keep copies of the scanning assessment and recovery training documentation (Appendix 5).

If the performance of a screening technician presents a patient safety risk, local services should inform their regional screening quality assurance service (SQAS) and public health commissioning team/screening and immunisation teams.

5.2 Reflection on learning

The screening technician is advised to reflect on their recovery training learning to:

• summarise what they have learnt from their recovery training
• identify gaps in their knowledge or skills
• plan how they will gain the knowledge or skills

The health screener diploma reflective practice template is a useful resource (Appendix 6).