Newborn Hearing Screening Programme (NHSP): checks and audits to improve quality and reduce risks What This is what we recommend you do Why These are the reasons why we are recommending this How This is how you might do this When This is how often we recommend you undertake the action/check Additional checks and audits 1. Identify the eligible population (new births): Have systems in to identify the new birth population that you have responsibility for, including babies on the neonatal unit and paediatric wards Maternity units must generate an accurate NHS number for all new births prior to screening, to populate the national IT system SMaRT4Hearing(S4H) NHSP local service to search S4H, to make sure all babies are entered into the screening pathway To make sure eligible population is offered screening in the correct timeframe. Screening by 4 weeks (5 weeks for community models) ensures early diagnosis and prompt treatment We have evidence from key performance indicators (KPI’s) and screening safety incidents of: babies who were not identified for screening babies who were not offered screening screening was delayed screening was not completed babies with serious medical conditions entering late into the screening pathway Have a mechanism in place to check birth registers/ward lists/home births to identify eligible cohort Local process for sharing information about babies between NICU/PICU/other paediatric wards, and births not occurring in hospital, (e.g. home births) with the NHSP service On every day the service operates As outlined in Use the national monthly data reports to check that eligible babies are identified as detailed in the guidance Submit data on KPI NH1 coverage to the NHS screening programmes quarterly. Review list of babies who have breached the KPI and investigate reason why to improve coverage
babies including those who were on NICU/PICU/other paediatric wards, who had delayed or missed screening Trust response: this row is for you to enter results, or, summarise whether you have these checks in place. If not, you can use this space to identify gaps and develop an action plan. What This is what we recommend you do Why These are the reasons why we are recommending this How This is how you might do this When This is how often we recommend you undertake the action/check Additional checks and audits 2.Identify the eligible population (movers in): Have systems in place to identify the movers in population that you have responsibility for Mechanism in place for NHSP services to be informed of any baby under 3 months of age moving into the area. A record for those born outside of England must be manually added to S4H. NHSP local service to search S4H to make sure all babies have entered into the screening pathway To ensure eligible population is offered screening in the correct timeframe. Earlier diagnosis leads to improved outcomes. Screening should be completed and a result recorded on S4H and the child health information system (CHIS) by 3 months of age We have evidence from KPIs and screening safety incidents of: babies who move in and are not identified for screening babies who are not offered screening unnecessary delays in completing screening Child health record department (CHRD) interrogate their information system, searching for any babies who are aged 3 months, without a valid screening result or, recorded decline. Inform the local NHSP service provider of this Health visitors (HV) to check that screening is performed and inform NHSP service provider if no evidence of screening Daily (Monday to Friday, excluding bank holidays) Use the national monthly data reports to check that eligible babies more than 4/5 weeks age are identified as detailed in the
What This is what we recommend you do Why These are the reasons why we are recommending this How This is how you might do this When This is how often we recommend you undertake the action/check Additional checks and audits 5. Provide information and offer screening test: Have systems in place for the screener to: check that parent/carer has received a copy of ‘Screening tests for you and your baby’ and for the information to be discussed seek verbal acceptance of screening as an informed choice from mother, (or person with parental responsibility), to carry out screening. This includes consent for storage of personal data within the national IT system Parents are aware of the screening test available for their baby and the standard national timescales, therefore, prompting requests if not offered/performed There is an expectation that if screening is accepted, the screening pathway will be completed Screening cannot be carried out without parental (or appropriate) informed choice to accept screening To make sure that the limitations of screening are understood that ‘Screening tests for you and your baby’ was given The informed choice to accept screening (which includes consent for storage of personal data within the national IT system), should be recorded on the NHSP proforma, the screening equipment, the NHSP IT system (S4H) and in PCHR ‘Screening tests for you and your baby’ is given during pregnancy and revisited before screening Informed choice to accept screening is obtained prior to screening being undertaken Ensure accept/decline is correctly ascertained by screening staff during their annual competency assessment Audit that the booklet was given, evidenced by records in the maternity notes/system - annually Trust response: this row is for you to enter results, or, summarise whether you have these checks in place. If not, you can use this space to identify gaps and develop an action plan. What This is what we recommend you do Why These are the reasons why we are recommending this How This is how you do this When This is how often we recommend you undertake the action/check Additional checks and audits
6. Informed choice to decline screening: To facilitate informed choice, have mechanisms in place for recording declined screening, in order to: ensure parents make an informed choice monitor declines outcome from the offer of screening is known To make sure that the limitations of the screen are communicated and understood Parents should have information to be able to decline the screen based on personal choice Declines should be recorded on S4H. Parents should be given a decline letter outlining what to do if they change their mind, and what they should do if they are worried in the future about their child’s hearing. The HV and GP should be informed At the time of the screen To review and monitor number of declines, as detailed in the quarterly data reports, and investigate any inequalities that may exist and any significant changes Trust response: this row is for you to enter results, or, summarise whether you have these checks in place. If not, you can use this space to identify gaps and develop an action plan. What This is what we recommend you do Why These are the reasons why we are recommending this How This is how you might do this When This is how we recommend you undertake the action/check Additional checks and audits 7. Identify babies where screening is incomplete: Have systems in place to track from offer to a valid screening result, or, confirmation of decline. Have a process in place for taking remedial action to offer and undertake screening Earlier diagnosis leads to improved outcomes We have evidence from screening safety incidents of: screening not completed babies with hearing impairment entering late into care NHSP local service to check S4H for babies without a screening outcome and take appropriate action, in line with Interrogate S4H and the child health information systems, searching for any Weekly Use the national monthly data reports to check that eligible babies have been identified, as detailed in the guidance (within the operational guidance)
Make sure screening pathway is completed where consent is given babies who are aged 3 months without a valid screening result, or, recorded decline HVs to check that screening has been performed, and inform NHSP service provider if no evidence of screening, to enable follow up Trust response: this row is for you to enter results, or, summarise whether you have these checks in place. If not, you can use this space to identify gaps and develop an action plan. What This is what we recommend you do Why These are the reasons why we are recommending this How This is how you might do this When This is how often we recommend you undertake the action/check Additional checks and audits 8. All screening equipment to have QA checks: Make sure all equipment has the necessary QA checks performed prior to undertaking screening, in line with NHSP protocols To make sure an accurate screening result is obtained We have evidence from screening safety incidents and quality assurance visits, of screening being performed using equipment that is not in line with NHSP protocols NHSP local service to check equipment prior to performing newborn hearing screening. QA results are uploaded to S4H and paper log maintained, which is routinely checked for adherence to protocol Equipment has QA checks undertaken on each day of use prior to any screening Screeners are responsible for checking before the equipment is used to screen babies, and reporting any problems to their local manager; who must investigate and take action if necessary. NHSP Local manager to carry out administrative functions and regular data quality checks within the national IT system, as specified by Screening equipment should be calibrated as per manufacturers’ recommendations
What This is what we recommend you do Why These are the reasons why we are recommending this How This is how you might do this When This is how often we recommend you undertake the action/check In addition to failsafe 10. Referral to audiology: Have systems in to ensure baby is referred in appropriate time scale and attends first audiological assessment. The audiology team should update S4H with outcome data Earlier diagnosis leads to improved outcomes. We have evidence from screening safety incidents of: delay in audiology appointment due to a delay in transferring the baby’s record on S4H delay in diagnosis due to non-attendance of audiological assessment Screening team that made the referral requests confirmation that the referral was received Screening and audiology teams have system in place to make sure parents receive and are reminded of audiology appointment Ideally, the system allows the screener to confirm an appointment with the family at the point of screen referral, e.g. via access to an online diary of audiology appointments Screening team monitor referrals until attendance at audiology is achieved DNAs are followed up in line with processes. For each referral. Weekly check on S4H to identify screen referrals that have not been appointed or seen in audiology. Liaise with the responsible audiology departments and check that they are taking action with regard to these children. GPs and HVs to be informed of any screen referral who has not attended an audiology appointment Use the national monthly data reports to check that eligible babies are identified as detailed in the Audiologists to use the national IT system audiology searches, to ensure they are following the audiology pathway to completion NHSP service data is submitted on KPI–NH2 to the NHS screening programmes quarterly Review list of babies who have breached the KPI to investigate reason why, follow up as necessary, and to help improve attendance rates The list of active records for each site is included in the monthly