26  |  Colposcopy and Programme Management
11. There must be a permanent couch and colposcope. 12. Appropriate sterilising facilities must be available in accordance with local and national health and safety recommendations. 13. In units offering a diagnostic service, there must be automatic referral to a unit where treatment is available if required. 14. Clinic staff must always be familiar with the treatment method(s) used (100%). 15. If laser or diathermy equipment is in use, there must be adequate safety guidelines in place with all staff trained in their operation; emergency guidelines must be available in each clinic. 16. Adequate resuscitation equipment must be immediately available and staff involved in the clinical care of patients must be familiar with its use. 17. There must be suitable information technology equipment and software to facilitate collection of data for the BSCCP minimum data set and for submission of the statutory quarterly KC65. 18. All clinics must have a named colposcopist with appropriate skills who leads the service, with a specialist team specific to the colposcopy unit. The named lead colposcopist must have a job description. 19. There must be at least two nurses for each clinic. 20. Nurse colposcopists working in a clinic role must be supported by another registered nurse and a second nurse or a clinic attendant. 21. There must be adequate dedicated clerical support for the clinic. 22. There must be written protocols for the management of non-attenders. 23. The default rate should be less than 15%. 24. Colposcopy clinics in GUM must have established protocols for liaison with gynaecological services (100%). 25. Multidisciplinary audit must be an integral part of the service. 26. The MDT should meet once each month (best practice) or at least once every two months (minimum standard). 27. All colposcopists should attend at least 50% of MDT meetings to ensure the timely management of difficult cases and discordant results (minimum standard). Attendance at MDT meetings should be recorded (minimum standard). 28. Decisions on each case must be recorded in patients’ medical records (minimum standard). The minutes of each meeting, including the outcome of any discussion, should be recorded and a letter describing the recommendation for future care must be sent to the colposcopist responsible for the patient (minimum standard). 29. All cases of cervical cancer must be reviewed by a gynaecological cancer centre MDT (minimum standard). 30. All colposcopists in the team should be certificated through the BSCCP/RCOG training scheme and compliance with the re-certification process every three years is highly desirable. 31. All colposcopists practising within the NHSCSP must see at least 50 new abnormal cytology referrals per year. Possession of a current BSCCP certificate does not exempt a colposcopist from achieving this standard. 32. All colposcopists must attend at least one BSCCP recognised colposcopy meeting every three years.
NHSCSP May 2010