UKAS Accreditation for IQIPS. Laura Booth Assessment Manager

Transcription

1 UKAS Accreditation for IQIPS Laura Booth Assessment Manager

2 Overview Accreditation UKAS IQIPS Scheme What assessors look for IQIPS update Benefits of accreditation

3 Accreditation ISO/IEC define accreditation as A third party attestation related to a conformity assessment body conveying formal demonstration of its competence to carry out specific conformity assessment tasks. Conformity assessment is defined as a demonstration that specified requirements relating to a product, process, system, person or body are fulfilled. Formal recognition that an organisation is competent to carry out specific tasks/activities

4 Accreditation Principals The customer must demonstrate competence against a recognised Standard The accreditation body must impartially verify evidence to support this claim

5 An accreditation scheme The Standard The Accreditation Body Assessors The Process

6 UKAS UK s national accreditation body Recognised by Government, via MOU, to assess and accredit UK organisations UKAS operates in the public interest and our performance is assessed internationally A private company limited by guarantee (non-profit distributing)

7 UKAS Owned by 15 members representing stakeholders Over 200 permanent staff (Head office in Feltham, Middx.) Over 150 Assessment Managers (mostly home-based) Over 500 Contracted Assessors & Technical Experts

8 UKAS customer-base Calibration and Testing Laboratories Certification Bodies Inspection Bodies Notified Bodies for EU Directives Proficiency Testing Providers Healthcare (medical pathology, diagnostic imaging & physiology services)

9 UKAS - IQIPS UKAS licensed to manage and deliver an accreditation scheme for 8 physiological science disciplines Accreditation is against the IQIPS standard IQIPS standard developed, owned and maintained by The Royal College of Physicians

10 IQIPS Standard IQIPS standard is set out under four quality domains: Clinical, CL (one for each discipline) Facilities, resources & workforce, FR Patient experience, PE Safety, SA Each domain comprises a number of standard statements/clauses Each standard statement includes a brief rationale and a list of criteria/sub-clauses

11 Accreditation process for IQIPS 1. Pre-Application 2. Application 3. Pre-assessment IQIPS Process 4a. Initial assessment (web-based assessment) 4b. Initial assessment (on-site assessment visit) 5.Provisional & Final Decision (Initial Grant of Accreditation) 6,7,& 8. Annual maintenance & Reassessment

12 Accreditation cycle

13 Assessors UKAS recruit, train and authorise assessors (currently 48 authorised assessors across the standard with about 70 having been trained) Technical assessors must be practising in the discipline Assessors paid for on-site assessment visit work Now have 12 Lay assessors trained and have been introduced from June 2015 to meet CQC requirements

14 Assessments Assessors assume that a competent organisation is committed to achieving good professional practice; will ensure appropriate quality of activities to meet the needs of users and, will assure the quality by using an appropriately designed management system All judgements are based on the documentary, observational and verbal evidence provided by the customer

15 Conformity with standards Information/ evidence to demonstrate that the service meet the requirements set out in the accreditation standard Agreed systems that are implemented and monitored Systems are the agreed ways of working within the given organisational structures, includes the processes, procedures, equipment and facilities, people and expected behaviours to achieve desired outcomes

16 A Quality Management System An organised approach to documentation of systems. A quality management system provides the integration of organisational structures, processes, procedures and the resources necessary to fulfil a quality policy in a manner that meet the needs and requirements of users. Assessors will want to see: Controlled documents (policies and procedures, checklists, records and forms, report templates etc.) Management review reports including major changes in organisation and management, resources or processes Internal audits findings and actions (status of corrective & preventative actions)

17 Quality Management System Customer feedback, complaints & appeals Contracting and sub-contracting arrangements; services, equipment and suppliers Reports by outside bodies Staff training/competency records Calibration records Risk assessments Request forms and clinical reports Records of meetings Staff and patient survey forms, reports and actions taken Patient information

18 Assessment Approach Assessors will only assess the evidence provided by / received from the customer All relevant standards and criteria have to be met for accreditation to be achieved The assessment team will use a holistic approach to determine overall conformity with the Accreditation Standard Standard statements and or criteria that are not relevant to the scope of the service must be agreed as non applicable with the assessment team

19 Assessment Approach Assessors will independently and impartially verify the information / evidence provided Assessors are trained to ask: Why (what is the expectation)? What? How? When? Where? and By Whom?

20 Assessment Approach Assessors are looking to be convinced that the service s processes will lead to valid outcomes Assessors will need to be generally assured that the organisation have systems in place to consistently deliver its activities to agreed performance levels Effective assessment relies on the customer operating with integrity and being open, cooperative and receptive to opportunities for improvement.

21 IQIPS Scheme update 31 physiology services 28 audiology, 1 GI and 1 Vascular 1 Neuro 30 further applicants in UKAS process and a further 4 organisations are at the provisional decision stage and is likely to be successfully granted accreditation before the end of Many more in RCP- SAIT process The scheme is open to receive applications from 7 physiology disciplines

22 Benefits for patients Key benefits for patients Strengthened focus on patient safety and quality of care Professionally endorsed standards of care Improved governance of standards, supporting continuous improvement Standards need to be formulated to promote the likelihood of the service being delivered safely and effectively, to be clear about what has to be done to comply, to be informed by an evidence base and to be effectively measurable. Robert Francis, QC, Chairman of the Mid Staffordshire NHS Foundation Trust Public Inquiry Increased confidence in the service

23 Benefits for professionals Key benefits for professionals Demonstrable professionalism and professional ownership of standards, in line with the recommendations of the Francis Report Helps to define ownership and maintain clarity of roles and responsibilities..the accreditation process is one that requires considerable effort, but if shared across the team it empowers everyone to feel that it is worthwhile. Indeed this empowerment reenergised the team to look at existing practices more critically and where appropriate, implement new ways of working. Opportunity for self-critical appraisal and improvement Martin Anderson, Advanced Practitioner in Audiology, Bolton NHS Foundation Trust

24 Benefits for Senior Management Key benefits for Boards Proactive risk anticipation and management Recognised by CQC Promotes reflective practice, improvement and innovation at an organisational level Secures confidence in the system for patients, service providers and the team Acts as a leverage for change, improves staff motivation and sharing of best practice.. the accreditation process was challenging but provided a good opportunity to ensure that all our services, policies and procedures are compliant with the latest clinical. Legal and regulatory standards and good practice. Jane Shaw, Chief Executive, Action for Deafness

25 Benefits for Commissioning Groups Key benefits for Commissioning Groups Raise local standards and choice Support decision-making by providing third party confirmation of good practice Enhance efficiency and value for money Accreditation is absolutely essential to ensure quality of supply. Lord Carter of Coles, Chair, The Independent Review of NHS Pathology Services

26 THANK YOU