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Healthcare services play a crucial role in our lives, and it is essential to ensure that they meet the highest standards of quality and safety. Just like we expect high standards when choosing products like toys and electronics, we should demand the same level of excellence when accessing healthcare.
Many industries, including calibration laboratories and private security companies, demonstrate their commitment to high standards through accreditation. This method provides assurances of competence and patient safety. In this article, we will explore the journey of a hospital department in gaining accreditation to the IQIPS standard (Improving Quality In Physiological Services) for Clinical Neurophysiology at a leading teaching hospital.
The journey towards accreditation
Having initially embarked on the accreditation journey, it quickly became apparent that there were numerous tasks to complete in order to meet the comprehensive requirements of the IQIPS Standard set by the Accreditation Clinical Advisory Group to then meet the assessment criteria required by the United Kingdom Accreditation Service (UKAS). The initial fear of lack of time and resources was overshadowed by the realisation of the potential for departmental improvement. Services often realise too late that it would be helpful to document the “before and after” of the department’s transformation throughout the process, so this is something that can be taken into consideration.
Accreditation in healthcare services, particularly for small and specialized departments, can be intimidating if it is introduced later than other services. However, it is important to remember that the NHS business plan of 2014/15 set a target of 70% scientific services engaging in the accreditation process or gaining accreditation by March 2015. Additionally, UKAS accreditation is now recognised by the Care Quality Commission (CQC), meaning that services could be visited as part of the CQC assessment.
Gaining support and collaboration
One of the critical factors in the accreditation journey is gaining support from within the hospital trust. It is essential to involve clinical audit departments and higher management in the process. Working collaboratively with other specialties within the trust can also prove beneficial. While the initial submission can be separate, joining together in subsequent years can reduce duplication of work and streamline the process by providing overarching trust documents and statements.
Organisation and document control
Organisational skills are paramount when embarking on the accreditation process. Creating new folders on a shared drive for each area of the department, including management, local policies, infection control, health and safety, and clinical testing, helps to keep everything organised and easily accessible.
In the past, updates to Standard Operating Procedures (SOPs) and guidelines were often delayed due to clinical workload. However, the accreditation process necessitates a rolling program to ensure prompt review and revision of these essential documents. Implementing version control ensures old versions are no longer accessible once updates have been made.
Document control becomes the nerve centre of the department, overseeing the writing and maintenance of new guidelines, policies, and SOPs. An Excel spreadsheet can be utilised to track the various documents, including risk assessments, SOPs, and patient leaflets. This centralised system with clear due dates helps to delegate tasks effectively and ensures nothing falls through the cracks.
Improving physical environment and infection control
An important aspect of the accreditation process is assessing the physical environment and implementing necessary improvements. It is advisable to take a proactive approach by inviting infection control staff, laypeople, estate managers, and trust managers to assess the surroundings. This fresh perspective can lead to a massive clearance of all rooms, redecoration, clearance of old data and equipment, and the purchase of new furniture. The department can effectively become part of an infection control accreditation program, implementing strict cleanliness protocols and displaying informative materials for patients and staff.
Enhancing patient safety and consent procedures
Ensuring patient safety is at the core of the accreditation process. It will be necessary to develop a robust written consent procedure that clearly outlines any risks associated with various tests and procedures. This information can be incorporated into patient leaflets to ensure patients are well-informed and understand the potential risks involved.
Continuous improvement and collaboration
The accreditation journey does not end with achieving the first grant of accreditation. It is an ongoing process that requires continuous improvement and a commitment to change. It will be necessary to continue to refine document and quality control systems, making future submissions significantly easier. The process can also contribute to enhanced delegation and ownership of tasks among staff, contributing to their professional development and increased confidence in conducting audits and service evaluations.
Positive outcomes of accreditation
The efforts put into gaining accreditation can yield numerous positive outcomes for physiological services. Through the process it may be possible to access support and funding for any required improvements to the physical environment and the management system will naturally evolve and improve. This can promote better personnel development and increased confidence among staff involved in audits and service evaluations. Most importantly, accredited services will receive positive feedback from patients and referring consultants, highlighting the positive impact of accreditation on the overall quality of care.
Conclusion
Accreditation plays a vital role in ensuring healthcare services meet high standards of quality and safety. The journey towards accreditation requires organisation, collaboration, and a commitment to continuous improvement. Through dedication and hard work, accredited services will not only achieve accreditation but also improve the overall quality of care and received positive feedback from patients and consultants. Accreditation is an ongoing process that fosters continuous improvement and inspires others to strive for excellence in healthcare services.