Whole Trust Accreditation University Hospitals Birmingham Diagnostic Services

Whole Trust Accreditation University Hospitals Birmingham Diagnostic Services Accreditation Programme (DSAP) Dr Debra Balderson WM GMC Diagnostic Services Accreditation Lead/ Healthcare Science Education Lead Debra. Balderson@uhb. nhs. uk http: //www. westmidsgmc. nhs. uk/professionals/diagnostic-services-accreditation/

UHB Accreditation Drivers? • NHSE and University Hospitals Birmingham (UHB) NHS Foundations Trust entered into a contract whereby UHB are undertaking the role of lead organisation, hosting the West Midlands Genomics Medicine Centre (WMGMC), based at the Institute of Translational Medicine (ITM). • Contract Schedule 2, General Terms and Conditions, 1. 2. 8 • The partnership provided an opportunity to focus collectively on all diagnostic services for the first time • The WMGMC comprises 18 local delivery NHS partner Trusts (LDPs) all of which, under the terms of the WMGMC partnership arrangements, have committed to working towards the accreditation of their diagnostic services against IQIPS, ISAS, and the JAG standards.

Initial approach • What is required? – 4 domains: 1. 2. 3. 4. Patient Experience (have a department!) Safety (have a department) Facilities, Resources and Workforce (have departments) Clinical (have the service) • What’s in place? – Other accredited services • What shared experience can we count on? – Other accredited services in the country?

Existing UHB Accreditation • UHB Accreditation Schemes UKAS Schemes: • • • ISO/IEC 17043 ISO 15189: 2012 Improving Quality in Physiological Sciences Imaging Services Accreditation Scheme NEQAS Medical Laboratories (IQIPS - Audiology) (IQIPS) (ISAS) Other Schemes: • • Joint Advisory Group on GI Endoscopy (JAG) Quality Assurance Standards audit by the Institute of Medical Illustrators Human Tissue Authority (HTA) Joint Accreditation Committee. International Society for Cellular Therapy. European Society for Blood and Marrow Transplantation (JACIE) European Society for Blood and Marrow Transplantation (EBMT) British Standards Institution (BSI) for the Radiation Protection Services College of Clinical Perfusion Scientists

Almost 2 years later…. • Clinical domains left largely unaddressed • Application for accreditation …. H&S Pat Ex Workforce Documentation Different services had offered systems and evidence for what should be an organisational system

Share the Knowledge and Experience? • Labs-years of CPA experience…. – Too busy – Not the same process – Different criteria – Where are the resources? – Where is the funding? Cost and time

Share the Knowledge and Experience? • Audiology-years of IQIPS experience…. – Too busy – Not the same clinical process – Where are the resources? – Where is the funding? – How robust is the system in place for Trust roll out? Cost and time

Sept 2016 • Diagnostic Services Accreditation Programme. DSAP – – – – Plan/Timescale Accreditation application Gantt chart-responsibilities Structure Included/Excluded Experts Sponsorship • • A structured process for achieving a predetermined aim using a unique set of co-ordinated activities following a life cycle with specified start and end dates. It is temporary in nature and normally uses a team approach with limited resources in terms of finance and people

IQIPS/ISAS Standards (before 2017 review) Create model for Trust-wide accreditation - UHB Accreditation Scheme 1. Patient Experience 2. Safety 3. Facilities, Workforce and Resources ORGANISATION SOLUTIONS 4. Clinical Discipline Solutions • 4. Integration of QM across all Diagnostics Clinical Services • Service Pathway Mapping • Quality Assurance • Protocol management review • SOPs (controlled and multi-disciplinary) • Clinical Risk Management • Practice review-innovation and collaboration 1. Bespoke Patient Experience Programme 2. Health and Safety programme • Site visits/Audit Revised Mandatory Training Programme 3. Workforce and Facilities refresh • HCS education and workforce Strategy • Collaborative Physiological Sciences meetings Audit programme • Medical Engineering • Contracts • Environment

Diagnostic Services Accreditation Programme IQIPS Cardiac Physiology Vascular Science ISAS Imaging • Radiography • Ultrasound • Mammography • CT • MRI • Bone Mineral Densitometry GI Physiology JAG • Radionuclide Imaging All Other UHB Accreditation Schemes NEQAS Endoscopy Med Labs Med Illustration Lung Function and Sleep HTA Neurophysiology JACIE Audiology EBMT Urodynamics BSI RPS Ophthalmology Perfusion

Essential Organisation Sponsorship To be effective, transformational work of this scale requires sponsorship and support at Director level within an organisation. The Executive Chief Operating Officer and the Executive Director of Delivery have supported the Trust-wide accreditation programme at UHB, acknowledging the benefits, such as continuous improvement in processes and patient outcomes. Allowed a meaningful governance structure to be established for DSAP.

UHB Diagnostic Accreditation Governance Structure Exec Board WM GMC Governance structure CEAG COOG Do. D Diagnostic Services Accreditation Programme Steering Group (DSAP SG) Diagnostic Services Accreditation Programme User Group (DSAP UG)

Governance Structure DSAP Steering Group Meeting frequency: Monthly • Chair: DDo. D • TOR • Strategic/Planning • Gap Analysis – IQIPS and ISAS criteria • Risk register Membership: • WM GMC Accreditation Lead • Head of Clinical Risk and Compliance • Head of Patient Experience • Head of Service Improvement • Diagnostics Theme lead • WMGMC Operational Programme Manager • Health and Safety Manager DSAP User Group Meeting frequency: Monthly Chair: WM GMC Accreditation Lead TOR • Operational performance review • TLR completion • Domain Compliance Reviews • Gap Analysis • Risk register • SOPs Membership: • Departmental Accreditation Leads • Diagnostics Theme lead • WMGMC Operational Programme Manager

Organisational Distribution of Diagnostic Services Division A Division B Division C Division D • Clinical Laboratory Services • Clinical Biochemistry • Histopathology • Microbiology • Haematology • Cellular Pathology • Cardiology Physiologists • Vascular Physiologists • GI Physiologists • Renal Technical Services • Liver Labs • Endoscopy • Lung Function and Sleep • Ophthalmology • • • NEQAS • Medical Physics • Perfusion • Tissue Services • Phlebotomists • Imaging Life Sciences Clin Eng/ Medical Physics Neurophysiology Audiology Max Fax Uro-Dynamics Corporate • Medical Illustration • Medical Engineering • Research Scientists • Bioinformatics Physiological Sciences Bioinformatics- sits both in Medical Physics (Physical Sciences) and Corporate (Health Informatics and Genomics),

Transformation (without any power!) • Get Organisational Sponsorship – UHB COO, ”The IQIPS programme at UHB will ensure that Physiological Scientific Services becomes part of the quality improvement and quality assurance agenda in the NHS. It provides a set of standards which will mark the quality of these services for commissioners, providers and users of service with patient quality outcomes at its core. ” • Project Management principles • Create Governance structure – up to Exec Board • Know the teams/experts – Trust and mutual respect • Give the work to the experts – H&S, Patient Exp, Clinical, Facilities • Do once and share – Why do more? Opportunity for peer review? Professional feedback? Standardisation.

Say Goodbye to SILOS

Highest Standards of Excellence and Professionalism • Not accredited! • Desire to share-get peer review and more uptake of standard protocols (think Audiology) • Sharing=networking=idea-exchange=collaboration=innovation • NHS Constitution: “provides high quality care that is safe, effective and focused on patient experience; in the people it employs, and in the support, education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion, conduct and use of research to improve the current and future health and care of the population. Respect, dignity, compassion and care should be at the core of how patients and staff are treated not only because that is the right thing to do but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported.

WM GMC Diagnostic Services Accreditation Programme • Phase 1 - Local Transformation – UHB Accreditation • Phase 2 - Regional Transformation – WM GMC Accreditation • Phase 3 – Sustainability – National Opportunity for Transformation