Dr Conall J. Garvey
Royal Liverpool University
Healthcare in the UK is undergoing a major restructuring. New untested independent healthcare providers are appearing on the scene, especially in medical imaging, making it crucial that clinical standards are implemented and improved.A leading UK accreditation programme is being jointly developed by the Royal College of Radiologists (RCR) and the Society and College of Radiographers (SCoR) to address this.
The programme is funded jointly by the RCR and SCoR, along with grants from BUPA, the Department of Health (England), the Nuffield Trust and Philips Medical Systems. These have enabled the project to go on from the initial scoping exercise in Autumn 2005 to subsequent pilot testing, which commenced in April 2007 and finally, UK-wide rollout is planned for early 2008.
Background of the Radiology Accreditation
Why is the medical imaging community so concerned with accreditation of quality? Previously, UK radiology departments benefited tangentially from visits by the RCR Training Assessment Committees (TACs). Although primarily focused on training of radiologists, these visits acted as a powerful driver to change, particularly where facilities and equipment were unsatisfactory. The establishment of the Postgraduate Medical Education and Training Board (PMETB) ended these regular visits and the consensus is that the new system is less likely to identify issues related to both service and training within radiology departments.
Moreover, following the publication of the NHS Plan (2000) and Cancer Plan (2001), the English government indicate that 15% of “diagnostics” will be delivered by independent sector providers from 2007. PACS is being installed across England and likely to be complete by the end of 2007. Payment by Results (PBR), a new method of reimbursement, will have a significant effect on radiology departments. Furthermore, patient choice is becoming an important driver for change in the NHS.
In order to respond effectively to these changes, the RCR developed the Radiology Accreditation Programme as a centralised, structured way of ensuring quality in this new environment.
How is the Programme Evolving?
The accreditation programme is voluntary and professionally- led, having attracted wide stakeholder involvement from the English Healthcare Commission, the NHS Confederation, the General Medical Council
(GMC) and the Institute of Physics and Engineering in Medicine (IPEM). Financial and other support has been forthcoming from various bodies including industry and private health providers and insurers.
Since September 2006 workstreams, consisting of a range of relevant professionals with significant input from patients, have been developing accreditation standards. These are currently being edited and crosschecked against existing requirements (for example with the HCC standards, which form part of the annu al health check required for all English hospitals) in order to reduce the burden of data collection.
How will the Programme be Structured?
Currently, it is intended that the accreditation programme will involve a three-year cycle. After registering with the programme, departments start applying the standards. After a period of between 6 and 12 months, a self-assessment against the standards will be completed and, together with a completed portfolio of evidence, will be submitted to the accrediting body. This will be followed by a peer review visit to validate the self-assessment. The visit will be followed by a report in three forms.
Firstly, a detailed report including areas requiring development will be given to the department. A less detailed, higher level report will be sent to the commissioners who purchase the service and a third report will be published on the web which can be accessed by patients of the service. This is intended to help inform patient choice. In order to maintain accreditation, the department will be required to submit an annual self assessment to ensure that standards are being maintained. Following the third year, the cycle recommences with a further peer review visit. As the system matures, it is expected that self assessment will be expanded and the burden of repeat visits reduced.
How are Standards being Developed?
In September 2006, twenty workstream leads were recruited to set up expert groups to develop standards. Each was multidisciplinary and involved patient representatives. Standards were originally commissioned under four major headings: Patient Safety, Patient Experience, Clinical Outcomes and Resource Efficiency. Further headings have subsequently been added to reflect underpinning aspects of a radiology service including management, audit and other governance issues. The standards are currently being edited to ensure consistency. Draft standards, now on the RCR website, will be finalised towards the end of 2007.
One of the features of this programme, is the use of developmental standards. The precise format of the standards is being re-evaluated but it is expected that a department working with the standards will be in a position to understand what is required to achieve excellence in each area of practice.
Wherever possible, the standards are designed as a series of statements of practice, often with four levels of achievement. The top line statement is aspirational, representing an exemplar of practice. Below this level will be up to three further levels of compliance reflecting good, fair and poor compliance.
Some standards, particularly those relating to legislation, will be straightforward. Others will focus on outcome measures rather than being process-driven. For example, to comply with an individual standard, it will usually be insufficient to have a policy in place; the standards are generally constructed to require evidence of policy implementation. This places a greater burden on the department but, increasingly, many accreditation programmes are moving to an outcome-based system.
One of the aims of the programme is to encourage and assist departments to improve the standards of their clinical service. This will be done partly through the developmental standards that highlight how individual departments comply with each area of performance. The assessment will be underpinned by development support. Precisely what this “support” will look like is being scoped at this time. One option would be to develop a web-based signposting system, linked to individual standards which could direct departments to key resources which will help them address areas of weakness or non-compliance.