Liver quest project
Project update
Dr James Fergsuon-Clinical Lead
Debbie Johnston–RCP Head of Assessors &
Accreditation Consultant
August 2014
Project aims (1)
1. Review and remap the standards framework, ensuring that they are fit
for purpose
2. Develop an effective partnership between the RCP, BSG and BASL to
achieve the project objectives
3. Establish a clear structure to achieve the pilot standards in a systematic
and staged way
4. Create clear underpinning quality indicators and auditable outcomes.
Link to information available (national data)
5. Develop the accreditation evidence requirements to achieve the
standards
6. Develop the IT system to support self assessment and knowledge
management
Project aims (2)
7.
Create and test a ‘pathway focused’ accreditation process
8.
Provide updates and learning to as appropriate to the Clinical Service
Accreditation Alliance on project work, ensuring that it feeds into
wider develop work for clinical service accreditation.
9.
Evaluate the project and make recommendations to key
stakeholders on the future of the standards and proposed
accreditation model.
Revised project stages & timescales
Project Phases
Timeline 2014-15
Phase one:
1. launch of project.
March-June
2. Review of framework-final agreement of domains/items
Phase two:
1. IT development final agreement of domains/items
2. Reassessment and action plan
3. WebEX contact with project sites.
4. Create evidence to support a pilot accreditation process
Phase three
1. Develop pilot accreditation process
2. Agree final pilot sites/services for visits to test
accreditation process (4 sites)
3. Prepare sites/services for visits (remote training)
4. WebEX contact with project sites-review of progress
July-August
SeptemberNovember
Project stages & timescales
Project Phases
Timeline 2014-15
Phase four:
10. Train assessors & lay reps-workshop
11. Conduct site/service assessments.
12. Review process and evidence criteria
13. Monthly WebEX calls
NovemberFebruary
Phase five:
14. Final meeting review and feedback
15. Evaluation report
March/April 2015
Liver QuEST domains & Standards
•
For the purposes of the pilot only the highlighted standards will be mandatory
and tested
The accreditation pathway-pilot
Objective 1 : test the standards in different levels of
liver services across a pathway
Proposed stages:
• Self-assessment against accreditation standards online
• Online submission of defined minimum data/evidence.
• Assessment of evidence and service:
• Remote-online assessment
• Site visit-interviews and assessment of further
evidence
• Assessment report draft
• Feedback on process
Accreditation pilot
•
•
•
4 different types of liver services will be assessed
Some pilot sites (not being assessed) will be invited to
form part of the assessment teams
Support will be provided through a number of
mechanisms:
– Direct training
– Remote support
8
Pathway - Stage One
Liver Service
complete online
self-assessment
Liver Service
works on
improvements
• Online system automates a rating for
each standard according to a traffic
light system (level 1-4)
Liver Service
reviews evidence
requirements &
gap analysis
• Access to
evidence
information &
upload
9
Stage Two
Agree date for
remote and site
review
• Pilot Services have access to
accreditation training,
Accreditation
• Agree who needs to be
interviewed
Assessors review
evidence prior to
visit
• Assessors review the evidence
portfolio, provide feedback to the
Service and add comments
Assessors
conduct an
assessment and
prepare a report
• Assessors conduct site
assessment and complete
their report with their
findings and
recommendations
10
Project teams-tasks summary
1. Complete a new assessment and action plans
2. Provide feedback on the updated standards and evidence
requirements (10 mandatory standards)
3. Host a site assessment (4 sites only)
4. Repeat the assessment (6 months later)
5. Provide feedback about the overall process
6. Share learning and improvement ideas