Liver Quest Project Implementation Plan
April 2015
Debbie Johnston
Accreditation Consultant, Head Assessor.
RCP Accreditation Unit
Tel: +44 (0) 20 3075 1625
Royal College of Physicians
11 St Andrews Place
Regent’s Park
London NW1 4LE
www.rcplondon.ac.uk
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Document Change Control
The following is the document control for revisions to this document.
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V1.0
08 April 2015
Debbie Johnston
Submitted for approval
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Purpose of the proposal
The purpose of this proposal is to:
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Define the specific structure and work schedule for the liver project.
Define the project approach to achieve its key objectives and outcomes.
Identify the benefits and risks associated with this project.
Identify the resources and costs associated with this work.
Demonstrate there is a sound case for proceeding AND
Gain approval to proceed with the work.
Background
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The liver service project that aims to improve the care of patients with liver disease. The next phase
of the project (2015) will further test a standards framework and make recommendations for a new
accreditation process for liver services (Liver Quest). This work is being led by the Royal College of
College of Physicians of London, supported by the British Society of Gastroenterology (BSG) and the
British Association for the Study of the Liver (BASL). Dr Michael Glen, NCD for Gastroenterology and
Liver, also fully endorses the project.
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This key project will contribute to the work of the Clinical Services Accreditation Alliance, a crossprofessional body approach. Specifically, it is anticipated that Liver Quest will be a test of whether it
is possible to use a generic framework to structure improvements – and ultimately service-focused
accreditation. It will therefore raise the profile of liver services and improve standards.
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The project is aimed at ‘Medical’ liver services (hepatology) including those provided by
gastroenterologists. It encompassed liver disease from risk assessment processes, through
identification and referral from primary care and subsequent management of the issues.
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This project will contribute to and benefit from the work of the multi-stakeholder Accreditation
Alliance.
Goals
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To improve liver services through a standards framework and assessment process that is flexible
enough to meet different levels of liver services.
To contribute to and benefit from the work of the Accreditation Alliance.
Objectives
1. Create a clear purpose and partnership with key stakeholders; BSG, BASL, RCN and patient groups
2. Develop and test an accreditation process for liver services. Agreement of criteria/evidence to
support self-assessment and peer review.
3. Align all work including the standards with the accreditation alliance in particular work streams 4
and 6.
4. Develop training for peer review teams to assess services and inform the planned development of
an accreditation process.
5. Map national and local information requirements and future methodology for capture of data that
might adequately support future accreditation.
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6. Development of an online self- and external-assessment tool that will be used to determine whether
standards are being met.
7. Rollout of standards framework nationally with development of underpinning guidance on how to
achieve the standards.
8. Develop updated guidance based on pilot site visits on how to meet the standards.
9. Development of training for services in quality improvement and use of the standards and online
tool.
10. Evaluate the project and make recommendations to key stakeholders on the development and
implementation of the proposed accreditation model for liver services.
Project plan
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The following outline project plan and activities are proposed. Timelines and ability to deliver will
depend on funding. The key activities in table 1 will be implemented in partnership with the key
stakeholders identified. The key funding requirements are identified in table 2. The exact timescales
for this work will need to be agreed with the stakeholder group but it has been assumed that this
initial work will take 12 months to complete.
Table 1-activities and proposed timescales
Activities
Timescales
1. Appoint funded clinical leadership and dedicated project management
a. Provide expert leadership for all aspects of work.
b. Ensure alignment to core project objectives.
c. Ensure engagement and support for all work.
d. Act as a key point of contact for other work stream clinical leads.
e. Provide update reports to the steering group.
f. Ensure delivery of all work within agreed timescales.
April/May
2015
2. Establish a project group
a. Advise on the further development of the liver standards, guidance and
pilot assessment process.
b. To monitor progress and ensure adherence to the agreed project plan,
agreeing completion of milestones.
c. Seek specialist advice where appropriate.
d. Ensure effective communication and dissemination with all key
stakeholders and services.
e. Majority of meetings will be by teleconference with one face-to-face
meeting to explore the work to be done.
May 2015
3. Develop a communication plan to support the project
a. Implement a quality communication plan for that reaches all interested
parties and engages fully with the project objectives.
May 2015
4. Development of pilot accreditation process
a. Develop methodology for peer review process.
b. Develop & agreement of criteria & evidence guidance to support selfassessment
May-July 2015
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c. Mapping of national and local information requirements and future
methodology for capture of data that might adequately support future
accreditation
5. Conduct site visits to support pilot accreditation process
a. Identify pilot services (maximum 6) to participate in pilot process.
b. Provide training for peer review teams to assess services and inform the
planned development of an accreditation process (Remote process). All
visit will be lead/overseen by Debbie Johnston
c. Provide remote training for liver teams to prepare for accreditation process
(Remote process)
d. Produce assessment reports for each site
e. Gather feedback from each site on the process (feeds into final report)
SeptemberOctober 2015
6. Development of an accreditation assessment tool (simple)
a. To support pilot assessments. The tool will have limited functionality and
will only support the uploading of evidence and comments. No reporting
functionality.
b. Testing of IT tool with pilot services.
c. Development of remote training for online self-assessment tool.
July-August
2015
7. Rollout of standards framework nationally with development of underpinning
guidance on how to achieve the standards.
a. Develop updated guidance based on pilot site visits on how to meet the
standards.
b. Development of training for services in quality improvement and use of the
standards and online tool (2 workshops)
c. Development of IT admin functions and outputs.
d. Completion of online assessment for all liver services and report
September –
December
2015
e. Gather feedback from services regarding the standards, guidance and tool.
8. Evaluate the project and make recommendations to key stakeholders
a. Final recommendations resulting from project and implementation of the
proposed accreditation model.
b. Summary of key learning from project work
Feb 2016
9. National meeting for all key stakeholders and project sites
a. To review key learning and launch next phase of work
April 2016
Key Stakeholders for this work
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The Royal College of College of Physicians of London.
The British Society of Gastroenterology (BSG).
The British Association for the Study of the Liver (BASL).
The Royal College of Nursing.
Dr Michael Glen, NCD for Gastroenterology and Liver.
The Accreditation Alliance.
Public Health England.
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NHS project sites (appendix A).
The British Liver Trust (Patient group).
Hepatitis C Trust (Patient group).
Governance
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The clinical leadership and governance structure will be established through the Royal College of
Physicians of London.
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The 12-month project will be led and supported by the following key people until the end of April
2016 (to support a national meeting in the April).
Project working group
1. Dr James Ferguson- Project Clinical Lead/chair, Consultant Hepatologist UHB.
2. Dr Mark Hudson-The British Association for the Study of the Liver (BASL).
3. Debbie Johnston-Project manager, RCP Accreditation Consultant, Head of Assessors and
Training lead
4. Caroline Rogers-RCP Accreditation Unit manager (oversight for governance)
5. Ruby Tailor-Liver project coordinator
6. BSG representative-TBA
7. Nurse lead representative-TBA
8. Patient/lay representative -TBA
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Dr Roland Valori - National Clinical Director for Accreditation, Royal College of Physicians, London
will provide leadership and strategy expertise as required.
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Project sites will provide updates to the project manager on a monthly basis.
Risks and challenges
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Ensuring appropriate engagement with key stakeholders is vital in ensuring the quality of the end
product and its acceptance among stakeholders.
Ensuring continued engagement with project sites is vital in ensuring their continued support of this
work. The issues with funding for this work and lack of continuity have impacted on levels of
engagement.
Ensuring appropriate and sufficiently wide consultation with good responses is vital in ensuring the
quality of the end product and its acceptance among liver services.
The underpinning assessment criteria and indicators used to determine whether a standard has
been met will need agreement with stakeholders. The BSG is currently investigating whether a
wider GI accreditation scheme, including liver might be possible and this may impact upon
agreements that need to be made for this project.
Developing an accreditation scheme for liver services is complex, new and quite different to what
the RCP has developed previously. The nature of liver services is that they are broad ad varied so
designing a robust agreed approach will be both a risk and challenge in terms of complexity and
cost.
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Ensuring full funding to deliver all components of this project is likely to be a challenge. An early
discussion with key stakeholders is required as well as identification of external funding sources.
Appendix A-Liver Project Sites
Dr James Ferguson- Consultant Hepatologist &
Clinical Lead for Liver Project
UHB Birmingham
Dr Emilie Wilkes – Consultant Hepatologist
Nottingham University Hospital Trust
Dr Stephen Ryder- Consultant Hepatologist
Nottingham University Hospital Trust
Dr Mark Hudson-Consultant Hepatologist
Freeman Hospital Newcastle
Dr Anne McCune – Consultant Hepatologist
University Hospitals Bristol
Dr Carole Collins- Consultant Gastroenterologist
West Middlesex Hospital
Dr Coral Hollywood-Consultant Gastroenterologist
Gloucestershire hospitals Foundation Trust
Amanda Clements- Hepatology Nurse Consultant
Derriford Hospital
Dr Sushma Saksena-Consultant Hepatologist
Co Durham and Darlington NHS Trust
Dr Tim Cross- Consultant Hepatologist
Royal Liverpool University Hospital
Dr Saket Singhal- Consultant Hepatologist
Sandwell & West Birmingham
Dr Richard Aspinall- Clinical Lead for Hepatology
Portsmouth Hospitals NHS Trust
Dr Kara Rye – Consultant Hepatologist
Shrewsbury & Telford Hospital NHS Trust
Dr Martin Phillips – Consultant Hepatologist
Norfolk & Norwich University Hospitals
Trust
Dr Anand Reddy – Consultant Gastroenterologist
Gateshead Health NHS Foundation Trust
Dr Charles Millson – Consultant Gastroenterologist
York Teaching Hospitals NHS Foundation
Trust
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