Liver Project-2014 to 2015
Dr James Ferguson-Clinical Lead
Debbie Johnston-Project Manager
1. Introduction

The liver service project that aims to improve the care of patients with liver disease. The
project will test a pilot standards framework and 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.

This key project will contribute to the work of the Clinical Services Accreditation Alliance,
a cross-professional 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.
.
•
•
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.
It was anticipated that the framework and process would facilitate service improvement
by providing teams with a road map of tasks that need to be done to provide high quality
care – and enable them to assess progress.
2. Project outline
•
The project will run for a year so that the benefits and good practice of the original pilot
are not lost.
•
The framework and accreditation pilot work will align with the RCP’s strategy for
accreditation, the wider Accreditation Alliance Project.
•
A new pilot accreditation model for liver services will be developed and tested.
•
The work will build alliances with other agencies and patient groups that have a stake in
ensuring there is high quality Liver Services and value for money
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•
The project will improve the use of nationally available
data to improve service planning (e.g. mortality and HES)
•
The clinical leadership and governance structure will be established through the Royal
College of Physicians of London.
Core project objectives:
1. Create clear purpose and clinical leadership
2. Identify key stakeholders and develop a communications plan
3. Build alliances with other agencies that have a stake in ensuring there is high quality liver services
and value for money
4. Review and remap the standards, ensuring that they are fit for purpose and add value
5. Establish a clear structure to achieve the standards in a systematic and staged way
6. Create clear underpinning quality indicators and auditable outcomes
7. Link to information available (national data)
8. Develop the evidence requirements to achieve the standards
9. Develop the IT system to support changes
10. Create and test accreditation process in agreed sites.
11. Provide updates and learning as appropriate to the Clinical Service Accreditation Alliance,
ensuring that it feeds into wider develop work for clinical service accreditation.
12. Evaluate the project and make recommendations to key stakeholders on the future of the
standards and proposed accreditation model.
13. Prepare a report for the RCP and accreditation alliance with recommendations for wider adoption
and accreditation rollout at month 12.
The project is structured into four phases; each phase up to phase four includes underpinning
objectives with tasks and time required to achieve them.
3. Project terms of reference
Purpose
The Liver Services project group is tasked with leading and overseeing the development
and implementation of standards for liver service supported by peer review accreditation.
Functions/
Responsibilities

To lead and oversee the establishment of a project group which will develop the
framework, standards and accreditation methodology that liver services will work
within.

The work of the project group will principally include the agreed core objectives and
any others that may transpire through the course of the project.

Develop and keep under review a communications strategy for this programme of
work.

Develop a business case for external funding to support the work of the Alliance.
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Meetings
Frequency: Meetings will be held four times per year.
Location: Meetings will be face to face or via video and teleconferencing as the agenda
dictates
Administration: Minutes will be prepared and circulated by the Royal College of
Physicians.
Chair/Project
lead
Dr James Fergusan
Project
Membership
Dr James Fergusan-Clinical Lead
UHB Birmingham
Debbie Johnston-Accreditation Unit, Head of
Assessors and Accreditation consultant
Dr Emilie Wilkes – Consultant Hepatologist
RCP London/QSfH
Dr Stephen Ryder- Consultant Hepatologist
Dr Mark Hudson-Consultant Hepatologist
Anne McCune – Consultant Hepatologist
Dr Carole Collins- Consultant Hepatologist
Dr Coral Hollywood-Consultant Gastroenterologist
Amanda Clements- Hepatology Nurse Consultant
Sushma Saksena-Consultant Hepatologist
Dr Tim Cross- Consultant Hepatologist
Dr Saket Singhal- Consultant Hepatologist
Dr Richard Aspinall- Clinical Lead for Hepatology
Kara Rye – Consultant Hepatologist
Martin Phillips – Consultant Hepatologist
Anand Reddy – Consultant Hepatologist
Charles Millson – Consultant Hepatologist
Nottingham University
Hospital Trust
Nottingham University
Hospital Trust
Freeman Hospital
Newcastle
University Hospitals Bristol
West Middlesex Hospital
Gloucestershire hospitals
Foundation Trust
Derriford Hospital
Co Durham and Darlington
NHS Trust
Royal Liverpool University
Hospital
Sandwell & West
Birmingham
Portsmouth Hospitals NHS
Trust
Shrewsbury & Telford
Hospital NHS Trust
Norfolk & Norwich
University Hospitals Trust
Gateshead Health NHS
Foundation Trust
York Teaching Hospitals
NHS Foundation Trust
Project
Manager
Debbie Johnston Accreditation Consultants, Royal College of Physicians
Reporting to

The Project Group will principally report to the RCP Clinical Standards Department
and its identified stakeholders

The terms of reference may be reviewed at any time during the Group’s tenure by
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special request at any formal meeting
4. Governance and reporting arrangements
The 12 month project will be led and supported by the following key people until the end of March
2015:
1. Dr James Fergusan- Project Clinical Lead/chair, Consultant Hepatologist UHB.
2. Debbie Johnston-Project manager, RCP Accreditation Consultant, Head of Assessors and Training
lead
3. Ruby Tailor-Liver project coordinator
4. Dr Roland Valori - National Clinical Director for Endoscopy and current Clinical Director for
Accreditation, Royal College of Physicians, London (oversight for governance)
5. Caroline Rogers-RCP Accreditation Unit manager (oversight for governance)
Project sites will provide updates to the project manager on a monthly basis.
Project reporting arrangements
The project will report to an RCP appointed project Executive Group through:
1. Dr Roland Valori - National Clinical Director for Endoscopy and current Clinical Director for
Accreditation, Royal College of Physicians, London (oversight for governance)
2. Caroline Rogers-RCP Accreditation Unit manager (oversight for governance)
The project team will provide quarterly reports on progress against agreed milestones.
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