detailed description of the ‘The Standard’ and all that it entails16
.
In preparing for assessment, an organisation must first outline how much of its service it wants to be considered for accreditation – this is called the ‘scope’. Usually the whole service would be included, but there may be instances where only part of the service is included in the scope: for instance, if a new part of the service has only recently been established and this is not ready for the first round.
The Standard comprises four domains. A total of 31 ‘standard statements’ are spread across these four domains, and each standard statement addresses one aspect necessary for the provision of the service. A list of criteria indicates the structures and processes necessary to deliver each particular standard statement. For each criterion, indicative examples of acceptable evidence is given.
The service will then work on its evidence over the upcoming months (typically a year) and will upload it to ISAS via the web-based tool. Once the evidence has been submitted, it is assessed and, if sufficient and appropriate evidence has been provided, a site visit will follow. The assessment team will usually comprise a radiologist, a radiographer, a lay member and a professional UKAS assessor.
Our experience at Great Ormond Street was that initially we completely underestimated the amount of work involved in the whole process. Gathering the evidence is a huge task; we found that it was not so much that we were not doing a lot of good things already, but more that we had never written it down in an organised and joined-up way. Whilst this may appear rather banal, it became evident that our processes were basically safe, and we hopefully offered a high quality, patient focussed and forward looking service but our documentation, whilst present, was scattered in different places (sometimes in people’s heads). Everyone knew what they were doing and were doing it well, but this knowledge had been learned over many years. Someone arriving new wouldn’t have one place to go to find out about our polices, procedures and protocols. Our document control was not as good as it should have been (and now is) and some areas of the department were doing things in a slightly different way to other areas.
To balance against this, we realised that there was almost nothing we were not already doing that we should have been. We were well ahead of the curve in our patient surveys, our audit programme, our risk management and in our patient–oriented practice. Financially, we were in good order and our management structure was effective and safe.
After a false start, we brought together a group of five key members in the department to lead and to champion the accreditation work. These included a consultant radiologist (who was also the clinical unit chair for the division and thus had professional radiology input, but also had an overview of the wider role of radiology within the hospital and of the hospital’s structure and policies), the radiology service chair, the radiology service manager, the
we believe we deliver a safer quality serviCe
lead radiology superintendent, and the departmental personal assistant (PA). The PA was invaluable in collating all the evidence once it had been submitted to her and organising it on the web based tool. She was also able to keep an overview of what information was missing, who was supposed to be providing it, and to do the chasing.
The radiology superintendent co-ordinated the activity of a wider group of modality superintendents with respect to their various modalities, and for the documentation and policy writing relating to those areas. The consultant radiologist took responsibility for some of the higher level organisation information and for many of the criteria in the clinical domain. The radiology service chair and service manager co-ordinated everything else. Early in the process, one of these five names was written against every single one of the 131 criteria, so it was very clear who was responsible for that criterion. Tentative dates for completion were added, which were reviewed at least once a month. By the end of the evidence gathering phase, every single person in the department had been involved in accreditation in some way. The task of collating the evidence would have been impossible without this cascade effect.
Once the evidence had been reviewed and accepted, the dates were set for a two-day site visit. This process really starts the adrenaline flowing and it was a time of great coming together for the department to prepare for this, knowing that any one of the 70 of us could be asked a question, or asked to demonstrate something. Many of the staff who had been aware of the accreditation work going on suddenly pricked up their ears and, in the last few weeks, there was a real momentum. People would ask me what it meant to be accredited and would it matter? I could only reply that I hoped it would make us special and would allow us to prove unequivocally that we are a good department, rather than just believing we are.
The two-day visit itself went off uneventfully. Many of the staff were outstanding (and this was recognised and commented on by ISAS) and were genuinely proud to have been involved with it and to be able to show our department, and what we have achieved, to ‘outsiders’. The feedback was given straightaway on the second afternoon and the senior management was requested (by ISAS) to be present as they are the
45 2011
IMAGING & ONCOLOGY
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