Insight

Accreditation is Key to Focusing on Quality and Improvement
Accreditation is Key to Focusing on Quality and Improvement
Juliette Lobley
InHealth Communications Ltd, Ipswich, UK and Jagdeep Kudhail, East and North Hertfordshire NHS Trust, United Kingdom

Using accreditation to improve the quality of patient care

Mount Vernon Cancer Centre, part of East and North Hertfordshire NHS Trust, is a renowned, highly-specialised cancer centre based in Northwood in Middlesex, UK. It provides radiotherapy services to a population of 2 million people and sees approximately 5,000 new patients each year. It operates a chemotherapy suite, an outpatient service from clinical referral to the first follow-up appointment, a radiotherapy facility that has eight linear accelerators, a CyberKnife® unit and a brachytherapy suite. The centre also has a nuclear medicine service providing imaging and radionuclide therapies.

The radiotherapy service became involved in the CHKS Accreditation programme,1 in line with standards and processes outlined by ISQua International Accreditation Programme,2 to ensure a focus on quality systems and improvements. Following its success and award of accreditation by CHKS, the whole trust then moved to the accreditation system as a way of ensuring quality management which leads to improved patient care.

Ms Jagdeep Kudhail is head of radiotherapy and divisional chair for cancer and has had experience of working with quality management systems before she joined Mount Vernon Cancer Centre in 2014. In her previous role, she had set up a quality assurance system and wanted to follow the same path. ‘Although we are a registered service, we didn’t have an all-encompassing quality system and I felt accreditation would help in this respect’ she says.

Accreditation helps trusts to take a more focused look at how they work, helping to create a culture of improvement and demonstrating a commitment to quality improvement for patients. Providing independent scrutiny, the process can cover an entire trust or be tailored to specific departments such as radiotherapy or maternity.

Patient care is always top of the agenda for every organisation, but through the accreditation process, departments can ensure that they are doing everything possible to create the best environment, from identifying risks to top-level record keeping and putting a framework in place to ensure quality improvement, such as regular scheduled meetings, formal performance reviews and policy updates, ensuring that all members of staff are included.

Accreditation is a valuable tool to help organisations assess where change is needed and where progress is being made. Quality markers such as surveys and audits are crucial in identifying these areas. An audit of the pre-treatment process in the Mount Vernon radiotherapy department showed the patient satisfaction rate varied when patients were questioned about privacy and dignity (Care Quality Commission Inspection Report, Feburary 2015; data on file). There were no changing rooms which caused concern for some.

Accreditation is a valuable tool to help organisations assess where change is needed and where progress is being made. Quality markers such as surveys and audits are crucial in identifying these areas. An audit of the pre-treatment process in the Mount Vernon radiotherapy department showed the patient satisfaction rate varied when patients were questioned about privacy and dignity (Care Quality Commission Inspection Report, Feburary 2015; data on file). There were no changing rooms which caused concern for some.

As a response, the staff put up curtains in the CT room to create more of a personal space for the patient. Variability was also identified in the patient perception of information given during the pre-treatment appointment, again due to lack of personal space. Following this audit, a full explanation about the treatment is now given in private and the patient is left alone to undress.

Monthly quality improvement and business planning meetings allow the management team to focus on development, looking at a range of indicators with a view to developing plans to improve the service. Smaller quality improvement teams lead on individual projects, ensuring staff are engaged and progress is maintained.

Monthly quality improvement and business planning meetings allow the management team to focus on development, looking at a range of indicators with a view to developing plans to improve the service. Smaller quality improvement teams lead on individual projects, ensuring staff are engaged and progress is maintained.

Ms Kudhail says support from the CHKS Accreditation client manager was helpful in the early days. It was useful to be able to discuss the standards and how they would apply to the centre. As one of the first users of Accreditation Online (AO) Ms Kudhail says this has made the process much more straightforward.

Ms Kudhail also decided that the centre should apply for the ISO 9001:2008 certification as an additional award. She says ‘Having investigated a number of service providers, I felt CHKS would best meet the needs of our service. What felt most relevant, on the ISO accreditation journey, was how CHKS had interpreted industry standards and translated them into meaningful statements pertinent to the clinical setting’.

Accreditation and CQC inspection

Being accredited and having access to AO has helped the radiotherapy department ensure it can provide records quickly without spending too much time searching for information. All staff can gain access to information about all aspects of a patient’s radiotherapy; the same records are available to those working in radiotherapy planning, treatment or radiotherapy physics. This is critical both for patient safety and also for patient experience as the patient does not need to tell their story several times. It was a key feature noted by the Care Quality Commission during a 2016 inspection which rated the radiotherapy department as ‘good’. It was the only department rated ‘good’ in every domain.

Ms Kudhail says ‘It [accreditation] has been an enormous help during other external inspections. By keeping AO up to date, we are able to pull the reports that are needed in a very time-efficient manner.

‘For me, the accreditation process played a significant part in this achievement – it meant we had a good understanding of our risks, incident reporting and so on. This was my selling point to the rest of the centre; working with CHKS and the accreditation process means we will be better equipped for any information request or external visit’.

Moving to whole organisation accreditation

‘I’m a surveyor myself and I am used to going into other services and helping to explain accreditation standards’ Ms Kudhail says. Having seen the impact of CHKS Accreditation, all heads of service are now using the standards.

In the last accreditation cycle chemotherapy and nuclear medicine were also accredited and this year the entire centre achieved accreditation. The next step will be to include Michael Sobell House and achieve accreditation for hospice standards.

The implementation of CHKS standards has been a fundamental tool to Ms Kudhail since she started the accreditation journey. She says ‘The whole process and has become my formula for a total quality management system and is something I would encourage other healthcare service providers to adopt’.

Support: Medical writing support was provided by Juliette Lobley from InHealth Communications Ltd and funded by CHKS.

References

1. CKHS. Quality and accreditations. Available at: www.chks.co.uk/Quality-and-Accreditations (accessed 16 March 2018).
2. ISQua. What is the International Accreditation Programme (IAP)?, 2008. Available at: https://isqua.org/accreditation-iap/what-is-the-iap (accessed 16 March 2018).