TRENT ACCREDITATION SCHEME AIMS

Trent Accreditation Scheme aims:

a) To provide a self assessment tool through which organisations can assess and continue to develop and improve their services by reference to external standards. At present, standards are available for hospitals (particularly small to medium sized ones), and Day Services. Work has been undertaken on learning disability services, primary care and mental health services for the elderly, and community-based services. Standards for District Nursing Services are being drawn up. The Scheme has the potential for development to cover a wider range of services. The Board is exploring these links to other services.

b) To support preparation for Healthcare Commission needs, particularly providing evidence of the self-assessment and adding value to process.

c) To assure the Healthcare Commission that there is an on-going process for maintaining quality development.

d) Through the delivery of the Scheme to offer individual development opportunities for staff, which will benefit both them and their organisations.

e) To offer those who commission health services and the public an objective means of being assured of the general quality of such services;

COSTS

There is a small annual charge for belonging to the Scheme, which covers all running costs, survey costs, training and seminars. No other charges are made. The Scheme is non-profit making and the fee charged may vary from year to year depending on the number of participants.

OBJECTIVES

To achieve these aims the Scheme will:

a) identify and keep under review commonly-agreed quality standards relevant to the services covered by the Scheme;

b) explore management and clinical issues, encouraging staff to think creatively about solving operational problems and developing services;

c) promote and facilitate innovative ideas and best practice;

d) provide appropriate training and on-going support to surveyors.

ACCREDITATION STATUS

a) When the hospital\service meets or exceeds the criteria, two years’ full accreditation is given. Recommendations for further development will be given by the Board.

b) Two-year accreditation may also be given but deferred for a short period if there are a number of actions which can be taken quickly to meet the standards. A brief re-survey will be undertaken to confirm that action has been taken and that the processes are robust.

c) Accreditation may be given for one year where there are some actions which need to be taken over that period and a re-survey carried out at the end of the year.

A re-survey can be applied for whenever the hospital\service managers feel that standards are being met.

d) Accreditation may be withheld for at least one year if the hospital\service does not meet all of the applicable essential criteria. It is invited to re-apply for accredited status after a period of twelve months has elapsed from the original survey.

(Note: Capital development issues, whilst clearly relevant to the potential for quality improvement, will not be given over-emphasis by surveyors or the Board unless the situation at the time of the survey clearly presents an unacceptable level of clinical or statutory risk.)

e) New hospitals or hospitals with significant new development will only be given one year’s accreditation initially to enable services to bed down.

f) Footnote

Participating hospitals' accreditation is extended until the Board confirms the new accreditation status if accreditation expires before a Board meeting dealing with a survey.

THE ACCREDITATION SCHEME BOARD

The Board runs the Scheme on behalf of the participating Trusts to which it is accountable

through the following mechanisms:

a) An annual report.

b) Trust chief executives and\or directors who are members of the Board. The participant Trusts are encouraged to raise issues and ideas directly with the Board.

1. Role of the Board

To ensure the success of the Scheme by providing direction, co-ordination and efficient delivery of its day-to-day operations. The Board is specifically responsible for:

(a) the development, review and upgrading of appropriate standards;

(b) monitoring the operation of the Scheme to ensure equity and fairness;

(c) deciding which level of accreditation should be awarded on the basis of the surveyors' reports and any additional relevant information;

(d) arranging and monitoring the delivery of relevant training for surveyors;

(e) maintaining a comparative knowledge of other similar schemes to ensure that the Trent Accreditation Scheme remains at the forefront of such developments;

(f) the preparation of an Annual Report and statement of accounts.

2. Membership

The present arrangements are as follows:-

a) Three people of director status.

b) One consultant

c) One modern matron

d) One AHP representative

e) Scheme manager

f) Note: The Chairman will be from the membership: at present a chief executive.

g) Members will either be nominated by their speciality or similar group or be invited by the existing Board members to ensure the right balance of skills and experience.

h) The Board has the right to co-opt additional members on an ad hoc basis where a particular skill or experience is required to fairly assess an applicant hospital or service.

i) A quorum will consist of one third of the membership of the Board.

j) A member will normally forfeit his or her seat if either they or their nominated deputy fails to attend two consecutive meetings.

k) The Board shall meet up to four times per year, with further meetings arranged if required.

l) All members will serve for three years, renewable for three years unless stated otherwise.

Changes will be made in a phased way so that expertise is not lost all at the same time.

NB: The Board should not be seen, nor hold itself out, as agent of any health service organisation so that no legal liability in civil or criminal term exists.

3. Protocol for Accreditation Decisions

a) The decisions taken by the Board are based solely on the surveyors' report plus any other relevant information that may emerge in the course of the discussions with the hospital's\service's representatives and the surveyors.

b) Any member of the Board who has an interest in the hospital\service of which the hospital\service under review is a part must declare it and withdraw from the discussion.

c) The surveyors' report must not contain any recommendation as to the level of accreditation and the surveyors should make no informal recommendation at the time of the survey or indication of the outcome to the hospital\service being surveyed.

d) When a survey is initiated, the surveyors will contact the relevant Patients’ Forum, giving them the opportunity to make any comments about the hospital\service they may wish. Any such comments must be appended to the surveyors' report.

e) At the Board meeting, up to three representatives of the hospital\service under review may attend with a PCT representative, together with the surveyors. Both parties will have the opportunity to clarify and comment upon any aspect of the survey and subsequent report.

f) One member of the Board will take the lead for each report, focusing on key issues and\or areas of uncertainty.

g) When the Board and the hospital\service representatives are agreed that there is nothing further to discuss together, then the latter will leave the meeting.

h) The surveyors will then be given the opportunity to make their final comments and recommendations to the Board but in doing so must not raise any new matters.

i) The decision of the Board will be communicated at the conclusion of the meeting and subsequently confirmed in writing. Full reasons will be given and in the case of an award of one year or less it will be specifically stated which aspects will be the focus of the follow-up survey. Where full accreditation is awarded, details will also be given of any areas which the Board feels warrant further attention.

j) There is no right of appeal against a Board decision; however the Board will always be willing to arrange for constructive discussions to provide further clarification and advice if this is requested.

k) The cost of attending Board meetings will be met by the hospitals concerned.

THE PROCESS OF SURVEY AND REPORT

The manual of standards will be reviewed, updated and\or expanded by working groups convened by the Board and drawn from surveyors and others with relevant expertise.

In conducting a survey the surveyors must ensure that:

a) all relevant sections of the Standards Manual are scored and explanations given to support the score;

b) external awards such as Charter Mark, Investors In People, IWL, CNST, ISO 9000, etc, are taken into account, but do not provide exemption from any area covered by the Standards Manual;

c) the wider Trust(s) context is taken into account, particularly where this affects the decision-making capacity of the hospital concerned;

d) the clinical or support services "bought in" by the hospital\service are included in the survey if they form part of the services which the hospital being surveyed is contracted to provide;

e) they do not make judgements on the appropriateness of different philosophies of care. The purpose of accreditation is to examine compliance with the Standards and consistency between application of local philosophies in practice and the local policy;

f) that any difficulties arising during the survey are resolved at the time;

g) that comprehensive and balanced feedback is given before surveyors leave and in particular any areas of non-compliance are discussed. The report will contain no “surprises”.

MENTORING

A lead surveyor, who will not be part of the survey team, can be made available to help organisations in preparation for a survey, or in implementing recommendations following a Board meeting.

GOOD PRACTICE

Examples of good practice are compiled on a regular basis and circulated to participating organisations. The TAS website shows the good practice examples presented at Good Practice Days and the appropriate contact number.

ADDITIONAL FEATURES

Good Practice presentation days and Health and Safety updates are held each year, free of charge.

A newsletter is published at regular intervals.

A website (www.trentaccreditationscheme.org) is available at where the standards document, examples of good practice and newsletters can be accessed. Planned developments for this include a noticeboard and discussion site.

Document revised: February 2006
A copy of this Aims & Objectives document is also available in Microsoft Word Format