August 2014

Dr James Fergsuon-Clinical LeadDebbie Johnston–RCP Head of Assessors & Accreditation Consultant

Liver quest projectProject update

Project aims (1)1. Review and remap the standards framework, ensuring that they are fit

for purpose

2. Develop an effective partnership between the RCP, BSG and BASL to achieve the project objectives

3. Establish a clear structure to achieve the pilot standards in a systematic and staged way

4. Create clear underpinning quality indicators and auditable outcomes. Link to information available (national data)

5. Develop the accreditation evidence requirements to achieve the standards

6. Develop the IT system to support self assessment and knowledge management

Project aims (2)7. Create and test a ‘pathway focused’ accreditation process

8. Provide updates and learning to as appropriate to the Clinical Service Accreditation Alliance on project work, ensuring that it feeds into wider develop work for clinical service accreditation.

9. Evaluate the project and make recommendations to key stakeholders on the future of the standards and proposed accreditation model.

Revised project stages & timescalesProject Phases Timeline 2014-15

Phase one: 1.launch of project. 2.Review of framework-final agreement of domains/items

March-June

Phase two: 1.IT development final agreement of domains/items2.Reassessment and action plan 3.WebEX contact with project sites.4.Create evidence to support a pilot accreditation process

July-August

Phase three1.Develop pilot accreditation process 2.Agree final pilot sites/services for visits to test accreditation process (4 sites)3.Prepare sites/services for visits (remote training)4.WebEX contact with project sites-review of progress

September-November

Project stages & timescales

Project Phases Timeline 2014-15

Phase four: 10.Train assessors & lay reps-workshop 11.Conduct site/service assessments. 12.Review process and evidence criteria 13.Monthly WebEX calls

November-February

Phase five: 14.Final meeting review and feedback15.Evaluation report

March/April 2015

Liver QuEST domains & Standards

• For the purposes of the pilot only the highlighted standards will be mandatory and tested

The accreditation pathway-pilotObjective 1 : test the standards in different levels of

liver services across a pathway Proposed stages:

• Self-assessment against accreditation standards online• Online submission of defined minimum data/evidence.• Assessment of evidence and service:

• Remote-online assessment • Site visit-interviews and assessment of further

evidence• Assessment report draft• Feedback on process

Accreditation pilot

• 4 different types of liver services will be assessed • Some pilot sites (not being assessed) will be invited to

form part of the assessment teams• Support will be provided through a number of

mechanisms:– Direct training – Remote support

8

Pathway - Stage One

9

Stage Two

10

Project teams-tasks summary

1. Complete a new assessment and action plans2. Provide feedback on the updated standards and evidence

requirements (10 mandatory standards)3. Host a site assessment (4 sites only)4. Repeat the assessment (6 months later)5. Provide feedback about the overall process6. Share learning and improvement ideas