qnic welcome pack

Cycle 20: Accreditation Welcome

Pack 2020 – 2021

Iesha, CAMHS Service User

QNIC Accreditation Welcome Pack – Cycle 2020 (2020-2021)

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What is Accreditation?

Background

During 2010, the advantages and disadvantages of introducing

accreditation were discussed, and it was decided that the accreditation process would be trialled during Cycle 10 (2010-2011) of the network.

Following Cycle 10, it was decided to continue to offer accreditation to QNIC members.

Some of the advantages covered in initial discussions included:

• QNIC will be taken more seriously as it will be seen “to have teeth”, i.e.

the ability to fail units or to defer accreditation until a trust gives the

team the necessary equipment or resources • An accreditation service led by QNIC will mean that it will be less likely

for external agencies, who may have less understanding of CAMH services, to be asked to accredit units

• Members will have formal recognition of their good work • Members will be able to use the accreditation award to demonstrate to

commissioners, senior trust managers, referrers, young people and carers that quality and safety standards have been met

• Members will be in a better position to be able to ask commissioners to meet the costs of QNIC membership

The Accreditation Process

A team must have participated in at least one year of the standard QNIC quality improvement peer reviews before having an accreditation review.

There are three main phases of the accreditation review: a self-review; a detailed peer review visit; the presentation of evidence to the Accreditation

Committee. These reviews are more thorough than the usual quality improvement reviews as they require evidence to validate self-ratings

through the collection of data from a variety of sources.

Teams that satisfactorily complete the accreditation process will be accredited for three years. If, during this three-year period, the employing

organisation is aware of changes to practice that may affect quality, it must report this to the QNIC team and the accreditation status will be

reconsidered. Maintenance of approved status will also be conditional on the satisfactory completion of an interim comprehensive peer review.

CAMHS teams that are participating in the accreditation process will be listed on the Royal College of Psychiatrists’ website.


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Introduction

Accreditation runs on a three year cycle, each following the cyclical

process outlined below.

Timetable

Self reviews September – May

Peer reviews September – May

Local Reports September – June

Annual Forum May/June

Annual Report June/July

Three Year Cycle explained

Year 1: The first year will be when teams receive their accreditation peer review visit, as outlined in this welcome pack.

Year 2: The unit will not receive a peer review visit during year 2.

Year 3: The third year of accreditation will be like the normal peer review cycle you have already become accustomed to, the difference being that

such reviews will involve a comprehensive review of the service in relation to all QNIC standards. The process will involve completing the self review

workbook and receiving a supportive peer review visit with discussions around standards that are ‘Not Met’ or ‘Partly Met’. This will help prepare

for the accreditation cycle to begin again the following year.


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The Self Review Stage

Please also see separate step by step guide

Scoring the self review workbook is slightly different for accreditation reviews, as standards cannot be marked as ‘Partly Met’ when deciding how

your service is performing against the criteria. If your unit is not fully meeting a criterion, it should be scored as ‘Not Met’.

The criteria are split into three types:

• Type 1: failure to meet these standards would result in a significant

threat to patient safety, rights or dignity and/or would breach the law.

• Type 2: standards that an accredited ward would be expected to

meet.

• Type 3: standards that an excellent ward should meet or standards

that are not the direct responsibility of the ward.

The process will not feel too different from what you are familiar with from

your participation in self reviews in previous cycles. The difference is that as well as the self review workbook, teams will also have to complete the

following:

• A set of online questionnaires for; o All clinical staff members

o 50% of young people (or a minimum of 5) o 50% of parents and carers

o At least one teacher o At least one referrer

o At least one commissioner • Teams will also have to complete a mini case note audit and policy

checklist

The data from the audit and questionnaire responses will be added into the

self review workbook and used as the basis for the peer review day. The audit and questionnaire responses provide an additional dimension of

information which will be balanced in the context of the self review workbook.

Completing the self review workbook provides a designated space for teams

to reflect on service provision and acts as a useful team-building opportunity. The completed workbook will be sent to the visiting peer

reviewers in advance of your visit so that they can familiarise themselves with the key issues raised.


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Key action points for the Self Review stage:

Distribute the information letters/emails for staff, young people,

parents/carers, referrers and commissioners giving the web-link to the online questionnaires

Let the team know that all clinical staff are required to complete the questionnaire

Allocate staff members to conduct the case note audit Allocate a staff member (usually a manager) to complete the policy

checklist Arrange suitable time(s) when the team can come together to work

through the self-review workbook The team should work through the workbook together, scoring

themselves against the criteria

Note down any additional comments that will enrich the peer review process

Submit the completed self review online in electronic format at least 4 weeks before your accreditation peer review is due to take place


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The Peer Review Stage

About the Peer Review

During the peer review day, the visiting team will ask questions and discuss

any challenges or unmet standards highlighted in your self-review workbook, audit and questionnaire results. Over the course of the visit the

team will cover every section of the QNIC standards.

In order for a peer-review visit to proceed, the team must have a minimum

of 4 members in the peer-review team which includes:

• A member of the QNIC team (i.e.: a project worker or manager) • A medic with at least one year’s CAMHS experience, such as a

Consultant Psychiatrist or Associate Specialist • A member of nursing staff with at least one year’s CAMHS

experience, such as a Charge Nurse or Modern Matron

• A member of a CAMHS MDT, such as an Occupational Therapist or Psychologist with at least one year’s CAMHS experience

• A patient or carer representative who has experience of being a patient on an inpatient ward/unit or cared for someone who has).

Accreditation reviewers will be experienced reviewers and have received

accreditation reviewer training.

Like quality improvement peer reviews, the purpose of all QNIC visits is to

share knowledge and best practice however on top of this, the additional aim of accreditation peer reviews is to validate how many of the QNIC

standards your team is meeting to determine your accreditation rating.

We advise that services plan for the review day as far in advance as possible

and ensure that arrangements allow staff to fully participate. Services should also liaise with parents, carers and young people well in advance so

that they are able to attend the interviews on the peer review day.

In order to be accredited, services must meet:

• 100% of Type 1 standards

• At least 80% of Type 2 standards

• At least 60% of Type 3 standards

If any standards are marked ‘Not Met’ on the review day, the QNIC team will ask for the service to provide evidence that they are meeting these

standards following the review day to present to the Accreditation

Committee.

Patient Safety on the Review Day

• The CCQI Human Resources Department ensures all CCQI project staff who attend peer-reviews have valid DBS checks.


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• The Network assumes that peer-review team staff members have valid DBS checks by virtue of being employed in mental health

settings and review members’ employment details are provided in peer-review packs.

• The Network assumes that service users and carers who may form part of the peer-review team do not necessarily have valid DBS

checks. • Those members of the peer-review team who do not have valid DBS

checks will be accompanied by a local member of staff or a checked visiting team member when in proximity with service users or other

vulnerable people

Key action points for the Peer Review stage:

Arrange the peer review day based on the timetable in this pack, and

the peer review step by step guide. If you need to alter the schedule in any way, please inform the QNIC team of your proposed timetable at

least 2 weeks in advance of your review

Inform all team members about the visit as soon as your peer

review date is confirmed and ensure members of your team are able

to attend all or part of the review day

Invite parents and young people to the parent and young person

interview sessions, and to lunch if you wish

Distribute information sheets and ensure that consent forms are

signed by young people, and parents for under 16s, in advance

Make sure that a set of blank template health records are accessible, for

example paper copies or via an electronic system. See the step by step

guide

Make sure that key policies and agreements are available, for example in a folder or on the intranet. See the step by step guide

for a list

Ensure staff are informed which sessions throughout the day they

should attend, including the morning brief and end of day feedback

sessions

Ensure that rooms are booked for interviews

Book refreshments (for the morning brief and afternoon review team

meeting) and lunch


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Time Session

9:30 – 10:10 Morning Brief 9:30 – 9:50 Reviewers meet to confirm aims of the day and to allocate roles 9:50 – 10:10 Reviewers meet with the host team

• Lead reviewer: a) introductions, b) aims of the day, c) check the programme

• Host unit to give a brief description of their service

• Reviewers to give a brief description of their services Tea and Coffee to be provided on arrival

10:10 – 11:10 Tour of the Unit During the tour the reviewers will complete the environment checklist and validate standards relating to ‘Environment and Facilities’.

11:10 – 12:00 Young People 2-3 reviewers will talk to young people about their experiences of using the

service.

Parents 2-3 reviewers will talk to parents/carers about their experience of using the service.

12:00 – 12:10 Coffee Break Tea and Coffee to provided

12:10 – 13:00 Senior Staff – Self Review Validation Review team will meet with senior members and review any discrepancies raised in the self-review under ‘Information, Consent and Confidentiality’ and ‘Young People’s

Rights and Safeguarding Children’.

13:00 – 13:40 Lunch Lunch to be provided by the host team

13.40 – 14.30

Senior Staff - Self Review Validation Review team will meet with senior members and review any discrepancies raised in the self-review under ‘Access, Admission and Discharge’ and ‘Care and Treatment’.

14:30 – 15:20 Ward Manager – Documentation Check 2-3 reviewers will meet with the ward manager to validate standards relating to

‘Clinical Governance’ and other items on the document checklist.

Documents should be provided in print or electronically for the review team.

Frontline Staff 2-3 reviewers will meet with non-managerial frontline staff to validate standards

relating to ‘Staffing and Training’.

15:20 – 16:10 End of Day Discussion Peer reviewers meet separately to summarise data and ensure that a decision has been made as to whether each standard has been met or not met

Tea and Coffee to be provided within this session

16:10 – 16:30 Feedback to the host unit Informal feedback will be given to the host team by the peer reviewers and clarification can be sought on any standards where further data is required

QNIC Review Day Timetable

12:10 – 13:00 Senior Staff

The reviewers ask the host team about issues raised in the self review and discuss QNIC standards relating to ‘Access, Admission and Discharge’ and ‘Care and Treatment’.

13:00 – 13:40 Lunch Lunch to be provided by the host team

13:40 – 14:30 Senior Staff - Case Note Audit & Supporting Documentation 1-2 reviewers will meet with senior members of the team to validate the case note

audit, and standards relating to ‘Information, Consent and Confidentiality’ and ‘Young People’s Rights and Safeguarding Children’

All supporting documentation specified in the self review information and an anonymised example set of case notes should be available in this session.

Ward Manager – Policies Check 1-2 reviewers will meet with the ward manager to validate standards relating to ‘Clinical

Governance’ A copy of the unit’s policies should be made available

14:30 – 15:20 Ward Manager – Policies Check Cont. 1-2 reviewers will meet with the ward manager to validate standards relating to

‘Clinical Governance’ A copy of the unit’s policies should be made available

Parents 1-2 reviewers will talk to parents/carers about their experience of using the service.

15:20 – 16:10 End of Day Discussion Peer reviewers meet separately to summarise data and ensure that a decision has been made as to whether each standard has been met or not met

16:10 – 16:30 Feedback to the host unit Informal feedback will be given to the host team by the peer reviewers and clarification can be sought on any standards where further data is required


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The Report

Following the peer review visit, a local report will be compiled by the QNIC project team and returned to your team, first as a consultation draft and

then as a finalised printed report.

The report will be an assimilation of the data from both the self review

and peer review stages. It highlights the team’s achievements and challenges, and makes recommendations on how to address areas for

improvement. The report acts as a useful tool for the team when action planning.

Services should disseminate the consultation draft amongst team members as appropriate. They should read through the consultation draft

and notify the report editor of any changes or amendments that may be necessary. If the service receives the consultation draft report and notices

that standards have been marked incorrectly, i.e.: ‘Not Met’ when it

should be marked as ‘Met’ please let a member of the QNIC team know as soon as possible. Services are also able to add a foreword to their report

if they so wish.

QNIC recommends that the final report should be disseminated as widely

as possible to team members, managers and commissioners.

Key action points upon receiving the QNIC Report:

Read through the consultation draft upon receiving it from QNIC

and notify the report editor of any changes or amendments that

may be necessary

Send the draft report back to the report editor at QNIC with notes

of any necessary amendments and a foreword

Use the comments and recommendations within the report to

formulate concrete action plans for the team to work on, with the aim of achieving improvements and developments within the

service (see overleaf for more information on action planning)

Key action points upon receiving the QNIC Report:

Read through the consultation draft upon receiving it from QNIC

and notify the report editor of any changes or amendments that

may be necessary

Send the draft report back to the report editor at QNIC with notes

of any necessary amendments and a foreword

Use the comments and recommendations within the report to

formulate concrete action plans for the team to work on, with the aim of achieving improvements and developments within the

service (see overleaf for more information on action planning)


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Action Planning

Description

Once the QNIC team have compiled your local report, your team is

encouraged to formulate an action plan to facilitate improvements.

Aims, Purpose and Outcomes

Action-planning allows the team to:

▪ Reflect on the outcomes of the review process ▪ Take recommendations within the QNIC report on board with the aim of

bringing about some improvements in the areas identified

Key things to do:

▪ Bring the team together for an open discussion around the areas

identified for improvement in your local report

▪ Make decisions on how to address these and draw up an action plan – who, how, and when by

▪ Return your action plan to the QNIC team within 6 weeks of receiving your draft report

▪ Carry out actions and monitor progress on a regular basis

Guidance:

▪ Include the entire team in the action planning process to encourage a

sense of ownership ▪ Outline clear responsibilities for taking action points forward so that

all staff know their obligations and level of commitment ▪ Develop a clear timescale for working on action points so that progress

can be monitored on a regular basis ▪ Minimise the burden on staff by providing allocated time within regular

job hours to work on the relevant actions

▪ E-mail the QNIC e-mail discussion group for advice on planning and implementing new initiatives: [email protected]

Key things to do:

▪ Bring the team together for an open discussion around the areas identified for improvement in your local report

▪ Make decisions on how to address these and draw up an action plan – who, how, and when by

▪ Return your action plan to the QNIC team within 6 weeks of receiving your draft report

▪ Carry out actions and monitor progress on a regular basis

Guidance:

▪ Include the entire team in the action planning process to encourage a

mailto:[email protected]


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The Accreditation Decision

Further evidence for the ‘Not Met’ standards is taken to the Accreditation Committee by a member of the QNIC team. Here, the evidence is presented

and considered by the Accreditation Committee members who consider the criteria below to make an accreditation decision.

Before evidence is presented to the Accreditation Committee, all reports

and evidence are anonymised so that no service is identifiable to ensure that the process if fair and unbiased. It is also a condition of membership

that the Accreditation Committee members agree that the accreditation report, peer review report and any additional documentation submitted as

part of the accreditation process are treated as confidential.

The aim of the accreditation decision is to ensure that services are

recognised for their good practice, as well as protecting the value of an accreditation award by maintaining high standards.

Potential Accreditation Committee outcomes

“Accredited”

If a service is accredited, this means that they meet: • 100% of Type 1 standards

• 80% of Type 2 standards • And at least 60% of Type 3 standards

“Accreditation Deferred”

This means that a service fails to meet one or more Type 1 standards but demonstrate the capacity to meet these within a short time and could

provide further evidence to demonstrate this

And/or:

A service fails to meet a substantial number of Type 2 standards but

demonstrates the capacity to meet the majority of Type 2 within a short time and could provide further evidence to demonstrate this

“Not Accredited”

A service fails to meet one or more Type 1 standards and does not

demonstrate the capacity to meet these within a short time

And/or:

A service fails to meet a substantial number of Type 2 standards and does

not demonstrate the capacity to meet these within a short time


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After the Accreditation Committee

If a unit is deferred…

The Accreditation Committee has the right to request further documentary evidence of compliance with accreditation standards and, if required, to

request a targeted revisit. The committee will also stipulate the time scale required to provide additional evidence or when the revisit will need to take

place.

Further documentation The QNIC team will forward the accreditation report to the link person and

confirm that further documentation is required and what evidence needs to be submitted to satisfy the committee that the standard is now met.

For example, the evidence could be: • An updated and ratified policy

• A summary of audit results for criteria such as access to outdoor space

• Photographs of environmental changes that have taken place

When received, the QNIC project team compiles a report with further supporting evidence to submit to the next Accreditation Committee.

When deferred the host unit should only provide supporting evidence for

the standards they have been deferred upon, usually this will be only the Type 1 standards. If the unit is accredited after a period of deferral the

three year accreditation period will be back dated to the first time the service was presented to the Accreditation Committee.

A service can only be deferred for a maximum of three committees (usually around 9 months).

If a unit is not accredited…

If a significantly large number of Type 1 standards are not evidenced on the day, the Accreditation Committee may decide to not accredit a service

at the first Accreditation Committee. The committee will not have time to go through evidence for lots of different standards - it is essential to be well

prepared and have almost all evidence ready for the peer review visit.

A service cannot be part of the Accreditation process for more than 12 months, as the initial evidence provided may no longer be an accurate

representation of the service. If this situation does arise, the Accreditation

Committee will mark a service as ‘Not Accredited’.


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In the event that the review finds evidence that practice is unsafe or threatens the dignity, safety or rights of children and young people or staff,

the Royal College of Psychiatrists will advise the provider organisation that it should take appropriate remedial action. If the Royal College of

Psychiatrists is not satisfied that appropriate action has been taken and that there is a substantial risk to patient safety, it reserves the right to

inform those with responsibility for the management of the service and/ or the relevant regulatory body.

Following a ‘Not Accredited’ decision, the service will be required to undergo a comprehensive peer review in the subsequent year, before entering into

the accreditation process again. This will give the service an opportunity to focus on meeting all the necessary standards prior to their next

accreditation review.

The Appeals Process

The grounds for an appeal against a decision about accreditation category are that:

• The service feels that a decision has been made based on factual inaccuracies about the team at the time of the review

• The decision made is deemed to be inconsistent with stated criteria that determine categories of accreditation or past decisions.

A written application to appeal the Committee’s decision must be lodged

within eight weeks of the accreditation decision having been communicated to the local lead staff member. Appellants are asked to

provide documentary evidence to support claims of factual inaccuracy and/or a clear statement of the way(s) they consider the decision to be

inconsistent with the stated criteria for the category of accreditation awarded.

If your service wishes to appeal an Accreditation decision, please contact a member of the QNIC team as soon as possible. A member of the team

will then be able to send you the CCQI-wide appeal procedure document.

QNIC Project Team contact details

If you have any queries about the Accreditation process, please contact:

Arun Das

Deputy Programme Manager [email protected]

020 3701 2664

QNIC Project Team

The Royal College of Psychiatrists’ Centre for Quality Improvement 2nd Floor

21 Prescot Street London E1 8BB

mailto:[email protected]