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3. IQIPS Accreditation – Facilities, Resources and Workforce

By Andrew Pellew-Nabbs (Warrington and Halton Hospitals NHS Foundation Trust) and  Alison Charig (Portsmouth Hospitals NHS Trust)

IQIPS Accreditation – Facilities, Resources and Workforce

(The FR Domain)

This is our third article in the series on IQIPS accreditation. We have previously given advice about how to gain Management support for IQIPs accreditation, how to approach the process, evidence your department’s compliance and covered the Patient Experience domain. This article will be focussing on “Facilities and Resources”, which is the second out of the 4 domains.

As stated in the IQIPS documentation, the purpose of the FR domain is to ensure that adequate resources are provided and that these are used effectively to provide a safe, efficient, comfortable and accessible service. FR ensures that this is achieved through:

  • appropriate and adequate facilities (rooms and equipment);
  • motivated and competent staff; and the
  • integration of sound business planning principles within the service.

Due to its nature, this domain covers some of the aspects of service provision that are the most challenging (….and frustrating!) for departmental Heads. But is also an opportunity to showcase the Trust processes that you will already have in place to ensure robust management of your resources. The NHS and private healthcare providers are coming under increased scrutiny and some of those processes that your organisation have put into place to ensure CQC-compliance will help out with this domain, even the dreaded Expenditure Control Forms!

Where do we start with fulfilling IQIPS requirements?

We covered these generic processes in some detail in the last article so please refer back to the Spring 2018 Newsletter for detailed information, but just as a reminder:

  • check your organisational and departmental policies:
    • are they up-to-date?
    • anything missing?
  • Remember the IQIPS mantra as you decide how you are going to satisfy each standard.
    • “The service implements and monitors…”
    • How do you implement the requirements of each standard?
      • Do you have a written procedure which staff can access?
      • Do staff know the correct procedure?

 

  • How are your standards maintained and monitored?:
    • Are processes followed?
    • Do you check?
    • How can you prove this?

 

Some examples of monitoring methods for FR:

System/Procedure                                        Monitoring

Equipment Procurement                                Asset Register – reviewed and updated?

 

Staff Competence                                          Compliance with Essential training/ CPD/Registration,

        and is it checked and documented?   

 

Budget Management                                      Regular meetings with finance department

 

Complaints management                               Review with PALS Team              

    

  • In most cases, good practice can be seen and evidenced at site visits, so the evidence provided on the online assessment tool doesn’t have to be exhaustive.
  • And remember the phrase: “We don’t know what we don’t know… This describes the principle that you don’t know whether the system is effective or not….until you monitor it.

 

The Facilities, Resources and Workforce Domain is subdivided into 7 parts:

FR1 – Do the facilities and environment support service delivery?

A service must be able to evidence that all areas meet the specific needs of the patient population. This includes those with particular needs and may include children. You may find some overlap with aspects of standards PE2 and PE4.

Some questions to get you thinking: Is your department signposted from all hospital entrances? Does the waiting area allow for maintenance of privacy for patients in gowns/night-clothes? Are the toilet facilities suitable for children and patients with disabilities? Do you tell waiting patients about delays? Do you have information leaflets related to your patient population? Does anyone check that the department is clean? Do you have access to resuscitation equipment?

These are the sort of questions that the assessors will be asking themselves as they visit your service. And you will also need to evidence that you have processes to monitor your compliance where this is relevant – does the hospital perform a regular audit of cleaning standards? – make sure that you receive, review and act on the results as this is the sort of evidence that will satisfy the standard very easily. If no-one else is monitoring cleanliness, add it to your clinic-opening checklist every day.

And don’t forget your staff. Are there adequate toilet and hand-washing facilities?, Do staff have a secure area for their personal possessions? Is there enough space for safe working in the clinic rooms? Are there enough reporting work-stations to ensure efficient use of Vascular Scientist time?

If you are struggling with your departmental facilities, you may need to “think-out-of-the-box” and approach with fresh eyes. Could you purchase some wheeled screens to ensure patient privacy? Could you restrict in-patients/wheelchair patients to the largest clinic room where you store all of your manual handling aids? Would rearranging your clinic lists help? Would an assistant speed things up?

As we mentioned previously, the IQIPS assessors are not going to demand that you have a particular environment to scan in – they are really interested in seeing how you care for your patients using the means you already have at your disposal. However, if it is impossible to currently meet the standards you may of course be able to use this to exert some leverage within your Trust …

FR2 – Equipment Procurement

This covers the appropriate procurement, installation, operation, maintenance, quality assurance and replacement of all equipment, and includes resuscitation equipment, protective clothing and consumables.

For large purchases such as Ultrasound Machines, you may have very prescriptive Trust procurement processes to follow – use your evidence of compliance as excellent evidence for this domain.

Other things to think about as you evidence this standard:

  • Do you have a “Vascular Ultrasound machine Specification” with detailed information about what you are looking for when you trial machines?
  • Do you have a form for all staff to complete when they test machines? Does it cover ergonomics as well as image quality?
  • Does your Trust have an “Imaging Group” who advise on priority replacements – do you have someone on this group to ensure Vascular doesn’t get forgotten?
  • Do you have a folder for each machine with installation certificates, service records, QA records, fault log, safety alerts all easily to hand? (This could be a paper folder or on your shared drive)
  • If you don’t yet have an established QA programme – can you evidence that you have started the process? perhaps a trainee could help?
  • Do you have a departmental asset register? This needn’t be complicated, it just requires a table with a list of machines, serial numbers, purchase dates, recommended replacement dates and perhaps a box to say whether each machine is still clinically adequate / costing more to repair than replace. Ensure the register is reviewed each year, and don’t forget to use your Trust Risk Management processes, where appropriate, to gain Management support for funding. This is all excellent evidence for IQIPS as well as to use within your Trust when you are seeking money to replace machines.
  • Do  you have a service contract for your machines so you can minimise “down-time”? If not, maybe you can evidence that your local Medical Physics department get them up and running quickly when they break down.
  • Does anyone do a regular stock-take? Do you have a process for ordering consumables? Could an assistant have responsibility this?

FR3 - Staff

We all know how much we depend on our staff for service delivery and are acutely aware of the impact of vacant Vascular Scientist positions on our workload. This standard requires that we do all we can to ensure we have a motivated, appropriately managed and supported workforce.

Do you have contracts of employment and job descriptions? Do you carry out annual appraisal, set reasonable objectives and support staff with their CPD and career progression? Do you comply with Trust HR processes for recruitment? Do you engage with the HR and Occupational Health departments when problems occur? Do you deal with issues fairly and take staff concerns seriously? Are staff able to contribute ideas to service management and improvement? Do you engage with training the future workforce – are any staff helping with national training, the STP programme, sit on the SVT Education Committee, help with study days?

An organised storage system of staff records and their maintenance is essential for this standard, and anonymised evidence of any of these processes can be uploaded to the web-tool, or shown to the assessor when they visit. 

FR4 – Staff Competence

This standard ensures that we implement and monitor systems to ensure staff are fully trained and competent to deliver the service.

Do staff receive induction (organisational and departmental) and can you evidence this with documentation? Are trainees always supervised according to your department’s processes? How do trainees know when they can scan unsupervised? What is the process if there is a problem with competence? Do locum staff have access to your protocols/reporting templates? Do you assess locum competency or just let them get on with it?

Many Trusts will have an electronic record of staff Essential Training and a maybe even a process for alerting staff when competencies need renewing. Ensuring the departmental manager can access this will be invaluable for your evidence – and you could add a review of these records to the staff annual appraisal meetings.

When you get a new machine, or have a Radiology/Surgery trainees scanning in the department – how do you know that everyone is competent with the machines? – is this documented?

FR5 – Workforce Planning

This standard focusses on workforce review, planning and management and the deployment of staffing for clinical and non-clinical practice.

It asks questions of our systems around the planning of our services and the support of staff; education and training and retention of staff.

Are there systems to support service review that involves input from our patients and staff? Are service development plans aligned with workforce planning to support any changes? Are senior managers engaged in decision making? Is staff retention monitored and thought given to succession planning?

This standard outlines the need to facilitate an effective service in the face of changing healthcare needs.

We are all continuously evaluating the future needs of our services, and the workforce planning that comes with that. So this standard invites us to simply outline the measures we already take to ensure continuity of our services and staffing.

How do we evidence this standard? -  we could perhaps think about business cases that may have been produced for the implementation of a new service, evidence that you submit bids for STP trainees Or maybe evidence around patient or staff surveys that have included questions about service development or staffing in your department.

 

FR6 – Management of Budgets and Service Contracts

We all feel the responsibility of ensuring that budgets and service contracts are well managed. This standard requires us to demonstrate that this is undertaken with due consideration to care for our patients.

Evidence for this covers areas such as: ensuring that there are clear lines of responsibility for budgeting and contract management; demonstrating a clear process for procurement of services and monitoring of the effectiveness of the service.

You may have 3rd party agreements in place for services such as departmental cleaning by an external provider, either arranged through your Trust or independently. Could you show how the quality of  service is monitored through the use of logs and audit?

If you have regular meetings to review the effectiveness of a procured service or contract – then minutes from these meeting could be useful evidence, as well as agreed action plans. Do you have regular meetings with your divisional accountants to review your spending?  – ask for copies of their documentation..

This standard also asks us to show how all staff are made aware of budgetary planning – this might be through departmental bulletins; newsletters or email updates etc…..or simply including a brief discussion in your regular team meetings so staff are aware of how much is spent on consumables etc.

FR7 – Complaints Management

Perhaps one of our least favourite things to deal with (!) – but quite easy to evidence good practice.

As you might expect from the pattern of the other standards, you will need to show that there are defined roles and clear lines of responsibility for handling and reacting to complaints, written or verbal – and that these are managed appropriately and in a timely fashion.

You will almost certainly already have a system in place to record complaints and how they were resolved. This standard requires us to show that the results of complaints investigation have been shared with staff to enable learning.

As with all other standards across the domains, we can also go further than just recording and disseminating information and analyse the effectiveness of our complaints handling. This might be achieved through audit of the types of complaints we receive to identify any particular areas for improvement.

Remember that a system is only deemed effective if there is continuous monitoring of that system and evidence of learning to drive delivery of high quality care.

One of the areas that UKAS is particularly focussed on is engagement with lay input and engagement with other services to enhance and improve our own practice. So this is a good area in which to evidence any collaboration you may have had with a PALS service for example in dealing with a complaint. It demonstrates a willingness to invite the input of wider services and colleagues with a different perspective to help us to improve our own care.

Final Thoughts

You may be surprised to know that FR4 (Staff Competence) is amongst the most common standards for departments to receive “findings” on during their accreditation visit. A “finding” is something that is found by the assessors to fall short of the required standard and requires further work and evidencing prior to granting accreditation. So our advice is to pay particular attention to FR4 which focusses on staff training, competence and associated documentary evidence.

We hope that this article has been helpful and, as ever, we would be very pleased to receive feedback and suggestions for the future articles. In the next one we will cover the Safety domain.

Alison Charig (Portsmouth Hospitals NHS Trust) and Andrew Pellew-Nabbs (Warrington and Halton Hospitals NHS Foundation Trust)

Abbreviations:

HR = Human Resources

IQIPS = Improving Quality in Physiological Services

PALS = Patient Advice & Liaison Service

STP = National School of Healthcare Science Scientist Training Programme

UKAS = United Kingdom Accreditation Service