August 2014 Dr James Fergsuon-Clinical Lead Debbie Johnston–RCP Head of Assessors & Accreditation Consultant Liver quest project Project 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 & timescales Project PhasesTimeline 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/items 2.Reassessment and action plan 3.WebEX contact with project sites. 4.Create evidence to support a pilot accreditation process July-August Phase three 1.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 PhasesTimeline 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 feedback 15.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-pilot Objective 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 Liver Service complete online self-assessment Liver Service works on improvements Online system automates a rating for each standard according to a traffic light system (level 1-4) Liver Service reviews evidence requirements & gap analysis Access to evidence information & upload 9

Stage Two Agree date for remote and site review Pilot Services have access to accreditation training, Accreditation Agree who needs to be interviewed Assessors review evidence prior to visit Assessors review the evidence portfolio, provide feedback to the Service and add comments Assessors conduct an assessment and prepare a report Assessors conduct site assessment and complete their report with their findings and recommendations 10

Project teams-tasks summary 1.Complete a new assessment and action plans 2.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 process 6.Share learning and improvement ideas