The Egg

Accreditation of stroke services A pilot project to test the hypothesis that service accreditation is the natural and necessary link between revalidation and a quality service for patients

Why? Quality and revalidation are both high national priorities Quality and revalidation are both high national priorities Intuitively they are linked Intuitively they are linked Missed opportunity not to study the link Missed opportunity not to study the link

Why? Revalidation for UK doctors starts 2009 Revalidation for UK doctors starts 2009 Revalidation “positive affirmation of competence” Revalidation “positive affirmation of competence” “missing a trick” “missing a trick”

Quality patient care Difficult to define Difficult to define Difficult to measure Difficult to measure Difficult to teach Difficult to teach Difficult to learn Difficult to learn Difficult to practice Difficult to practice

Physician competence Difficult to define Difficult to define Difficult to measure Difficult to measure Difficult to teach Difficult to teach Difficult to learn Difficult to learn Difficult to practice Difficult to practice

Most doctors will revalidate 95% or more will revalidate 95% or more will revalidate More than 100k doctors to revalidate More than 100k doctors to revalidate How does this process capture the 5% of underperformers? How does this process capture the 5% of underperformers? How does it improve the performance of the majority? How does it improve the performance of the majority?

Linkage Revalidation of individuals Revalidation of individuals Revalidation of services Revalidation of services The same process “individual vs team” The same process “individual vs team” Collection of information to demonstrate competence and a continuous process of improvement Collection of information to demonstrate competence and a continuous process of improvement

Multi stakeholder project Department of Health Department of Health Health Foundation Health Foundation Health Care Commission Health Care Commission Royal College of General Practitioners Royal College of General Practitioners Royal College of Nursing Royal College of Nursing Stroke Association Stroke Association

Revalidation for Physicians 5 year cycle 5 year cycle The sum of 5 years work The sum of 5 years work “positive affirmation of competence” “positive affirmation of competence” Collection of supporting information Collection of supporting information Structured annual appraisal Structured annual appraisal

Two parts to revalidation Performance Performance Award of licence to practise by General Medical Council Award of licence to practise by General Medical Council Competence Competence Award of certificate of competence by the relevant Royal College Award of certificate of competence by the relevant Royal College

Revalidation certificate issued by GMC License to practice + Certificate of competence

Supporting information Performance in areas of patient care, including complaints, 360˚appraisal, audit, team performance and quality outcomes Performance in areas of patient care, including complaints, 360˚appraisal, audit, team performance and quality outcomes Competence in specialist area as defined by the medical specialist society and Royal College including audit, team performance and quality outcomes Competence in specialist area as defined by the medical specialist society and Royal College including audit, team performance and quality outcomes

Quality outcomes in defined conditions Linked to team performance Linked to team performance Linked to high quality data Linked to high quality data Linked to national audit Linked to national audit Linked to national benchmarks Linked to national benchmarks

Assumptions High quality doctors more likely in high quality teams High quality doctors more likely in high quality teams Doctors will find revalidation easier in high quality services Doctors will find revalidation easier in high quality services High quality services will not tolerate low quality doctors High quality services will not tolerate low quality doctors Low quality doctors are likely to improve in high quality services Low quality doctors are likely to improve in high quality services

Our model Describes a service in terms of Competence “what it can do” Describes a service in terms of Competence “what it can do” Measures the service Performance “how it does it” Measures the service Performance “how it does it” Benchmarks performance Benchmarks performance Commissioner adds capacity/size/site Commissioner adds capacity/size/site

Simple model Competence + performance = Accreditation Competence + performance = Accreditation Accredited service = quality service Accredited service = quality service Capacity “how much, where” is for commissioners depending on size and complexity of population Capacity “how much, where” is for commissioners depending on size and complexity of population

We are designing an accreditation model that is: Based on quality assurance Based on quality assurance Uses data already available Uses data already available Uses few targeted peer review visits Uses few targeted peer review visits Is not site specific: “what not how” Is not site specific: “what not how” Is based on performance and competence Is based on performance and competence

How do we define an accredited service? Must be a high (ish) bar Must be a high (ish) bar Must be potentially attainable by all Must be potentially attainable by all Must improve quality year on year Must improve quality year on year Must move bar up year on year Must move bar up year on year Status must be demonstrated regularly Status must be demonstrated regularly

Why stroke? Good national data Good national data Good national network Good national network “small service” “small service” Complex service, Complex service, moves between hospital/community moves between hospital/community acute, peri-acute and chronic care acute, peri-acute and chronic care Keen staff Keen staff

How stroke? One strategic health authority One strategic health authority Index first stroke or TIA Index first stroke or TIA End point leaving rehabilitation End point leaving rehabilitation Measures based around national stroke audit Measures based around national stroke audit Benchmark Benchmark

Competent stroke service must be able to: Assess TIA Assess TIA Assess new stroke Assess new stroke Image within 24 hours Image within 24 hours Admit to acute stroke unit Admit to acute stroke unit Transfer to stroke rehabilitation unit Transfer to stroke rehabilitation unit Assess for carotid surgery Assess for carotid surgery And more And more

Commissioning for Quality Accredited Services Accredited Services Commission for size Capacity Capacity

Too much inspection Model is simple Model is simple Enables regulation Enables regulation Replaces 1000 questions Replaces 1000 questions Reflects values of the service Reflects values of the service Reflects patient requirement Reflects patient requirement Engages clinicians useful measurement Engages clinicians useful measurement

If successful link demonstrated Patterned accreditation Patterned accreditation How many services to ensure high performance trusts/commissioners? How many services to ensure high performance trusts/commissioners?

The Egg