1. Whole Trust Accreditation University Hospitals Birmingham Diagnostic Services Accreditation Programme (DSAP)
Dr Debra Balderson
WM GMC Diagnostic Services Accreditation Lead/ Healthcare Science Education Lead

2. UHB Accreditation Drivers?
NHSE and University Hospitals Birmingham (UHB) NHS Foundations Trust entered into a contract whereby UHB are undertaking the role of lead organisation, hosting the West Midlands Genomics Medicine Centre (WMGMC), based at the Institute of Translational Medicine (ITM).
Contract
Schedule 2,
General Terms and Conditions,
1.2.8
The partnership provided an opportunity to focus collectively on all diagnostic services for the first time
The WMGMC comprises 18 local delivery NHS partner Trusts (LDPs) all of which, under the terms of the WMGMC partnership arrangements, have committed to working towards the accreditation of their diagnostic services against IQIPS, ISAS, and the JAG standards.

3. Initial approach What is required? What’s in place?
4 domains:
Patient Experience (have a department!)
Safety (have a department)
Facilities, Resources and Workforce (have departments)
Clinical (have the service)
What’s in place?
Other accredited services
What shared experience can we count on?
Other accredited services in the country?

4. UHB Accreditation Schemes
Existing
UHB Accreditation
UHB Accreditation Schemes
UKAS Schemes:
ISO/IEC NEQAS
ISO 15189: Medical Laboratories
Improving Quality in Physiological Sciences (IQIPS - Audiology)
Improving Quality in Physiological Sciences (IQIPS)
Imaging Services Accreditation Scheme (ISAS)
Other Schemes:
Joint Advisory Group on GI Endoscopy (JAG)
Quality Assurance Standards audit by the Institute of Medical Illustrators
Human Tissue Authority (HTA)
Joint Accreditation Committee . International Society for Cellular Therapy. European Society for Blood and Marrow Transplantation (JACIE)
European Society for Blood and Marrow Transplantation
(EBMT)
British Standards Institution (BSI) for the Radiation Protection Services
College of Clinical Perfusion Scientists

5. Almost 2 years later…. Application for accreditation ….
Clinical domains left largely unaddressed
H&S
Pat Ex
Workforce
Documentation
Different services had offered systems and evidence for what should be an organisational system

6. Share the Knowledge and Experience?
Labs-years of CPA experience….
Too busy
Not the same process
Different criteria
Where are the resources?
Where is the funding?
Cost and time

7. Share the Knowledge and Experience?
Audiology-years of IQIPS
experience….
Too busy
Not the same clinical process
Where are the resources?
Where is the funding?
How robust is the system in place for Trust roll out?
Cost and time

8. Sept 2016 Diagnostic Services Accreditation Programme-DSAP
A structured process for achieving a predetermined aim using a unique set of co-ordinated activities following a life cycle with specified start and end dates.
It is temporary in nature and normally uses a team approach with limited resources in terms of finance and people
Diagnostic Services Accreditation Programme-DSAP
Plan/Timescale
Accreditation application
Gantt chart-responsibilities
Structure
Included/Excluded
Experts
Sponsorship

9. Create model for Trust-wide accreditation - UHB Accreditation Scheme
IQIPS/ISAS Standards
(before 2017 review)
Create model for Trust-wide accreditation - UHB Accreditation Scheme
Patient Experience
Safety
Facilities, Workforce
and Resources
Clinical
Bespoke Patient Experience Programme
Health and Safety programme
Site visits/Audit
Revised Mandatory Training Programme
Workforce and Facilities refresh
HCS education and workforce Strategy
Collaborative Physiological Sciences meetings
Audit programme
Medical Engineering
Contracts
Environment
ORGANISATION SOLUTIONS
Discipline Solutions
4. Integration of QM across all Diagnostics Clinical Services
Service Pathway Mapping
Quality Assurance
Protocol management review
SOPs (controlled and multi-disciplinary)
Clinical Risk Management
Practice review-innovation and collaboration

10. Accreditation Programme
JAG
Endoscopy
Diagnostic Services
Accreditation Programme
ISAS
Imaging
Radiography
Ultrasound
Mammography CT
MRI
Bone Mineral Densitometry
Radionuclide Imaging
IQIPS
Cardiac Physiology
Vascular Science
GI Physiology
Lung Function and Sleep
Neurophysiology
Audiology
Urodynamics
Ophthalmology
All Other UHB Accreditation Schemes
NEQAS
Med Labs
Med Illustration
HTA
JACIE
EBMT
BSI RPS
Perfusion

11. Essential Organisation
Sponsorship
To be effective, transformational work of this scale requires sponsorship and support at Director level within an organisation.
The Executive Chief Operating Officer and the Executive Director of Delivery have supported the Trust-wide accreditation programme at UHB, acknowledging the benefits, such as continuous improvement in processes and patient outcomes.
Allowed a meaningful governance structure to be established for DSAP.

12. UHB Diagnostic Accreditation Governance Structure
Exec Board
WM GMC Governance structure
DoD
COOG
Diagnostic Services Accreditation Programme
User Group (DSAP UG)
Steering Group (DSAP SG)
CEAG

13. Governance Structure DSAP Steering Group DSAP User Group
Meeting frequency: Monthly
Chair: DDoD
TOR
Strategic/Planning
Gap Analysis
IQIPS and ISAS criteria
Risk register
Membership:
WM GMC Accreditation Lead
Head of Clinical Risk and Compliance
Head of Patient Experience
Head of Service Improvement
Diagnostics Theme lead
WMGMC Operational Programme Manager
Health and Safety Manager
DSAP User Group
Meeting frequency: Monthly
Chair: WM GMC Accreditation Lead
TOR
Operational performance review
TLR completion
Domain Compliance Reviews
Gap Analysis
Risk register
SOPs
Membership:
Departmental Accreditation Leads
Diagnostics Theme lead
WMGMC Operational Programme Manager

14. Organisational Distribution of Diagnostic Services
Division A
Clinical Laboratory Services
Clinical Biochemistry
Histopathology
Microbiology
Haematology
Cellular Pathology
NEQAS
Medical Physics
Perfusion
Tissue Services
Phlebotomists
Imaging
Division B
Cardiology Physiologists
Vascular Physiologists
GI Physiologists
Renal Technical Services
Liver Labs
Endoscopy
Division C
Lung Function and Sleep
Ophthalmology
Division D
Neurophysiology
Audiology
Max Fax
Uro-Dynamics
Corporate
Medical Illustration
Medical Engineering
Research Scientists
Bioinformatics
Life Sciences
Clin Eng/
Medical Physics
Physiological
Sciences
Bioinformatics- sits both in Medical Physics (Physical Sciences) and Corporate (Health Informatics and Genomics),

15. Transformation (without any power!)
Get Organisational Sponsorship
UHB COO, ”The IQIPS programme at UHB will ensure that Physiological Scientific Services becomes part of the quality improvement and quality assurance agenda in the NHS. It provides a set of standards which will mark the quality of these services for commissioners, providers and users of service with patient quality outcomes at its core.”
Project Management principles
Create Governance structure
up to Exec Board
Know the teams/experts
Trust and mutual respect
Give the work to the experts
H&S, Patient Exp, Clinical, Facilities
Do once and share
Why do more? Opportunity for peer review? Professional feedback? Standardisation.

16. Say Goodbye to SILOS

17. Highest Standards of Excellence
and Professionalism
Not accredited!
Desire to share-get peer review and more uptake of standard protocols
(think Audiology)
Sharing=networking=idea-exchange=collaboration=innovation
NHS Constitution:
“provides high quality care that is safe, effective and focused on patient
experience; in the people it employs, and in the support, education,
training and development they receive; in the leadership and management
of its organisations; and through its commitment to innovation and
to the promotion, conduct and use of research to improve the current and
future health and care of the population.
Respect, dignity, compassion and care should be at the core of how patients
and staff are treated not only because that is the right thing to do but
because patient safety, experience and outcomes are all improved when staff
are valued, empowered and supported.

18. WM GMC Diagnostic Services Accreditation Programme
Phase 1- Local Transformation
UHB Accreditation
Phase 2 - Regional Transformation
WM GMC Accreditation
Phase 3 – Sustainability
National Opportunity for Transformation