Reviewer s Conference 14 October Anaesthesia Clinical Services Accreditation (ACSA) R E D I TAT I O

Transcription

1 ROYAL C O A CC TISTS HE ST GE OF ANAE E LL R E D I TAT I O N Anaesthesia Clinical Services Accreditation (ACSA) Reviewer s Conference 14 October am to 4.30 pm The Royal College of Anaesthetists, London

2 1 PROGRAMME 5 CPD CREDITS 9.00 am Registration and refreshments Sessions Chaired by Dr Peter Venn 9.30 am Welcome and Introduction Dr JP van Besouw, President, RCoA 9.45 am Keynote Speaker Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission am ACSA One Year On Mr Charlie McLaughlan, Director of Clinical Quality, RCoA am Break am Dr Sade Okutubo Congratulations and Introduction Dr JP van Besouw, President, RCoA am Review of ACSA Process from Start to Finish Dr Sade Okutubo, Clinical Lead in Perioperative, Critical Care and Chronic Pain Services, Homerton Hospital, London am Standard Development and the Use of Standards in Healthcare Mr Rob Turpin, Market Development Manager Healthcare, British Standards Institution (BSI) Group pm The Use of Audits to Improve the Quality of Your Service Dr Dave Murray, Consultant Anaesthetist, James Cook University Hospital, Middlesbrough pm Lunch 1.30 pm Peer Review for Quality Improvement Professor Michael Horrocks, Council Lead for Service Accreditation, Royal College of Surgeons of England 2.00 pm Sheffield Site Gap Analysis and Evidence Gathering a Focussed Discussion Dr George Eapen, Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust Dr Guy Veall, Consultant Anaesthetist and Clinical Lead for Service Improvement, Sheffield Teaching Hospitals NHS Foundation Trust 2.20 pm Lay Reviewers and their Contribution to the ASCA Process Mr John Hitchman, The Lay Committee 2.50 pm Quality Gaps and How to Close Them Dr Emma Jackson, Specialty Registrar, Merseyside 3.20 pm The Future of ACSA Professor Ravi Mahajan, Chair, Professional Standards Committee 3.45 pm Closing Comments Mr Charlie McLaughlan, Director of Clinical Quality, RCoA

3 2 Congratulations to Homerton Hospital who are the first anaesthetics department in the United Kingdom to receive Anaesthesia Clinical Services Accreditation. ROYAL COLLEGE OF ANAESTHETISTS ACCREDITED Dr Sade Okutubo, Clinical Lead in Perioperative, Critical Care and Chronic Pain Services at Homerton Hospital, will be delivering a presentation on the ACSA process at am.

4 3 ROYAL COLLEGE OF ANAESTHETISTS ACCREDITATION PEER REVIEW FOR QUALITY IMPROVEMENT ANAESTHESIA CLINICAL SERVICES ACCREDITATION (ACSA) And so it is, one review visit, and a year to the date of that first meeting with the ACSA team later, in August 2014, we were delighted to receive the news of a successful ACSA accreditation of our service. Engaging in the process and working together for a common purpose has boosted department morale and team spirit. The peer review process has led to our going over every aspect of our service with a fine tooth comb. We can confidently evidence a high quality service and care for our patients. Dr Sade Okutubo, Clinical Lead in Perioperative, Critical Care and Chronic Pain Services, Homerton Hospital I strongly support the work on accreditation being undertaken by the Royal College of Anaesthetists. The ACSA accreditation programme should in due course be a very useful source of information on the quality of anaesthetic service for the Care Quality Commission. Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission This is a very positive step in the continuous movement to improve the safety of anaesthesia. The opportunity to share best practice and learning through the ACSA library is also to be commended and is supportive of Don Berwick s ambition for the NHS to be a system devoted to continual learning and improvement of patient care. Dr Mike Durkin, National Director of Patient Safety, NHS England

5 4 INTERNAL DECISION CONTACT STEP 1 STEP 2 Department agrees to engage with ACSA. A lead is appointed to act as the main point of contact with ACSA team. Department fills in the registration form which can be downloaded from the website. ACSA team sets up informal (optional) teleconference to discuss details, practicalities and concerns or issues arising. ENGAGEMENT SELF-ASSESSMENT & GAP-ANALYSIS STEP 3 STEP 4 Once the department meets the majority of the Priority 1 ACSA standards, and are ready to officially engage, the department is invoiced for services (Priority 1 standards are those that must be achieved in order for accreditation to be awarded). On receipt of payment, agreed term of engagement begins. Department completes self-assessment and works to close the gaps between current practice and the required standards with the help of an assigned College Guide who is a clinical expert provided by the College. REVIEW ACCREDITATION STEP 5 STEP 6 Once department assess themselves as compliant with 100% of the Priority 1 ACSA standards, they request an on-site review. The review team comes to visit the department. When 100% compliance with Priority 1 standards is confirmed by onsite review team, and after any recommendations are implemented, the department is awarded with an accreditation plaque.

6 5 What is ACSA? Why does it matter? The Anaesthesia Clinical Services Accreditation (ACSA) is a voluntary scheme for anaesthetic departments in the UK to formally and actively demonstrate their commitment to high quality service provision and improvement. It is based on a set of standards selected from the Guidelines for the Provision of Anaesthetic Services (GPAS) recommendations. The standards focus on the following areas: Care Pathway; Equipment, Facilities and Staffing; Patient Experience and Clinical Governance. The scheme has been developed by the Royal College of Anaesthetists (RCoA) Clinical Quality Directorate and offers departments quality improvement through peer review. Reviews are undertaken by senior doctors from within the speciality who know what to look for in service delivery, thereby enabling positive change. The ACSA accreditation process provides clinical directors, managers and medical staff the opportunity to benchmark their service against existing national standards and provides them with the necessary support to achieve any unmet standards. ACSA works with the department leadership to ensure that all members of engaged departments are actively involved in meeting standards recognised by their peers, and are committed to improvement through establishing an action plan. ACSA standards are based on Guidelines for the Provision of Anaesthetic Services (GPAS) recommendations. As these are reviewed annually it allows us to remain up to date with standards that incorporate best practice in anaesthesia. What does it mean for my department? Benefits of accreditation The ACSA process is a partnership between the College and departments in the pursuit of quality improvement. It provides a benchmark to identify areas for improvement, and to create a better working/ teaching/learning environment for staff and better services for patients. The CQC has stated that it regards accredited departments as low risk. As a marker of quality, accredited departments will become more attractive to trainees/employees. Associations are already being made between delivering a high quality service and providing high quality training. Patients will also be assured that they are receiving outstanding service. Organisations that engage with ACSA will benefit from: A proactive, structured and supported process for improving services. An expert advisory on-site review. Benchmarking against standards and anonymised local, regional and national performance. The engagement of staff in service improvement. All departments will receive an ACSA report to support funding and resource bids. Accredited departments will: Be entitled to use a quality mark to denote their commitment to quality and patient care. Be awarded a plaque to display in the department. Be more attractive to potential employees and trainees.

7 6 Dr J-P van Besouw President, Royal College of Anaesthetists Professor Sir Mike Richards Chief Inspector of Hospitals, Care Quality Commission Jean-Pierre van Besouw, known to all simply as JP, is President of the Royal College of Anaesthetists. JP qualified in 1981 from Barts where he began his anaesthetic training; he subsequently trained in London and Australia before appointment to St George s Hospital NHS Trust, London, where he has been a consultant and honorary senior lecturer with a specialist interest in cardiothoracic anaesthesia since He was elected to the Council of the Royal College of Anaesthetists in 2008, became Vice-President in 2010 and President in During his time on Council, he has been responsible for the development of College policies on examinations, recruitment and workforce. In 2013 he was elected Vice-Chairman of the Academy of Medical Royal Colleges. He is an elected Governor of St George s Hospital. He is a past chairman of the Association of Cardiothoracic Anaesthetists (ACTA). JP is married to Liliane, a medico-legal adviser, and has three grown up children. He enjoys gardening, rugby and travel particularly in South West France. Sir Mike Richards was appointed as the First Chief Inspector of Hospitals for England at the Care Quality Commission (CQC) in July He has been asked to lead a new programme of inspections across acute hospitals, mental health services, community services and ambulance services both in the NHS and in the independent sector. The new inspection programme involves a radically new approach for the CQC with large teams of clinicians, patients, carers and CQC inspectors visiting NHS Trusts. Each inspection will lead to a rating for service: outstanding, good, requires improvement or inadequate. Prior to joining the CQC Mike was Director for Reducing Premature Mortality at NHS England ( ) and National Cancer Director at the Department of Health ( ). Prior to these appointments Mike was a consultant and Reader in Medical Oncology at Guy s and St Thomas NHS Trust ( ) and Professor of Palliative Medicine ( ). Mike was appointed CBE in 2001 and Knight Batchelor in 2010.

8 7 Mr Charlie McLaughlan Director of Clinical Quality and Deputy Chief Executive, Royal College of Anaesthetists Dr Sade Okutubo Clinical Lead in Perioperative, Critical Care and Chronic Pain Services, Homerton Hospital Sade Okutubo has been a Consultant Anaesthetist at Homerton University Hospital in Hackney, East London since She has served as Clinical Director for the Department of Anaesthesia since Through a longstanding commitment to the delivery of high quality patient care, efficiency and effectiveness, she has led many improvements in the staffing and practice of the department. Charlie McLaughlan is Deputy Chief Executive and Director of Clinical Quality at the Royal College of Anaesthetists. This position includes responsibility for College standards and guidelines, revalidation and CPD, patient safety, communications and good governance of anaesthesia in the UK. Currently Sade is the Trust Lead for Appraisal and Revalidation and is also working on the latest upgrade to the electronic patient record (EPR) project. Outside of the clinical arena, In her spare time she can be found in a dance hall perfecting her Charleston technique amongst other things. Charlie has been at the College for 11 years and immediately prior to that he was the senior Royal Navy Medical Services Officer with responsibility for co-ordinating and integrating Joint Services medical administration structures in London. Charlie lives near Winchester and is married with one daughter and three grandsons. His interests include the management of risk, team based approaches to safer healthcare, cycling and the domestic management of three unruly feline companions.

9 8 Mr Rob Turpin Market Development Manager Healthcare, British Standards Institution (BSI) Group Dr Dave Murray Consultant Anaesthetist, James Cook University Hospital, Middlesbrough Rob Turpin joined British Standards Institution in 2001 and is currently Market Development Manager for healthcare. He leads on the creation of new standards opportunities relating to medical technologies and healthcare services. Current topics for focus include supporting clinical service accreditation; and the role of standards to support innovation in healthcare. Previously, Rob was involved in managing national and international standards development programmes across a variety of subject areas. He has a degree in Chemical Engineering from the University of Teesside. Dave Murray has been a consultant anaesthetist at James Cook University Hospital in Middlesbrough since He established the NHS Emergency Laparotomy Network in 2010, and led the development of the National Emergency Laparotomy Audit with the Healthcare Quality Improvement Partnership (HQIP). He is now the National Clinical lead for this audit. He has a long held interest in patient safety and Human Factors, is a founding member of the Clinical Human Factors Group, an Associate member of the Institute of Ergonomics and Human Factors, and chairs the Human Factors Steering Group at JCUH. He also has a Masters in Medical Education. When not working, he is also somewhat obsessed with competing in triathlons, and has represented GB within his age group at the European Long Distance Duathlon Championships, and the World Long Course Triathlon Championships.

10 9 Professor Michael Horrocks Council Lead for Service Accreditation, Royal College of Surgeons of England Dr George Eapen Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust George Eapen qualified in Chennai, India and completed his anaesthetic training through Mumbai, Ayrshire, Newcastle and Sheffield. He is employed by Sheffield Teaching Hospitals and his main speciality interest is neuro anaesthesia and neurointensive care. His interests are varied including education, neuroanaesthetic research and accreditation. His experience at working at different trusts has got him interested in importance of accreditation and establishment of standards. Professor Michael Horrocks qualified from Guy s Hospital Medical School in He acquired the FRCS in 1974 and was appointed consultant surgeon at the Bristol Royal Infirmary in 1982, moving to Bath in 1991 to take up the Postgraduate Chair in Surgery. His hobbies include cooking and wine tasting. He is married and lives close to the Peak district in Sheffield. Professor Horrocks has been secretary general of the European Society of Vascular Surgery and President of the Vascular Society of Great Britain and Ireland and serves on the Court of Examiners for the intercollegiate examinations. He is an active member of the Wessex regional training committee, having chaired it for five years. Professor Horrocks is a RCSEng Council Member and lead for service accreditation and served as Vice-President for two years.

11 10 Dr Guy Veall Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust Mr John Hitchman The Lay Committee, Royal College of Anaesthetists Guy trained at St Bartholomew s Hospital London. He took up anaesthesia in Leicester moving then to Sheffield, Alder Hey and British Columbia s Children s Hospital Vancouver before his appointment as a Consultant Anaesthetist in Sheffield. Guy is immediate past Clinical Director of Operating Theatres, Critical Care and Anaesthesia in Sheffield and has just been appointed Service Improvement Clinical Lead in the Trust. Principal of architectural practice for 30 years. For 20 years a non-executive director of the leading residential training college for the disabled. Currently on the boards of various local charities and statutory bodies. John s particular interests are the improvement of the patient experience, informed consent, accidental awareness and paediatric anaesthetic services. As a member of the Lay Committee he has the opportunity to contribute a patient perspective to many of the College s initiatives directed at achieving the highest quality of patient care and comfort.

12 11 Dr Emma Jackson Specialty Registrar, Merseyside Professor Ravi Mahajan Chair, Professional Standards Committee, Royal College of Anaesthetists Emma is an Anaesthesia ST6 working in Merseyside. She has an active interest in patient safety and quality improvement, developing from experience as Head of Communications for Mersey Medical Leadership School, and staff side representative alongside the BMA for the Lead Employer Local Negotiating Committee. In August 2012 Emma worked out-of-programme as a Medical Leadership and Management Fellow. Here she supported hospital trusts in strategy and implementation of working practices for doctors in training, focusing on both education and patient safety. Ravi is a Consultant Anaesthetist at Nottingham University Hospital NHS Trust, Queen s Medical Centre, Nottingham. He is a clinical academic with interest in patient safety and quality improvement in perioperative medicine. Ravi is the past-chairman of the National Institute of Academic Anaesthesia, Chairman of the Sub-committee of Patient Safety at the European Society of Anaesthesiology, Chairman of the Data Intelligence Group of the Safe Anaesthesia Liaison Group, and Editor-in- Chief of the British Journal of Anaesthesia. In August 2013 Emma was appointed to Quality and Clinical Governance Lead with a South London Clinical Commissioning Group, working in partnership with local and national stakeholders to monitor and assure against delivery of the quality, patient safety and patient experience agenda in healthcare providers. Emma has completed a Diploma in healthcare management; and hopes to work towards the MBA in her final years of training.

13 12 ACSA will be exhibiting at each of the following events: Current Concepts Symposium 2014: A Celebration of Anaesthetic Specialities Date: Thursday, 20 November to Friday, 21 November 2014 Location: The Royal College of Anaesthetists Recent Advances in Anaesthesia, Critical Care and Pain Management Date: Tuesday, 10 February to Thursday, 12 February 2015 Location: The Royal College of Anaesthetists Anniversary Meeting: Beyond the Boundaries Date: Wednesday, 11 March to Thursday, 12 March 2015 Location: The Mermaid, London Cardiac Disease and Anaesthesia Date: Wednesday, 29 April to Thursday, 30 April 2015 Location: The Royal College of Anaesthetists Further information on the above is available via the Events Calendar on the website at: RCoA EVENTS

14 CONTACT INFORMATION More information on ACSA, including the ACSA standards and advice on how to engage, is available at THE ACSA TEAM Carly Melbourne Quality and Safety Manager Emily Young Quality and Safety Supervisor Amalia Ndebele Accreditation Co-ordinator Dawn Pace Appointments and Accreditation Co-ordinator If you would like an electronic copy of any of the presentations delivered today, please