Good afternoon and thank you to the organisers for inviting me to speak to day. It’s a privilege to be here. I have been asked to talk about our accreditation programmes and specifcally accreditation in primary health care.
So after an introduction as to who we are and what we do,……I will explain a bit about accreditation and specfically the primary care programme of standards.
CHKS is part of a much larger corporation since April 2009. As you can see, CAPITA is involved in many areas, and particularly around public health functions as well as ..... CHKS are part of the health division and there are many different businesses within..... Havign said that, we continue to operate very much as we did before with some additiional demands for reporting etc but very much to continue business as usual.
The accreditation arm of the organisation, was acquired in 2006, seven years ago and originally stemmed from the Kings Fund Organisational Audit of the 90s which then became an accreditation programme. The goals and pillars of this programme remain today – that is: emphasis on patient /user involvement Evidence based practice Drive towards improving clinical outcomes# Over the years, the organisation and its standards have gained and currently maintain their accreditation with ISQua the international Society of Quality In Health Care, which requires that we organise ourselves with the same quality management systems as we expect from organisations we accredit.
ISQua accreditation for organisation, Surveyor Selection and Training Course and Standards.
So where do do we work? Varied clients across a number of countries. Wide variety of programmes from Full hospital, Ambulance services, Hospices, Care Homes, and primary care of course.
So what is Accreditation?? The importance of quality in health care seems obvious..... But in recent years, horror stories have been published, and reports published suggesting we can not assume it just because we want it. So there are many systems and support to assure us that patient safety and high quality of care are being considered - and we have heard about some already this morning. Accreditation is one system and one that then provides a banner and statement to the public that an organisation has been through a process, which may vary, but should demonstrate minimum standards of quality, competency and consistency. Accredit means to furnish with credentials.... Our programme In the UK, Accreditation has developed under the leadership of professional associations. There is some distinction (although not always clear) between clinical services accreditation and organisational accreditation. CHKS standards cover the common elements of quality management systems for any organisation to operate appropriately as well as additional standards which look at patient safety. Such standards ensures all elements of the organisation are linked together with the same quality principles and ensures, as has been discovered in the Mid Staff enquiry and the Francis Report on this, that communication, following up complaints etc are as key to patient safety, impact on the culture and morale of organisations and on the delivery of clinical services. Accreditation can be described as:...................emphasis on the ways to continually improve.....very much a developmental process – not an inspection for regulatory requirements only. CHKS accreditation includes key principles of : evidence based standards, external peer group and three yearly cycle - community hospitals accreditation programme and a programme which accreditation healthcare records. In principle the accreditation approach used by CHKS is a framework of standards researched and developed from documented best practice which are assessed by an external, independent survey team and an award then judged and awarded by an independent Accreditation Panel.
So what is the process of accreditation......................
We do have a web-based accreditation online tool to facilitate tracking of progress against each criterion and standard as well as a portal to upload evidence to demonstrate performance against the standards.
This is the 2009 version, but we are in the final stages of its revision and production of the 2013/14 edition which is intended for publication January 2014.
Each standard has subsections within criteria listed. Each criterion has a criterion statement, guidance on interpretation and references as to origin of statement. Along side there are relevant mappings and tags to indicate their relevance to accreditation or ISO programmes and other Mention CQI tags and why Currently these are the 2009 version, but is in final stages of revision for the 2013 version which is for publication January 2014.
Lots of feedback as to why people do accreditation: There is for many a requirement from their insurers An expectation from patient or client base Among hospices in UK, we have been told by a CEO that ‘it helps her sleep at night’ Standards are clear and instructive Nothing speaks louder than our client base..... Nothing to fear – very positive process... We are currently talking to Centric Health about the programmes and an approach which would work for their practices.
Moyra Amess, Associate Director, CHKS
CHKS Accreditation in Primary Health Care
Working together to improve quality in healthcare
13th November 2013
Moyra Amess, Associate Director
Introduction to CHKS
Quality and Accreditation
The CHKS Accreditation Cycle
Primary Health Care Programme
Benefits of Accreditation
primarily in NHS
Work with more than 100
large acute hospitals in
We help them to
performance around key
indicators including rates
of mortality, length of
stay, patient outcomes,
complication rates and
accreditation and ISO
Provide high quality
Work with more than
100 clients throughout
We are dedicated to
3. Our coverage in Europe
UK excl NI – 50 accounts
Northern Ireland – 1 account
Ireland – 35 accounts
Portugal – 18 accounts
Cyprus – 3 accounts
Italy – 4 accounts
Cruise Ships – 2 accounts
Other experience in:
Accreditation in health care
assessment and external peer
assessment process used by health care
organisations / clinical services to accurately assess
their level of performance in relation to
established standards and to implement ways to
The CHKS Accreditation Cycle
Against standards at outset
12 months prior
to accred expiry
at 12 and 24 mths
Monitoring visit at 18mths if not ISO certification
12-18mths after start
accreditation from date
Accreditation on-line -web-based portal
Contact Name & Job Title
Philosophy that informs our approach
• Focused on Patient Safety, the patients’ and families’ experience of
care , professional competence, clinical governance, leadership and
• Strong commitment to continuous quality improvement
• Incorporates current national and professional guidance
• Bringing together standards of best practice
• Evidence based standards
• Referenced to CQC and GMS requirements
• Originates from global policy developments, research evidence,
professional guidance and extensive consultation with people working
in the field
• Demanding but realistic
Standards for Primary Health Care
Contact Name & Job Title
Layout of criteria
8.36 There is a designated person appointed to handle complaints for
the practice and to manage the complaints procedure
The designated person may also be the 'Responsible Person' who ensures that complaints are
handled in compliance with the Regulations.
The Local Authority Social Services and National Health Service Complaints (England)
NHS Complaints in England: Regulations and Principles. Medical Protection Society. 2009
8.42 There are notices displayed in the practice advising patients how
to make a complaint.
Such notices may invite suggestions, comments and complaints from patents
and carers, and do not need to focus exclusively on complaints.
EASY TO USE AND UNDERSTAND
The Health and Social Care Act 2008 (Registration Requirements) Regulations
2009, Complaints, 17(2) (a)