Standards & Accreditation for Occupational Health Services

Paul J Nicholson

Scope

• Background

• Developing the standards

• Definitions

• The scope and aims

• The standards

• The accreditation process

Standards for Health

2006 – Department of HealthStandards for Better Health • Require a rigorous approach to assessment

and accreditation of providers of NHS services.

2008 – Lord Darzi’s Report High Quality Care for All: NHS Next Stage

Review• Confirmed Government support for provider

accreditation schemes in the NHS.

Standards for Occupational Health

An integrated approach to working age health should be underpinned by: clear standards of practice and formal accreditation for all providers

Developing the standards

• Faculty of Occupational Medicine led

• 47 people represented 35 organisations

• Occupational medical & nursing professional bodies [AOHNP(UK),

RCN, SOM]

• Commercial OH providers [including COHPA]

• Employer representative bodies [BITC, CBI, CIPD, EEF]

• Worker representative bodies [Unite, USDAW]

• NHS Plus / HSE / DETINI

• Benchmarking to avoid re-work (ISO, Network Rail)

Key milestones

Q4 08 Q1 09 Q2 09 Q3 09 Q4 09 Q1 10 Q2 10 Q3 10 Q4 10

Agreed domains

Agreed 1st draft

Consultation& piloting

STANDARDSLAUNCH

Accreditation body chosen

Pilot web tool

ACCREDITATIONLAUNCH

Definitions

• Standard

• Minimum requirement

• Accreditation

Definitions

A standard is something considered by an authority or by general consensus as a basis of comparison in measuring or judging adequacy, quality, etc

Definitions

• Minimum requirements relate typically to existing professional guidance

– They must be met to satisfy the standard

– They are intended to be well-defined and easy to understand

Definitions

Accreditation is a self-assessment and external peer assessment process used to accurately assess level of performance in relation to established standards and to implement ways to continuously improve the healthcare system.

International Society for Quality in Health Care (ISQua)

Accreditation is a voluntary process.

What does accreditation mean?

The scope of the OHS standards

• The standards apply to broad-based clinical occupational health services, be they:– in-house services in the public and private sectors– commercial occupational health providers from

single handed providers to large organisations

• They do not apply to non-clinical services, e.g. occupational hygiene, ergonomics, etc.

• They reflect existing professional guidance

Aims

• Enable OHS to identify the standards of practice to which they should aspire

• Credit good work being done by high quality OHS, providing independent validation that they satisfy standards of quality

• Raise standards where they need to be raised

• Help purchasers differentiate OHS that attain the desired standards from those that do not

The standards

13 standards are grouped into 6 domains:

A. Business probity

B. Information governance

C. People

D. Facilities and equipment

E. Relationships with purchasers

F. Relationships with workers

The standards

Business probityA1 Conduct business with integrityA2 Maintain financial propriety

Information governanceB1 Maintain adequate OHCRsB2 Implement systems to protect

confidentiality

PeopleC1 Ensure staff are competentC2 Ensure appropriate supervision

The standards

Facilities and equipmentD1 Conduct business in safe, accessible and

appropriate facilities D2 Ensure that medical equipment is safe

and appropriateD3 Ensure that medicines are handled

appropriately

Relationships with purchasersE1 Deal fairly with purchasers E2 Be customer focused

Relationships with workersF1 Ensure that workers are treated fairlyF2 Respect and involve workers

Standard A1An OHS must conduct its business with integrity

Minimum requirements:The following minimum requirements apply to all OHS:

A1.1 An OHS must only publish information about services which is factual and verifiable

The following additional minimum requirement applies to all OHS except single-handed practitioners:

A1.2 An OHS must take reasonable steps to ensure that all of its staff are honest and trustworthy

The following additional minimum requirement applies to an OHS that outsources work to another organisation:

A1.3 An OHS must maintain systems to check the qualifications of and monitor the standard of work that is outsourced to third party providers

Examples of evidence

A1.1 A file containing all information about the service published in leaflets or on a website or in CV’s and used for the purpose of promoting its services with objective data to verify that the information is factual and verifiable

A1.2 A documented procedure for recruitment and selection processes that includes obtaining references

As a minimum, a system of self declaration for criminal convictions and any investigations or disciplinary action by an organisation responsible for regulating a health care professional, e.g. GMC, NMC, HPC

A1.3 Documentation of regular contract performance reviews

Customer survey

E1.1 An OHS must provide purchasers & potential purchasers with clear & user-friendly information on fees

E1.2 An OHS must agree with purchasers the extent and scope of any business continuity planning that is required to protect service delivery

E1.3 An OHS must agree with customers, at the outset, the processes for referrals to the OHS, case management and reporting of cases of occupational disease and any onward referral of workers for further investigation

E2.1 An OHS must be in touch with individual purchasers to understand their culture, values & needs based on reliable and recent information

E2.4 An OHS must use formal & informal methods to regularly seek information about customer satisfaction from purchasers & referring managers

Assessment & accreditation

Register for information

Register as a user / input OHS details

Upload evidence against minimum requirements

Perform self-assessment / develop action plans

Apply for accreditation

Application

Will include an attestation to:– meeting eligibility criteria– providing true and contemporaneous

information– complying with all applicable laws and

regulations and – having appropriate insurances

Must be signed or co-signed by at least one registered health professional

Assessment & accreditation

SEQOHS manager assesses

readiness for audit

Annual self-assessment Verified by SEQOHS manager

Apply for accreditation

Online assessment by 2 auditors

On-site audit by 2 auditors

Accreditation

At least once every 5 years

What happens if an OHS fails?

• It depends on what the challenges are• Clear recommendations• Timescales for improvement• Direct support from the SEQOHS office to

attain full accreditation

We want services to pass,

it’s a supportive process

We want services to pass,

it’s a supportive process

Web-based tool

• Online self assessment tool

• Evidence record for external audit

• Knowledge management system

Knowledge Management System

Introduction

1.2.3.4.5.

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Presentations

1.2.3.4.5.

1.2.3.4.5.

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Knowledge Management System

How do I find out more?

Online:

www.facoccmed.ac.uk/library/docs/standardsjan2010.pdf

STANDARDS

Hard copy:

Faculty of Occupational Medicine6 St Andrews PlaceRegent’s ParkLondon NW1 4LB

How do I find out more?

ACCREDITATION

FOM Winter Conference:

1st December 2010Royal College of PhysiciansRegent’s ParkLondon

Online:

SEQOHS will have its own web address