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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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
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