SMJ 2001: 46(6); 165
Background
The Clinical Standards Board for Scotland (CSBS) was established as a special Health Board in April 1999. The task of the CSBS is to develop and run a national system of quality assurance and accreditation of clinical services with the aim of promoting public confidence in the National Health Service in Scotland. The Board’s remit varies from looking at the services provided for patients with a particular condition or diagnosis (eg schizophrenia) and in other cases at those relating to a range of manifestations (eg coronary heart disease).
The CSBS has initially focussed on the national clinical priorities of cancer, coronary heart disease and mental health but over time all the services provided by the NHS will be reviewed. The CSBS standards relate to the patient’s journey through different parts of the NHS to reinforce their patient focus and to highlight the links between primary, community and hospital services and between the work of all healthcare professionals involved in the provision of each service.
The accreditation system comprises three processes:
1. Setting standards
In
developing standards the CSBS have implemented an open and inclusive process
involving a wide range of both lay and professional people through open
meetings, focus groups etc.
2. External peer review
When
the clinical standards are complete the Trust will undertake a
self-assessment exercise of their service against the standards. The data
produced as a result of the self-assessment exercise forms a major
component of the written submission of evidence considered by each peer review
team prior to their visit to the Trust.
The peer review visit is multidisciplinary with lay person/user involvement. It is based on an objective assessment of the written evidence and meetings with patients and staff. The ultimate aim of the visit is to assess performance in a constructive manner and to disseminate good practice.
3. Reporting findings
All
CSBS reports will be published. They will include information on the
performance in each Trust against the standards. In relation to those standards
deemed to be essential, a service will be categorised as being accredited or not
yet accredited. In the case of the latter, the CSBS will recommend improvements
and may revisit such a service to assess progress. Reports will be distributed
widely within the NHS, to professional and voluntary bodies and to the general
public.
Preparation for a peer-review visit
Based
on our own previous experience, we estimate six to eight weeks work is involved
in preparing for a CSBS peer review visit to a large teaching hospital based
across two separate sites. A considerable number of staff, not only from the
acute sector, but also involving primary and tertiary services are involved in
collation of evidence to support the self-assessment documentation. The
main tasks involved in preparing for and co-ordinating a Clinical
Standards Board review visit are outlined in Table I.
|
Table
II Costs
involved in a peer-review visit |
||
|
Staff |
Estimated Hours |
Estimated Cost |
|
Clinical Effectiveness Staff |
391 |
£5551.97 |
|
Medical Staff |
65.5 |
£2220.45 |
|
Nursing Staff |
73.5 |
£1030.25 |
|
Paramedical Staff |
9.5 |
£173.76 |
|
Primary/Tertiary Care Staff |
26 |
£502.98 |
The CSBS peer-review visit
The CSBS peer review team generally comprises six to eight members. This multidisciplinary team is made up of clinical, managerial and lay representatives who have all been trained as reviewers. The review team is supported by members of the CSBS who collate the reviewers’ findings following examination of the self‑assessment and interview with staff members. Members of staff from the Clinical Effectiveness Department act as guides to the review team and ensure the smooth running of the visit to the Trust. At the end of the visit, the review team provide some informal feedback to the staff on their findings. A formal report on service provision against the standards is sent to the Trust approximately six to eight weeks following the visit.
As far as the Trust is concerned the process does not end with production of a CSBS report following the service review. The CSBS report continues the process of quality improvement and allows the clinicians to build on the strengths and address the challenges identified in the report. Following on from the CSBS policy of no surprises, a well-prepared self-assessment document backed up by supporting evidence should allow the multidisciplinary Trust team an opportunity to identify and address areas of weakness ahead of the review team visit.
Costs involved in a peer-review visit
Preparing
for and co-ordinating a CSBS peer review visit does not only involve the
significant time and effort of the many personnel involved in the service being
reviewed, but the costs to the Trust of freeing a large number of clinicians to
take part in a visit are substantial.
The authors have, to date, co-ordinated four CSBS peer review visits to their Trust and although the information shown in Fig.1(not on web page) is very rough estimate, it does give a good guide to the substantial staff time and costs involved in co-ordinating a recent review of colorectal cancer services at this Trust.
As previously highlighted, considerable effort is required by Clinical Effectiveness staff in preparing for a CSBS peer review visit. These staff are responsible for ensuring that all policies, procedures, individuals, facilities and supplies are available for the CSBS reviewers. In co-ordination with the lead clinician these staff set deadlines, complete the self-assessment and remind staff of their responsibilities.
Although the CSBS strives to minimise the disruption to services and the time commitment of any one individual there has been a need to cancel outpatient clinics and other clinical commitments to attend the necessary meetings required prior to and on the days of the peer review visit. The knock-on effect of cancelling clinical commitments has not been costed here, but must be borne in mind when considering the overall price tag of a CSBS peer review visit.
Conclusions
It
is a truism for all healthcare staff if no one questions what you’re doing,
you most likely think you are doing it right. The process of healthcare
accreditation is not new; indeed the Hospital Standardisation Program began as
early as 1917 in the United States. External assessment and peer review of the
health service is now widespread and for some clinicians this has led to a case
of accreditation fatigue. Lack of an efficient IT infrastructure makes the task
of meaningful clinical data‑collection a labour intensive chore. Even
amongst the most fervent supporters of health‑service accreditation the
burden of data collection feels great, but all the more so given that patients
aren’t yet demanding such data.
It must be remembered that the process of preparing for a CSBS peer review visit, as outlined above, is not necessarily the best nor the only way to do it, but has proved effective in this Trust. The key to a successful review visit is planning and organisation. The process must be a partnership between the Trust and the peer review team. It is the Trust’s job to show the CSBS how they perform and it’s the review team’s job to report on that conformance.
Although
still in pilot mode, the CSBS meets many of the characteristics of effective
external assessment programmes as described in Charles Shaw’s recent paper.2
The increasing focus on national clinical standards helps patients to recognise
that it is acceptable to have high expectations of the clinical care they
receive.3
The
CSBS peer review visit complements the Trust’s commitment toclinical
governance by providing an external assessment of the quality of care provided
to patients. What remains to be seen is whether the Clinical Standards Board for
Scotland has the clout to make the difference or is it another expensive paper
pushing exercise.
S M Wilson, G Burke
South Glasgow University Hospitals NHS Trust
Langside Road
Glasgow
Corresponding
author: Steven M Wilson