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Thursday 24th August 2017

Unit accreditation - apply NOW



We wish to invite all units to submit data to this accreditation process. A peer review carried out by at least 6 peers who are ordinary members of The Society will allow feedback as to whether these standards are met or where components of unit performance may be improved. It is hoped that, if carried out correctly, such a process will benefit its members in terms of recognition if standards are met and providing leverage for more resource if standards are not met. More importantly the patient will benefit from confidence that quality assurance is guaranteed as far as possible.

The proposed criteria and their weighting are detailed below. Some are regarded as mandatory (ie they require a score of greater than zero). A total score of greater than 75 indicates achievement of the necessary standards.

The process is not meant to be dictatorial, merely to provide peer review. It is proposed that those that meet current standards will be registered as ‘accredited by The Pelvic Floor Society’ for a period of 3 years. Those that do not meet all the criteria will be directed to areas that may be improved and invited to resubmit at any time. Wherever possible, support will be provided with the aim that all units that apply will eventually meet these criteria and be accredited.

This process is still in the pilot phase and two ‘guinea pig’ units will undergo assessment as a test. However, we need both feedback and, more importantly volunteers for peer reviewers to assess those units that apply. Assessors will be required to analyse data from each of the units and score each key performance indicator. After scoring assessors will join together to provide consensus as to the overall score as well as suggestions for refinement of the process.

If you would like to be an assessor could you send your details to steven.brown@sth.nhs.uk. If you have feedback regarding this process please also feel free to contact.

 

Domain

KPI

Minimal Standard

Aspirational Standard

Score

Process

Information giving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Information gathering

Patient information sheets for all major procedures

-SNS

-LVMR

-Sphincter repair

-STARR

-Posterior repair

as well as conservative management eg

-Diet

-biofeedback

-irrigation

 

 

 

Unit protocol algorithm for

1.     Constipation management

2.     Incontinence management

3.     Pelvic pain management

 

 

History and examination proforma

 

 Quality of life assessment for all patients undergoing intervention

Website based information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evidence of follow up QoL assessment

5 (M)

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

5

 

 

 

5 (M)

 

MDT

Representation

 

 

 

 

 

 

 

 

Frequency

 

 

Selection

 

 

 

 

 

 

 

 Administration

Colorectal Surgeon (>1)

Urogynaecologist

Radiologist

Clinical Scientist and/or nurse specialist

Trainees

 

 

Some membership of TPFS

 

 Monthly

 

 

Discussion of

  - Px considering surgery

  - Px with FI considering SNS

  - Px with multi compartmental disorders

  - Px who have failed conservative treatment

 

 

Register of attendees

Meetings minuted

Additionally:

Physiotherapist

Gastroenterologist

Psychologist

Pain specialist

Research fellow/nurses

 

All enrolled in TPFS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

annual AGM (review of process)

10 (M)

 

 

 

 

 

 

5

 

 

5

 

 

5(M)

 

 

 

 

 

 

 

5

Personnel

Lead

 

 

 

 

 

 

 

 

Other consultants  with interest

 

 

 

 

 

 

 

Allied health professional support (eg, continence nurse, GI physiologist, physiotherapist)

- CV to include training, CPD etc- Job plan to include at least 1 PA per week

- Evidence of an average of at least 1 major pelvic floor op per week (SNS, rectopexy, sphincter repair, etc)

- Evidence of referrals from general colleagues

- up to date appraisal

 

 

-CV to include training, CPD etc

-Job plan

- Evidence of pelvic floor work

- Evidence of referrals from general colleagues

-up to date appraisal.

 

 

 

 -CV to include training, CPD etc

-Job plan

-up to date appraisal.

-National or international involvement in pelvic floor topics

(leadership, quality improvement etc)

 

 

 

 

 

 -National or international involvement in pelvic floor issues

(leadership, quality improvement etc)

 

 

 

 

 

 

 

 

5 (M)

 

 

 

 

 

 

 

 5

 

 

 

 

 

 

 

 

5

Procedures

Unit throughput data

 

 

 

 

 

 

 

 

 

Auditable Outcomes

 

 

 

 

 

 

 

 

 

 

 

 

 

Evidence of NICE compliance

 

New Procedure Implementation

12 month data kept for:

  - New OPD referrals

  - Follow up appointment numbers

  - Radiology investigation

  - Physiology iinvestigation

  - Physiotherapy

  - Biofeedback

  - Surgical activity

 

 Morbidity recording and monitoring

 

 

 

 

 Evidence of use of TPFS audit database

 

Recurrence data for 12 month period

 

 

 

 

NICE guidance CG49 for FI

 

 

Local Policy

 

 

 

 

 

 

 

 

 

 

Patient reported outcome measures

  - Severity scores

  - QofL scores

 

 

 

 

 

 

 

Recurrence data for >12 months

5 (M)

 

 

 

 

 

 

 

 

 

5 (M)

 

 

 

 

 

5 (M)

 

5

 

 

 5(M)

 

 

5