KPIs for Unit accreditation

Criteria updated July 2021. New areas highlighted in red. 

Domain	KPI	Minimal Standard	Aspirational Standard	Score	Comments for markers
Process	Information giving	Patient information sheets for all major procedures -SNS -LVMR -Sphincter repair -STARR -Posterior repair as well as conservative management eg -Diet -biofeedback -irrigation	Website based information	5	4 marks for core 1 for aspirational
		Unit protocol algorithm for 1.Constipation management 2.Incontinence management 3.Pelvic pain management		5	2 for constipation 2 for incontinence 1 for pain
		History and examination proforma
	Information gathering	Quality of life assessment for all patients undergoing intervention		5	4 marks for assessment of all new 1 for follow up
			Evidence of follow up QoL assessment	5
	MDT Representation (SEE website for guidance)	Colorectal Surgeon (>1) Urogynaecologist Radiologist Clinical Scientist and/or nurse specialist Trainees	Additionally: Physiotherapist Gastroenterologist Psychologist Pain specialist Research fellow/nurses	10	8 marks for core 2 for others
		Some membership of TPFS	All enrolled in TPFS   More frequently	5	2 marks for 1 member. 5 for all
	Frequency	Monthly	More frequently	5	4 for monthly 1 for more frequently
	Selection	Discussion of ALL - Patients considering surgery, including SNS (and other continence procedures), rectal prolapse (IRP&ERP), defunctioning stomas, colectomy, STARR.		15	Fail if not provided
		Evidence of conversion rate to surgery [from annual nos of new patients seen in OPD for 1) Constipation/ODS  2) Continence]		10	Fail if not provided
		Register of attendees
	Administration		annual AGM (review of process)	5	4 for evidence of register 1 mark for AGM
	Regional/multi Trust MDM	2 or more Trust MDM’s	Regional	10	8 for multi-trust 2 for regional
Personnel	Lead	-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 colleagues	-National or international involvement in pelvic floor topics (leadership, quality improvement etc)	10	4  marks for >1PA 2 mark for op evidence 1 mark for CPD 1 mark for national involvement 2 marks for training
	Other consultants  with interest	-CV to include training, CPD etc -Job plan - Evidence of pelvic floor work - Evidence of referrals from general colleagues Summary of numbers	National or international involvement in pelvic floor issues (leadership, quality improvement etc) Details of CPD	5	2 marks for >1PA 1 mark for op evidence 1 mark for CPD 1 mark for national
	Allied health professional support (eg, continence nurse, GI physiologist, physiotherapist)			5	1 mark for evidence CPD 4 marks for evidence of AHP attendance
Procedures	Unit throughput data	12 month data kept for:   - New OPD referrals   - Biofeedback   - Surgical activity	- Physiology   investigation - Physiotherapy	5	1 mark for each of these
	Auditable Outcomes	Morbidity recording and monitoring  for 12 months, including reporting any mesh related complications to MHRA	Patient reported outcome measures   - Severity scores   - QofL scores	15	10 marks for M&M  5 for aspirational (PROM’s) Fail if mesh related complications not reported
		Evidence of use of TPFS audit database for LVMR (if done)		5	Fail if no evidence (if LVMR done)
		Recurrence data for external rectal prolapse (12 month period)	Recurrence data for >12 months
		Local audit		5
	Engagement in R&D		Recruitment to national portfolio study		Up to 3 for local audit, full 5 if national recruitment
Research				5
PF Training	Evidence of training core trainees/AHCP’s	For surgical trainees, logbook evidence. AHCP’s annual appraisal evidence of training	PF fellow	15	10 for minimum standard, 5 for PF fellow

 

Total mark achievable 150 (previously 90)

Pass mark is still 65%

 

Notes to accompany the new PF accreditation submission document for submitting units and markers

Changes and new KPI’s are indicated in red in the new submission document.

Patient selection

Proof that ALL patients having surgery are recorded at the MDM (12 months data).  The relevant elective surgery lists for all consultant surgeons for that period are to be provided and cross referenced with the corresponding MDM minutes.

For calculation of the conversion rate to surgery following failed conservative management, the numbers of new OPD referrals for constipation/ODS and faecal incontinence are to be provided for the index 12 months.  The elective surgery numbers for these conditions will be available on the submitted elective surgery lists.  It is the responsibility of the submitting unit to calculate and provide this evidence.

Auditable outcomes

Morbidity and mortality reporting, depends upon the trust and integrity of the unit and it is expected that these are reported in the MDM minutes.  Any mesh/implant related complications should be visible in the MDM minutes and cross-referenced with evidence (or not) of reporting to the MHRA

 

Revisions to Accreditation Process for MDTs 2023

 

Accreditation was launched in 2018, with rounds of reaccreditation starting in 2022.

The current process is thorough but onerous on both Unit and Reviewer, who have to review significant amounts of evidence.

Key Performance Indicators remain but these revisions aim to reduce burden, streamline and increase transparency

The passmark remains unchanged

We hope this will lead to more units applying and getting through process.

 

New Process

Move towards self-assessment against streamlined KPIs.

It should be clear to Unit if they have passed before submission

Submitting unit fill out self-assessment form, describing how they meet criteria and attaching evidence where recommended

Submitting unit should discuss their submission with their clinical lead (Departmental-Divisional or Medical Director) who is outside of the pelvic floor MDT who signs the submission off prior to sending.

Nominated reviewers from TPFS check the self-assessment and return marks to the Lead (Jonathan Randall)

The submitting unit will be told if they have been successful or not and then invited to a virtual debrief. Areas of excellence and suggestions from other MDTs will be made at this time.

Unsuccessful submissions will be invited to resubmit in the future.

 

Revision of current KPIs

Remove need for demonstrating Proformas

Remove need for trying to calculate a Conversion rate of referrals to operations

Reduce scores for access to regional/multi-trust MDT. Whilst this is still encouraged by TPFS it is recognised that it can be challenging based on geography.

 

Process of Reaccreditation

The new process will also apply for re-accreditation.

As introduced in the last few years, some KPIs will be assumed from the original submission so only KPIs marked with a red star on the mark sheet need to be filled out.

 

Notes for units that are applying for re-accreditation

Renewal is required every 4 years.  Six months prior to the date for renewal the PFS Accreditation Chair will contact the unit to remind them.  Any unit that does not comply with the timely submission of data required will be removed from the published list of accredited units (unless there are extenuating circumstances).

Data required:

• New requirements as per the newly published KPI’s for accreditation
• Any change in MDT representatives, job plans etc
• Any change in personnel
• Unit throughput data, including 12 months auditable outcomes,  conversion rates, M&M, use of TPFS database, recurrence data for ERP
• R&D
• PF training