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KPIs For Unit Accreditation

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



-Sphincter repair


-Posterior repair

as well as conservative management eg




Website based information


4 marks for core

1 for aspirational


Unit protocol algorithm for

1.Constipation management

2.Incontinence management

3.Pelvic pain management


2 for constipation

2 for incontinence

1 for pain


History and examination proforma


Information gathering

Quality of life assessment for all patients undergoing intervention


4 marks for assessment of all new

1 for follow up

      Evidence of follow up QoL assessment 5  



(SEE website for guidance)

Colorectal Surgeon (>1)



Clinical Scientist and/or nurse specialist






Pain specialist

Research fellow/nurses


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


4 for monthly

1 for more frequently


Discussion of ALL

- Patients considering surgery, including SNS (and other continence procedures), rectal prolapse (IRP&ERP), defunctioning stomas, colectomy, STARR.



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]



Fail if not provided

    Register of attendees      

annual AGM (review of process)


4 for evidence of register

1 mark for AGM


Regional/multi Trust MDM

2 or more Trust MDM’s



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)


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


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


Unit throughput data

12 month data kept for:

  - New OPD referrals

  - Biofeedback

  - Surgical activity

- Physiology   investigation

- Physiotherapy


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


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


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


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