The value of implementing a nursing and midwifery clinical accreditation programme at two NHS trusts

Clinical accreditation programmes are known to bring a sense of pride in what staff do and in their place of work. They create positivity, promote a quality improvement culture and a shared purpose, and encourage staff to aspire to best practice and excellence in care.

As with any organisational quality improvement approaches, a variety of enablers are critical to success. Key among them are the right culture, people engagement and empowerment, and strong leadership (The Health Foundation, 2021). It is therefore vital that the programme is aligned with a healthcare organisation's overarching strategy, to ensure its success and sustainability. It is also essential for the organisation's chief nursing officer (CNO)/director of nursing to champion the programme, acting as lead and securing support from the wider trust board.

NHS England has defined accreditation initiatives as follows:

‘Accreditation brings together key measures of nursing, midwifery and clinical excellence in care into one overarching framework to enable a comprehensive assessment and evaluation of the quality of excellence in care … When used effectively, it can drive continuous improvement in patient outcomes, and increase patient satisfaction and staff experience … it creates the collective sense of purpose necessary to help communication, encourage ownership and achieve a robust programme to measure and influence excellence in care delivery.’

NHS England, 2019

As outlined in NHS England's (2019)Guide to Developing and Implementing Ward and Unit Accreditation Programmes, there are clear benefits to implementing an accreditation scheme, which include:

• Reduction of unwarranted variation by providing an evidence-based, standardised approach to supporting the delivery of excellence in nursing and midwifery care and improving quality
• Increased staff engagement, improved team working and staff morale
• Helping nurses, midwives and care staff to understand what the expected standards are at ward and unit level
• Ward-to-board assurance on the quality of excellence in nursing and midwifery care and demonstrates compliance with Care Quality Commission standards
• Creation of a platform for continuous quality improvement in patient safety and patient experience
• Improvement in accountability and shared governance
• Provision of a platform for shared learning
• Creation of a culture of pride and accomplishment, and a fostering of collective leadership, personal and professional development.

Implementation

Initial work

Preparatory work commenced well in advance of implementing the accreditation programme at the Royal Wolverhampton NHS Trust (RWT) and Walsall Healthcare NHS Trust (WHT). This included undertaking a literature review to gather evidence-based information, and networking with other organisations that had implemented ward/unit accreditation programmes.

A shared professional decision-making council was set up nearing the launch to steer the process. It was decided to use some of the approaches and documentation previously developed by other organisations, such as Oxford University Hospitals NHS Foundation Trust and Northern Care Alliance NHS Foundation Trust, rather than start from scratch.

The resources, collated as part of the preparatory work, were adapted to suit the needs and requirements of both RWT and WHT, and involved seeking the views of staff across both RWT and WHT. An overarching framework, which describes the approach and step-by step processes associated with clinical accreditation, was developed prior to the launch.

Before each accreditation visit, key quality data are collated into a brief report, which is presented to the visiting team on the day of the visit, to inform them about specific areas on which to focus. These data are sourced from a variety of reporting platforms used by both organisations. Colleagues participating in the visits are allocated specific roles and are guided by a template document, which includes key lines of enquiry to be explored at the visit.

There is no specific preparation required of the wards, because the visits are unannounced. However, wards that have already been subject to the clinical accreditation visit and have received their rating are advised to develop an action plan, to address recommendations following the assessment visit and support their progression to the next level of accreditation. The accreditation levels have been developed and agreed following a wide consultation with staff across both organisations, as illustrated in Figure 1 (RWT and WHT, 2018:14):

The current template document is applicable to adult inpatient ward areas and was implemented as part of phase 1 of the implementation. However, in recognition of the breadth of services provided by both organisations, it is important to also engage with specialist areas, such as emergency portals, maternity, paediatrics and community, and develop a tool that specifically reflects these services. Work on a template document for these areas is ongoing, with plans to test it in the coming spring, in advance of phase 2 that will provide accreditation for the specialist areas.

Once the template document was agreed by the senior nursing and midwifery leaders at both RWT and WHT, overarching guidance was developed following wider staff consultation via the nursing and midwifery governance structures. The guidance includes all the resources necessary and explains the phased approach to implementation. As well as adapting the resources developed by other organisations to use as part of the programme, the trusts' overarching quality framework (RWT and WHT, 2023) was used to inform priority areas for review during the visits, with a focus on quality and safety.

Using quality improvement and project management methodologies, it was concluded that a pilot was required to test the proposed approach and templates, which was conducted 2 months ahead of the ‘go live’ date. Following the pilot, final amendments to the guidance and associated templates were made, before the accreditation programme was agreed by the senior nursing and midwifery forums at both organisations.

Accreditation assessment

The programme was launched in April 2023 and embraced by the nursing and midwifery teams. It is overseen by the corporate nursing quality team, under the leadership of a head of nursing–quality and a deputy CNO, and the strategic leadership of both CNOs. There are usually two accreditation visits per week, one at each organisation; each visit is conducted by an accreditation team, consisting of nursing (CNOs, deputy CNOs, heads of nursing/divisional directors of nursing and matrons), patient experience representatives, nursing and midwifery education, and governance colleagues.

The day starts with a member of the visiting team observing the handover in the ward/unit earmarked for accreditation to note whether the process covers key issues, such as critical patient information, safety points, any matters staff should be aware of and/or any actions required. Following observation, there is a meeting of the whole visiting team, where the plan for the visit is agreed and individual roles allocated. There is also a discussion about the clinical area, which includes triangulation of data and soft intelligence on its key quality indicators.

The visiting team then has about 4 hours to undertake the visit and make observations of practice, staff and patient interactions, prior to reconvening for ‘Time to Shine’ part of the visit, which is a concept adapted from Oxford University Hospitals and Northern Care Alliance trusts. ‘Time to Shine’ encourages the clinical area leads to showcase their best practice initiatives, their successes and the improvement work they have been undertaking. This part of the visit is important for ensuring a balanced approach to the assessment and enables the visiting team to gain broader knowledge of the clinical area.

After the ‘Time to Shine’ part of the day, the visiting team discusses individual observations, their views on the clinical area and agrees on an accreditation level for the elements assessed. An overall accreditation outcome is then agreed in principle, subject to further discussion and corroboration. A summary draft report, with the recommended accreditation level is usually produced within 2 weeks of the visit.

Governance

The governance process implemented as part of the programme reflects improvement aspects, at the same time as recognising the importance of maintaining evidence of decision-making and agreement on the accreditation outcomes.

Two key groups were established to implement the accreditation programme: a clinical accreditation board and a subgroup.

The subgroup

The role of the subgroup is to review individual draft reports following each visit, which are shared with key clinical area leaders for review, ahead of the subgroup meeting, which relays its discussions to the board. A deputy CNO, the head of nursing–quality and representatives from each of the clinical areas visited, who are all on the subgroup, meet to finalise and prepare this for discussion by the Clinical Accreditation Board, which takes the final decision on the accreditation to be awarded.

The board

The board brings together colleagues from both organisations, including the CNOs, deputy CNOs, heads of patient experience, a head of education, quality team representatives, chief allied health professions officer and governance representatives. Other members are co-opted as required. Chaired by the CNO the board's remit includes:

• Oversight of the programme from a strategic perspective, including discussion and agreement of key changes to the accreditation programme, guidance and templates
• Review of the progress update reports
• Discussion and approval of each visit report
• Its key function is to make decisions on clinical accreditation.

Each area visited is presented with a certificate of accreditation once the decision has been made. Leaders in each clinical area are then recommended to develop a plan to take forward recommendations from the visit, for example making improvements in documentation, meal services and strengthening how feedback is provided to patients.

The board receives monthly progress reports on each area seeking accreditation, which include the number of visits undertaken to date, number of wards accredited, key themes from visits and future plans; the senior nursing and midwifery forums also receive monthly updates. In addition, monthly summary updates are provided to the respective quality committee and trust board via the CNOs' reports.

Work to embed and further develop the accreditation programme is aligned with the objectives agreed as part of the quality framework programme, evidenced through the progress reports.

Key considerations and learning

Experience of implementing the clinical accreditation programme has shown that the following are crucial:

• Identifying and securing resources to lead the clinical accreditation programme. This includes ensuring that there are designated staff and sufficient material resources
• Having a fully supportive CNO/director of nursing who champions the approach and helps with securing support from the wider trust board
• Engagement of staff across all levels of the organisation from the outset
• A combination of evidence-based materials should underpin the initiative: examples from other organisations should be considered, as should feedback from staff and patients
• The unique needs of the organisation should be incorporated in the process
• Robust governance
• Those leading the process must be flexible and open to suggestions. Implementation of the programme should be viewed as an iterative process, rather than set in stone, with periodic built-in evaluations following the initial launch
• Anticipation that some clinical areas may need to be visited outside the set day to collate key evidence
• Robust triangulation mechanisms in place to maintain credibility of assessments and their outcomes
• The process should be digitalised as much as possible to minimise the burden on the co-ordination team and enable easy access to assessments and the collation of reports. This will also help monitor trends and improvement
• The process must be seen as supportive, with improvement in mind. Therefore, teams need to be mindful of the language used to describe the accreditation visit (ie it is not an inspection)
• Learn and celebrate: this is critical to success.

Impact on outcomes, patients and staff

Clinical accreditation programmes positively contribute to improvements in the performance and quality of care in a hospital setting (Hussein et al, 2021).

Although it is not possible to attribute subsequent improvements in patient outcomes and experience at RWT and WHT solely to the introduction of the clinical accreditation programme, it has had positive benefits. These include, for example:

• More patient observations are completed on time, resulting in more timely escalation of deteriorating patients
• There has been a sustained reduction in patient falls and some improvement in pressure ulcer incidence
• Staff participating in the accreditation programme report enjoying the experience of being involved
• The programme has further strengthened the blended approach to assessing the quality of patient care and experience applied at both trusts.

Conclusions and next steps

Introducing the clinical accreditation programme has undoubtedly brought many benefits to the wider approach taken at RWT and WHT to ensuring continuous quality improvement and shared learning, enhancing the blended approach of gaining assurance on quality and safety, and providing a platform for celebrating successes and excellence. Colleagues involved in the programme and the accredited clinical areas have commented how helpful and supportive the approach has been.

Over the next few months, accreditation visits and assessments will continue to be undertaken in line with the plan. In addition, formal evaluation of the programme is currently taking place, to review the current approach and take forward any necessary enhancements, including digitalisation of the assessment tools and reports. It is envisaged that phase 2 of the programme, which will see implementation of the programme in specialist areas, such as maternity, paediatrics and emergency portals, will begin from April 2024.

The authors are members of the local Integrated Care System and Midlands Nursing and Midwifery Excellence groups, where they share their learning and network with other organisations and regional colleagues. They recognise that this is an evolving programme and, as a result, they will continue to review and continuously enhance it.

KEY POINTS

• The clinical accreditation programme has positively contributed to improving patient outcomes, with more observations being completed on time, reductions in patient falls and some reduction in pressure ulcer incidence, with positive feedback from participating teams and frontline colleagues
• The concept, where it is championed by the executive team and senior leaders, and where resources are secured to implement and maintain the scheme, can be sustainably embedded
• Such programmes have great benefits for both patients and staff, contributing to the wider improvement and quality oversight mechanisms across an organisation

CPD reflective questions

• Why is it important to ensure that each organisation has a blended approach to testing and assessing the quality of care provided to the population their serve?
• What are the benefits of clinical accreditation programmes?
• It is important that clinical accreditation approaches are ever evolving and why?