Demonstrating quality is an important aim for all healthcare services. An accreditation scheme allowed mental health services to show their strengths
Mathew J Page, MSc, Foundation degree in Arts, DipHE, Dip integrated approaches to serious mental illness, RN,is business development and governance manager, 2gether Foundation Trust, and director of policy and standards, National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU); Alan Metherall, BSc, RMN, is deputy director of nursing, Avon and Wiltshire Mental Health Partnership Trust, and director of communication, NAPICU; Graham Hinchcliffe, BA, is deputy programme manager, AIMS-PICU, Royal College of Psychiatrists’ College Centre for Quality Improvement, London.
Page M et al (2010) Using an accreditation scheme to demonstrate quality in mental healthcare settings. Nursing Times; 106: 25, early online publication.
A new accreditation programme for psychiatric intensive care units aims to improve the quality of services. This article examines the programme’s content, the process of accreditation and why such schemes are important.
Keywords Mental health, Psychiatric intensive care unit, Accreditation
- This article has been double blind peer reviewed
- The accreditation of inpatient mental health services for psychiatric intensive care units (AIMS-PICU) programme provides an opportunity for services to demonstrate quality care.
- All psychiatric intensive care units can register to follow the accreditation process by clicking here.
- Teams need to commit to a process of both self and peer review against standards.
The Royal College of Psychiatrists launched the first ever accreditation scheme for psychiatric intensive care units (PICU) in the UK last year (Cresswell et al, 2009). It developed the accreditation of inpatient mental health services for PICUs (AIMS–PICU) by building on the success of the AIMS programme for acute inpatient wards (Cresswell and Beavon, 2009). Working closely with the National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU), the RCP put together a scheme which aims to ensure that people using PICU services receive excellent standards of care.
What is AIMS–PICU?
AIMS-PICU is an accreditation scheme which ensures that a PICU meets required standards in a variety of areas. The RCP developed the standards by examining the published evidence and consulting with stakeholder groups and NAPICU (Cresswell et al, 2009).
Standards are categorised as one of three types:
- Type 1: failure to meet these standards would result in a significant threat to patient safety, rights or dignity and/or would breach the law;
- Type 2: standards that an accredited ward would be expected to meet;
- Type 3: standards that an excellent ward should meet or standards that are not the direct responsibility of the ward (Cresswell et al, 2009).
The standards are grouped as follows:
- General standards;
- Timely and purposeful admission;
- Environment and facilities;
- Therapies and activities (Cresswell et al, 2009).
General standards include issues such as the existence of policies on staff availability and staff awareness of them, while the standards on admission focus on clinical care, how it is delivered and by whom. The safety standards require PICUs to have policies and procedures in place to ensure safety.
The environment and facilities standards ensure that PICU services are only provided in buildings which are fit for purpose. The final standard on therapies and activities reflect the need for a holistic range of interventions.
Some of these standards are, by their nature, aspirational; it is envisaged that as wards begin the process of self review they will set themselves the objective of meeting unmet standards, if not immediately then by subsequent reviews.
How is a PICU accredited?
The decision to join the AIMS-PICU programme should involve all team members, as it requires the cooperation of all those working on a unit. Once a team has made the decision to join, a financial commitment from the unit’s funding organisation is required over four years (the cycle of the review process), as AIMS-PICU costs £2,400 a year; after this a simple registration form needs to be completed with details of the local lead.
This staff member acts as the link between the unit and the RCP’s College Centre for Quality Improvement (CCQI). The lead then needs to motivate and champion the team through the accreditation process, which has three main phases:
- Self review;
- Peer review;
- Accreditation decision.
The route to accreditation requires full participation from all members of the multidisciplinary team. It is also essential to ensure that service users and carers are fully represented.
The first stage is to undertake a range of self asessments. Data on self assessment is submitted to the CCQI via questionnaires completed by service users, carers, staff and ward managers. The lead contact for the PICU also has to ensure that evidence of a range of policies are in place, training has been completed by appropriate staff and that the unit meets the environmental standards; evidence of the provision of activities is also needed.
Teams undertaking the self review process can share experiences and seek solutions via an email support group with other participants and via the wider interest group through NAPICU (membership of which is a level 2 standard).
After receiving data from the self review process, the CCQI starts the peer review phase around 4-8 weeks later. A peer review team consists of four trained people, one of whom is a service user, and a visit is normally undertaken in one day. The review team completes a questionnaire based on face to face feedback from current service users and carers in the unit, and also verifies the evidence submitted in the self review process, which includes interviews with multidisciplinary team members. The lead reviewer gives feedback at the end of the day, helping the unit to identify areas for future development or focus on minimum standards not achieved.
The accreditation decision is the third and final phase. The decision making phase cannot start until the lead reviewer from the peer review has ensured the accuracy of the information obtained in the first two phases. This report is then submitted to the accreditation advisory committee, which recommends a decision to the education, training and standards committee, which awards the level of accreditation (Box 1).
Box 1. Four categories of accreditation
Category 1 - accreditation with excellence
The unit can demonstrate it meets:
- All type 1 standards;
- At least 95% of type 2 standards;
- All or the majority of type 3 standards, with a clear plan for how to achieve the others.
Category 2 - accredited
The unit can demonstrate it meets:
- All type 1 standards;
- 80-85% of type 2 standards;
- Many type 3 standards.
Category 3 - accreditation deferred
- The unit fails to meet one or more type 1 standards but demonstrates the capacity to meet these within a short time;
- It fails to meet a substantial number of type 2 standards but demonstrates the capacity to meet the majority within a short time.
The unit receives a report detailing the strengths and weaknesses identified, with an emphasis on those standards that need to be addressed for accreditation. Data is collected through a further self and/or peer review within six months to confirm that the unit now meets the criteria for category 2 approval.
Category 4 - not accredited
- The unit fails to meet one or more type 1 standards and does not demonstrate the capacity to meet these within a short time;
- It fails to meet a substantial number of type 2 standards and does not demonstrate the capacity to meet these within a short time.
The unit receives a report detailing the strengths and weaknesses identified and a clear statement of which standards need to be met for accreditation.
The benefits of accreditation
Quality is currently a key theme in the health service. The NHS operating framework for 2009/10 (Department of Health, 2008a) aspired to make quality the organising principle of the NHS and Lord Darzi’s report (DH, 2008b) highlighted the importance of quality based on effectiveness, patient experience and safety.
AIMS-PICU offers an opportunity to drive up quality in psychiatric intensive care. As a service quality assessment tool, it provides information for service users and commissioners and aspirational targets for clinicians, managers and provider organisations.
While there are many accepted ways of ensuring quality in the health service, such as making sure that outcome measures are achieved, AIMS-PICU falls into a different category of quality assessment. By setting certain standards it assesses the quality of the service clients can expect to receive. The advantage of such a broad spectrum approach is that it ensures quality throughout the experience, not simply limited to admission and discharge. The breadth of the standards provides a degree of sophistication to the understanding of quality, which is often lost in more simplistic input/output type assessments.
The adage that we have a tendency to “make important what’s measurable rather than find a way of measuring what’s important” has never been truer than at this point in UK healthcare. While simple activity data is easily recorded, finding a way of recording how satisfied service users are is much more complicated and resource intensive.
AIMS-PICU, with its processes of self and peer review, is resource intensive. It requires sustained effort to check against the standards, action planning to ensure they are met and peer review. But the process can be effectively project managed and the potential benefits to users and the reputation of the service are immense.
The government’s determination to drive up quality has led to Commissioning for Quality and Innovation (CQUIN) (DH, 2008c), a new initiative based on goals agreed locally between commissioners and providers. On the one hand, successful attainment of these goals leads to full release of the agreed budget, but if certain targets are not met, a proportion of the annual budget is withheld until they are fulfilled. Service standards such as AIMS-PICU may well form the basis of such locally agreed goals. Providers of PICU services should start considering now whether they can meet the standards.
As quality becomes a driving force in healthcare, service standards such as AIMS-PICU will be scrutinised closely to see if they guarantee quality. Based on our experience of developing and working with AIMS-PICU, we believe it offers a systematic and evidence based way of improving services for people at a point where quality care counts most.
- AIMS-PICU is the first accreditation scheme for psychiatric intensive care units.
- The programme consists of evidence based quality standards, which cover the full range of PICU characteristics to ensure service users receive high quality care.
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Cresswell J et al (2009) Accreditation for Inpatient Mental Health Services (AIMS): Standards for Psychiatric Intensive Care Units (PICUs). London: Royal College of Psychiatrists.
Cresswell J, Beavon M (2009) Accreditation for Inpatient Mental Health Services (AIMS): Standards for Acute Inpatient Wards – Working-ageAdults (3rd edition). London: Royal College of Psychiatrists.
Department of Health (2008a) The Operating Framework for the NHS in England 2009/10. London: DH.
Department of Health (2008b) High Quality Care For All: NHS Next Stage Review Final Report. London: DH.
Department of Health (2008c, updated 2009) Using the Commissioning for Quality and Innovation Payment Framework – an Addendum to the 2008 Policy Guidance for 2010/11. London: DH.