Background
This paper is intended to clarify requirements of the IQIPS standard 2023 and UKAS’s expectations of how a physiological science service demonstrates the competence of its clinical staff delivering the whole pathway associated with the accreditation activity.
This paper has been developed by the UKAS Accreditation Clinical Advisory Group with agreement and endorsement of the relevant professional bodies following concerns raised around the approach to assessment to ensure that the whole pathway associated with the accredited activity is assured and not limited to just the healthcare physiologist input. It is an expectation that services understand that the activity assured by independent assessment covers the whole patient pathway and all staff involved in that pathway relating to that activity. Their competence processes and records must include all staff involved in the activity delivered in order to meet the IQIPS standard requirements.
UKAS accreditation provides independent confirmation of a service’s competence to carry out specified activities. UKAS assessments are conducted to gather objective evidence to demonstrate that a physiological science service is competent; assessing the competence of a service will include the competence of the personnel, the validity of test methodologies and the validity of outcomes/test results and reports. Assurance of competence in the provision of clinical activity/advice/opinion shall be based on multiple components including direct observation of clinical activity.
It follows that UKAS must assess the procedures that a service has in place to evaluate the on-going clinical competence of all staff and the associated evidence and records that demonstrate implementation, not just limited to registration and CPD.
The service will make clear to UKAS the activities it wishes to become accredited for and which staff are involved in those patient pathway activities prior to accreditation to enable UKAS to perform a robust assessment to capture all roles and responsibilities in the accreditation assessments. For example, clear definition will be needed to understand where activities may be delivered by physiologists only, consultants only, nursing staff only or a combination of staff. Assurance of competence will therefore be required for all involved in that patient pathway activity to enable accreditation to be offered, granted, maintained, and renewed.
The assessment
It is the service’s responsibility to define reasonable system/s to determine the competence of its staff across their patient pathway. UKAS uses competent Technical Assessors (this will include consultants where deemed necessary) that have the demonstrable knowledge, skills, and experience to evaluate the service’s approach and assess examples of records to determine that the approach is followed and is effective.
IQIPS clause FR6.4 states that there must be tailored induction, training, and supervision programmes specific for each role, circumstance and/or environment (for example staff taking on new roles, temporary staff, those returning to work following extended leave and students). The assessment of the service’s approach to evaluating staff competence may include assessment of, but not necessarily be limited to, the following:
- Qualification records, experience, knowledge, appointment process, induction, training authorisation and sign off.
- Records of any External Quality Assurance (EQA) participation or external peer review.
- Mechanisms to monitor on-going competency internally, and associated records.
- Any competency assessment programme shall have defined acceptance criteria, including for clinical staff. It is expected that such an on-going programme is suitably robust to cover all of the staff members’ scope of activity, at sufficient frequency.
- Records of knowledge sharing, for example MDT involvement, case review discussions, case handovers, on call involvement.
- Suitability of competency programme acceptance criteria.
- CPD (e.g. College CPD, external meetings, course evaluations, iEQA).
- Review of test reports.
- Coverage of all areas by internal audit.
- Minutes of meetings aimed at service improvement.
It is acknowledged that information relating to a medical consultant’s competence is essential for the GMC revalidation process and will be gathered and reviewed as part of the regular appraisal process. Competence records held by the service may be used by clinical staff to generate evidence for appraisal and vice versa however the GMC appraisal/revalidation on its own is not enough to assure standard competence requirements.
The assessment team will review the service’s competence assessment process which shall be clearly documented and cover regular review of performance and competence of all staff involved in the patient pathway for the activities under review, to meet the requirements of FR6.7. This may include physiologists, medical consultants, nursing staff, and administrative staff, and will then be reflected in the observed practice of these staff.
The IQIPS standard criteria FR6.3 defines there must be a system to ensure verification that each member of staff, including locum staff, is qualified, trained and authorised (registered where necessary) to perform their intended functions and this is reflected in their job description. Therefore, a sample of records across the range of staff involved will be reviewed during each UKAS assessment and supported by direct observation of the relevant clinical activity.
Records and reporting
IQIPS standard criteria FR6.6 specifies the content of the records to be held for all personnel and requires that the records are readily available. The service should consider carefully how it will retain access to this information, taking into account that some competence information may be held as part of confidential appraisal records or performance reviews. The assessment team needs to assess the evidence that is used to demonstrate competence and the service should seek to provide this without compromising confidential information that is not relevant to the assessment.
Where UKAS identifies nonconformities, it is the responsibility of the service to specify its improvement/corrective action. It is typical for the service to discuss its proposals with the assessor(s) and there is usually some discussion regarding the possible routes to take and the impact of each. Should the service reconsider its original proposal and develop an alternative solution to an agreed improvement that addresses the finding, such evidence can be submitted and would be considered by UKAS. In such circumstances, the service should inform UKAS in advance of evidence submission to agree the alternative action sufficiently assures redress of the nonconformity raised.
References
- Medical Appraisal Guide: A guide to medical appraisal for revalidation in England Sept 2014 v4.
- IQIPS standard:2023.
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