Pulmonary Rehab: embedding quality

NHS England’s Long Term Plan highlights pulmonary rehabilitation (PR) as a key intervention in preventing hospital admissions and improving patient outcomes for those with chronic lung disease. In the first part of a Frontline series, Neena Garnavos introduces the PRSAS and physiotherapist Rhian Perry reflects on her own experiences of working towards accreditation.

Accreditation and the PRAS 

Accreditation is a supportive process aimed at guiding services through a quality framework and helping them to show that they are meeting a set of professional and clinical standards. The accreditation process involves self and external peer assessment to evaluate the service against a set of standards developed with multi-professional input. 

The PRSAS is led by the Royal College of Physicians (RCP) who lead a number of other accreditation programmes. The need for investment in PR services through the development of an accreditation programme was identified and agreed by key stakeholders and the NHS England Chief Scientific Officer in 2015. Following a successful pilot, the full accreditation programme launched in April 2018. 

Currently, it’s a voluntary process for services to engage with. It is team-led and acts as an indicator of quality for patients, services, commissioners and the wider community. Now, with the long term plan’s focus on PR as a key intervention for those with chronic lung disease, the programme will be vital in ensuring PR services are commissioned to a high quality and are sustainable.

Benefits of accreditation 

Recent evidence and the RCP’s experience in accreditation shows that participating in the programme benefits services and patients in various ways, including: 

• increasing efficiency and improving patient safety through self-assessment
• embedding quality improvement in everyday practice
• supporting the commissioning process by improving service delivery and quality of care for patients
• reducing variation in clinical services
• increasing satisfaction with working conditions, leadership and accountability. 

The accreditation pathway

The infographic overleaf depicts the accreditation pathway. Throughout the ‘quality improvement’ phase, services are supported by the RCP team and their fellow PR services, to enable them to demonstrate they are meeting the standards. This process generally takes 12 to 18 months. We are currently exploring how we can support services to accelerate their progress through phase one by supporting groups of services to work through the accreditation pathway together. If you are interested in joining as a group of services, please contact the team at pulmrehab@rcplondon.ac.uk

When services are ready to be assessed, the assessment team - made up of a lead assessor, a clinical assessor and a lay assessor - starts by reviewing the evidence uploaded on the accreditation web tool. This is a supportive and collaborative process to ensure the services have the chance to upload any missing evidence before the assessment. During the assessment, the team talk to staff and patients, and they share the preliminary outcome on the day. We have an ambitious aim to accredit 100 percent of services and provide support to help achieve this.

Once services are accredited, they submit evidence annually to demonstrate that they are continuing to meet the standards. We carry out a five-yearly on-site assessment. 

Support available

For individual services joining, a range of support is available including: 

• comprehensive training on accreditation standards and quality improvement
• regular webinars to network and share good practice
• an easy to use web platform to support you through the accreditation process
• a dedicated team to guide you through the process.

For groups of services joining together we also offer:

• training at a location and time convenient to them
• workshops to create regional templates
• support to work together to reduce regional variation
• case studies of good practice and quality improvement 
• opportunities to publish quality improvement work 

How to get involved 

To get involved as an individual service, sign up here  and follow the instructions. 

If you are part of a group of PR services, such as an Academic Health Science Network, a regional PR network or an informal group of PR services that meet and work together to improve patient care, and wish to explore joining as a group then please contact the RCP team on pulmrehab@rcplondon.ac.uk Joining as a group has a number of advantages but services will still be accredited individually. Contact us to discuss the personalised group support available aimed at decreasing the load through collaborative working and shared learning. Discounts are also available for groups joining together.

The annual fee for PR services will vary depending on their needs, for example how many types of sites PR takes place in and therefore how many sites we are likely to have to assess.

• £1300 for services that have 1 type of site  
• £1400 for services that have 2-3 types of sites
• £1500 for services that have 4 types of sites

If a service has more than five types of sites or several types that are managed separately, we will create a bespoke package to meet their particular needs.

Here at the RCP we will work tirelessly with the PR community to drive improvements in quality of care and protect PR services in the face of increasing referrals and an aging population. 

The physiotherapist’s perspective

Rhian Perry is a band six physiotherapist within the PR team at Guy’s and St Thomas NHS Foundation Trust, who are currently working towards accreditation. 

Has being involved in the accreditation process influenced your professional development? 

Yes, definitely. As part of the accreditation process, I led a project that aimed to gain feedback from patients who were referred but did not attend PR assessments and classes, in order to address waiting times for our patients. This gave me experience of developing telephone questionnaires, qualitative data evaluation and presenting findings and recommendations to the wider physiotherapy team within the trust. This experience has given me the opportunity to develop new skills and increased my confidence in leading service improvement projects in the future. 

How has your own practice changed as a result?

There are a number of changes that we are implementing to support accreditation of the service. One is providing a home exercise plan for patients at the beginning of PR, so they are prompted to do at least one independent home exercise session a week in addition to the two they do with us. We then aim to review and update these plans at the end of their rehab course to encourage patients to continue exercising independently at home. 

Have you noticed any changes in your team?

The accreditation process requires you to evaluate your current service, and this has encouraged the team to look for areas of improvement within our practice. As the day-to-day running of the programme can be extremely busy, prompting the 
team to take a step back and question why we do things in the way that we do them has been useful. I think it has helped to create a very open culture within the team, where staff members of all levels feel comfortable to share ideas on how we can improve to provide the best service for our patients.  

What about changes for patients? 

We have now produced a trust-specific leaflet for PR, which will be given to patients at the point of referral, so they have more information about the benefits of our class and how to get in touch with us, before coming to their assessment. This aims to decrease the rates of non-attendance so we can get people into pulmonary rehab quicker. The home exercise programmes that we are now aiming to give to patients at the start and end of the course are making them more aware of how they can exercise at home, without any specialist equipment.  

What are the main benefits for working towards accreditation? 

It is really encouraging the team to look for ways to improve the service for the better. 

We hope that becoming accredited will highlight the high quality programme that we provide, and keep us at the forefront 
of national standards. 

Has working towards accreditation posed any challenges? 

The biggest challenge would probably be finding the time to bring all the relevant evidence for accreditation together. 

How have you tried to address that challenge?

We are overcoming this by tackling it as a team. By giving members of the team individual projects to contribute towards accreditation, we are sharing the load and its less time consuming for one person.

More information

If you have any questions about the accreditation programme or wish to get involved contact us at pulmrehab@rcplondon.ac.uk or visit the visit the Royal College of Physicians website.

The PRSAS standards are based on the British Standards Institution (BSI) PAS1616 and the BTS quality standards for PR. The standards cover all aspects of a clinical service and are organised into eight domains