What is accreditation?

Accreditation is a supportive process of evaluating the quality of clinical services against established standards. Accreditation promotes quality improvement through highlighting areas of best practice and areas for change, encouraging the continued development of the clinical service. Accreditation is a voluntary process for services to engage in.

Services participating in primary immunodeficiency accreditation work to an accreditation pathway which involves self-assessment and improvement against the standards. The standards have been developed with a multi-professional group of clinicians, managers and patient representatives. Services can take anywhere between 12-24 months to be ready for an assessment, though this timeframe does vary depending on the support and time available in the service; there is no set deadline to have an assessment and the QPIDS team understand there are many factors influencing how services progress.

Services that are awarded accreditation submit evidence annually to demonstrate that they are continuing to meet the standards and have a 5-yearly on-site assessment carried out by our experienced assessment team.

Accreditation pathway

By participating in accreditation, services are enrolled on an ongoing programme of service improvement. An overview of the accreditation pathway is shown below.

Tracking progress

Participating services have access to the accreditation standards via a bespoke online self-assessment tool. The webtool allows services to review:

• which standards they meet and have evidence for
• which standards they meet but need to collate evidence for
• which standards they are not currently meeting.

Undertaking the self-assessment enables services to target their team’s improvement efforts and work towards achieving QPIDS accreditation.

Once a service can demonstrate evidence to meet the standards, an accreditation assessment will be organised. This involves bringing together a multi-professional assessment team to review the evidence submitted by the service. An on-site assessment will also take place, usually lasting one day.

There are three possible outcomes of an accreditation assessment; accreditation awarded, accreditation not awarded or accreditation deferred. Accreditation deferred indicates that the assessment team felt that a few areas of the standards needed improvement or additional evidence to demonstrate full achievement. A service has a maximum of 6 months to improve on those standards before a final outcome is reached; at the end of this period, accreditation is either awarded or not awarded. As accreditation is an ongoing process of improving quality, recommendations for improvement are to be expected as part of the assessment.

Accreditation is awarded for five years and then another site assessment will take place. Between the site assessments, there is an annual remote review of key pieces of evidence to show that the service is maintaining the QPIDS standards.

Assessment teams

The programme provides a comprehensive training package for supporting assessors. Typically, the assessment team consists of a doctor and nurse who work in an immunology service and a lay assessor, representing the patient voice; they may not have personal experience of using an immunology service.

Assessors undergo a blended training programme of both face to face and online learning to fully understand the accreditation pathway, the standards and how to carry out assessments.