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Guidance on Accreditation visits

Accreditation visits are conducted by the National School of Healthcare Science (NSHSC) as part of our quality assurance process for departments hosting STP or HSST trainees. Most applications for accreditation are decided on the basis of written submissions only, but in some cases we decide a visit is necessary. The reasons can include:

  • Concerns raised by any party about training quality;
  • Specialties in which a significant number of training centres have experienced difficulties;
  • Departments new to training at postgraduate level, or in the specialty concerned;
  • A pattern of trainees in difficulty, exiting the programme or failing final assessment.

In some cases, departments may be selected for a panel visit randomly, for quality assurance purposes. An accreditation panel visit may be required in order to decide your application for accreditation. We might also decide a panel visit is needed to a department that already has accreditation, because of new information.

Aims of the visit

A panel visit should not be seen as a negative for your department. The main aim is to find out all we can about the training you offer. Our panels do not set out to exclude departments from training. We will share best practice, and give advice and guidance where possible.

Spirit of the event

We try in our panel meetings to treat you as human beings, and have open and frank conversations. We do not want the event to be adversarial, and you do not need to feel defensive. We appreciate the pressures you are working under to deliver your service. We have no hidden agenda or desire to catch you out. Our only concern is to achieve the best training environment possible.  

Pre visit and documentation

Ahead of any visit you will be provided with the name and contact details of the lead member of staff for the event, who will be able to respond to any queries. We will need the following documentation:

  • A completed self-assessment form;
  • CVs of the main individuals delivering training;
  • A training plan (which should be aligned to the STP curriculum and include rotations, specialist training, opportunities for multi-professional working, and details of patient-facing activities);
  • Minutes of trainee/supervisor meetings.

These documents should be provided to the panel at least three weeks before the date of the visit. If you do not provide the documents, the visit will still go ahead but may have to be extended.

The panel

The visiting panel normally consists of:

  • A clinical expert in the specialty concerned, usually a senior scientist with a thorough knowledge of the programme;
  • A lay representative, who provides a patient-focused perspective;
  • A member of staff from the National School of Healthcare Science, who is responsible for the arrangements, the agenda, the conduct of the visit and the report.

Others may attend as observers. They might include:

  • A representative from the local Health Education England Quality team;
  • A commissioner from Health Education England (responsible for agreeing commissioned placements for healthcare science trainees);
  • A representative of the Academy for Healthcare Science.

We will notify you if there are any observers attending. The panel will seek assurances on a range of areas. The essential issues are specified in the agenda. However, unforeseen questions will sometimes arise and the panel may pursue anything relevant that comes up in discussion.

Facilities

The room for the panel visit needs to comfortably accommodate the panel (usually three to five in total) and the trust attendees, so that all can actively participate in the discussions without any distractions. It should be a private room where the panel can be conducted behind closed doors. As a minimum, there should be enough table space for the whole panel, with room for note-taking and laptops, and access to a power supply. The trust should determine the maximum number of representatives who will be in the room at any time (usually up to fifteen or so for plenary sessions) and ensure that there is adequate seating. We know there is often a lack of space in a department to accommodate a meeting of this size. If you do not have a suitable room in the department, please arrange for the panel to take place elsewhere on the site: for example, most trusts will have an education centre or suite of meeting rooms.

Hospitality - if possible, please provide the panel with tea/coffee/water throughout the day, and a working lunch. Sometimes the panel arrange to meet with trainee(s) over lunch, and it would be welcome if lunch is provided for all. If this is not feasible, please ensure the lead officer is aware of this prior to the visit.

Format of event

The event is usually divided up into the following sessions:

Private panel meetings - these should take place in a room where the panel will not be disturbed. No member of the trust’s team is invited into these sessions. The purpose of the first private panel meeting is to enable the panel to highlight any areas of particular concern, formalise the agenda and agree who will lead on each area. Subsequent private panel meetings throughout the day enable the panel to confer and agree any further areas of discussion that may be required.

Welcome and introductions - this is the time when the panel, having already formulated the agenda, meet with the trust team. At the invitation of the Chair, all present should introduce themselves, giving their name, job title and brief role in the programme. This should be kept brief, especially if there is a large team and panel. The panel will ask you to sign an attendance record.

Discussion sessions - the panel Chair leads the agenda items and will invite colleagues from the panel to contribute.

Meeting with trainee(s) - this session is for the panel, trainee(s) and any observers (not the training team). The purpose is to seek information confidentially from the trainee(s) about their experience to date and talk through a range of issues such as their current progress, the support they receive, how they raise any concerns and how feedback is provided. The panel will wish to meet all STP or HSST trainees currently in training. If they are not available the panel will contact them separately and interview them by telephone.

Final private panel meeting - this enables the panel to review the evidence presented and the discussions from the day. At this stage the panel decide whether accreditation can be granted. They will also agree any conditions, recommendations and commendations from the event.

Feedback session - at the end of the panel meeting the panel will give immediate feedback. This will normally be a clear indication of the outcome - whether or not the department has achieved accreditation, any conditions the panel consider necessary, etc. This will be given with the caveat that a written report will follow, and the panel may in the course of preparing the report decide that further items should be included.

Timings - while the panel chair will endeavour to adhere to the times on the agenda, discussion may sometimes overrun or end ahead of schedule. Timings are given as a guide.

Trust team - all staff who contribute to the delivery of the programme should attend the discussions. They should be given a copy of this guidance and should have access to the relevant documentation. They should be actively encouraged to participate and answer relevant questions.

We ask that representatives of senior management are present, in order to assure the panel that the training is fully supported by the trust.

Outcomes

The chair will feed back the outcomes of the event to the team. The outcomes can be:

  • Accredit/decline accreditation

Normally, accreditation will be granted, with or without conditions and recommendations. If accreditation is granted, the duration will be five years from the date of the report, or the date on which any conditions are met. In the rare event that accreditation is declined, further discussion will be needed to decide the next steps for the trainees (e.g. withdrawing trainees from the department and moving them elsewhere). Any such decisions will require full discussions between the trust, the commissioners from Health Education England, and the National School of Healthcare Science.

Conditions

Conditions are actions without which accreditation could not be granted. If the panel decides to accredit your department with conditions, you will be given a date by which the conditions must be met and, if they are not met by the due date, accreditation will be declined or removed.

Recommendations

Recommendations are actions of changes the panel consider will improve training in your department. They are offered to be helpful to you and your trainees. You are not obliged to follow recommendations, but you should consider them carefully. If you decide not to implement them, you should have a justification for that decision.

Commendations

Where the panel see notably good practice or positive characteristics in the training you offer, they will commend it in the report.

Post event

Report – the outcome(s) from the event will form the basis of a formal report from the National School of Healthcare Science. When the report has been agreed by the panel it will be sent to the main contact in the trust, as identified in correspondence. We would prefer this to be the Head of Department. The report should normally be sent to you within four weeks of the visit.

We ask you to circulate the report in your trust. As a minimum, we would expect it to be copied to:

  • Staff members and trainees who participated in the event;
  • Your Divisional Director;
  • Your trust’s Lead Healthcare Scientist;
  • Your trust’s Learning and Development team.

The report will be copied to the local Health Education England Quality and Commissioning team. All accreditation reports are reviewed by the Academy for Healthcare Science, the body that quality assures the National School of Healthcare Science accreditation processes.

Conclusions

If in doubt about any aspect of the accreditation visit, please speak to your contact in the National School of Healthcare Science. If during the day any member of the team is unsure about any question being asked, please seek clarification from the panel.