Guiding Gloucestershire’s Pulmonary Rehabilitation towards accreditation

The pathway to accreditation involves self-assessment against 40 standards and preparation of evidence to show that those standards are met, followed by a review of evidence, and a site assessment of PR sessions.

We worked with the Gloucestershire Respiratory Service to understand their current systems and identify areas for improving the service to support their PR accreditation. This included:

• Conducting a gap analysis to collate current PRSAS evidence using the self-assessment tool
• A review of all documentation and improvements required to meet the requirements for accreditation.
• Building a rapport as trusted clinicians through attending respiratory team staff meetings to understand the challenges faced and provide innovative ideas and new approaches.
• Developing their annual staff survey, and providing an anonymised analysis of results
• Organising and facilitating an interactive off-site annual team Away Day. This gave the team time and space to focus on connecting, reflecting, learning, developing, and planning towards their PRSAS accreditation.

As registered physiotherapists, our SCW team were able to bring a “fresh pair of eyes”, new perspective, and clinical insight to check and challenge and widen the scope considered for change.

As a result of our clear outputs from the Away Day and support in developing their Operational Plan for the year ahead, Gloucestershire now have a clear vision for their Pulmonary Rehabilitation service. These were major milestones in the accreditation journey.

Our overview enabled the whole team to understand the challenges and opportunities for the service. This included:

• Referral numbers and expected trajectory for the year ahead
• Current waiting lists
• Workforce challenges
• National and local audit data (Review of NACAP Run charts and KPI audits)
• Patient/carer feedback
• Staff annual survey results

From SCW providing simple Quality Improvement (QI) directions the team were able to undertake and develop prioritised SMART action plans to make quality service improvement.

Bringing the team together provided a collaborative environment where everyone took ownership of developing the service as a team whilst taking on individual QI projects.

The Away Day started the conversation and encouraged collaborative thinking around how they could make service improvements as a team in pursuit of their vision. Individual Quality Improvement projects are now in place which include and involve the whole team in improving the quality of the Pulmonary Rehabilitation service.

Get involved in improving pulmonary rehabilitation services through accreditation of your service