Both the accreditation and developmental memberships have a self-review and peer-review phase. All new QNPICU members will begin on the Developmental membership. Accreditation will be suggested to members when they are meeting a certain number of type
1 standards. See below for the review phases:
Phase 1: Self-review
During this phase, the service will undertake a self-review, including a series of surveys for staff, patients and carers.
These enable the multi-disciplinary team to review their local procedures and practices against the standards and, if necessary, to make the changes required to achieve accreditation. The self-review will take place either over two months (developmental
membership) or three months (accreditation membership). A summary of the results from the self-review forms the basis of the discussion at the peer-review visit.
Phase 2: Peer-review visit
The peer-review visit takes places up to four weeks after you have completed your self-review. A team of up to four professionals (comprising of staff from other member services), a service user and/or carer representative, and a Network
representative will undertake a peer-review visit. In addition to validating your self-review, the peer-review provides an opportunity for discussion, sharing of ideas and for the visiting team to offer advice and support.
Phase 3: Accreditation decision (accreditation membership)
Information from the self- and peer-review is compiled into a summary report which is verified by the peer-review team and the service before being submitted to the Accreditation Committee (AC). If services are not reaching a certain threshold
of type 1 standards, they may be deferred to the developmental membership. The committee makes a decision about the service’s accreditation.
There are three categories of accreditation status:
- Accreditation deferred
- Not accredited
Services that cannot achieve accreditation at the point of review but are expected to be able to do so in the near future are deferred for a time-limited period in which they must meet the necessary standards. Services can be presented to the AC
up to three times within a 12 month period.
Accreditation is valid for up to three years, subject to satisfactory completion of an interim self-review.
Phase 3: Local report and benchmarking (developmental membership)
Information from the self- and peer-review is compiled into a local draft report which is verified by the peer-review team and the service. They will be given an opportunity to comment and provide further evidence before finalising the report. All final
reports will be compiled into an annual aggregated report where services can benchmark.
Since March, COVID-19 has had a huge impact on everyone’s lives and the way we work. Given the ongoing requirement to social distance and the risks associated with having reviewers travel across the country, the decision has been made to hold
all peer-reviews virtually until at least July 2021.
As a team we have been working hard to recreate all the elements of an in-person review in a virtual environment. In order to do this, careful preparation is required both by the QNPICU project team and your service to ensure the day runs as smoothly
The involvement of patients and carers on our peer-review days remains vital and is something we do not wish to let slip given the circumstances with virtual reviews. We would like to work collaboratively with our member services to find ways in which
we can engage patients and carers and gather their feedback in a meaningful, confidential way.
For some recommendations on how best to involve patients and carers in your services virtual review, please view this guidance document.