The Safe Effective Quality Occupational Health Service (SEQOHS) accreditation scheme is looking set to become the recognised standard across occupational health providers. Nic Paton reports.
Should you ever be invited to an occupational-health-themed pub quiz (and assuming such things do not already exist, perhaps it is high time that they were invented), chances are you could throw your opposition into disarray with the following question: in 2011, what was the connection between Manchester-based occupational health provider Healthwork and Mansfield-based occupational health provider RPS?
The answer is that they are the first two occupational health providers to be accredited with the SEQOHS standards, with Healthwork achieving the workplace health kitemark in May and RPS joining it in June.
The SEQOHS standards were launched back in January 2010, with a voluntary accreditation scheme unveiled in December at the Faculty of Occupational Medicine's winter conference.
The scheme is managed by the Royal College of Physicians of London on behalf of the faculty and, on top of the significant achievement of having successfully fast-tracked two providers through within six months of launch, it has more than 100 occupational health services already signed up as members, which is the first stage of the process of becoming accredited.
Dr Paul Nicholson, SEQOHS clinical lead at the faculty and associate medical director at Procter & Gamble, says that the popularity of the accreditation process and the way it has been embraced by the profession has exceeded his expectations.
"We are ahead of where we anticipated we would be at this point in the year, which is excellent news. The take-up has been rapid, and to go beyond 100 in such a short time has been amazing," he adds.
The take-up has been rapid, and to go beyond 100 in such a short time has been amazing."
Dr Paul Nicholson,
Faculty of Occupational Medicine
"We always expected the most rapid take-up would be in the first six months. But it has become clear that there is huge interest in and a clear commitment to accreditation among the large number of early adopters."
So now we are more than six months in, how are people finding it? Are some standards proving harder to meet than others? Does it (or will it) make a difference to tendering and landing contracts? Are there any issues of concern? And is the cost of the process off-putting, especially to smaller, perhaps single-handed, providers?
Dr Tok Hussain, operations director of Healthwork, says: "For us the process was simple. We first submitted evidence via the website around the end of March, which was then sub-divided into different elements. We had expected it would take a long time to get to the next stage but they came back within a few days to say we were ready to be visited.
"A lot of it, to be honest, was just ticking boxes. In many respects, the biggest challenge was simply formally writing down what we do. For some of it we had to create policies and procedures for work that we do anyway, so definitely, in that respect, it was a useful exercise in itself.
"We had to create quite a few new documents and amend others. The standard about premises was probably the most difficult for us because in some areas, such as disability access, we had it but did not have it written down.
"It was also useful to have someone leading the process, in our case, it was me. I also brought in a nurse manager and the office manager, who were tasked with covering specific areas."
With the auditors still to be appointed at that time - around 50 auditors have now been trained or are being trained - the external audit was carried out by Nicholson and Debbie Johnston, project manager for the SEQOHS scheme.
"We were initially a little concerned about who the auditor would be, and whether they were going to be from a rival company. But the fact it was Nicholson and Johnston meant it never arose as an issue," says Hussain.
Conduct and credibility
The issue of commercial confidentiality, or the worry that you may end up having someone from a rival company snooping around your business, is something providers have been seeking reassurance about.
Karen Talbot, managing director of Diverse Health Solutions and chair of the Commercial Occupational Health Providers' Association, points out: "There are issues around confidentiality; even just uploading documents can be quite scary for some people."
Having said that, Talbot, whose business has registered but so far has not gone beyond that stage, stresses that SEQOHS has been proactive in addressing concerns. "There is a facility to say if you do not want to get a particular auditor," she says.
I have a strong belief that it is going to be a fantastic process, although there are still some things that need to be ironed out."
People Asset Management
As Nicholson clarifies: "We have an assessor code of conduct that defines responsibilities related to conflict of interest and confidentiality and which assessors have to sign. We notify services of the chosen assessors and the service can object if there are valid reasons, in other words, if an assessor works for a direct competitor. In that situation we will inform the service of another assessor's name."
Another longer-term question for Talbot is what will happen when we start to see providers failing the process - as some inevitably must if it is to have any credibility - and how that process will be communicated and managed. Similarly, the way the process is structured in regards to cost - based on number of sites - has raised a few eyebrows among OH providers.
"Perhaps the cost should be based on turnover? That, in my view, would be a fairer way to do it. You may get a situation where a smaller provider is put off going for accreditation because they have five small satellite sites and that puts them into a higher bracket," says Talbot.
Jane Fairburn, OH services director at People Asset Management in Warrington, agrees that this does appear to be something of an anomaly. She says: "We have a head office and a peripatetic team of around 60 people. But you could easily have just eight people working in eight different clinics; the charging system is nothing to do with the number of people that are being looked after, just the number of sites being looked after."
Nevertheless, Fairburn, who has put herself forward as an auditor, firmly believes in the value of the accreditation process. "I have a strong belief that it is going to be a fantastic process, although there are still some things that need to be ironed out," she says.
The issue of commercial confidentiality remains a concern, as does the requirement to give SEQOHS your key client list. Having said that, for some clients, being able to say that their provider is SEQOHS-accredited may be a bonus.
"My biggest client is Asda, which of course has regular meetings with the Government - they would be only too happy to say their OH service is SEQOHS accredited because it gives them kudos as well as us," Fairburn says.
Points of view
Another concern that has been raised is the fact the SEQOHS document states that it will be reviewed "by January 2015", which has led to some confusion that it is set in stone until then.
Nicholson, however, emphasises that this is not the case and January 2015 is "the very latest" point it will be reviewed by, not necessarily the point of review.
He adds: "We are already collecting notes that will contribute to the process of review. The date of the review will be determined by need and experience. Minor adjustments or added examples of suitable evidence can be made at any stage."
Within the NHS, the fact that an extra NHS-specific set of requirements, Domain G, has been added to the standards has ruffled a few feathers. Ian Aston, head of service for the Nottingham Occupational Health Board at Nottingham University Hospital, argues that Domain G was added with very little debate or consensus, is confusing and, worst of all, does not appear even to be NHS-specific.
Nicholson says: "You would expect to see things about, say, hepatitis B or needlestick injuries but there aren't. Most of them are about business issues, for example, your business plan or accounting methods, which should probably be included in the main standards."
We are confident we are meeting the levels within SEQOHS, however, meeting them isn't enough for the purpose of accreditation."
"It has been imposed on us without a great deal of clarity or discussion, so there is some resistance to complying with it. But we have said we definitely want to be accredited for the SEQOHS standards and be able to compete with other organisations that have SEQOHS."
In a large, bureaucratic organisation such as the NHS, one challenge has simply been getting the relevant practical support to gather together all of the information required, especially the financial documentation, argues Aston.
"The hardest challenge is to evidence our standards," adds Chris Woon, service director for Working Well, 2gether NHS Foundation Trust at Gloucestershire Royal Hospital.
"We are confident we are meeting the levels within SEQOHS, however, meeting them isn't enough for the purpose of accreditation," he points out.
"We are working harder to ensure our auditing and reporting mechanisms support the standards so that when we move for accreditation we will achieve, and prove we can achieve.
"For example, we are reviewing our electronic systems to ensure that they are supporting our clinical practice, so that SEQOHS doesn't progressively become a labour burden on our resources."
One key aspect, whether for NHS or commercial providers, is to make the process as much of a team effort as you can, even if you still have specific leads, emphasises Mandy Murphy, general manager for the occupational health service at London's St Thomas' Hospital, part of Guy's and St Thomas' Hospital NHS Trust.
"We have a very large team and we wanted to engage everyone in this process. We split the standards into segments. Each segment had a lead and they were responsible for recruiting additional support if they needed it, both internally and external to the OH service," she explains.
"There was a continual process of updating at each of the team meetings and some specific sessions dedicated to SEQOHS, where we discussed the gap analysis. This gave the leads an opportunity to identify areas they were having trouble finding evidence for and to ask for other ideas.
"We created an electronic folder where all the leads could place their evidence for review. A nominated person would periodically check when evidence has been added and chase the leads where there were gaps. We set a final date as to when evidence could be added. I checked every folder and piece of work to ensure it met the requirements of SEQOHS and prepared it for uploading," she adds.
Ultimately, for most providers, the benefits of finally having something to prove regarding the quality and value of the service they are providing appear to far outweigh any bedding-down or teething issues there may be - and the level of take-up is clear evidence of how the profession has engaged with this new arrival.
As Paul Faupel, head of campus health and safety and scientific facilities at the Wellcome Trust Sanger Institute in Hinxton, Cambridgeshire, points out, for any provider that has experienced the tendering process, having something such as SEQOHS up your sleeve will be worth its weight in gold.
If you are putting a contract out to tender, being able to see they have gone through an accreditation process would save a lot of aggravation."
Wellcome Trust Sanger Institute
"If you are putting a contract out to tender, even if you are in most likelihood keeping your current contractor, being able to see they have gone through an accreditation process would save a lot of aggravation. It is so obvious you almost wonder why we never did it before now," he says.
"I think it is not only good from my specific point of view of needing to find good quality OH providers or users, it is also a model that could be useful when you are setting up an internal service and be one that could be replicated elsewhere. I think it will become the de facto standard," he adds.
Andrew Noble, managing director of provider Health Management, agrees SEQOHS will be "essential to the industry".
He advises: "Do not go into it lightly. You have to be well documented, and not just the processes but the evidence recorded. The key, as with anything, is do you walk the walk rather than just talk the talk? You have got to be running the processes and be able to demonstrate that you are running the processes.
"If you are not, it is going to be hard work getting yourself documented. So you need to get in shape before you start the process," he adds.
SEQOHS will, in time, become its "bedrock governance standard", predicts medical director of AXA ICAS Mark Simpson, with the organisation aiming to go through the pre-accreditation process in Q3 and Q4 this year, and then accreditation itself in Q1 to Q2 next year.
"As we expand into new rehabilitation areas we can use it as a unifying principle across all the diverse clinical activities within the organisation. We can use it to inform a much broader approach to governance," he says.
What the accreditation process comprises
A pre-qualification questionnaire
Largely an information-gathering and (hopefully for most providers) box-ticking exercise, this requires occupational health providers to: show that they are meeting the eligibility criteria for accreditation; show that they can provide true and contemporaneous, and not misleading, information; comply with all applicable laws and regulations; and have appropriate insurances. The attestation, the standards stress, have to be signed or co-signed by at least one registered health professional from the occupational health service.
Providers have to submit a list of customers and key contacts, from which a sample is then approached to complete and return a "customer satisfaction" survey in which they will be asked to provide answers to a series of set questions.
The evidence that the provider has gathered is first submitted online to determine the readiness of the occupational health service for an on-site assessment visit by an auditor. Once this hurdle has been passed, the provider is contacted and told that they have made it through to the inspection stage. To address issues of commercial confidentiality and competition, it is possible to request a change of auditor if it is felt that there may be a potential conflict of interest.
On-site assessment visit
An external audit is undertaken by an auditor to the occupational health service. The auditors are recruited against people-specification criteria posted on the SEQOHS website and are a mix of OH nurses, occupational physicians and OH or business managers. They are required to complete five remote learning modules, attend a training day, complete a mock assessment and shadow a real assessment before being certified.
Occupational health providers seeking either accreditation or re-accreditation are required to undertake self-assessments in the years when an external audit is not performed.
Key practical challenges
Mandy Murphy, general manager for the OH service at Guy's and St Thomas' NHS Foundation Trust, London, and Chris Woon, service director for Working Well, 2gether NHS Foundation Trust at Gloucestershire Royal Hospital discuss the key practical challenges relating to SEQOHS accreditation.
What has been the hardest standard to meet?
Murphy: Information Governance, standard B1. Our information governance has changed rapidly in the past 18 months as we move to paperlight systems. The accreditation system has helped us to look at what governance systems we had in place and what we needed to do to improve.
Woon: The hardest challenge is to provide evidence of our standards. We are working harder to ensure that our auditing and reporting mechanisms support the standards so that when we move for accreditation we will achieve, and prove we can achieve. For example, we are reviewing our electronic systems to ensure that they are supporting our clinical practice, so that SEQOHS doesn't progressively become a labour burden on our resources.
Which standards would you like to see raised and why?
Murphy: Professional development of staff and audit of clinical activity. If staff keep their skills up to date and their practice is audited against good benchmarks, the rest should fall into place.
Woon: I expect to see the standards improve as time progresses, and I would like to see some detailed consideration of operational performance metrics, and also see further transparency for customers, for example with clearer sub-contracting assurances.
What advice would you offer the smallest OH units?
Murphy: Some of the smaller units may be able to manage their accreditation better than a larger one, as they will be able to focus on it more than a larger unit. My advice would be to consider SEQOHS as a project, divide into manageable chunks, delegate where you can and do a bit every week (or whatever you can manage). Also, talk to neighbouring OH colleagues.
Woon: Don't underestimate the importance of the standards for our future, not least if you sell services to external commissioners. Although the pressure to achieve accreditation may be daunting, within a smaller unit it will be easier to embed changes or updates in a process and therefore smaller units should be able to reposition quicker than larger units. Finally, don't allow the paper exercise to detract from embedding systems, or clinical delivery. Make sure time is invested to train and ensure that all employees are adopting all of the governance established.
What advice would you give about demonstrating that you are meeting the standards?
Murphy: Brainstorm with your team, contact the regional quality facilitator and colleagues in other trusts/organisations. You'll be amazed at the variety of evidence that can be used to demonstrate that the business is meeting the standards.
Woon: Keep it simple and don't be swamped by the detail. Explaining what you do isn't enough - you will need policy, process and audit to back up practice.
What form should the evidence take?
Murphy: Anything you can get your hands on, of relevance of course. Not everything has to be in policy format. We have used a wide variety of documents, from one-page statements from IT, flow charts, protocols, emails and letters - even handwritten customer feedback was used to demonstrate how we met one standard.
Woon: Evidence can include anything, from hard-copy paperwork to electronic documents - and don't rely on an opportunity to explain verbally. Ensure that evidence is clear and make sure that all your information is neatly segmented so that you can access it quickly, and also that you maintain a clear and manageable version control system. This ensures that you keep evidence up to date and you always refer to the current information.
How do you organise yourself to produce evidence?
Murphy: We have a very large team and we wanted to engage everyone in this process. We split the standards into segments. Each segment had a lead and they were responsible for recruiting additional support if they needed it (both internally and externally to the occupational health service). There was a continual process of updating at each of the team meetings as well as some specific sessions dedicated to SEQOHS, in which we discussed the gap analysis. This gave the leads an opportunity to identify those areas that they were having trouble finding evidence for and to ask for other ideas. We set a final date as to when evidence could be added.
Woon: Begin by undertaking a simple gap analysis, and build it into an action register from which responsibilities can be delegated. Also, ensure that you have a clearly defined document-management system, which can be as simple as individual folders on a hard drive. Make sure that all your evidence is dated with authors and has clear review dates. Also make sure that your system is backed up, either centrally or locally.
From where do you collect evidence?
Murphy: We enlisted the help of IT, finance, HR and the commercial directorate.
Woon: Across the organisation. Although many elements are specific to our service, there are a number of requirements for corporate material, or information which as part of a large NHS Foundation Trust we do not replicate locally at a service level. These include financial documents, HR material, etc. In some instances we are adding statements to accompany corporate-level material, which will help an outside assessor position corporate material within our environment.
What issues might there be about commercial confidentiality? (For example, if an external provider is assessing an in-house provider, could they use the information if bidding to take over the service?)
Murphy: When it comes to commercial sensitivities we have not provided any information where we felt this was a risk.
Woon: We have faith that the process will be managed within appropriate ethical boundaries and we have confidence in the selection and management of assessors. Although we do not anticipate issues, we are confident that should a concern or issue arise it will be handled appropriately.