Putting pulmonary rehabilitation into practice

How PRSAS is supporting pulmonary rehabilitation services to evidence they meet quality standards and improvements in patient care

Putting Pulmonary Rehabilitation into practice part 2 (Illustration: Carole Verbyst)

In part two, Neena Garnavos explains how the scheme works in practice for services working towards accreditation

The pulmonary rehabilitation (PR) services accreditation programme (PRSAS) launched in April 2018 and as of August 2019, 20 services are registered and working towards accreditation. This equates to around 10 per cent of known services in England, which is a considerably higher recruitment rate than expected for new programmes. This accelerated rate of uptake is testament to the enthusiasm from the PR community about quality improvement and raising standards to improve patient outcomes.

Sharing learning 

The 20 services registered to PRSAS are based across the whole of England and vary in size, type (community/hospital-based) and by leadership (physio led/nurse led). In order to accommodate this variety and still ensure that services are able to share best practice and learning, the Royal College of Physicians (RCP), who run the programme, provide bespoke face-to-face training and web-based support. Services have fed back that meeting colleagues in other services has been invaluable in helping them improve the quality of their services and progress through the accreditation pathway.

The RCP supports groups of services to sign up together to share the load, share learning and reduce variation at a regional level for the benefit of patients. They are currently working with a number of groups, including Academic Health Science Networks (AHSN) and local PR networks, and groups in the devolved nations. If you are part of a group of PR services, such as an AHSN, a regional PR network or an informal group of PR services that work together to improve patient care, and wish to explore joining as a group then please contact the RCP team on pulmrehab@rcplondon.ac.uk. Joining as a group has a number of advantages but services will still be accredited individually. 

Discounts are also available for groups joining together. Services believe that working to a nationally recognised accreditation framework provides structure to help streamline services, which will help reduce variation in PR services nationally.

Specific examples of how our registered services have benefited since registering include:

  • ‘Being part of the programme has allowed us to prioritise the re-evaluation of equipment and organising new staff training.’
  • ‘Being part of the programme has allowed us to standardise the service provided at all our community venues, and standardise our educational materials and delivery.’
  • ‘The framework of the accreditation programme has allowed us to review our current practice and helped us identify areas of good practice as well as areas for quality improvement.’
  • ‘The programme has allowed us to start developing a business case to increase staffing for the respiratory physiotherapy service and PR.’
  • ‘The programme has allowed us to evidence the need for more staff, and because of this we are now able to recruit to the team.’

Challenges and solutions 

  • The greatest challenge that services face when working through the accreditation pathway is time. 
  • The option to sign up as a group of services has been created to help overcome this challenge by decreasing  the load through collaborative working and shared learning.

It can be challenging to get support to join the accreditation programme so the RCP has written a letter that can be shared with CEOs and managers, and created a presentation for staff to use when making the case for their service to be involved in the accreditation programme. These resources can be found here along with a number of vlogs that can further support the case for involvement. Furthermore, following the publication of the NHS England Long Term Plan Implementation Framework, it is anticipated that accreditation will form part of the commissioning guidance on PR. As such, services can gain approval and buy-in from service providers or CCGs by promoting the benefits of getting ahead of the curve and signing up sooner rather than later. 

How to get involved

To get involved as an individual service, please go to this website and follow the instructions on how to sign up. To get involved as a group, or for any questions about the accreditation programme, email the team on pulmrehab@rcplondon.ac.uk 

The service’s  perspective

Laura Graham, (respiratory team lead and specialist respiratory physiotherapist) and Alice Kenward, (cardiorespiratory rehabilitation service physiotherapy lead) provide leadership within the Adult Cardiorespiratory Enhanced and Responsive Service (ACERS) at Homerton University Hospitals NHS Trust, who are currently working towards accreditation. Laura Graham explains:

What is ACERS? 

ACERS is a large integrated cardiorespiratory service in City and Hackney, London. The rehabilitation service includes integrated PR, heart failure (HFR) rehabilitation and cardiac rehabilitation (CR). The PR programme is run at multiple sites and includes a lower level group for cardiorespiratory patients limited by breathlessness who would otherwise require home rehabilitation. Overall the rehabilitation is physiotherapy-led, but is supported by a large multidisciplinary team including ACERS nurses, psychologists, occupational therapists, and speech and language therapists. An exciting new development is our fully integrated cardiorespiratory rehabilitation maintenance pathway supported by the local GP exercise on referral scheme. 

How did you go about gaining approval from senior decision makers to be part of the accreditation scheme? 

ACERS is commissioned by the local CCG; however, we are employed by Homerton hospital therefore approval needed to be sought from our divisional director. This was surprisingly easy: I asked when an opportunity came from another meeting. The divisional management team was encouraged that gaining accreditation would demonstrate the quality of the ACERs PR service, and that it was recognised by the CQC. They have been very supportive since we have applied, providing financial support for training.

As a team, we appreciate our experience has been a lot easier than that of other PR services. We always imagined that the cost would be a barrier, believing that it would have to come from the service budget, but this was not the case. Had we needed to apply for the funding from our CCG, I think the story would have been different. Although they see the benefit for the service that accreditation will bring, currently there isn’t the same emphasis on commissioners to support accreditation as there is on providers to become accredited. I am sure this will change in the future and may give services more leverage. 

ACERS’ top tips

  1. Have the conversation with your senior managers early – do not wait until you think you have your house in order, this is part of the process. 
  2. Factor in time and costs of further training and working on accreditation from the beginning. Consider sending members of the team on the PRSAS Accreditation and the British Thoracic Society (BTS) and Association of Chartered Physiotherapists in Respiratory Care (ACPRC) pulmonary training courses which are recommended aspart of the accreditation process. These are excellent courses, which add value to any PR service and help meet the standards, therefore need to be accounted for in total costs. Costing up time spent is difficult but needs to be done at the start. 
  3. Start with the PRSAS Action Plan. On our first meeting we sat down and went through all the standards, this helped us as a team to understand what we needed to do and gave us focus moving forward. We would recommend this as a starting point.

Has being part of the scheme highlighted areas for improvement? 

It has definitely meant getting our house in order. Although this is a daunting task, we have embraced it as a team because it has given us focus to do the things we have been meaning to for a while. The team has identified many project/quality improvement opportunities, but it was also really reassuring to identify all the areas of good practice within the team as well. We all see the benefit of becoming accredited and that helps keep up motivation. One project that has come out of working towards accreditation has been solutions to improve engagement with referrers, particularly those who refer from primary care. This has involved a number of different things, including revamping the ACERs PR webpage and the creation of an ACERS pulmonary rehabilitation newsletter that we send out to referrers on a quarterly basis. The newsletter includes service information and patient testimonies, signposting referrers to patient information they can use to inform patients on what PR is. 

What are the main benefits of being involved in the accreditation process? 

Accreditation is a marker of quality, recognised by the CQC as well as other national bodies. With PR a priority in the Long Term Plan, hopefully when ACERS’ PR service achieves accreditation, it will reassure referrers and patients that they are referring to and receiving an intervention from a quality service. Service improvement has also had a number of benefits for patients, including revamped patient information, development of service user groups and the delivery of PR education in Turkish. As a team we have always felt proud to work for ACERS’ PR service, however working towards accreditation brings a new motivation to be recognised at a national level. As service lead, I see it as protective, supporting service growth and expanding the services reputation. 

What challenges have you faced while working towards accreditation and how did you overcome them? 

The biggest challenge we have faced as a service is time. As an integrated cardiorespiratory team, we cover a large respiratory admission avoidance service as well - if this part of the service is short staffed, all non-clinical work is deprioritised. Had I thought about this when I first asked divisional directors about financial support for the accreditation process, I would have planned for time to support the process. I would recommend that any service applying to their managers should include the cost of the time they need to do it. This may be back filling staff, speaking with quality improvement teams to see what support is available, or something else. One solution we have come up with is accreditation away days, currently every four to six weeks, which has helped keep focus and gives some protected time. However, this may not be possible within smaller services.

Benefits of accreditation 

The most common reasons services chose to sign up are that: 

  • they want to showcase the fantastic work their team are doing
  • they want to improve the quality of the service they are providing 
  • they want to improve outcomes for their patients. 

    References and resources

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