The Impact of Accreditation for 10 Years on Inpatient Units for Adults of Working Age in the United Kingdom

Despite continued advances in the delivery of community mental health services (1), inpatient care remains necessary for the most severe episodes of mental illness. In the United Kingdom, there has been a rise in the number of compulsory admissions under the Mental Health Act (2), yet the number of beds available for acute admission of adults of working age has fallen. This has resulted in increasing levels of psychiatric morbidity among those admitted and a more challenging environment for patients and staff.

In 2013, a public inquiry was conducted into serious failings at a British Hospital, culminating in the Francis Report (3). In the aftermath of the report, there was an expansion in the number of nursing posts in mental health trusts. By 2015, however, 17.5% of nursing posts across the London area remained vacant (4). This is a challenging context in which to work because the hospital is expected to deliver improved quality of care for the most severely unwell and vulnerable people with mental health problems (5). In addition, these improvements are expected to address multiple areas, including safety of the environment, effectiveness of treatment, and the overall patient experience.

In order to improve the quality of inpatient care, the Royal College of Psychiatrists established Accreditation for Inpatient Mental Health Services (AIMS) in 2006. Since then AIMS has delivered accreditation to various types of inpatient mental health units, including acute wards for adults of working age. This report aimed to analyze the key changes in the quality of care in mental health inpatient units in England for adults of working age (18–65 years) over the 10-year period between 2006 and 2016. An evaluation of the initial pilot of AIMS was previously published (6), but this report is the first time that AIMS data have been aggregated on a longitudinal basis.

The AIMS Process

AIMS was established in 2006 to promote better standards of care within mental health inpatient wards (6). It is run by the Royal College of Psychiatrists’ Centre for Quality Improvement and works with service users, caregivers, and clinicians from multidisciplinary backgrounds working in inpatient services.

The pilot of the AIMS project was conducted in 2006 with 16 wards, and seven of these wards have subsequently gone through three cycles of AIMS. The project has rapidly expanded over the past 10 years and had 145 members as of July 2016. Services are reviewed against a set of evidence-based standards specific to wards for working-age adults. They are reviewed by a multiprofessional group, service users, and caregivers on a regular basis, and member wards are expected to update their practices in line with the revised standards.

Accreditation involves assessing wards against a set of evidence-based standards through a process of self-review and peer review. These standards are developed following a literature review, which is guided by a multidisciplinary steering committee, including patients and caregivers. Sources of information include research, government policy documents, and guidance from the National Institutes of Health and Care Excellence. Further information on the methodology, including the instruments developed, is available online (https://www.rcpsych.ac.uk/PDF/AIMS-WA%20-%20Third%20National%20Report%20for%20Working-Age%20Adult%20Acute%20Wards.pdf).

There are three phases of the AIMS accreditation process. Wards undergo a self-review, which requires the service to gather data by using a range of audit tools, including ward manager, patient, staff, and caregiver questionnaires; an environment and facilities audit; and health record audits. Next, a one-day visit by a peer review team is arranged. The teams usually consist of five reviewers—three professionals from other services (at least one of whom is a nurse), and service user and caregiver representatives. The role of the peer review team is to validate the self-review data as well as identify areas of achievement and areas for improvement.

Finally, the data are presented to an accreditation committee, which is made up of individuals who are representative of the multidisciplinary nature of member services, as well as service users and caregiver representatives. The role of the accreditation committee is to review the data and reach an accreditation decision. A ward’s accreditation may be deferred for up to a year while improvements are made to address unmet standards.

The accreditation cycle takes three years. Eighteen months after accreditation, there is an interim self-review to ensure the ward is maintaining standards. Once a ward has completed the full three-year cycle, the process begins again and the ward moves to the next cycle.

The Impact of AIMS

Data have been amalgamated from four National Reports of AIMS, beginning with the report on the 2007 pilot. The most recent National Report was published in 2016. The goal of the study was to investigate changes in adherence to standards that are most commonly identified as not being met. Failure to comply with these standards is the most common reason for deferral of accreditation. Trends in adherence to these standards have been tracked over the 10-year time period to highlight which areas of care have improved or deteriorated. By July 2016, 145 wards for working-age adults had enrolled in AIMS. Of these, 134 were located in England, four in Wales, three in Northern Ireland, three in Scotland, and one in Jersey. Of these, seven wards are suspended and six wards are not accredited and are not participating in the AIMS process. Ninety-two wards currently have accreditation.

This analysis focused on key standards, which were selected based on whether they directly focus on patient caregiver experience, are most commonly not met, and could be measured longitudinally throughout the time period.

From 2006 to 2016, performance improved on several standards, including increased access to therapy and activity. The percentage of wards with access to psychological therapy, measured by the ward manager's questionnaire, increased from 44% in 2007 to 91% in 2016.

Likewise, the percentage of wards with staff who are trained to deliver psychological interventions increased from 60% to 98%, as measured by the ward manager’s questionnaire. This standard was also measured more recently by directly asking staff whether they had received training in psychological interventions. In 2013, 58% stated they had been trained in basic cognitive-behavior therapy and 60% reported having been trained in other basic psychological interventions. By 2016, 70% indicated having been trained in psychological therapies.

The percentage of patients invited for one-to-one therapeutic contact during each shift varied depending on the source, with patients consistently reporting lower rates than staff. However, in 2016, a potentially more robust measure of this standard was added to the health record audit; the results indicated that 98% of patients had received such invitations. The percentage of patients who reported one-to-one contact increased from 57% in 2007 to 76% by 2016.

The percentage of wards providing activities on weekends and in the evenings also increased, from 47% and 42%, respectively, in 2007 to 63% and 61% in 2009. However, there has been no improvement since 2009. Results from the anonymous patient questionnaire indicated that the percentage of patients who reported being treated with respect (yes/no item) rose from 75% in 2007 to 93% in 2016. Likewise, the percentage of patients who indicated that they received information about their level of observation increased from 44% to 71%.

With regard to patient safety, the percentage of units reporting availability of a doctor within 30 minutes increased from 50% in 2007 to 88% in 2016. There was also better attention to addressing blind spots in wards (areas that cannot be seen from the nursing station)—98% of wards took measures to address blind spots in 2016 compared with 31% in 2007. Similarly, for the past two AIMS audits, 100% of wards had made ligature points safe compared with 75% of wards in 2006. In 2016, 93% of wards had crisis plans for patients at risk of absconding, compared with 33% in 2007. Finally, the percentage of wards recording any incident requiring rapid tranquilization, physical intervention, or seclusion rose from 75% in 2007 to 96% in 2016. With regard to staff experience, the percentage of staff responding to anonymous questionnaires who reported being able to take breaks away from the unit increased from 54% in 2007 to 82% in 2016, but this proportion fell short of the requirement that all staff be allowed to take breaks.

Among the standards we have measured over the successive years, the only one that has not improved in this time period is the requirement that all qualified nurses be assessed in the competence to deliver medication, with compliance falling from 81% of wards in 2007 to 77% in 2016. This standard was measured more robustly in the most recent audit, however, which included a requirement for annual assessment for the first time. Previously there had been no requirement for how frequently to assess this standard.

Discussion and Conclusions

There have been improvements in many areas of care, including patient activity, therapy, and safety. There are still many standards that have not reached full compliance, particularly the provision of activities outside office working hours. The reasons for noncompliance are unclear, but failure to comply with such standards is a common reason for a ward’s failure to obtain accreditation status. There may be implications for staffing, in providing occupational therapy and activities coordination in weekends and evenings with resource implications. The accreditation process enables wards to highlight such concerns to senior management in order to provide extra resources to achieve accreditation.

There is still a problem with staff reporting inability to take breaks away from the unit, but compliance with this standard has been improving. A likely cause for inability to take breaks is understaffing, a problem that is unlikely to significantly improve. An area in which accreditation has been associated with improved staffing is in the provision of psychological therapies to inpatients, once a neglected area of care. Compliance with this standard has doubled over the 10-year period and appears to be continuing to rise.

The finding of improved compliance with key standards of care in successive waves of accreditation cycles is similar to a finding from data on accreditation of electroconvulsive therapy (ECT) services. Here standards of practice improved over a 10-year period following the introduction of accreditation. Accreditation for ECT was introduced after two decades in which audit without accreditation failed to show any improvements in the delivery of ECT (7). There is one important caveat though: it is not possible to attribute changes in inpatient care as having been directly caused by the accreditation process, given that other factors are likely to have been involved in driving up quality—for example, care quality commission inspections and other quality improvement projects. In order to investigate this relationship more robustly, it would be necessary to perform a randomized controlled trial. This is currently underway in another type of psychiatric inpatient care (8), an area that overlaps significantly with inpatient mental health treatment.

Evidence for the effectiveness of accreditation programs is still less than optimal. A randomized controlled trial comparing patients in accredited programs versus patients waiting for enrollment in an accredited program in South Africa demonstrated improved compliance with key quality standards but no change in measurable outcomes (9). A systematic review of accreditation in health care concluded that accreditation could help promote change and professional development but had inconsistent effects on other areas of quality (10). There is clearly a need to assess the impact of accreditation of inpatient mental health care on clinical outcomes.

A strength of this study was that it contained data from a large number of inpatient units and collected data from multiple sources (staff, patient, and caregiver questionnaires; interviews with key ward staff; peer review visits; and interviews with patients and caregivers on the wards). The standards are evidence based, developed by a multidisciplinary panel of experts and recipients of care, and are regularly subject to review.

There were some limitations in the methodology. First, although this is a large sample, the total number of acute admission wards in the United Kingdom for adults of working age remains unknown. Furthermore, the sample of accredited wards was not the same in each audit. Second, not all standards are measured at each time point. Some were either dropped or modified, making successive measurements either impossible or difficult to interpret. Third, some of the methods of data collection have changed.

This study demonstrated improvements in compliance with some key quality standards in the inpatient care of adults of working age. However, there is still a need for improvement, especially related to provision of patient activities. It is unclear whether the accreditation program was directly responsible for the changes in inpatient care. To establish a more robust evidence base for accreditation, it is necessary to incorporate measures of clinical outcome.