Maintaining quality | Medical Care - Guidance for Desiging Services and Developing Physicians for Specialties

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Immunology

Maintaining quality

Quality in Primary Immunodeficiency Services (QPIDS) is the accreditation scheme for adult and paediatric primary immunodeficiency (PID) services in the UK. It was established by the UK Primary Immunodeficiency Network (UKPIN) and is now hosted by the Royal College of Physicians. PID services engage in a self-led programme of quality improvement before being assessed against established best-practice standards, which have been developed after extensive consultation with the PID community and with patients. Those who are found to meet the standards are accredited for five years, subject to an annual renewal process.

The Improving Quality in Allergy Services (IQAS) accreditation scheme is the equivalent for adult and paediatric allergy services.

The key standards for the practice of immunology are detailed in the tables below:

Guidance	Comments
Specialist society and patient organisation standards and guidelines	UK Primary Immunodeficiency Network (UKPIN) guidelines provide an evidence-based process against which to audit British Society for Immunology and Clinical Immunology (BSACI) guidelines provide an evidence-based process against which to audit BSI (British Society for Immunology) Immunology committee guidelines provide an evidence-based process against which to audit
NICE guidance and quality standards eg referral of anaphylaxis eg referral of drug allergy	NICE has produced a large number of technology appraisals, clinical guidelines and quality standards relevant to immunology (mainly allergy).
Other NHS standards specific to immunology	The national database for appropriate use of pooled human immunoglobulin therapies The specialist commissioning wing of NHS England is producing a series of guidelines and governance frameworks for the use of specialised treatments
CPA/UKAS laboratory standards	These cross link to UKPIN and QPIDS requirements and are essential for a high-quality laboratory diagnostic service. Participation in national external quality assurance schemes (NEQAS) for all immunology laboratory test is mandatory

Audits and appraisals	Comments
Supra regional and national audits	These are coordinated via immunology networks across the UK
National and international disease registries	Under the auspices of specialised commissioning, national registries of rarer disease are already maintained (eg UK immunology centres feed into the European Society for Immunodeficiencies (ESID) database ).
Local audit	Immunology units have local audit programmes which link to regional audits looking at both national guidance and local guidelines
Local and national peer review	Immunological peer review is achieved via local annual appraisal, and at intervals by accreditation inspection bodies.
Medical appraisal and revalidation	Participation in annual appraisal demands involvement in quality improvement ventures and patient surveys. These are also key requirements for revalidation and service accreditation
Internal governance processes	All trusts have rigorous internal governance structures for reporting and investigation of complaints and clinical incidents, and review of mortality

Accessing data for quality improvement

Accreditation schemes in immunodeficiency ( QPIDS ) and allergy ( IQAS ) are hosted by the Royal College of Physicians (RCP) and described above.

Laboratory services are accredited by a UK inspectorate ( UKAS ) to internationally agreed standards. UKAS inspections occur on a 5-year cycle and are fully supported by the Royal College of Pathologists UK. Test results must be measured against performance in external quality control schemes, where shared samples are tested by participating labs to highlight poor performance and help to address it.

Commissioners require participation in both of these accreditation schemes.

The use of expensive immunotherapy is or will often be linked to funding. One way to regulate this could be through national databases that specify approved clinical indications and conditions of use. These national databases are at various stages of development.