epas: supporting practice development

AbstractWe outline the development of the Excellence in Practice Accreditation Scheme (EPAS),devised by the practice development team in the Postgraduate Institute at the University ofTeesside, UK. The aim of the EPAS is to provide individuals, teams and organizations with aframework through which professionals can develop, implement and evaluate advances inpractice. The scheme incorporates an analysis of organizational accreditation and reviewschemes that already exist. These have been reviewed to develop a simple yet comprehensivesystem of practice accreditation.

Key words: clinical governance, evidence-based practice, excellence in practice,outcomes, practice development

BackgroundThe drivers for excellence in practice are vast, varied and complex. They are primarilyassociated with societal changes, government reform and professional requirements(McSherry and Pearce, 2002). Rising public expectations and media accounts ofreported clinical incidents or system failures in the National Health Service (NHS)have led to a growing lack of confidence in the quality of the services provided topatients. To resolve this issue and to improve standards and quality in the NHS, thegovernment has introduced policy initiatives such as The New NHS: Modern,Dependable (DoH 1997), Quality in the New NHS (DoH 1998) and The National Plan(DoH 2000). The emphasis of these initiatives is on quality improvement throughmodernization of health and social care (McSherry et al. 2003), and the only way todemonstrate quality is through evidence of enhanced performance, by having demon-strable efficiency and effective measurement tools. Practice development teams andindividuals are being used as vehicles to promote the quality agenda, under theauspices of clinical governance, across trusts, directorates and units. The challenge

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EPAS: supportingpractice development

Innovation in practice

Jenny Kell—Senior Lecturer, Practice Development, University of Teesside, UKRob McSherry—Principal Lecturer, Practice Development, University of Teesside,

UKDavid Mudd—Senior Lecturer, Practice Development, University of Teesside, UK

Practice Development in Health Care, 3(1) 4–14, 2004 © Whurr Publishers Ltd

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facing individuals working in practice development is to find a framework to supportthem when facilitating advances and evaluations in practice within the context ofclinical governance.

Practice development teams and individuals are being used asvehicles to promote the quality agenda, under the auspices ofclinical governance.

The processes involved in practice development incorporate many of the elements that promote change and advances or evaluations in practice within the clinicalgovernance framework (Page et al. 1998; McSherry and Bassett 2002). This is becausepractice development can be used as a vehicle to implement clinical governancethrough engaging individuals and teams in the following aspects of quality improve-ments:

# clinical risk management# quality and standards# clinical audit# research and development# lifelong learning# continuing professional development.

The role of the Excellence in Practice Accreditation Scheme (EPAS) within a practiceenvironment is to enable practitioners to demonstrate how they are providing goodpractice. The EPAS provides a robust framework that supports the clinical governanceagenda because of its associations with the key components of clinical governance.There are many examples of organizational accreditation schemes, but none of themcapture the essence of clinical governance or evidence-based practice within a practicedevelopment framework. The EPAS is unique in that it collectively addresses key issueswhen developing, advancing and evaluating practice. The core themes of the EPAShave emerged after critical review of organizational and accreditation frameworks, suchas the Commission Health Audit and Inspection (CHAI), the Investors in People(IIP), the European Foundation Quality Management (EFQM), the ClinicalNegligence Scheme for Trusts (CNST) and Charter Mark.

The disadvantages of organizational standards and accreditation within theNHS today are found in the duplication of time, resources and support needed forindividuals, teams and organizations to collect, collate and provide evidence to meetrequired standards. Health and social care organizations seem to be pressurized not justto meet the criteria for one, but for several, awards at any one time. Standards andaccreditation schemes are essential to demonstrate acquired levels of excellence withinany organization: they provide excellent frameworks for promoting quality improve-ments and, as a result, support practice development when making practices open and

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accountable. Our recent experiences of working with organizational standards, alongwith assessing levels of achieved practice, revealed that managerial support, resourcesand financial backing were all needed to meet them.

The measurement of organizational standards is an integral part of any qualityimprovement: practice areas need to provide evidence to accrediting bodies to showhow they have achieved a particular standard. Within the modernization agenda,bodies such as the CHAI require practice areas to demonstrate how they are providingeffective quality care. Incorporated into everyday activities, the EPAS will enablepractice areas to record and maintain a standard to show any accrediting body that theservice they are providing is of a quality standard.

Here, we discuss the process of developing the EPAS, and how the scheme canhelp to advance and evaluate practice.

Development of EPASThe practice development team from the University of Teesside School of Health andSocial Care, in partnership with local professional bodies, addressed the matter ofproviding evidence-based practice within the context of clinical governance throughpromoting continuous quality improvement. The EPAS measures the standard ofpractice for a given health and social care setting by providing objective data thatindicate a level of clinical excellence obtained. The EPAS differs from other organiza-tional accreditation schemes by facilitating excellence based upon a comprehensive setof measurable core standards and sub-standards. These have been derived from aprofessional peer review of the CHAI, the IIP, the EFQM, the CNST and CharterMark. The practice development team developed the EPAS to incorporate all thesestandards into one accreditation scheme that would meet all the standards of otherschemes within the context of everyday practice.

The processesThe processes involved in the development of the EPAS are illustrated in Figure 1. The EPAS was developed by following four stages:

# examination of existing organizational and professional accreditation standards# critical review of those standards# identification of themes# establishing the EPAS framework.

Within each of the core standards, sub-standards were developed to explore eachtheme in more depth. The standards were all benchmarked, and each benchmarkclearly articulates the standard to be achieved. Figures 2 and 3 demonstrate how thecore standards and sub-standards were designed to support teams or organizations whenachieving a certain level of measurable practice.

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Figure 1. Development of the EPAS.

EPAS: supporting practice development 7

Stage 1Examination of existing

organizational accreditation schemes

• Commission for Health Improvement• Clinical Negligence Scheme for trusts• Investors in People• European Foundation for Quality Management• Charter Mark

Stage 3Standard identification

After critical review, six primary standards were identified:

• working in organizations• collaborative working• user-focused care• continuous quality improvements• performance management• measuring efficiency and effectiveness

For more in-depth analysis of each of the primary themes, each section wasbroken down into standards that would be meaningfull to all patients and staff

Stage 4Development of the EPAS

Once the primary and sub-standards were identified the EPAS was developed,containing measurable primary standards and sub-standards that could be implemented and evaluated in practice. EPAS was mapped to show how thestandards related to the organizational accreditation schemes reviewed

Stage 2Critical review of existing

organizational accreditation schemes

• A critical review of the organizational accreditation standards;

• information synthetized to identify primarythemes emerging, denoting excellence in practice

Each of the standards and sub-standards within the EPAS was developed so that itfocused on the service provided.

Working in organizations

This standard explores the initiatives under the policy outlined in Improving WorkingLives for the Allied Health Professionals and Healthcare Scientists (DoH 2002) and concen-trates on team development, communication and the sharing of information. Thestandard focuses on a ‘whole-systems’ approach to supporting innovation.

Collaborative working

This standard focuses on multiprofessional working and development as the mainreason for achieving quality improvement, with the use of multidisciplinary teams tobreak down barriers to promote integrated care.

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User-focused care

The main theme of the modernization agenda is to incorporate users’ views into thedevelopment of practice. This theme focuses on the standards to be reached toachieve this in practice, through the involvement of users in aspects of innovationand development.

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Standard 2 of 6: Collaborative working

Statement of Expectation:Evidence that the team is working collaboratively in developing innovative and creative ways of enhancing the care experience and workingenvironment

Definition of actual achievement (example):A collaborative team approach is evident that involves and values each teammember’s contribution.

Achievement criteria:1 Staff can demonstrate active participation in the innovation(s).2 Innovations are not lead by one particular discipline or individual.3 There is shared responsibility in decision-making when advancing

practice.4 There is evidence of patient or service user involvement in the care

process.5 The user and carers or service user and carers are actively involved with

the development/evaluation of services.6 There is evidence of liaison with other groups both internal and external

to the organization.7 Working practices reflect innovative collaborative ways of working.8 Evidence of multidisciplinary documentation and patient or service user

information.9 Collaborative practice underpins the quality of the service.10 Practice support is based on a multidisciplinary approach.

0

There is no evidenceof a collaborativeapproach.

2

There is minimalevidence of a collaborativeapproach but thisdoes not consistentlyinvolve and valueeach team member’sor user and carers’contributions.

3

A collaborativeapproach is evidentthat involves andvalues each teammember’s contribution butdoes not reflect aservice user-focusedapproach.

4

A collaborativeapproach is evidentthat involves andvalues each teammember’s contribution andbegins to reflect thisin the delivery ofcare.

5

A comprehensivecollaborativeapproach is evidentinvolving andvaluing all members’contributions. This isclearly reflected in auser-focusedapproach to care.

This statement is anexample of one thatwill be given by theteam to show howthey reached theachievement criteria.

‘Statement ofExpectation’ refers tothe evidence that isexpected by theassessor to back upthe application.

These are all theachievement criteriafor the givenstandard. Thenumber of criteriamay differ betweenstandards.

The above are benchmarks against which the ‘overall level ofachievement’ will be measured for each standard. The ‘overall level of achievement’ can found on the ‘summary sheet’for each standard.

Figure 2. Explanation of a core standard. (Adapted from McSherry et al. 2003.)

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List of evidence provided Remarks

Benchmark achieved:

Summary statement:

Points of action:

Continuous quality improvements

Within all quality improvement systems that have been introduced into the health serviceover the last 12 years, the inclusion of improving the quality of care has always been aconcern. Can individuals and teams incorporate the concept of quality issues into every-thing that they do? This standard aims to make quality part of everyday working practice.


Figure 3. Explanation of the achievement criteria. (Adapted from McSherry et al. 2003.)

0

There is no writtenevidence ofexecutive and seniormanagers’endorsement of theinnovation.

2

There is writtenevidence ofexecutive and seniormanagers’endorsement, butthis is not reflectedin documentationand practice.

3

There is significantevidence ofexecutive and seniormanagers’endorsement, andthis is reflected indocumentation butnot supported inpractice.

4

There is substantialevidence ofexecutive and seniormanagers’endorsement, andthis is reflected indocumentation andsome evidence of thisin practice.

5

There is comprehensiveevidence ofexecutive and seniormanagers’endorsement, andthis is not reflectedin documentationand fully supportedin practice.

1.1 The executive and senior managers endorse the innovation.

Evidence of best practice:

1 A letter of endorsement from executive and senior managers.2 Evidence of executive/senior managers’ support in the innovations.3 Active participation of executive/senior managers in the innovations.4 Evidence of executive/senior managers’ presence at Steering Group.5 Demonstrate evidence (verbal/written) of executive/senior managers

facilitating and enabling innovations.

This is the statementindicating theachievementcriterion to bemeasured.

These are the benchmarks againstwhich theachievement criteriaare measured.

This is where theassessor will makerecommendations forfuther development,relating to this particularachievement criterion.

This section shouldindicate the information providedfor evidence of bestpractice.

These are examplesof evidence of bestpractice, and indicatewhat should/could beincluded.

This section is whereassessors cancomment on the ‘List of evidenceprovided’.

This refers to theassessors’ overallsummary of theorganization’sachievements for thiscriteria.

The ‘benchmarkachieved’ will be agrade between 0 and5, relating to theabove benchmarks.

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Performance management

To manage effectively is to improve performance and user satisfaction. This standardconcentrates on how this can be achieved in practice. Performance managementexplores how the right people carry out the right role to meet service objectives.

Measuring efficiency and effectiveness

To demonstrate efficiency and effectiveness in practice is to show how systems can bemeasured and audited to illustrate developments and improvements in practice.

These core standards are embedded in practice, and many units and wards willalready have many systems that measure each of them. Developing the EPAS willcomplement existing standards, and will demonstrate how units can incorporate allthese elements into a single framework. For some, the EPAS framework will be used foradvancing and evaluating practice within the context of clinical governance andevidence-based practice. However, while affording this opportunity, the EPAS alsoallows units to be accredited for the level of excellence they have achieved. Theprocesses involved in this are outlined below.

Gaining the EPASThere are eight main stages to gaining the EPAS:

1 Initial enquiry, followed up with a letter and information leaflet.2 Formal presentation made by the team to the unit, ward or department.3 Formal letter to proceed with the accreditation process is endorsed by

organizational management.4 Formal application and purchase of the EPAS package.5 Baseline assessment of existing practices. This assessment informs the devel-

opment of a strategy and action plan.6 Final accreditation, over a three-day period, with notification of the outcome

at the end of the visit.7 Conferment of the award, resulting in the presentation of an official plaque

and attending the University of Teesside Academic Award Ceremony.8 Review 18 months later, to ensure that standards are being maintained.

The EPAS is unique in offering individuals, teams or organizations a choice of supportto aid advancing practice. Each unit, ward or department will have reached a differentstage in the development of its quality processes. The EPAS acknowledges this, and abaseline assessment is undertaken to review existing practice against set benchmarks.The baseline assessment is undertaken by a member of the practice development team.It will give units an outline of their strengths and weaknesses, from which an actionplan can be developed and on which the subsequent accreditation is interlinked withthe development of practice. The baseline and final assessments involve data collection

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by use of ‘triangulation’. Triangulation concerns the evaluation of evidence throughthree sources: patient and staff interviews; a staff and patient questionnaire; anddocumentary analysis.

The EPAS may also be used as an adjunct to personal and professional devel-opment. Individual personal and professional reviews can be based on the corestandards to promote the integration of theory to practice, as identified below.

EPAS supporting individual, team and organizational practice development

The value of the EPAS lies in promoting and developing practice, which creates amanagerial and organizational culture that ‘acts in partnership, providing supportbetween clinical practice, education and management, enabling them to increaseresearch utilisation’ (Bassett 1995; Cutcliffe and Bassett 1997). The EPAS is uniquebecause it provides a foundation for individuals, teams and organizations to use in theirquest for quality which encompasses the principals of evidence-based practice withinthe clinical governance agenda. This is achieved by supporting the development ofbest practice based upon the core organizational accreditation standards outlinedabove in Figure 1, Stage 3. The EPAS is ideal when promoting best practice within thecontext of clinical governance because it is pertinent to all health and social careprofessionals, teams and organizations, and it builds upon current practice develop-ments. The EPAS can be used by individual practitioners to advance an aspect orstandard of the scheme as a basis for their own development review. For example, anurse or therapy consultant could use the user-focused care standard to assess the wayin which information is written, or presented verbally, and an evaluation could beundertaken to see how this is received by patients. From this review, individual practi-tioners can formulate their development plans, built on the benchmarks set out in eachindividual sub-standard. This may be used to identify professional development and tolink to educational programmes as elements of theoretical frameworks on which tobuild individuals’ personal and professional profiles.

A team approach when using the EPAS will focus on developing the team andwill also provide a common goal for individuals. The EPAS could be used to developindividuals by giving them leadership of sub-standards or core areas in which theycould lead a smaller group of practitioners to develop and achieve benchmarks. Forexample, after their individual performance reviews individuals could be identified ashaving the enthusiasm, motivation and expertise to focus the development of a specificaspect of practice. This approach to involving and engaging teams supports theprinciples of the EPAS because the accreditation system values work achieved by theteam and demonstrates to users of the service what the service can provide.

At a organizational level, the EPAS could be used as framework to support theimplementation and evaluation of the clinical governance agenda at a division ordirectorate level. The EPAS could be used to encourage sharing, networking and peer-review of existing standards and practices because it is unique in providing primary


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themes associated with achieving excellence in practice. Annual reviews could beundertaken to illustrate changes or improvements in practice. From such reviews,project plans could be developed to support further ‘excellence in practice’. The EPAScould be modified or adapted to demonstrate the achievement of government targets orinitiatives, such as the implementation of the national service frameworks.

The EPAS could be used to develop individuals by giving themleadership of sub-standards or core areas in which they couldlead a smaller group of practitioners to develop and achievebenchmarks.

Lastly, practice development personnel could adopt the EPAS as a framework becauseits themes encourage multiprofessional collaboration within an organization. One ofthe main factors inhibiting practice development is the dissemination of developmentswithin organizations. If each area is working towards the same goals, cross-fertilizationof ideas and good practice can influence practice development and demonstrate collab-oration. But, how does the EPAS differ from other practice development accreditationschemes?

How is the EPAS different?Other practice development schemes are available for individuals, teams and organiza-tions to use; however, a review of them revealed that they had specific aims andobjectives when supporting staff to advance and evaluate their practices. The ClinicalPractice Development Accreditation process at the Faculty of Health, Social Work andEducation at Northumbria University focuses on a patient or clinical issue within thecontext of research and education. The criteria for achievement of accreditation arelinked to policy and the modernization agenda through education, audit or research.The emphasis of the scheme is on encouraging individuals to enhance their learningand education by showing how they have influenced developments in practice, andalso affects users, staff and the organization. The University of Leeds, Centre forDevelopment of Healthcare Policy and Practice Scheme ‘facilitates an increase ineffective leadership behaviours, strategic awareness, creative problem solving andeffective team working’ by working on the four core pillars of the programme. Theseare: sustainable practice development; intentional improvement; building capacity forthe future; and professional accountability. The scheme goes some way towardspromoting achievement of clinical governance but is not specific to uniting variousorganizational accreditation standards. Similarly, the scheme does not set out toprovide a simplistic set of standards that are easily adopted and reviewed by staffworking in practice.

The EPAS is unique in that it consolidates various organizational standards toelicit the core themes related to best practice where individuals, teams and organizations

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can be bench-marked and accredited for a level of excellence. EPAS incorporates theclinical governance agenda within the context of evidence-based practice by providinga measurable framework that can be used by individuals, teams and organizations. Byusing EPAS, practice areas will be able to offer evidence to many of the inspectionteams which visit them without further work.

The test of any organizational accreditation scheme is the uptake and feedbackfrom users of the service—so what has been the response to the EPAS to date?

Response to the EPASSince the launch of the EPAS in February 2003, 30 teams and organizations haveengaged with the scheme. The teams range across primary, secondary and acuteservices, involving individual specialist teams such as Macmillan services at NorthTees and Hartlepool NHS Trust and Bede Ward (Forensic Mental Health) St NicolasHospital NHS Trust, Gosforth. The true measure of the value of any accreditationscheme is found in its effect on practice.

Evaluating the EPASAn ethnographic research study is currently underway, focusing on demonstrating theusefulness and value of the EPAS in practice. A larger study, involving those whocurrently engaged with the scheme, is planned.

ConclusionThe EPAS supports the government’s plans for modernization of the NHS by providinga unique framework for advancing health or social care practice. It was created byhealth and social care professionals who reviewed best practice standards, as identifiedby several organizational accrediting bodies. The EPAS is easy to use and to apply inthe practice setting, enabling individuals, teams and organizations to review,implement and evaluate their standards against set measurable criteria that promotethe principles of evidence-based practice within the context of clinical governance andpolicy initiatives. Practice development teams, individuals and organizations whoengage with the EPAS will find that it becomes part of their everyday culture.

Supporting informationUseful websites:

# Department of Health (www.doh.gov.uk).# Modernisation Agency (www.modernnhs.nhs.uk).# National Institute for Clinical Excellence (NICE) (www.nice.org.uk).# Social Care Institute of Excellence (SCIE) (www.scie.org.uk).# Commission for Health Improvements (CHI) (www.chi.org).


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# Resources for Critical Appraisal (www.nzgg.org.nz/tools/resource_critical_appraisal.cfm).

# The Developing Practice Network (www.dpnetwork.org.uk).# Netting the Evidence (www.shef.ac.uk/~scharr/ir/netting/).# University of Teesside, Practice Development Team Information

(www.tees.ac.uk/PGIH/practice_development.cfm).# Centre for the Development of Health Care Policy and Practice, University of

Leeds (www.leed.ac.uk/healthcare/consult/CDNPP/practicedev.htm).# Faculty of Health Social Work and Education, University of Northumbria

(http://online.nortumbria.ac.uk/faculties/hswe/research/PDRP/cpda.htm).

Useful reading:

# McSherry R, Bassett C. Practice Development: a guide to implementation.Cheltenham: Nelson Thornes, 2002.

# Page S, Allsopp D, Casley S. The Practice Development Unit: an experiment inmultidisciplinary innovation. London: Whurr Publishers, 1998.

ReferencesBasssett C. The sky’s the limit. Nursing Standard 1995; 9: 18–19.Culcliffe J, Bassett CC. Introducing change in nursing: the case of research. Journal of Nursing

Management 1997; 5: 241–7.Department of Health. The New NHS: modern, dependable. London: HMSO, 1997.Department of Health. Quality in the New NHS. London: HMSO, 1998.Department of Health. The National Plan: a plan for investment, a plan for reform. London: DoH, 2000.Department of Health. Improving Working Lives for the Allied Health Professionals and Healthcare

Scientists. London: DoH, 2002.McSherry R, Bassett C. Practice Development: a guide to implementation. Cheltenham: Nelson Thornes,

2002.McSherry R, Pearce P. Clinical Governance: a guide to implementation for healthcare professionals.

Oxford: Blackwell Science, 2002.McSherry R, Kell J, Mudd D. Best practice using Excellence in Practice Accreditation Scheme. British

Journal of Nursing 2003; 12: 623–9.Page S, Allsopp D, Casley S. The Practice Development Unit: an experiment in multidisciplinary

innovation. London: Whurr Publishers, 1998.

Address correspondence to: Ms Jenny Kell, Senior Lecturer, Practice Development,University of Teesside, UK.

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epas: supporting practice development

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