Laura Booth
Senior Assessment Manager – IQIPS
United Kingdom Accreditation Service

In April 2024, the Electrophysiology department at Moorfields Eye Hospital received United Kingdom Accreditation Service (UKAS) accreditation to the Improving Quality in Physiological Sciences (IQIPS) standard, marking a significant achievement in its commitment to quality and patient care. This department spans six laboratories in the adult clinic and three in the paediatric clinic, serving approximately 3,000 patients annually, 40% of whom are external referrals.

The team, led by Professor Anthony Robson, comprises 22 members, including clinical scientists, physiologists, and support staff. Dr. Magella Neveu, the department’s Consultant Clinical Scientist and Quality Lead, reflects on the accreditation journey, underscoring its transformative impact.

IQIPS and UKAS

IQIPS is a professionally developed standard underpinned by five domains: Leadership and Management, Clinical, Patient/Client Experience, Safety and Risk Management, and Facilities and Resource. The standard ensures high-quality diagnostic services through comprehensive frameworks and robust processes.

In 2017, UKAS took over management of the IQIPS scheme, engaging with key stakeholders to update the standard, including specific input from ophthalmic and vision science professionals. The updated standard provided the foundation for Moorfields’ Electrophysiology department to align its processes and systems.

The Accreditation Journey

The department began its accreditation journey in July 2020, conducting a gap analysis to identify areas for improvement. Led by Quality Manager Joanne Ball, this analysis resulted in a roadmap emphasizing the adoption of a Quality Management System (QMS) to document processes, manage non-compliances, and oversee change control.

By March 2021, the department had applied for UKAS accreditation. Over the following two years, the team systematically documented Standard Operating Procedures (SOPs), implemented an audit schedule, and conducted training aligned with newly established processes. Despite challenges such as resource constraints and post-pandemic clinical backlogs, the team persevered, guided by regular support from UKAS Senior Assessment Manager Laura Booth.

Key Challenges and Improvements

A major challenge was addressing Measurement Uncertainty, particularly patient-related variables like blinking or eye movement. The department undertook targeted exercises to quantify and address these uncertainties. Additionally, the COVID-19 pandemic provided unexpected opportunities to focus on documentation and SOP development, albeit with increased pressure once clinical activities resumed.

Training represented another hurdle. While staff were previously trained, these efforts were undocumented. The Educational Lead developed a training matrix to align roles with SOPs, ensuring proper documentation and validation.

On-Site Assessment and Accreditation

The UKAS on-site assessment in December 2023 highlighted the department’s patient-focused approach, attention to detail, and collaborative ethos. While minor non-conformities were identified, the team addressed these promptly, leading to the accreditation being granted in April 2024.

Benefits of Accreditation

The accreditation process has delivered long-term benefits to the department, including:

• Skills management: Identifying section leads improved staff development and workload distribution.
• Training: A centralised training matrix has facilitated efficient onboarding and record management.
• Document control: The QMS ensures staff access current, validated documents.
• Patient feedback: Improved mechanisms for collecting and acting on feedback enhance patient care.
• Equipment management: The QMS streamlines calibration and maintenance schedules.
• Change control: A new change management process proved invaluable when transitioning to updated patient testing electrodes.

Looking Ahead

Since achieving accreditation, the department has proceeded to win Moorfields’ ‘Team of the Year’ award. Two additional departments within Moorfields are now pursuing IQIPS accreditation, while the Electrophysiology team is preparing for a significant relocation in 2027.

Dr. Neveu emphasizes that quality improvement is an ongoing commitment, adding, “It is wonderful to have gone through this process and to have been awarded our grant of accreditation, however quality improvement is never a one-off event, it is a continuous process, that all the team are committed to and engaged in.”