Thank-you to the team at SCW for sharing their experience in supporting Gloucestershire in starting their PRSAS journey, read more on the SCW website.
What was the challenge?
The Royal College of Physicians runs the Pulmonary Rehabilitation Services Accreditation Scheme (PRSAS) and aims to improve the quality of pulmonary rehabilitation services throughout the UK. The pathway to accreditation can take up to two years, requiring a comprehensive self-assessment against seven domains and 40 standards. Services must prepare robust evidence to demonstrate that these standards are being met. Once this step is completed, the service undergoes a thorough assessment, including a detailed review of the submitted evidence, followed by a site visit, where a pulmonary rehabilitation session is observed.
For the Gloucestershire Respiratory Service – a countywide service run by Gloucestershire Health and Care NHS Foundation Trust - the journey to accreditation presented a significant challenge, particularly in allocating the necessary time to begin the process. While they recognised the importance of enhancing pulmonary rehabilitation services, they also understood that their clinical and operational teams were already stretched thin, making it hard to prioritise accreditation efforts.
In this context, our role was to act as a critical friend, providing expert guidance and unwavering support as the team navigated their accreditation journey. Through close collaboration, we identified key opportunities to add value, benefitting both the team and the people who depend on their services.
What they did:
We supported Gloucestershire Respiratory Service to embark on their journey towards Pulmonary Rehabilitation Service Accreditation, working closely with the team to assess current systems and identify key areas for improvement. Through our participation in a respiratory team staff meeting, we fostered strong working relationships, gaining valuable insight into their challenges and offering innovative solutions to enhance their processes.
Our accreditation preparation work included:
Gap analysis
By conducting a thorough gap analysis using the self-assessment tool, we were able to refine standard operating procedures, risk assessments and educational resources to ensure they meet accreditation requirement.
Service standard operating policy
We developed a comprehensive 60-page service policy, covering all seven assessment domains, and supported it with relevant Trust policy, job descriptions and standard operating procedures (SOPs).
Staff and patient surveys
We designed and implemented an annual staff survey, analysed the results and shared actionable recommendations during an away day. Additionally, we created a patient survey and produced ’You Said, We Did‘ posters to effectively communicate the actions taken.
Team away day
We organised an engaging away day focused on connection, learning and reflection. This event not only propelled the team towards achieving PRSAS Standards accreditation but also provided an opportunity to review performance and plan for the year ahead.
Audit data analysis
We conducted an in-depth analysis of both local and national audit data, reviewing National Respiratory Audit Programme (NRAP) run charts and KPIs to pinpoint opportunities for improvement.
Embracing and embedding improvement
Our team provided guidance on quality improvement (QI) initiatives, including Plan-Do-Study-Act (PDSA) cycle training and the creation of service-specific QI plans. We then helped integrate these enhancements into daily operations, ensuring continuous improvement and alignment with PRSAS Standards reviews moving forward.
Impact:
The PRSAS Standards submission was made in December 2024, with the site assessment taking place in April 2025. Following the assessment, a two-week extension was granted to allow the service to complete two outstanding actions. As a result, the service successfully achieved certification at the end of April 2025. Moving forward, the service has the plans, policies and processes in place to consistently uphold PRSAS standards. A central element of our successful collaboration was our ability to empathise with the team–clinician to clinician, fully appreciating the challenges they face in delivering high-quality care to those who would benefit the most.
Click here if you would like to read about how SCW supporting Gloucestrshire in their first stage of their journey.