This has been prepared to support applicable and interested organisations to effectively assess, monitor and / or assure their own, and others’, implementation of and ongoing conformance with SCCI1605 Accessible Information – referred to as ‘the Accessible Information Standard’ or ‘the Standard’. ‘Applicable organisations’ are those to which the Standard applies (i.e. with specific requirements as part of the Specification), whilst ‘interested organisations’, as the term suggestions, includes all those with an ‘interest’ in the Standard, such as voluntary and community sector groups and local Healthwatch organisations.

Organisations should continue (and are advised) to refer to the Specification and Implementation Guidance for definitions and specific details about the Standard’s scope and requirements, which the below does not alter or supersede.

With regard to terminology and definitions, readers should consult the Specification for clarity on relevant and particular terms including terms specifically defined by the Standard (especially sections 1 and 7.1).  Where the term ‘patients’ is used in this document, it should be taken to mean, “patients or service users with information and / or communication support needs relating to a disability, impairment or sensory loss”. Note that the terms ‘conformance’ and ‘compliance’ are used interchangeably in this and other documents relating to the Standard.

1. The importance of conformance
2. Central assessment and assurance of conformance
3. Assessment of conformance – overview from Implementation Guidance
4. Assessment of conformance – conformance criteria
5. Assessment of conformance – the role of commissioners
6. Assessment of conformance – other interested organisations
7. Practical assessment of conformance
8. Measuring improvement
9. Support for conformance and best practice
   • Appendix 1 – Conformance criteria
   • Appendix 2 – Checklist for preparatory actions
   • Appendix 3 – Policy guidance
   • Appendix 4 – ‘Maturity Index

1.    The importance of conformance

Organisations should note that conformance with the Standard is a specific legal duty (section 250 Health and Social Care Act 2012). Organisations that provide NHS care and / or publicly-funded adult social care are required to implement the Standard in full by 31^st July 2016, and then ensure ongoing conformance thereafter.

The Standard is in line with the Equality Act 2010 (including service providers’ ‘reasonable adjustment’ duties), and is also associated with the meeting of obligations under the NHS Constitution, the Care Act 2014 and the Mental Capacity Act 2005.

Implementation of the Standard is associated with significant benefits to patients and service users, and is in line with commitments to equitable, high quality, accessible and personalised care. Further information about the benefits of conformance is included in the Specification (section 13 and appendix a) and in ‘Notes on the Cost of Meeting Individuals’ Needs’.

Organisations that do not implement the Standard are at risk of failing to effectively provide high-quality healthcare to individuals with information and / or communication needs, and potentially denying them their rights to confidentiality and independence when accessing healthcare. Organisations that do not comply with the Standard leave themselves open to legal challenge, as well as to complaints, investigation and reputational damage.

Compliance with the Accessible Information Standard is also a specific requirement of the NHS Standard Contract 2016/17.

2.    Central assessment and assurance of conformance

The Accessible Information Standard is an ‘information standard’ as defined by section 250 of the Health and Social Care Act 2012. However it does not have – and has not established – an associated national data collection, data extraction or return. This means that there is no requirement for applicable organisations to report, extract or send data centrally to NHS England as the organisation responsible for the Standard or to the Health and Social Care Information Centre (as the organisation responsible for overseeing information standards).

Notwithstanding the above, organisations from which NHS England directly commissions NHS services should note that this lack of central monitoring does not mean that assurance will not be sought from them about their conformance. NHS England, as a service commissioner, will expect assurance in line with requirements set out in the Specification and as outlined in section 6 – as will other relevant commissioning organisations.

3.    Assessment of conformance – overview from Implementation Guidance

The following extract is taken from section 13 of the Implementation Guidance for the Standard which provides guidance on how local assurance may be approached:

“The Specification for the Standard includes conformance criteria which should be used in order to assess compliance, and the Implementation Plan also outlines proposals for supporting implementation and conformance. Commissioning organisations are required to seek assurance from provider organisations of their compliance with this standard, including evidence of identifying, recording, flagging, sharing and meeting of needs. At a local level, applicable organisations will wish to assure themselves that they are complying with the Standard […]

Consideration should be given to recording a formal incident each time an individual’s information or communication support needs are not met. This will inform assessment of unmet need, support the making of relevant adjustments / arrangements to meet needs, and highlight the importance of the Standard internally within organisations and to commissioners.

As part of the Standard, organisations are required to publish an accessible communications policy, to implement an accessible complaints policy and to support individuals with information and communications needs to provide feedback on their experience of services and of receiving information in appropriate formats and / or communication support.

Organisations should consider how they can capture feedback from individuals with information and communication needs as part of their existing patient experience and patient engagement approaches. This may necessitate development of relevant materials, such as feedback forms and comment cards, in alternative formats and the establishment of mechanisms for the receipt of feedback in formats such as audio or British Sign Language. Face-to-face opportunities for feedback, supported by relevant communication professionals, should also be considered.

Organisations may wish to work in partnership with their local Healthwatch organisation(s), with patient groups and / or with organisations from the voluntary and community sector to facilitate the development of accessible materials and approaches for individuals with information and communication needs to feedback on their experiences. Such groups may also be able to directly support engagement with individuals and communities with information and communication needs…”

There is further information about many of the points above, including advice and suggested actions, in subsequent sections of this document.

4.    Assessment of conformance – conformance criteria

The following extract is taken from section 13 of the Implementation Guidance for the Standard which provides guidance on how local assurance may be approached:

The Specification for the Standard includes ‘conformance criteria’ (copied at appendix one) which “…should be used to demonstrate conformance.” Each Requirement has an associated conformance criterion, which should be used by health and social care providers, health and social care commissioners, and IT system suppliers (respectively) to demonstrate conformance. The Specification clarifies that:

• All MUST requirements must be met.
• All SHOULD requirements must be met or there must be a credible, legitimate reason documented for why they have not been.
• MAY requirements are optional.

Conformance criteria may also be used by commissioners as a way of assessing or assuring provider organisations’ conformance with the Standard, and as a similar tool by other interested organisations.

5.    Assessment of conformance – the role of commissioners

As outlined in Implementation Guidance (section 15.6),  “Although exempt from implementing the Standard themselves, commissioners are required to ensure that their actions, especially through contracting and performance-management arrangements (including incentivisation and penalisation), enable and support provider organisations from which they commission services to implement and comply with the requirements of the Standard.

This includes ensuring that contracts / frameworks enable and support provider organisations to be responsive to the needs of individuals with information and communication support needs, for example by facilitating the provision of longer appointments and allowing for flexibility within patient pathways.

Commissioning organisations should review their existing contracts / frameworks and make any adjustments necessary to allow for, and indeed support, providers to comply with the Accessible Information Standard – in line with compliance deadlines.”

Specifically, by 1 September 2016, commissioners should be able to evidence that they have sought and received assurance from provider organisations of their compliance with the Standard, including receipt of evidence of identifying, recording, flagging, sharing and meeting of needs.

Beyond adhering to published requirements, commissioners are not required to take any specific or particular approach to assurance, and should use their judgement to implement an approach most appropriate to their own, and their providers’, circumstances. It is recommended, however, that commissioners explicitly include the requirement to comply with the Standard as part of procurement / tender documents, service specifications and contracts with providers, and clearly indicate expectations around the receipt of evidence in this regard, which should be documented.

Commissioners may also wish to include explicit statements with regards to the Standard as part of their Annual Operating Plans, Business Plans, Commissioning Intentions, Equality and Diversity Objectives / Strategy (including linking to EDS2) and / or as part of Annual Reports. It would be good practice for commissioners to proactively contact existing provider organisations in advance of 31 July 2016 to seek assurance that they will be compliant with the Standard and to confirm that evidence of conformance will be sought in September.

Commissioners may also wish to consider their role in supporting locality or region-wide initiatives which support cost-effective, efficient and added value approaches to implementation of the Standard across the local health and care system. There is further information about the benefits of coordinated, collaborative approaches in ‘Notes on the Cost of Meeting Individuals’.

6.    Assessment of conformance – other interested organisations

There is significant interest in, and support for, the Standard from a range of voluntary and community sector organisations, patient groups, and local Healthwatch organisations. After 31 July 2016, it is anticipated that many such organisations will request evidence of conformance with the Standard from organisations that provide and / or commission NHS care and / or publicly-funded adult social care, for example through Freedom of Information (FOI) requests. There may also be interest from local stakeholder and partner organisations, and in some areas, there is the potential for local media interest.

In addition, the Care Quality Commission (CQC) have stated that, for health services, “as part of our inspection work, CQC will look at evidence of how services implement the Accessible Information Standard when we make judgements about whether services are responsive to people’s needs,” and, for adult social care services, “as part of our inspection work, CQC will look at evidence of how services implement the Accessible Information Standard when we make judgements about whether services are responsive to people’s needs and whether they are well led.”

All of the above suggests that organisations would be advised to take proactive steps to ensure that they are able to evidence the actions they have taken to effectively implement and conform with the Standard, in advance of receipt of a request for such assurance.

7.    Practical assessment of conformance

a.    Overview

In summary, assessment of conformance with the Standard should be undertaken by a provider organisation themselves, and by their commissioning organisation – to ensure requirements are being met – and may also be undertaken by one or more interested third parties such as local Healthwatch, a relevant voluntary sector organisation or patient group.

In all cases, judgement about conformance may be made in a variety of ways including by assessing evidence of performance against the conformance criteria (as outlined in section four and listed at appendix one), by looking at evidence that key aspects of the Standard are being followed, and through assurance of key outputs.

The following sub-sections (b to e) include specific suggestions in this regard.

b.    Assessment of policy

The Standard includes requirements for organisations to publish or display:

• An accessible communications policy, which explains how they will follow the Standard; and
• An accessible complaints policy.

The requirement to have an accessible communications policy is intended to support transparency and clarity, for staff and service users, as well as other interested organisations and individuals, by necessitating publication of information about how the organisation has implemented the Standard.

The requirement to have an accessible complaints policy is intended to ensure that people with information and communication support needs are able to provide feedback to organisations about their experiences. This in turn should support continual improvement in the context of providing a high quality service to all.

The requirement to publish these two policies also supports practical demonstration of conformance.

In addition to publication / availability requirements noted above, organisations that provide NHS care and / or adult social care should also be aware of two specific conformance criteria with regards to the impact of the above policies:

• By 30.09.16 feedback from patient surveys, PALS (Patient Advice and Liaison Service), local Healthwatch or other sources demonstrates that individuals with relevant needs have received communication support and / or information in alternative formats which is of a suitable quality and is effective in meeting those needs.
• By 30.09.16 feedback has been received from individuals with communication and information needs.

Such organisations should, therefore, be mindful of the need to be able to demonstrate (for example to their commissioner) that individuals have had their information and communication needs met, and that individuals with information and / or communication needs are able to provide feedback on their experiences. A full list of conformance criteria is included at appendix 1.

1. Practical assessment of conformance – the ‘five steps’ of the Standard

Progress with implementation of the Standard and achievement of conformance can be assessed at a high level by reviewing whether there is evidence of an organisation routinely and consistently following the ‘five steps’ of the Standard as part of ‘business as usual’. The ‘five steps’ require organisations that provide NHS care or publicly-funded adult social care to identify, record, flag, share and meet the information and communication needs of people with a disability or sensory loss.

d.    Practical assessment of conformance – preparatory actions

The Implementation Guidance includes a ‘checklist for preparatory actions’ (section 15.4), produced to support organisations with implementation, which may also be used by other organisations, after the full implementation date, to assess conformance. This checklist is included at appendix two.

e.    Practical assessment of conformance – policy

The Implementation Guidance also includes direction about the content of local policy for following the Standard (section 15.3). This is included at appendix three.

As part of assessment and assurance of conformance, as well as verifying the existence of a policy, consideration should also be given to, for example, assessing its publication, availability, accessibility and staff awareness.

8.    Measuring improvement

Organisations interested in improving their performance / assessing organisational improvement over time may wish to assess progress against the ‘maturity index’ included in the Implementation Guidance (appendix b). This is copied at appendix four.

9.    Support for conformance and best practice

A range of advice, guidance, tools, templates and resources to support effective implementation and ongoing conformance with the Standard are available on the NHS England website.

A number of voluntary and community sector organisations have also produced resources and information, including: Action on Hearing Loss, CHANGE, the Royal National Institute of Blind People and Sense.

Appendix 1 – Conformance criteria

a.    Conformance criteria – health and social care providers

b.    Conformance criteria – health and social care commissioners

 c.    Conformance criteria – I T system suppliers

Appendix 2 – Checklist for preparatory actions

The following checklist is taken from the Implementation Guidance (section 15.4), and may be used to assess conformance.

• Developed / modified accessible communication policy which is in line with the Accessible Information Standard.
• Agreed approach to identifying individuals with information / communication needs relating to a disability, impairment or sensory loss.
• Clear process for recording individuals’ information / communication needs in line with the Standard.
• Flags, alerts or prompts established to highlight / make individuals’ information / communication needs ‘highly visible’ to staff, supported by relevant prompts to action.
• Identified range of ways for individuals with communication needs to contact the service, and for the service to contact them, supported by agreed process for using any ‘alternative’ approaches.
• Agreed process for sending out correspondence in alternative formats.
• Agreed process for producing / obtaining information in alternative formats.
• Agreed process for arranging / booking professional communication support.
• Agreed process for booking / arranging longer appointments for patients / service users with communication needs.
• Training / briefing given to staff to explain the Accessible Information Standard, detail processes to be followed and raise awareness of support which staff can provide themselves.
• Consideration given to accessibility of relevant website(s) and availability of relevant information online.

Appendix 3 – Policy guidance

The Implementation Guidance (section 15.3) states that local policy and processes for following the Accessible Information Standard should include:

• How to identify individuals with information / communication needs, including who will ask, what question(s) will be asked, how, where and when.
• How to record individuals’ information and communication needs as part of existing patient / service user record systems and administrative processes, including using specific categories / codes.
• How to ensure that there is an alert, flag or other prompt to notify staff of an individual’s information / communication needs such that they are ‘highly visible’ whenever the record is accessed and prompt for relevant action(s) to be taken.
• Alternative ways to contact individuals with information / communication needs and for them to contact the service, for example via email, text message or telephone.
• How to send correspondence in alternative formats (for example in large print, via email, in easy read, in braille).
• How to obtain patient information in alternative formats (for example patient information leaflets in ‘easy read’).
• How to arrange for a communication professional to provide support to a patient / service user either as soon as possible (in an urgent situation) or for an advance appointment. Note whether there are facilities for remote British Sign Language (BSL) and / or speech-to-text-reporting (STTR).
• Guidelines for arranging a longer appointment for a patient / service user with communication needs.
• How staff can support individuals with communication needs, for example to lipread / use a hearing aid.

Appendix 4 – ‘Maturity Index’

The following is taken from Implementation Guidance (appendix b).

a.    Overview

The Accessible Information Standard allows for flexibility in implementation approaches, subject to the successful achievement of requirements and outcomes. There is, however, a ‘maturity index’ or improvement trajectory, ranging from ‘basic’ implementation (in which the organisation is compliant but as part of which the Standard has limited integration with other systems / processes and there is limited or no automation) working up to an ‘exemplar’ level in which the essential requirements of the Standard are embedded into systems / processes, highly supported by automation and activities go beyond this baseline to achieve good / best practice.

It is hoped that all organisations seek to strive towards good and best practice with regards to meeting the information and communication support needs of people with a disability, impairment or sensory loss.

b.    Basic level

The requirements of the Standard – typified by the five step process – are achieved using separate processes – either paper-based or using electronic ‘work-arounds’.

A paper-based approach would involve recording of an individual’s information / communication support needs (most probably by hand), and ensuring that these were ‘highly visible’ / flagged using a highlighter or sticker system. The ‘prompt for action’ would rely on staff awareness and following of policy, and sharing likewise would be reliant on staff including information as part of handover / referral conversations and correspondence (for example copying relevant data from paper records into a letter). Meeting of needs would be achieved again through staff awareness of the need to make adjustments / send out information in alternative formats / arrange support from communication professionals, as prompted by a sticker or other flag on paper records.

An electronic approach would involve recording of an individual’s information / communication support needs using ‘free text’ (in line with the ‘fully specified names’ (FSNs) or categories of the data items associated with the four subsets of the Standard). Staff must manually select – and elect – to add a flag or alert to a patient’s record when they record that they have information / communication support needs. Once a flag is (manually) applied to an individual’s record, a ‘special requirements’, ‘access needs’ or ‘communication needs’ alert appears whenever the record is accessed. Having noticed the alert, staff must then search for relevant information about the type of information / communication needs which the patient has, and follow relevant policies in order to meet those needs.

Staff must arrange for the printing / production of any and all information needed by patients using manual processes. The service’s website is not screen-reader compatible and there is no availability of information in alternative formats online.

c.    Intermediate level

The Standard is implemented using clear approaches and supported by relevant policy, but remains somewhat separate to ‘business as usual’ processes. There is use of electronic systems, but no automation of processes.

Individuals’ information / communication needs are recorded using Read v2, CTV3 or SNOMED CT codes. Electronic flags are available, and electronic systems prompt for their use, but must be applied by staff when recording individuals’ needs (they are not automatically applied by electronic systems). The flags do not trigger any auto-generation of correspondence or other automatic processes in order to meet individuals’ needs, but are highly visible and prompt staff to take action, however, they do not send specific alerts.

Staff are able to manually select and print / produce some alternative formats using standard templates, but are reliant on external or bespoke processes for others. Longer appointments can be arranged, as well as support from communication professionals, however, whilst there are clear policies, successful implementation relies on staff awareness and ability to make adjustments in systems.

The service’s website is accessible to some screen-reader uses, but there is no availability of information in alternative formats online.

d.    Advanced level

The Standard is partly embedded into ‘business as usual’ processes, with some automation in electronic systems.

Individuals’ information / communication needs are recorded using Read v2, CTV3 or SNOMED CT codes. Electronic flags are automatically applied upon selection of any of the data items associated with one of the four subsets of the Standard. The flags do not trigger any auto-generation of correspondence or other automatic processes in order to meet individuals’ needs, but are highly visible and prompt staff to take action – including sending alerts at relevant points. Staff are able to manually select and use a range of standard templates to enable correspondence and other information to be printed ‘in-house’ and provided in alternative formats. Effective processes are in place to enable provision of longer appointments, and the arrangement of support from communication professionals, and these are supported by clear policies and protocols which can be followed by any and all staff.

The service’s website is accessible to most or all screen-reader users, with some information available online in alternative formats.

e.    Exemplar

The Standard is highly embedded into ‘business as usual’ processes and highly automated in electronic systems.

Individuals’ information / communication support needs are recorded using SNOMED CT codes, with flags automatically applied upon selection of any of the data items which are associated with one of the four subsets of the Standard. The electronic flags automatically trigger actions to enable needs to be met, without relying on staff, for example, leading to automatic generation of correspondence and printed information in alternative formats, selection of a longer appointment time and sending an appropriate email to agencies to book a communication professional as appropriate. Staff input into processes is minimal, and prompted by automatic processes, for example drop-down lists requiring selection of information / communication needs prompt (and require) staff to record / review individual’s needs whenever they contact the service.

Online registration forms include a section about information / communication support needs which is in-line with the SNOMED CT codes (and their FSNs) and which is then directly included onto the patient’s record. Patients with online access can view, verify the accuracy of and if necessary update their records as and when their needs (or ways of meeting those needs) change. Full use is made of remote, virtual and digital solutions to meet individuals’ needs, including access to remote BSL interpretation and speech-to-text-reporting.

The service’s website is highly accessible, enabling individual’s to access information online using a screen-reader or other assistive technology, and includes key information in easy read and BSL formats too.

Staff have received training in Total Communication approaches and basic BSL / deafblind manual to support communication with patients in reception areas and the building of rapport (with communication professionals used to support appointments / clinical conversations).