NHS England » Accessible Information Standard

Introduction

The Accessible Information Standard (AIS) sets out how organisations should ensure people who have a disability, impairment or sensory loss get information they can access and understand and any communication support they need from health and care services.

This guide outlines a step-by-step process for conducting a self-assessment to ensure your organisation meets the AIS requirements.

This self-assessment should be completed using the Accessible information standard and Implementation guidance.

By completing the self-assessment, an organisation can evaluate how well people’s communication and information needs are being met when using services. The template offers a standard method and supports ongoing evaluation and improvement within local systems.

Using the self-assessment framework

For the self-assessment to apply in both health and social care settings, it refers to people or individuals using services, rather than solely referring to patients or service users.

The framework uses readily available data and follows the 6 AIS steps. The assessment statements ask organisations to evidence how they are meeting each step. When viewed together, each question can be seen to follow a hypothetical patient journey.

Organisations should consider how they are meeting the communication and information needs of families and carers when they are involved in or supporting the care of an individual.

This framework is in its first year following pilot testing and will be subject to annual review. It is for all organisations providing health and / or adult social care services.

You can:

read more information about who needs to meet the standard
learn more about assessing your level of compliance
understand why it’s important to meet the standard

All providers should discuss with their commissioner how to demonstrate their compliance with the standard.

The AIS has from its inception applied to both NHS services and adult social care. While this framework has been prepared by NHS England, it is supported by the Department of Health and Social Care and has been agreed and set out for social care providers to support their approach to improving information for people with disabilities in line with the standard.

Steps to complete the self-assessment framework

Step 1: Understand the Accessible Information Standard

Before conducting a self-assessment, it is crucial to understand the requirements and the steps your organisation should take in implementing it by:

identifying if someone has communication or information needs due to a disability, impairment or sensory loss
recording needs clearly and consistently
alerting / flagging needs, ensuring recorded needs are highly visible whenever the individual’s record is accessed
meeting needs by providing the appropriate information and communication support
reviewing and updating communication needs

Step 2: Assemble a self-assessment team

Identify a team that includes:

management to ensure organisational commitment and resource allocation
IT and record-keeping staff to review and adapt information systems
frontline staff to provide insights into practical communication challenges
people who have a disability, impairment or sensory loss to provide first hand perspectives on needs and effectiveness

Step 3: Review current practices

Conduct an internal review to assess how well current practices align with AIS requirements. Your review should include:

policies and procedures to check they explicitly mention the standard and detail processes for identifying, recording, flagging, meeting, and reviewing communication needs
training programmes to ensure staff are trained on the standard’s requirements and understand how to implement them
information systems to check they can record and flag communication needs effectively
communication methods to assess the availability and use of alternative formats such as Braille, large print, easy read, and communication support such as British Sign Language (BSL) interpreters

Step 4: Conduct staff and user surveys

Surveys can provide insights into how well the organisation is meeting the standard:

staff surveys ask staff about their awareness and understanding of the standard, and their confidence in meeting people’s communication needs
user surveys collect feedback from individuals with disabilities on their experiences with the organisation’s communication methods and support

Step 5: Gap analysis

Identify gaps between current practices and the standard’s requirements:

are there missing or incomplete policies regarding accessible information?
is there a lack of staff training on the requirements of the standard?
are there technological limitations in recording and flagging needs?
is there insufficient access to alternative formats and communication support?

Step 6: Develop an action plan

Based on the gap analysis and the RAG rating from the self assessment framework , create an action plan that includes:

specific actions to improve the RAG rating, such as updating policies, providing additional training, or investing in new technology
set realistic deadlines for each action
assign responsibilities to specific team members or departments
allocate necessary resources, including budget and personnel

Step 7: Implement and monitor

Put the action plan into practice:

roll out changes according to the plan, ensuring all staff are aware of and adhere to new policies and procedures
regularly monitor progress against the action plan. Use internal audits, feedback from staff and users, and performance metrics to measure effectiveness

Step 8: Continuous improvement

Accessible information and communication needs can evolve, so continuous improvement is essential:

periodically review policies, procedures, and practices to ensure ongoing compliance
establish mechanisms for ongoing feedback from individuals with disabilities and staff to identify new needs or issues
continuously update training programmes to incorporate new best practices and technologies

Roles and responsibilities

Integrated care boards (ICB)

NHS England or any future organisation holding its powers is responsible for overseeing ICB performance and has included AIS requirements within the quality measures.

ICBs or the responsible commissioners should publish assurance evidence from their services in relation to the standard’s requirements.

The ICB or equivalent should have a responsible officer for the standard and provide support and leadership within the health and social care system of which they are a part.

Monitoring should take place at a health and social care system level with a review of the local position and co-ordinated work being undertaken to improve areas.

Commissioners

The commissioner is responsible for ensuring that any organisation it commissions is complying with the AIS and meeting the needs of relevant people and assuring these needs have been met.

Commissioners should review the completed evidence of compliance for each provider. Commissioners should ascertain how evidence of compliance will be shared and published.

Where a commissioner identifies a provider is not meeting the standard or is not evidencing its position, it is expected that the commissioner would take suitable action.

Care Quality Commission (CQC) as regulator

The CQC has revised its approach to assessment, with a new assessment framework. The AIS is not assured by the CQC, that is the role of the commissioner. However, the performance of organisations in meeting people’s needs is considered in CQC assessment of providers. Where the CQC has learned that an organisation is not meeting accessible communication and information needs, it may act.

More information about the CQC assessment framework is on the CQC website.

Organisations

Organisations should publish annually (on their websites) their own performance against the measures in the AIS self-assessment framework as well as detailing the actions put in place to enhance and improve outcomes. Organisations are encouraged to publish both the completed template and any supporting action plans. They should also make sure the published information is accessible in a number of formats.

Organisations should also prioritise ensuring their complaints process is accessible to all those with communication and information needs covered by the standard and where it is not accessible take action to remove those barriers.

In addition to the relevant website accessibility rules, consideration should be given to suitable formats used, for example easy read and BSL videos.

Each publication should:

show how the organisation is performing in meeting the accessible communication and information needs of people, families and carers
highlight success and improvements made
showcase planned future actions or link to an AIS action plan
where challenges exist, show how these will be addressed

Scoring and measuring performance

The AIS self-assessment framework performance rating should be based on a red, amber, green scoring (RAG).

Where an organisation does not have suitable systems in place, does not hold the data or cannot show how it delivers against the statements, it should give a self-assessed rating of Red.

Where a question is not relevant to an organisation, they should leave out the RAG rating Organisations must use their judgment on this and provide an explanation as to why the question is not relevant

Action planning should linked to the key areas of priority identified. The action plan should have clear actions including realistic timeframes and identified ownership for the actions. The action plan should be updated and progress reported to the senior leadership team. The publication of the action plan and progress reports will give confidence to both commissioners and people using services that the organisation is working to improve things.

Download the self-assessment template

Accessible information standard – self-assessment template

Future developments

This AIS self-assessment framework is the first iteration. Future enhancements will be co-produced with the Accessible Information Implementation Standard board and key stakeholders.