JAG Accreditation outline of the process

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JAG Accreditationoutline of the process
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• Purpose of the visit
• To enable the centre to be accredited/re-accredite
  d
• Accreditation for Bowel Cancer Screening
• Standards and measures against which centres are
  assessed
• High quality training
• Safe and effective care for patients

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• To pass a visit, a unit must provide evidence of
  level B or better for the following domains of
  the GRS
• Clinical quality
• Quality of the patient experience
• Training
• Workforce
• Waiting times for all procedures must be lt9
  weeks(level A for timeliness)
• Surveillance lists must be up to date
• The visit includes an assessment of the
  environment, decontamination facilities and
  processes

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JAG Visits

• Should be seen as supportive and educational
  opportunity to assist you in providing the
  highest standards in patient care and training

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The visit process- timeframe
Stage 1
Unit contacts JAG office requests visit
JAG Central Office set up visit on visits website
Completion of online questionnaire
Evidence Upload
Minimum 3 months
Stage 2
JAG confirms assessors/visit details
Assessors review online evidence
Formal visit and interviews
Feedback and report
1 month
QA of report and process
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Readiness

• Thinking about your own units how JAG ready do
  you think you are and what are your challenges?

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JAG Team Roles and Responsibilities
Lead for visit Training Finalisation of Report
Training Lead
SHA Lead
GRS validation Waiting list validation
Workforce Decontamination Environment
Nurse Lead
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Unit Team Roles and Responsibilities

• Agree date for visit
• Raise awareness
• Read guidelines
• Review website
• Prepare folders of evidence
• Upload evidence through one point

• Agree strengths/weaknesses and any deficiencies
• Agree any additional information or
  reorganisation of programme before site visit
• Presentation
• Unit walkthrough
• Prepare Interviewees

Refer to the JAG guidance for visits in your
resource pack
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The JAG Accreditation System

• Provides centralised coordinated approach to JAG
  accreditation
• A central reference/communication point
• Provides support tools and information

The system is underpinned by the GRS. This forms
the heart of accreditation
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New online system
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Checklist to complete
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GRS Measures
Evidence Required
Upload your Evidence
Communicate with Assessors
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Uploading evidence

• P presentable
• Stick to one style or format
• Make one person responsible for uploading
• R relevant
• Only supply what is asked for JAG accreditation
• E excluding
• Do not upload Trust policies, provide separately
• S specific to the item
• Do not upload the same document for numerous items

Use the comments field to communicate with JAG
assessors
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The Main Event

• PowerPoint Presentation
• Summary of achievements and challenges
• An opportunity for you to provide any final
  information
• Final documents, audits
• The walkthrough is a key part of the assessment

Refer to the JAG preparation Guidance in your
book for final checks
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What happens if you defer?

• It depends on what the challenges are
• You will be given clear recommendations
• Timescales for improvement
• Direct support from the JAG (Bethany Ince) to
  attain full accreditation

We want you to pass its a supportive process
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Common causes for deferral

• Decontamination
• Non-compliant AERs
• Flow of endoscopes (separation of clean and
  dirty)
• Evidence of training
• Audits
• No comprehensive rolling audit programme,
  supported by ERS
• Environment
• Privacy and dignity
• Recovery space
• Sustainability of waits

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Final Tips

• Book a date for the visit now
• Start preparing your evidence
• Consider having a lead coordinator manage the
  process
• Visit other JAG approved sites for examples of
  good practice
• Read the JAG guidance carefully
• Only provide what is asked for
• Use all the resources available through
• www.grs.nhs.uk and www.thejag.org.uk
• Contact us for advice

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Environment
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Benchmark

• The environment should
• Reduce anxiety
• Maintain privacy and dignity
• Protect the patient from harm
• Protect the staff from harm
• Provide adequate facilities to maintain a
  positive working environment

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Entrance/Exit (outpatients/inpatients)

Endo 1


Nurses Recovery
Station (7beds)



Seated Recovery
Waiting area Pre Post (patients relatives)
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Entrance/Exit (outpatients/inpatients)

Endo 1


Nurses Recovery
Station (7beds)



Seated Recovery
No prep room No PD room Lack of toilets Staff
transferring food through patient areas
Waiting area Pre Post (patients relatives)
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Decontamination
Store

Endo 1
Endo 2
Store
Sisters Office
Staff Room


Nurses Recovery
Station



Seated Recovery
Private room
D/C lounge
Sub-wait (non-gowned pts)
Admit / consult
General waiting area
Admit / consult
Reception / bookings office
w/c
Prep W/C
PrepW/C
Outpatient Entrance / Exit
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Assess your own unit

• Walk through the unit as a team
• See it through the patients eyes
• Recruit someone from outside the unit to gain a
  fresh perspective

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Reduces Anxiety

• Dedicated waiting area
• Noise levels
• Adequate toilets
• De-clutter unit

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Privacy Dignity

• Private admission/consent process
• Dedicated bowel preparation room
• Sub-wait area
• Ability to give feedback of results
  confidentially
• Decor

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Safety

• Appropriately sized recovery area
• Monitoring equipment
• Size of rooms
• Hazards eg cables / water / fixtures
• Decontamination
• Use of obsolete equipment

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Timeliness and Sustainability
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JAG Criteria for Waiting Times

• Waiting times for all procedures must be lt9 weeks
• Surveillance/planned programmes must be up to
  date

Achieved at least 3 months before the visit
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Timeliness Sustainability
Have you hit the target?
Y
N
Can you stay there?
When will you get there?
What have you put in place to make this happen ?
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Timeliness Sustainability

If..
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Policy and Procedures

• Unit Access/Operational Policy/Operating
  Procedures
• Endoscopy Classification
• Referral guidelines (appropriateness)
• Waiting list management system
• Vetting practices
• Surveillance
• Clerical and clinical validation
• Guidelines
• Pooling
• Scheduling practices

These should be understood and actively applied
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• This section is looked at closely alongside
• Booking and Choice
• Appropriateness
• Communicating results

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• This operational policy effectively covers all
  the key requirements.

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Validation
Further Examples are available on your CD and
the KMS
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Pooling
How this is done in practice ?
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Every organisation has a system
Ensure that your data reflects your true position
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Diagnostic Returns

• Trust to provide as supporting evidence
  (reported to the DH)
• It does not cover everything (surveillance and
  other tests)

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Trust 9 Weeks Endoscopy

• Meeting structure
• - Trust Performance
• - Local unit level
• Weekly capacity review meetings
• Scheduler/planner role
• Individual responsibilities

Keeping on top of it is crucial, I take it
personally when someone cancels their
appointment Admin Lead-Doncaster and Bassetlaw
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Waiting List Data
This includes patients who have chosen to wait
beyond their dues date
Ensure the assessors are getting the real picture
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Endoscopy Primary Targeted List (PTL)

1. This will be looked at closely on the day of the
   visit (live system)
2. Patient Comments need to be up to date
3. Patients will be explored

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Workforce

• Knowledge and skills What should they know?
• Staffing Compliment what's reasonable?

They should have the same opportunities as other
staff in the service
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Admin Workforce

• A 2 roomed Endoscopy requires 3.0 wte support
  staff
• Admin Tasks
• I waiting list lead (Band 4)
• 1 support scheduler (Band 3)
• 1 reception admin (Band 2/3)

There are many different models of working
that will impact upon this
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• Questions?

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Workforce
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Issues

• Total Establishment
• 12.99 WTE
• Less
• Vacancy 1.0 wte
• Unit Manager 1.0 wte
• Nurse Endoscopist 1.0 wte
• Porter 1.0 wte
• Equals 7.99 wte in post to run 3 rooms

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Benchmark

• Adequate staffing levels and skill mix to provide
  a patient centred, safe endoscopy service in
  accordance with national guidance.
• Up to date, relevant, induction, training and
  appraisal systems to support and encourage
  personal and professional development.

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Endoscopy Staffing levels
Decontamination
Recovery
Endoscopy Room
Admit
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Endoscopy Staffing levels
Decontamination
Recovery
Endoscopy Room
Admit
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Admit
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Endoscopy Skill Mix

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Staffing Levels (draft)
Staff required Extra Recovery Nurse Unit Manager WTE required Plus Leave Loading
One Room 5 1 1 7 15-22
Two Rooms 10 (5 x 2) 1 1 12 15-22
Three Rooms 15 (5 x 3) 0 1 16 15-22
Four Rooms 20 (5 x 4) 1 (HCA) 1 22 15-22
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Skill Mix (draft)
One Room Two Rooms Three Rooms Four Rooms
Unit Manager Unit Manager Unit Manager Unit Manager
RN x 4 RN x 8 RN x12 RN x 16
HCA x 2 HCA x 3 HCA x 4 HCA x 5
7 WTE 12 WTE 16 WTE 22 WTE
Plus Leave Loading 15 22 Plus Leave Loading 15 22 Plus Leave Loading 15 22 Plus Leave Loading 15 22
Mix will depend on local needs
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Workforce Domain

• Adequate staffing levels and skill mix
• Training and development
• Structured assessment - Endoscopy Competence
  Framework
• Appraisal and PDPs
• Staff are involved in planning and managing the
  service
• Recognition and reward

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Endoscopy Competence Framework

• Outlines
• the knowledge and skills required to care for
  patients undergoing an endoscopic procedure from
  booking appointment to safe discharge.
• Administrative and Clerical
• Nursing and support roles
• Endoscopists

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The Endoscopy Framework

• END1 Communicate and relate to individuals
  during endoscopic procedures
• END2 Provide information on endoscopic
  procedures to individuals
• END3 Refer individuals for endoscopic
  procedures
• END4 Schedule endoscopic procedures for
  individuals
• END5 Agree endoscopic procedures for
  individuals
• GEN6 Prepare the delivery of endoscopic
  procedures
• END7 Prepare individuals for endoscopic
  procedures
• END8 Position individuals during endoscopic
  procedures
• END9 Assist colleagues during endoscopic
  procedures
• END10 Administer sedation and analgesia to
  individuals during endoscopic procedures
• END11 Assess and optimise the condition of
  individuals during endoscopic procedures
• END12 Perform diagnostic and therapeutic
  endoscopic procedures
• END13 Identify signs of abnormality revealed by
  endoscopic procedures
• END14 Collect specimens through the use of
  endoscopic procedures
• END15 Manage polyps through the use of
  endoscopic procedures
• END16 Manage strictures through the use of
  endoscopic procedures
• END17 Manage haemostasis through the use of
  endoscopic procedures
• END18 Review the results of endoscopic
  procedures
• END19 Provide reports on endoscopic procedures

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Technical Support

• END1 Communicate and relate to individuals
  during endoscopic procedures
• END2 Provide information on endoscopic
  procedures to individuals
• END3 Refer individuals for endoscopic
  procedures
• END4 Schedule endoscopic procedures for
  individuals
• END5 Agree endoscopic procedures for
  individuals
• GEN6 Prepare the delivery of endoscopic
  procedures
• END7 Prepare individuals for endoscopic
  procedures
• END8 Position individuals during endoscopic
  procedures
• END9 Assist colleagues during endoscopic
  procedures
• END10 Administer sedation and analgesia to
  individuals during endoscopic procedures
• END11 Assess and optimise the condition of
  individuals during endoscopic procedures
• END12 Perform diagnostic and therapeutic
  endoscopic procedures
• END13 Identify signs of abnormality revealed by
  endoscopic procedures
• END14 Collect specimens through the use of
  endoscopic procedures
• END15 Manage polyps through the use of
  endoscopic procedures
• END16 Manage strictures through the use of
  endoscopic procedures
• END17 Manage haemostasis through the use of
  endoscopic procedures
• END18 Review the results of endoscopic
  procedures
• END19 Provide reports on endoscopic procedures

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Endoscopy Nursing Staff

• END1 Communicate and relate to individuals
  during endoscopic procedures
• END2 Provide information on endoscopic
  procedures to individuals
• END3 Refer individuals for endoscopic
  procedures
• END4 Schedule endoscopic procedures for
  individuals
• END5 Agree endoscopic procedures for
  individuals
• GEN6 Prepare the delivery of endoscopic
  procedures
• END7 Prepare individuals for endoscopic
  procedures
• END8 Position individuals during endoscopic
  procedures
• END9 Assist colleagues during endoscopic
  procedures
• END10 Administer sedation and analgesia to
  individuals during endoscopic procedures
• END11 Assess and optimise the condition of
  individuals during endoscopic procedures
• END12 Perform diagnostic and therapeutic
  endoscopic procedures
• END13 Identify signs of abnormality revealed by
  endoscopic procedures
• END14 Collect specimens through the use of
  endoscopic procedures
• END15 Manage polyps through the use of
  endoscopic procedures
• END16 Manage strictures through the use of
  endoscopic procedures
• END17 Manage haemostasis through the use of
  endoscopic procedures
• END18 Review the results of endoscopic
  procedures
• END19 Provide reports on endoscopic procedures

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Endoscopists

• END1 Communicate and relate to individuals
  during endoscopic procedures
• END2 Provide information on endoscopic
  procedures to individuals
• END3 Refer individuals for endoscopic
  procedures
• END4 Schedule endoscopic procedures for
  individuals
• END5 Agree endoscopic procedures for
  individuals
• GEN6 Prepare the delivery of endoscopic
  procedures
• END7 Prepare individuals for endoscopic
  procedures
• END8 Position individuals during endoscopic
  procedures
• END9 Assist colleagues during endoscopic
  procedures
• END10 Administer sedation and analgesia to
  individuals during endoscopic procedures
• END11 Assess and optimise the condition of
  individuals during endoscopic procedures
• END12 Perform diagnostic and therapeutic
  endoscopic procedures
• END13 Identify signs of abnormality revealed by
  endoscopic procedures
• END14 Collect specimens through the use of
  endoscopic procedures
• END15 Manage polyps through the use of
  endoscopic procedures
• END16 Manage strictures through the use of
  endoscopic procedures
• END17 Manage haemostasis through the use of
  endoscopic procedures
• END18 Review the results of endoscopic
  procedures
• END19 Provide reports on endoscopic procedures

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Competences for Endoscopy Nurses

• END1 Communicate and relate to individuals
  during endoscopic procedures
• END2 Provide information on endoscopic procedures
  to individuals
• END4 Schedule endoscopic procedures for
  individuals
• GEN6 Prepare the delivery of endoscopic
  procedures
• END7 Prepare individuals for endoscopic
  procedures
• END8 Position individuals during endoscopic
  procedures
• END9 Assist colleagues during endoscopic
  procedure
• END11 Assess and optimise the condition of
  individuals during endoscopic procedures
• END20 Provide care for individuals recovering
  after endoscopic procedures
• END21 Reprocess endoscopy equipment
• CHS3 Administration medications

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Competences

• 1. A description of the content
• 2. Links to the related KSF dimensions and
• levels
• 3. Scope
• 4. Performance criteria
• 5. Knowledge and understanding

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Performance Criteria

• A set of statements which define what is required
  of the practitioner in demonstrating the selected
  competence
• These should be referred to when presenting
  evidence

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Provision of Evidence

• Formal education project work, study days
• Evidence of learning distance/e-learning, CD
  ROM, induction packages
• Resource collection guidelines, journal
  articles
• Reflective account
• Witness statement
• Direct observation of practice (DOPS)
• Case study
• Care plan

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Competency Assessment Scale

1. Minimal knowledge and understanding about how the
   competence relates to practice
2. Needs supervision to effectively carry out the
   range of skills within the competence
3. Performs some skills within the competence
   effectively without supervision
4. Confident of knowledge and ability to perform all
   the identified skills within the competence
   effectively
5. Can facilitate the knowledge and understanding of
   other professionals on the skills within the
   competence

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GIN Programme

• A new training initiative, rolled out nationally
• Currently available to every NHS acute endoscopy
  unit
• Independent sector invited to participate in Wave
  3.

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Aim of the GIN programme

• Improve access to training
• Support the development of specialist knowledge
  and skills relating to GI endoscopy
• Ensuring sustainability by equipping the
  workforce with the skills and knowledge to
  identify local training needs
• Create a highly skilled workforce to provide a
  safe and patient centred endoscopy service

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Delivery Plan 3 Waves
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GIN Programme Training Pathway
Endoscopy Unit
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Programme Structure
GIN Training Teams
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GIN Course Content

• Quality Assurance in Endoscopy
• Bowel Cancer Screening Programme
• Decontamination in endoscopy
• Consent in GI Endoscopy
• Endoscopy Competence Framework
• E-Portfolio
• Team objective setting

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e-Portfolio

• Electronic evidence folder
• Self Assessment
• Formative Assessment
• Summative Assessment
• Generates PDP based on structured and
  standardised performance/assessment criteria
• Passport of competence

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www.jets.nhs.uk/gin
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Decontamination

• Understanding the Standards

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The JAG VisitAssessment Validation

• GRS scores
• Clinical Quality
• Patient Experience
• Training
• Workforce
• Environment Safety Unit tour
• Patient flows
• Privacy Dignity
• Decontamination

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Problem Areas For Units
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• Decontamination of re-usable medical devices
  undertaken in Trusts will be carried out to an
  acceptable standard and there will a process in
  place to encourage Trusts to move closer to
  excellence.
• Department of Health, 2004

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Endoscope Decontamination 2009
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Most common question

• Where have these new guidelines come from?

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Influences on endoscope decontamination practice
1994 An endoscope cleaning room should have
dirty area and a separate clean area.a sink
unit with two sinks and a double drainer
HBN 52 - Accommodation for Day Care
Endoscopy Unit
1988 1996
2004 2007
HIV
vCJD
Hine Report
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Influences on endoscope decontamination practice
1997 A technical guide detailing requirements
for Design Operation and testing of WDs HTM2030
Washer Disinfectors
1988 1996
2004 2007
HIV
vCJD
Hine Report
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Influences on endoscope decontamination practice
2002 ..suitable environment, with validated
automated processes, managed and operated by
trained staff.separate sinks for washing and
rinsing. Infection control in the built
environment NHS Estates
1988 1996
2004 2007
HIV
vCJD
Hine Report
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Influences on endoscope decontamination practice
2003 Clean and dirty equipment and processes
should be segregated.. Instruments should be
tracked to patients.. Department of Health
1988 1996
2004 2007
HIV
vCJD
Hine Report
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Influences on endoscope decontamination practice
2006 There is a monitoring system in place to
ensure that decontamination processes are fit for
purpose and meet the required standard. Health
Act
1988 1996
2004 2007
HIV
vCJD
Hine Report
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Influences on endoscope decontamination practice
1988 1996
2004 2007
HIV
vCJD
Hine Report
JAG Accreditation
Over 20 documents relating to endoscope
decontamination
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Influences on endoscope decontamination practice
Too many documents Not accessible Not user
friendly Unit design ref. 14 years old Minimal
support
1988 1996
2004 2007
HIV
vCJD
Hine Report
JAG Accreditation
Majority of endoscopy units still non-compliant
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Influences on endoscope decontamination practice
1988 1996
2004 2007
HIV
vCJD
Hine Report
JAG Accreditation
Decontamination Standards for Flexible Endoscopes
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Decontamination Standards for Flexible Endoscopes
Environment Equipment
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What do you need to do to pass?
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Operational management

• Decontamination lead at executive level
• Local decontamination operational policy
• Robust tracking system
• Out of hours protocol for decontamination
• vCJD protocols

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Environment, design and layout

• Designated decontamination area
• Identified one way flow for equipment
• Separation of dirty, clean and storage areas
• Adequate ventilation and extraction
• Double sink for manual cleaning
• Designated hand washing basin

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Safety

• Risk assessments
• Drying cabinets
• Out of hours
• Pre-cleaning of scopes
• COSHH HS
• PPE
• Spillage policy
• Automated processes are used at all times

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Workforce Training

• Appropriate personnel
• Evidence of up to date training and revalidation
• Training of test person(s)
• Training to carry out HTM testing

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Maintenance, Testing Validation

• Evidence of planned and unplanned maintenance,
  period tests and action plans
• Assessed by AE(D)

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Automatic Endoscope Reprocessor (AER)

• Is your AER compliant?
• Responsibility for the AER has been given to the
  Authorised Engineer (D)
• AER Certificate of compliance

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JAG Accreditation

• Full Accreditation 5 years
• Deferred Accreditation - within 3 months
• Adherence to processes practices but AER not
  compliant
• Commitment to purchase full accreditation
  informal re-visit
• If not achieved, JAG Accreditation will be
  withdrawn
• Poor decontamination practices
• Improvements to be made within 3 months formal
  re-visit
• New builds ie. Centralised units
• Re-visit to assess processes
• Fail
• If patient safety is compromised, and the
  assessors judge that patients are at significant
  risk of immediate and serious harm that cannot be
  rapidly rectified

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Future

• NHS Supply Chain commissioned by DH to produce a
  National Service Framework for AERs due out
  March 2009
• Quality Care Commission
• Liaison between JAG and QCC
• HTM-01-06 due out April 2009
• covers all aspects of decontamination
• new decontamination accreditation group to audit
  endoscope decontamination

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