JAG Accreditation JAG Accreditation outline of the process.
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JAG AccreditationJAG Accreditationoutline of the process
Purpose of the visit To enable the centre to be accredited/re-accredited Accreditation for Bowel Cancer Screening
Standards and measures against which centres are assessed High quality training Safe and effective care for patients
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 <9 weeks(level A for timeliness) Surveillance lists must be up to date
The visit includes an assessment of the environment, decontamination facilities and processes
JAG Visits
“Should be seen as supportive and educational opportunity to assist you in providing the highest standards in patient care and training”
The visit process- timeframe
Unit contactsJAG office requests visit
Unit contactsJAG office requests visit
JAG Central Office set up visiton visits website
JAG Central Office set up visiton visits website
Completion of online questionnaire
Completion of online questionnaire
Minimum 3 months
Evidence
Upload
Evidence
Upload
Stage 1
Stage 2
JAG confirms assessors/visit details
JAG confirms assessors/visit details
Assessors review online evidenceAssessors review online evidence
1 month
Feedback and reportFeedback and report
Formal visit and interviews Formal visit and interviews
QA of report and processQA of report and process
Readiness Thinking about your own units how JAG ready do you
think you are and what are your challenges?
JAG Team Roles and Responsibilities
Training LeadTraining Lead
SHA LeadSHA Lead
Nurse LeadNurse Lead
Lead for visitTrainingFinalisation of Report
GRS validationWaiting list validation
WorkforceDecontaminationEnvironment
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
Refer to the JAG guidance for visits in your resource pack
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
The JAG Accreditation System
New online system
Checklist to complete
GRS Measures Evidence Required
Upload your Evidence
Communicate with Assessors
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
Use the comments field to communicate with JAG assessors
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
The Main Event
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
it’s a supportive process
We want you to pass
it’s a supportive process
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
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
Environment
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
NursesRecovery Station (7beds)
Endo 1
Entrance/Exit (outpatients/inpatients)
Seated Recovery
Decontamination
Kitchen
Reception
Endoscope Store
Endo 2
Sister’s Office
Store
Staff room
Wheelchair w/c Physiology
room
w/c Unused w/c Unused Entrance/Exit
Pre- procedure
Peri - Procedure
Post procedure
Waiting areaPre & Post (patients & relatives)
NursesRecovery Station (7beds)
Endo 1
Entrance/Exit (outpatients/inpatients)
Seated Recovery
Decontamination
Kitchen
Reception
Endoscope Store
Endo 2
Sister’s Office
Store
Staff room
Wheelchair w/c Physiology
room
w/c Unused w/c Unused Entrance/Exit
Pre- procedure
Peri - Procedure
Post procedure
Waiting areaPre & Post (patients & relatives)
No prep roomNo P&D roomLack of toiletsStaff transferring food through patient areas
Decontamination
Endo 1
Store
Staff Room
Store
Endo 2
Sister’s Office
NursesRecovery Station
Private room
Admit / consult
Admit / consultReception / bookings office
w/c Prep W/C
PrepW/C
D/C lounge
Sub-wait(non-gowned pts)
General waiting area
Outpatient Entrance / Exit
Pre- procedure
Peri - Procedure
Post procedure
Seated Recovery
Inpatients
Assess your own unit
• Walk through the unit as a team• See it through the patient’s eyes• Recruit someone from outside the unit to gain a
fresh perspective
Reduces Anxiety
• Dedicated waiting area• Noise levels • Adequate toilets• De-clutter unit
Privacy & Dignity
• Private admission/consent process• Dedicated bowel preparation room• Sub-wait area• Ability to give feedback of results confidentially• Decor
Safety
• Appropriately sized recovery area • Monitoring equipment• Size of rooms• Hazards eg cables / water / fixtures• Decontamination• Use of obsolete equipment
Timeliness and Sustainability
JAG Criteria for Waiting Times
Waiting times for all procedures must be <9 weeks
Surveillance/planned programmes must be up to date
Achieved at least 3 months before the visitAchieved at least 3 months before the visit
Have you hit the target?
Can you stay there?
Y
When will you get there?
N
What have you put in place to make this happen ?
Timeliness & Sustainability
Timeliness Sustainability
System & processes
Workforce
Policy & procedures
DataIf…..
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
These should be understood and actively applied
This section is looked at closely alongside;
• Booking and Choice
• Appropriateness
• Communicating results
This operational policy effectively covers all the key requirements.
This operational policy effectively covers all the key requirements.
Validation
Further Examples are available on your CD and the KMS
PoolingHow this is done in practice
?How this is done in practice
?
Ensure that your data reflects your true position
Ensure that your data reflects your true position
Every organisation has a system
Diagnostic Returns
Trust to provide as supporting evidence (reported to the DH)
It does not cover everything (surveillance and other tests)
Trust + 9 Weeks + EndoscopyMeeting structure - Trust Performance- Local unit level
Weekly capacity review meetingsScheduler/planner roleIndividual responsibilities
“Keeping on top of it is crucial, I take it personally when someone cancels their appointment”
Admin Lead-Doncaster and Bassetlaw
“Keeping on top of it is crucial, I take it personally when someone cancels their appointment”
Admin Lead-Doncaster and Bassetlaw
Ensure the assessors are getting the real picture
Waiting List Data
This includes patients who have chosen to wait beyond their dues date
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
Endoscopy Primary Targeted List (PTL)
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
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
• Questions?
Workforce
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
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.
Endoscopy Staffing levels
Endoscopy Room
Admit
Decontamination
Recovery
Endoscopy Staffing levels
Endoscopy Room
Admit
Decontamination
Recovery
+
Named Nursing
+ Endoscopy Room
Admit
Decontamination
Recovery
Admit
Endoscopy Skill Mix
Endoscopy Room
Admit
Decontamination
Recovery
RN
RN & HCAMin. of 2 RNs in
recovery
RN & HCA
HCA
+
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
Three Rooms
15 (5 x 3) 0 1 16
Four Rooms
20 (5 x 4) 1 (HCA) 1 22
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%
* Mix will depend on local needs
Workforce Domain• Adequate staffing levels and skill mix• Training and development• Structured assessment - Endoscopy
Competence Framework• Appraisal and PDP’s• Staff are involved in planning and managing the
service• Recognition and reward
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
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
END20 Provide care for individuals recovering after endoscopic procedures
END21 Reprocess endoscopy equipment
CHS3 Administration of medicines
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
END20 Provide care for individuals recovering after endoscopic procedures
END21 Reprocess endoscopy equipment
CHS3 Administration of medicines
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
END20 Provide care for individuals recovering after endoscopic procedures
END21 Reprocess endoscopy equipment
CHS3 Administration of medicines
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
END20 Provide care for individuals recovering after endoscopic procedures
END21 Reprocess endoscopy equipment
CHS3 Administration of medicines
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
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
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
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
Competency Assessment Scale1. 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
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.
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
Delivery Plan – 3 Waves
GIN Programme Training Pathway
Endoscopy Unit
Nominate Local Facilitator
TNT Course
GIN Facilitators
Course
Locality GIN Course
Evaluation
Programme Structure
15
5
5
5
5
25
5
5
5
5
35
5
5
5
5
25
5
5
5
5
Cluster Units
GIN Training Teams
6 TNT Teams
Training &Nurse Lead
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
e-Portfolio
• Electronic evidence folder– Self Assessment– Formative Assessment– Summative Assessment
• Generates PDP based on structured and standardised performance/assessment criteria
• Passport of competence
www.jets.nhs.uk/gin
Decontamination
Understanding the Standards
The JAG VisitAssessment & Validation:
• GRS scores– Clinical Quality– Patient Experience– Training – Workforce
• Environment & Safety – Unit tour– Patient flows – Privacy & Dignity – Decontamination
Problem Areas For UnitsTOP 1O AREAS REQUIRING IMPROVEMENT
0
1
2
3
4
5
6
7
8
9
10
DECONTA
MIN
ATION
UNIT D
ESIGN
QUALI
TY OF
PROCEDURE
CLINIC
AL QUALIT
Y
ENVIRONM
ENT & T
RAININ
G
SAFETY
ASSESSMENT &
APPRAIS
AL
COM
FORT
PRIVACY &
DIG
NITY
EDUCATIONAL
MATERIA
LS
Endoscope Decontamination 2009
Most common question…
• Where have these new guidelines come from?
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJDHine Report
HIV
Decontamination Standards for flexible endoscopes
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
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJDHine Report
HIV
Decontamination Standards for flexible endoscopes
1997: A technical guide detailing requirements for Design; Operation; and testing of WDsHTM2030 Washer Disinfectors
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJDHine Report
HIV
Decontamination Standards for flexible endoscopes
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
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJDHine Report
HIV
Decontamination Standards for flexible endoscopes
2003: ‘Clean’ and ‘dirty’ equipment and processes should be segregated….. Instruments should be tracked to patients.. Department of Health
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJDHine Report
HIV
Decontamination Standards for flexible endoscopes
2006: There is a monitoring system in place to ensure that decontamination processes are fit for purpose and meet the required standard. Health Act
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJD
JAG Accreditation
Hine Report
HIV
Decontamination Standards for flexible endoscopes
Over 20 documents relating to endoscope decontamination
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJD
JAG Accreditation
Hine Report
HIV
Decontamination Standards for flexible endoscopes
Too many documentsNot accessibleNot user friendlyUnit design ref. 14 years oldMinimal support
Majority of endoscopy unitsstill non-compliant
Influences on endoscope decontamination practice
1988 1996 2004 2007
vCJD
JAG Accreditation
Hine Report
HIV
Decontamination Standards for Flexible Endoscopes
Decontamination Standards for Flexible Endoscopes
Systems & Processes
Environment & Equipment
Workforce & Training
Policy & Procedures
Decontamination
What do you need to do to pass?
Operational management
• Decontamination lead at executive level• Local decontamination operational policy• Robust tracking system• Out of hours protocol for decontamination• vCJD protocols
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
Safety• Risk assessments
– Drying cabinets– Out of hours– Pre-cleaning of scopes– COSHH & H&S
• PPE• Spillage policy • Automated processes are used at all times
Workforce & Training
• Appropriate personnel • Evidence of up to date training and
revalidation• Training of test person(s)
– Training to carry out HTM testing
Maintenance, Testing & Validation
• Evidence of planned and unplanned maintenance, period tests and action plans
• Assessed by AE(D)
Automatic Endoscope Reprocessor (AER)
• Is your AER compliant?• Responsibility for the AER has been given to
the Authorised Engineer (D)• AER Certificate of compliance
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
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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