JAG Accreditation JAG Accreditation outline of the process.

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

http://www.grs.nhs.uk/

http://www.thejag.org.uk/

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






















Endoscopy Nursing Staff END1 Communicate and relate to individuals during endoscopic procedures






















Endoscopists END1 Communicate and relate to individuals during endoscopic procedures






















Competences for Endoscopy Nurses END1 Communicate and relate to individuals during

endoscopic procedures






END9 Assist colleagues during endoscopic procedure




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


1988 1996 2004 2007

vCJDHine Report

HIV


1997: A technical guide detailing requirements for Design; Operation; and testing of WDsHTM2030 Washer Disinfectors


1988 1996 2004 2007

vCJDHine Report

HIV


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

vCJDHine Report

HIV


2003: ‘Clean’ and ‘dirty’ equipment and processes should be segregated….. Instruments should be tracked to patients.. Department of Health


1988 1996 2004 2007

vCJDHine Report

HIV


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

vCJD

JAG Accreditation

Hine Report

HIV


Over 20 documents relating to endoscope decontamination


1988 1996 2004 2007

vCJD

JAG Accreditation

Hine Report

HIV


Too many documentsNot accessibleNot user friendlyUnit design ref. 14 years oldMinimal support

Majority of endoscopy unitsstill non-compliant


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

JAG Accreditation JAG Accreditation outline of the process.

Documents

clinical quality quality

process slide

high quality training

patient experience training

effective care

evidence of level b

following domains