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JAG Accreditation outline of the process

JAG Accreditation outline 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.

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JAG Accreditation outline of the process

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  1. JAG Accreditationoutline of the process

  2. 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

  3. 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

  4. JAG Visits “Should be seen as supportive and educational opportunity to assist you in providing the highest standards in patient care and training”

  5. 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

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

  7. 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

  8. 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

  9. Provides centralised coordinated approach to JAG accreditation A central reference/communication point Provides support tools and information The JAG Accreditation System The system is underpinned by the GRS. This forms the heart of accreditation

  10. New online system

  11. Checklist to complete

  12. GRS Measures Evidence Required Upload your Evidence Communicate with Assessors

  13. 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

  14. 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 The Main Event Refer to the JAG preparation Guidance in your book for final checks

  15. 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

  16. 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

  17. 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

  18. Environment

  19. 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

  20. Entrance/Exit (outpatients/inpatients) Decontamination Pre- procedure Endoscope Store Endo 2 Peri - Procedure Post procedure Kitchen Sister’s Office Reception Store Staff room Wheelchair w/c Physiology room w/c Unused w/c Unused Entrance/Exit Endo 1 Nurses Recovery Station (7beds) Seated Recovery Waiting area Pre & Post (patients & relatives)

  21. Entrance/Exit (outpatients/inpatients) Decontamination Pre- procedure Endoscope Store Endo 2 Peri - Procedure Post procedure Kitchen Sister’s Office Reception Store Staff room Wheelchair w/c Physiology room w/c Unused w/c Unused Entrance/Exit Endo 1 Nurses Recovery Station (7beds) Seated Recovery No prep room No P&D room Lack of toilets Staff transferring food through patient areas Waiting area Pre & Post (patients & relatives)

  22. Pre- procedure Peri - Procedure Post procedure Decontamination Inpatients Store Endo 1 Endo 2 Store Sister’s 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 PrepW/C Prep W/C Outpatient Entrance / Exit

  23. 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

  24. Reduces Anxiety Dedicated waiting area Noise levels Adequate toilets De-clutter unit

  25. Privacy & Dignity Private admission/consent process Dedicated bowel preparation room Sub-wait area Ability to give feedback of results confidentially Decor

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

  27. Timeliness and Sustainability

  28. 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 visit

  29. Timeliness & Sustainability Have you hit the target? N Y When will you get there? Can you stay there? What have you put in place to make this happen ?

  30. Timeliness Sustainability If…..

  31. 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

  32. This section is looked at closely alongside; • Booking and Choice • Appropriateness • Communicating results

  33. This operational policy effectively covers all the key requirements.

  34. Validation Further Examples are available on your CD and the KMS

  35. Pooling How this is done in practice ?

  36. Every organisation has a system Ensure that your data reflects your true position

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

  38. 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

  39. Waiting List Data This includes patients who have chosen to wait beyond their dues date Ensure the assessors are getting the real picture

  40. Endoscopy Primary Targeted List (PTL) • This will be looked at closely on the day of the visit (live system) • Patient Comments need to be up to date • Patients will be explored

  41. 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

  42. Admin Workforce There are many different models of working that will impact upon this • A 2roomed 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)

  43. Questions?

  44. Workforce

  45. 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

  46. 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.

  47. Endoscopy Staffing levels Decontamination Recovery Endoscopy Room Admit

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