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JAG Accreditation JAG Accreditation outline of the process.

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1 JAG Accreditation JAG Accreditation outline 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 Unit contacts JAG office requests visit Unit contacts JAG office requests visit JAG Central Office set up visit on visits website JAG Central Office set up visit on visits website Completion of online questionnaire Minimum 3 months Evidence Upload Evidence Upload Stage 1 Stage 2 JAG confirms assessors/visit details Assessors review online evidence 1 month Feedback and report Formal visit and interviews 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 Training Lead SHA Lead Nurse Lead Lead for visit Training Finalisation of Report GRS validation Waiting list validation Workforce Decontamination Environment

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 system is underpinned by the GRS. This forms the heart of accreditation The JAG Accreditation System

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

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 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 www.grs.nhs.ukwww.thejag.org.uk  Contact us for advice

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19 Environment

20 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

21 Nurses Recovery 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 area Pre & Post (patients & relatives)

22 Nurses Recovery 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 area Pre & Post (patients & relatives) No prep room No P&D room Lack of toilets Staff transferring food through patient areas

23 Decontamination Endo 1 Store Staff Room Store Endo 2 Sister’s Office Nurses Recovery Station Private room Admit / consult Reception / 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

24 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

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

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

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

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29 Timeliness and Sustainability

30 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

31 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

32 Timeliness Sustainability System & processes DataWorkforce Policy & procedures If…..

33 Policy and Procedures Unit Access/Operational Policy/Operating Procedures –E–Endoscopy Classification –R–Referral guidelines (appropriateness) –W–Waiting list management system –V–Vetting practices –S–Surveillance –C–Clerical and clinical validation –G–Guidelines –P–Pooling –S–Scheduling practices These should be understood and actively applied These should be understood and actively applied

34 This section is looked at closely alongside; Booking and Choice Appropriateness Communicating results

35 This operational policy effectively covers all the key requirements.

36 Validation Further Examples are available on your CD and the KMS

37 Pooling How this is done in practice ?

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

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

40 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 “Keeping on top of it is crucial, I take it personally when someone cancels their appointment” Admin Lead-Doncaster and Bassetlaw

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

42 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)

43 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

44 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

45 Questions?

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47 Workforce

48 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

49 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.

50 Endoscopy Staffing levels Endoscopy Room Admit Decontamination Recovery

51 Endoscopy Staffing levels Endoscopy Room Admit Decontamination Recovery +

52 Named Nursing + Endoscopy Room Admit Decontamination Recovery Admit

53 Endoscopy Skill Mix Endoscopy Room Admit Decontamination Recovery RN RN & HCA Min. of 2 RNs in recovery RN & HCA HCA +

54 Staffing Levels (draft) Staff required Extra Recovery Nurse Unit Manager WTE required Plus Leave Loading One Room 511715-22% Two Rooms 10 (5 x 2)1112 Three Rooms 15 (5 x 3)0116 Four Rooms 20 (5 x 4)1 (HCA)122

55 Skill Mix (draft) One RoomTwo RoomsThree RoomsFour Rooms Unit Manager RN x 4RN x 8RN x12RN x 16 HCA x 2HCA x 3HCA x 4HCA x 5 7 WTE12 WTE16 WTE22 WTE Plus Leave Loading 15 – 22% * Mix will depend on local needs

56 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

57 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

58 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

59 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

60 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

61 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

62 Competences for Endoscopy Nurses END1 Communicate and relate to individuals during endoscopic procedures END2Provide information on endoscopic procedures to individuals END4Schedule endoscopic procedures for individuals GEN6Prepare the delivery of endoscopic procedures END7Prepare individuals for endoscopic procedures END8Position individuals during endoscopic procedures END9Assist 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 CHS3Administration medications

63 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

64 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

65 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

66 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

67 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.

68 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

69 Delivery Plan – 3 Waves 1 September to November 2 December to February 3 March to May

70 GIN Programme Training Pathway Endoscopy Unit Nominate Local Facilitator TNT Course GIN Facilitators Course Locality GIN Course Evaluation

71 Programme Structure 1 5 5 5 5 5 2 5 5 5 5 5 3 5 5 5 5 5 2 5 5 5 5 5 Cluster Units GIN Training Teams 6 TNT Teams Training & Nurse Lead

72 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

73 e-Portfolio Electronic evidence folder –Self Assessment –Formative Assessment –Summative Assessment Generates PDP based on structured and standardised performance/assessment criteria Passport of competence

74 www.jets.nhs.uk/gin

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89 Decontamination Understanding the Standards

90 The JAG Visit Assessment & Validation: GRS scores – Clinical Quality – Patient Experience – Training – Workforce Environment & Safety – Unit tour – Patient flows – Privacy & Dignity – Decontamination

91 Problem Areas For Units

92 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

93 Endoscope Decontamination 2009

94 Most common question… Where have these new guidelines come from?

95 Influences on endoscope decontamination practice 1988 1996 2004 2007 vCJD Hine 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

96 Influences on endoscope decontamination practice 1988 1996 2004 2007 vCJD Hine Report HIV Decontamination Standards for flexible endoscopes 1997: A technical guide detailing requirements for Design; Operation; and testing of WDs HTM2030 Washer Disinfectors

97 Influences on endoscope decontamination practice 1988 1996 2004 2007 vCJD Hine 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

98 Influences on endoscope decontamination practice 1988 1996 2004 2007 vCJD Hine 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

99 Influences on endoscope decontamination practice 1988 1996 2004 2007 vCJD Hine 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

100 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

101 Influences on endoscope decontamination practice 1988 1996 2004 2007 vCJD JAG Accreditation Hine Report HIV Decontamination Standards for flexible endoscopes Too many documents Not accessible Not user friendly Unit design ref. 14 years old Minimal support Majority of endoscopy units still non-compliant

102 Influences on endoscope decontamination practice 1988 1996 2004 2007 vCJD JAG Accreditation Hine Report HIV Decontamination Standards for Flexible Endoscopes

103 S ystems & Processes E nvironment & E quipment W orkforce & Training P olicy & Procedures Decontamination

104 What do you need to do to pass?

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

106 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

107 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

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

109 Maintenance, Testing & Validation Evidence of planned and unplanned maintenance, period tests and action plans Assessed by AE(D)

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

111 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

112 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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