JAG Accreditation outline of the process 1

Standards and measures against which centres are assessed 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 2

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” 4

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

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

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 7

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 8

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

New online system

Checklist to complete

GRS Measures Evidence Required Upload your Evidence Communicate with Assessors

Use the comments field to communicate with JAG 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

The Main Event Refer to the JAG preparation Guidance 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

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

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 19 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 20 20

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

Entrance/Exit (outpatients/inpatients) Decontamination Kitchen Reception Endoscope Store Endo 2 Sister’s Office Store Staff room Wheelchair w/c Physiology room Unused w/c Unused Entrance/Exit Pre- procedure Peri - Procedure Post 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)

Outpatient Entrance / Exit Decontamination Inpatients Pre- procedure Store Endo 1 Endo 2 Peri - Procedure Post procedure 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 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

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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 visit

What have you put in place to make this happen ? 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 ?

Timeliness Sustainability If…..

These should be understood 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

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

This operational policy effectively covers all the key requirements.

Validation Further Examples are available on your CD and the KMS

How this is done in practice ? Pooling How this is done in practice ?

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

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

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

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

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

They should have the same opportunities as other staff in 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

There are many different models of working that 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 44

Questions?

Workforce 47

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 48

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. 49

Endoscopy Staffing levels Decontamination Recovery Endoscopy Room Admit 50

Endoscopy Staffing levels Decontamination Recovery + Endoscopy Room Admit 51

Named Nursing + Endoscopy Room Admit Decontamination Recovery Admit 52

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

Staffing Levels (draft) Staff required Extra Recovery Nurse Unit Manager WTE required Plus Leave Loading One Room 5 1 7 15-22% Two Rooms 10 (5 x 2) 12 Three Rooms 15 (5 x 3) 16 Four Rooms 20 (5 x 4) 1 (HCA) 22 Based on running 10 sessions per room. If less, may need less. Need more if doing on-call, high proportion of therapeutic lists, lists outside the unit, 3 shift patterns etc. 54 54

Skill Mix (draft) Plus Leave Loading 15 – 22% One Room Two Rooms Three Rooms Four Rooms 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 55

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 56

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 57

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 An illustration of all 21 documents within the Endoscopy Competence Framework. The content of each document follows the same format and can be viewed online through www.skillsforhealth.org 58

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 An illustration of all 21 documents within the Endoscopy Competence Framework. The content of each document follows the same format and can be viewed online through www.skillsforhealth.org 59

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 An illustration of all 21 documents within the Endoscopy Competence Framework. The content of each document follows the same format and can be viewed online through www.skillsforhealth.org 60

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 An illustration of all 21 documents within the Endoscopy Competence Framework. The content of each document follows the same format and can be viewed online through www.skillsforhealth.org 61

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 62

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 63

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 Most important part of the document – details what you will be assessed against. 64

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 65

Competency Assessment Scale Minimal knowledge and understanding about how the competence relates to practice Needs supervision to effectively carry out the range of skills within the competence Performs some skills within the competence effectively without supervision Confident of knowledge and ability to perform all the identified skills within the competence effectively Can facilitate the knowledge and understanding of other professionals on the skills within the competence This assessment model is based on the one used by the Open University originally published by Bondy. Stage four is the accepted level of competence. The fifth stage exists for post registration students working at degree rather than diploma level. This was created to allow universities and further education bodies to identify a difference between students working toward a diploma and those working toward a degree. The higher level includes the addition of teaching skills – an accepted role of registered nurses – and evidence should demonstrate their ability to impart knowledge and skills to others. 66

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. 67

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 68

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

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

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

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 72

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

www.jets.nhs.uk/gin 74

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Understanding the Standards Decontamination Understanding the Standards 89 89

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

Problem Areas For Units 91 91

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 92 92

Endoscope Decontamination 2009 93 93

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

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 Decontamination Standards for flexible endoscopes 95 95

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 Decontamination Standards for flexible endoscopes 96 96

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 Decontamination Standards for flexible endoscopes 97 97

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 Decontamination Standards for flexible endoscopes 98 98

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 Decontamination Standards for flexible endoscopes 99 99

Influences on endoscope decontamination practice 1988 1996 2004 2007 HIV vCJD Hine Report JAG Accreditation Decontamination Standards for flexible endoscopes Over 20 documents relating to endoscope decontamination 100 100

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 Decontamination Standards for flexible endoscopes 101 101

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

Decontamination Standards for Flexible Endoscopes Workforce & Training Systems & Processes Decontamination Environment & Equipment Policy & Procedures 103

What do you need to do to pass? 104

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

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 106

Safety Risk assessments PPE Spillage policy Drying cabinets Out of hours Pre-cleaning of scopes COSHH & H&S PPE Spillage policy Automated processes are used at all times 107

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

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

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

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 Decontamination design suggestions for shared room and segregated dirty and clean refer to Health Protection Scotland 2007 (reference list) 111 111

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 112

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