Transcript A high Performing Unit

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
 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
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
1 month
QA of report and process
Feedback
and report
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 Lead
SHA Lead
Nurse Lead
Lead for visit
Training
Finalisation of Report
GRS validation
Waiting list validation
Workforce
Decontamination
Environment
Unit Team Roles and Responsibilities
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Agree date for visit
Raise awareness
Read guidelines
Review website
Prepare folders of evidence
Upload evidence through one
point
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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
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
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
 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
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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
Entrance/Exit (outpatients/inpatients)
Decontamination
Preprocedure
Endoscope Store
Endo 1
Endo 2
Peri Procedure
Post
procedure
Kitchen
Sister’s Office
Reception
Nurses
Station
Recovery
(7beds)
Seated
Recovery
Store
Staff room
Waiting area
Pre & Post
(patients & relatives)
Wheelchair
w/c
Unused w/c
w/c
Unused Entrance/Exit
Physiology
room
Entrance/Exit (outpatients/inpatients)
Decontamination
Preprocedure
Endoscope Store
Endo 1
Endo 2
Peri Procedure
Post
procedure
Kitchen
Sister’s Office
Reception
Nurses
Station
Recovery
(7beds)
No prep room
No P&D room
Lack of toilets
Staff transferring food through
patient areas
Seated
Recovery
Store
Staff room
Waiting area
Pre & Post
(patients & relatives)
Wheelchair
w/c
Unused w/c
w/c
Unused Entrance/Exit
Physiology
room
Decontamination
Preprocedure
Inpatients
Store
Endo 1
Endo 2
Peri Procedure
Post
procedure
Store
Sister’s Office
Staff Room
Nurses
Station
Recovery
Seated
Recovery
Private room
Sub-wait
Admit / consult
Admit / consult
D/C
lounge
(non-gowned pts)
General waiting area
Reception / bookings
office
w/c
PrepW/C
Prep
W/C
Outpatient Entrance / Exit
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 visit
Timeliness & Sustainability
Have you hit the
target?
N
When will you
get there?
Y
Can you stay
there?
What have you put in place
to make this happen ?
Timeliness Sustainability
System &
processes
Policy &
procedures
Workforce
If….
.
Data
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
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
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)
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
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
Decontamination
Recovery
Endoscopy Room
Admit
Endoscopy Staffing levels
Decontamination
Recovery
Endoscopy Room
+
Admit
Named Nursing
Decontamination
Recovery
+
Endoscopy Room
Admit
Admit
Endoscopy Skill Mix
Decontamination
HCA
Recovery
RN & HCA
Min. of 2
RNs in
recovery
Endoscopy Room
+
RN &
HCA
RN
Admit
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
END2
END3
END4
END5
GEN6
END7
END8
END9
END10
END11
END12
END13
END14
END15
END16
END17
END18
END19
END20
END21
CHS3
Communicate and relate to individuals during endoscopic procedures
Provide information on endoscopic procedures to individuals
Refer individuals for endoscopic procedures
Schedule endoscopic procedures for individuals
Agree endoscopic procedures for individuals
Prepare the delivery of endoscopic procedures
Prepare individuals for endoscopic procedures
Position individuals during endoscopic procedures
Assist colleagues during endoscopic procedures
Administer sedation and analgesia to individuals during endoscopic procedures
Assess and optimise the condition of individuals during endoscopic procedures
Perform diagnostic and therapeutic endoscopic procedures
Identify signs of abnormality revealed by endoscopic procedures
Collect specimens through the use of endoscopic procedures
Manage polyps through the use of endoscopic procedures
Manage strictures through the use of endoscopic procedures
Manage haemostasis through the use of endoscopic procedures
Review the results of endoscopic procedures
Provide reports on endoscopic procedures
Provide care for individuals recovering after endoscopic procedures
Reprocess endoscopy equipment
Administration of medicines
Technical Support
END1
END2
END3
END4
END5
GEN6
END7
END8
END9
END10
END11
END12
END13
END14
END15
END16
END17
END18
END19
END20
END21
CHS3
Communicate and relate to individuals during endoscopic procedures
Provide information on endoscopic procedures to individuals
Refer individuals for endoscopic procedures
Schedule endoscopic procedures for individuals
Agree endoscopic procedures for individuals
Prepare the delivery of endoscopic procedures
Prepare individuals for endoscopic procedures
Position individuals during endoscopic procedures
Assist colleagues during endoscopic procedures
Administer sedation and analgesia to individuals during endoscopic procedures
Assess and optimise the condition of individuals during endoscopic procedures
Perform diagnostic and therapeutic endoscopic procedures
Identify signs of abnormality revealed by endoscopic procedures
Collect specimens through the use of endoscopic procedures
Manage polyps through the use of endoscopic procedures
Manage strictures through the use of endoscopic procedures
Manage haemostasis through the use of endoscopic procedures
Review the results of endoscopic procedures
Provide reports on endoscopic procedures
Provide care for individuals recovering after endoscopic procedures
Reprocess endoscopy equipment
Administration of medicines
Endoscopy Nursing Staff
END1
END2
END3
END4
END5
GEN6
END7
END8
END9
END10
END11
END12
END13
END14
END15
END16
END17
END18
END19
END20
END21
CHS3
Communicate and relate to individuals during endoscopic procedures
Provide information on endoscopic procedures to individuals
Refer individuals for endoscopic procedures
Schedule endoscopic procedures for individuals
Agree endoscopic procedures for individuals
Prepare the delivery of endoscopic procedures
Prepare individuals for endoscopic procedures
Position individuals during endoscopic procedures
Assist colleagues during endoscopic procedures
Administer sedation and analgesia to individuals during endoscopic procedures
Assess and optimise the condition of individuals during endoscopic procedures
Perform diagnostic and therapeutic endoscopic procedures
Identify signs of abnormality revealed by endoscopic procedures
Collect specimens through the use of endoscopic procedures
Manage polyps through the use of endoscopic procedures
Manage strictures through the use of endoscopic procedures
Manage haemostasis through the use of endoscopic procedures
Review the results of endoscopic procedures
Provide reports on endoscopic procedures
Provide care for individuals recovering after endoscopic procedures
Reprocess endoscopy equipment
Administration of medicines
Endoscopists
END1
END2
END3
END4
END5
GEN6
END7
END8
END9
END10
END11
END12
END13
END14
END15
END16
END17
END18
END19
END20
END21
CHS3
Communicate and relate to individuals during endoscopic procedures
Provide information on endoscopic procedures to individuals
Refer individuals for endoscopic procedures
Schedule endoscopic procedures for individuals
Agree endoscopic procedures for individuals
Prepare the delivery of endoscopic procedures
Prepare individuals for endoscopic procedures
Position individuals during endoscopic procedures
Assist colleagues during endoscopic procedures
Administer sedation and analgesia to individuals during endoscopic procedures
Assess and optimise the condition of individuals during endoscopic procedures
Perform diagnostic and therapeutic endoscopic procedures
Identify signs of abnormality revealed by endoscopic procedures
Collect specimens through the use of endoscopic procedures
Manage polyps through the use of endoscopic procedures
Manage strictures through the use of endoscopic procedures
Manage haemostasis through the use of endoscopic procedures
Review the results of endoscopic procedures
Provide reports on endoscopic procedures
Provide care for individuals recovering after endoscopic procedures
Reprocess endoscopy equipment
Administration of medicines
Competences for Endoscopy Nurses
END1
END2
END4
GEN6
END7
END8
END9
END11
END20
END21
CHS3
Communicate and relate to individuals during
endoscopic procedures
Provide information on endoscopic procedures
to individuals
Schedule endoscopic procedures for individuals
Prepare the delivery of endoscopic procedures
Prepare individuals for endoscopic procedures
Position individuals during endoscopic
procedures
Assist colleagues during endoscopic procedure
Assess and optimise the condition of individuals
during endoscopic procedures
Provide care for individuals recovering after
endoscopic procedures
Reprocess endoscopy equipment
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 Scale
1.
2.
3.
4.
5.
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
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
1
2
3
• September to November
• December to February
• March to May
GIN Programme Training Pathway
Endoscopy Unit
Nominate Local Facilitator
GIN
Facilitators
Course
TNT
Course
Evaluation
Locality GIN
Course
Programme Structure
6 TNT
Teams
GIN Training Teams
Training &
Nurse Lead
5
5
5
5
5
2
5
2
5
5
5
5
5
5
Cluster
Units
5
5
5
3
5
1
5
5
5
5
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 Visit
Assessment & Validation:
• GRS scores
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–
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Clinical Quality
Patient Experience
Training
Workforce
• Environment & Safety – Unit tour
– Patient flows
– Privacy & Dignity
– Decontamination
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Problem Areas For Units
TOP 1O AREAS REQUIRING IMPROVEMENT
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9
8
7
6
5
4
3
2
1
0
• 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
Endoscope Decontamination 2009
Most common question…
• Where have these new guidelines come from?
Influences on endoscope
1994: An decontamination
endoscope cleaning room
practice
should have ‘dirty’ area and a
1988
2007
separate
clean1996
area….a sink 2004
unit with
two sinks and a double drainer’
HIV
vCJD
HBN 52 - Accommodation
for Day Care Endoscopy
Unit
Hine Report
Decontamination
Standards for
flexible
endoscopes
1988
HIV
Influences on endoscope
decontamination practice
1997: A technical guide detailing
requirements
for Design;
Operation;
1996
2004
2007
and testing of WDs
HTM2030
Washer Disinfectors
vCJD
Hine Report
Decontamination
Standards for
flexible
endoscopes
1988
HIV
Influences
on endoscope
2002:
..suitable environment,
with
decontamination
practice
validated automated processes,
managed
and
operated
by
trained
1996
2004
2007
staff….separate sinks for washing and
rinsing.
vCJD
Infection control in theHine
builtReport
environment NHS
Estates
Decontamination
Standards for
flexible
endoscopes
1988
HIV
Influences on endoscope
decontamination practice
2003: ‘Clean’ and ‘dirty’ equipment
1996
2004
2007
and processes should be
segregated….. Instruments should be
vCJD
tracked to patients..
of Health
Hine Department
Report
Decontamination
Standards for
flexible
endoscopes
1988
HIV
Influences on endoscope
decontamination practice
2006: There is a monitoring system in
2007
place 1996
to ensure that2004
decontamination
processes are fit for purpose and meet
thevCJD
required standard.
Health Act
Hine Report
Decontamination
Standards for
flexible
endoscopes
Influences on endoscope
decontamination practice
1988
HIV
1996
vCJD
2004
Hine Report
2007
JAG
Accreditation
Decontamination
Standards for
flexible
endoscopes
Over 20 documents relating to endoscope decontamination
Influences on endoscope
decontamination practice
1988
HIV
1996
vCJD
Too many
2004 documents2007
Not accessible
Not user friendly
Unit
Hinedesign
Reportref. 14 years old
JAG
Minimal support Accreditation
Decontamination
Majority
of
Standards units
for
endoscopy
flexible
still
non-compliant
endoscopes
Influences on endoscope
decontamination practice
1988
HIV
1996
vCJD
2004
Hine Report
2007
JAG
Accreditation
Decontamination
Standards for Flexible
Endoscopes
Decontamination Standards for Flexible
Endoscopes
Systems &
Processes
Workforce &
Training
Decontamination
Environment &
Equipment
Policy &
Procedures
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 revisit
• 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