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JAG Accreditation –An Overview & Update
Dr John GreenChair Endoscopy Services Quality
Assurance Group
Endoscopy QI Programme Workshop Dublin November 30th 2017
Background• University Hospital Llandough
• ESQAG
• GRS (QI tool)
• JAG Accreditation
• Wales
Global Rating Scale (GRS)
NQAISQI Targets
GRS - Stepwise Quality Improvement
Level A -Aspirational
Level B -target
Assess every measure Y/N
Updated GRSCQ-ClinicalQuality QP-QualityofthePatientExperience
CQ1-LeadershipandOrganisation
CQ2-Safety
CQ3-Comfort
CQ4-Quality
CQ5-Appropriateness
CQ6-Results
QP1-RespectandDignity
QP2-ConsentProcessincludingPatientInformation
QP3-PatientEnvironmentandEquipment
QP4-AccessandBooking
QP5-PlanningandProductivity
QP6-Aftercare
QP7-PatientInvolvement
WR-Workforce TR-Training
WR1-Teamwork
WR2-SkillMixandRecruitment
WR3-ProfessionalDevelopment
TR1-EnvironmentandTrainingOpportunity
andResources
TR2-TrainerAllocationSkills
TR3-Assessmentandappraisal
Accreditation• Level 1 & level 2
• Uploaded evidence
• 5 yearly peer review visit • Lead, technical & lay assessors
• Annual - evaluation
• Aligns to national policy
• No performance management
Provides Assurance
Assesses against agreed
standards
Strengthens Services
Identifies areas for
improvement
Recognisestrengths
Purpose of Accreditation
What does accreditation mean?
JAG Accreditation• Benefits
• Raising standards of endoscopy• Governance & openess• Patients• Staff & Trainees• Profile in hospital
• Main challenges• Waiting times - ↑↑Demand• Physical environment• Training• Workforce gaps• ‘Time’
JAG Survey April 2017
0
10
20
30
40
50
60
70
80
90
England NHS Acute units (n=215) England NHS non-acute units(n=34)
Northern Ireland (n=11) Scotland (n=43) Wales (n=19)
Pe
rce
nta
ge(%
) o
f se
rvic
es
me
eti
ng
nat
ion
al w
aiti
ng
tim
es
Overview of the services across UK meeting National waiting time
Urgent Cancer Urgent Non-Cancer Routine Surveillance
November 2017
1/54
6/25
2/16
9/35
172/250
55/162
JAG Accreditation• No financial lever
• Screening – everywhere 2007
• National Programme
• Lobbied WAG
• Ministerial announcement
• Endoscopy group
• JAG support
What does this process need?
Leadership
Baseline understanding
Time & resourceProject
management
Communication & engagement
Successful servicesActions Questions
Lead, plan, involve the whole team Who is leading? Who is coordinating?
Are clear about their starting point What does your GRS say?
Run it as a project, meticulous organisation will pay off
How will you organise yourselves to be successful?
Develop a communication plan Who needs to know about this?
Have effective meetings What meeting structure do you have?
Gather new knowledge and examples How will you do this?
Conclusions• A personal affinity
• Benefits of accreditation
• Needs• National direction
• Local enthusiasm & time
• Support / facilitation
“Its really hard work getting there but worth every second of it”
Diolch, Thanks, Go raibh maith agaibh!