JAG recognises that many services use a centralised decontamination service (for example one which is on site but not necessarily within the endoscopy unit footprint or management structure) or a remote decontamination service (for example where endoscopes are sent off site to be decontaminated).
Both of these models are acceptable and fulfil the requirements for JAG accreditation.
The decontamination service should provide the JAG/IHEEM decontamination audit which has been undertaken within a year of the JAG visit (available through the assessment dashboard on the JAG accreditation website). Any areas which require action should have been met or have a clear, time agreed action plan to address them.
Decontamination policy and processes should be demonstrated to meet JAG standards (for example the same as if decontamination was being undertaken within the endoscopy service).
Staff should have the appropriate skills and competencies for decontamination, in line with HTM 01-06. This should include all staff roles, for example staff who undertake bedside cleaning and tracking within the unit, and staff who undertake decontamination within the centralised unit.
Where endoscopes are decontaminated from areas other than endoscopy (for example theatres or outpatients), the processes, record keeping, traceability, and training should be equal to that of endoscopy (for example, a endoscope from theatres can be shown that it is traced). The endoscope should be processed the same as when used in endoscopy, and staff should have the appropriate training and competencies at each step of the endoscope journey.
Decontamination services provided by an outside provider, which is not part of the parent organisation, should have the following:
- a clear contract identifying a service level agreement between the two organisations, in line with HTM 01-06 requirements
- leadership for decontamination services, linking directly to the point of delivery for the endoscopes
- an agreement to undertake the required audits for JAG
- external review of decontamination by ISO certification and an IHEEM report carried out by an AE(D)
- clear policies, protocols and training for staff involved in the endoscope journey
- at the accreditation assessment JAG would expect to see safe and contemporary practices within the endoscopy service from the point at which the endoscope enters the organisation to when it leaves it.