A service should declare the activity they undertake prior to an assessment so that the assessment team can consider this during the assessment. Accreditation would then be granted for these activities.
In scope
The following services/procedures fall under the scope of JAG accreditation. They could be undertaken in the main endoscopy unit or in another facility within the organisation, unless otherwise noted. All procedures in scope should be recorded on ERS and uploaded to NED or national equivalent.
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GI diagnostic, surveillance and therapeutic procedures
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- The service must be performing regular activity at a minimum of two lists per week. Activity should meet the minimum BSG requirements for the number of procedures performed by individual endoscopists. For individual endoscopist KPIs, whole practice data should be available and considered.
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GA and/or propofol supported lists
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- Also included in JAG accreditation if performed outside of the endoscopy unit, for example in main theatres, in a shared theatre facility or as part of an integrated daycase/treatment centre.
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ERCP / spyglass / EUS / capsule endoscopy
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- Also included in JAG accreditation if performed outside of the endoscopy unit, for example in radiology, and is undertaken or supported by endoscopy and/or radiology staff.
- Not included if undertaken or supported solely by non-endoscopy staff (for example, by radiology staff).
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Oesophageal stents
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- Also included in JAG accreditation if performed outside of the endoscopy unit and endoscopy staff support the procedure by admitting and discharging patients (including if procedure is undertaken by radiology team. JAG would not look at the competencies of the radiology team but would look at the patient pathway). If any part of the admission and discharge process is supported in radiology, then this is reviewed. If the procedure is performed by radiology staff KPIs are not reviewed.
- Not included if undertaken and supported solely by radiology staff outside of the endoscopy unit (this is covered by the ISAS accreditation scheme).
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Transnasal endoscopy (for upper GI investigation only)
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- Also included in JAG accreditation if undertaken by endoscopists and staff outside of the endoscopy unit (for example, outpatients). This should be included within the endoscopy service governance.
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Research
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- Also included in JAG accreditation if it is undertaken in a separate facility and if there is shared governance with the main endoscopy service, or if there are shared patient support or care pathways with the main endoscopy service.
- Some research facilities may also apply for independent accreditation. They must meet the same requirements as a standard service.
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Decontamination facilities
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- Also included in JAG accreditation if decontamination is undertaken off-site or is managed independently of the endoscopy team.
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Other areas out of scope
The following procedures are not assessed or included in JAG accreditation:
- Physiological services (this is accredited by the IQIPS accreditation scheme)
- Bronchoscopy
- Cystoscopy
- Hysteroscopy or colposcopy
The scope of accreditation is agreed at the time of the assessment. If requested by the endoscopy service, the scope of accreditation can be modified outside of the standard assessment process. This would require assessment by JAG and may be done remotely or require a site assessment.