Following the COVID-19 pandemic, the assessment pathway has been modified to:
- Ensure the safety of patients, staff and assessors
- Recognise that some hospitals are restricting non-essential visitors to hospitals
- Reduce the burden on services, many of whom have been significantly affected by COVID-19
This article contains a summary of the changes and is aimed at endoscopy services that would like to book an assessment or that are completing their annual review. We will continually update this where necessary to maintain the quality of assessments and to keep in line with government advice.
Tolerances have been applied to certain areas where services have been unable to maintain standards due to the impact of COVID-19 and where quality and safety has been maintained. These include:
- Evidence - evidence should ideally be up to date and within 12 months of the assessment. Some tolerance can be shown if assessments have been delayed due to COVID-19 and some evidence falls outside the 12-month timeline by up to 2 months.
- Waiting times - tolerance will be given where services can provide a detailed recovery plan (up to 12 months). Progress against this will be reviewed at the next annual review.
- Clinical audit - tolerance will be given where there is an alternative approach to EUG presentation and sign-off, and where every effort has been made to continue with safety KPIs. No tolerance will be given where there are low numbers not impacted by COVID-19 or where quality or safety has been compromised.
- Environment - Local infection prevention and control protocols must be in place and a general IPC audit form the local hospital team. Environment plans and building works may be impacted by COVID-19. Tolerance will be given where the environment has been modified and privacy and dignity has been maintained (this includes maintaining gender segregation in England).
- Decontamination - The IHEEM audit should be completed and signed off by an IHEEM registered AED. We are currently speaking to IHEEM about remote IHEEM assessments and will communicate this once this has been agreed; until then, if services cannot have an IHEEM assessment in time then they should provide details of when their assessment is booked for and give evidence that any amber or red measures in their last audit have been resolved.
- Training (workforce) - tolerance will be given where COVID-19 has impacted access to training. Services should provide a plan to improve access to training.
- Training (endoscopist training) - Many services are operating all lists as training lists as capacity is limited. Assessors will be flexible towards different approaches to this. There should be a plan to improve access to training and alternatives offered.
A standard assessment team will be organised including a medical, nurse, management (for acute services) and lay assessor. The lay assessor and one other assessor will not attend your site assessment and will undertake the assessment and interviews remotely.
Your lead assessor will notify you 6 weeks before the site assessment to clarify who will not be in attendance.
Assessors will wear PPE in line with government and hospital guidelines, but won't be tested for COVID-19. Assessors will self-screen before arriving at the service and will check their temperature. They will follow any hospital infection control guidelines and will discuss this with you in advance of the site assessment.
Remote review of evidence
As per our usual process, your evidence will be reviewed remotely by your assessment team in advance of the site assessment. The above tolerances will be applied, however this stage of the assessment will otherwise continue as normal.
The lay assessor would normally interview patients having their procedure on the day of the site assessment. This will now take place via teleconference during or a few days before the site assessment (this can be flexible based on patients’ availability).
Services will be asked to select five patients who have had a range of different procedures eg colonoscopy, flexi-sigmoidoscopy, OGD within the past 3 months.
Your administrator will provide you with a patient information sheet that details the role of JAG and why we would like their feedback. Services should send this to patients when inviting them to be interviewed. Your administrator will then organise the interview.
Your administrator will give you further information on this when you book your assessment.
The technical assessor who does not attend your assessment will interview the relevant staff remotely before or during the site assessment. Your administrator will organise a time for these interviews to take place with both the service and assessor.