Accreditation
JAG accreditation provides a framework for the quality improvement and assurance of endoscopy services
General
- My service is accredited, when is the GRS due for submission ?
- How can I upload GRS evidence ?
- How do I register my service for JAG accreditation?
- What are the effects of outsourcing and insourcing on JAG accreditation?
- What are the requirements to register for the JAG scheme?
- Does JAG provide guidance on the number of endoscopes required by an endoscopy service?
Assessment
- Does the service need to be functioning as normal during the assessment?
- How should I complete the census?
- When do I do the GRS or JAG census?
- When will I need to submit the annual review?
- Can mobile units be used for the delivery of bowel scope screening at a JAG accredited site?
- Can we book an assessment if we are having building works?
Clinical quality
- Do endoscopy services need to audit the comfort levels of all patients, or only patients that have been sedated?
- Does JAG expect to see a full audit of a service’s Post Colonoscopy Colorectal Cancer Rates (PCCRC)?
- Does JAG have any guidance on general anaesthetic?
- Is it a requirement for blood pressure to be checked before an endoscopy procedure?
- Is it appropriate for services to send oral bowel preparation and enemas to patients through the post?
- What are JAG's requirements for CO2 monitoring?
Environment
- Can an endoscopy unit be used as an inpatients' facility?
- Can JAG review proposed building layouts and designs for endoscopy services, or provide consultancy?
- Does the gas in the recovery area need to be piped, or will portable gas suffice?
- How often should a procedure room be deep-cleaned?
- Is it mandatory to have doors on the recovery room?
- Is there a policy for the amount of air exchanges per hour and what is the ISO regulation?
Decontamination
- Where can I find the Infection Prevention Society (IPS) audit?
- The decontamination of endoscopes for my service is undertaken off-site. Do I still need to provide an IHEEM report?
- My decontamination facility has just opened - do we need to provide an IHEEM report?
- Should our decontamination lead be accountable to the theatre manager or an executive board member?
- Can my unit be accredited if an external person supports our decontamination team?
- Can Infacol be used through the biopsy channel in an Endogator pump?
Accreditation webtool
- How do I get a login to the JAG website?
- Where can I locate the PPAT?
- Where do we find the assessor comments and how do we respond?
- Criteria TR3.2 - The endoscopy service shall have policies and systems in place to ensure safe and effective supervision of trainees inside and outside of the endoscopy service. What does this mean?
- What is the Factual Accuracy (FA) process and how do I complete it?
- How do I respond to comments on the evidence?
Access and booking
- Can I remove unresponsive surveillance patients from the list?
- Does GRS measure 6.10 refer to sending reports to general practioners?
- Does GRS measure 10.9 include colonoscopy? What if this referral is received on a Friday?
- What is an acceptable level for DNA rates?
- What is the 'within agreed tolerance' option for GRS standards 10.10 and 10.11?
- What is the expected percentage growth in endoscopy procedures each year?
Patient experience
- Is it appropriate to ask patients and endoscopists to sign more than one copy of a consent form?
- Please can you provide some guidance with regards to the GRS measure 13.11?
- Is postal consent a valid form of consent?
- Is postal consent appropriate for EMR patients? If so, do they require medical consent or can a trained nurse confirm this?
- Do we need an active patient panel present at user group meetings?
Workforce
- How much time should clinical leads and training leads be given in their job planning?
- Does JAG mandate staffing levels?
- How does JAG assess staffing in endoscopy services?
- Can nurses draw up intravenous drugs used during endoscopy, or is this the responsibility of the endoscopist?
- What are the required staffing levels in a procedure room?
- Is there a limit to the number of endoscopy lists a non-clinical endoscopist is allowed to perform?