Endoscopy Assessment Report. Wishaw General Hospital NHS Lanarkshire

Transcription

1 Endoscopy Assessment Report Wishaw General Hospital NHS Lanarkshire 25 May 2011

2 Healthcare Improvement Scotland is committed to equality. We have assessed the performance assessment function for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Officer on or contactpublicinvolvement.his@nhs.net On 1 April 2011, Healthcare Improvement Scotland took over the responsibilities of NHS Quality Improvement Scotland. Copyright 2011 Healthcare Improvement Scotland First published August 2011 The contents of this document may be copied or reproduced for use within NHSScotland, or for educational, personal or non-commercial research purposes only. Commercial organisations must obtain written permission from Healthcare Improvement Scotland prior to copying or reproducing any part of this document. Information contained in this report has been supplied by NHS boards/nhs organisations, or taken from current NHS board/nhs organisation sources, unless otherwise stated, and is believed to be reliable on publication. 2

3 Contents 1 Setting the scene 4 2 Validation of the Global Rating Scale score 6 3 Overview of local service provision 7 4 Detailed findings against the Global Rating Scale 10 Appendix 1: Glossary of abbreviations 21 Appendix 2: Overview of Global Rating Scale and Joint Advisory Group Accreditation System 22 Appendix 3: Assessment process 23 3

4 1 Setting the scene Healthcare Improvement Scotland was established 1 April The organisation has been created by the Public Services Reform (Scotland) Act 2010 and marks a change in the way the quality of healthcare across Scotland will be supported nationally. Our key purpose is to support healthcare providers in Scotland to deliver high quality, evidence-based, safe, effective and person-centred care; and to scrutinise services to provide public assurance about the quality and safety of that care. We are building on the work previously done by NHS Quality Improvement Scotland and the Care Commission and will work collaboratively with all our partners to achieve our purpose. For further information on Healthcare Improvement Scotland, please visit our website ( Background In July 2008, we were given responsibility to take forward quality improvement of endoscopy services and to implement and roll out a programme of pre-assessment of endoscopy units in NHSScotland with effect from February There are two elements of the work involved in undertaking these assessments: the Global Rating Scale (GRS) and Pre-Joint Advisory Group (JAG) Accreditation System visits. Global Rating Scale The overall performance of endoscopy units is rated using the GRS scoring system. GRS is a web-based self-assessment tool used by endoscopy units to assess how well they provide a patient-centred service for endoscopy procedures. Its principle purpose is to help improve the quality of patient care across a range of measures. In England, the use of GRS has been linked to the successful achievement of formal accreditation of a unit by the JAG. Joint Advisory Group Accreditation System The aim of the pre-jag assessment visit programme is to assess the state of readiness across NHSScotland endoscopy units for formal accreditation through the JAG Accreditation System. On completion of the visit programme, Healthcare Improvement Scotland will recommend for accreditation those units that can demonstrate they are delivering safe, effective and patient centred care within endoscopy services to a high standard. Further information on GRS and JAG is provided in Appendix 2. Pre-JAG assessment visit This report presents the findings from the pre-jag assessment visit to NHS Lanarkshire, Wishaw General Hospital, on 25 May The visiting team consisted of the following: Nicholas Church (Team Leader) Consultant Gastroenterologist, NHS Lothian Wendy Dowdles Senior Charge Nurse, NHS Tayside Brydie Du Pon Endoscopy Service Support Manager, NHS Grampian Norman Gibb Public Partner 4

5 Supported by: Morag Kasmi Programme Manager, Healthcare Improvement Scotland Susan Lowes Project Officer, Healthcare Improvement Scotland Observed by: Elaine Leslie Endoscopy Nurse Practitioner, NHS Grampian Deborah McIntyre Project Officer, Healthcare Improvement Scotland 5

6 2 Validation of the Global Rating Scale score Each endoscopy unit submits its GRS scores every 6 months. The GRS assessment tool makes a series of statements requiring a yes or no answer. From the answers, it automatically calculates the GRS scores, providing a summary of service provision (levels D A). Level D is a minimum acceptable level and Level A is excellent. Units scoring levels B or A are said to deliver commendable quality of care. A JAG checklist is used to validate the GRS scores on the assessment visits. There are occasional variations between the checklist and the GRS self-assessment tool, particularly within the consent, communicating results to referrer, timeliness and ability to provide feedback to the service items. This can result in differences in the unit s self-assessed GRS scores and the validated scores. Where applicable, validation of GRS takes account of standards and targets which apply in NHSScotland, for example Scottish Health Technical Memorandum (SHTM) 2030 in relation to washer disinfectors. The validated results for Wishaw General Hospital are illustrated in Table 1. Table 1: Validated GRS level: Wishaw General Hospital, NHS Lanarkshire Domain Item Validated level Clinical quality Quality of patient experience Workforce Training Consent process including patient information Safety Comfort Quality of procedure Appropriateness Communicating results to referrer Equality of access and equity of provision Timeliness Booking and choice Privacy and dignity Aftercare Ability to provide feedback to the service Skill mix review and recruitment Orientation and training Assessment and appraisal Staff are cared for Staff are listened to Environment and training opportunities Endoscopy trainers Assessment and appraisal Equipment and education material D B D C B D B D A D B A A D C A B D D D B Further information about the assessment process can be found in Appendix 3. 6

7 3 Overview of local service provision NHS Lanarkshire provides endoscopy services within three endoscopy units in Hairmyres Hospital, East Kilbride; Monklands Hospital, Airdrie; and Wishaw General Hospital. Serving a population of 560,000, Wishaw General Hospital performed 9,463 endoscopic procedures last year. The endoscopy service at Wishaw General Hospital is part of the day surgery unit. Procedures undertaken include colonoscopy, flexible sigmoidoscopy, gastroscopy and endoscopic retrograde cholangiopancreatography (ERCP). ERCP is undertaken at a separate location within the hospital. Major strengths The assessment team considers Wishaw General Hospital endoscopy service to have the following major strengths: considerable engagement with the JAG process excellent team working across all specialties positive patient feedback commitment to improvement across all disciplines rapid implementation of changes a significant reduction in did not attend (DNA) rates maintaining waiting times despite increase in demand having an open and transparent service, and developing a training culture. Leadership structure The endoscopy clinical lead and associate nurse director have responsibility for endoscopy services across NHS Lanarkshire. These individuals report directly to the chief executive and NHS Lanarkshire Board through the director of acute services. At a local level there is a nominated clinical lead for each of the three sites. The theatre managers manage nursing staff. Endoscopy unit layout and design The reception and administration facilities in day surgery are adequate. Confidentiality is maintained throughout the patient journey and there are processes in place for patient admission and consent. There are facilities for private patient discussion and admission is undertaken in private adjoining rooms to the main waiting area. Staff reported, at the time of the assessment visit, that overcrowding was common at the beginning of morning lists as competing specialties use the same facilities. In these circumstances, recovery bays are used to ease the flow of patients. Endoscopy appointments are staggered throughout the list to minimise congestion and waiting times for patients. The unit is made up of three endoscopy rooms, which is appropriate for the service. These rooms are a good size for endoscopy procedures, with adequate monitoring, oxygen and suction equipment. Resuscitation equipment is easily accessible and checked on a daily basis. The recovery area is of an adequate size with sufficient bays, seats, monitoring, oxygen and suction equipment for all patients. The assessment team noted that there was only access to one unisex toilet for 12 patients during the recovery stage of their procedure. This toilet 7

8 provision is inadequate. The privacy and dignity of patients is also compromised through parts of the unit. This is discussed in further detail within this report. Processes and facilities are in place for private patient discussion at discharge. The assessment team advises that the unit would benefit from an additional separate room for discharging patients to help ease the volume of patients. The assessment team noted that there was adequate storage throughout the endoscopy unit and that staff wore appropriate personal protective equipment at the time of the assessment visit. Decontamination Wishaw General Hospital has a local decontamination policy in place with guidelines and standard operating procedures for use. However, at the time of the assessment visit, the decontamination facilities were considered inadequate for use. Within the facilities, there is no clear separation of clean and dirty decontamination areas. This creates significant risks of cross-contamination of endoscopes. The unit reported that plans were in place to extend decontamination facilities to accommodate this and architect plans have been drawn up for consideration. The assessment team recommends that this should be progressed as a matter of urgency. The unit needs to urgently review the current process of storing clean endoscopes in the procedure rooms, due to the possibility of aerosol contamination. This is a significant risk to patient safety. An alternative appropriate clean environment must be found as soon as possible, within a maximum of one month and an immediate risk assessment undertaken. The assessment team noted that staff manually clean endoscopes using an Olympus Manual Disinfector trolley system within procedure rooms, prior to processing in the endoscope washer disinfector. This causes a risk of chemical spillages within the procedure room. The assessment team recommends that all cleaning of endoscopes should be undertaken in the decontamination area, in accordance with national guidelines. This has been risk assessed by NHS Lanarkshire. The NHS board reported that once redesign of the decontamination area has been undertaken, these trolleys will no longer be required for manual decontamination of endoscopes. The unit reported that there were insufficient trays to transport endoscopes to the designated decontamination areas. The team recommends the use of a colour coded tray liner system such as used in the cleanascope tray system. There are sinks available in the decontamination areas for the manual cleaning of endoscopes, however these are not used as there are no plugs or fill lines for chemicals. The assessment team suggests replacing plugs and manually cleaning endoscopes within these sinks. The assessment team noted that there was a procedure in place for keeping valves with the endoscope as a unique set. Effective tracking is used in endoscope reprocessing and audit of efficacy has been undertaken. However, the assessment team noted that tracking is currently undertaken using a paper-based system and recommends purchasing an electronic tracker system. At the time of the assessment visit, staff reported that one endoscope washer disinfector was repeatedly out of action. The team recommends consideration of purchasing pass through washers as part of the decontamination reconfiguration exercise. Manual leak testing facilities are available and procedures are in place for scheduling and validation. Procedures are also in place for failed tests. Risk assessments were available for drying cabinets and procedures were in place for out-of-hours decontamination. Disinfectants were also stored and used safely. 8

9 No evidence was presented to support that ventilation and extraction facilities were in place in the decontamination area. However, hand washing facilities are available in the decontamination area and the assessment team witnessed that personal protective equipment was available and used appropriately by staff. There was evidence of decontamination training and validation. Staff in the unit were aware of the processes to record adverse incidents. 9

10 4 Detailed findings against the Global Rating Scale Domain 1: Clinical quality Consent process including patient information Validated level: D The endoscopy unit at Wishaw General Hospital does not have patient information leaflets in place for the full range of endoscopic procedures undertaken. However, those submitted as evidence were comprehensive and written appropriately for patients. These contain contact telephone numbers and review dates. The assessment team noted that leaflets for procedures not yet covered were in development at the time of the assessment visit. NHS Lanarkshire has a patient consent policy and procedures for the withdrawal of patient consent. Furthermore, Wishaw General Hospital endoscopy unit has a localised endoscopy consent policy. The NHS Lanarkshire operational policy details the process in place for obtaining patient consent outside endoscopy treatment rooms. The assessment team encourages the unit to consider nurse-led consent to help increase efficiency. Safety Validated level: B Adverse incidents are recorded on the centralised Datix system and evidence of review and action in the endoscopy unit in response to these was provided. At the time of the assessment visit, British Society of Gastroenterology guidelines were available in hard copy and accessible via computers within the unit. Local policies for anticoagulation, antiplatelet and antibiotic prophylaxis are also in place in the service and are detailed within the unit operational policy. The unit has a local decontamination policy in place and has undertaken a comprehensive decontamination standards audit. An action plan has been developed in response to this audit with responsibilities and appropriate timescales for action assigned. The assessment team further noted that 30-day mortality and non-elective operations data have been collated as the first step in the audit process and encourages continued progression with this, including a robust analysis and action plan. The Information Services Division of NHS National Services Scotland is currently working to provide a national solution to this challenge. This will enable all NHS boards to identify deaths and non-elective admissions following endoscopic procedures. Comfort Validated level: D Patient comfort scores are monitored and recorded during procedures and there are procedures in place within the unit to ensure this is consistently undertaken. Patient satisfactions surveys from October 2010 and April 2011 were submitted as evidence. However, comfort is not consistently addressed in these surveys. The unit is encouraged to ensure it consistently includes questions concerning comfort in all patient satisfaction surveys. The assessment team recommends that surveys are distributed to a minimum of 50 patients to enable valid conclusions to be drawn. Feedback on comfort scores is circulated to endoscopists by . The assessment team would encourage this process to be formalised as a standard item within the endoscopy users 10

11 group. Furthermore, the assessment team recommends that comfort scoring should be presented as part of audit of endoscopy performance indicators. The data should be for a 6- month period and be linked to completion rates and sedation doses. The audit should be a comparative audit including all endoscopists and different procedures should be dealt with separately. The audit presented at the time of the review visit contained only a small number of procedures from each endoscopist and lacked analysis and action planning. The assessment team further noted that a local policy was in place detailing support for endoscopists whose performance indicators do not meet national standards. Quality of procedure Validated level: C At the time of the assessment visit, British Society of Gastroenterology quality indicators were available in the unit. The IT reporting software, Unisoft, is in place in the unit to facilitate audit and the unit has a rolling audit programme in place. However, the assessment team recommends that this audit programme requires further development to include the required GRS audits, individuals responsible and completion timeframes. The assessment team noted that the recent employment of an endoscopy improvement officer will facilitate progress with the audit programme. The assessment team noted that significant data collection has been undertaken within the unit. However, to achieve the JAG standard all audits require analysis of the data and subsequent action plans. Evidence is also required that audit results are discussed within the users group and fed back to individual endoscopists. The assessment team further recommends that the unit links flumazenil usage with the sedation audit. An action plan should be produced to reduce usage, with flumazenil usage discussed in the endoscopy users group. The ERCP audit also needs to be more comprehensive, and in particular, needs to cover the completion rate of intended therapeutic procedures and decompression of obstructed ducts. A policy is also in place within the unit to address poor staff performance. Appropriateness Validated level: B At the time of the assessment visit, the unit had referral guidelines in place for all diagnostic, open access, therapeutic and recall procedures. These have been agreed with representatives from primary care. Pathways for the three common gastrointestinal symptoms and processes have also been agreed. A policy for the vetting of patient referrals has recently been implemented in the unit, which includes auditable outcomes for timeliness and the completeness of vetting. However, the assessment team noted that audit of this has not yet been undertaken. The unit also has up-todate processes for both administrative and clinical validation of surveillance procedures. Communicating results to the referrer Validated level: D Endoscopy reports are completed on the day of the procedure at Wishaw General Hospital and are placed within patient notes in the unit. These reports contain follow-up details and are dispatched to the referrer within 5 working days. The assessment team recommends that the unit standardises the reporting process for communicating results to referrers across specialties, and that this is supported by a written protocol. 11

12 No evidence was submitted to demonstrate that there is a process in place for the management of pathology results for patients showing signs of cancer. The assessment team noted that current practice varies between clinicians. Evidence could not be produced to demonstrate that pathology reports are received and acted upon within 5 working days of receipt of report. The assessment team recommends that the unit develops this paperwork and audits against it. Good examples can be found on the knowledge management system section of the GRS website. Recommendations the unit must: Consistently include questions concerning comfort in all patient satisfaction surveys. Present comfort scores as part of audit of endoscopy performance indicators. Develop the audit programme to include the required GRS audits, individuals responsible and completion timeframes. Analyse audit data and develop subsequent action plans. Standardise the reporting process for communicating results to referrers across the specialties and ensure this is supported by a written protocol. Develop a process for the management of pathology results. 12

13 Domain 2: Clinical quality of patient experience Equality of access and equity of provision Validated level: B NHS Lanarkshire has an up-to-date equality and diversity policy in place. Staff involved in the endoscopy patient pathway have undertaken equality and diversity training within the formal NHS board induction. The assessment team recommends that improved access to a condensed version of this training would be beneficial. Comprehensive demographic and language profiling has been undertaken by the NHS board and information is available in a variety of formats according to the needs of the population. An interpreting service is available and written information is available in the prevalent community languages. However, access to interpreting services is dependent on the information provided on the referral form. The assessment team advises that the unit has access to Language Line or an equivalent service. The use of friends and family members as interpreters is discouraged in the unit and this is detailed in the interpreting policy. Booking procedures also provide equality of access. Timeliness Validated level: D Management of waiting lists and the patient booking process for all endoscopic procedures within NHS Lanarkshire is undertaken by the patient focused booking service at Wishaw General Hospital. The service has a waiting list management system in place. The assessment team noted that, at the time of the assessment visit, an overview was not available to evidence that GRS data correspond with diagnostic returns data. This is due to the recent implementation of TrakCare (electronic patient management system). The unit did not submit a snapshot of surveillance waiting lists. The assessment team acknowledges that this is also due to the recent implementation of TrakCare. There is an informal process in place for effective management of surveillance lists and the unit is commended for managing and delivering surveillance within appropriate timescales. However, staff expressed concerns that the new TrakCare system was not providing current robust and accurate data. The assessment team recommends that the unit standardises management of the surveillance list providing a clear overview across all specialties. The assessment team noted that the unit has an endoscopy list pooling process between consultants and procedures in place for the administrative and clinical validation of waiting lists. The assessment team commends the unit for addressing the issues identified in its demand and capacity audit. Particularly concerning capacity for colorectal screening patients, and note the planned work to reduce the demand in the future. Booking and choice Validated level: A Patient focused booking at Wishaw General Hospital undertakes booking services for the three endoscopy units within NHS Lanarkshire. This is a paper-based scheduling system, which is cumbersome and carries high risk of error. The assessment team noted that the Unisoft scheduling component has been purchased for booking, but is not yet available for use. This should be discussed with the provider as a matter of urgency. 13

14 DNA and cancellation rates are monitored and reported in the service, and action is taken in response to high rates. The assessment team commends the unit for its reduction in DNA rates from 20% to less than 5% as a result of patient focused booking. Privacy and dignity Validated level: D Facilities for private patient discussions are available in the unit for admission and discharge purposes. All patients have their clinical care discussed in private facilities. However, the assessment team advises that the unit would benefit from an additional separate room due to volume of patients. A section on the patients experience of privacy and dignity in the unit was included as part of the patient satisfaction questionnaire, and the unit had also undertaken a privacy and dignity audit. On the whole, the audit demonstrated that patients felt their privacy and dignity was maintained throughout the patient journey. The assessment team commends the unit on the attempts to preserve privacy and dignity and the positive comments regarding this in the feedback questionnaire. However, at the time of the assessment visit, the assessment team noted that there were some areas where patient privacy and dignity could be compromised and recommends these are reviewed. The unit has mixed sex admission and recovery facilities. The numerous cross over points in the patient journey compromise privacy and dignity, both in the main endoscopy unit and the ERCP unit. The assessment team noted that the service has considered a trial of gender separation of lists and would encourage this approach if it proves to be feasible. There is insufficient provision of toilets and changing facilities for patients. Although the essence of care standards are not used within Scotland, the unit has undertaken significant work in this area. The assessment team commends staff for compiling essence of care documentation. Aftercare Validated level: B The endoscopy service at Wishaw General Hospital has standard post procedure information sheets available for all procedures and aftercare sheets for common gastrointestinal disorders. These contain relevant contact information and recent patient audit showed that patients were aware of this information. The patient satisfaction survey includes a relevant section on the patients experience of aftercare. The unit has a procedure in place for informing patients on procedure outcomes on discharge and there is a procedure in place for informing patients with cancer. Patients are offered a patient centred copy of the endoscopy report upon discharge. However, no evidence was submitted to show that follow-up appointments were agreed and arranged prior to discharge. 14

15 Ability to provide feedback on the service Validated level: A There is an NHS Lanarkshire complaints policy and also a local complaints policy within Wishaw General Hospital Endoscopy Unit. This is reviewed regularly as part of the endoscopy users group. Patients provide feedback on the endoscopy service through the patient survey and through a patient comments box located in the unit. Patient feedback is monitored and reviewed regularly and changes are made in response to feedback where appropriate. The assessment team was also satisfied that there was patient involvement in the planning and evaluation of services. Recommendations the unit must: Progress the installation of the Unisoft scheduling component for booking appointments, as a matter of urgency. Improve access to a condensed version of equality and diversity training. Standardise management of the surveillance list to provide a clear overview across all specialties. Review the patient journey where privacy and dignity are compromised. 15

16 Domain 3: Workforce Skill mix review and recruitment Validated level: A NHS Lanarkshire has a policy in place for the recruitment and selection of staff, underpinned by allocated funding. There is an adequate skill mix, and the staff establishment and skill mix is reviewed regularly. However, the assessment team recommends that the skill mix in endoscopy rooms should be reviewed to ensure an efficient and appropriate use of available skills. For example, scope cleaning could be performed by Agenda for Change (AfC) Band 2 or 3 roles rather than AfC Band 5 staff. The endoscopy service lead is involved throughout the recruitment process and there is sufficient support from senior staff to recruit into vacant posts. The unit reviews staff sickness and absence levels. Flexible staff rostering is also undertaken to provide adequate cover across the endoscopy service. The assessment team noted that the unit needs to ensure that vacancies are filled in a timely manner. Workforce requirements are fed back into the workforce planning strategy and staff reported that any unresolved workforce needs would be placed on the risk register. Orientation and training Validated level: D NHS Lanarkshire has policies in place for staff recruitment and induction, training and development. New staff are allocated trained mentors and there is access to funds for training. However, at the time of the assessment visit, staff reported that access to training was inconsistent within the unit. Staff reported that the unit could release staff for mandatory training, but there was often no training accessible within the hospital. The assessment team recommends that there should be equitable access to training for all staff, including nurse endoscopists. This should include both internal and external training. The assessment team noted that current training programmes are based on the endoscopy competency framework. The unit is encouraged to review the training package once staff have completed the gastrointestinal endoscopy for nurses (GIN) facilitators course. The assessment team further recommends that student nurses should be encouraged to have a placement within endoscopy. No evidence was submitted to demonstrate that feedback is gathered from staff on training provision. The staff survey should include questions regarding both training for the nursing team and nursing involvement in endoscopist training. This feedback should be acted upon within 6 months. Furthermore, evidence submitted does not demonstrate that patient feedback is used in training. The assessment team advises that the in-house training programme could include lessons learned from patient stories. Assessment and appraisal Validated level: C Policies are in place across NHS Lanarkshire for staff assessment and appraisal through the Knowledge Skills Framework; a national system for appraisal in the NHS; and personal development plan process. Staff in the endoscopy unit undergo regular appraisal supported by the agreed documentation. Poor performance is addressed and managers are supported to manage unacceptable performance. However, there was no evidence provided to demonstrate 16

17 that feedback is sought annually from staff on their experience of appraisal. The assessment team recommends that a specific question on staff experience of appraisal should be included on the staff satisfaction survey. This feedback should be acted upon within 6 months. National workforce competencies are available in the unit and these are used to assess performance within the service. Staff in the unit have attended the required competencies to practise independently and encourage succession planning and career progression. Staff are cared for Validated level: A There are health and safety, and equality and diversity policies available within the endoscopy unit at Wishaw General Hospital. Health and safety risk assessments and annual review of health and safety policies and procedures have been undertaken in the unit. A range of policies are available to support staff in improving working lives standards. Action plans are in place to support this and are acted upon. NHS Lanarkshire also has a dignity at work policy, which details the process in place for staff to raise concerns over discriminatory behaviour. All staff complete full mandatory training within 3 months of appointment and evidence was submitted to support that staff have fed back on the service through the endoscopy staff satisfaction survey. Furthermore, outcomes of service reviews are acted upon and fed into development plans. Staff are listened to Validated level: B The endoscopy service has a regular multidisciplinary endoscopy unit meeting where staff are able to contribute views and ideas on the delivery of the service. The assessment team commends the unit on the multidisciplinary attendance at the endoscopy users group. The unit also has an endoscopy staff satisfaction survey to allow staff to feedback about the service and the quality of their work environment. However, the assessment team noted that no action plan was developed following the staff satisfaction survey. Exit interviews are undertaken and recorded, and action plans developed in response to these. The assessment team noted that staff actively share knowledge and experience of service developments with others. Informal and formal reward systems are in place within the service and there is formal recognition of staff through reward systems. Staff are also aware of the process to report adverse incidents. Recommendations the unit must: Review the skill mix in endoscopy rooms to ensure an efficient and appropriate use of available skills. Ensure equitable access to training for all staff, including nurse endoscopists. Encourage student nurses to have a placement within endoscopy. Include a specific question on the staff experience of appraisal on the staff satisfaction survey. 17

18 Domain 4: Training Environment and training opportunities Validated level: D There are two nominated training leads within Wishaw General Hospital: one medical and one surgical lead. The medical lead has overarching responsibility for the planning and co-ordination of endoscopy procedure training lists. There is an appropriate number of trainees within the endoscopy service and an induction programme has been developed. However, this was not fully implemented in the unit at the time of the assessment visit. The assessment team noted that there are inadequate numbers of training lists to meet the needs of current trainees. However, the unit has recently appointed training leads and has a clear intention to further develop a comprehensive training programme. This should include an annual assessment of trainer s expertise. The assessment team further recognises that processes for training lists to be identified and planned 6 weeks in advance are in the development stage. Adopting such a system would maximise training opportunities whilst allowing any unused training lists to be converted into service lists. Trainees are exposed to emergency and urgent procedures where appropriate. However, endoscopy lists are not segmented to maximise training opportunities for rarer procedures. The assessment team notes that trainee feedback is in the early stages of development, but consistent use of the JAG Endoscopy Training System (JETS) would facilitate this. The assessment team also recommends that, although use of the JETS is in the early stages of development, all trainees and trainers should use this system. Endoscopy trainers Validated level: D There is a nominated training lead at Wishaw General Hospital endoscopy unit to co-ordinate training list utilisation and a nominated trainer is available for every trainee. Training list details are also included in trainer job plans. The assessment team further recommends that the training lead should have time identified within their job plan in order to deliver the role effectively. Trainers have attended relevant training courses including Train the Trainer. However, the assessment team recommends that the trainers who have attended the Train the Trainer course more than 4 years ago attend a refresher course to ensure they are familiar with the recent advancement in JAG training methodology. The assessment team noted that the current training programme is in the early phases of implementation and annual evaluation of trainer s expertise is not due until The assessment team encourages this is completed on target. Due to the number of patients in the department, pressure on lists and lack of current dedicated training lists in the endoscopy unit, nursing input into training is currently minimal. The assessment team recommends that experienced and senior nurses have a role in supporting the training of endoscopists. 18

19 Assessment and appraisal Validated level: D There are guidelines and policies in place for the assessment, supervision and monitoring independent practice of trainees within the endoscopy unit at Wishaw General Hospital. At the time of the assessment visit, there was no formal system in place to assess trainees on arrival at the unit or to allow them to operate independently. The assessment team noted that training leads plan to formally assess trainees using JAG summative direct observation of practical skills (DOPS), but this has not yet been implemented. The assessment team noted that the unit intends to adopt a consistent induction process, but this has not yet been implemented in the unit. There is evidence to support that DOPS forms are used for training at the endoscopy unit. The assessment team recommends that all trainers and trainees consistently use the JETS e-portfolio. Examples of trainee portfolios were available at the time of the assessment visit and the assessment team noted that all assessors have undergone training in assessment. Trainees are also adequately supervised outside the unit. At the time of the assessment visit, procedure rooms contained registers of trainees allowed to perform specific procedures independently. The nursing team is aware of the requirement for registering an adverse event and supported in the event that a trainee without the required competencies attempts to perform a procedure. Equipment and education materials Validated level: B The endoscopy unit at Wishaw General Hospital has access to training equipment and education materials including video endoscopy equipment and DVDs. All trainees in the endoscopy unit have access to written and electronic clinical guidelines and JAG documentation. Still photographic equipment is accessible during routine lists; however, video photographic equipment is not available. The assessment team also noted that there is no seminar room available to video link to procedure rooms. Equipment is provided to support therapeutic endoscopy and advanced endoscopic techniques. There is a reporting system available to trainees and regular reports are provided to trainees on key quality and safety indicators. The unit would benefit from the following additional equipment. A twin channel therapeutic gastroscope would facilitate adequate treatment of acute upper gastrointestinal bleeding. A diathermy unit is required for the mobile endoscopy stack in order to maximise the availability of the argon plasma coagulator. A transnasal upper endoscope would facilitate therapy of oesophageal stricturing pathology. The team noted that the unit would like to develop an endoscopic ultrasound service. The assessment team also noted that provision for emergency therapeutic endoscopy out-of-hours would be made safer and more effective by the adoption of an on-call system for endoscopy nurses. This was noted to be supported by the endoscopy nursing workforce. 19

20 Recommendations the unit must: Ensure all trainees and trainers use JETS. Identify time in the training lead s job plan in order to deliver the role effectively. Ensure trainers attend refresher courses to update skills. Ensure that experienced and senior nurses have a role in supporting the training of endoscopists. Ensure all trainers and trainees consistently use the JETS e-portfolio. 20

21 Appendix 1: Glossary of abbreviations Abbreviation AfC BSG DNA DOPS ERCP GIN GRS JAG JETS SHTM Agenda for Change British Society of Gastroenterology did not attend direct observation of practical skills endoscopic retrograde cholangiopancreatography gastrointestinal endoscopy for nurses Global Rating Scale Joint Advisory Group JAG Endoscopy Training System Scottish Health Technical Memorandum 21

22 Appendix 2: Overview of Global Rating Scale and Joint Advisory Group Accreditation System Global Rating Scale In March 2006, a Diagnostic Collaborative Programme was established to support NHS boards to redesign and improve their endoscopy services. The Diagnostic Collaborative Programme introduced the Global Rating Scale (GRS) as a web-based self-assessment tool to be used by endoscopy units to assess how well they provide a patient-centred service for endoscopy procedures. Its principle purpose is to help improve the quality of patient care across a range of measures. This unique tool was developed and implemented in England by the English National Endoscopy Team and has now been widely adopted throughout Scotland. GRS is used by clinical staff and management to self assess an endoscopy unit s ability to deliver a quality service. The following key areas are considered: clinical quality quality of patient experience workforce, and training. Endoscopy units work through the GRS tool which applies various levels from D A. Level D is the minimum acceptable level and Level A is excellent. Units scoring levels B or A are said to deliver commendable quality of care. Completion of GRS is an essential element of the Clinical Standards for the Bowel Screening Programme, published by NHS Quality Improvement Scotland in February 2007, (Standard 6: Colonoscopy and histopathology). Endoscopy units participate in the twice yearly national census in April and October. Further information on GRS can be downloaded from the website. ( Joint Advisory Group Accreditation System In England, the use of GRS has also been linked to the successful achievement of formal accreditation of a unit by the Joint Advisory Group (JAG). There has been discussion among Scotland s clinical community for some time about JAG visits across Scotland s endoscopy units. JAG has defined the criteria necessary for successful accreditation (and re-accreditation), for example safety issues, plant, equipment, decontamination requirements and the training environment. Achievement of Level A for timeliness and Level B for all other aspects of the GRS is required to become an accredited unit. The aim of the pre-jag visit programme is to assess the state of readiness across NHSScotland endoscopy units for formal accreditation. Following completion of the programme, Healthcare Improvement Scotland will recommend for accreditation those units that can demonstrate they are delivering safe, effective and patient-centred care within endoscopy services to a high standard. 22

23 Appendix 3: Assessment process The assessment process has three key phases: preparation prior to the assessment review which involves NHS boards and endoscopy units completing a twice yearly GRS census return and submitting a local self-assessment (JAG online checklist) an external assessment review by Healthcare Improvement Scotland, and publication of a report following the visit. Preparation Firstly, each NHS board assesses its own performance using GRS (a web-based service improvement tool) to determine how well it provides a patient-centred service. The GRS assessment tool makes a series of statements requiring a yes or no answer. From the answers it automatically calculates the GRS scores, which provide a summary view of service provision. In addition, in advance of the visit, the NHS board endoscopy unit completes the JAG online checklist which includes guidance about the type of evidence (for example, protocols and audit reports) required to allow an external assessment of performance to be undertaken. An external assessment team validates the GRS scores, both by considering the self-assessment data and by visiting the NHS board to discuss related issues. Pre-JAG visit Each assessment team is led by an experienced assessor, who is responsible for guiding the team in its work and ensuring that the team members are in agreement about the assessment level reached. The team also has a member of the public to bring a patient s perspective to the review of services. Members of the assessment team have no connection with the NHS board they are assessing. This factor helps to facilitate the sharing of good practice across NHSScotland. During the visit, each multidisciplinary team assesses performance using the GRS rating scores D A. Where applicable, validation of GRS has taken account of standards and targets which apply in NHSScotland. For the purposes of pre-jag accreditation, we are assessing and verifying that processes are in place to meet the requirements of SHTM 2030 in relation to washer disinfectors. Health Facilities Scotland is charged with ensuring that all decontamination standards are met by NHS boards in accordance with SHTM Reporting The final step in the assessment process is to publish the local reports on our website ( 23

24 You can read and download this document from our website. We are happy to consider requests for other languages or formats. Please contact our Equality and Diversity Officer on or Edinburgh Office Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA Telephone Fax Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP Telephone Fax The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group, the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium are key components of our organisation.