Endoscopy Assessment Report

Transcription

1 Endoscopy Assessment Report Borders General Hospital NHS Borders 21 October 2010

2 NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed the performance assessment function for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. For this equality and diversity impact assessment, please see our website ( The full report in electronic or paper form is available on request from the NHS QIS Equality and iversity Officer. NHS Quality Improvement Scotland 2011 First published January 2011 You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing 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 5 3 Overview of local service provision 6 4 etailed findings against the Global Rating Scale 8 Appendix 1: Glossary of abbreviations 19 Appendix 2: Overview of Global Rating Scale and Joint Advisory Group Accreditation System 20 Appendix 3: Assessment process 21 3

4 1 Setting the scene In July 2008, NHS QIS was 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, NHS QIS 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 Borders, Borders General Hospital, Melrose, on 21 October The visiting team consisted of the following: Tim Reilly (Team Leader) Consultant Gastroenterologist, NHS Lanarkshire Wendy owdles Senior Charge Nurse, NHS Tayside Lynn Heatley Modernisation Manager, NHS National Waiting Times Centre Mairi Brown Public Partner Supported by: Morag Kasmi Programme Manager, NHS Quality Improvement Scotland Edel Sheridan Project Officer, NHS Quality Improvement Scotland Observed by: Julie Huntly Endoscopy Nurse, NHS Greater Glasgow and Clyde 4

5 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 A). Level 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 Borders General Hospital are illustrated in Table 1. Table 1: Validated GRS level: Borders General Hospital, NHS Borders omain 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 C C C C C C Further information about the assessment process can be found in Appendix 3. 5

6 3 Overview of local service provision At the time of the assessment visit, NHS Borders had one endoscopy unit based at Borders General Hospital. The unit formally opened in spring 2010 as a purpose-built endoscopy service. It includes two fully equipped procedure rooms and a large self-contained decontamination area to provide decontamination of endoscopic equipment. Borders General Hospital serves a local population of approximately 112,700. The unit undertakes 12 endoscopy sessions each week, and performed 3,221 endoscopies last year. Endoscopic procedures performed include gastroscopy, colonoscopy, flexible sigmoidoscopy, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous endoscopic gastrostomy, oesopho-gastro-duodenoscopy (OG), cystoscopy and prostate biopsy. NHS Borders is part of the National Bowel Screening Programme, offering preassessment and colonoscopy to patients who have a positive screening result. Major strengths The assessment team considers Borders General Hospital endoscopy service to have the following major strengths: modern, well equipped unit enthusiastic and highly motivated team - staff feel valued good communication skills within the unit and across departments low number of patients cancelling or not attending their appointment, and short waiting times for most procedures. Leadership structure Endoscopy sits within the diagnostics service at Borders General Hospital. The unit has physical infrastructure to undertake up to 20 endoscopy sessions each week. There is currently unused physical capacity. The demand for endoscopy exceeds the capacity of staff. The assessment team noted insufficient numbers of endoscopists to cover the workload. NHS Borders should consider developing unused physical capacity to spread the endoscopy workload more evenly throughout the week. This could be achieved through role development of existing staff to undertake additional endoscopy procedures. The assessment team recommends a review of the nursing skill mix, particularly the Agenda for Change (AfC) Band 5 staff. When there is more than one endoscopy list taking place, the assessment team would encourage NHS Borders to provide additional nursing staff within the recovery area. NHS Borders is also encouraged to explore role development of the AfC Band 2/3 within decontamination and the circulatory nurse role. AfC Band 2 staff need to be in place to decontaminate endoscopes on a daily basis, rather than part-time. The use of an AfC Band 7 role to co-ordinate colonoscopy bookings is not advised. The role should be undertaken by an appropriate staff grade such as AfC Band 2/3. The assessment team recommends a review of the senior nurse AfC Band 7 role to ensure that her varying duties do not conflict. Support is also needed for this role through provision of appropriate backfill, using at least full-time equivalent AfC Band 6/7 staff. 6

7 The assessment team commends the work of the booking clerk in co-ordinating many aspects of the endoscopy administration. Endoscopy unit layout and design The assessment team commends NHS Borders for its pleasant purpose-built endoscopy unit which includes two large procedure rooms. The service is well equipped with modern endoscopy equipment and accessories. Signage both within and to the unit is excellent, providing clear directions for patients and staff. There is an adequate patient waiting area and separate rooms available for private discussions with patients. Processes are in place for patient admission, consent and discharge. Oxygen and suction equipment is provided at each patient bay and there is appropriate monitoring and resuscitation equipment. Storage facilities are adequate. While there are sufficient toilet facilities for patients within the unit, there is only one patient toilet facility within the recovery area. This is potentially insufficient if the unit is operating at full capacity. The assessment team encourages the unit to review its bowel preparation procedures to enable all patients to have access to toilet facilities when required. econtamination NHS Borders has a local decontamination policy. However, the assessment team encourages the NHS board to make the local decontamination policy endoscopyspecific and separate from the operational policy. A protocol is in place for out-of-hours decontamination. The unit layout enables clear separation of dirty and clean equipment. Endoscopes are manually checked for leaks and cleaned according to national decontamination guidelines. Evidence was provided for rinse water results for the past 3 months including a procedure for failed tests. At the time of the visit, the unit reported that the endoscope washer disinfectors were in good working order. Endoscopes are transported appropriately. Ventilation and extraction facilities are in place to ensure staff and patients are protected from exposure to hazardous chemicals. isinfectants are stored and used safely. The unit undertakes testing and validation, and risk assessments are undertaken for the endoscope drying cabinets. The assessment team recommends use of an attachment to ensure endoscopes do not rest on the floor of the cabinet. A protocol is in place to support adherence to the 3-hour rule regarding appropriate use of endoscopes removed from the cabinet. There is also a procedure for keeping valves with endoscopes as a unique set. Evidence was provided to demonstrate that actions are taken in response to adverse incidents. The assessment team noted that NHS Borders has set aside funding for an electronic tracking system to track endoscope usage. The implementation of an electronic system is encouraged. Staff were observed using appropriate personal protective equipment. The assessment team advises NHS Borders to develop a more competency-based package as evidence of staff training and validation. 7

8 4 etailed findings against the Global Rating Scale omain 1: Clinical quality Consent process including patient information At the time of the visit, NHS Borders had just signed off a board-wide consent policy. The assessment team advises the unit to also develop a local endoscopy-specific consent policy in order to meet JAG accreditation requirements. Borders General Hospital has patient information leaflets for all endoscopy procedures. The assessment team encourages the unit to review the leaflets for consistency and to include document control and review dates. A protocol is in place for obtaining patient consent outside of the endoscopy treatment rooms. There are procedures for the withdrawal of patient consent. The assessment team encourages the unit to develop a flow chart to accompany the withdrawal of consent policy to provide clearer guidance for staff. This should be made easily available within the procedure rooms. The assessment team encourages NHS Borders to undertake patient surveys which include specific questions on consent. Follow-up plans should then be devised and actioned in response to patient survey results. Safety Validated level: C At the time of the visit, the British Society of Gastroenterology (BSG) guidelines were available in hard copy and electronic formats. Any identified resource constraints are included on a risk register. Local policies are in place, including a diabetes protocol and an anticoagulant flow chart. The assessment team encourages NHS Borders to make the local decontamination policy endoscopy-specific and separate from the operational policy. The endoscopy service uses the electronic system, MediRisk, to record adverse events. The assessment team encourages the unit to introduce a list of trigger events to guide staff and to provide adequate training to ensure appropriate events are recorded. Evidence was provided of an endoscopy users group with management support and protected time allocated for its activities. At the time of the visit, the group had met once. The assessment team encourages the continuation of this user group. The unit needs to undertake audits of decontamination standards every 6 months. The assessment team encourages the unit to undertake audits of 30-day post-procedure hospital mortality and non-elective surgery readmissions within 8 days. Audit results should be reviewed by the endoscopy users group and agreed actions taken forward. Comfort A comfort form is contained within the unit s care plan to monitor and record patient comfort during endoscopy procedures. However, the form is not consistent with the 8

9 Unisoft system for recording patient comfort. The assessment team encourages the unit to adapt the comfort record form to make it consistent with Unisoft. Evidence is required that individual comfort scores are fedback to all endoscopists. The team noted that the recently introduced Unisoft system would support this. The unit needs to demonstrate evidence of review and action of patient comfort scores as appropriate. Engagement should be obtained from all users for the development of a locally agreed policy for reviewing patient comfort levels. NHS Borders has a policy for managing poor performance. The assessment team encourages the NHS board to introduce a separate section within the policy specific to patient comfort. Quality of procedure The endoscopy service has BSG quality indicator documentation and a supporting IT system to facilitate audit. Some individual audits of quality indicators have been undertaken. These include audits of flumazenil usage and therapeutic ERCP procedures. Summary data were provided on the complication rate of ERCP and the failure rate to decompress the biliary and pancreatic duct. The assessment team noted that this particular audit was being conducted under a surgical protocol. The team would encourage the unit to consider using Unisoft to record data relating to therapeutic ERCP, for ease of audit. A rolling audit programme focusing on all BSG quality indicators needs to be developed with timescales and nominated staff to take forward actions. The assessment team noted the unit has an action plan in place to undertake these audits. Appropriateness Referral guidelines are in place within the endoscopy unit for all diagnostic, open access, therapeutic and recall procedures. Evidence was provided of the dyspepsia referral guidelines being agreed with users and representatives from the primary care sector. The assessment team encourages the unit to develop similar agreed referral guidelines for other modalities. All endoscopy patient referrals are vetted individually by a small team of staff. This is supported by a vetting procedure within the endoscopy standard operational policy. There are up-to-date processes in place for the administrative validation of surveillance procedures. However, there needs to be regular clinical validation of surveillance procedures, at least 2 months prior to the procedure date. Surveillance procedures are currently not undertaken within the time expected and are not clinically validated with a local policy. Communicating results to the referrer Endoscopy reports are completed on the day of the procedure and dispatched within 1 working day. The reports, which contain follow-up details, are placed within patient notes. 9

10 The assessment team advises the unit to gather evidence of the process for dispatching pathology reports (including patients diagnosed with cancer), supported by audit results. Recommendations the unit must: evelop a local endoscopy-specific consent policy. Undertake audits of decontamination standards every 6 months. Provide evidence of individual comfort score reports being fed back to all endoscopists. emonstrate an agreed policy for reviewing comfort levels, ongoing review of comfort scores and a record of action taken where appropriate. Implement a rolling audit programme focusing on BSG quality indicators with timescales and nominated staff to take forward actions. evelop agreed referral guidelines with users and representatives from primary care for all modalities. Undertake regular clinical validation of surveillance procedures at least 2 months prior to due procedure date. Provide evidence of the process for dispatching pathology reports (including patients diagnosed with cancer) with supporting audit. 10

11 omain 2: Clinical quality of patient experience Equality of access and equity of provision NHS Borders has an equality and diversity policy. However, evidence is required to show that staff are provided with an induction on the policy or race equality scheme. A demographic and language profile has been undertaken and written information is provided for patients in the most prevalent community languages. An interpreting service is available and patients with communication needs are offered a full range of appropriate services. The assessment team encourages the unit to include a section on equality monitoring within the patient satisfaction survey to enable feedback from minority groups on the service provided. Timeliness Validated level: C The endoscopy service has a waiting list management system including a process for pooling patient lists between consultants. emand and capacity audits are undertaken. The unit demonstrated the capability to provide a snapshot of the waiting list position and provided recent consecutive evidence showing 3 months of data. There is a procedure for administrative validation of waiting lists. However, there needs to be an up-to-date clinical procedure for validation and management of waiting lists. The assessment team noted a process is in place for managing surveillance lists. The team recommends a review of the process to improve its effectiveness and to prevent surveillance endoscopies going beyond their due date. Booking and choice The endoscopy service has a system for booking patients which appears to work very well. However, the assessment team would encourage the unit to undertake a trial of a patient-focused booking process such as the national New Ways procedure. New Ways offers patients a choice of two dates which are 7 days apart and 4 weeks in advance of the booking date. The incidence of patients not attending or cancelling their appointments is monitored and action is taken in response to increased rates where appropriate. The assessment team commends the unit for its impressively low rate of patients cancelling or not attending their appointment. Processes are in place to monitor the number of patients who are partially or fully booked. 11

12 Privacy and dignity The unit has dedicated rooms for private patient discussion to support privacy and dignity. All patients are offered the choice of discussing their clinical care in private. However, the existing patient flow within the unit does not always enable patient privacy and dignity to be maintained. The assessment team recommends the installation of a partition within the recovery area to better support patient privacy. Patients views on privacy and dignity should be sought through a patient satisfaction questionnaire. This could be incorporated into an overall patient satisfaction survey. The assessment team acknowledged that the unit had reviewed essence of care standards and adapted them for local use within the endoscopy standard operational policy. The team advises the service to introduce a privacy and dignity benchmarking tool to enable regular review and action of privacy and dignity standards. Aftercare Validated level: C General post procedure sheets are available within the unit for all endoscopy procedures including aftercare sheets for common gastrointestinal (GI) disorders. Patients are offered a 24-hour contact telephone number should they experience problems out-ofhours following their endoscopy procedure. Follow-up appoints are agreed prior to discharge and protocols are in place for informing patients diagnosed with malignancy of disease. Endoscopists inform patients about the outcome of their procedure. The assessment team encourages NHS Borders to explore nurse-led discharge to help improve the efficiency of the service. The unit is encouraged to continue to develop patient-centred endoscopy reports. All patients should be offered a copy of the endoscopy report or a patient-centred version of it. A patient survey on aftercare needs to be undertaken with evidence of action on issues arising. The assessment team would encourage the inclusion of questions on aftercare within the patient satisfaction survey. Ability to provide feedback on the service The assessment team acknowledged a draft version of the NHS Borders complaints policy and recommends that the policy is approved and implemented. A local procedure for handling complaints is included within the endoscopy standard operational policy. However, the assessment team encourages the unit to provide more detailed guidance on handling complaints locally. This could include a flow chart to support and guide staff through managing a complaint. The patient satisfaction survey needs to be incorporated into reviews of patient feedback. The assessment team would encourage the unit to include an additional suggestion box within the recovery area. 12

13 There was evidence that complaints had been discussed at the initial endoscopy user group meeting. The unit is encouraged to maintain complaints as a standard agenda item, supported by action plans where appropriate. The assessment team noted that NHS Borders involved the public throughout the planning and building of the new unit. However, it would encourage the endoscopy service to further involve patients in the evaluation of service delivery. Recommendations the unit must: Provide evidence of staff undergoing induction on equality and diversity or race equality scheme. Introduce an up-to-date clinical procedure for validation and management of waiting lists. Review the process for managing surveillance lists to prevent surveillance endoscopies going beyond their scheduled date. Undertake a trial of a patient-focused booking system. Install a partition within the recovery area to better support patient privacy. Seek patients views on privacy and dignity and aftercare through a patient satisfaction survey. Introduce a privacy and dignity benchmarking tool to enable regular review and action of privacy and dignity standards. Approve and implement the NHS Borders complaints policy. Incorporate the patient satisfaction survey within reviews of patient feedback and introduce an additional suggestion box within the recovery area. 13

14 omain 3: Workforce Skill mix review and recruitment NHS Borders has a policy for the recruitment and selection of staff. Flexible staff rostering is undertaken to provide adequate cover across the endoscopy service, and the unit reviews staff sickness and absence levels. The assessment team commends the unit for its excellent staff absence record. There is adequate senior support and ability to recruit into vacant posts. The staff establishment and skill mix is reviewed regularly particularly when vacancies arise or in anticipation of service changes. The assessment team recommends formal monthly meetings between the diagnostic manager and lead nurse to discuss ongoing service issues. The assessment team noted that the current skill mix is insufficient to meet demand. The recommendation for a two room unit would be one AfC Band 7 and two AfC Band 6 full-time equivalent staff. The SHTM 2030 guidelines advise the use of full-time technicians within decontamination. Implementing AfC Band 3 staff roles would be advantageous to the staff skill mix and would enable progression within the unit for AfC Band 2 nurses. The assessment team strongly recommends a review of the staffing skill mix. There was evidence of allocated funding for the endoscopy service. The assessment team advises NHS Borders to introduce additional endoscopy sessions within the unit to cope with the workload. Orientation and training NHS Borders has a staff induction policy and a strategy for staff training and development. Staff have access to training and new staff are allocated trained mentors. The endoscopy service has a local policy for staff induction, training and development. The assessment team encourages the unit to review the local policy in accordance with the gastrointestinal endoscopy for nurses (GIN) framework. Staff have attended training on the GIN competency framework. However, the framework is not used as time constraints and numbers of senior nursing staff make it difficult to implement. The assessment team recommends the unit gathers feedback from all endoscopy staff on the training provision at least annually. Patient feedback needs to be incorporated into staff training to develop awareness. Assessment and appraisal Policies are in place for staff assessment and appraisal. NHS Borders has a policy for managing poor performance and managers are supported to address poor performance where necessary. The assessment team would encourage the unit to adopt the electronic Knowledge and Skills Framework (KSF) system. It is further recommended that all endoscopy personnel undergo regular appraisal. Although the majority of staff appear to have 14

15 personal development plans (PPs), the booking co-ordinator requires an up-to-date PP. The national endoscopy competency framework is not used. Staff who have accessed GIN training should follow the competency framework. Local competencies are used within the unit to assess staff performance. The assessment team would encourage the unit to undertake future staff assessment using the national competency framework within the GIN e-portfolio. There needs to be an annual capture of staff feedback on their experience of appraisal. Staff are cared for Validated level: C There is a health and safety policy, an equality and diversity policy, and health and safety risk assessment available within the unit. The policies are reviewed on an annual basis. All staff complete full mandatory training within 3 months of appointment. There are processes for staff to raise concerns about discriminatory or unacceptable behaviour. However, there was no evidence provided of staff feedback. Policies are in place to support flexible working and to enable staff to maintain a good balance between work and their other commitments. Staff are listened to Staff actively share knowledge and experience of service development with others. The endoscopy unit provided evidence of service team meetings where staff can contribute views and ideas. Informal reward systems are in place for all staff. Staff are aware of the process to report adverse incidents and the endoscopy team participates in the appraisal of policies and strategies. In order to meet JAG accreditation requirements, the assessment team advises that exit interviews are recorded and fed back to clinical and general managers. Recommendations the unit must: Review the staff skill mix. Consider introducing more endoscopy sessions within the unit to cope with the workload. Introduce formal meetings between the diagnostic manager and lead nurse to discuss ongoing service issues. Gather feedback from all endoscopy staff on the training provision at least annually. Incorporate patient feedback into staff training to develop awareness. Ensure that staff who have accessed GIN training follow the national workforce competencies. 15

16 Introduce a process to make sure that all endoscopy personnel undergo regular appraisal. Capture staff feedback on appraisal at least annually. ocument evidence of annual staff feedback on the quality of their work environment. Provide evidence of staff exit interviews being recorded and fed back to clinical and general managers. 16

17 omain 4: Training Environment and training opportunities At the time of the assessment visit, the endoscopy service had two trainees, one training in ERCP examination and one undertaking colonoscopy training. The unit needs to demonstrate evidence of trainees having attended basic skills courses. There is a single nominated training lead for planning and co-ordination of training lists. However, there are currently no dedicated training lists. The assessment team encourages NHS Borders to identify protected time in the training lead s job plan. Use of the JAG Endoscopy Training System (JETS) website is also encouraged. While the endoscopy service has a staff induction policy, the assessment team recommends the development of an induction programme suitable for the needs of endoscopists. The unit needs to obtain feedback from trainees during training. Endoscopy trainers Validated level: C There is a single nominated training lead for the planning and co-ordination of training lists. Each trainee has a nominated trainer and there is nursing input to support endoscopist training. All trainers in the unit have undertaken an approved Train-the-Trainers course and the training lead has participated in JAG approved training courses. Records are maintained to reflect all courses attended by trainers. Information is compiled each week on the lists performed by each trainer. The assessment team advises the unit to undertake an evaluation of trainers expertise. Evidence is also required of annual evaluation of staff input into endoscopist training. Assessment and appraisal The endoscopy service has a procedure for the supervision of trainees. There is a unit policy for defining and monitoring independent practice of trainees, and all assessors have received training in assessment. The assessment team recommends that all trainees be formally assessed by direct observation of practical skills (OPS) before they are permitted to operate independently. Furthermore, all trainees should have formal assessments on arrival at the endoscopy unit. The process for trainee supervision within the endoscopy service was considered to be good. However, the assessment team encourages the unit to formally document the process. The JETS e-portfolio would support this. A register is available in each procedure room documenting which endoscopy procedures each trainee can undertake independently. 17

18 Equipment and education materials Validated level: C 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. Equipment is provided to support therapeutic endoscopy and advanced endoscopic techniques. A reporting system is available to trainees. The assessment team recommends that trainees are provided with audit reports. Training equipment and education materials are provided for trainees, although there was no evidence of Vs and other electronic aids with suitable playback equipment. Recommendations the unit must: emonstrate evidence of trainees attending basic skills courses. Introduce a dedicated training list. Obtain feedback from trainees during training. Revise the induction programme to reflect the specific training needs of endoscopists. Evaluate trainers expertise on an annual basis. Undertake annual evaluation of staff input into endoscopist training. Formally document the process for trainee supervision supported by the JETS e-portfolio system. Assess all trainees using OPS before they are permitted to operate independently. Formally assess all trainees on arrival at the endoscopy unit. emonstrate evidence of Vs and other electronic aids with suitable playback equipment. Provide trainees with audit reports. 18

19 Appendix 1: Glossary of abbreviations Abbreviation AfC BSG CP OPS ERCP GI GIN GRS JAG JETS KSF NHS QIS OG PP SHTM Agenda for Change British Society of Gastroenterology diagnostic collaborative programme direct observation of practical skills endoscopic retrograde cholangiopancreatography gastrointestinal gastrointestinal endoscopy for nurses Global Rating Scale Joint Advisory Group JAG Endoscopy Training System Knowledge and Skills Framework NHS Quality Improvement Scotland oesopho-gastro-duodenoscopy personal development plan Scottish Health Technical Memorandum 19

20 Appendix 2: Overview of Global Rating Scale and Joint Advisory Group Accreditation System Global Rating Scale In March 2006, a iagnostic Collaborative Programme (CP) was established to support NHS boards to redesign and improve their endoscopy services. The CP 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 A. Level 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 NHS QIS Clinical Standards for the Bowel Screening Programme (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, NHS QIS 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. 20

21 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 selfassessment (JAG online checklist) an external assessment review by NHS QIS, 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. uring the visit, each multidisciplinary team assesses performance using the GRS rating scores 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 ( 21

22 We can also provide this information: by in large print on audio tape or C in Braille (English only), and in community languages. Edinburgh Office Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA Phone: Textphone: Glasgow Office elta House 50 West Nile Street Glasgow G1 2NP Phone: Textphone: The Scottish Health Council, the Scottish Intercollegiate Guidelines Network (SIGN) and the Healthcare Environment Inspectorate are also key components of our organisation.