1 GRS and Accreditation March 2012

Learning objectives After reviewing this presentation, you will understand  How the Global Rating Scale supports accreditation  Understand what is meant by quality improvement  Understand the tools available to support improvements in endoscopy services 2

The basics  The Endoscopy Global Scale (GRS) is a quality improvement system designed to provide a framework for continuous improvement for endoscopy services to achieve and maintain accreditation 3

Accreditation definition  Usually a voluntary process by which an independent agency grants recognition to organisations which meet certain standards that require continuous improvement in structures, processes and outcomes. 4

Accreditation represents A risk reduction strategy  That an endoscopy service is doing the right things and doing them well;  Thereby significantly reducing the risk of error in the delivery of services 5

Accreditation process The process stimulates continuous improvement  Continuous: uninterrupted, without cessation  Improvement: bringing into a more desirable or excellent condition; making more valuable; making or becoming better. (Macquarie Dictionary definition) 6

JAG Accreditation What is JAG Accreditation intended to accomplish?  Stimulate continuous improvement in processes and patient outcomes  Strengthen endoscopy services  Provide a knowledge base of best practices  Increase patient confidence in services  Improve the management and efficiency of services  Provide education on better/best practices 7

SEQOHS Accreditation (Cont’d) What is JAG Accreditation intended to accomplish?  Provide comparison with self and others  Enhance the workforce, retention and satisfaction  Increase chances to add to and grow services 8

Strengths of JAG Accreditation  Stimulates quality improvement culture in the service  External, objective evaluation  Uses agreed standards  Involves health professionals  Puts the patient at the heart of the process  Proactive not reactive  Annual re-evaluation against standards 9

Benefits for medical and nursing staff  Improves professional staff development  Provides education on standards  Provides leadership for quality improvement within medicine and nursing  Increases satisfaction with working conditions, leadership and accountability 10

Benefits for all employees  Values employee opinions  Involves them in quality activities  Improves employee job satisfaction and retention  Clearer lines of authority and accountability  Promotes teamwork 11

12 Endoscopy Services What does a quality endoscopy service look like?

13 Quality Endoscopy Service 1.Patient centered with good customer service 2.Use standards and guidelines to continually improve safety and quality of care and the environment 3.Led and coordinated with efficient safe processes 4.Safe, low risk facility and environment 5.Staff with excellent skills and knowledge 6.Quality improvement culture supported by leaders and managers

Quality Endoscopy Service The GRS & accreditation pathway will assist you to both achieve and demonstrate this.

JAG Requirements  The JAG Accreditation process is based on the GRS Standards  The JAG will require GRS levels to be demonstrated though clear evidence submission  The JAG accreditation website, incorporates the GRS standards has an online accreditation system that services will have to participate in and upload the required evidence 15

Pathway - Stage one Endoscopy service registers to complete GRS self- assessment Guidance and set up with Online GRS System by the JAG Office Endoscopy service completes self assessment and gather evidence Online system automates a rating for each item according to the measures completed Endoscopy service reviews results and plans improvements Access to action planning and KMS 0yr 1yr

To progress to stage two An endoscopy service must:  Be operational for a minimum of a year with supporting audits/evidence over an agreed period  Have completed the GRS over 2 census points  Ensure that evidence demonstrate agreed levels for domains of the Endoscopy Global Rating Scale (GRS): –Clinical quality –Quality of the patient experience –Workforce –Training  Ensure that there is a safe environment for patients and staff  Meet requirements for decontamination

Making progress: working through the standards Actively progressing well with good engagement Achieving all the standards Ready now for accreditation Had a look at: progressing slowly Had a look at: progressing slowly Where are you on the GRS and accreditation pathway? 20% 40% 60% 100% 80%

Successful services … ActionsQuestions Lead, plan, involve the whole teamWho is leading? Who is co coordinating? Are clear about their starting pointWhat does your GRS assessment really say? Run it as a project, meticulous organisation will pay off How will you prioritise the work and organise yourselves to be successful? Develop a communication planWho needs to know about this? Have effective meetingsWhat meeting structure do you have ? Gather new knowledge and examples How will you do this?

Meeting the standards  The GRS is not a “one man show” leadership across the disciplines was cited as the number one factor in achieving success. Clinical engagement is key

The GRS-practical advice  Complete it at each census point. The GRS must be completed twice a year to apply for and maintain accreditation  Answer the statements critically each time  Look the tools and advice available on the KMS  Involve the whole team  Engage with as many people as you can and publish results

Work in partnership  Clinical lead for endoscopy  All endoscopists  General Manager  Nursing lead for endoscopy  Nursing staff  Support services: IT Audit Patient groups Documentation groups Clinical Governance  External networks Involve as many as possible in doing the work :

Pathway- Stage two Agree date for JAG Accreditation Access to training How to pass accreditation Seminars JAG Assessors review evidence prior to visit Review checklist, provide feedback to the endoscopy service and add comments for fellow assessors JAG Assessors conduct assessment and prepare a report Assessors carry out assessment and complete their report online with their findings and recommendations

Other specific support  Specific Training –How to pass your accreditation assessment  Schedule of teleconferences and Webinars –Specific Webex training and support  Dedicated support through ‘contact us’ on the website 24

Conclusion  Accreditation is the most comprehensive and powerful tool for quality improvement  Accreditation has been found to be effective in many systems in many other countries with very different systems  The JAG Accreditation Scheme is working to improve endoscopy services through the accreditation process 25