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GRS and AccreditationMarch 2012

Learning objectives

After reviewing this presentation, you will understandHow the Global Rating Scale supports accreditationUnderstand what is meant by quality improvementUnderstand the tools available to support improvements in endoscopy services

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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

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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.

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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

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Accreditation process

The process stimulates continuous improvementContinuous: uninterrupted, without cessationImprovement: bringing into a more desirable or excellent condition; making more valuable; making or becoming better. (Macquarie Dictionary definition)

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JAG Accreditation

What is JAG Accreditation intended to accomplish?Stimulate continuous improvement in processes and patient outcomesStrengthen endoscopy servicesProvide a knowledge base of best practicesIncrease patient confidence in servicesImprove the management and efficiency of servicesProvide education on better/best practices

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SEQOHS Accreditation (Cont’d)

What is JAG Accreditation intended to accomplish?Provide comparison with self and othersEnhance the workforce, retention and satisfactionIncrease chances to add to and grow services

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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

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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

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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

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Endoscopy Services

• What does a quality endoscopy service look like?

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Quality Endoscopy Service

1. Patient centered with good customer service2. 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 environment5. Staff with excellent skills and knowledge6. 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

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Pathway - Stage one

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 periodHave completed the GRS over 2 census pointsEnsure 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 staffMeet 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

Where are you on the GRS and accreditation pathway?

20%

40%

60%

100%

80%

Successful services …

Actions Questions Lead, plan, involve the whole team

Who is leading? Who is co coordinating?

Are clear about their starting point What 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 plan Who needs to know about this?

Have effective meetings What 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: ITAuditPatient groupsDocumentation groupsClinical Governance

External networks

Involve as many as possible in doing the work:

Pathway- Stage two

Other specific support

Specific Training– How to pass your accreditation assessment

Schedule of teleconferences and Webinars– Specific Webex training and support

Dedicated email support through ‘contact us’ on the website

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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

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