GRS and Accreditation
March 2012
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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
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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)
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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
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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
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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 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
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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
Endoscopy
service registers
to complete
GRS selfassessment
• 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
0yr
• Access to
action planning
and KMS
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
Where are you on the GRS and
accreditation pathway?
100%
80%
60%
40%
20%
Making progress:
working through
the standards
Had a look at:
progressing
slowly
Achieving all
the standards
Actively
progressing well
with good
engagement
Ready now for
accreditation
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
Involve as many as possible in doing the work:
 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
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 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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