Accreditation Frequently Asked Questions


• How do I book a JAG visit?
Once you have completed two GRS censuses with the most recent scoring level B in all standards, the JAG visit request form will become live on your GRS dashboard. You can complete this form and submit this to the JAG office. Once the JAG office receives the form, the date will be put in an ‘expression of interest’ email to our assessors. Only once an assessment team has been put together will the date of the JAG visit be confirmed. You will be able to upload evidence as soon as your JAG visit request form has been received.

• Is JAG accreditation transferable?
No, JAG accreditation is awarded to a site as the environment will have been reviewed during the accreditation process. If the unit moves to a new location, then usually a ‘triggered visit’ will occur in which one assessor will visit the unit to validate if it is meeting the JAG standards.

• How long do I have to upload my evidence?
You are able to upload evidence to the JAG checklist from when you submit your JAG visit request form until 6 weeks before your visit is to take place.

• What will happen once my evidence is uploaded?
Once your evidence has been submitted and your checklist signed off, the assessors will review your evidence. If the assessors need any clarification on your evidence or require any additional information, they will leave a comment on your checklist for you to review. If they do require additional information then the checklist will be unlocked for you to add additional information.

• Is there any training we can undertake to help us prepare for our visit?
The JAG offers ‘Preparing for your JAG Accreditation Assessment Training Day’ based at the Royal College of Physicians in London. For more information on these days please contact askjag@rcplondon.ac.uk or refer to the Training Day Registration section of the download centre on the JAG website.

• Can we have individual advice on issues facing our unit?
The JAG offers a Quality Improvement Support Service which can provide units with individual help for the issues they may be facing. Please contact us at AskJAG@rcplondon.ac.uk for more information.

• How much does a JAG visit cost?
The cost of a JAG visit is covered in the annual fee which units pay each year for access to the GRS and associated services. Please note if you book a JAG visit and cancel it within 4 weeks of the given date, then a cancellation fee may apply.
 

Completing the checklist

• How do I know what evidence to upload?
The JAG has produced an ‘evidence guide’ which outlines the required evidence to gain JAG accreditation. We highly recommend using this guide in conjunction with your upload. This can be found on the KMS or from the JAG office. Please note that if you have further evidence than is outlined in this guide then this can also be uploaded on the checklist.

• What file types can I upload to the checklist?
jpg, jpeg, gif, png, tiff, tif, bmp, ppt, pptx, pps, ppsx, doc, docx, docm, xls, xlsx, csv, rtf, pdf, pub, eml, mht, msg.

• Do you have any templates we can use to present our evidence?
Yes – we have several templates available on the KMS which can be used to present your evidence. Several of these templates are mandatory for evidence presentation, these are:

  • Clinical Audit data template
  • Clinical audit report template
  • Staff satisfaction survey
  • Waits Template

 

• What if we have a very low number of patients over the guidance for waiting times?
The timeliness domain is strict in that there should not be any patients breaching the waiting times given. However, if in a rare case 1 or 2 cases have breached this, then the assessors will take this into consideration as long as the breach was recognised and actioned upon so it would not happen again.

• How can I find my JAG registration number?
Please contact askjag@rcplondon.ac.uk

• What if I don’t have evidence for a particular measure or it will be presented on the day?
Not all measures require evidence uploaded against them. If you wish to clarify that that measure will be presented on the day then please enter a comment against the measure saying this for the assessors to review.

JAG Visit

• Do assessors need to see a list running on the day of a JAG visit?
Yes – the assessors need to see the unit functioning as normal with patients and require a list to be taking place.

• What do the assessors need on the day?
The assessors will need to be met at reception and shown around the unit. They will require rooms for interviews with staff and a room with a computer and internet access in the afternoon for compilation of the report. The assessors will usually take a working lunch with sandwiches being acceptable. We will inform you in any parking or dietary requirements are needed.

• Where is the timetable template found?
The timetable is found by clicking on your unit name on the accreditation dashboard or by emailing askjag@rcplondon.ac.uk Please submit the timetable as soon as possible to allow the assessors to review it and to let you know of any changes.
 

After the visit

• What is the annual report card?
The annual report card (ARC) is completed by accredited units once a year in order to maintain their accreditation ‘criteria met’ status. This report card requests various information from units. The annual report card is designed to not be burdensome on a unit in order for them to keep their accreditation.

• When do I need to complete the annual report card?
The annual report card is open in October and must be submitted by the end of the month. The JAG office will communicate what information will be required in the ARC at least a month before it opens online to allow units enough time to compile their evidence.

• When will I have another visit?
Visits are currently run in 5 year cycles. You are due a visit 5 years from the date of your original visit providing you have maintained your accreditation through this time with completion of the GRS and annual report card.

• If I have been deferred, how do I submit my outstanding evidence?
If you have been deferred then the report will state which evidence needs to be submitted. A revisit will be set up for you on the website where you can upload your evidence to the relevant standards in the same way you did the checklist for your original visit.

Miscellaneous

• What are the minimum staffing levels for an endoscopy room?
Minimum staffing levels are 1 registered nurse and an appropriately trained other person (to include Nurses, Health Care Assistants, Operating Department Practitioners, Endoscopy Practitioners etc. all of whom are suitable). For ERCP procedures we would expect a third person in the room preferably a registered nurse.

Appropriately trained staff refers to meeting the standards outlined to level B in Orientation and Training, and Assessment and Appraisal, in the Workforce domain of the GRS. Staff should have the knowledge, understanding, and skill to assist with any procedure. This should be measured using a competency based model. Each procedure must be reviewed independently, with the staff undertaking the procedure. For example, assistant A may be competent to assist with a simple polypectomy, but assistant B has not yet achieved that competency.

• What is classed as ‘urgent’ in relation to two week waits?
Urgent category may include 2 week wait patients, but also includes a category of clinical needs agreed and identified by the endoscopy team. These form part of the referral guidelines. The service should identify which patients are urgent by developing their guidelines from contemporary evidence e.g. NICE/BSG/accepted practice on KMS.

Examples would be:-

  • New onset dysphagia
  • Melaena
  • Bloody diarrhoea
  • Dark blood mixed with stools


• What is the difference between ‘fully booked’ and ‘partially booked’?

Full booking: the patient is given the opportunity to agree a date at the time of, or within one working day of, the referral or decision to treat. The patient may choose to agree the date when initially offered, or defer their decision until later. Examples of this in practice are:

  • Patients using a choose and book system
  • Patients attending the endoscopy or pre assessment unit, and agreeing a date
  • Patients being phoned within 24 hours by the booking team to plan a date
  • Patients being given a telephone number to contact the booking team the following day, to plan a date of choice


Partial booking: the patient is given an named appointment and has the opportunity to change the date if it is unsuitable. Examples of this in practice are:

  • Patients on a surveillance programme pre planned into schedules
  • Patients who do not book directly on the day of the visit (or within one working day) as booking systems do not allow this eg open access
  • Patients who do not respond to booking office contact by telephone to plan a fully booked appointment
  • Patients awaiting procedures which need multidisciplinary planning due to clinical complexity eg general anaesthetic cases