GRS and Accreditaion March 2012

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					GRS and Accreditation
     March 2012




                        1
                                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
                     Endoscopy Services

• What does a quality endoscopy
  service look like?




                                          12
                   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

                                                 13
                     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




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
                           Where are you on the GRS and
                                  accreditation pathway?
100%

 80%


 60%

 40%
                    Making progress:                  Achieving all
                    working through                  the standards
 20%                 the standards




       Had a look at:                      Actively                   Ready now for
        progressing                    progressing well                accreditation
           slowly                         with good
                                         engagement
                                         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        How will you prioritise the work and
organisation will pay off              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               How will you do this?
examples
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    Support services:
    endoscopy               IT
   All endoscopists        Audit
   General Manager         Patient groups
   Nursing lead for        Documentation groups
    endoscopy               Clinical Governance
   Nursing staff        External networks
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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