Journal Article

P156 Why are endoscopy services unsuccessful in obtaining jag accreditation? A review of the standards not met at assessment

Jura, Roza, Bano, Madeline, Jarvis, Mark, Pohl, Keith, Butler, Jessica, Rutter, Matt, Feeney, Mark

2025

Overview

IntroductionJAG accreditation is a supportive process of evaluating the quality of clinical services. A voluntary process, accreditation promotes quality improvement through highlighting areas of best practice and areas for change.19 individual standards are assessed through a combination of evidence submission and an on-site visit. All must be met in order to gain accreditation. Re-accreditation occurs every 5 years.We aim to evaluate what factors influence success in accreditation, and if any difference is seen between the NHS and private sectors.MethodsData on all assessments from 2023 and 2024 was extracted from the JAG accreditation database. Data is presented descriptively, and Fisher’s exact test was used to identify differences in categorical data between the private and NHS sectors.ResultsThere were 26 new applicant assessments. 53.8% (n=14) were for NHS sites, and 46.2% (n=12) for private. 42.3% met criteria on the first attempt (n=11). All sites that were deferred met criteria after remote evidence re-assessment. Private-sector sites were significantly more likely to meet criteria at the initial assessment (p=0.0043).There were 96 re-accreditation assessments. 55.2% met criteria on the first attempt. Of the deferrals, 2 were not awarded after reassessment. 63.2% of re-accreditations were for NHS sites, with the remainder private. Private-sector sites were significantly more likely to meet criteria at the initial assessment (p=0.0355).Across all assessments, 857 actions were generated from standards that were not met. The most commonly ‘triggered’ standard in both the NHS and private sector was 9.3: ‘The facilities and environment support service delivery’, making up 13.1% and 6.0% of actions respectively. The remainder of the top 5 most commonly triggered standards in the NHS were around confidentiality and privacy, waiting times, maintenance and flow in facilities and decontamination. In comparison, the private sector triggered most on key performance indicator (KPI) feedback to endoscopists, comfort score feedback to endoscopists, safety feedback to endoscopists and the presence of operational, nursing and governance meetings.ConclusionsPrivate-sector sites are more likely to succeed in accreditation at the first time of asking, but almost all applications are successful following re-assessment. All services most commonly trigger actions based on the physical endoscopy environment. Beyond this there is a difference between the NHS and private sectors as to where services do not meet standards. The independent sector most commonly triggers on issues surrounding clinical leadership and governance, whereas the NHS perhaps predictably does not meet standards for waiting times, maintenance and patient flow. 5.7% of the actions generated in NHS assessments were for issues in confidentiality and privacy. This is concerning and requires further evaluation.

• Publisher: BMJ Publishing Group LTD
• Subject: Accreditation / Confidentiality / Decontamination / Endoscopy / Feedback / Privacy / Quality control