Service accreditation

What is accreditation? Accreditation pathway | Tracking progress | Assessment teams | The standards


Accreditation is a supportive process of evaluating the quality of clinical services by guiding services through a quality framework. Accreditation promotes quality improvement through highlighting areas of best practice and areas for change, encouraging the continued development of the clinical service. Accreditation is a voluntary process for services to engage in.

Having developed standards with a multi-professional group of clinicians, managers and patients, services participating in JAG accreditation work to an accreditation pathway which involves self-assessment and quality improvement against the standards. Accredited services submit evidence annually to demonstrate that they are continuing to meet the standards and have a 5-yearly on-site assessment carried out by our experienced assessment team.

Accreditation pathway

By participating in accreditation, services are enrolled on an ongoing programme of service and quality improvement. A high-level overview of the accreditation pathway is depicted below.

Tracking progress

Participating services have access to the accreditation standards via a self-assessment tool. The tool allows services to review:

• which standards they meet and have evidence for
• which standards they meet but need to collate evidence for
• which standards they are not meeting

The tool enables services to target their team’s improvement efforts. Downloadable summaries are available which enable services to track and share the progress being made towards achieving JAG accreditation.

A service must provide evidence that they have met all of the JAG standards and have completed on GRS return at level B or above across all domains. Once a service can fully demonstrate these requirements, an accreditation assessment will be organised to review the evidence submitted by the service. A site assessment will also take place, usually lasting one day.

A site assessment is undertaken every 5 years and between these assessments there is an annual remote review of key pieces of evidence to show that the service is maintaining the standard.

There is an annual subscription for participating in the programme.

Assessment teams

The programme provides a comprehensive training package for supporting assessors. Typically, the assessment team consists of a doctor, nurse and manager who have experience in the service. A lay assessor is also part of the assessment team, though may not have personal experience of using the service.Assessors undergo a blended training programme of both face to face and online learning to fully understand the accreditation pathway, the standards and how to carry out assessments.

The standards 

The standards have been established with the gastrointestinal (GI) community and are intended to provide patients/service users, healthcare professionals and senior leaders with assurance of the quality of the service provided. The standards cover all aspects of a high-quality clinical service and are organised into four domains:

Clinical quality - The clinical quality domain encompasses the service's role in safe and effective diagnosis, treatment and ongoing management. Key to this is the service infrastructure including leadership and governance. 

Patient experience - The patient experience domain encompasses the service's role in providing efficient and patient-centred care for all patients, which includes reviewing waiting times, facilities and the environment. 

Workforce - The workforce domain focuses on effective training and support for staff, including the recruitment, retention and continued professional development of team members.

Training - The training domain reviews the support and development of trainee endoscopists, including appraisal and competencies. Services that do not provide training in endoscopy, typically those in the independent sector, are only assessed against the first three domains.

For further information on the standards, please refer to the standards document.

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