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Aintree University Hospital's Journey to accreditation
11 June 2024

Following Aintree University Hospital achieving their JAG accreditation, we caught up with Shaheen Mumtaz-Wong to hear about the service's journey.

What was the motivation for looking to achieve JAG Accreditation? 

Aintree is proud to have the JAG Accreditation hallmark, we know this sends a clear strong message to all our patients that our service delivers high quality procedures in a timely manner, and these are the things that matter to them. The JAG accreditation enables us to ensure regular and ongoing review of our services which means that we are motivated to consistently prioritise our patients by reducing wait times, providing world class procedures, and are committed to developing and maintaining a skilled workforce through robust training. 

We mention often in our training sessions that having a team to share the workload helps with the journey towards accreditation, was that something you were able to do and was that helpful?  

Absolutely, it is a whole team effort. The service standards cover every aspect of endoscopy and are thoroughly comprehensive. Having a team approach helps to manage the workload as it can quickly become overwhelming. It is so important to have a whole team approach by having regular meetings and ensuring activities are in line with the standards. By following the guidance, the evidence needed to showcase the service seems to shape itself. Having your Trust support is equally important, so sharing the JAG journey with the wider team helps with any support that may be needed.  

Over the years JAG has become more prominent in the UK and now has over 500 services registered with JAG, what impact does having the JAG accreditation mark have for your service?  

The JAG accreditation mark has over the years become synonymous with being the best and having a gold standard service. Having this mark from a staff perspective means we are proud of our service, and proud to belong to a Trust that values our department in having this standard. From a patient perspective patients can feel assured that they are being cared for by a team of professionals who have undergone an external assessment and validation process and have demonstrated they met the standards. This is reassuring and helps us to keep our patients safe. 

What hurdles did you have to overcome during the process and how did you overcome those? 

There were hurdles, we are a large service with 8 theatres and a new nursing workforce and furthermore the triumvirate leadership team had also been in their roles for a few short Covid years. It was our first formal 5-year accreditation process, it was exciting although slightly stressful but overall, a very positive experience. Having good communication, being open with the challenges and barriers and asking for help to overcome any issues is key. Ensuring good time management and prioritising meetings to keep each other updated with action plans ensured the processes stayed on track, despite any operational pressures that inevitably arose.  

Were there any quick wins that you discovered during the process? 

There were quick wins as one meeting or training session or patient feedback was able to evidence several standards and by reviewing the standards back and forth it helped with the mapping. This in turn helped give us an understanding and the standards quickly became embedded.  

What was the assessment day like? 

The assessment day went very smooth and played out as planned. It was timetabled carefully, and this is evidenced in advance. We did need to swap the order of a few of the meetings and this was due to operational challenges, the assessors were very friendly and flexible. Overall, the day flew past, and it was almost like a whirlwind romance. The feedback session was delivered in a professional manner, and I recall sitting in the meeting feeling very proud of my service and achievements.

What would your top tips for gaining accreditation be? 

My top tips would be to embrace the journey, there is a lot to learn and a lot to do. Plan and meet with your team. Have a clear strategic approach, do not leave things to last minute. Respect that everyone is time pressured and keep service meetings on track. Have clear goals and reward yourselves along the way. When a standard has been uploaded and you are happy you have evidenced it, give yourself a little break/reward, as a little reminder you are ever closer to the accreditation. For me a little wellness walk would do the trick, just around the hospital grounds with a colleague to draw a line, refresh and ready myself for the next action. 

What would you say to any service thinking of going for JAG accreditation?  

Go for it. You will learn so much and your service will be better for it. Your productivity and quality will be much improved, you will perhaps consider things that you may not have even thought about. Your workforce and patients will be happier and feel more included. As an individual your learning will deepen, and you will make new friends/colleagues on the way.


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