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CHEC Nottingham's Journey to accreditation
7 June 2024

Following CHEC Nottingham achieving their JAG accreditation, we spoke to Prof. Des Breen, Chief Medical Officer, to find out more about the service’s journey.

What was the motivation for looking to achieve JAG Accreditation? 

CHEC’s ambition is to deliver healthcare of the highest quality. Our motivation to achieve JAG accreditation would mean that our services, as judged by an external, very credible organisation, would match the highest standards that are recognised nationally. 

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

There is too much preparatory work for any one individual and no one individual could have the complete set of knowledge required. Our team consisted of many people with multiple skillsets such as executive leads; decontamination experts; leads for endoscopy, nursing, medical, IPC and representation from human resources, education, administration, procurement, and estates.

What impact does having the JAG accreditation mark have for your service? 

The JAG accreditation mark means that we are judged as providing a service of high quality. That is reassuring for the patients, the referrers and the commissioners. Over the next 12 months we will have multiple sites operating nationally. Having our first site gain accreditation shows our ability to deliver this, and our commitment to achieving accreditation on all sites.

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

There were no major hurdles. All the GRS standards are fair. There is nothing unachievable in them. While CHEC only delivers services for NHS patients, it is an independent organisation. As such, CHEC is very agile. If things are needed such as extra equipment or alteration to the estate, it can be achieved in days, rather than months.

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

I don’t think there are any quick wins as such. One of CHEC’s advantages was how prepared we were as an organisation to deliver high quality care before we applied for JAG accreditation. For instance, CHEC has very robust clinical governance processes, demonstrable good outcomes, supporting policies, automated process/outcome data collection, strong human resources processes, an efficient administration/booking team, an EPR, appropriately skilled clinical leads and a well-resourced education department. If an organisation has all this in place, it makes it relatively easy to add on the extra requirements for JAG accreditation.

What was the assessment day like?   

The assessment day was really enjoyable. All the staff had worked so hard towards JAG accreditation, there was palpable excitement on the day. The assessment team were really relaxed and friendly. They gave the impression they were there to help, rather than judge. The assessment team made it very easy for us to showcase our service, while at the same time being very thorough with the assessment. Most of us on the day were quite emotional when we achieved accreditation on the day, at our first site and JAG assessment, with no conditions attached. 

What would your top tips for gaining accreditation be? 

My top tips would be:

  • Don’t underestimate the workload involved. There is a lot for any individual. Having a team approach is crucial. It is preparation over many months, not last minute.
  • Having the Executive Team on board is essential, preferably with an Executive Senior Responsible Officer for JAG. This can unlock doors within minutes. 
  • Be as thorough as you can with the pre-assessment information you supply to JAG. This helps enormously on the day. When you start populating the assessment on the JAG website, there is lots of information to guide you on the requirements.
  • Treat your preparation as a journey towards a quality assurance process, not an exam at the end you may pass or fail. JAG are genuinely trying to improve the quality of services, not criticise them.
  • Finally relax on the day. It is not as bad as your driving test!

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

There are many standards and accreditation schemes out there. JAG is well recognised as being one of the most thorough quality kitemarks to acquire. Any institution that wishes to aspire to deliver high quality care should be applying for JAG accreditation. It is not just about achieving the mark; it is a journey to genuinely improve the standards of endoscopy services. 


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