Endoscopy Assessment Report

Endoscopy Assessment Report

Aberdeen Royal Infirmary

NHS Grampian

25 February 2010

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Endoscopy Assessment Report (Aberdeen Royal Infirmary, NHS Grampian) – August 2010

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Contents

1 Setting the scene 4

2 Validation of the Global Rating Scale score 5

3 Overview of local service provision 6

4 Detailed findings against the Global Rating Scale 10

Appendix 1: Glossary of abbreviations 23

Appendix 2: Overview of Global Rating Scale and Joint Advisory

Group Accreditation System 24

Appendix 3: Assessment process 25


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1 Setting the scene

In July 2008, NHS QIS was given responsibility to take forward quality improvement of endoscopy services and to implement and roll out a programme of pre-assessment of endoscopy units in NHSScotland with effect from February 2010. There are two elements of the work involved in undertaking these assessments: the Global Rating Scale (GRS) and Pre-Joint Advisory Group (JAG) Accreditation System visits.

Global Rating Scale

The overall performance of endoscopy units is rated using the GRS scoring system. GRS is a web-based self-assessment tool used by endoscopy units to assess how well they provide a patient-centred service for endoscopy procedures. Its principle purpose is to help improve the quality of patient care across a range of measures. In England, the use of GRS has been linked to the successful achievement of formal accreditation of a unit by the JAG.

Joint Advisory Group Accreditation System

The aim of the pre-JAG assessment visit programme is to assess the state of readiness across NHSScotland endoscopy units for formal accreditation through the JAG Accreditation System. On completion of the visit programme, NHS QIS will recommend for accreditation those units that can demonstrate they are delivering safe, effective and patient centred care within endoscopy services to a high standard. Further information on GRS and JAG is provided in Appendix 2.

Pre-JAG assessment visit

This report presents the findings from the pre-JAG assessment visit to Aberdeen Royal Infirmary, NHS Grampian on 25 February 2010. The visiting team consisted of the following:

Nicholas Church (Team Leader) Consultant Gastroenterologist, NHS Lothian

Rachael Hodson Lead Nurse East Yorkshire School of Endoscopy, Hull and East Yorkshire NHS Trust Joanna McGregor Public Partner

Supported by:

Susan Lowes Project Officer, NHS Quality Improvement Scotland Morag Kasmi Programme Manager, NHS Quality Improvement Scotland


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2 Validation of the Global Rating Scale score

Each endoscopy unit submits its GRS scores every 6 months. The GRS assessment tool makes a series of statements requiring a yes or no answer. From the answers, it automatically calculates the GRS scores, which provide a summary view of service provision (levels D–A). Level D is a minimum acceptable level and Level A is excellent. Units scoring levels B or A are said to deliver commendable quality of care.

Where applicable, validation of GRS has taken account of standards and targets which apply in NHSScotland, for example Scottish Health Technical Memorandum (SHTM) 2030 in relation to washer disinfectors.

The validated results for Aberdeen Royal Infirmary are illustrated in Table 1. The most appropriate level is agreed by the assessment team to describe the endoscopy unit’s current position against each domain.

Table 1: Aberdeen Royal Infirmary, NHS Grampian

Domain Item Validated level

Consent process including patient information D

Safety D

Comfort D

Quality of procedure D

Appropriateness D

Clinical quality

Communicating results to referrer D

Equality of access and equity of provision B

Timeliness D

Booking and choice D

Privacy and dignity D

Aftercare C

Quality of patient experience

Ability to provide feedback to the service D

Skill mix review and recruitment D

Orientation and training D

Assessment and appraisal D

Staff are cared for D

Workforce

Staff are listened to D

Environment and training opportunities D

Endoscopy trainers D

Assessment and appraisal D Training

Equipment and education material B

Further information about the assessment process can be found in Appendix 3.


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3 Overview of local service provision

NHS Grampian currently provides endoscopy services within 11 endoscopy units sited across acute and community hospitals throughout the NHS board area, consisting of:

secondary level service provision

tertiary level service provision for Elgin, Orkney and Shetland Islands

full range of upper and lower endoscopic procedures including stenting, percutaneous endoscopic gastrostomy (PEG), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and bowel screening, and

diagnostic upper gastrointestinal endoscopy (UGIE) and flexible sigmoidoscopy in the community.

Aberdeen Royal Infirmary is the largest of the hospitals and serves a population of 452,250. The endoscopy service provision is appropriate for the underlying population, with 10,398 procedures performed this year. The endoscopy services are undertaken within six procedure rooms: three rooms located in the main endoscopy unit; one room in the theatre suite; one room in the accident and emergency department (AED) and ERCP procedures are performed in the radiology department. In addition, there is also one virtual room in the community setting for diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy.

At the time of the assessment visit, the unit at Aberdeen Royal Infirmary was in the process of redesign and building work to increase capacity and create a centralised decontamination facility. The assessment team noted that the redesigned unit should be seen as a temporary bridging unit, with the NHS board making provision for a purpose built endoscopy unit in the future.

Major strengths

The assessment team considers Aberdeen Royal Infirmary endoscopy service to have the following major strengths:

development of team working

strong team work ethics

significant and sustained reduction in waiting times

engagement with the JAG process and drive to improve

planning of new facilities and a centralised decontamination area, and

recognition of significant challenges and action planning.

Leadership structure

The clinical lead for endoscopy, based at Aberdeen Royal Infirmary, is responsible for all endoscopy services provided within NHS Grampian. Nursing and reception staff report directly through the endoscopy services sister to the endoscopy services manager and the administration team reports to the unit support manager. The assessment team recommends that the organisational structure for the service identifies clear lineage and responsibility for all endoscopists within all disciplines in the acute and community sector. The management and clinical governance structure needs to be established as a single service in order to support the clinical lead and training lead to use the Global Rating Scale (GRS) as a service development system.


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There are currently four budgets for non pay endoscopy provisions. While the endoscopy service manager holds the core nursing budget for the main endoscopy unit, additional staff are provided by other budget holders for endoscopy outside the main unit. The assessment team recommends that a clear line of accountability and staffing analysis for work is undertaken, alongside identification of a single stakeholder to collectively manage all budgets.

Endoscopy unit layout and design

The endoscopy service at Aberdeen Royal Infirmary is undertaken within four discrete locations throughout the hospital, with procedures being undertaken within the main endoscopy unit, theatre, AED and the radiology department. The assessment team noted that this structure was not ideally placed to provide a satisfactory standard of care to patients.

The patient flow and access in all areas of the service should be reviewed and improved, and signage, giving directions to the endoscopy unit should be more visible. Pre-procedure patients pass through a clinical area within the AED endoscopy facility and on the day of the visit, clearly visible emergency care was being undertaken, which could cause distress for patients. The patient journey from short stay unit admission to the theatre endoscopy suite is exceptionally long and unacceptable for patients. There are no toilets along the journey and patients are escorted by a registered nurse, which lowers staffing capacity within the admission/recovery area. The assessment team recommends alternative facilities be considered. If not available, the patient pathway should be remapped and patients escorted by a healthcare assistant or porter. Furthermore, sedated patients returning from theatre require oxygen, suction, monitoring and resuscitation facilities on their transfer trolley due to long journey times.

There was no reception area within the AED facility and the reception area in theatre was unwelcoming with no access to toilets or immediate staff. In theatre, endoscopy patients wait in the ante room. This area should be made more welcoming with an emergency call system for patients, limiting access in the room to one patient to enable private discussions for consent.

Resuscitation equipment is not checked on a daily basis throughout all areas of the service and equipment not regularly replaced. Staff at Aberdeen Royal Infirmary were informed, at the time of the visit, to implement robust checking procedures and educate all relevant staff immediately. The positioning of resuscitation equipment to allow rapid access, particularly in the radiology department where ERCP is undertaken, requires immediate review for patient safety.

The assessment team noted that inadequate access to bathroom facilities was found within all endoscopy areas, in particular in relation to enema administration. The unit must ensure that adequate facilities are available to all patients. Equipment was also stored around the unit in corridors and decontamination areas. The assessment team recommends this be removed and stored in an appropriate area. In addition, all bed areas require access to oxygen and suction and monitors are required for each patient bed in all areas of the service.

The current plans for redesign of the unit do not include the endoscopy procedure rooms. The assessment team recommends that all rooms should be incorporated into the redesign and upgraded with the current works as a number of concerns were identified at the time of the visit. These include:

inappropriately positioned screens when layouts are changed


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unsafe cables and sockets which are trip hazards on the floor

degraded cupboard surfaces, and

redundant equipment and facilities and open storage areas which cannot be effectively cleaned and pose an infection control risk.

The assessment team recommends immediate review and action for the above and would also encourage review of door access to endoscopy rooms. Access should be limited to maintain patient dignity during procedures, with either curtains or a call system in place prior to entry. The NHS board subsequently reported that portable screens are present in all endoscopy rooms.

Inadequate staffing levels were recorded within both AED and the short stay unit, especially in regards to recovery. The assessment team informed the unit at the time of the visit that post sedation patients should not be left unaccompanied and immediate action was required. Additionally, there is only space for three beds in the short stay unit recovery area, which is inadequate should sedation be used for all patients. The unit should review capacity on the ward. In addition, at the time of the assessment visit, staff reported feeling isolated in the satellite units and regularly only one member of staff is present in recovery or decontamination areas; this raises concerns for both staff and patients’ safety. The assessment team recommends that a review of this is undertaken as a matter of urgency.

Decontamination

The assessment team noted that there was no endoscopy specific decontamination policy in place at the time of the assessment visit. The assessment team recommends this be developed in accordance with manufacturer and national guidelines and should clearly define decontamination in each area of endoscopy service.

Decontamination has multiple deficiencies in practice across all endoscopy decontamination areas. Decontamination rooms in all areas of the hospital were small, cluttered, contained inappropriate storage items and did not have adequate separation of dirty and clean equipment. The assessment team observed that members of staff in decontamination areas were not wearing full personal protective equipment and valves were not kept as a unique set to the endoscope.

There were inadequate sink facilities for manual cleaning of endoscopes, issues observed included: inadequate marking of water lines or dispensing of detergent, no temperature gauges, missing plugs which prevented the effective submersion and decontamination of endoscopes, and endoscope sinks were being used for hand washing. In addition, endoscope decontamination was not undertaken in accordance with endoscope manufacturer instructions, despite appropriate equipment being available. Staff consulted reported that they had been advised the practice of flushing endoscopes took too long and was not to be undertaken. Leak testers were showing clear signs of wear and inadequate cleaning.

At the time of the assessment visit, the assessment team noted that decontamination was being undertaken within temporary facilities with plans in place to build a central decontamination facility. The assessment team recommended that these temporary areas be reviewed and risk-assessed to ensure they are equipped with appropriate ventilation in line with Control of Substances Hazardous to Health Regulations. NHS Grampian provided evidence that risk assessments and staff health surveillance have been undertaken within the decontamination areas at Aberdeen Royal Infirmary.


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The assessment team also found relatively unrestricted access to endoscopes in many areas, including access by non-endoscopy staff to drying cabinets for gastrointestinal and non-gastrointestinal endoscopes. The endoscope washer disinfectors (EWD) in theatre and AED could also be accessed by non-endoscopy staff. The standards of training, competency and health surveillance were unknown for all staff members in these areas at the time of the visit and it could not be confirmed that endoscopes were used within the specified 3 hours of disinfection and drying. The NHS board subsequently reported that appropriate staff are trained in the use of drying cabinets and EWDs. The assessment team recommends that a full policy is developed for all areas to restrict access to endoscopes and equipment, and to ensure all staff with access have appropriate competencies and updates, with line management accountability to the endoscopy structure.

None of the decontamination areas could be effectively relied upon to provide a suitable method for endoscope tracking. A manual system must be implemented immediately across all areas, with a planned move to electronic tracking. An audit should be undertaken of the system once developed with resultant action plans. A full testing schedule with results is not available for all machines and areas. This should commence immediately in line with the action planning undertaken by the decontamination manager.

NHS Grampian has an out-of-hours policy on decontamination, however the assessment team recommends that this is reviewed to ensure safe reprocessing, eg including detergents used, amounts, storage of endoscopes, and tracking. Unit guidelines and a standard operating procedure for all endoscopy areas should also be developed, following immediate review by the decontamination manager.


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4 Detailed findings against the Global Rating Scale

Domain 1: Clinical quality

Consent process including patient information

Validated level: D

NHS Grampian has a clearly defined consent policy, which outlines the process for obtaining consent for clinical procedures and healthcare interventions. Evidence submitted prior to the assessment visit indicated that there was a local procedure in place for obtaining consent within the units at Aberdeen Royal Infirmary. However, in accordance with national guidelines, the assessment team recommends that a formal policy is developed that highlights the requirement for consent to be obtained outwith all endoscopy procedure rooms, and that measures are implemented to ensure this is undertaken.

In addition, the assessment team noted that there was no formal allocation of private discussion facilities available specifically for endoscopy patients and that the planned redesign of the main endoscopy unit will facilitate the consent process. At the time of the assessment visit, the unit highlighted proposals for both a nurse-led and postal-led consent process and the assessment team encourages this be pursued as an urgent action to improve the consent process. The withdrawal of consent policy was adequate and follows JAG Knowledge Management System (KMS) best practice.

At the time of the assessment visit, patient information leaflets for all procedures were under review. Assessment of existing leaflets highlighted a number of areas of proposed improvement. These include: adding information and recommendations with regard to latest National Patient Safety Agency (NPSA) bowel preparation alert for colonoscopy; adding information for patients who take clopidogrel; specifically quantifying individual risks for ERCP; and adding patient frequently asked questions within all leaflets. The assessment team recommends that following review, these leaflets also detail future review dates and a policy for subsequent annual review is developed. The assessment team also recommends the development of a unit policy detailing ward procedures when a patient calls the advice lines given on leaflets. The policy should also include an out-of-hours algorithm for specialist advice.

The patient satisfaction survey undertaken at Aberdeen Royal Infirmary contains questions regarding consent, however audit data submitted highlight that some patients responded that they were not aware of the risks of their procedures. This should be clearly identified within the pre-admission information and at the consent stage. The assessment team recommends an action plan be developed to address and rectify these findings.

Safety

Validated level: D

The endoscopy unit has procedures for adverse events recording. Events are recorded on a patient safety risk management software system (Datix) and linked to the endoscopy service risk register for review and action.

At the time of the assessment visit, local policies were in place for antibiotic prophylaxis, anticoagulant pathways and management of patients with diabetes undergoing endoscopic procedures. The assessment team noted that all policies require review dates and the unit should have a policy for annual review. It was further noted that the anticoagulation policy requires clarification and simplification with evidence that it is followed by endoscopy


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service staff. Adoption of the British Society of Gastroenterology (BSG) flowchart is suggested, with a local policy for implementation. BSG guidelines were not immediately accessible on the unit at the time of the visit and it was further proposed that an electronic version be placed on the desktop of the reporting computer to facilitate easy access.

A decontamination of general purpose equipment and reusable medical devices policy is in place across NHS Grampian. However the assessment team noted that there was no endoscopy specific decontamination policy, which reflects JAG standards and manufacturer guidelines, in place at the time of the assessment visit. The assessment team recommends that this be developed as a matter of urgency.

It was noted that service improvements including development of a centralised decontamination facility were in progress. However, at the time of the assessment visit, clear breaches in decontamination practice across all endoscopy service areas were identified. A complete JAG decontamination standards audit and safety risk assessment should be undertaken in each endoscopy area with an independent assessor. This will identify action plans to be implemented with immediate effect. Further recommendations include incorporating and embedding the process of decontamination audits within the clinical governance structure.

Prior to the assessment visit, the unit highlighted that there was no process in place for identifying in-patient deaths following an endoscopy procedure and all non-elective operations within 8 days. The assessment team recommends that processes are put in place to capture these data.

Comfort

Validated level: D

There are processes in place within the endoscopy service to monitor patient comfort scores during procedures. However, no subsequent audit of these data or feedback to staff has been undertaken. At the time of the assessment visit, the unit highlighted that it was currently awaiting the updated version of the Unisoft reporting software to allow reporting and feedback to individual endoscopists.

The assessment team recommends that following update of the Unisoft system, comfort score reports should be fed back to all endoscopists as part of performance review and comfort scoring discussed in endoscopy governance meetings with clear evidence of action plans and timescales. In the meantime, the assessment team recommends a snapshot audit of comfort be undertaken to baseline all endoscopists, using a paper-based system if required, with results actioned by the clinical lead. Development of a local policy for supporting colonoscopists who do not meet comfort standards should also be undertaken on the unit. The assessment team further suggests a section on comfort be added to the patient satisfaction survey to allow a clear representation of practices within the service.

Quality of procedure

Validated level: D

At the time of the assessment visit, there were no processes in place within the endoscopy service to undertake rolling audit of the required endoscopy standards within Aberdeen Royal Infirmary. The audits that were undertaken included the quality of bowel preparation, adenoma detection rates, colonoscopy completion figures, satisfactory PEG placements and sedation rates within the unit. However, the assessment team noted that the PEG audit should include more extensive data as in line with the BSG quality and


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safety indicators. The sedation audit should include dose ranges and separate patients into those over and under 70 years old in line with the BSG guidelines for sedation dosing. The comparative audit of reversal agents should include all endoscopists, associated sedation doses, procedure information and outcomes with appropriate action plans.

The colonoscopy completion audit figures presented at the time of the assessment visit demonstrated that a number of colonoscopists were not achieving the accepted standard of 90% unadjusted caecal intubation rate, with a number achieving less than 80%. Whilst it is accepted that there may be factual inaccuracies in the data due to input variability, these figures should be urgently reviewed and confirmed, and action plans with timescales implemented as required. Given the higher risks associated with ERCP, a paper record based audit of intended completion of therapeutic ERCP and decompression of obstructed ducts should be undertaken to baseline the endoscopists, with associated action plans.

In addition, data concerning the numbers of procedures undertaken by each endoscopist should be better organised and there needs to be further clarification surrounding which were substantive endoscopists and which were trainees. The JAG has issued guidance for supporting colonoscopists who do not achieve the national standards. The assessment team recommends that these be adapted for local use within the endoscopy service.

The assessment team further recommends that the updated Unisoft endoscopy reporting system be installed as a matter of urgency and that all endoscopists are trained in its use and input relevant data for all procedures. The unit should also institute a rolling audit programme, examples of which are available on the JAG KMS. Once audit data are available, the assessment team recommends these are discussed in the endoscopy service and governance meetings with associated action plans.

Appropriateness

Validated level: D

At the time of the assessment visit, there was no evidence to suggest that the unit had referral guidelines available for all diagnostic, open access, therapeutic and recall procedures within the service, or that local policies were in place for the vetting of referrals.

The assessment team recommends the unit develops clear referral guidelines and pathways for all patients, coming into a single point of entry, to provide equitable access for all. A local policy detailing procedures for the vetting of all referrals to the unit, including auditable outcomes for timeliness and completeness of vetting should also be developed. Furthermore, a clear process for the clinical validation of all surveillance procedures according to GRS standards needs to be developed and implemented within the unit.

The unit has a dedicated registered nurse to undertake pre-assessment of colonoscopy patients. Currently, a triage system is used to assign patients to the appropriate pathway and facility. The assessment team recommends that full pre-assessment be undertaken by the registered nurse via a telephone call to: determine specific health needs, eg anticoagulation management; to provide a discussion regarding bowel preparation in accordance with NPSA alerts and; to reduce the admission time on arrival at the unit.

Communicating results to the referrer

Validated level: D

Within the endoscopy service at Aberdeen Royal Infirmary, the service reported that endoscopy reports are completed on the day of the procedure and reports with follow-up


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procedures dispatched to the referrer within 5 working days of the procedure. Pathology reports for patients diagnosed with cancer are dispatched to referrers within 1 day of receipt of the report. There are procedures in place for receiving these reports and acting upon them within 5 working days.

However, the assessment team noted at the time of the visit that the current practice within the unit for communicating results to the referrer was inadequate, with results delayed and errors encountered due to the number of endoscopy sites and staff involved. The assessment team recommends the process is incorporated into the endoscopy booking team workload with additional resources allocated.

Recommendations – the unit must:

● Develop a formal policy to ensure consent is obtained out–with the procedure room.

● Initiate proposals for nurse-led and postal-led consent and pre-assessment.

● Improve patient information leaflets and develop a rolling system of review with clear review dates for all.

● Ensure all patients are suitably briefed on the risks associated with procedures.

● Develop an endoscopy specific local decontamination policy.

● Complete a JAG decontamination standards audit and safety risk assessment in each endoscopy area, with an independent assessor.

● Embed decontamination audits into the clinical governance structure.

● Ensure that the updated Unisoft endoscopy reporting system be installed as a matter of urgency and that all endoscopists are trained in its use and input relevant data for all procedures.

● Develop systems to effectively monitor patient comfort scores and ensure these are fed back to staff as part of performance review.

● Develop a local policy for the management of colonoscopists who do not meet comfort standards.

● Regularly audit endoscopy service quality standards and develop clear action plans and review, with results fed back to the team and clinical governance structure.

● Develop clear referral guidelines and pathways for all patients.

● Develop a clear process for clinical validation of all surveillance procedures.

● Develop a clear process for communicating results to the referrer.


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Domain 2: Clinical quality of patient experience

Equality of access and equity of provision

Validated level: B

NHS Grampian has had an equality and equal opportunities statement in place since 2005, alongside three specific equality policy statements relating to race, disability and gender. The assessment team was satisfied that all staff involved in the endoscopy patient pathway had undertaken equality and diversity training and that the equality and diversity policy and race equality scheme are included in endoscopy ward inductions.

NHS Grampian has conducted intensive demographic profiling of local communities and language profiling to ensure effective communication with the local population. Results confirm that the minority population in the area is below 3% and therefore written communication is only available in English. However, feedback is actively sought from minority groups. Involvement and consultation seminars are conducted twice every year with local ethnic communities in the planning of services.

Timeliness

Validated level: D

The endoscopy service at Aberdeen Royal Infirmary has a waiting list management system and demonstrated the capability to provide a snapshot of the waiting list position. However, at the time of the assessment visit, lists were used by endoscopists to add their own patients outwith the pooling process. The assessment team recommends full review with associated action planning for all lists, to ensure there is pooling across all specialty lists in all areas.

The assessment team was informed at the time of the visit that the service was using activity as a measure of capacity in the unit using procedure start and end times; this does not allow for an assessment of service efficiency in utilising available capacity. The assessment team would encourage senior endoscopy service managers to undertake a full review of activity before, during and after a session in all endoscopy areas, with action planning around service redesign. The assessment team recommends the process be reviewed using support available within the JAG KMS and Lean process.

Booking and choice

Validated level: D

The endoscopy unit at Aberdeen Royal Infirmary has a direct patient contact booking system. Patients are contacted initially by letter asking them to phone the booking unit to arrange a mutually convenient appointment. Patients are offered a choice of two appointments. Individuals who have not contacted the unit within 14 days are removed from the list and referred back to GPs. Urgent cases are initially allocated an appointment, with a choice offered if they are unable to attend. The assessment team highlighted that the current system of contacting patients by letter and awaiting their response could become problematic once waiting time limits are reviewed, and recommends further examination of the booking system.

Evidence submitted prior to the assessment visit indicated that there were relatively low levels of cancellation and did not attend (DNA) rates in the unit. However, staff indicated at the time of the assessment visit that a number of booking issues had been encountered at ward level regarding patients missing appointments and attending at alternative times.


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The assessment team recommends that the endoscopy service develops ways to identify these patients and creates procedures for the booking unit to address this. The service reported that individual errors are discussed within the booking team and a Datix report created to address these.

Privacy and dignity

Validated level: D

The patient pathway is severely breached with regard to privacy and dignity in all areas where endoscopy is undertaken at Aberdeen Royal Infirmary and the satellite areas are not suitable. The main endoscopy area was undergoing redesign at the time of the assessment visit and the assessment team recommends that these plans should incorporate the requirement for single gender pathways when patients are undressed or vulnerable. The recovery area is currently planned as single sex and requires redesign or single gender list allocation. The assessment team further suggested the unit offers dignity shorts to all patients, and gowns changed to front-fastening wear.

At the time of the assessment visit, endoscopy provision within the AED was found to be unsuitable with a small combined admission and recovery area. Patients were clearly on view to non-clinical staff and there was a lack of visitor accommodation. This area supports undressed patients, and at the time of the assessment visit was mixed gender. There was a lack of adequate toilet facilities, with enema administration conducted in a screened trolley area or within other rooms where available. The assessment team recommends a separate permanent ensuite facility is identified for enema administration. The assessment team recommends using the more suitable minor injury recovery facility for endoscopy patients.

Endoscopy provision within the day care unit was also found to be unsuitable. The combined admission and recovery area was small with only three beds and four chairs, and again supported undressed patients. The area was mixed gender and located on an open access corridor with patients on view to non-clinical staff and waiting visitors. Though a private discussion facility exists, nursing allocation does not support its use. There were no toilet facilities within easy access for patients; at the time of the assessment visit a commode was to be used by the bedside. The separate room for the administration of enemas does not have an ensuite toilet, though could be adapted.

While the essence of care standards do not currently apply in Scotland, equivalent standards do exist and the assessment team encourages NHS Grampian to develop a local action plan for the implementation of these.

Aftercare

Validated level: C

The endoscopy service at Aberdeen Royal Infirmary has general post procedure information sheets available for all procedures and aftercare sheets for common gastro-intestinal disorders. These include 24-hour contact information, however the assessment team recommends the unit develops a policy detailing who is appropriate to respond to calls and how those members of staff deal with telephone advice, alongside a process for logging calls.

Procedures are in place for providing information to patients post endoscopy, including processes for when malignancy is suspected. However, the assessment team noted that the discharge policy in place at Aberdeen Royal Infirmary was unsuitable and not patient


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focused, with the endoscopist discharging patients at the end of the endoscopy list. This creates long waiting times within the unit, breaches patients’ privacy and dignity, and causes problems concerning multiple discharges at a given time. The assessment team recommends that the unit develops a nurse-led discharge procedure based on national endoscopy competencies as a matter of urgency.

The unit has a patient survey in place, however this was not current and did not include action plans to respond to issues raised. The assessment team recommends that the unit implements regular patient surveys on a rolling basis for aftercare.

Ability to provide feedback on the service

Validated level: D

NHS Grampian has a clearly developed policy for complaints and a local policy has been developed for endoscopy services in Aberdeen Royal Infirmary. A rolling process of monitoring and review, with robust action planning required to ensure complaints are effectively addressed.

Patient feedback is obtained through the completion of feedback cards within the unit and through post procedure patient experience surveys. Evidence submitted prior to the assessment visit indicated that changes are being made in a direct response to patient feedback. For example a policy of staggered booking times was implemented as a direct response to patient waiting times within the unit. The assessment team recommends that feedback forms be clearly visible in all reception areas for patients to complete and would also encourage patient involvement in the planning and evaluation of services.


● Review the list management system and initiate a pooling system across all specialty areas.

● Undertake full review of activity before, during and after a session in all endoscopy areas to measure capacity.

● Review the current booking system and create procedures to address DNA and cancellation rates.

● Undertake immediate review and action in regards to patient privacy and dignity breaches detailed in the report.

● Provide private en-suite facilities for enema administration.

● Develop a rolling system of review with clear review dates for all post procedure booklets and develop a policy for patient telephone advice lines.

● Develop a nurse-led discharge procedure based on national endoscopy competencies as a matter of urgency.

● Review the local policy for complaints handling.

● Ensure feedback forms are clearly visible in public areas.


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Domain 3: Workforce

Skills mix review and recruitment

Validated level: D

There is a recruitment and selection policy and procedure in place throughout NHS Grampian. The Grampian area partnership forum, managed centrally by the director of human resources and strategic change, reviews the recruitment selection policy and procedure every 2 years. This ensures that the establishment and skill mix of NHS Grampian staff are reviewed when vacancies arise and that there is adequate support and the ability to recruit into vacant posts. However, the specific funding and establishment of the endoscopy service at Aberdeen Royal Infirmary requires urgent review in line with workforce planning using a workforce tool. The endoscopy service workforce needs a single directorate line responsibility to establish appropriate staffing levels and skill mix within the unit.

At the time of the assessment visit, the assessment team considered that the skill mix of the service could be improved. There should be a core endoscopy team which can provide a high level, well trained continuity of service. The use of bank staff, ‘flying start’ nurses and additional staff from other units, eg surgical staff who do not rotate around gastroenterology and endoscopy, does not provide the appropriate workforce required for the service requirements. The assessment team also noted that the relatively high sickness rate has impacted on staffing levels and action planning is required in line with establishment figures.

Orientation and training

Validated level: D

NHS Grampian has a policy in place for the induction, training and development of staff. The induction programme within the endoscopy service is suitable, but the assessment team recommends review in line with the national Gastrointestinal Endoscopy for Nurses programme.

A number of training issues were identified within the unit. Nursing staff interviewed at the time of the assessment visit did not demonstrate full understanding and competencies in endoscopy areas, particularly related to decontamination practice and patient recovery, thus causing a breach in patient and staff safety. Substantial training of nursing staff in decontamination using national competencies and guidelines should commence immediately. The unit would benefit from an intensive bespoke study day for all nursing staff to begin to accelerate the learning required. This should be supported by key training and review around decontamination.

In addition, there is a shortage of nursing staff within the service, which means that new nurses do not spend enough quality time with their mentors; the assessment team recommends that trained mentors work with junior staff to escalate the competency levels within the unit. Protected learning times have also been withdrawn within the unit, resulting in depreciation of key area competencies and the high through-put of junior staff has not been supported by additional learning time. The service should invest immediately in mandatory and competency-based programmes for nurses and protected learning times should be introduced.


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The assessment team also recommends urgent national endoscopy competencies training for additional staff. This will increase the cohort of registered nurses able to undertake ERCP and this should be linked to a formal rota for nurses to undertake on-call ERCP.

The assessment team also noted a number of concerns raised by patients in the patient satisfaction survey in regards to the endoscopy service. Patient feedback should be incorporated into learning outcomes for the nursing staff. The assessment team recommends action planning from the results of the staff feedback survey, with senior management support to implement changes in the service.

Assessment and appraisal

Validated level: D

Policies for the knowledge skills framework, appraisal and managing poor performance are in place throughout NHS Grampian and staff demonstrated understanding of these processes. Personal development plans (PDPs) are agreed following every appraisal and feedback from staff is sought annually on the appraisal process. Managers are supported to address poor performance within the system

The assessment team raised concerns about the availability of national workforce competencies as these were not used to assess performance at the time of the visit. There was also lack of evidence to support that all staff had attained the required competences to practice independently. The assessment team recommends that all nursing staff, who care for endoscopy patients, undertake competency-based training and review in line with national endoscopy standards and that these are independently monitored.

Staff are cared for

Validated level: D

NHS Grampian has policies in place for both health and safety and equality and diversity and these are available to all staff. However, at the time of the assessment visit, the health and safety policy was out of date. The NHS board reported that this had been recognised and accepted by the risk management group until the new head of health and safety was appointed.

At the time of the assessment visit, there were clear non-compliance in decontamination and health and safety legislation around the unit. These were primarily related to the use of Cidex ortho-phthalaldehyde (Cidex OPA) high-level disinfectant solution in inappropriate settings and access to storage. The assessment team recommends the unit undertakes immediate rigorous health and safety risk assessments across all endoscopy decontamination areas, alongside associated action planning to ensure staff practices are safe.

Staff feedback submitted as evidence prior to the assessment visit indicates that staff feel excessive pressure on a long-term basis. Insufficient time is given for breaks, the workload is increasing and becoming less manageable, staff are not receiving the required training to undertake their roles safely, they are not listened to, and regularly work additional unplanned hours. As a result, the nursing team morale is being significantly reduced and clear action planning is required to address concerns raised.


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Staff are listened to

Validated level: D

The endoscopy service at Aberdeen Royal Infirmary has monthly team meetings. The assessment team recommends that all endoscopy staff should have the opportunity to attend endoscopy service team meetings to contribute views and ideas about the running of the service. Resource constraints had caused some meetings to stop temporarily within the service and the assessment team recommends that these recommence on a monthly basis.

NHS Grampian reported that all unit policies and strategies are discussed at the endoscopy service users group for staff consultation.

Staff are aware of the processes to report adverse incidents in the unit, using the Datix incident reporting system. Feedback is obtained at exit interview when a member of staff leaves the unit, however completion of an exit interview questionnaire is not compulsory. Feedback is held centrally by HR and this is only relayed to the unit if there are difficulties in recruiting new staff. NHS Grampian reported, however, that an endoscopy staff satisfaction questionnaire had been developed to obtain annual feedback from staff on service developments and the quality of the work environment. This will be administered at the time of the next annual survey.

At the time of the assessment visit, there were no formal or informal reward systems reported to be in place for staff.

In addition, staff feedback on the day of the assessment visit highlighted that the rotation system between the gastroenterology department, bleed unit and endoscopy service is supported and enjoyed by the nursing staff. However, the time spent in each area needs to be reviewed as staff feel as though they are out of the main endoscopy area too long. The assessment team encouraged increasing methods of communication to ensure all staff groups are adequately represented and consulted over service delivery.


● Review funding and establishment of the endoscopy service, in line with workforce

planning, using a workforce tool.

● Review the endoscopy induction programme.

● Ensure that trained mentors work with junior staff to raise competency levels within the unit.

● Invest in mandatory and competency-based programmes for nurses and reintroduce protected learning times.

● Ensure that all staff that care for endoscopy patients undertake competency-based training and review in line with national endoscopy standards.

● Undertake action planning to address issues raised in the staff satisfaction survey.

● Undertake rigorous health and safety risk assessments across all endoscopy decontamination areas, alongside associated action planning to ensure staff practices are safe.


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● Ensure systems are in place to ensure all staff are represented at endoscopy team meetings, receive appropriate feedback and that their views are regularly sought.


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Domain 4: Training

Environment and training opportunities

Validated level: D

At the time of the assessment visit, the unit had 31 trainees with 12 designated training lists each week. The assessment team highlighted that this was too many trainees for the available training capacity. It recommends the training lead should identify those trainees with the greatest need in line with their deanery requirements and prioritise these to match training activity with capacity.

Current practice within Aberdeen Royal Infirmary highlighted areas of concern regarding training practices within the hospital. The assessment team recommends that endoscopy training should be formalised and organised in line with JAG standards. This should include the development of an endoscopy specific induction programme, organisation of training lists according to the needs of trainees, feedback to and from trainees, assessment and appraisal of trainees and trainers, and supervision and sign off according to competencies.

Endoscopy trainers

Validated level: D

At the time of the assessment visit, all non-surgical trainees have nominated endoscopy trainers. However surgical trainees do not have a specific endoscopy trainer allocated. The assessment team recommends that there should be a nominated endoscopy trainer for each endoscopy trainee, who is responsible for their endoscopy training, and feeds back to the training lead and the trainee’s clinical supervisor. The list of trainers should include all independent endoscopists who supervise trainees. To achieve the required standard for JAG accreditation, at least 50% of these trainers must have attended a train the trainer course and the unit should support this attendance.

Furthermore, the unit should identify a single nominated training lead that is separate from the endoscopy lead. It is recommended that the training lead is a faculty member on a JAG approved training course. This training lead should have time within their job description and be responsible for co-ordinating and planning the training of all trainee endoscopists regardless of specialty. In addition, endoscopy training should also be identified in trainer job plans. Key performance indicators within the GRS should be clearly linked to a trainer’s performance, with only those achieving key outcomes in line with BSG and JAG standards undertaking training of juniors in endoscopy.

The assessment team also recommends that the unit regularly seeks feedback from trainees regarding trainer expertise and noted that the proposed national roll out of the JAG Endoscopy Training System (JETS) e-portfolio will facilitate this process. There should be a unit policy concerning the input of endoscopy nursing staff into endoscopist training. An example can be found on the GRS KMS. Questions concerning endoscopist training should be included in the endoscopy nursing staff survey.

Assessment and appraisal

Validated level: D

NHS Grampian has a clear process in place for the appraisal and assessment of trainees. However, at the time of the assessment visit, there was no formal policy in place for the supervision, or defining and monitoring of the independent practice of trainees. The


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assessment team recommends the unit develops and implements a local policy reflecting JAG guidelines for supervision and competency-based sign-off of endoscopy trainees. This should incorporate all actions required for JAG accreditation and be implemented across all disciplines and endoscopy areas.

Examination of the unit, at the time of the assessment visit, confirmed that each room contained a register of trainees who were allowed to perform specified procedures independently. However, there was no evidence that trainees undergo full assessment on arrival or departure from the unit, or that direct observation of procedural skills forms were in use.

The assessment team also suggested that endoscopy trainers would benefit from a ‘supporting the trainers’ day within the unit to launch the formalised training process and clearly identify what is required for training in endoscopy. In addition, a nominated trainee from each of the disciplines should link with the training lead to ensure high quality training is provided, and to feedback on the training process.

Equipment and education materials

Validated level: B

The assessment team noted the standard of equipment and educational materials available within the unit and highlighted that the planned video link to endoscopy rooms from the education centre will be of great benefit to training when implemented.

The team further recommends that audit cycles should include outcomes for trainees in addition to independent endoscopists, noting that the adoption of the JETS e-portfolio will facilitate this.


● Review training activity and capacity within the service.

● Formalise and organise endoscopy training in line with JAG standards.

● Identify a nominated endoscopy trainer for each endoscopy trainee.

● Identify a single nominated training lead that is separate from the endoscopy lead.

● Identify endoscopy training in trainer job plans and link GRS key performance indicators to a trainer’s performance.

● Regularly seek feedback from trainees regarding trainer expertise.

● Develop a policy concerning the input of endoscopy nursing staff into endoscopist training.

● Develop and implement a local policy reflecting JAG guidelines for supervision and competency-based sign-off of endoscopy trainees.

● Ensure that audit cycles include outcomes for trainees in addition to independent endoscopists.


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Appendix 1: Glossary of abbreviations

Abbreviation

AED accident and emergency department BSG British Society of Gastroenterology Cidex OPA Cidex ortho-phthalaldehyde DCP Diagnostic Collaborative Programme DNA did not attend EUS endoscopic ultrasound ERCP endoscopic retrograde cholangiopancreatography EWD endoscope washer disinfectors GRS Global Rating Scale KMS Knowledge Management System JAG Joint Advisory Group JETS JAG Endoscopy Training System NHS QIS NHS Quality Improvement Scotland NPSA National Patient Safety Agency OGD oesopho-gastro-duodenoscopy PDP performance development plan PEG percutaneous endoscopic gastrostomy UGIE upper gastrointestinal endoscopy


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Appendix 2: Overview of Global Rating Scale and Joint Advisory Group Accreditation System

Global Rating Scale

In March 2006, a Diagnostic Collaborative Programme (DCP) was established to support NHS boards to redesign and improve their endoscopy services. The DCP introduced the Global Rating Scale (GRS) as a web-based self-assessment tool to be used by endoscopy units to assess how well they provide a patient-centred service for endoscopy procedures. Its principle purpose is to help improve the quality of patient care across a range of measures. This unique tool was developed and implemented in England by the English National Endoscopy Team and has now been widely adopted throughout Scotland.

GRS is used by clinical staff and management to self assess an endoscopy unit’s ability to deliver a quality service. The following key areas are considered:

● clinical quality

● quality of patient experience

● workforce, and

● training.

Endoscopy units work through the GRS tool which applies various levels from D–A. Level D is the minimum acceptable level and Level A is excellent. Units scoring levels B or A are said to deliver commendable quality of care.

Completion of GRS is an essential element of the NHS QIS Clinical Standards for the Bowel Screening Programme (February 2007) (Standard 6: Colonoscopy and histopathology).

Endoscopy units participate in the twice yearly national census in April and October. Further information on GRS can be downloaded from the website. (www.grs.scot.nhs.uk).

Joint Advisory Group Accreditation System

In England, the use of GRS has also been linked to the successful achievement of formal accreditation of a unit by the Joint Advisory Group (JAG).

There has been discussion among Scotland’s clinical community for some time about JAG visits across Scotland’s endoscopy units. JAG has defined the criteria necessary for successful accreditation (and re-accreditation), for example safety issues, plant, equipment, decontamination requirements and the training environment. Achievement of Level A for timeliness and Level B for all other aspects of the GRS is required to become an accredited unit.

The aim of the pre-JAG visit programme is to assess the state of readiness across NHSScotland endoscopy units for formal accreditation. Following completion of the programme, NHS QIS will recommend for accreditation those units that can demonstrate they are delivering safe, effective and patient centred care within endoscopy services to a high standard.


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http://www.grs.scot.nhs.uk/


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Appendix 3: Assessment process

The assessment process has three key phases:

● preparation prior to the assessment review which involves NHS boards and endoscopy units completing a twice yearly GRS census return and submitting a local self-assessment (JAG online checklist)

● an external assessment review by NHS QIS, and

● publication of a report following the visit.

Preparation

Firstly, each NHS board assesses its own performance using GRS (a web-based service improvement tool) to determine how well it provides a patient-centred service. The GRS assessment tool makes a series of statements requiring a yes or no answer. From the answers it automatically calculates the GRS scores, which provide a summary view of service provision. In addition, in advance of the visit, the NHS board endoscopy unit completes the JAG online checklist which includes guidance about the type of evidence (for example, protocols and audit reports) required to allow an external assessment of performance to be undertaken. An external assessment team validates the GRS scores, both by considering the self-assessment data and by visiting the NHS board to discuss related issues.

Pre-JAG visit

Each assessment team is led by an experienced assessor, who is responsible for guiding the team in its work and ensuring that the team members are in agreement about the assessment level reached. The team also has a member of the public to bring a patient’s perspective to the review of services. Members of the assessment team have no connection with the NHS board they are assessing. This factor helps to facilitate the sharing of good practice across NHSScotland.

During the visit, each multidisciplinary team assesses performance using the GRS rating scores D–A.

Where applicable, validation of GRS has taken account of standards and targets which apply in NHSScotland. For the purposes of pre-JAG accreditation, we are assessing and verifying that processes are in place to meet the requirements of SHTM 2030 in relation to washer disinfectors. Health Facilities Scotland is charged with ensuring that all decontamination standards are met by NHS boards in accordance with SHTM 2030.

Reporting

The final step in the assessment process is to publish the local reports on our website (www.nhshealthquality.org).

http://www.nhshealthquality.org/

We can also provide this information:

by email

in large print

on audio tape or CD

in Braille (English only), and

in community languages.

Edinburgh Office Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA Phone: 0131 623 4300 Textphone: 0131 623 4383

Glasgow Office Delta House 50 West Nile Street Glasgow G1 2NP Phone: 0141 225 6999 Textphone: 0141 241 6316

www.nhshealthquality.org

The Scottish Health Council, the Scottish Intercollegiate Guidelines Network

(SIGN) and the Healthcare Environment Inspectorate are also key components of

our organisation.

Endoscopy Assessment Report

Documents

Transcript of Endoscopy Assessment Report