Accreditation Deferral At Jag Assessment: Where Do Endoscopy Services Need To Improve?

Introduction Endoscopy services are expected to meet standards in four domains to achieve JAG accreditation: clinical quality, patient experience, training and workforce. At a JAG assessment, accreditation is ‘deferred’ if the service does not achieve the standards. The aim of this study was to analyse the standards on which NHS and independent sector (IS) services have their accreditation deferred to highlight themes for improvement and identify where support is needed. Methods A retrospective analysis of accreditation assessments from Nov 2016 to Jan 2020 was performed. Services were included if they had a deferral based on one or more standards. Where services had multiple reasons for deferral under one standard, records were de-duplicated. The proportion of deferrals per standard was calculated. Wilcoxon signed-rank test was used to compare deferral proportions between NHS and IS services. Results 276 services underwent assessment, 90 services had reasons for deferral, across 1255 standards. 73% of services included in the analysis were NHS. Table 1 shows the standards that were most and least likely to cause deferral across each domain: When NHS and IS services were compared, there were significant differences for deferral reasons in the clinical quality (p Conclusions This study provides insights into reasons for accreditation deferral between NHS and IS services. There are clear differences with NHS services more likely to defer on patient experience standards and IS services on clinical quality standards. Further work will focus on qualitative studies to investigate these findings further with the aim of supporting services seeking accreditation.