Going digital: our journey to JAG accreditation

Ysbyty Ystrad Fawr is one of four endoscopy units within ABUHB. We provide elective outpatient services and are the ABUHB centre for bowel screening, which accounts for almost half of our elective activity. When our team was put forward for our first JAG assessment, we saw an opportunity to do more than prepare for accreditation. We wanted to examine how our service worked, involve the whole team in making improvements and create resources that would remain useful long after the assessment.

Creating a living digital resource

Instead of producing a conventional operational policy primarily for the assessment, we created a digital resource with standard operating procedures covering all aspects of the service and organised on the health board’s intranet. Each document has a named owner, approving body, approval date and review date. Procedures are regularly reviewed through our endoscopy user group, helping us keep information current and well governed, and where possible, policies are shared across all four endoscopy units. Local policies remain where arrangements are specific to Ysbyty Ystrad Fawr.

Our intranet brings together the weekly timetable, competency matrices, clinical guidance, patient information, forms, contact details and resources for training, audit, research and decontamination. It has replaced printed documents with an accessible resource that can evolve with the service.

Applying lean methodology to patient care

Some team members had trained with the Lean Management Centre and we adapted elements of the Toyota Production System for our service. One of our first projects examined every stage between an endoscopic cancer diagnosis and discussion by the multidisciplinary team, and using a point-of-occurrence approach, we identified delays. As a result, staging CT scans, and rectal MRI where required, can now be undertaken on the same day as an endoscopic cancer diagnosis.

We also introduced fast-tracking for urgent suspected cancer pathology and earlier referrals to prehabilitation and health optimisation services. Endoscopy nurses can make these referrals, helping patients receive support without unnecessary delay.

Designing information around patients

Working with our clinical psychology team, we developed easy-read information to help patients understand and prepare for endoscopic procedures. We also produced a short video walk-through for each endoscopy unit. All materials are available in English and Welsh.

Our patient representative helped shape this work and attended the assessment. We also updated our patient survey to reflect the People’s experience framework: guidance for NHS Wales, which has developed into an all-Wales patient endoscopy survey, enabling services to learn from feedback.

Making better use of capacity

Preparing for accreditation prompted us to review the efficiency of our endoscopy lists. All patients are now pre-assessed before their procedure date, either by specialist screening practitioners or an endoscopy nurse. Dedicated time for pre-assessment has improved list use and reduced wasted appointments. Procedures are allocated points according to their expected duration, with additional time for complex procedures and training. This has reduced under-booking and over-booking. Realistic scheduling supports patient safety, reduces waiting times and helps protect staff wellbeing.

Involving the whole team

A central lesson from lean management was the importance of involving everyone in improving the service. We established a task and finish group for the JAG application, with colleagues leading projects such as completing standard operating procedures and outstanding audits. A nominated nurse had protected time to upload evidence, but responsibility was shared across the team. We ensured the assessment reflected different experiences of the service. A resident doctor met the assessors, while clinical endoscopists, nursing colleagues, managers and our patient representative all contributed. Accreditation was not treated as a separate project imposed on the team. It became a way to recognise good practice, address gaps and make lasting improvements together.

Sharing what we learned

Following minor amendments, we were awarded JAG accreditation in September 2025. The assessors recognised our digital model, use of lean methodology and commitment to sharing innovation.

Accreditation was an important milestone, but the greater achievement was creating a resource and a way of working that will continue to support patients and staff. We are now working with the National Endoscopy Programme to develop shared resources, and our digital platform has been selected as a Bevan Commission Exemplar.

Our experience shows that preparing for accreditation does not have to mean producing documents that are used once and put aside. It can be an opportunity to improve care, build accessible resources and create a shared culture of continuous improvement.

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