Endoscopy targets/ DOPS/JETS/JAG

  1. JAG/JETS
  2. What is a JAG portfolio?
  3. The DOPS form- The e portfolio
  4. How to keep records or portfolio?
  5. What are the standards to meet-Certification Requirements
  6. What are the practical targets in different phases of the training?

What is JAG

The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was set up in 1994 to define the standards for all Endoscopists irrespective of their professional background and is responsible:

  1. For setting standards for individual Endoscopists
  2. To set standards for training in endoscopy
  3. To assure quality checks on the endoscopy units
  4. To assure quality checks on the endoscopy training courses

What is JAG portfolio

A completed JAG portfolio includes:

  • A lifelong summary of endoscopic training and procedure numbers.
  • Qualitative End-of-attachment Summary in each training unit.
  • Quantitative End-of-attachment Summary in each training unit including the necessary quality information:

JETS

  1. JETS (JAG Endoscopy Training System) comprises an e-portfolio and a booking system for JAG endoscopy courses.
  2. The e-portfolio module is a log book for trainees to document their endoscopic experience and demonstrate their performance and competencies. Some of the data logged into trainee e-portfolios populates a trainer portfolio. This will gradually replace the paper based portfolio and Endoscopy DOPS forms.
  3. The e-portfolio records procedure data, electronic DOPS assessments, endoscopy courses and personal development plans. It allows a trainee to ‘carry’ their data and certification levels with them from attachment to attachment, building up a training log accumulated from multiple sites and placements.
  4. Trainers can review recent progress of their new trainees, providing a seamless transition for trainees from one training unit to another.
  5. JETS produces procedure data and DOPS progression outputs, which provide an in-depth analysis of a user’s competencies, suitable for RITA panels and JAG certification.
  6. Trainees can give anonymous feedback on the training they receive. This combined with a record of each trainer’s training activity, DOTS forms (Direct Observation of Training Skills) and courses delivered and attended, builds up a portfolio of a trainer’s training experience.
  7. The ultimate aim of the JAG is for trainees to use the e-portfolio to create and submit JAG certification portfolios electronically, simplifying the process for trainees and JAG staff.
  8. The e-portfolio is setup per Trust or optionally for sites outside England and Wales. Each trust will be required to enter on the system a training lead, a trust administrator, a list of trainers and a list of trainees.

How to keep a record or portfolio

A simple log of proceedings for a minimum of 12 months containing

  1. Procedure type
  2. Procedure
  3. Date
  4. Age of patient
  5. Indication
  6. Findings ( for colonoscopy polyp detection)
  7. Sedation dose (mg midazolam etc)
  8. Assisted or unassisted and complications
  9. Level reached
  10. Complete/incomplete
  11. Bowel prep ( for lower gi)
  12. Biopsy result ( not needed but added value)

The data provided in the log must support the quality data provided in the portfolio.

Traditionally most trainees have kept their own records using a spreadsheet etc. It is envisaged that in future all trainees will keep their log/DOPS forms on the e-portfolio on the JETS website.

What are the standards to meet-Certification Requirements


  1. OGD
    • D2 >95%
    • ‘J’ Manoeuvre >95%
    • Serious Complications under 0.5%
    • Sedation Rates:Under 70 (? 5mg of Midazolam), Over 70 (?2.5 mg Midazolam)
  2. Colonoscopy
    • Caecal intubation> 90%
    • Polyp detection and removal >10%
    • Serious Complications under 0.5%
    • Sedation Rates: Under 70 (? 5mg of Midazolam), Over 70 (?2.5 mg Midazolam)
  3. Flexible Sigmoidoscopy
    • Descending Colon >90%
    • Polyp detection and removal >10%
    • Complications under 0.5%.
  4. ERCP
    • Success at Grade 1 >80%
    • Serious Complications < 5%

For certification, you will also need a declaration signed by your supervisor. Please be aware that this a separate document separate from the declaration attached to the summative DOPS forms.

The DOPS forms- directly observed procedural skills

  1. Allows formative assessment of endoscopic performance
  2. The forms provide supervisors with a quick and easy system for assessing and recording skills during supervised procedures.
  3. Whilst trainees should be supervised for all procedures until assessed and certified as competent,
  4. It is not necessary to complete a separate form for every individual case.
  5. It may be helpful to do this from time to time. However, it may be more pragmatic to complete the relevant form at the end of a training list, summarising the skills observed and the areas for development.
  6. Only those areas assessed at each training session should be graded.
  7. Current DOPS forms ( FORMATIVE AND SUMMATIVE)

Certification- General rules

The JAG will issue certificates to trainees if they have met the agreed criteria for each endoscopic procedure.The criteria for each procedure are specified in individual documents (see below: What are the standards to meet-Certification Requirements). Certification is a two-stage process:

  1. Provisional Certification- Endoscopists can scope independently, but should have a supervisor available for further targeted training on more advanced techniques and for difficult cases.
  2. Full Certification – Endoscopists can scope independently, but should still seek focussed endoscopic development

How to apply for certification

You need to complete, collate and send the following to the JAG office:

  1. Portfolio of all relevant procedures, including all DOPS forms
  2. Summary of performance data for that procedure – the Lifelong Summary of Endoscopic Training
  3. Must have met the agreed criteria for each endoscopic procedure (see below: What are the standards to meet-Certification Requirements)
  4. Verification of portfolio, performance data, and of summative DOPS assessment – the Declaration- found in the last page of the document- www.thejag.org.uk/Assessment/DOPSforms/Portfolio.aspx
  5. Payment -A cheque to the sum of £30 ( one cheque per discipline eg colonoscopy) made out to the JRCPTB to cover the administrative and certificate fee.
  6. Four summative DOPS assessment forms (assessed over two cases simultaneously by two different consultant assessors (not your supervisor) and achieve a scores of over ’3′ in all relevant areas.) and two declarations signed by both supervisors.

What are the standards to meet-Certification Requirements

Diagnostic OGD:

Eligibility Criteria: Performance Standards

  • Sedation levels in the under and over-70’s (?5mg midazolam in <70 yrs; ?2.5mg midazolam  in ?70 yrs in those patients not having topical anaesthesia)
  • Retroflexion in stomach to visualise fundus in ? 95%
  • Duodenal 2nd part intubation rates on an intention-to-intubate basis ? 95%

DOPS Standards
Grade 3 or 4 across all domains ( No grade 1’s or 2’s.)

*Criteria Thresholds
Lifetime endoscopy number > 200 (recommended)
Lifetime serious complications < 0.5%
Mean sedation rates under 70 yrs / 70+ Midazolam ? 5 / ?2.5 mg
Endoscopies in previous 12 months > 100 (recommended)
Retroflexion in stomach > 95%
D2 intubation > 95%
Data certified by the Endoscopic supervisor

To get full accreditation- as above plus

  • Trainer available within endoscopy unit to supervise next 50 “independent procedures”
  • Trainer available within hospital to supervise subsequent 50 procedures
  • Targeted training on difficult / complex cases
  • Peer review annually, using DOPS over 4 cases, by consultant trainers

Therapeutic UGI endoscopy

Eligibility Criteria: Performance Standards

  • Sedation levels in the under and over-70’s (?5mg midazolam in <70 yrs; ?2.5mg  midazolam in ?70 yrs in those patients not having topical anaesthesia)
  • Successful application of appropriate therapy in ? 90% patients (?success of the therapy)
  • Significant & immediate complication rate ?10% (or as deemed appropriate for that procedure)

Full accreditation in diagnostic upper endoscopy
> 300 (recommended)
Lifetime serious complications < 10%
Mean sedation rates under 70 yrs / 70+ Midazolam ? 5 / ?2.5 mg
Therapeutic procedures in previous 12 months > 30 (recommended)
Data certified by the Endoscopic supervisor

To get full accreditation- as above plus

  • Trainer available within endoscopy unit to supervise next 50 “independent procedures”
  • Trainer available within hospital to supervise subsequent 50 procedures
  • Targeted training on difficult / complex cases
  • Peer review annually, using DOPS over 4 cases, by consultant trainers

Flexible sigmoidosocpy

Eligibility Criteria: Performance Standards for Flexible Sigmoidoscopy

  • Descending colon intubation rates on an intention-to-intubate basis ?90%
  • Polyp detection rate of ?10%

Lifetime Flexible Sigmoidoscopy number > 150 (recommended)
Lifetime perforations < 0.5%
Flexible Sigmoidoscopy in previous 12 months > 100 (recommended)
Descending colon intubation > 90%
Polyp detection > 10%
Data certified by the Endoscopic supervisor

To get full accreditation- as above plus

  • Trainer available within endoscopy unit to supervise next 50 “independent procedures”
  • Trainer available within hospital to supervise subsequent 50 procedures
  • Targeted training on difficult / complex cases
  • Peer review annually, using DOPS over 4 cases, by consultant trainers

Colonoscopy:

Eligibility Criteria: Performance Standards for Colonoscopy

  • Caecal intubation rates on an intention-to-intubate basis ?90%
  • Sedation levels in the under and over-70’s (?5mg midazolam and ?50mg pethidine in <70 yrs; (?2.5mg midazolam and ?25mg pethidine in ?70 yrs)
  • Polyp detection & removal rate of ?10%

*Criteria
Lifetime colonoscopy number > 200 (recommended)
Lifetime perforations < 0.5%
Colonoscopies in previous 12 months > 100 (recommended)
Mean sedation rates under 70 yrs / 70+ Midazolam ? 5 / ?2.5 mg
Pethidine ? 50 / ?25 mg
Caecal intubation > 90%
Polyp detection & removal > 10%
Data certified by the Endoscopic supervisor

To get full accreditation- as above plus

  • Trainer available within endoscopy unit to supervise next 50 “independent procedures”
  • Trainer available within hospital to supervise subsequent 50 procedures
  • Targeted training on difficult / complex cases
  • Peer review annually, using DOPS over 4 cases, by consultant trainers

ERCP

Eligibility Criteria: Performance Standards*

  • ?80% satisfactory completion of intended therapeutic procedure in grade 1 cases
  • Complication rates < 5% (specify)

Lifetime ERCP number > 200 (recommended)
Complications < 5%
Satisfactory completion of intended
therapeutic procedure in grade 1 cases ?80%
ERCPs in previous 12 months > 75 (recommended)
Data certified by the Endoscopic supervisor

To get full accreditation- as above plus

  • Trainer available within endoscopy unit to supervise next 50 “independent procedures”
  • Trainer available within hospital to supervise subsequent 50 procedures
  • Targeted training on difficult / complex cases
  • Peer review annually, using DOPS over 4 cases, by consultant trainers

What does DOPS forms tell you: Passing grade is 3 and 4: Grade 1 and 2 means fail

Diagnostic and therapeutic OGD

Assessment, Consent and Communication

4 –

  1. Complete and full explanation in clear terms including proportionate risks and consequences with no omissions of significance, and not unnecessarily raising concerns.
  2. No jargon.
  3. Encourages questions by verbal and non verbal skills and is thoroughly respectful of individual’s views, concerns, and perceptions.
  4. Good rapport with patient.
  5. Seeks to ensure procedure is carried out with as much dignity and privacy as possible.
  6. Clear and appropriate communication throughout the procedure and afterwards a thorough explanation of results and management plan.
  7. Full endoscopy report, using objective description, agreed grading systems where possible, including all relevant details and sites of pathology.

3 –

  1. Good clear explanation with few significant omissions, covering key aspects of the procedure and complications with some quantification of risk.
  2. Little jargon, and gives sufficient opportunity for questions. Responds to individual’s perspective.
  3. Aware of and acts to maintain individual’s dignity.
  4. Appropriate communication during procedure including warning patient of probable discomfort.
  5. Satisfactory discussion of results and management plan with adequate detail. Satisfactory endoscopy report, using largely objective description, agreed grading systems where possible, including most relevant details and sites of pathology and therapy.

Safety and Sedation

Grade 4 –

  1. Safe and secure IV access with doses of analgesia and sedation according to patient’s age and physiological state, clearly checked and confirmed with nursing staff.
  2. Patient as comfortable throughout as possible.
  3. Oxygenation and vital signs monitored continually as appropriate, remaining satisfactory throughout or rapid and appropriate action taken if sub-optimal.
  4. Clear, relevant and proactive communication with endoscopy staff

Grade 3 –

  1. Secure IV access with a standard cannula and appropriate dose of analgesia and sedation within current guidelines, checked and confirmed with nursing staff.
  2. Patient reasonably comfortable throughout, some tolerable discomfort may be present.
  3. Oxygenation and vital signs regularly monitored and satisfactory throughout, or appropriate action taken.
  4. Clear communication with endoscopy staff.

Endoscopic Skills during Insertion and Withdrawal

Grade 4 –

  1. Excellent luminal views throughout the vast majority of the examination, with judicious use of key manoeuvres.
  2. Skilled scope steering and well judged use of distension, suction and lens clearing. Quick to use different technical strategies or manoeuvres when appropriate. Immediately aware of patient discomfort with rapid response.
  3. Smooth rapid and effective scope manipulation using angulation control knobs and torque.

Grade 3 –

  1. Check scope functions.
  2. Intubates oesophagus readily, and largely under direct vision.
  3. Clear luminal view most of the time.
  4. Adequate use of the angulation control knobs with smooth scope control.(into D2 & J-manoeuvre)
  5. Aids examination using distension, suction and lens washing.
  6. Aware of any discomfort to patient and responds with appropriate actions.
  7. Timely completion of procedure, not too quickly or too slowly for the circumstances.

Diagnostic and Therapeutic Ability

Grade 4 –

  1. Rapid recognition of all major anatomical landmarks present and rapidly identifies abnormal anatomy.
  2. Fluid pools fully suctioned.
  3. Thorough assessment and accurate identification of pathology present.
  4. Skilled and competent management of diathermy and therapeutic techniques.
  5. Rapid recognition and safe and comprehensive management of complications.

Grade 3 –

  1. Recognises all major anatomical landmarks and identifies abnormal anatomy.
  2. Fluid pools suctioned.
  3. Assesses and identifies pathology present.
  4. Competent management of diathermy and therapeutic techniques. Recognises and manages complications safely

Colonoscopy

Endoscopic Skills during Insertion and Withdrawal

Grade 4 –

  1. Excellent luminal views throughout the vast majority of the examination, with judicious use of “slide-by”.
  2. Skilled torque steering and well judged use of distension, suction and lens clearing. Rapid recognition and resolution of loops.
  3. Quick to use position change or other manoeuvres when appropriate.
  4. Immediately aware of patient discomfort with rapid response.
  5. Smooth scope manipulation using angulation control knobs and torque steering.

Grade 3 –

  1. Check scope functions,
  2. Performs PR.
  3. Clear luminal view most of the time or uses slide-by appropriately.
  4. Appropriate use of the angulation control knobs.
  5. Uses torque steering adequately. Aids progress using distension, suction and lens washing.
  6. Recognises most loops quickly and attempts logical resolution.
  7. Good use of position changes to negotiate difficulties.
  8. Aware of any discomfort to patient and responds with appropriate actions.
  9. Timely completion of procedure, not too quickly or too slowly for the circumstances

Diagnostic and Therapeutic Ability

Grade 4 –

  1. Excellent mucosal views throughout the majority of the procedure.
  2. Recognition of all caecal landmarks present or rapidly identifies incomplete examination.
  3. Faecal pools fully suctioned.
  4. Retroflexes in rectum.
  5. Thorough assessment and accurate identification of pathology present.
  6. Skilled and competent management of diathermy and therapeutic techniques.
  7. Rapid recognition and appropriate management of complications.

Grade 3 –

  1. Adequate mucosal visualisation with only occasional loss or sub-optimal views unless outwith control of endoscopist (eg stool, severe diverticular disease).
  2. Faecal pools adequately suctioned.
  3. Attempts to retroflex in rectum.
  4. Correctly identifies caecal landmarks or incomplete examination.
  5. Accurately identifies pathology and manages appropriately according to current guidelines.
  6. Correct and safe use of diathermy and therapeutic techniques.
  7. Rapid recognition of complications with safe management.

ERCP

Additional Safety issue
Grade 4

  1. Minimal radiation exposure commensurate with high quality imaging.

Grade 3

  1. Satisfactory screening, using techniques to reduce scatter, exposure times
  2. and radiation dose.

Endoscopic Skills during Insertion and Withdrawal

Grade 4 –

  1. Excellent views throughout the vast majority of the examination, with judicious use of key manoeuvres.
  2. Skilled scope steering and well judged use of distension, suction and lens clearing. Quick to use different technical strategies when appropriate.
  3. Immediately aware of patient discomfort with rapid response.
  4. Smooth rapid and effective scope manipulation using angulation control knobs and torque.

Grade 3 –

  1. Check scope functions.
  2. Intubates oesophagus readily, and negotiates pylorus under direct vision.
  3. Clear ampullary (or target) view most of the time.
  4. Adequate use of the angulation control knobs with smooth scope control facing the ampulla
  5. Aids examination using distension, suction and lens washing.
  6. Aware of any discomfort to patient and responds with appropriate actions.
  7. Timely completion of procedure.

Diagnostic and Therapeutic Ability

Grade 4 –

  1. Rapid location of ampulla and rapidly identifies abnormal anatomy.
  2. Smooth, rapid and preferential cannulation of the duct of interest.
  3. Thorough assessment and accurate identification of pathology present.
  4. Highly skilled management of catheters and other accessories, diathermy and therapeutic techniques.
  5. Rapid recognition and appropriate and comprehensive management of complications. High quality images.

Grade 3 –

  1. Recognises ampulla and anatomical landmarks and identifies abnormal anatomy. Preferential cannulation of the duct of interest in reasonable time.
  2. Assesses and identifies pathology present.
  3. Safe and competent management of catheters and other accessories, competent management of diathermy and therapeutic techniques.
  4. Recognises and manages complications safely.
  5. Satisfactory images.

What are the practical targets in different phases of the training?

  • Year one: Complete Basic upper GI Endoscopy course, learn OGD. It is useful to concentrate and become competent in one procedure before taking up another (like FS)
  • Year Two: Basic colonoscopy course, consolidate on year one learning and gains expertise in colonoscopy
  • Year Three: Therapeutic upper GI endoscopy course, Build up the numbers and consolidate above
  • Year Four: Participate in bleeding rota?
  • Before CCST: Must be signed off for diagnostic OGD and colonoscopy

If decided to go for ERCP/EUS – need at least 3 years of training +/- a fellowship

References/Acknowledgements:

  1. http://www.jets.nhs.uk
  2. http://www.thejag.org.uk/

Post a Comment