Job overview
The postholder will lead the strategic and operational delivery of the Trust’s Endoscopy JAG accreditation programme, ensuring the service consistently meets nationally defined standards of quality, safety, efficiency, and patient experience. As the Trust’s specialist for JAG Global Rating Scale (GRS) compliance, they will provide expert guidance, oversight, and assurance to clinical and operational teams, supporting the Endoscopy Unit to maintain continuous accreditation and embed a culture of excellence.
Working collaboratively with endoscopy leadership, governance teams, and wider divisional colleagues, the postholder will coordinate all aspects of the accreditation cycle, including evidence collection, service audits, patient experience measures, workforce development, and pathway optimisation. They will lead on the development and implementation of improvement plans, ensuring the service remains aligned with national best practice, regulatory requirements, and Trust priorities.
The role requires strong analytical, organisational, and communication skills, with the ability to influence at all levels and drive sustainable service improvement. The postholder will act as a key liaison with JAG, external assessors, and internal stakeholders, ensuring the Trust’s endoscopy services remain safe, effective, and responsive to patient needs.
Main duties of the job
* Lead, coordinate, and oversee the Trust’s JAG accreditation and re‑accreditation processes.
* Ensure the Endoscopy Unit remains fully compliant with all JAG Global Rating Scale (GRS) domains, KPIs, and quality standards.
* Develop and maintain a robust accreditation action plan, ensuring timely progress and escalation of risks.
* Act as the primary liaison with JAG, external assessors, and national endoscopy networks.
Working for our organisation
South Tees Hospitals NHS Foundation Trust and North Tees and Hartlepool NHS Foundation Trust now form University Hospitals Tees and as such you may be required to work at any site across both Trusts.
At North Tees & Hartlepool NHS Foundation Trust, we want our organisation to be the best place to work with the right staff, in the right roles, at the right time, to ensure we deliver exceptional patient care and experience.
We will support staff through providing an inclusive and supportive workplace with health and well‑being initiatives, staff benefits and opportunities for personal and professional development.
Evidence Management & Reporting
* Collate, validate, and submit all required evidence for biannual GRS submissions.
* Lead the preparation and coordination of the 5‑yearly face‑to‑face JAG re‑accreditation visit, including staff briefings, documentation, and service walkthroughs.
* Produce high‑quality reports for governance meetings, highlighting performance, risks, and improvement actions.
* Maintain accurate, up‑to‑date records of all JAG‑related documentation, audits, and quality metrics.
Quality Improvement & Patient Safety
* Promote a culture of continuous quality improvement across the Endoscopy Unit.
* Lead QI projects aligned to JAG standards, patient experience, and service efficiency.
* Support the implementation of national guidance, safety alerts, and best practice recommendations.
* Work closely with clinical leads to ensure safe staffing, training compliance, and competency frameworks.
Operational & Clinical Governance
* Contribute to the operational management of the Endoscopy Unit, supporting service planning and pathway optimisation.
* Participate in clinical governance activities including incident review, risk management, and audit.
* Ensure robust systems are in place for decontamination, equipment safety, and environment monitoring.
* Support workforce development, including training coordination, competency assessment, and staff engagement.
Stakeholder Engagement & Leadership
* Work collaboratively with nursing, medical, managerial, and administrative teams to embed JAG standards.
* Represent the service at Trust‑wide and regional endoscopy meetings.
* Provide expert advice and education to staff on JAG requirements and quality standards.
* Champion patient‑centred care, ensuring patient feedback informs service improvement.
Key Working Relationships
* Matron / Head of Nursing
* Clinical Endoscopy Lead
* Endoscopists and Nursing Teams
* Governance & Quality Teams
* JAG Assessors and National Endoscopy Programme
* Patient Experience Teams
Qualifications
* Registered Nurse or Senior Clinical Practitioner or Senior Administrator, with experience in Endoscopy.
Knowledge
* Detailed knowledge of the JAG accreditation process and Global Rating Scale (GRS).
* Previous experience of successfully achieving JAG accreditation.
Equality, Diversity and Inclusion
Everything we do is shaped by our values: Respect, Support, and Collaborate.
At University Hospitals Tees we want our workspaces to be places where everyone feels welcome, valued and safe. We treat people with respect, and we celebrate the differences that make each of us unique.
We welcome applications from everyone, no matter your age, background, race, religion, disability, sex, sexual orientation, gender identity, family circumstances or beliefs.
We are here to support you throughout your application and at every stage of your career with us. We believe we work best when we collaborate, learn from each other and build teams that reflect the communities we serve.
Disability
We are a Disability Confident Lead employer. This means we give fair and full consideration to applicants and will offer reasonable adjustments during the recruitment process. If you need help with your application, or need the information in a different format, please contact our recruitment team and we will support you.
Right to Work in the UK
The Trust welcomes applications from all candidates who meet the criteria for the role. Please note that from January 2021, to work in the UK all candidates who are not UK or Republic of Ireland (RoI) nationals require sponsorship unless they have permission to work via another route. Non UK/RoI candidates wishing to apply can self‑assess the likelihood of obtaining a Certificate of Sponsorship here: Work in the UK - GOV.UK (www.gov.uk)
We do not require a ‘Skilled Worker’ visa for all applicants. Those applying for health or social care may be eligible to apply for the Health and Care Worker visa instead.
As a supporter of the Armed Forces and an employer of Reservists, North Tees and Hartlepool NHS Foundation Trust are proud to be a signatory of the Armed Forces Covenant, which is a promise by the nation to ensure that those who serve or who have served in the UK Armed Forces (and their families) are treated fairly.
We recognise that reservists and veterans bring a variety of transferable skills and qualities to our workplace, developed through their military careers. Our commitment to supporting the Armed Forces Community has been recognised through the Armed Forces Covenant as a Silver Employer.
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