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.
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.
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.
We support the ' Making Every Contact Count' approach to behaviour change in the promotion of health and wellbeing of individuals and communities.
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
Endoscopy Service Manager
Matron / Head of Nursing
Clinical Endoscopy Lead
Endoscopists and Nursing Teams
Decontamination Leads
Governance & Quality Teams
JAG Assessors and National Endoscopy Programme
Patient Experience Teams
