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Joint Advisory Group on Gastrointestinal Endoscopy (JAG) framework for managing underperformance in gastrointestinal endoscopy
  1. Srivathsan Ravindran1,2,
  2. Siwan Thomas-Gibson3,4,
  3. Keith Siau5,
  4. Geoff V Smith1,6,
  5. Mark Coleman1,7,
  6. Colin Rees8,
  7. Chris Healey1,9
  1. 1 Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
  2. 2 Department of Surgery and Cancer, Imperial College London, London, UK
  3. 3 Wolfson Endoscopy Unit, St Mark's Hospital and Academic Institute, London, UK
  4. 4 Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
  5. 5 Department of Gastroenterology, Dudley Group of Hospitals NHS Trust, Dudley, UK
  6. 6 Health Education England South West, Bristol, UK
  7. 7 Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
  8. 8 Population Health Sciences Institute, Newcastle University Centre for Cancer, South Shields, UK
  9. 9 Department of Gastroenterology, Airedale General Hospital, Keighley, UK
  1. Correspondence to Dr Srivathsan Ravindran, Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London NW1 4LE, UK; sravindran1{at}


Underperformance can be defined as performance which persistently falls below a desired minimum standard considered acceptable for patient care. Within gastrointestinal endoscopy, underperformance may be multifactorial, related to an individual’s knowledge, skills, attitudes, health or external factors. If left unchecked, underperformance has the potential to impact on care and ultimately patient safety. Managing underperformance should be a key attribute of high-quality endoscopy service, as recognised in the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation process. However, it is recognised that not all services have robust mechanisms to do this.

This article provides the JAG position on managing underperformance in endoscopy, defined through a practical framework. This follows a stepwise process of detecting underperformance, verification, identification of additional causative factors, providing support and reassessment. Detection and verification of issues may require use of multiple evidence sources, including performance data, feedback and appraisal reports. Where technical underperformance is identified, this should be risk stratified by potential risk to patient safety. Support should be tailored to each individual case based on the type of underperformance detected, any causative factors with an action plan developed. Support may include coaching, mentoring, training and upskilling. Wider support from the medical director’s office or external services may also be required. Monitoring and reassessment is a crucial part of the overall process.

  • endoscopy

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  • Contributors SR prepared the manuscript. ST-G, KS, GVS, MC, CR and CH contributed to manuscript drafts. All authors agreed on the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CR has received grant funding from ARC medical, Norgine, Medtronic and Olympus medical. He was an expert witness for ARC medical.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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