Successful applicants to the ASGE Endoscopy Unit Recognition Program (EURP) submit a summary of a recently conducted quality improvement (QI) project as part of the application process. The QI project in the spotlight this month looks at improving documentation of cecal intubation.
Quality Issue Addressed
Complete and accurate documentation is an important part of medical care. [Our endoscopy center] aims to provide and document care that meets the recommendations of the American Society for Gastrointestinal Endoscopy (ASGE) and American College of Gastroenterology (ACG), as well as others. [Our endoscopy center] utilizes the GIQuIC registry to collect and categorize data for quality improvement and for reporting to the Centers for Medicare and Medicaid Services Merit-Based Incentive Payment System. Measure QPP425 measures photo documentation of cecal intubation. While reporting quality measures in a Board meeting, some of the physicians felt that their documentation was better than the reported data.
We have been using our current electronic medical record (EMR) system for less than two years. In this timeframe, we have learned that reporting through the EMR sometimes leads to inaccurate data due to knowledge deficit. To have accurate reporting, the staff and physicians must document specifically as the EMR intended (i.e., free texting is not readily recognized by the reporting software, data are pulled from specific, predetermined parts of the chart)
Problem and Performance Goal
- Problem: Not meeting Goal for Measure QPP425 2022 Photo Documentation of Two or More Cecal Landmarks - Screening and Surveillance Colonoscopies.
- Goal: We will use this external benchmark goal of 95 percent as our goal.
Per GIQuIC, the goal is 95 percent documentation of two or more cecal landmarks on screening and surveillance colonoscopies. (Editor’s note: GIQuIC uses this goal based on the ASGE/ACG published paper Quality indicators for colonoscopy.)
Evidence of Data Collection
- Information collected: Initial data will be collected from the real-time reports in GIQuIC for quarters 2 and 3 in 2022. The percentage of patients who had a screening or surveillance colonoscopy and had 2 or more cecal landmarks documented is calculated by GIQuIC. Data that results below 95 percent is highlighted in blue.
Data Analysis
- Goal: We will use this external benchmark goal of 95 percent as our goal.
- Quarter 2: Three physicians fall below the goal mark of 95 percent, one physician is at 95 percent and one physician is above 95 percent.
- Quarter 3: Two physicians fall below 95 percent, two physicians are at 95 percent and one physician is above goal.
Comparison of Data
- The records that did not fall into the numerator for each physician were analyzed to determine why they were not included.
- Based on this data collection, we determined that there are multiple reasons that contribute to the low percentage rate of photo documentation.
- The physicians DID take cecal photos in all the cases where they should have, but in 69 records the documentation required for the EMR to capture was not there (did not label the photos at all or labeled with incorrect verbiage, i.e., "cecum" instead of "ileocecal valve" or "appendiceal orifice").
- In 18 cases, the patients underwent surgery and did not have a cecum. In these cases, the physicians had documented the surgery, but the EMR required the documentation in a specific format to accurately report it to GIQuIC.
- Based on this information we determined that both scenarios were caused by lack of knowledge about how the EMR reports and can be corrected with education on how to correctly document the data for reporting purposes.
Development and Implementation of Corrective Action
- Realizing that reporting through the EMR requires documentation to meet specific requirements, educational material from the EMR system was handed out and discussed with each of the physicians.
- The data regarding surgical patients is being reviewed with the EMR support team to determine the best way to document. The EMR does not have formatting for ileocecal or ileocolonic surgery with anastomosis. This is being addressed with the EMR and cases updated manually.
- Cases for which the physician entered the data in the incorrect location for capture will be reviewed with the physicians.
- There were multiple charts kicked out due to the technician documenting a cecum time despite previous surgery and no cecum. This scenario will be discussed with the technicians in the room and physicians will be reminded to notify technicians when there is no cecum.
- One physician’s numbers are lower due to not reaching cecum due to difficult procedures. The facility is moving to new scopes at the end of March 2023.
- Remeasurement will take place in 2022 fourth quarter and 2023 first quarter.
Remeasurement
- One physician falls below 95 percent at 92.62 percent for 2022 quarter 4.
- Same physician falls below 95 percent at 91.74 percent for 2023 quarter 1.
Additional Corrective Actions, New Current Performance Versus Performance Goal
- MD 8 documentation of two or more cecal landmarks decreased over the initial evaluation period. Although his percentage was lower it was determined that he was documenting correctly when he reached cecum but is having difficulty with the current scopes. This physician is rescheduling procedures where cecum is not reached, to be completed once scope transition at the facility is complete. The facility moved to new scopes at the end of March 2023. Re-evaluation will be completed on a month-by-month basis until the goal is consistently met.
Methods of Communication of the Study Findings Throughout the Organization
- Results of the study were presented to the Board and to the staff during the regular staff meeting. It will be submitted to the QI Committee at the next meeting.
- Staff were shown what to look for on the pictures of final record. Advised to remind MD to label pictures if not labeled.
Re-evaluation
- March 2023: All members were above 95 percent; site, 97.23 percent
- April 2023: All members were above 95 percent; site, 99.69 percent
- Although this is no longer a MIPS measure, our facility will continue to monitor for completeness of the record. (Editor’s note: The Quality indicators for colonoscopy paper listsp Cecal Intubation Rate [also known as photo documentation of cecal intubation] as a priority indicator for monitoring physician performance on colonoscopy. Maintaining this measure in a quality improvement program, as this unit is doing, is advised.)
We hope sharing this project summary will be useful to you and your practice.