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 establishing a QI/QA program to track endoscopy-specific quality metrics.
DEFINE
[Our] Medical Center is a National Cancer Institute-designated comprehensive cancer center that provides tertiary and quaternary cancer treatments. Historically, our gastrointestinal (GI) endoscopy division had focused on the diagnostic and therapeutic evaluation of cancer and cancer-related complications. However, with long-term survivorship with many of our patients, in 2018 we created a colorectal screening and prevention program. Our division has grown in the last four years from two faculty to five, and our screening/prevention clinic has attracted patients from the local/regional community. Mirroring this, our colonoscopy volume has also grown 78% with a 70% increase in screening and surveillance colonoscopies. As such, it was necessary that the development of a GI endoscopy-focus quality improvement (QI) and quality assurance (QA) program ensured that we were providing high quality patient care and emphasized endoscopy quality. In collaboration with the medical center’s Department of Quality, Risk, and Regulatory Management, Endoscopy nursing and technicians (within perioperative services at our institution), the Division of Gastroenterology established a GI Endoscopy QI/QA program in 2020 with the goal of establishing and tracking QI metrics and maintaining the highest level of QA. On a quarterly basis a meeting is held to review data, provide endoscopist’s report cards and discuss any QA cases using standardized medical center protocol. Our initial goals were to: (1) Track and report endoscopy quality metrics (cecal intubation rate, withdrawal time, adenoma detection rate/ADR, bowel preparation); (2) Identify areas for improvement/standardization of reporting; (3) Identify areas for future QI projects. This project reports the outcomes implementation of the endoscopist report cards of the measured QI metrics.
MEASURE
We used a combination of our endoscopy reporting software and electronic medical records to identify all patients undergoing screening and surveillance (for history of polyps) and manually extracted data (direct chart review) on QI metrics. We also assessed for standardization of colonoscopy reports with an emphasis on standardized polyp description. We initially gathered data on the preceding three months of procedures (September-December 2020; additional new endoscopists joined in 2021 and were included for 2nd quarter data in 2021) and initially presented the data in January 2021 (report card) with quarterly report cards thereafter to track progress. Individual endoscopists not meeting QI metric standards had meetings with the QI lead to identify ways to improve performance to meet metrics.
ANALYZE
Initial data showed four endoscopists met procedural QI metric thresholds (cecal intubation rate 96-100%; negative withdrawal time 7-15 minutes; ADR 30-45%; adequate bowel preparation 90-100%; n-65 procedures); a single endoscopist did not meet the ADR threshold on first report card with ADR of 13.6%, though this was based on just 22 procedures. Additionally, we identified incomplete pre-procedure history and physical documentation in 40 and 60% of reviewed cases in three endoscopists (100% in the other endoscopists). Furthermore, there was variation in the description of polyps in reports (size descriptions varying from use of millimeters to descriptors such as small, medium, large and morphology classifications varying from Paris classifications to no morphology classifications).
IMPROVE
We provided all endoscopists with quarterly report cards detailing their performance on QI metrics. Evidence-based best practices for improvement in ADR (i.e., withdrawal time, second look at proximal colon, retroflexion in proximal colon, use of distal scope attachments) were discussed regularly at monthly divisional journal clubs as well as quarterly QI/QA conferences, and we acknowledged that small sample size likely contributed to low ADR calculation in the single endoscopist with low value. Improvement in ADR was found in all endoscopists (including those who began above the benchmarks) with an improvement in the initial underperforming endoscopist to goal of 25%.
Pre-procedure H&P note writing was proctored by the lead QI physician with attention to the required components. Repeat measurement showed 100% compliance with complete H&Ps in 4/5 endoscopists with ongoing work to improve performance in the single endoscopist not meeting the goal.
Lastly, discussion of standardized polyp description in reports led to a consensus to abandon descriptive terms (small, medium, large) and uniformly use millimeter measurements for size as well as standard terms of sessile, pedunculated, flat (height less than 2 times the diameter) for all polyps (with one endoscopist continuing to further characterize by Paris classification). There was 100% adherence to this standardized description on repeat measurements by all endoscopists.
CONTROL
We found that regular report cards on performance improved endoscopist performance on endoscopy quality metrics as well as changed behavior to standardize reporting across endoscopists to allow for consistency. This was consistent with the published literature on report cards for ADR improvement and confirmed a similar effect in other outcome measures. We found that by gathering and reporting data (in pre-procedure H&Ps in particular), we were able to identify deficiencies that could be improved. Our QI/QA program is still in an early stage and there is enthusiasm and shared vision in providing high quality care. Future projects will focus on endoscopy efficiency, patient experience, and utilization of electronic medical records to improve tracking metrics.
We hope sharing this project summary will be useful to you and your practice. Learn more about gaining honoree status in the ASGE Endoscopy Unit Recognition Program. EURP honoree units may use the ASGE Quality Star logo in promotion of their units, receive premium educational content bimonthly via an exclusive e-newsletter, The Huddle, and enjoy a range of additional benefits. Questions should be directed to eurp@asge.org.