The best programs are those where the QA process is mandatory and are overseen by those who have authority to act on the findings. If a scheme is voluntary, those whose performance is suboptimal may simply not participate to the ongoing detriment of patient care. Where it is not possible to mandate participation, some success has been achieved with schemes that incentivize participation—this has happened in both the United Kingdom and the United States, where participation or nonparticipation may result in financial reward or penalty.28
9.3.5 Negative Aspects
PMs are designed to measure and improve quality. However, there can be unintended consequences. Perhaps, the best described is the concept of “gaming”—that is, the endoscopist may either inappropriately adjust his/her practice simply to chase the PM target, or may adjust his/her reporting to make his/her figures appear better than they actually are (e.g., claiming that a failed colonoscopy was actually a flexible sigmoidoscopy so that it does not count against their cecal intubation rate). Clearly, this is an issue of integrity. Centralizing the process and using robust and objective measures less susceptible to gaming helps mitigate this risk, although it does not remove the risk altogether.
Another potential negative aspect of PMs relates to how data are published. Open publication of PMs, either among the wider health care service or to the public, permits users and commissioners of the service to assess quality for themselves. This can be very powerful in incentivizing improvements in quality. However, it can also have unintended consequences if data are open to misinterpretation or inappropriate comparison. This may lead to a defensive endoscopic culture, where endoscopists are unwilling to take on more complex cases where outcomes are likely to be worse. Strategies to address these issues include clear descriptions about the limitations of each PM, using procedure complexity adjustment, and carefully defining exclusions when calculating PMs. The pros and cons both of open publication of data and of using named or anonymized reporting of PM data should also be considered, particularly when programs are being investigated—the initial use of a degree of data anonymity can give individuals greater confidence that the process is a supportive one.
Fig. 9.4 An example of automated output from the English Bowel Cancer Screening Programme.35
9.4 Quality Improvement
Measuring quality is only one component of the broader concept of quality improvement. Quality improvement also requires the creation of a supportive culture within endoscopic services, including training, accreditation, and management of underperformance.
In recent years, the quality of endoscopy training has become increasingly sophisticated and structured, incorporating virtual reality simulators, cadaveric models (particularly for therapeutic procedures) and programs involving evidence-based one-to-one training, bespoke courses with trainers with expertise not only in endoscopy but also in teaching methodology, and formative training assessments (
Formal accreditation (credentialing) of endoscopy trainees prior to independent practice is increasingly common and undoubtedly adds a level of protection for patients from inexperienced and incompetent endoscopists. Nevertheless, its global introduction, particularly for endoscopists who are currently practicing independently, is controversial. Many services have compromised by introducing accreditation only for newly-trained endoscopists, anticipating that, within a generation, all independently practicing endoscopists will have been accredited at inception.
When potential underperformance is identified by measuring PMs, it is important that further analysis and action is handled in a supportive and constructive manner. Many organizations have developed well-defined, open, structured processes for managing underperformance,29 and when handled sensitively, experience shows that most endoscopists embrace such support. However, this is not universal and on occasions there may be resistance to engagement with such processes from individuals or even from services. This may be driven by embarrassment or fear that one’s abilities might be demonstrated to be suboptimal, and may be pronounced if there are financial or service drivers to continue with the status quo. Nevertheless, it is essential for high-quality patient care that these barriers are overcome.
Unfortunately, trials of initiatives to improve specific aspects of endoscopic quality have not been universally successful. For example, evidence reveals that endoscopists who spend more time inspecting the colonic mucosa find more pathology11; however, initiatives to mandate a minimum withdrawal time have produced mixed results.30,31,32 We should not use this as evidence to give up on quality improvement though—these studies further our understanding of the techniques that underpin high-quality endoscopy, allowing us to refine training methodology. Moreover, such direct interventions are only one component of quality improvement—more global quality improvement initiatives have been highly successful: for example, in the United Kingdom, introducing PMs along with additional measures such as structured training programs resulted in significant improvement in endoscopy quality, where cecal intubation rate improved from 76.9 to 92.3%.18
Fig. 9.5 An example of automated endoscopy training data from the UK JETS training scheme.
9.5 Summary
Quality in endoscopy is essential to maximize the benefit and minimize potential harm from these common, invasive procedures. The potential benefit to public health from improving endoscopy quality is large. Despite half a century having passed since the advent of flexible endoscopy, embedding QA and quality improvement into everyday endoscopic practice remains very much in its infancy. PMs are being developed for all aspects of clinical care. The importance of objective, standardized, and automated processes, mandated and coordinated at a regional or national level, is increasingly recognized. There remains, however, a need to prioritize research to strengthen the evidence base for quality metrics and effective quality improvement initiatives.
References
[1] Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine; 2000
[2] Rutter MD, Rees CJ. Quality in gastrointestinal endoscopy. Endoscopy. 2014; 46(6):526–528
[3] Rajasekhar PT, Rutter MD, Bramble MG, et al. Achieving high quality colonoscopy: using graphical representation to measure performance and reset standards. Colorectal Dis. 2012; 14(12):1538–1545
[4] Baillie J, Testoni PA. Are we meeting the standards set for ERCP? Gut. 2007; 56(6):744–746
[5] Cotton PB. Are low-volume ERCPists a problem in the United States? A plea to examine and improve ERCP practice-NOW. Gastrointest