Measuring quality in endoscopy includes the assessment of appropriateness of a procedure and the skill with which it is performed. High-quality pediatric endoscopy is safe and efficient, used effectively to make proper diagnoses, is useful for excluding other diagnoses, minimizes adverse events, and is accompanied by appropriate documentation from beginning through end of the procedure. There are no standard quality metrics for pediatric endoscopy, but proposed candidates are both process and outcomes oriented. Both are likely to be used in the near future to increase transparency about patient outcomes, as well as to influence payments for the procedure.
Key points
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Quality measurements in pediatric endoscopy can be used to increase transparency about patient care processes and outcomes.
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Although the definition of quality for pediatric endoscopy is yet to be fully developed, it can be promoted by adhering to various established metrics for procedural documentation.
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The Gastrointestinal Endoscopy Competency Assessment Tool for Pediatrics Colonoscopy (GiECAT KIDS ) is a rigorously developed quality measure of procedural competence.
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Continuous quality improvement initiatives that engage trainees, as well as established pediatric endoscopists, to examine their own procedural processes and outcomes can be considered to be valuable at both the individual provider and endoscopy unit level.
Introduction
Measuring procedural quality should be expected to become an increasingly standard component of performing gastrointestinal endoscopy in children in the twenty-first century. Quality measurements in endoscopy, as in all aspects of medical practice, are increasingly being used to appraise clinical care processes, as health care in the United States and beyond continues down its current path of reformation. Such metrics are also likely to be used to increase transparency about patient outcomes, as well as to influence payments for the procedure. In turn, pediatric gastroenterologists must be open to defining aspects of high-quality endoscopy, as well as to begin to self-identify opportunities for improvement. The risk to not engage in the quality movement is that others (including regulatory boards, administrative agencies, or third-party payers) will define these measures for us.
Box 1 lists candidate quality metrics for pediatric endoscopy, which can be either process or outcomes oriented. Regardless of their origin or intended use, it is reasonable to mandate that all metrics devised to assess quality of pediatric endoscopy be accurate, meaningful, and practical. Measuring quality in endoscopy involves assessing 2 dimensions of care: (1) appropriateness of a procedure and (2) the skill with which the procedure is performed. It also should encompass the 6 domains of quality put forth by the Institute of Medicine, by ensuring that procedures are effective, patient-centered, safe, efficient, timely, and equitable. The definition of pediatric endoscopic quality is still to be fully developed; however, when viewed at the societal level, it is plausible to assume that endoscopy should be recommended and performed, when indicated, in an expeditious, skillful, successful, safe, and comfortable manner. Performance of pediatric endoscopy also should be of high value, providing the best quality for the least cost.
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To date, there are limited measures of endoscopic quality that have been universally accepted when treating either adult or pediatric patients. However, a number of high-stake interest groups, including the American Society of Gastrointestinal Endoscopy (ASGE), have put forward individual and multisociety consensus statements on the topic. In short, there is good agreement that a quality endoscopic procedure is safe and efficient, is used effectively to make proper diagnoses, can essentially exclude other diagnoses, minimizes adverse events, and is accompanied by appropriate documentation from beginning through the end of the procedure. This includes the documentation of timely communication of all results, including pathologic analysis of tissue sampling.
Common methods for improving quality in health care include the identification of threshold standards, below which care can be considered to be inadequate; benchmarking personal practice with that of peers; the provision of additional training and education; the performance of self-evaluation and reporting; as well as engagement in continuous quality improvement processes. The process of identifying a standard, and then evaluating whether all practice meets that standard, can be considered quality assurance. Although quality assurance is critical to all procedures, it only targets improvement or elimination of performance below the set threshold. In contrast, quality improvement assumes that there is variability in practice that can be used to motivate all performers on a “bell-shaped curve” to improve toward the highest levels.
Introduction
Measuring procedural quality should be expected to become an increasingly standard component of performing gastrointestinal endoscopy in children in the twenty-first century. Quality measurements in endoscopy, as in all aspects of medical practice, are increasingly being used to appraise clinical care processes, as health care in the United States and beyond continues down its current path of reformation. Such metrics are also likely to be used to increase transparency about patient outcomes, as well as to influence payments for the procedure. In turn, pediatric gastroenterologists must be open to defining aspects of high-quality endoscopy, as well as to begin to self-identify opportunities for improvement. The risk to not engage in the quality movement is that others (including regulatory boards, administrative agencies, or third-party payers) will define these measures for us.
Box 1 lists candidate quality metrics for pediatric endoscopy, which can be either process or outcomes oriented. Regardless of their origin or intended use, it is reasonable to mandate that all metrics devised to assess quality of pediatric endoscopy be accurate, meaningful, and practical. Measuring quality in endoscopy involves assessing 2 dimensions of care: (1) appropriateness of a procedure and (2) the skill with which the procedure is performed. It also should encompass the 6 domains of quality put forth by the Institute of Medicine, by ensuring that procedures are effective, patient-centered, safe, efficient, timely, and equitable. The definition of pediatric endoscopic quality is still to be fully developed; however, when viewed at the societal level, it is plausible to assume that endoscopy should be recommended and performed, when indicated, in an expeditious, skillful, successful, safe, and comfortable manner. Performance of pediatric endoscopy also should be of high value, providing the best quality for the least cost.
|
|
|
|
|
|
To date, there are limited measures of endoscopic quality that have been universally accepted when treating either adult or pediatric patients. However, a number of high-stake interest groups, including the American Society of Gastrointestinal Endoscopy (ASGE), have put forward individual and multisociety consensus statements on the topic. In short, there is good agreement that a quality endoscopic procedure is safe and efficient, is used effectively to make proper diagnoses, can essentially exclude other diagnoses, minimizes adverse events, and is accompanied by appropriate documentation from beginning through the end of the procedure. This includes the documentation of timely communication of all results, including pathologic analysis of tissue sampling.
Common methods for improving quality in health care include the identification of threshold standards, below which care can be considered to be inadequate; benchmarking personal practice with that of peers; the provision of additional training and education; the performance of self-evaluation and reporting; as well as engagement in continuous quality improvement processes. The process of identifying a standard, and then evaluating whether all practice meets that standard, can be considered quality assurance. Although quality assurance is critical to all procedures, it only targets improvement or elimination of performance below the set threshold. In contrast, quality improvement assumes that there is variability in practice that can be used to motivate all performers on a “bell-shaped curve” to improve toward the highest levels.
Measuring quality through procedural documentation
Quality in endoscopy can be promoted by adhering to various established metrics for procedural documentation. Box 2 lists recommendations for endoscopic procedure documentation that were proposed by the ASGE in a monograph on quality in 1998 that reviewed recommendations of various regulatory bodies, including the Department of Health and Human Services’ Agency for Healthcare Research and Quality, as well as the Joint Commission. Many of these key elements of documentation have since been supported by adult and pediatric studies as appropriate for universal application across endoscopic procedures. Generally speaking, pediatric procedural documentation of endoscopy is intended to maintain standards upheld in documentation of surgeries, as well as procedures in adults. Whenever possible, such standards should be evidenced-based.
Procedure Report
Date of procedure
Patient identification data (eg, Medical record number, account number, encounter number)
Procedure type
Indication for procedure
Patient medical history/comorbidities
Physical Status (American Society of Anesthesiology)
Endoscopic instrument identification data
Medications used (eg, general anesthesia, sedatives, antibiotics)
Anatomic extent of examination
Limitations of examination
Tissue or fluid samples obtained (number, location)
Findings
Diagnostic impression
Results of therapeutic intervention
Adverse events (immediate vs delayed)
Disposition
Recommendations for further care
Endoscopic Unit Record
(In addition to Procedure Report Data)
Duration of procedure
Presence of informed consent document
Evidence of preprocedural and postprocedural evaluation
Procedure Sedation Record
Evidence of postprocedure recovery (ie, Aldrete score)
Endoscopic quality should be assessed at each time point of a procedure, including before, during, and after its performance. Strictly speaking, the process of performing endoscopy often begins in the clinic with referral for the procedure, and ends after patients have left the procedural unit. Documentation that reflects the quality of each time point in the procedure is an imperative and must relate to critical elements.
Preprocedural elements that can be used to assess the quality of documentation of pediatric gastrointestinal endoscopy include clear mention of the procedural indication; discussion of informed consent, including discussion of risks, benefits, and alternatives to the procedure; evidence that the endoscopist performed a preprocedure assessment, either by documentation of a physical examination and/or by noting the patient’s physical status; as well as evidence that the endoscopist established a plan for how sedation would be achieved, even if that routinely involves an anesthesiologist-administered regimen.
Major intraprocedural elements should include a full description of the procedure performed, delineation of any findings with specific mention of anatomic landmarks, quantification of estimated blood loss, and note of any complications. Ideally, standard language is used to describe findings. Postprocedural elements that should be clearly documented to ensure reflection of procedural quality include cataloging of any patient recommendations postprocedure. There also should be clear documentation of communications that ensued regarding results of the procedure, including immediately after the procedure in terms of endoscopic impressions, and later, after processing and review of tissue samples.
Large multicenter studies of quality of endoscopy reports have shown clear gaps in documentation quality that may benefit from improvement. In particular, investigators examining data from the Clinical Outcomes Research Initiative or CORI project of more than 400,000 procedures over a 2-year period found tremendous variation in reporting, with many basic elements of procedural reports found to simply be missing. In similar findings using different methodology, Robertson and colleagues reviewed 122 separate endoscopy centers for adherence to ASGE guidelines for reporting. They set a threshold for adequate performance for any criterion at 70% compliance, and found that colonoscopy reporting practices were widely variable and often suboptimal, even with this low standard.
Endoscopy reports by pediatric gastroenterologists may similarly suffer from inconsistencies and significant provider variation. One recent study by Thakkar and colleagues examined more than 21,000 records from 14 pediatric centers in the pediatric endoscopy database system – clinical outcomes research initiative (PEDS-CORI) network for adherence to key quality indicators and found that more than half of pediatric endoscopy notes analyzed were missing at least one element. Key indicators included documentation of bowel preparation, ileal intubation rate, American Society of Anesthesiologists physical status, and procedure time. This study underscores the importance of focusing on standardizing documentation as a starting point for engaging in discussions of quality, even as we continue to explore best measures for pediatric procedures.
Quality and endoscopic training
Training in pediatric endoscopy may represent the most critical time to teach best practices around not only performing procedures, but also their documentation. The goals of training in endoscopy are to perform procedures, safely, completely, independently, and expeditiously; to accurately interpret and describe findings; to integrate endoscopic findings into the management plan; to recognize and manage complications; and to effectively communicate both the endoscopic and pathologic results of procedures to patients and to other clinical providers. Recent pediatric guidelines stipulate that trainees must aim to know appropriate indications, contraindications, and alternatives to procedures; appearances of both normal and abnormal findings; and how to select and apply appropriate sedation strategies and equipment. High-quality documentation of a procedure from both trainees and experienced endoscopists should routinely reflect attainment of each of these goals.
Of course, beyond learning to document, it is paramount that trainees develop procedural competence during their fellowship years. In this regard, the Gastrointestinal Endoscopy Competency Assessment Tool for Pediatric Colonoscopy (GiECAT KIDS ) should be recognized as the most rigorously developed quality measure to date for pediatric gastrointestinal procedures. The GiECAT KIDS was developed by Dr Catharine Walsh at the University of Toronto to support a competency approach to training and assessment of pediatric colonoscopy. Dr Walsh used a Delphi method involving more than 40 expert endoscopists from a variety of practice settings across North America. Through this process, 3 major domains of colonoscopy competency were developed: (1) technical (psychomotor skill), (2) cognitive (knowledge), and (3) integrative (judgment, clinical reasoning).
A final score on the GiECAT KIDS is calculated from 2 components. The first is an 18-item highly structured checklist, which outlines key steps required to complete the procedure. This checklist is modeled after validated versions used in general surgery and is scored dichotomously, where 1 = done correctly and 0 = not done or done incorrectly. The second component of the GiECAT KIDS score is a 7-domain Global Rating Scale (GRS), which is designed to assess holistic aspects of skill in terms of provider autonomy, including technical skill, strategies for scope advancement, visualization of mucosa, independent procedure completion (vs need for assistance), knowledge of procedure, interpretation and management of findings, and patient safety. Each domain of the GRS is scored on a 5-point Likert scale, with higher scores reflective of better performance (more autonomy demonstrated) by the endoscopist ( Box 3 ).
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