Introduction

Variability in the quality, safety, and patient experience in endoscopy is well recognized and therefore quality assurance programs that have the potential to assess all aspects of care and support safe and high‐quality patient‐centered care are important. Even if a patient has a procedure which is technically excellent, adverse experiences such as poor communication can negatively influence patient experience and therefore there is a need for a holistic assessment. Whilst quality improvement is a process based upon cycles of measuring, planning, implementing, and further measuring, quality assurance is a process that ensures a predetermined set of standards is achieved.

The Global Rating Scale (GRS) is a web‐based, self‐assessment quality improvement tool, that enables units to assess how well they provide a patient‐centered service, track their progress during quality improvement, and drive changes. The GRS was initially developed and implemented in the adult endoscopy services in England in 2004. Adult experience demonstrated that although adult endoscopy services were encouraged to generate a continuous quality improvement cycle, it was insufficient to achieve sustained results. Quality assurance via the professionally led peer‐reviewed accreditation process helped achieve the stepwise change in quality of endoscopy care [1,2]. All adult endoscopy units in the UK currently complete the GRS online census twice a year and after a unit achieves the required levels across all items, it can apply for accreditation.

Internationally, the GRS has been shown to be applicable in Dutch adult endoscopy units [3] and has been adapted for use in Canadian adult endoscopy units [4]. A Scottish study conducted focus groups with patients and concluded that the GRS did address quality issues that mattered to patients undergoing endoscopy and validated its use as a quality assessment tool [5].

However, it is evident that the adult GRS is not applicable to pediatric endoscopy services and there has been a need for a pediatric‐relevant and ‐applicable GRS.

Pediatric endoscopy GRS

The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) and Royal College of Physicians of London (RCP) collaborated to develop a pediatric GRS by adapting the established adult framework. This was successfully piloted nationally and ensured that the standards and measures were relevant to pediatric endoscopy services and fit for purpose [6].

The pediatric GRS provides a holistic assessment and consists of four domains, each of which refers to a broad aspect of care (Table 7.1): clinical quality, quality of patient experience, workforce, and training. Each domain is composed of qualitatively different items or standards covering all the aspects of endoscopy delivery and no standard is more or less important than any other.

Different levels can be achieved for each standard, ranging from D (Basic) to A (Aspirational). Levels create a more complete picture of what is going on by describing the different levels of achievement for a standard.

Each standard is composed of several measures which are unambiguous statements that have been designated a level from D to A. They would either have been achieved or not achieved by the service completing the assessment. To attain a level, the service must achieve all the measures up to and including that level. Based on the responses, levels for each standard are generated and provide a summary of the service. It is recommended that a core team consisting of clinical endoscopy lead, nurse endoscopy lead, and operational manager completes the GRS census.

The results of the national pediatric endoscopy pilot [6] were similar to the experience of the adult endoscopy units when they first started using the adult GRS in the UK [2] and to the Canadian adult endoscopy services when they first used the modified Canadian GRS [4]. It is important to highlight that this does not imply poor performance but is simply a starting point. This could occur because there may be areas where improvements are needed such as access to an electronic endoscopy reporting system or the unit is currently unable to measure, record, and review their performance. It did allow pediatric endoscopy units to identify what the quick wins for their unit were and in addition promoted collaboration between units, sharing of good practice documents and pathways and supported greater patient involvement in pediatric endoscopy services (P. Narula, unpublished results).

When the adult GRS was first implemented in 2004, the majority of the adult endoscopy units were achieving a level C or D. Following the implementation of the GRS and development of a professionally led peer‐reviewed accreditation process, there was an acceleration in service improvement and endoscopy units developed policies and processes to help meet the standards, resulting in a majority achieving the required level B across all standards [1,2]. A knowledge management system was also created which allowed services to share best practice pathways, policies, and guidelines [2].

The future

Adult experience has shown that the endoscopy GRS allows for continuous quality improvement as the endoscopy units are regularly reviewing practice, looking for opportunities to further improve care and putting in measures to help achieve the highest standards of quality and patient‐cenetred care. The GRS also promotes benchmarking and collaborative working, allowing units to share solutions to common service problems or deficiencies. It is flexible in practice as it does not set specific outcomes but refers to current speciality guidelines and ensures adherence to these. As pediatric endoscopy services embed the use of the GRS in their clinical practice as a quality improvement tool, this will help not only to identify any gaps or improvements needed to deliver high‐quality patient‐centered care but also serve as leverage for clinicians to request the necessary support from their hospital management. It is envisioned that in time, quality assurance by a pediatric accreditation process will help sustain and accelerate service improvements triggered by the pediatric GRS.