Quality Indicators Common to All Gastrointestinal Endoscopic Procedures

Abstract

The field of endoscopy has evolved substantially in recent years, with advances in procedural capabilities, technologies, and delivery models. One constant, however, has been the commitment of professional societies, including the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG)—the 2 co-sponsors of this series—to the delivery of high-quality endoscopic care. This commitment is reflected, in part, by quality indicator documents, which aim to provide endoscopists and practices a framework through which quality improvement efforts can be operationalized. Generally speaking, quality in health care is the degree to which health services for individuals and populations increase the likelihood of a desired outcome and are consistent with current professional knowledge (1). In the endoscopic context, a high-quality procedure is one that is clearly indicated, during which relevant diagnoses are established or excluded, any therapy provided is appropriate and effective, and harm is minimized to the greatest extent possible. Toward this ideal, quality indicators have been developed to compare the performance of an individual or a group of individuals with available benchmarks. Quality indicators can be divided into 3 categories: structural measures, assessing characteristics of the entire healthcare environment (e.g., availability and maintenance of endoscopy equipment at a hospital); process measures, assessing performance during the delivery of care (e.g., proportion of patients who undergo biopsy sampling when Barrett's esophagus is suspected); and outcome measures, assessing the results of the care that is provided (e.g., proportion of patients who survive ≥30 days after endoscopic therapy for a bleeding gastric ulcer). By developing evidence-based quality measures; establishing performance targets, known as benchmarks, that reflect high-quality practice; measuring performance against these benchmarks; and implementing interventions to improve this performance, the quality of care delivered at the endoscopist, practice, and field levels can be maximized. Herein we present the quality indicators considered fundamental to the conduct of any endoscopic procedure. As such, most of these indicators are attached to a performance target of >98%, implying they should be achieved in nearly every case. The indicators that are unique to esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) are presented in detail in separate documents dedicated to these procedures (2–5). Revised versions of these documents are forthcoming. METHODOLOGY This work represents the third iteration of the ACG/ASGE quality indicators documents. The first version of this document was published by the ACG/ASGE Task Force on Quality in Endoscopy in 2006 (6) and was revised in 2015 (7). To the greatest extent possible, this current revision integrates new data relevant to existing quality indicators and introduces new indicators as appropriate based on interval progress in the field. This document focuses on quality indicators that are common to all gastrointestinal (GI) endoscopic procedures (Table 1). Table 1. - Quality indicators common to all endoscopic procedures with associated performance targets Quality indicator Strength of recommendation Measure type Performance target (%) Preprocedure 1. Frequency with which endoscopy is performed for an indication that is included in a published standard list of appropriate indications and the indication is documented (priority indicator) 1C+ Process >95 2. Frequency with which informed consent is obtained and documented 3 Process >98 3. Frequency with which preprocedure history and directed physical examination are performed and documented 3 Process >98 4. Frequency with which a sedation plan that includes risk for sedation-related adverse events is developed and documented before sedation is initiated 3 Process >98 5. Frequency with which prophylactic antibiotics are administered for appropriate indications (priority indicator) Varies Process >98 6. Frequency with which management of antithrombotic therapy is formulated and documented before the procedure (priority indicator) 3 Process >95 7. Frequency with which a team pause is performed and documented 3 Process >98 8. Frequency with which endoscopy is performed or supervised by an individual who is fully trained and appropriately credentialed to perform that particular procedure 3 Process >98 Intraprocedure 9. Frequency with which photo documentation is performed 3 Process >95 10. Frequency with which patient monitoring during sedation is performed and documented 3 Process >98 11. Frequency with which procedure interruption and premature termination because of sedation-related issues is documented 3 Process >98 12. Frequency with which endoscopic specimen verification is performed and documented 3 Process >98 Postprocedure 13. Frequency with which discharge from the endoscopy unit according to predetermined discharge criteria is documented 3 Process >98 14. Frequency with which patient instructions are provided 3 Process >98 15. Frequency with which endoscopic findings, pathology results, and follow-up recommendations are communicated to the patient and appropriate providers 3 Process >98 16. Frequency with which a complete procedure report is created 3 Process >98 17. Frequency with which adverse events are documented (priority indicator) 3 Process >98 18. Frequency with which adverse events occur 1C Outcome N/A 19. Frequency with which patient satisfaction data are collected N/A Outcome N/A Clinical implications of each strength of recommendation are as follows: 1A, strong recommendation, can be applied to most clinical settings; 1B, strong recommendation, likely to apply to most practice settings; 1C+, strong recommendation, can apply to most practice settings in most situations; 1C, intermediate-strength recommendation, may change when stronger evidence is available; 2A, intermediate-strength recommendation, best action may differ depending on circumstances or patients' or societal values; 2B, weak recommendation, alternative approaches may be better under some circumstances; 2C, very weak recommendation, alternative approaches are likely to be better under some circumstances; 3, weak recommendation, likely to change as data become available. As in preceding versions, we prioritized indicators that have wide-ranging clinical implications and have been validated in clinical studies. Unlike the documents pertaining to procedure-specific indicators, variation in practice and outcomes was not prioritized in this document because most indicators that pertain to all endoscopic procedures are expected to occur almost universally with minimal variability. data indicators the to be of clinical by progress has been in the in to however, and the to a of relevant not indicators to As quality indicators are divided according to 3 and each quality indicator is as an outcome or process outcome are considered quality of some can be or to in clinical practice because of the for of data follow-up and because or may be by In we provide process indicators as of high-quality endoscopic The of a process indicator on the evidence that with a relevant and with a strong The in this document pertain to endoscopic care. the quality of care delivered to patients is by including to the in which endoscopy is structural are in a separate document dedicated to quality The process and outcome included in this of documents are attached to a performance and each is considered a quality possible, the performance targets based on published informed by most indicators in this particular considered to perform a quality indicator a and the performance target was as >98%, because in very circumstances the quality indicator not be this the existing quality indicators and to or by based on including and strength of indicators for which was the a through a of of of from of the of this through The for each indicator included a of in and To the and of relevant each based on a revised when the strength of recommendation was according to a framework (Table this the strength of each quality indicator is divided a from a strong quality indicator that can be applied to most clinical to a weak quality indicator because of an of evidence the on The strength of recommendation for each indicator was established by of the Table 2. - Strength of recommendation Strength of recommendation of strength evidence can be applied to most clinical settings with results, likely to apply to most practice settings 1C+ evidence from can apply to most practice settings in most 1C may change when stronger evidence is available best action may differ depending on circumstances or patients' or societal with results, alternative approaches may be better under some circumstances weak alternative approaches are likely to be better under some circumstances 3 likely to change as data available from from evidence to to the is to that the included quality indicators and associated performance targets not reflect the standard of or and is a to apply any of the indicators in this document as the quality indicators are and to as a framework for quality improvement To improvement for endoscopists and in of quality the a of indicators based on clinical and of of the of procedures to an with and the of that quality improvement efforts on the indicators and progress to indicators is that endoscopists are at or after The preprocedure at the of first the patient and of the endoscopy team and at the of of sedation of the in Quality indicators for all endoscopic procedures that apply during this are appropriate informed risk management of prophylactic antibiotics and antithrombotic and team 1. Frequency with which endoscopy is performed for an indication that is included in a published standard list of appropriate indications and the indication is documented (priority indicator) Strength of 1C Performance of process indications for each endoscopic procedure are in the quality indicator document dedicated to that procedure. every an appropriate indication that in of these standard should be a procedure is performed for a the for the procedure should be in the In endoscopy is when the or the therapy provided improve patient outcomes and the clearly any have that when and are for appropriate relevant diagnoses are is most likely to in harm when performed in patients who the procedure In this revision of the quality indicator documents, indications have been for and endoscopy and and The indications for have been revised in which patients for endoscopy with the endoscopist, has been for 2 have that are for appropriate indications quality improvement efforts to endoscopy should developing for to indication and establishing that of some to the 2. Frequency with which informed consent is obtained and documented Strength of 3 Performance of process should be obtained and documented before the in some of should a of the sedation indication for the of the likely common adverse to the and patient is In when the patient is to provide consent and a is not procedures to the best should be applied (e.g., sedation for the procedure is provided by an a separate consent for sedation and obtained by that may be informed consent has patient and a process that patient and the patient to the relevant the procedure and to an informed or not to with the of the patient the to patient and in the healthcare on informed consent in endoscopy that consent may be obtained by any of the team practice or who are of and to the and of that and may be by and as as provided by and consent for a particular procedure that all the of consent may a with the may be for and The quality of informed consent has been an in most procedures that in the of high-quality for procedures associated with a risk of adverse events 3. Frequency with which preprocedure history and directed physical examination are performed and documented Strength of 3 Performance of process a preprocedure history and directed physical examination should be performed and The and American Society of a preprocedure that includes a health history and directed physical examination that are performed before the patient is and before endoscopy The history should on indications for the procedure as as that may the performance and of the procedure. The history should sedation-related issues including of adverse events with sedation or current and and history of or or physical examination that the conduct of the procedure should be performed by the This should at the very an examination as a for in the that an adverse as a is during or after the procedure. of the and is when sedation is administered by the and is the as in the of known or of a for after sedation to for events or adverse The history should the and of the to practice patients should not for 2 for a for or a with or for before sedation with and may a of to the risk of pertaining to by and management in patients and that may gastric as clinical data may the of quality indicator including before endoscopic have that patients have minimal in the and this was patients the or all the on the before the procedure 4. Frequency with which a sedation plan that includes risk for sedation-related adverse events is developed and documented before sedation is initiated Strength of 3 Performance of process any endoscopic a sedation plan that includes a risk for sedation-related adverse events should be considered and The of sedation should be as minimal sedation or of patients by established as the a commitment to harm and with or the procedure and the procedural sedation when sedation is administered by an from the can be to the and the The most for risk before endoscopic procedures are the and the The and patients on a from to and to and at risk of have that adverse events during to sedation The is based on a of the with in This has not been validated as a risk for endoscopic has clinical with the of sedation and a for management is a and may not be to an individual patient the that to a of sedation should be to patients of sedation sedation should be to patients who a of sedation should be to patients who a of 5. Frequency with which prophylactic antibiotics are administered for appropriate indications (priority indicator) Strength of according to procedure Performance of process antibiotics should be administered in settings for which existing evidence that they are This quality indicator to that antibiotics are in in which they have been however, the of antibiotics to is an clinical care and quality improvement endoscopy is not considered to be a risk for according to antibiotics to or adverse events are not for patients who are at the risk for these are not for patients with or any endoscopic in the of with complete the and and any endoscopic procedure In prophylactic antibiotics are in the in patients in is (e.g., in patients who have in patients any endoscopic procedure in patients with and the of adverse endoscopic in all or in patients and of a or This indication and be in detail in the indications for are in the procedure-specific documents. management is as a preprocedure quality that are during the procedure as appropriate indications 6. Frequency with which a plan for the management of antithrombotic therapy is formulated and documented before the procedure (priority indicator) Strength of 3 Performance of process plan the management of antithrombotic should be formulated and documented of the procedure and communicated to the patient and healthcare should be and at the of the procedure. and of Gastroenterology pertaining to the management of antithrombotic in patients endoscopy provide the most recent evidence-based on the of these in the In endoscopic procedures biopsy are considered to be of risk for bleeding and not of and endoscopic procedures are considered risk for and most circumstances of evidence that interventions to the interruption of as of in patients on may not and this should be considered in the management at risk for adverse events may of with a associated with (e.g., or or a history of a or after In most antithrombotic may be they In patients who have interventions with a bleeding the of to be into the type of endoscopic therapy performed and the risk of all endoscopic procedures can be performed on an to of and recent against interruption of this when for evidence that is before endoscopic procedures and that interventions can this a quality improvement in endoscopy 7. Frequency with which a team pause is performed and documented Strength of 3 Performance of process the the team pause to patient and procedure This should be performed and before sedation or before the in with team pause to as a before any procedure sedation or is by the for and The of this pause is to that the patient is the desired procedure and that as report and are to the the pause may for of or data that may the performance or of the endoscopic procedure. may provide the an to team the procedure and of from practice that or 8. Frequency with which endoscopy is performed or supervised by an individual who is fully trained and appropriately credentialed to perform that particular procedure Strength of 3 Performance of process quality endoscopic procedure is one that is performed by an who is credentialed on the of and for is most achieved through can be the of the desired and adverse events the quality of an endoscopic procedure. evidence the of a strong procedure with providers an risk of and bleeding during and procedural during of are in to and procedural to that providers are appropriately credentialed to perform endoscopic that criteria and and not the of procedures performed in or practice, should be to to in these are as follows: of when are should be and not by in procedure should not in and in a endoscopic procedure should that the is to perform to that procedure (e.g., standard in and for in The from the of or of the when sedation is the is This includes all the of the endoscopy as as the for the and of the procedure. to most endoscopic procedures is the of sedation and for patient 9. Frequency with which photo documentation is performed Strength of 3 Performance of process documentation of and pathology should be performed as a quality and to improve and care. the of endoscopic is to be in clinical current best practice and should be of pathology may patient of the with and for during This may provide the quality and of when patients present at a with are in documentation of the is the and most of that a complete has been achieved and is fundamental to the quality indicator is that the with and a of the with should be the or the the of or endoscopic of the before and after an (e.g., or and of any should be a of the before the procedure and of are The of photo documentation for procedures are in the procedure-specific documents. 10. Frequency with which patient monitoring during sedation is performed and documented Strength of 3 Performance of process with and should be during all endoscopic and should be at monitoring is in patients sedation and is that patient monitoring during sedation monitoring recommendations for and are included in published by the and and provide a to and in a during sedation monitoring has been associated with and in of patients endoscopy under sedation with and can be considered in this 11. Frequency with which procedure interruption and premature termination because of sedation-related issues is documented Strength of 3 Performance Measure process sedation-related including of and that interruption premature termination of the procedure should be Clinical in which the is the and of the endoscopic procedure is the of clinical care and should be of and premature termination of procedures have been as of sedation events should not be considered adverse events because the of these the to an endoscopic procedure may clinical depending on the this quality indicator should be documented and to practices and targets for is to that for these interventions may have events and should be in a the of process improvement and not as an of The should be to the of events that interruption or termination not to clinical and in the of a This is to apply to in which sedation is delivered by endoscopy efforts the endoscopy team and to risk when an or is are as 12. Frequency with which endoscopic specimen verification is performed and documented Strength of 3 Performance Measure process that obtained during endoscopy are in the with the endoscopy and are delivered to the appropriate is fundamental to high-quality care and by The of can in including or and The appropriate of is a process that are to and the most of which to be and of quality improvement interventions have been to the of specimen The document on quality indicators for endoscopy the of a on of specimen to and on specimen as a and quality This verification which and is by and should be performed for every specimen quality improvement in this on of the specimen as delivery to the or measuring the of or The from the the is Postprocedure procedure instructions to the and patients from adverse pathology with and assessing patient 13. Frequency with which discharge from the endoscopy unit according to predetermined discharge criteria is documented Strength of 3 Performance Measure process that the patient has predetermined discharge criteria is before discharge from the endoscopy endoscopy unit should have a criteria the patient before discharge from the unit criteria a of and of or and that the patient has these criteria should be 14. Frequency with which patient instructions are provided Strength of 3 Performance Measure process discharge should be provided in with the instructions should be provided to the patient before instructions should any or change in antithrombotic and new to as and should a or should be informed of and of adverse events that should a to the and to the clinical should be they be informed of relevant biopsy follow-up or of for should be 15. Frequency with which endoscopic findings, pathology results, and follow-up recommendations are communicated to the patient and appropriate providers Strength of 3 Performance Measure process The of the endoscopic procedure and follow-up recommendations should be communicated to the patient and all relevant providers in a have been the results and associated management implications should be communicated with the patient and appropriate To all results to the endoscopic procedure should be communicated in a of with patients can in and and action on of with care providers may in and patient results management (e.g., of colonoscopy, for of pathology results into the care plan that the patient and care team are of these and should in the after the procedure through and by of the procedure report and discharge may be when follow-up provided by or patient In patients with or to have for and of the care team should be of all results, and recommendations by or The with which patients and complete is a quality indicator that be with and of 16. Frequency with which a complete procedure report is created Strength of 3 Performance Measure process and procedure report is for every endoscopic procedure. The and documentation of endoscopic and recommendations patient care The report should be because the of may from relevant of the and of endoscopic may improve performance improvement and and endoscopic in this Quality and care that on the of data from The minimal of an endoscopy report are as of procedure data including in procedure in procedure patient history and physical examination not of informed consent and team pause procedure and of endoscopic including and of extent of examination Quality of for or in of examination of or obtained of events for care 17. Frequency with which adverse events are documented (priority indicator) Strength of 3 Performance Measure process adverse events should be according to of of to the endoscopic and degree of on the and this should be the of endoscopy is a of the and and is consistent with efforts by the of and consistent documentation of adverse events are fundamental quality because they provide endoscopists and practices the to quality to performance and to compare outcomes to for some adverse events that be providers and (e.g., efforts to the of adverse events to performance high-quality are and documentation of adverse which are known to be in and targets for quality improvement adverse is one that of the procedure or results in to the of the existing or and of adverse events in an to data and events can be based on as to and after an adverse the of that the adverse was to the endoscopic procedure possible, or should be have developed for adverse events and bleeding and efforts pertaining to procedures be for quality and improvement and The of adverse events or should be by the degree of to the patient and any in the plan of care. Preprocedure and adverse events that are at the of the endoscopy should be in the endoscopy events that are should be this documentation should be to the endoscopy report as an To document adverse events that occur after the patient has been from the endoscopy unit be on of an adverse by the patient or is likely because of adverse events or efforts to patients and adverse 2 after the are with the of documentation of adverse that the and to perform follow-up we that with this quality indicator become with of health practice management and endoscopy report which data to adverse to the patient and endoscopy may the associated with these 18. Frequency with which adverse events occur Strength of 1C Performance according to procedure Measure outcome events from to The of adverse events in is and for endoscopic procedures to for is during endoscopy in can occur in to of with The of during is with and from to is most associated with can after with or or clinical practice, bleeding for should be for and be in the of when the of is considered and is expected to be under when is as the for the of bleeding is after or endoscopic and The of bleeding after with is the clinical of is not and and the of these events to is a quality improvement and adverse indicators (e.g., as they pertain to quality improvement are in detail in the procedure-specific quality indicator documents, which should as the standard for each individual procedure. 19. Frequency with which patient satisfaction data are collected Strength of 3 Performance N/A Measure process on patient and satisfaction should be collected and validated The in and outcomes in gastrointestinal the of validated of patient satisfaction for after endoscopic procedures may be to to all in a may be is that these results be a quality improvement As of patients provide satisfaction and as for patient satisfaction are outcome indicators of patient and satisfaction may become The indicators common to all endoscopic procedures are appropriate as endoscopy performed for an indication present a standard list of appropriate prophylactic which are prophylactic antibiotics administered for settings in which they are antithrombotic which is antithrombotic and a plan management of antithrombotic and adverse with the plan to and document adverse events on preprocedure and efforts to and for adverse events are indicators can be in a of and improvement is very likely to have a on quality of care. In this we the quality indicators common to all endoscopic of these indicators fundamental patient or as informed a and and adverse events are in the into which providers with the fundamental of these indicators, the of and be data a of with these indicators are performed for adverse events are not and and the and patient is these to the quality indicators in this document and an plan for improvement in of should be a of the practice of In the quality indicators in this document are the on which the documents in this As the field of endoscopy to the and plan to this evidence and indicators of the the criteria for that to and of the and of data for the the work or for and of the version to be to be for all of the to

Topics & Concepts