The importance of quality in everyday endoscopy practice is increasingly recognized.
The advent of organized bowel cancer screening programs has brought a focus on high-quality
colonoscopy worldwide and has driven the desire to extend quality assurance to all
aspects of endoscopic practice. Quality assurance has been shown to improve performance
[1], leading to increased patient satisfaction and improved health outcomes[2].
A significant variation exists in the performance of endoscopists and of endoscopy
units [3]. In colonoscopy, rates of cecal intubation, adenoma detection, and post-colonoscopy
colorectal cancer (an indicator of overlooked or incompletely excised premalignant
or malignant lesions) vary considerably between units [4], raising concerns about the quality of some services. These differences only come
to light when performance is measured, without which there is no opportunity to support
individuals or for endoscopy services to improve.
To maximize the potential to improve endoscopy quality, all domains of the service
should be measured, including equipment, staffing levels, timeliness, adherence to
clinical guidelines, and adherence to minimum recognized clinical quality standards
of procedures.
However, establishing a quality assurance structure for endoscopists and endoscopy
units is not a simple task. Candas and colleagues attempt to address this hot topic
in this issue of EIO [5]. The authors performed a robust mixed-methods systematic review of current literature
aiming to identify barriers and facilitators of colonoscopy quality program implementation
in endoscopy units. They examined the issue from four different perspectives: endoscopists,
nurses, patients, and healthcare managers. In total, 15 studies from across the globe
were included in the analysis, most being questionnaires or surveys. Disappointingly,
but perhaps not surprisingly, very few studies examined the issue from the perspective
of patients, nurses or managers.
Mixed-methods review methodology, although technically challenging due to the methodological
diversities between qualitative and quantitative studies [6] , is appealing as it incorporates qualitative and quantitative components of the
subject under research and can potentially provide robust answers to complex questions.
Candas and colleagues should be credited for selecting this method to determine factors
that can facilitate policy changes in endoscopy units toward the goal of quality improvement.
They grouped responses into three broad categories: features of continuous quality
improvement (CQI) programs, attitudes and perceptions, and organizational characteristics.
A couple of themes emerge. First, receptive users understand and are willing to embrace
quality improvement, particularly when there is clear evidence of gain and they have
some sense of ownership of the process. Nevertheless, they desire such a process to
be formative – involving education and training – and supportive rather than punitive.
We concur that such a holistic approach is far more likely to succeed. Users express
concern about the safeguarding of endoscopists’ confidentiality: this is understandable
and should be acknowledged when programmes are being instigated – in our experience
using a degree of data anonymity gives individuals greater confidence that the process
is supportive. The paper identifies that users want quality improvement programs to
be voluntary; surprisingly the authors appear to support this. We would argue to the
contrary: while a voluntary program is better than nothing, when possible, quality
assurance programs should be mandatory, otherwise those whose performance is suboptimal
may simply not participate, to the ongoing detriment of patient care.
Second, users correctly identify that for quality improvement to work, it needs to
be part of a broader culture of clinical excellence, incorporating strong leadership
and multidisciplinary teamwork. For such a program to succeed in the long term, it
needs to be organized and embedded in the routine activities of an endoscopy service.
Management buy-in and support with adequate resourcing (both financial and time) is
seen as important, as is keeping the scope of the project feasible by focusing on
a manageable number of key performance measures. Their study also shows that there
is a need to increase multidisciplinary involvement (nurse, managers, and patients,
as well as clinicians) in the development of quality improvement programs and in their
evaluation. This is especially pertinent for performance measures assessing the quality
of pre- and post-endoscopy components of a service, including patient satisfaction
and procedure timeliness.
While the paper does not deliver any surprises, it does nicely encapsulate the perceived
challenges of implementing quality assurance programs, which may promote the success
and endurance of future quality initiatives. Although the paper in this issue focuses
on colonoscopy, the message it delivers is equally applicable to all endoscopy.
There are several aspects of quality improvement and performance measures that are
not covered by the paper, presumably because they were not identified in the underlying
studies. These include using objective performance measures less susceptible to “gaming,”
and using standardized, evidence-based performance measures to allow meaningful comparison
between endoscopy services. We believe that these aspects are important. The ESGE,
supported by UEG, is currently developing such performance measures for endoscopy,
incorporating endoscopy service measures along with lower gastrointestinal, upper
gastrointestinal, small bowel, and pancreatobiliary endoscopy. This process is truly
multidisciplinary, involving clinicians, nurses, managers and, importantly, patients
[7].
The need for a standardized, global approach to quality improvement processes is now
more relevant than ever. Comparison of local quality data with standardized, international
performance measures can be a powerful motivation for individual services to aim to
higher standards, reducing performance variation between operators and units. That,
of course, is not an easy task, as it requires commitment from all involved parties,
including management. Nevertheless, the goal of improved patient health outcomes alone
justifies coordinated efforts towards this approach.
