Quality indicators for gastrointestinal endoscopy units

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1 GUIDELINE Quality indicators for gastrointestinal endoscopy units Prepared by: ASGE ENDOSCOPY UNIT QUALITY INDICATOR TASKFORCE Lukejohn W. Day, MD, Jonathan Cohen, MD, FASGE, David Greenwald, MD, FASGE, Bret T. Petersen, MD, FASGE, Nancy S. Schlossberg, BSN, RN, Joseph J. Vicari, MD, MBA, FASGE, Audrey H. Calderwood, MD, FASGE, Frank J. Chapman, MBA, Lawrence B. Cohen, MD, Glenn Eisen, MD, MPH, FASGE, Patrick D. Gerstenberger, MD, FASGE, Ralph David Hambrick, III, RN, John M. Inadomi, MD, Donald MacIntosh, MD, Justin L. Sewell, MD, MPH, Roland Valori, MD INTRODUCTION fi cation and adoption for use in other countries across 10,11 8,9 However, there are limitations and Canada. Europe with the GRS. Whether improvements in 1 particular cant efforts have been dedicated to de fi ning what Signi fi indicator are correlated with other areas of endoscopy constitutes high-quality endoscopy. These efforts, centered unit performance and outcomes cannot be ascertained fi ning, and implementing procedure- on developing, re 1-5 from the GRS data. Also, the process for developing and associated quality indicators have been helpful in pro- reaching consensus on the GRS indicators has varied moting best practices among endoscopists and providing extensively in their rigor and breadth of stakeholder partic- evidence-based care for our patients. At the same time, ipation. To date, no such effort to identify and promote the American Society for Gastrointestinal Endoscopy endoscopy unit – level quality indicators has been per- (ASGE) has generated programming to assist physicians formed in the United States. and allied healthcare professionals in understanding how A compendium of quality indicators for endoscopy units in to translate quality concepts into practice. With this the United States is needed to strengthen programming work, we now have a stronger sense of how to measure around the promotion of quality and to give endoscopy units quality at the patient and procedural level. an organizational framework within which they can direct A critical component of high-quality endoscopy services their efforts. As healthcare reimbursement in the United relates to the site of the procedure: the endoscopy unit. States becomes moredependent upon demonstrationofper- Unlike many procedure-associated quality indicators, formance and quality, endoscopists,governingorganizations, evidenced-based indicators used to measure the quality payers, and patients will be looking for guidance on endos- of endoscopy units are lacking. Outside of the United – wide performance. Consequently, the ASGE copy unit s National Health Services ’ States, the United Kingdom 6 convened a taskforce whose primary objectives were to (1) developed the Global Rating Scale (GRS) in 2004 with es key qual- develop a comprehensive document that identi fi the dual aims of enhancing quality while developing fi ity indicators for endoscopy units as de ned by the literature uniformity in endoscopy unit processes and operations. and expert opinion and (2) achieve consensus on these qual- This scoring system was the fi rst to assess service at the ity indicators from important stakeholders involved in endos- level of the endoscopy unit and has been instrumental in copy unit operations and quality improvement ( Video 1 , reducing wait times, identifying service gaps, increasing available online at www.VideoGIE.org ). patient satisfaction, and reducing adverse events within 7 endoscopy units in the United Kingdom. Additionally, the GRS has demonstrated that measuring an endoscopy METHODS unit parameter repeatedly and incorporating it into a quality improvement program leads to improvement for 6-8 Endoscopy unit quality indicator taskforce many indicators. Use of the GRS has spread with modi- A taskforce composed of a diverse group of 16 represen- tatives from various GI practice settings both in the United States and internationally was assembled on May 19, 2013. The taskforce consisted of gastroenterologists (14) and GI 2017 American Society for Gastrointestinal Endoscopy. ª Copyright nurses (2); 8 of the members also held leadership roles Published by Elsevier Inc. This is an open access article under the CC BY- within their endoscopy units. The taskforce was further NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). http://dx.doi.org/10.1016/j.vgie.2017.02.007 divided into 5 working subgroups to address the following domains: (1) patient experience, (2) employee experience, If you would like to chat with an author of this article, you may contact Dr (3) ef fi ciency and operations, (4) procedure-related Day at [email protected] . www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 119

2 Endoscopy unit quality indicators endoscopy unit issues, and (5) safety and infection control. respondents agreed with the importance and relevance The leader of each working subgroup plus the 2 taskforce of a potential quality indicator and (2) the extent to which 16 chairs (L.W.D and J.C.) formed the steering committee. The consensus respondents agreed with one another. process consisted of 2 rounds of online voting using the REDCap program (UCSF, San Francisco, Calif). Each Study design participant was randomly assigned to complete a survey The project was divided into 3 phases: (1) systematic related to 1 of the 5 domains. There were 495 individuals literature review and generation of potential endoscopy invited to participate in the survey, including physicians, unit quality indicators by each of the 5 subgroups; (2) fi cers who were nurses, practice managers, and quality of approval of these potential endoscopy unit quality indica- involved with or impacted by quality in U.S. endoscopy tors by the steering committee and then rating of these po- units. tential indicators on several parameters by invited fi In the rst round of voting, participants provided demo- ed Delphi method; and (3) fi participants using a modi graphic information, including gender, role within an reaching consensus on a fi nal set of endoscopy unit quality endoscopy unit, and practice setting, and then were asked indicators. The steering committee unanimously agreed to rate each potential quality indicator on the following 4 upon the methodology as outlined above. questions: “  Is this potential indicator an important parameter nalization of Generation, development, and fi related to the quality of care for a patient in an endos- potential endoscopy unit quality indicators ” (ie, related to quality) copy unit? Over the course of 9 months each subgroup leader “  Is this a meaningful element of a high-quality endos- conducted a systematic literature review using PubMed, copy unit / important outcome? ” (ie, meaningful to Google Scholar, Embase, and Medline using key search measure) terms to identify endoscopy unit quality indicators for their Is this feasible to measure?  “ ” (ie, feasible to measure) respective domain. In the absence of data that linked  Is your endoscopy unit currently compliant with this “ endoscopy unit level indicators with improved patient ” parameter? (ie, compliance with the indicator in their outcomes, subgroups relied on expert opinion and existing own endoscopy unit) regulatory standards. The subgroups initially examined the 6 strongly Z Ratings were based on a 5-point scale (1 work of the United Kingdom ’ s GRS and the Canadian neutral/uncertain, 4 agree, disagree, 3 Z disagree, 2 Z Z Association of Gastroenterology consensus guidelines on 10 strongly agree). Only those respondents who partici- Z 5 safety and quality indicators to help develop a pated in the rst round of voting were invited to partici- fi framework for generating potential endoscopy unit pate in the second round. In the second round, quality indicators. The subgroups used this framework to participants were shown the same set of potential quality generate a candidate list of endoscopy unit quality s previous response indicators along with the individual ’ indicators that were then reviewed by the steering and the most common response of the overall group for committee. The steering committee subsequently met on the question on relatedness of the indicator to quality. ne these potential endoscopy fi March 7 to 8, 2014, to re Participants were then asked How would you now rate “ unit quality indicators and unanimously agreed upon using the same rating scale. Two reminder ” this parameter? 155 potential quality indicators (patient experience, 46; emails were sent to all invited participants during the ciency and operations, 25; fi employee experience, 33; ef course of the survey. No incentives were offered. procedure-related, 24; and safety and infection control, After both rounds of voting were complete, research 27) for the voting phase of the study. questions were generated by each subgroup and then ned fi For the purposes of this guideline, the taskforce de reviewed and unanimously agreed on by the steering a quality indicator as a particular parameter that is being committee. used for comparison. A quality indicator is often reported as a ratio between the incidence of correct performance and the opportunity for optimal performance, or as the Invited participants proportion of interventions that achieve a prede fi ned Given that a number of groups are involved with quality 12 goal. as it pertains to an endoscopy unit, a broad range of indi- viduals were invited to participate in the survey. Invited participants included the nurse manager and medical Reaching consensus on endoscopy unit quality indicators s ’ director from endoscopy units participating in the ASGE Endoscopy Unit Recognition Program, all members of the Given the lack of available data on endoscopy unit qual- ASGE s Quality Assurance in Endoscopy Committee, ’ ed fi ity indicators, the steering committee used a modi 13-15 regional presidents of the Society for Gastrointestinal Delphi method to reach consensus on which of the Nursing Association, and members of the American Gastro- fi nal guideline. 155 proposed indicators to include in the enterological Association and American College of Gastro- The goal of the Delphi process was to measure 2 enterology ’ s committees on quality. All respondents were main parameters for consensus: (1) the extent to which 120 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

3 Endoscopy unit quality indicators TABLE 1. Characteristics of the respondents for the endoscopy unit quality indicator survey Safety and Employee Patient * infection control, Total, Procedure-related, experience, Efficiency and experience, N (%) n (%) n (%) operations, n (%) n (%) n (%) 90 495 Invited, n 102 103 93 107 32 (31.4) 29 (28.2) 171 (34.5) Any partial or complete 39 (43.3) 35 (32.7) 36 (38.7) response, n (%) 8 (8.9) 10 (10.8) 8 (7.8) 11 (10.7) 49 (9.9) 12 (11.2) Completed part 1 only, n (%) 15 (14.0) 30 (33.3) 25 (26.9) 22 (21.6) 18 (17.5) 110 (22.2) Completed part 1 and 2, n (%) Female gender, n (%) 24 (68.6) 26 (66.7) 21 (58.3) 15 (46.9) 14 (50.0) 100 (58.8) Role, n (%) 15 (53.6) Physician 15 (42.9) 17 (43.6) 16 (44.4) 18 (56.3) 81 (47.6) 37 (21.8) 5 (17.9) 5 (15.6) 7 (19.4) 11 (28.2) 9 (25.7) Nurse 23 (13.5) 3 (10.7) 4 (12.5) 6 (16.7) 5 (12.8) 5 (14.3) Practice manager 4 (10.3) 5 (13.9) 4 (12.5) 5 (17.9) 21 (12.4) 3 (8.6) Quality officer/administrator Other 3 (8.6) 2 (5.1) 2 (5.6) 1 (3.1) 0 (0.0) 8 (4.7) Setting, n (%) 18 (64.3) Hospital-based 17 (48.6) 19 (48.7) 18 (50.0) 18 (56.3) 90 (52.9) 13 (40.6) 9 (32.1) 18 (50.0) 71 (41.8) Ambulatory center 16 (41.0) 15 (42.9) 3 (7.7) 0 (0.0) Office suite 0 (0.0) 1 (3.6) 7 (4.1) 3 (8.6) VA 0 (0.0) 1 (2.6) 0 (0.0) 1 (3.1) 0 (0.0) 2 (1.2) VA , Veterans Administration. *Note: 1 respondent did not complete the demographics section. endoscopy unit. These 5 indicators were selected using ed with respect to name and institution during fi deidenti high-priority quality indicator “ ” nitions of a fi previous de the 2 rounds of voting. and were based on clinical relevance and importance, and cant perfor- fi evidence or consensus that there was signi Statistical analysis 4 mance variation of the indicator among endoscopy units. Respondent characteristics that were collected as To avoid excluding other important endoscopy unit continuous data were presented as means with standard quality indicators, all potential endoscopy unit quality deviations, whereas categoric data were presented as pro- indicators, and their representative scores from the survey, Table 1 portions ( ). The median was reported along with are included in Tables 2 to 6 . the associated percentage of individuals who reported rst that median for each of the questions asked on the fi Ethical considerations and second rounds of voting for all of the potential This study was part of an ongoing quality improvement ). endoscopy unit quality indicators ( Tables 2-6 project aimed at developing quality indicators for endos- Potential indicators had to meet 2 initial requirements to copy units in the United States. Given that the study was be considered for inclusion in the fi nal guideline (ie, the related to quality improvement and no personal health consensus threshold): (1) the indicator had to have a me- information was collected at any time, formal institutional ” dian of “ 5 (strongly agree) on the second round of voting, review was not required. 80% of respondents  and (2) the indicator needed to have ” on the second round of voting. rate that indicator as a “ 5 Afterward, only the 6 highest-rated indicators (ie, those in- RESULTS dicators with the highest percentage scores for respondents in the second round of voting) ” 5 “ rating that indicator a Survey respondent characteristics nal guideline. fi from each domain were included in the There were 495 individuals that were invited to partici- These cutoff criteria were established to identify those indi- pate in the survey. The overall survey response rate for cators that were rated most important by respondents and rst and the second round of voting was 22.2% both the fi to provide endoscopy units a feasible framework for which (range, 14.0% to 33.3%) with the greatest response rate to identify and start measuring quality indicators. Finally, in the domains of employee experience and ef fi ciency from among this group of indicators, the steering commit- and operations. The majority of respondents were female tee identi fi ed 5 priority indicators that were determined (58.8%) with respondent s role in the endoscopy unit ’ as those most compelling to measure for a high-quality being either a physician (47.6%) or a nurse (21.8%). Most www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 121

4 Endoscopy unit quality indicators TABLE 2. Survey results using the Delphi method to examine potential endoscopy unit quality indicators for the Patient Experience domain [ 27), median (%), 1st round voting (n 2nd round voting strongly disagree, 5 [ 15), median (%) [ strongly agree 1 (n [ ’ communication needs and Related to Patients Meaningful to Related to Feasible to Compliance in own measure (%) endoscopy unit (%) quality (%) quality performance measure (%) 5 (64.7) 4 (22.9) 5 (80.0) Communication needs are recorded as 5 4.5 (50.0) part of the nursing assessment. 5 5 (71.4) 5 (74.3) Language translation services are available 5 (80.0) 5 (58.8) * when needed. The identity of the interpreter is documented. 4 4 (31.4) 5 (60.0) 4 (28.6) 5 (75.0) Patient information is available on all 4 (31.3) 5 (65.6) 5 (56.3) 5 5 (75.0) endoscopic procedures performed in the endoscopy unit that conforms to literacy, language, and cultural appropriateness of the patient population cared for by the endoscopy unit. 5 5 (51.5) 5 (56.3) 5 (75.0) The method of provision of information 5 (57.6) to the patient is documented. 5 (55.9) 5 (58.8) 4 (23.5) 5 (55.0) Endoscopy unit has access to a quiet area 5 that provides privacy for discussions with patients and care partner(s). 4 Unit policy discourages the use of family 4 (28.6) 4 (25.7) 4 (15.8) 4 (17.1) and friends as interpreters. Meaningful to Feasible to Related to Compliance in own Related to quality measure (%) endoscopy unit (%) quality (%) Scheduling and appointments measure (%) 5 (85.0) 5 Patients are informed of their appointment 5 (79.4) 5 (75.8) 5 (79.4) (ie, in person, by mail, phone, or email). A preprocedure review is undertaken to 5 (80.0) 5 5 (88.2) 5 (79.4) 5 (73.5) screen patients for appropriateness and to communicate with patients about * key elements of their procedure. Methods are in place for identifying appropriate 5 5 (66.7) 5 (60.0) 5 (46.9) 5 (57.6) surveillance appointment needs, and timely notification and scheduling of appointments is provided. Patients and referring physicians are informed of 4 (35.0) 4 (18.2) 5 5 (54.6) 5 (54.6) their missed appointments, with commentary regarding the potential health consequences * of missed appointments. 4 5 (51.5) 3 (27.3) 4 (10.0) Data on facility costs and quality are available 4 (18.2) and transparent to prospective patients, families, and referring physicians. Related to Compliance in own Meaningful to Related to quality Feasible to measure (%) endoscopy unit (%) quality Informed consent (%) measure (%) 5 5 (82.4) 5 (91.2) 5 (87.5) 5 (95.0) Signatures are obtained on a consent form for all patients who are able to sign the form, and procedures are in place for those who cannot provide consent independently. All patients are given an opportunity to ask 5 5 (79.4) 5 (76.5) 5 (76.5) 5 (90.0) questions about the procedure before the endoscopy by a professional trained in the consent process. 5 (80.0) 5 (72.7) 5 5 (79.4) 5 (82.4) Informed consent is obtained and documented * by the provider performing the procedure. 5 (70.0) 5 (51.4) 5 (51.5) 4 (15.2) Unit has a policy to review informed consent 5 forms and process on a regular basis. ( ) continued on the next page 122 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

5 Endoscopy unit quality indicators TABLE 2. Continued Related to Feasible to Compliance in own Related to quality Meaningful to measure (%) endoscopy unit (%) Informed consent (%) quality measure (%) 5 5 (52.9) 5 (57.7) 5 (50.0) 5 (65.0) Published written patient information sheet that includes guidance on frequently asked questions for all procedures (both endoscopic and nonendoscopic) performed in the department is available to patients. 3 (70.0) 4 (18.8) 4 (25.0) 3 (33.3) Endoscopy unit has a written policy for 4 withdrawal of consent during an endoscopic procedure. Meaningful to Feasible to Compliance in own Related to quality Related to quality measure (%) (%) measure (%) Procedural indications endoscopy unit (%) 5 (60.6) 5 (84.2) 5 5 (79.4) 5 (75.8) The unit adopts standard indications for endoscopic procedures based upon * current national guidelines. 5 5 (58.8) 5 (52.9) 4 (14.7) 5 (60.0) Unit policy exists to regularly review the indications for performed procedures according to published list of standard indications. 4 (25.0) 3 (28.1) Use of an indication or time-to-procedure 4 (18.2) 4 4 (27.3) interval that is outside of accepted standards is clearly documented in s health record. the patient ’ Compliance in own Related to Feasible to Meaningful to Related to quality quality endoscopy unit (%) measure (%) (%) Communication of results measure (%) 5 (72.7) Procedure reports are communicated to 5 5 (90.9) 5 (87.9) 5 (95.0) * referring providers. Pathology reports for patients with cancer 5 5 (78.8) 5 (75.8) 5 (64.5) 5 (90.0) are dispatched to referrers after the receipt * of the report. 5 (87.9) 5 5 (90.9) Pathology reports are received by the 5 (81.8) 5 (87.9) endoscopist (or referrer) responsible for acting upon them within a timely manner. * The unit uses a process for timely 5 (85.0) 5 (64.5) 5 5 (78.1) 5 (78.1) communication of results to referring providers that complies with HIPAA statutes * and other state or federal privacy guidelines. 5 5 (51.5) 5 (45.5) 5 (72.2) Results (ie, from the endoscopy report) for all 5 (54.6) inpatients are available in the medical record before the patient leaves the department. If the endoscopist has responsibility for taking 4 (18.2) 5 (51.5) 5 (60.6) 5 (65.0) 5 action or making recommendations based on pathology reports, then the time it takes the endoscopist to act on the results or provide recommendations is tracked. * Compliance in own Postprocedure communication/coordination Meaningful to Related to Feasible to Related to quality quality endoscopy unit (%) measure (%) (%) measure (%) of care 5 (81.8) 5 (84.9) 5 (87.9) 5 5 (90.0) Patients receive discharge instructions that include recommendations for follow-up, anticoagulation plan, need for antibiotics or other specific therapy (as indicated), and timing of resumption of prior medications. * 5 (66.7) 5 (69.7) 5 (75.8) Process in place for patient to receive a copy 5 (90.0) 5 of the endoscopy report. ( ) continued on the next page www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 123

6 Endoscopy unit quality indicators TABLE 2. Continued Related to Meaningful to Feasible to Compliance in own Related to quality Postprocedure communication/coordination measure (%) endoscopy unit (%) of care (%) measure (%) quality 5 5 (81.8) 5 (78.8) 5 (68.8) 5 (85.0) Communication of results to the patient and/or family is complete and timely, including prompt acknowledgement of recognized adverse events and incomplete or neglected therapies, or sampling. 5 (63.6) 5 (85.0) 5 5 (81.3) 5 (78.8) Upon discharge from the endoscopy unit, patients are given instructions, both written and verbal, that conforms to literacy and language appropriateness. Instructions document pertinent procedure findings, treatment, contact number in case of emergencies, and follow-up care. * Related to Meaningful to Feasible to Compliance in own Related to quality Disaster preparedness endoscopy unit (%) measure (%) (%) measure (%) quality 5 (87.9) 5 (87.9) 5 (84.9) 5 (78.8) 5 Endoscopy unit maintains a written disaster preparedness plan that provides for the emergency care of all persons in the facility in the event of fire, natural disaster, equipment failure, or other unexpected events or circumstances that are likely to threaten the health and safety, and they coordinate the plan with state and local * authorities, as appropriate. 5 Appropriate drills of disaster preparedness 5 (74.2) 5 (72.7) 5 (87.9) 5 (66.7) plan are performed and documented. Compliance in own Meaningful to Related to Feasible to Related to quality quality endoscopy unit (%) measure (%) (%) measure (%) Ability to provide feedback 5 (85.0) 5 (64.5) 5 Endoscopy unit has a person or committee 5 (78.1) 5 (78.1) * responsible for reviewing patient complaints. Basic monitoring and recording of patient 5 (84.9) 5 (84.4) 5 (81.8) 5 (85.0) 5 comfort and pain levels before, during, and after the procedure. 5 5 (84.4) 5 (81.3) 5 (74.2) 5 (80.0) Endoscopy unit has a system for gathering patient feedback such as satisfaction surveys, focus groups, or invited comments. Actions are planned in response to reported 5 5 (81.3) 5 (78.1) 5 (67.7) 5 (80.0) patient complaints. * Documented process for adjudicating patient 5 5 (75.0) 5 (75.0) 5 (68.8) 5 (80.0) grievances exists on the unit, as required by state or federal law. 5 (75.0) 5 5 (68.8) 5 (63.6) 5 (60.6) Patients can submit ad hoc patient concerns or positive comments about their care. Patient is given realistic expectation that some 5 5 (71.9) 5 (62.5) 5 (62.5) 5 (75.0) discomfort may be experienced during the procedure. Patient comfort and respect (surveys and 5 5 (56.3) 5 (57.6) 5 (56.3) 5 (70.0) nurse records) are reviewed. 5 (69.7) 5 5 (69.7) 5 (75.0) Yield of return from patient satisfaction 5 (70.0) surveys is tracked and trended. 5 (65.0) Patient comfort and respect results (from 5 (54.8) 5 (67.7) 5 5 (70.0) surveys and nurse records) are fed back to individual endoscopists and the endoscopy team and are acted upon to ensure issues have been effectively addressed. continued on the next page ( ) 124 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

7 Endoscopy unit quality indicators TABLE 2. Continued Feasible to Related to quality Compliance in own Meaningful to Related to measure (%) measure (%) quality endoscopy unit (%) Ability to provide feedback (%) 5 (65.0) 4.5 (50.0) 5 (66.7) 5 (66.7) 5 Patient satisfaction surveys include questions regarding the quality of patient information provided. 5 (54.6) 5 (51.5) Accessibility to facilities (ie, parking, 4 4 (40.0) 4 (30.4) way-finding). 4 (35.0) 4 4 (21.9) 4 (24.2) 4 (39.4) Waiting room amenities are conducive to a positive patient experience (ie, ambiance, WiFi, seating, cleanliness, noise). Indicators that are shaded white had consensus reached on them (ie, median of “ 5 ” on the second round of voting for the relatedness parameter with  80% of respondents ) and were the 6 highest-rated indicators for this domain. rating it a “ 5 ” Note: Patients and payers did not participate in the voting process. Both groups were initially invited but opted not to participate. HIPAA , Health Insurance Portability and Accountability Act of 1996. *Mandated by national regulatory or accreditation standards. respondents were located at a hospital-based endoscopy Again, in each of the 5 domains there was marked varia- unit (52.9%), followed by ambulatory endoscopy centers tion. Although most potential indicators had a median of (41.8%). ” “ Compliance with indicator in their “ in the parameter 5 There were 155 potential endoscopy unit quality indica- own endoscopy unit, the percentage of respondents ” tors that were assessed. With regard to the individual who reported this median ranged from 13.3% to 93.3%. parameters related to quality, meaningfulness, feasibility, Similar to the feasibility results, greater compliance was re- and current compliance, the majority of potential indica- ported for indicators that addressed speci fi c policies or “ (ie, strongly agree) in each of ” 5 tors had a median of processes as compared with those that focused on gath- these 4 areas on the rst round of voting. 66 quality indica- fi ering and reporting data. tors met our consensus threshold (ie, had a median of “ 5 ” 5 “  with ” in the second 80% of respondents rating it a Patient experience round of voting). From this list, the highest-rated 6 indica- The patient experience domain incorporated 46 proposed tors from each of the 4 domains were selected (1 domain structural and process quality indicators related to 8 had only 5 indicators that met the consensus threshold), subdomains.Thesesubdomainsincludedpatients ’ communi- yielding 29 endoscopy unit quality indicators that were cation needs and performance, scheduling and appoint- included in the nal guideline. fi ments, informed consent, procedural indications, communication of results, postprocedure communication and coordination of care, disaster preparedness, and ability Feasibility for measuring endoscopy unit toprovidefeedback.Initially,23indicatorsacrossthe8subdo- quality indicators mains met the initial consensus threshold with the highest- Across all 5 of the domains there was marked variation ). These top 6 fi rated 6 indicators then identi Table 2 ed ( in perceived feasibility of measuring the proposed quality quality indicators centered on 3 areas: (1) informed consent indicators. Although most quality indicators had a median ’ (ie, obtaining necessary signatures and answering patients “ Feasible to measure, 5 the percent- ” of “ in the parameter ” questions), (2) communication of results, speci fi cally to age of respondents who reported this median ranged from referring providers, and (3) postprocedure communication 96.2% to 44.8%. It was well recognized that some indica- to patients about discharge instructions and the process for cant and deemed meaningful but tors are clearly signi fi how patients could receive their endoscopy reports. Among are less feasible for measurement and implementation in these 6 indicators there was strong agreement during round practice and therefore limited in application. Those that Meaningful to measure Feasible “ and for ” 1 voting for the “ were rated highly with regard to feasibility addressed spe- parameters. The majority of voters deemed ” to measure ci fi c endoscopy unit policies and processes. In contrast, their own units to be in compliance with all 6 of these the feasibility of measuring endoscopy unit quality indica- endoscopy unit quality indicators. Among the originally tors was rated most dif fi cult in areas where data were proposed indicators that did not reach the initial consensus more detailed, harder to collect, and/or needed to be “ threshold, 16 had a median of 5 ( )with ” strong agreement communicated to staff. less uniformity ( 80%), 6 had a median of 4, and 1 had a < “ neutral median of 3 ( ) in the second round of voting. None ” Compliance on measuring endoscopy unit of the proposed indicators had a median of 2 quality indicators )onany ” strong disagreement ( “ disagreement ” )or1( “ Respondents were asked whether their endoscopy units parameter in both rounds of voting. were compliant with the proposed quality indicators. www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 125

8 Endoscopy unit quality indicators TABLE 3. Survey results using the Delphi method to examine potential endoscopy unit quality indicators for the Employee Experience domain 1st round voting (n 38), median (%), [ 2nd round voting [ [ strongly disagree, 5 (n 1 30), median (%) strongly agree [ Feasible to Compliance in own Related to quality Meaningful to Related to Employee orientation endoscopy unit (%) measure (%) (%) quality measure (%) 5 5 (66.7) 5 (65.8) 5 (70.0) Employee orientation process is in place 5 (64.1) and documented. * 5 5 (50.0) 5 (54.1) 5 (70.0) Current professional physician and nursing 5 (52.6) practice guidelines and position statements are available. 5 5 (65.8) 5 (68.4) 5 (81.1) 5 (66.7) Staff are oriented to HIPAA compliance and * safety in addition to their job specific tasks. Related to Meaningful to Feasible to Compliance in own Related to quality Employee safety endoscopy unit (%) measure (%) (%) quality measure (%) 5 5 (84.6) 5 (71.1) 5 (66.7) Staff are up to date on their influenza 4.5 (50.0) vaccinations. 5 4 (43.6) 5 (50.0) 5 (63.3) Disruptive staff behavior is addressed and 5 (56.4) resolved. Organization provides information on 5 (73.0) 5 5 (61.5) 5 (69.2) 5 (53.3) environmental health and safety policies * that must be followed in the workplace. 4 (41.0) 4 (30.8) 5 (55.3) 5 (53.3) Workplace policies include processes to reduce 5 or prevent occupational injuries and illnesses through appropriate training and preventive activities. * Related to Compliance in own Meaningful to Related to quality Feasible to measure (%) endoscopy unit (%) quality Employee recognition (%) measure (%) 4 4 (34.2) 4 (42.1) 4 (36.7) Employee recognition program is in place. 4 (39.5) Meaningful to Feasible to Compliance in own Related to quality Related to measure (%) measure (%) (%) Employee growth quality endoscopy unit (%) 5 5 (61.5) 5 (56.4) 4 (43.2) Organization provides continuing education 5 (63.3) opportunities. 4 4 (38.5) 4 (41.0) 4 (39.5) 4 (56.7) Employees are given opportunities for leadership and promotion. Related to Feasible to Compliance in own Meaningful to Related to quality endoscopy unit (%) measure (%) quality (%) Employee feedback measure (%) Unit promotes a culture where staff are 5 (58.3) 4 (18.9) 5 5 (80.6) 5 (90.0) empowered to raise concerns about safety and quality in daily operations without fear of retribution. Formal staff meetings (including staff and clinic 5 (79.0) 5 (57.1) 5 (83.3) 5 5 (57.9) leadership) occur. 5 (62.2) 5 (54.1) 5 (52.8) 5 (73.3) Employees have formal avenues of unit and 5 organizational communication. 5 (70.0) System in place for ongoing and regular 5 5 (66.7) 5 (51.4) 4.5 (47.2) feedback from staff on the quality of their work environment. Employees receive results of employee feedback 5 5 (48.7) 5 (59.5) 5 (41.7) 5 (63.3) surveys. Employees are invited to provide job satisfaction 5 5 (54.1) 5 (62.2) 5 (58.3) 5 (58.6) feedback to their organization. continued on the next page ) ( 126 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

9 Endoscopy unit quality indicators TABLE 3. Continued Related to Feasible to Compliance in own Related to quality Meaningful to measure (%) endoscopy unit (%) quality (%) Employee feedback measure (%) 4 4 (33.3) 4 (14.7) 5 (55.2) 4 (36.1) Employee satisfaction survey results are considered in development of facility/unit plans. 4 4 (16.7) 4 (43.3) 4 (40.5) 4 (24.3) Process in place for exit interviews to be recorded and/or feedback to clinical and general managers. Feasible to Compliance in own Meaningful to Related to quality Related to measure (%) quality (%) measure (%) Performance evaluation endoscopy unit (%) 5 5 (70.3) 5 (69.4) 5 (62.9) 5 (82.8) Employees receive individualized performance * evaluations with reports. 5 (75.9) 5 5 (71.1) 5 (70.3) 5 (62.2) System in place for ongoing and regular feedback to staff on the quality of their work, with periodic formal documentation. 5 5 (67.6) 4 (13.5) 5 (75.9) Action plans are in place to address performance 5 (52.6) issues identified during appraisal and assessment. 5 (54.1) 5 (31.4) 5 (62.1) 5 Rate of unauthorized absenteeism is tracked. 5 (37.8) 4 Average retention rates for employees are 5 (54.1) 4 (21.6) 4 (43.3) 3 (40.0) tracked and benchmarked. 4 (21.6) 5 (54.1) 4 (36.1) 4 (28.6) Job vacancy rate is tracked. 4 4 4 (27.0) 5 (55.6) 4 (8.6) 4 (27.6) Overall and first-year staff turnover rates are tracked. Related to Meaningful to Related to quality Compliance in own Feasible to measure (%) quality endoscopy unit (%) Training (%) measure (%) Endoscopy unit has regular education, 5 (90.0) 5 5 (76.3) 5 (63.2) 5 (51.4) training programs, and continuous quality improvement for all staff on new equipment/ * devices and endoscopic techniques. 5 5 (56.8) 4 (27.0) 5 (86.7) Team training is used for new techniques/ 4.5 (50.0) technology to emphasize communication between providers and nurses. 5 5 (57.9) Staff feedback is considered in development 4.5 (47.2) 5 (83.3) 4 (26.3) of training programs and in-services. 5 5 (68.4) 5 (62.2) 4 (13.5) 5 (80.0) Endoscopy unit uses training checklists to maximize training opportunity for low-volume procedures. Training includes emphasis on trouble-shooting 5 (80.0) 5 5 (63.2) 5 (52.6) 4 (27.0) commonly experienced and high-risk problems. Training programs are competency-based and 5 5 (63.2) 5 (52.6) 4 (26.5) 5 (80.0) modified in response to staff feedback. Trainers are competent for what they teach 5 5 (63.2) 4 (29.0) 4 (35.1) 5 (80.0) and a mechanism is in place to assess their ability to teach. 4 (32.4) 5 5 (55.3) 5 (55.3) Identified staff member coordinates training 5 (66.7) checklists. Indicators that are shaded white had consensus reached on them (ie, median of 5 ” on the second round of voting for the relatedness parameter with  80% of respondents “ “ 5 ” ) and were the 6 highest-rated indicators for this domain. rating it a Note: Patients and payers did not participate in the voting process. Both groups were initially invited but opted not to participate. *Mandated by national regulatory or accreditation standards. www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 127

10 Endoscopy unit quality indicators TABLE 4. Survey results using the Delphi method to examine potential endoscopy unit quality indicators for the Efficiency and Operations domain 1st round voting (n [ 35), median (%), 2nd round voting [ strongly disagree, 5 (n [ 25), median (%) [ 1 strongly agree Meaningful to Related to Feasible to Related to quality Compliance in own endoscopy unit (%) measure (%) (%) quality measure (%) Leadership/strategic planning 5 (83.3) 5 (77.8) 5 (92.0) 5 Endoscopy unit has a defined leadership 5 (66.7) * structure. 5 (66.7) 5 (69.4) 5 (61.1) 5 (84.0) Designated individual within the leadership 5 * hierarchy oversees quality. Mission statement incorporates and physician 5 (76.0) 5 (63.9) 5 5 (61.1) 4 (30.6) “ ” culture of quality. leadership champions a 5 (63.9) 4 (37.1) 5 (72.0) Endoscopy unit participates in formal quality 5 5 (63.9) benchmarking. 5 5 (75.0) 5 (61.1) 5 (61.1) 5 (72.0) Staff participates in appraisal of unit policies and daily operations and are encouraged to suggest improvements. Endoscopy unit has a process in place to address 5 5 (58.3) 4 (41.7) 4 (37.1) 5 (68.0) unexpected operational challenges in a timely manner. Endoscopy unit has a practice administrator with 3 (27.8) 4 (27.8) 5 (50.0) 4 (48.0) 4 advanced business training or experience. 4.5 4 (25.0) 5 (63.9) 4 (28.6) 4 (32.0) Endoscopy unit leadership has an annual strategic planning meeting. Related to Related to quality Meaningful to Compliance in own Feasible to measure (%) quality endoscopy unit (%) Operations (%) measure (%) Endoscopy unit adheres to regulatory 5 (87.5) 5 5 (83.3) 5 (83.3) 5 (91.7) requirements, including federal, state, local, and institutional, with respect to facilities * and operating space. Endoscopy unit has a policy on administering 5 5 (64.7) 5 (61.1) 5 (51.4) 5 (87.5) monitored anesthesia care (MAC) and moderate sedation. 5 5 (86.1) 5 (85.7) 5 (88.6) 5 (84.0) Unit committee(s) structure includes effective governance with physician and other stakeholder participation. 5 (72.0) Endoscopy unit has a quality assurance 5 (69.6) 5 (63.9) 5 (80.6) 5 committee that develops and enforces quality standard policies, meets regularly, generates quality reports for the endoscopy center and leadership, and manages quality improvement projects. * Unit has a process in place to regularly trend 5 (68.0) 5 5 (58.3) 5 (61.8) 4 (31.4) and adjust resource availability, including equipment, space, time, and staff (eg, procedures/room/day, number of endoscopes/room) Endoscopy unit has a policy on the formal 5 (68.0) 4 (33.3) 5 5 (55.6) 5 (58.3) review and evaluation for new devices * and equipment. 5 (64.0) 5 5 (65.7) 5 (63.9) 5 (72.2) Endoscopy unit staff (eg, technician, nurse) are cross-trained. Key intervals of patient throughput in the 5 (60.0) 5 4 (47.2) 5 (66.7) 4 (42.9) endoscopy unit are measured (eg, room turnover time, recovery time). continued on the next page ) ( 128 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

11 Endoscopy unit quality indicators TABLE 4. Continued Related to quality Feasible to Compliance in own Related to Meaningful to endoscopy unit (%) (%) quality measure (%) Operations measure (%) 5 (52.8) 5 (66.7) 5 (52.8) 4 and canceled ” no shows Rate of “ 5 (56.0) appointments or procedures. 5 Endoscopy unit has a policy for late-arriving 5 (55.9) 5 (58.8) 4 (20.0) 4 (32.0) staff (including physicians). Endoscopy unit has a policy for late-arriving 4 (30.6) 4 (31.4) 3 (30.6) 4 (28.0) 4 patients. 4 4.5 (50.0) 5 (66.7) 4 (25.2) 4 (28.0) Rate of on-time first case start. Rate of room turnover time (case complete 4 (28.0) 4 4 (30.6) 5 (63.9) 5 (54.3) to next case start time). Related to Meaningful to Feasible to Compliance in own Related to quality measure (%) (%) measure (%) quality endoscopy unit (%) Timeliness Time from procedure request to procedure 4 (28.0) 3.5 (19.4) 4 (22.9) 4 (38.9) 4 date for routine procedures is tracked. Endoscopy unit has a system in place to classify 5 5 (47.2) 4.5 (44.4) 4.5 (36.1) 4 (20.8) endoscopy referrals into emergent, urgent, and routine categories. 3 (28.0) 3 (23.5) Endoscopy wait times are communicated to 4 (13.9) 4 (27.8) 4 the endoscopy team and made available to referring physicians. 3 (28.0) Wait time for urgent and semiurgent 4 4 (20.6) 4 (25.7) 3 (31.4) (within 24 hours) procedures. 80% of respondents on the second round of voting for the relatedness parameter with  ” Indicators that are shaded white had consensus reached on them (ie, median of “ 5 rating it a “ 5 ” ) and were the 6 highest-rated indicators for this domain. Note: Patients and payers did not participate in the voting process. Both groups were initially invited but opted not to participate. *Mandated by national regulatory or accreditation standards.  How can endoscopy unit quality programs (EUQPs) Overall patient experience quality indicators were rated evaluating patient experience best develop, select, and highly with respect to the feasibility of their measurement, ed, accurately fi measure indicators that are patient identi with 41 of 46 indicators having a median of 5. Lower scores actual health care encounter ’ measure our patients own unit compliance “ ” were more closely associated for experience, and address those concerns that are of with the excluded indicators on round 2 voting than greatest importance to our patients? meaningful ”“ relatedness to quality, “ were lower scores for  Can the GI professional societies facilitate standardized feasible to measure. ” or “ ” to measure, Indicators receiving and benchmarked unit quality programs by developing lower compliance ratings and considered by the respon- a web-based program modeled on the GRS and Gastro- dents to be less related to quality included: making data intestinal Quality Unit Improvement Consortium on facility costs and quality available, documentation in (GIQuIC)? the patient ’ s health record of indications or surveillance  To what extent do patient experience quality indicators intervals that depart from recommendations or guidelines, correlate with other indicators of traditional quality out- and maintenance of a written policy for withdrawal of con- comes in endoscopy? sent during a procedure. Research questions as opposed to To what extent does  ” “ documentation, Employee experience performance measurement, stimulate improvement, or There were 33 potential endoscopy unit quality indica- enhance care? tors that were originally developed by expert consensus  Canlanguagebarriersinwrittenandverbalcommunication in the employee experience domain. This domain was be overcome with acceptable quality at tolerable expense? further subdivided into areas that covered employee feed- Do written and verbal informed consent processes pro-  back, performance evaluation, training, employee orienta- vide adequate patient and family understanding of the tion, employee safety, employee recognition, and true risks, alternatives, and rates of adverse events? employee growth. Initially, 10 of those indicators that Once indicators pertaining to processes are established,  were proposed met our consensus threshold, of which how should an endoscopy unit measure its performance the 6 top rated indicators were highlighted ( ). Table 3 on the indicator? Among these 6 quality indicators, all had a median of www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 129

12 Endoscopy unit quality indicators TABLE 5. Survey results using the Delphi method to examine potential endoscopy unit quality indicators for the Procedure-Related domain 1st round voting (n 2nd round voting [ 30), median (%), strongly agree 1 (n [ [ strongly disagree, 5 [ 22), median (%) Feasible to Compliance in own Related to quality Meaningful to Related to endoscopy unit (%) measure (%) (%) quality measure (%) Preprocedure 5 5 (86.7) 5 (82.8) 5 (83.9) 5 (90.9) Endoscopy unit has a process to ensure that all elements of the preprocedure assessment are documented before the procedure begins. 5 (62.1) 5 (69.0) 5 (71.4) Preprocedure process is reviewed by clinic 5 5 (62.1) leadership on a regular basis. 5 (61.9) 5 5 (66.7) 4 (23.3) 5 (67.7) Preprocedure space is monitored to ensure that it meets patient and staff needs and is clean, functional, quiet, ensures patient privacy, and has amenities conducive to a positive patient experience. 4 Patients and families are kept informed about 5 (48.4) 5 (46.9) 4.5 (50.0) 4 (22.6) procedure-related wait to manage expectations. Related to Feasible to Compliance in own Related to quality Meaningful to endoscopy unit (%) quality (%) Procedure measure (%) measure (%) 5 5 (89.7) 5 (75.9) 4 (17.2) 5 (86.4) Mechanism(s) are in place to detect, assess, and ’ address concerns raised regarding physicians competence. Endoscopy unit records, tracks, and monitors 5 5 (89.7) 5 (75.9) 5 (62.1) 5 (86.4) procedure quality indicators for both the endoscopy unit and individual endoscopists. Unit has policy in place for patient pause/time-out 5 5 (90.0) 5 (82.8) 5 (93.3) 5 (82.8) * that satisfies all key elements. 5 (82.1) 5 (85.7) 5 (81.8) 5 (58.6) 5 Endoscopy unit has a privileging policy and committee to make decisions that a physician ’ s training and performance is in accordance with nationally accepted * indicators. Data on quality indicators are communicated 5 (81.8) 5 (53.6) 5 (81.8) 5 5 (89.7) to staff and endoscopists. 5 (69.0) 5 (69.0) 5 (75.9) 5 (81.8) Endoscope and accessories used in a procedure 5 * are identified in a procedure record. Endoscopy unit develops quality improvement 5 5 (78.6) 5 (75.9) 5 (60.0) 5 (81.8) projects that address indicators which are below targets. Peer review of procedures by endoscopists is 5 5 (80.0) 5 (82.8) 4 (10.3) 5 (77.3) performed. ERCP volume and sphincterotomy volume 5 5 (41.3) 5 (44.8) 5 (13.3) 5 (57.9) by physician and unit are tracked and considered for privileging. 4 (20.7) 5 5 (51.7) 5 (56.7) Rate of scheduled procedures 5 (52.4) cancelled/rescheduled by provider. 4 5 (55.2) 4 (20.7) 4.5 (50.0) Rate of scheduled procedures 4 (10.3) cancelled/rescheduled by patient. Compliance in own Related to Feasible to Meaningful to Related to quality (%) endoscopy unit (%) measure (%) quality Postprocedure measure (%) 5 (95.5) 5 (86.2) 5 Unit has a policy on reconciliation of specimen 5 (90.0) 5 (82.8) requisition to ensure physician and staff agree on specimen labeling. * 5 (86.4) 5 5 (89.3) 5 (85.7) 5 (86.2) Patients are not discharged unless formal discharge criteria are met. * continued on the next page ) ( 130 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

13 Endoscopy unit quality indicators TABLE 5. Continued Compliance in own Related to Meaningful to Related to quality Feasible to measure (%) quality endoscopy unit (%) measure (%) (%) Postprocedure 5 (69.0) 5 (79.3) 5 (81.8) 5 (75.9) 5 Recovery space is clean, functional, quiet, ensures patient privacy, has adequate postprocedure monitoring for patients, and has amenities conducive to a positive patient experience. Rate of hospital admissions after procedure. 5 5 (79.3) 5 (75.9) 5 (66.7) 5 (77.3) Patient has an opportunity to speak with the 5 5 (69.0) 5 (55.2) 5 (64.3) 5 (77.3) provider who performed the procedure before discharge. 5 (73.3) 5 (75.9) 5 (72.4) 5 5 (77.3) Unit has a policy in place for postprocedure follow-up call. Rate of mislabeled/missing pathologic specimens. 5 (82.8) 5 (75.9) 5 (69.0) 5 (77.3) 5 Unit has a policy in place for lack of a responsible 5 (72.7) 5 (83.3) 5 5 (69.0) 5 (69.0) * adult patient escort after procedure. Success rate of patient follow-up call after 5 (54.6) 5 5 (58.6) 5 (65.0) 5 (53.3) procedure. Indicators that are shaded white had consensus reached on them (ie, median of “ 5 ” on the second round of voting for the relatedness parameter with  80% of respondents ) and were the 6 highest-rated indicators for this domain. ” “ 5 rating it a Note: Patients and payers did not participate in the voting process. Both groups were initially invited but opted not to participate. *Mandated by national regulatory or accreditation standards. Is there a relationship between the quality of the educa-  whereas 3 5 in the parameter of Meaningful to measure, ” “ tion and a quality outcome (eg, education on endo- of these indicators had a median of 5 for “ Feasible to scope reprocessing and subsequent compliance with measure ” during round 1 voting. One third of all steps)? respondents deemed their own units to be out of  Is there a relationship between the manager/supervisor compliance with these 6 indicators. By contrast, among performance and the quality of employee experience? the originally proposed indicators that did not meet our  Is there a relationship between physician attitudes and initial consensus threshold, 17 had a median of 5 with the overall quality of the endoscopy unit? < less uniformity ( 80%) and 6 had a median of 4 in the  What are ways to improve compliance for education second round of voting. None of the proposed indicators and training quality indicators that are rated as meaning- or “ strong disagreement ” disagreement “ had ratings for ” ful and feasible? on any parameter.  What is the relationship between employee recognition Several themes emerged among the top rated 6 quality programs and the overall quality of the unit? indicators for employee experience. For example, half of  What are the important opportunities for leadership these indicators underscored the important relationship and professional growth in the endoscopy unit? between training and overall employee experience. What durations of training are required for safe and in-  Respondents agreed that endoscopy units should provide fi c roles within the dependent performance in speci regular education programs and continuous quality endoscopy unit? improvement for all staff on new equipment/devices and  How effective are efforts to enhance staff satisfaction/ endoscopic techniques, using tools such as checklists training in improving patient satisfaction and other pro- and team training. Furthermore, this training should be cedure outcomes? ed in response to staff feedback, fi competency based, modi and provided by competent trainers. One third of the 6 indicators valued the importance of employee feedback. ciency and operations Ef fi In this arena, respondents thought that high-quality In the ef fi ciency and operations domain, 25 potential endoscopy units should foster a culture wherein staff feel endoscopy unit indicators were originally developed by empowered to raise concerns about the safety and quality expert consensus. They primarily addressed endoscopy of the endoscopy unit and that there were formal staff ciency, fi unit and individual leadership, endoscopy unit ef ected the importance of fl meetings. Finally, 1 indicator re and speci fi c endoscopy unit policies, and were organized performance evaluations and formalized goal setting for into 3 subdomains of leadership/strategic planning, opera- employees. tions, and timeliness. Five indicators met our consensus Research questions threshold on the second round of voting ( Table 4 ). All 5  Is there a correlation between employee experience of these indicators had a median of 5 in the parameter of and other measures of endoscopy unit quality? “ ”“ Feasible to measure, ” Meaningful to measure, and www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 131

14 Endoscopy unit quality indicators TABLE 6. Survey results using the Delphi method to examine potential endoscopy unit quality indicators for the Safety and Infection Control domain [ 1st round voting (n 29), median (%), 2nd round voting [ strongly disagree, 5 (n [ 18), median (%) [ 1 strongly agree Meaningful to Related to Feasible to Related to quality Compliance in own endoscopy unit (%) measure (%) (%) quality measure (%) Safety 5 (82.1) 5 (85.7) 5 (85.7) 5 (92.3) Nurses and physicians are credentialed with 5 endoscopy unit policy relative to moderate sedation. * 5 (81.5) 5 (85.2) 5 (76.9) 5 (92.3) Endoscopy unit has a written environmental 5 disinfection policy. 5 (83.3) 5 (71.4) 5 5 (92.3) 5 (77.8) Endoscopy unit has a system for reviewing adverse events and implementing strategies * to prevent or reduce them. Presence of all sedation reversal agents is 5 5 (64.3) 5 (75.0) 5 (75.0) 5 (83.3) verified each day the facility is in operation. * Endoscopy unit has a system for monitoring 5 (83.3) 5 (66.7) 5 (85.7) 5 5 (75.0) that all medical equipment, including rescue devices, are in proper working condition, and this is verified each day the facility is * in operation. 5 (82.4) Resuscitation equipment, availability, and 5 5 (82.1) 5 (92.9) 5 (82.1) functional status are verified each day the facility is in operation. * Endoscopy unit has written policies detailing 5 5 (57.1) 5 (75.0) 5 (67.9) 5 (72.2) safety procedures in the facility. 5 (72.2) 5 (67.9) 5 5 (89.3) Endoscopy unit has a system for recording and 5 (71.4) * tracking endoscopy-related adverse events. 5 (53.6) 5 (57.1) 5 (57.1) 5 (72.2) Endoscopy unit has a process in place to 5 identify patients at risk for falls. * 5 (69.2) 4 (48.2) 2 (22.2) 5 (66.7) Rate of unplanned admissions, emergency 5 department visits, and observation stays within 7 days after receiving a colonoscopy. Use of reversal agents for sedation is 5 5 (64.3) 5 (81.5) 5 (64.3) 5 (61.1) * documented and tracked on a regular basis. Rates of modification, interruption, or 5 5 (60.7) 5 (64.3) 4.5 (50.0) 5 (61.1) termination of scheduled procedures * because of sedation-related events. 5 5 (64.3) 5 (51.9) 4 (14.3) 5 (33.3) Number of adverse events that occur within 14 days of an endoscopic procedure including in-hospital deaths and nonelective hospital admissions is recorded. 4 (27.8) Mechanism in place to contact patients 14 to 5 4 (25.0) 4 (17.9) 2 (14.3) 30 days after their procedure to identify delayed adverse events. Related to Feasible to Compliance in own Meaningful to Related to quality measure (%) Infection control measure (%) (%) quality endoscopy unit (%) Process is in place to track each specific 5 (94.4) 5 5 (82.1) 5 (78.6) 5 (85.7) endoscope from storage, use, reprocessing, and back to storage. 5 (94.4) Endoscopy unit has instructions immediately 5 (89.3) 5 (85.7) 5 5 (81.5) available for high-level disinfection that are specific to the endoscope models being * used. ) continued on the next page ( 132 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

15 Endoscopy unit quality indicators TABLE 6. Continued Related to quality Compliance in own Feasible to Meaningful to Related to quality measure (%) endoscopy unit (%) (%) Infection control measure (%) 5 (94.4) 5 (85.2) 5 (88.9) 5 5 (78.6) Endoscopy unit has policies and procedures in place to ensure that reusable medical devices are cleaned and reprocessed in accordance s instructions appropriately ’ with manufacturer before use in another patient. * 5 (66.7) Endoscopy unit has policies and procedures in 5 (94.4) 5 (75.0) 5 (75.0) 5 place to identify damaged equipment and * remove that equipment from service. 5 (88.9) 5 (84.6) 5 (84.6) 5 (85.2) 5 Process is in place to maintain a log on the successful completion of each key step in reprocessing, including sufficient patient demographic information and endoscope identification for appropriate postprocedure event. 5 (71.4) 5 5 (75.0) 5 (85.7) Endoscopy unit has a specific policy discussing 5 (88.9) the proper use of single-dose medication vials. Endoscopy unit has policies and procedures that 5 (70.4) 5 (85.7) 5 5 (88.9) 5 (82.1) adhere to current ASGE and SGNA guidelines concerning safety and infection control in endoscopy. 5 (82.1) 5 (78.6) 5 Endoscopy unit has policies and procedures in 5 (82.1) 5 (88.9) place to ensure the proper use of devices marked single use only. 5 (77.8) 5 (77.8) 5 Policy to avoid the use of multidose vials when 5 (88.9) 5 (74.1) possible and document their appropriate use when they are used. 5 (88.9) Handwashing facilities and alcohol-based hand 5 5 (78.6) 5 (78.6) 5 (85.2) gel are available to patients, visitors, and staff. Core competencies for personnel involved in 5 (88.2) 5 (84.6) 5 (96.2) 5 (85.2) 5 reprocessing endoscopes are verified initially and at least annually or when there is an adverse event or change in endoscopes or reprocessing equipment. * 5 5 (77.8) Endoscopy unit monitors and records adherence 5 (67.9) 5 (60.7) 5 (64.3) to hand hygiene guidelines and provides feedback to personnel. 3.5 (17.9) 4 (32.1) 4 (22.2) Process is in place to document the successful 4 (21.4) 4 completion of training in safe injection practices, and then verification of compliance of all personnel regarding safe injection practices on a semiannual basis.  Indicators that are shaded white had consensus reached on them (ie, median of “ 5 ” 80% of respondents on the second round of voting for the relatedness parameter with ” ) and were the 6 highest-rated indicators for this domain. 5 “ rating it a Note: Patients and payers did not participate in the voting process. Both groups were initially invited but opted not to participate. , American Society for Gastrointestinal Endoscopy; SGNA , Society of Gastroenterology Nurses and Associates. ASGE *Mandated by national regulatory or accreditation standards. 2 had a median of 3 in the second round of voting. None Compliance in own endoscopy unit. “ These indicators ” ” or disagreement “ of the proposed indicators received tended to concentrate on leadership in the endoscopy “ ” strong disagreement on any parameter. Additionally, re- unit, with a particular emphasis on its structure and spondents deemed that several important indicators were governance, and also focused on quality and meeting not feasible to measure and that their endoscopy units regulatory requirements. were noncompliant. These included the following: that Among the 20 original quality indicators that did not the endoscopy unit has a policy for late arriving patients, meet our initial consensus threshold, 10 had a median of wait times for urgent and semiurgent procedures are 80%), 8 had a median of 4, and < 5 with less uniformity ( www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 133

16 Endoscopy unit quality indicators How should the privileging and credentialing process  tracked, and wait times are communicated to the endos- be used to maintain and improve quality in the endos- copy team and made available to referring physicians. uence proced- fl copy unit, and how does this process in Research questions ure outcomes?  What methods are there to foster/develop physician and What is the optimal process for endoscopy units to  administrative endoscopy unit leadership skills? c data on fi maintain and aggregate endoscopist-speci  What methods should be used to identify a “ physician behalf of individual practitioners? champion ” for the endoscopy unit quality program?  What methods should be developed to implement a at all levels of patient care and delivery ” quality culture “ Safety and infection control of services within an endoscopy unit? In this domain, 27 quality indicators were originally How do ef c pa- fi cient practices correlate with speci fi  developed and were divided into 2 subdomains: safety tient satisfaction measures and other procedure- and infection control. These proposed indicators included related outcomes? issues related to endoscopy equipment and its handling and issues related to personnel and training in safety and Procedure-related infection control. Seventeen indicators across both subdo- In the procedure-related domain, 24 quality indicators mains met our initial consensus threshold. The were originally developed. This domain was further divided highest-rated 6 indicators from this domain were then into 3 subdomains: preprocedure, procedure, and postpro- ed ( identi fi Table 6 ). Among these 6, all had a median of cedure. Among these 3 subdomains, 11 quality indicators ”“ Meaningful to measure, “ 5 for the Feasible to measure, ” met our initial consensus threshold. Among the ” during round 1 and Compliance in own endoscopy unit “ highest-rated 6 indicators in this group, all had a median voting. The core elements of these top 6 indicators of 5 during the fi rst round of voting for both “ Meaningful focused on disinfection and maintenance of endoscopic with only 1 of these to measure ” ” and “ Feasible to measure equipment and associated devices and the credentialing indicators not having a median of 5 in the “ Compliance in of staff (including physicians and nurses) with regard to ). Moreover, ” own endoscopy unit Table 5 parameter ( moderate sedation. several themes were observed among these 6 highlighted osed indicators that did Among the 10 originally prop procedure-related quality indicators, which included the not meet our initial consensus de fi nition, 8 had a median preprocedure processes (eg, preprocedure assessment, 80%), and 2 had a median < of 5 with less uniformity ( patient pause/time out) and postprocedure processes of 4 on the second round of voting. None of the pro- (eg, discharge criteria, pathology specimen reconciliation), posed indicators received strong disagreement on any assessing and addressing physician competence, and qual- parameter. Importantly, nearly all of the proposed ity measurement and improvement. quality indicators were rated highly with respect to the Among the 13 originally proposed quality indicators that “ ” parameter on both rounds of voting, Related to quality did not meet our initial consensus threshold, 11 had a me- and most respondents reported compliance within their < dian of 5 with less uniformity ( 80%) with 2 having a me- own endoscopy units, showing that indicators of high- dian of 4.5 on the second round of voting. None of the quality safety and infection control practices in endo- potential indicators in the procedure-related domain scopic facilities are now well recognized and being received ratings of neutral, disagreement, or strong practiced. disagreement on any of the 4 m easured parameters. Addi- cant Several indicators were judged to be of signi fi tionally, an overwhelming majority of proposed procedure- importance, but ultimately were thought to be less feasible related quality indicators scored highly as they related to to measure and were among those that were rated lower in quality, meaningfulness, and feasibility with most respon- terms of compliance. Indicators in this category included dents reporting that their endoscopy units were currently the following: mechanisms are in place to contact patients compliant with all of these indicators. Yet, 2 main areas regarding any adverse event after a procedure, and scored lower in terms of endoscopy units currently being tracking the rate of unplanned admissions/emergency compliant with proposed indicators: (1) assessing compe- rooms visits for patients who had undergone a colonos- cally having a process in place tence of endoscopists, speci fi copy. It was well recognized that some safety and infection ’ competence and per- to detect and address endoscopists fi cance, and control indicators may be clearly of signi forming peer review of procedures by endoscopists, and deemed to be meaningful, but ranked as not feasible to (2) measuring the rate of scheduled procedures cancelled/ be put into easy practice and therefore possibly limited rescheduled by both the patient and the provider. in practical application. Research questions Research questions What systems can be incorporated into the current data  What is the exact rate of mislabeled specimens obtained  collection programs (eg, endoscopy report – generating in endoscopic procedures? software) to capture essential indicators on safety and cient method for collecting What is the optimal and ef  fi infection control without undue burden? data on procedure quality indicators? 134 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

17 Endoscopy unit quality indicators  How would vendor participation in designing and main- perspective), which are now recognized to be ’ patients 20 taining systems for capturing essential indicators on For an increasingly important element of validity. safety and infection control improve data collection? ed that most fi example, a recent meta-analysis identi  What is/are the best method(s) for capturing informa- studies have varied between a focus on the generation of tion on delayed adverse events? new endoscopy-speci c patient experience measures fi  What is/are the best approach(es) to collate, trend and versus modi cation or validity testing of existing measures, fi remediate adverse events? and that most patient experience measures are derived 21 What is/are the best method(s) for tracking and trend-  s perspective. from a clinician ’ Finally, although it is ing unplanned admissions/emergency room visits after important to ensure that patients have a positive procedures? healthcare experience, it does remain unclear whether higher patient satisfaction results in better outcomes for 22 patients. In the future, other measures of patient DISCUSSION satisfaction and experience will likely be developed and be correlated with accepted quality outcomes in Through a comprehensive process that consisted of an endoscopy. Finally, future work will need to focus on extensive literature review and soliciting expert opinion, developing and validating interventions aimed at 155 proposed endoscopy unit quality indicators were improving the patient experience in endoscopy units. developed. These proposed quality indicators spanned 5 domains, which included patient experience, employee experience, ef fi ciency and operations, procedure-related Employee experience endoscopy unit issues, and safety and infection control. Although patient satisfaction is well accepted as a quality Subsequently, to reach consensus on which indicators to metric in medicine, employee engagement and experience fi ed Delphi method was include in this guideline a modi has been less well explored. Existing literature in the ed 29 quality indicators related to the used and identi fi healthcare and nonhealthcare industries demonstrates a rst effort quality of an endoscopy unit. This represents the fi direct and positive relationship between patient/customer ed for U.S. fi in which quality indicators have been identi experience and employee engagement and performance. endoscopy units, and it serves as a tool by which endos- In healthcare, overall employee workplace experience copy units can begin to measure and improve their quality, has tangible consequences, including the successful initiate the process of benchmarking these indicators, and recruitment and retention of skilled employees. Further- further determine which indicators are closely aligned with more, the link between employee engagement and patient outcomes. patient satisfaction ultimately affects the quality of patient 23-48 care. Research published by well-known organizations, including Gallup and Press Ganey, demonstrates the direct Patient experience correlation between patient and employee experience. Consistent with the national adoption of patient experi- However, to date, there are limited studies that identify ence indicators and reporting mechanisms, numerous speci fi c indicators measuring employee experience in GI studies of patient satisfaction and experience have been 37,40,49-54 and endoscopy unit settings in the United States. performed to assess their correlation with variables of care. Through this work a number of factors have been Much of the literature on employee experience in health- associated with greater patient satisfaction in endoscopy care has examined promoting high-level leadership prac- 55 ’ s personal manner, units. Such factors include the staff tices, having a strong relationship with and support 56,57 technical skill of the endoscopist, endoscopy unit environ- from managerial staff, organizational commitment, ment, clear communication from the endoscopist both work content that is valued by the employee, and work- 58,59 before and after the procedure, and prompt access to place environment. Improvements in these areas leads 17,18 endoscopic services. to improved staff retention, less absenteeism, improved Additionally, the importance of team communication, and greater patient satisfaction. pain control and patient experience at an endoscopy unit rst attempts to Our current study provides one of the fi has been widely reported, with the correlation between identify quality indicators as they pertain to employee the 2 varying among studies. In fact, recent data suggest experience in the endoscopy unit and builds on many of a surprising inverse relationship between patient comfort these key concepts noted in the literature. Key indicators and dosing of moderate sedation, but directly correlated identi fi ed through our approach highlight that staff with outcomes of adenoma detection and cecal intubation 19 empowerment through meetings; ongoing performance rates. fi ed in this Many of the quality indicators identi evaluations; and training that is continuous, team-based, guideline serve to monitor and measure many of these and modi ed on the basis of staff feedback are essential fi factors with the goal of ultimately improving them. to measure, track, and improve on within the endoscopy At the same time, none of the studies on patient expe- unit. By measuring employee experience, an endoscopy rience have developed or evaluated patient-reported unit can better understand and implement strategies to outcome or experience measures (ie, generated from the www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 135

18 Endoscopy unit quality indicators improve employee, and therefore patient, experience and improved safety outcomes have been demonstrated for thus the overall quality of the unit. performing a patient pause/time-out immediately before 71-75 ; and the use of validated, the beginning of a procedure ts in fi standardized discharge criteria has documented bene Ef fi ciency and operations 76-79 safely discharging patients home after a procedure. In the current healthcare environment, value is best Likewise, intraprocedural quality indicators have been fi ned by the delivery of ef fi cient and high-quality health- de 1-3,5 80 enumerated; monitoring data and communicating care. Although the study of ef fi ciency has been the focus of on quality indicators to providers performing endoscopic management in many industries, incorporating ef ciency fi procedures has resulted in improved quality and reduced models into healthcare has occurred only recently. In the practice variation among providers. Not surprisingly, United States there are few evidence-based publications 60-62 some of the highest-rated indicators in the procedure- evaluating operations and ef fi ciency in GI endoscopy related domain from our study correlated with work and only 1 of these was performed during a time period from the published literature. However, much of the liter- that represents the current environment of endoscopic ature on procedure-related quality indicators for endos- practice in the United States. These articles; an expert, 63 copy units is based on expert opinion. Areas such as opinion-based review article ; and previous operations privileging and credentialing for performing proced- research conducted by the ASGE and the Medical Group 4,12,81-85 6,10 ures, obtaining/documenting informed consent, Management Association provided the foundation that 4,86,87 and performing a preprocedure assessment, was used to develop the categories within the domain of 4,10 providing discharge instructions to patients, although fi rst ef fi ciency and operations. Our indicators offer the identi ed as important procedure-related quality indica- fi attempt to expand on and re fi ne this expert opinion and tors, have no patient outcomes-related data available to also construct a framework by which endoscopy units date. This void in robust studies examining outcomes can begin to more consistently measure and track their with regard to procedure-related quality indicators high- ned operations management and ef fi ciency. Having a de fi lights the need for continued research in this area. and inclusive leadership with a focus on meeting regulatory requirements with regard to space and operations appeared to be areas of greatest agreement among respondents in our study. Given that these Safety and infection control quality indicators and the majority of others in this Safety and infection control are of paramount impor- domain were process measures with little supporting fi tance to the overall success and ef cacy of GI endoscopy. data from the literature, future studies aimed at Consequently, performance assessment of endoscopic developing more outcome-based indicators are needed. units must include measures designed to evaluate these elements. Infections related to GI endoscopy are rare events, and most have been related to breaches in estab- Procedure-related lished protocols for handling and reprocessing endoscopes. There has been a dramatic rise in the request for GI spe- In line with this and concordant with ASGE guidelines, indi- cialty care in the United States, in particular endoscopic 64-66 cators deemed of highest importance in the safety and services, over the past 3 decades. In parallel, multiple infection control domain were related to the proper training quality indicators for various endoscopic procedures have 1-5 of staff and having policies and processes in place to ensure fi ed. been identi However, these indicators have been maintenance of adequate infection control in the endos- fi c procedures focused on individual providers and speci copy unit. Safety and infection control in endoscopic facil- rather than on how they relate to or impact the endoscopy ities have been the topic of many reviews and unit. Our study addressed this observation by focusing on 88,89 guidelines procedure-related indicators and how they impact the and recently have been the focus of media quality of an endoscopy unit. From our data we discovered headlines, with patients experiencing carbapenem- several important indicators in the preprocedure, intrapro- resistant Enterobacteriaceae infections after undergoing 90 cedure, and postprocedure processes in the endoscopy ERCP. Multiple individual guidelines exist on infection 92 91 unit. control in endoscopy, fi adequate room staf ng, 87 Few studies are available that have examined procedure- sedation in endoscopy, and quality indicators in GI 4 related quality indicators for endoscopy units. Further- endoscopy. Although several guidelines in this area exist, more, indicators that have been reported in this domain in general many requirements for safety and infection are overwhelmingly process measures with little support- control have little supporting outcomes data. Instead, ing data. Much of the literature on procedure-related qual- such recommendations come from consensus by experts ity indicators has focused on aspects of the preprocedure with experience in the safe delivery of care in the GI and postprocedure process. For example, documenting endoscopy setting. Continued work in this area will likely and performing endoscopic procedures for an appropriate be centered on the development and study of more ndings indication increases the diagnostic yield of fi outcome-based indicators, with supporting benchmark 67-70 during endoscopy and decreases inappropriate use data to help guide improvement work in endoscopy units. ; 136 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

19 Endoscopy unit quality indicators indicators should be considered a starting point from PRIORITY INDICATORS FOR A HIGH-QUALITY which an endoscopy unit could build on during ongoing ENDOSCOPY UNIT quality improvement efforts. fi rst comprehensive list of This guideline provides the quality indicators for U.S. endoscopy units. Our rigorous LIMITATIONS process of examining the available literature, leveraging the knowledge of experts in the fi eld, and soliciting feedback Several limitations exist with our method. Selection bias from endoscopy unit stakeholders yielded 155 indicators was present because respondents were a highly motivated across 5 key domains, of which we discuss 29 of the and engaged group. Although patients and payers were highest-rated indicators. Yet, given the large number of qual- invited to participate, our voting sample did not include ity indicators proposed, we wanted to highlight 5 endoscopy these representatives. Moreover, our response rate of unit quality indicators from among this list that were consid- 22.2% is low and can impact the generalizability of our ered the most compelling to measure and track for a high- interpretation of whether an results. Our respondents ’ quality endoscopy unit. The taskforce selected these priority uenced indicator was related to quality may have been in fl indicators using the following criteria: by their own endoscopy units experience and compliance. ’ Existing support in the literature for an association with  Our proposed indicators do not establish formal measure improved patient outcomes de fi nitions or performance thresholds. The latter is  Consensus among the taskforce members that perfor- currently limited because of the lack of adequate methods mance gaps and variation existed for benchmarking these parameters in practices across the These 5 priority endoscopy unit quality indicators country. The majority of the quality indicators included in include: the study were process and structural measures; many Endoscopy unit has a de ned leadership structure. fi  require development of systems for data gathering and Endoscopy unit has regular education, training pro-  tracking. We acknowledge and anticipate variability in mea- grams, and continuous quality improvement for all staff surement across different practice settings. Last, many of on new equipment/devices and endoscopic techniques. the quality indicators in the survey received high ratings Endoscopy unit records, tracks, and monitors proced-  fi that ultimately did not meet our prede ned consensus ure quality indicators for both the endoscopy unit and threshold; it is for this reason that all potential endoscopy individual endoscopists. unit quality indicators queried appear in the tables.  Procedure reports are communicated to referring pro- viders, and a process is in place for patients to receive a copy of their endoscopy report. CONCLUSION  Process is in place to track each speci fi c endoscope from storage, use, reprocessing, and back to storage. A lack of information on the performance variation These priority indicators re ect the key elements of a fl among endoscopy departments, and the lack of a current high-quality endoscopy unit, and several of them span organizational framework by which endoscopy units many of the domains discussed in this guideline. First, can direct their quality improvement efforts, suggest a ensuring that a de fi ned leadership is in place helps to pro- need for evidence-based quality indicators targeted at the mote high-performance leadership and organizational endoscopy unit level. Using the Delphi method to establish ciency and fi es ef fi commitment, which not only magni consensus among leaders in U.S. endoscopy units, we eval- operations of the endoscopy unit but advances staff expe- uated proposed indicators for endoscopy unit quality. This rience. Second, promoting education and training among fi rst of its kind in the United States, was survey, the staff and endoscopists, and monitoring and providing feed- comprehensive in scope and rigorous in design. The back on their performance, not only stimulates profes- consensus process identi fi ed 29 quality indicators related sional development but helps ensure that patients to the quality of an endoscopy unit among 5 domains undergoing endoscopic procedures are receiving high- that included patient experience, employee experience, quality and safe care. Third, communication with patients ciency and operations, procedure-related, and safety fi ef ’ and referring providers about a patient s care within the and infection control. Five priority endoscopy unit quality endoscopy unit helps foster a more patient-centered envi- ed as the most compelling to mea- indicators were identi fi ronment, thereby improving the patient experience and sure and track for a high-quality endoscopy unit. improves transitions in care. Finally, embedded within a The intent for disseminating this information is to high-quality endoscopy unit is a culture of safety and guide endoscopy units in their efforts to assess and high standards for infection control; central to this theme improve quality by identifying those areas currently are practices and policies along with monitoring related deemed most important to measure. Future efforts to endoscope reprocessing. Although these elements are should include maturation of the indicators into formal the foundation of a high-quality endoscopy unit, they are measures and development of appropriate tools to cap- by no means complete and all-inclusive. These priority ture these types of quality data. As the capability to record www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 137

20 Endoscopy unit quality indicators Sewitch MJ, Gong S, Dube C, et al. A literature review of quality in 18. and track these endoscopy unit quality indicators grows lower gastrointestinal endoscopy from the patient perspective. Can J over time we will learn which parameters are most closely Gastroenterol 2011;25:681-5 . linked to important patient outcomes. We will also be 19. Ekkelenkamp VE, Dowler K, Valori RM, et al. Patient comfort and quality able to apply the same principles of quality improvement in colonoscopy. World J Gastroenterol 2013;19:2355-61 . using these data on endoscopy unit performance that are Dawson J, Doll H, Fitzpatrick R, et al. The routine use of patient re- 20. . ported outcome measures in healthcare settings. BMJ 2010;340:c186 currently used to improve endoscopic procedure-related 21. Brown S, Bevan R, Rubin G, et al. Patient-derived measures of GI endos- outcomes. copy: a meta-narrative review of the literature. Gastrointest Endosc This document was reviewed and approved by the gov- 2015;81:1130-40; e1-9 . erning board of the American Society for Gastrointestinal Fenton JJ, Jerant AF, Bertakis KD, et al. The cost of satisfaction: a na- 22. Endoscopy (ASGE) and was reviewed and endorsed by tional study of patient satisfaction, health care utilization, expendi- tures, and mortality. Arch Intern Med 2012;172:405-11 . the Society of Gastroenterology Nurses and Associates The AMGA Employee 23. American Medical Group Association, “ (SGNA). Satisfaction and Engagement Benchmarking Program. ” Available at: http://www.powershow.com/view1/ 2577ed-ZDc1Z/The_AMGA_Employee_ powerpoint_ppt_ Satisfaction_and_Engagement_Bench marking_Program_ DISCLOSURE presentation . Accessed May 1, 2015. 24. Bersin J. Becoming irresistible: a new model for employee engage- Dr Valori is a director of Quality Solutions for Health- https://dupress.deloitte.com/dup-us-en/deloitte- ment. Available at: review/issue-16/employee-engagement-strategies.html . Accessed March care LLP and of Anderval Ltd. All other authors disclosed 20, 2015. no nancial relationships relevant to this publication. fi 25. Bullseye Business Solutions Small Business Advisory Toolkit. Table of key performance indicators. Bullseye Business Solutions, 2006. 26. Burger J. Why Hospitals Must Surpass Patient Expectations. GALLUP REFERENCES www.gallup.com/ Business Journal, May 1, 2014. Available at: . Ac- businessjournal/168737/why-hosiptals-surpass-pateint experience Adler DG, Lieb JG, 2nd, Cohen J, et al. Quality indicators for ERCP. 1. cessed March 20, 2015. Gastrointest Endosc 2015;81:54-66 . 27. Cataldo P. Focusing on employee engagement: how to measure it and Park WG, Shaheen NJ, Cohen J, et al. Quality indicators for EGD. 2. https://www.kenan-flagler.unc.edu/executive- improve it. Available at: . Gastrointest Endosc 2015;81:17-30 /media/E93A57C2D74F4E578A8B1012E70A56FD. development/about/ w 3. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonos- . Accessed March 20, 2015. ashx . copy. Gastrointest Endosc 2015;81:31-53 28. Collins KS, Collins SK, McKinnies R, et al. Employee satisfaction and Rizk MK, Sawhney MS, Cohen J, et al. Quality indicators common to all 4. employee retention: catalysts to patient satisfaction. Health Care Man- GI endoscopic procedures. Gastrointest Endosc 2015;81:3-16 . . ag (Frederick) 2008;27:245-51 Wani S, Wallace MB, Cohen J, et al. Quality indicators for EUS. Gastro- 5. The challenging state of employee engage- 29. Cornerstone On Demand, “ intest Endosc 2015;81:67-80 . ment in healthcare today - and strategies to improve it . Available at: ” 6. Global Rating Scale. Available at: http://www.globalratingscale.com . http://www.cornerstoneondemand.com/sites/default/files/whitepaper/ Accessed May 5, 2015. . Accessed on csod-wp-healthcare-employee-engagement-012015.pdf Williams T, Ross A, Stirling C, et al. Validation of the Global Rating Scale 7. May 1, 2015. . for endoscopy. Scott Med J 2013;58:20-1 30. Custom Insight. Industry-specific benchmarks and employee engage- Sint Nicolaas J, de Jonge V, de Man RA, et al. The Global Rating Scale in 8. http://www.custominsight.com/ ment. July 24, 2013. Available at: clinical practice: a comprehensive quality assurance programme for employee-engagement-survey/industry-benchmarks.asp . Accessed . endoscopy departments. Dig Liver Dis 2012;44:919-24 May 1, 2015. 9. Sint Nicolaas J, de Jonge V, Korfage IJ, et al. Benchmarking patient ex- 31. Dale Carnegie Training Whitepaper. What drives employee engage- periences in colonoscopy using the Global Rating Scale. Endoscopy http://www. ment and why it matters. October 2012. Available at: . 2012;44:462-72 /driveengagement_101612_wp.pdf dalecarnegie.co.za/assets/229/7 . 10. Armstrong D, Barkun A, Bridges R, et al. Canadian Association of Accessed May 1, 2015. Gastroenterology consensus guidelines on safety and quality indica- 32. Fassel D. Building better performance. Health Forum J 2003;46:44-5 . . tors in endoscopy. Can J Gastroenterol 2012;26:17-31 100 Best Companies to 33. Fortune Magazine and Great Place to Work. “ MacIntosh D, Dube C, Hollingworth R, et al. The endoscopy Global Rat- 11. ” Work For in 2015. Available at: http://fortune.com/best-companies . ing Scale-Canada: development and implementation of a quality Accessed June 4, 2015. improvement tool. Can J Gastroenterol 2013;27:74-82 . 34. Worldwide 13% of employees are engaged at work. Gallup World. 12. Petersen BT. Quality assurance for endoscopists. Best Pract Res Clin /165269/worldwide-employees- Available at: http://www.gallup.com/poll . Gastroenterol 2011;25:349-60 . Accessed May 1, 2015. engaged-work.aspx 13. Helmer-Hirschberg O. The use of the Delphi technique in problems of 35. Harter JK, Schmidt FL, Agrawal S, et al. The relationship between educational innovations. Santa Monica, CA: Rand; 1966. engagement at work and organizational outcomes. Available at: 14. Dalkey NC, Helmer-Hirschberg O. An experimental application of the http://employeeengagement.com/wp-content/uploads/2013/04/2012- Delphi method to the use of experts. Santa Monica, CA: Rand; 1962. . Accessed March 20, 2015. Q12-Meta-Analysis-Research-Paper.pdf Delbecq AL, Van de Ven AH, Gustafson DH. Group techniques for pro- 15. 36. Harter JK, Schmidt FL, Hayes TL. Business-unit-level relationship be- gram planning: A guide to nominal group and delphi processes. Mid- tween employee satisfaction, employee engagement, and business dleton, WI: Green Briar Press; 1975. . outcomes: a meta-analysis. J Appl Psychol 2002;87:268-79 16. Nair R, Aggarwal R, Khanna D. Methods of formal consensus in classi- 37. LeonardD.Puttingsuccessinsuccessionplanning:theroleoflearningand fication/diagnostic criteria and guideline development. Semin Arthritis ” development. University of North Carolina Business School, April 2013. . Rheum 2011;41:95-105 Available at: http://www.kenan-flagler.unc.edu/executive-development/ 17. Ko HH, Zhang H, Telford JJ, et al. Factors influencing patient satisfac- media/Files/documents/executive-development/ custom-programs/ ” tion when undergoing endoscopic procedures. Gastrointest Endosc success-in-succession-planning.ashx . Accessed May 1, 2015. 2009;69:883-91 . 138 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

21 Endoscopy unit quality indicators Day LW, Belson D, Dessouky M, et al. Optimizing efficiency and oper- 60. 38. Lowe G. How employee engagement matters for hospital perfor- ations at a California safety-net endoscopy center: a modeling and mance. Healthc Q 2012;15:29-39 . simulation approach. Gastrointest Endosc 2014;80:762-73 . 39. Marketing Innovators International, White Paper. The effects of Harewood GC, Chrysostomou K, Himy N, et al. A ” time-and-motion “ 61. employee satisfaction on company financial performance. Marketing study of endoscopic practice: strategies to enhance efficiency. Gastro- Innovators International, 2005. intest Endosc 2008;68:1043-50 . Metcalf R, Tate R. Shared governance in the endoscopy department. 40. 62. Yong E, Zenkova O, Saibil F, et al. Efficiency of an endoscopy suite in a Gastroenterol Nurs 1995;18:96-9 . teaching hospital: delays, prolonged procedures, and hospital waiting 41. Mulhern F, Bolger B. People performance management: the science times. Gastrointest Endosc 2006;64:760-4 . http://businessfinancemag. that supports soft metrics. Available at: 63. Pike IM, Vicari J. Incorporating quality measurement and improvement com/business-performance-management/people-performance-manag . into a gastroenterology practice. Am J Gastroenterol 2010;105:252-4 . Accessed March 20, 2015. ement-science-supports-soft-metrics Bohra S, Byrne MF, Manning D, et al. A prospective analysis of inpatient 64. 42. Peltier J, Dahl A. The relationship between employee satisfaction and consultations to a gastroenterology service. Ir Med J 2003;96:263-5 . hospital patient experiences. Forum for People Performance Man- 65. Cai Q, Bruno CJ, Hagedorn CH, et al. Temporal trends over ten years in agement and Measurement. Available at: http://www.info-now. formal inpatient gastroenterology consultations at an inner city hospi- userimg/FORUM/Hospital lib/pi1/press2web/html/ com/typo3conf/ext/p2w . tal. J Clin Gastroenterol 2003;36:34-8 %20Study%20-Relationship%20Btwn%20Emp.%20Satisfaction%20and 66. Jordan MR, Conley J, Ghali WA. Consultation patterns and clinical cor- . Accessed March 20, 2015. %20Pt.%20Experiences.pdf relates of consultation in a tertiary care setting. BMC Res Notes 2008;1: 43. Press Ganey Associates. Performance insights, every voice matters: the . 96 bottom line on employee and physician engagement, April 23, 2014. Bersani G, Rossi A, Ricci G, et al. Do ASGE guidelines for the appropriate 67. [email protected] . Accessed March 23, 2015. Available at: use of colonoscopy enhance the probability of finding relevant pathol- 44. Public Services Health & Safety Association. Stakeholder consultation . ogies in an open access service? Dig Liver Dis 2005;37:609-14 s ’ paper: potential health and safe workplace indicators for Ontario ASGE Standards of Practice Committee; Early DS, Ben-Menachem T, 68. health care system. Public Services Health & Safety Association, et al. Appropriate use of GI endoscopy. Gastrointest Endosc 2012;75: January 2013. . 1127-31 45. Pund LE, Sklar P. Linking quality assurance to human resources: de Bosset V, Froehlich F, Rey JP, et al. Do explicit appropriateness 69. improving patient satisfaction by improving employee satisfaction. criteria enhance the diagnostic yield of colonoscopy? Endoscopy Available at: https://spea.indiana.edu/doc/undergraduate/ugrd_ 2002;34:360-8 . . Accessed May 1, 2015. thesis2012_hmp_pund.pdf 70. Froehlich F, Repond C, Mullhaupt B, et al. Is the diagnostic yield of up- 46. Rabinowitz R. Expert incite: Focus on these 5 engagement drivers per GI endoscopy improved by the use of explicit panel-based appro- to boost your HCAHPS scores. The Advisory Board, March 15, 2015. priateness criteria? Gastrointest Endosc 2000;52:333-41 . esearch/hr-advancement- http://www.advisory.com/r Available at: 71. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to center/expert-insights/2015/engagement-drivers-to-improve-hcahps- reduce morbidity and mortality in a global population. N Engl J Med scores . Accessed June 4, 2015. . 2009;360:491-9 47. Verma A. Whitepaper: Designing and measuring human capital key 72. Howell AM, Panesar SS, Burns EM, et al. Reducing the burden of surgi- performance indicators: the balanced scorecard approach. Tata cal harm: a systematic review of the interventions used to reduce Consultancy Services. Available at: www.tcs.com/resources/white_ adverse events in surgery. Ann Surg 2014;259:630-41 . papers?Pages/Designing-Measuring-Human-Capital . Accessed May 1, 73. Lepanluoma M, Takala R, Kotkansalo A, et al. Surgical safety checklist is 2015. associated with improved operating room safety culture, reduced 48. West JS. Engaged or disengaged? That is the question. National Busi- wound complications, and unplanned readmissions in a pilot study ness Research Institute, Inc. Available at: www.nbrii.com/pdf/ in neurosurgery. Scand J Surg 2014;103:66-72 . employee . Accessed March 21, 2015. 74. Lyons VE, Popejoy LL. Meta-analysis of surgical safety checklist effects De Jonoge VKEJ, van Leerdam ME. Qua 49. lity assurance in the endoscopy unit: on teamwork, communication, morbidity, mortality, and safety. West J tline Gastroenterol 2012;3:115-20 the view of endoscopy personnel. Fron . . Nurs Res 2014;36:245-61 Greenwald B. How the gastroenterology nurse can establish and meet 50. Pugel AE, Simianu VV, Flum DR, et al. Use of the surgical safety check- 75. career goals. Gastroenterol Nurs 2006;29:291-4 . list to improve communication and reduce complications. J Infect Pub- s shoes. Gastroenterol 51. Hobgood E. Leading the way: walking in a nurse ’ lic Health 2015;8:219-25 . Nurs 2003;26:215-8 . 76. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth Lee CK, Park DI, Lee SH, et al. Participation by experienced endoscopy 52. 1995;7:89-91 . nurses increases the detection rate of colon polyps during a screening Chernik DA, Gillings D, Laine H, et al. Validity and reliability of the Ob- 77. colonoscopy: a multicenter, prospective, randomized study. Gastroint- server ’ s Assessment of Alertness/Sedation Scale: study with intrave- . est Endosc 2011;74:1094-102 nous midazolam. J Clin Psychopharmacol 1990;10:244-51 . Salmore R. Praise as a means to increase job satisfaction. Gastroenterol 53. Trevisani L, Cifala V, Gilli G, et al. Post-anaesthetic discharge scoring 78. . Nurs 1990;13:98-100 system to assess patient recovery and discharge after colonoscopy. . 54. Schaffner M. They is we. Gastroenterol Nurs 2009;32:121-2 . World J Gastrointest Endosc 2013;5:502-7 Coomber B, Barriball KL. Impact of job satisfaction components on 55. 79. White PF, Song D. New criteria for fast-tracking after outpatient anes- intent to leave and turnover for hospital-based nurses: a review of the research literature. Int J Nurs Stud 2007;44:297-314 . ’ s scoring system. thesia: a comparison with the modified Aldrete percep- ’ 56. Moneke N, Umeh OJ. Factors influencing critical care nurses . Anesth Analg 1999;88:1069-72 tion of their overall job satisfaction: an empirical study. J Nurs Adm de Jonge V, Sint Nicolaas J, Cahen DL, et al. Quality evaluation of co- 80. 2013;43:201-7 . lonoscopy reporting and colonoscopy performance in daily clinical 57. Moneke N, Umeh OJ. How leadership behaviors impact critical care . practice. Gastrointest Endosc 2012;75:98-106 nurse job satisfaction. Nurs Manage 2013;44:53-5 . Beller GA, Winters WL, Jr, Carver JR, et al. 28th Bethesda Conference. 81. 58. Task Force 3: Guidelines for credentialing practicing physicians. J Am Irvine DM, Evans MG. Job satisfaction and turnover among nurses: . Coll Cardiol 1997;29:1148-62 . integrating research findings across studies. Nurs Res 1995;44:246-53 Eisen GM, Baron TH, Dominitz JA, et al. Methods of granting hospital 82. Atefi N, Abdullah KL, Wong LP, et al. Factors influencing registered 59. privileges to perform gastrointestinal endoscopy. Gastrointest Endosc nurses perception of their overall job satisfaction: a qualitative study. . 2002;55:780-3 Int Nurs Rev 2014;61:352-60 . www.VideoGIE.org Volume 2, No. 6 : 2017 VIDEOGIE 139

22 Endoscopy unit quality indicators ASGE Quality Assurance in Endoscopy Committee; Petersen BT, Chennat 88. 83. Ensuring competence in endoscopy. Available at: http://www.asge.org/ J, Cohen J, et al. Multisociety guideline on reprocessing flexible gastro- clinicalpractice/clinical-practice . Accessed June 26, 2015. . intestinal endoscopes: 2011. Gastrointest Endosc 2011;73:1075-84 Houghton A. Variation in outcome of surgical procedures. Br J Surg 84. ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force; 89. 1994;81:653-60 . Calderwood AH, Chapman FJ, Cohen J, et al. Guidelines for safety in the 85. ASGE Standards of Practice Committee; Dominitz JA, Ikenberry SO, An- . gastrointestinal endoscopy unit. Gastrointest Endosc 2014;79:363-72 derson MA, et al. Renewal of and proctoring for endoscopic privileges. Muscarella LF. Risk of transmission of carbapenem-resistant Enterobac- 90. . Gastrointest Endosc 2008;67:10-6 during gastrointestinal endoscopy. ” superbugs “ teriaceae and related 86. ASGE Standards of Practice Committee; Apfelbaum JL, Connis RT, Nick- . World J Gastrointest Endosc 2014;6:457-74 inovich DG, et al. Practice advisory for preanesthesia evaluation: an up- ASGE Standards of Practice Committee; Banerjee S, Shen B, et al. 91. dated report by the American Society of Anesthesiologists Task Force Infection control during GI endoscopy. Gastrointest Endosc on Preanesthesia Evaluation. Anesthesiology 2012;116:522-38 . . 2008;67:781-90 Standards of Practice Committee of the American Society for 87. ASGE Standards of Practice Committee; Jain R, Ikenberry SO, et al. Min- 92. Gastrointestinal Endoscopy; Lichtenstein DR, Jagannath S, Baron imum staffing requirements for the performance of GI endoscopy. TH, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Gastrointest Endosc 2010;72:469-70 . Endosc 2008;68:815-26 . 140 VIDEOGIE Volume 2, No. 6 : 2017 www.VideoGIE.org

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