Clinical Safety & Effectiveness Cohort # 13
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1 Clinical Safety & Effectiveness Cohort # 13 Development of Gastrointestinal Endoscopic Quality Improvement Program, Quality Metrics & Reporting Tools (Equipment)
2 The Team Division: GI Adewale Ajumobi, MD, MBA (CS&E Participant) Patty McCarroll, MBA (CS&E Participant ) Tisha Lunsford, MD (Team Member) Rick Pena (Team Member) Natalie Vasquez (Team Member) Glenn W Gross, MD (Team Member) Facilitator: Iba Aburizik Sponsor Department GI Department Tisha Lunsford, M.D
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4 Background Colonoscopy is recommended for the prevention & detection of colon cancer. The quality of colonoscopy varies among endoscopists. To ensure uniform quality, national standards have been established. Some of the national standards have been incorporated in the Physician Quality Reporting System (PQRS). At the University Health System, there are no colonoscopy quality metrics or tools for reporting them.
5 What Are We Trying to Accomplish? OUR AIM STATEMENT Increase the availability of reports on colonoscopy metrics (clinical performance) at University Health System from 0% to 100% by January 2014.
6 Pre-Intervention Data
7 Are you satisfied with the provision of data to show your personal clinical effectiveness? 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% dissatisfied somewhat dissatisfied neutral somewhat satisfied very satisfied
8 Knowledge of personal colonoscopy metrics Knowledge of cecal intubation rate: 0% Knowledge of cecal intubation time: 0% Knowledge of withdrawal time: 0% Knowledge of polyp detection rate: 0% Knowledge of adenoma detection rate: 0% Would like to know personal colonoscopy related quality metrics -Yes: 100% -No: 0%
9 Knowledge of national standards for colonoscopy metrics ADR for males -Correct answer: 40% -Incorrect answer: 60% ADR for females -Correct answer: 40% -Incorrect answer: 60% ADR for all -Correct answer: 40% -Incorrect answer: 60%
10 Knowledge of national standards for colonoscopy metrics Cecal intubation rate for screening colonoscopy -Correct answer: 10% -Incorrect answer: 90% Minimum Withdrawal time for screening colonoscopy -Correct answer: 60% -Incorrect answer: 40%
11 People Method Measurement Expert Interface Metrics Interest Registry Goals EMR Training Institution Software GI Metrics Endowriter Culture Database Machine Environment Materials
12 What to Measure? Literature Review -Guidelines -Scientific Studies -Opinion AHRQ Quality Measure Tools & Resources 2013 Physician Quality Reporting System (PQRS) Measures National Quality Forum
13 Endoscopy Unit Efficiency Clinical Performance Patient Satisfaction Wait Time Adenoma Detection Rate Availability Flow Time throughput Cecal Intubation Rate Comfort Preparation Time Complication Rate Courtesy Procedure Time Withdrawal Time Promptness Recovery Time Appropriate surveillance interval Competence
14 Clinical Performance Quality Metrics in Colonoscopy Cecal intubation rate: 95% for screening CSP Withdrawal time: minimum of 6mins Appropriate surveillance interval based on presence and type of polyp -PQRS & NQF Measure Adenoma detection rate: 25% for males, 15% for females & 20% general population PQRS measure -Associated with interval cancer & mortality
15 ADR & Interval CA Kaminski et al NEJM 2010
16 ADR & Interval CA Douglas Corley DDW 2013 For every 1% in ADR -Interval CRC risk by 3% -Interval CRC death by 4%
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18 Appropriate surveillance interval 45.1% got unnecessary colonoscopies 69% did not get necessary colonoscopy 42.5% got unnecessary colonoscopy after a negative exam NQF 0658
19 How to obtain performance data Manual collection Database extraction and software integration. Registry -GIQUIC (Quintiles Outcome, ACG, ASGE) -AGA Digestive Health Outcomes Registry( Inovalon, AGA)
20 EEndoscopy unit Endowriter (Endoworks) EMR Sunrise Patient EPathology ECecal Intubation Rate EAdenoma Detection Rate EWithdrawal Time ECecal Intubation Time Appropriate surveillance interval
21 Log in to Endoworks Search Endoworks for screening colonoscopies (SCSP) Search individual reports for completed SCSP Search individual reports for SCSP with polyps Identify adenoma in pathology reports Search individual pathology report using list B Log in to sunrise Create a list of all completed SCSP (list A) and SCSP w polyps (list B) Create a list of completed SCSP with adenoma (list C) Calculate ADR by dividing list C by list A
22 Time spent obtaining 1 colonoscopy data necessary for ADR calculation Log in to Endoworks and Sunrise: mins Obtaining list of screening CSP and screening CSP with polyps: 1: mins Obtaining pathology reports: mins Total time: mins
23 Which registry to join?
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25 Unexpected Problem Objection to language in contract with registry Change in director of endoscopy Flawed GIQUIC Interface from Olympus -No connectivity -Difficult to use template -Missing data Change in physician behavior -More required items to complete in report -Need to add pathology results & revise recommendations.
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28 Post-Intervention Data
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37 Return on Investment Cost Olympus Interface b/w Endowriter and GIQUIC =$11,400 Benefit Work hours saved 10mins per CSP=166.6hrs/1000CSP Last year: 4000 CSP (UH)=666.4hrs This year projection: >10,000 CSP (UH,MARC, Brady)=1,666hrs At minimum UH of $11.8 =19,658.8 At appropriate work title of data manager =$65,000/yr. GIQUIC (Registry) =$5400 annually Meets PQRS requirement =0.5% payment bonus or 1.5% payment penalty avoidance on Medicare beneficiaries. Meets NQF Measure. After year 3, Interface maintenance =$1,500 annually Basis for other quality improvement efforts Marketing Contracts acquisition 37
38 Next Step: Moving Forward Improve areas of deficiency Fellows performance Under performers vs. Over performers Patient satisfaction Endoscopy unit efficiency
39 Acknowledgement UH leadership team GI Fellows and Staff GI Techs and Nurses IT Manager-Juan Navarro Dr. Patterson & CES Course Facilitators
40 Thank you! Educating for Quality Improvement & Patient Safety 40
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