THERE IS NO I IN TEAM: HOW TO IMPROVE QUALITY OF CARE IN THE ENDOSCOPY UNIT Alan N. Barkun Professor, Division of Gastroenterology Chairholder of the DG Kinnear Chair in Gastroenterology, Chief Quality Officer, Division of Gastroenterology, McGill University and the McGill University Health Centre Chair of the Clinical Standards and of the Evaluation of Endoscopic Competence Committees, Quebec Colorectal Cancer Screening Program Conflicts Dr. Barkun is a consultant for: Olympus Inc. Cook Inc. Dr. Barkun receives a stipend from the Direction Québécoise du Cancer 1
Objectives 1) Understand current quality standards for a digestive endoscopy unit 2) Appreciate the different tools required to optimize quality 3) Become familiar with future evolutions in the field 2
Quality Assurance Quebec model Deviation from the organizational standards and expectations (ex.: access delays) First level of action: the institution, and the CSSS Second level: the regional agency (ex.: referral patterns, unit designation) Third level: central committee in quality assurance, the MSSS (support to supraregional centres) Deviation from the professional standards of practice First level of action: the professional tries to auto-ccorect his practice Second level: the institution (CMDP- DSI-CII-CM / CA) Must have obtained his endoscopy privileges from the CMDP, must have done 150 colonoscopies per year, can receive additional training if needed. Third level: the central committee in quality assurance (audit: CMQ collaboration, Associations) 5 3
QUALITY IS EVERYONE S BUSINESS IN THE ENDO UNIT! Quality is NOT just I NOT just the quality of the individual endoscopist but rather THE WHOLE TEAM Robertson, GUT, 2015 Quality and the Quebec Colorectal Cancer Screening Program ENDOSCOPY UNIT A.Global Rating Scale B. Decontamination of endoscopes A specific training will be developed for Primary Care Physicians for referral 8 4
September 2011 Publication of Nursing Clinical Guidelines for adult colonoscopy NO pushing or retrieving of colonoscope by nurses Organizational steps 06/11 Education blitz on guidelines for 8 PQDCCR pilot sites September Publication of guidelines Implementation of guidelines in the pilot units Implementation of nursing documentation sheet: pre/intra/post-scope Development of the education plan Development of E-learning module on sedation (Spring 2014) QI: Development of an audit tool to monitor the integration of the nursing guidelines in pre, intra post procedure Development of the contents of the education plan (modules) and validation with pilot sites Development of the competencies: evaluation and surveillance Delayed development/implementation because of lack of funding but work now under way again, for the ENTIRE province 5
National German survey: 44-item questionnaire to 2113 participants in 1056 institutions 21.2 % response rate; 54% hospital-based New staff hired in 21%; rosters changed in 10% Almost all issues improved after course participation but did not reach statistical significance except for: Availability of peri-interventional ECG-monitoring Use of ASA classification 34% to 55% Documentation of discharge 19% to 40% Schilling, Z Gastroenterol, 2013 Endoscopic non-technical skills team training Matharoo, W J Gastro, 2014 6
Continuing Professional Development program for the ENDOSCOPE REPROCESSING STAFF Physical restructuring identified at the 8 pilot sites and changes implemented Actual program developed QC standards in decontamination are being applied Being rolled out to the entire province including some infrastrucural funding QA-QI - FOR THE ENDOSCOPIST The program has 3 objectives targeting: Knowledge base Skills set Self reflection and career long professional quality improvement attitude 7
STANDARDS INDICATORS SPECIFIC TARGETS Annual volume No. of colonoscopies : completed completed with polypectomy completed without polypectomy Pre-colonoscopy No. of colonoscopies with evaluation evaluation >150 colonoscopies completed Priority level No. of colonoscopies where level is respected 95% of all requests Bowel preparation No. of colonoscopies where preparation is documented Quality of bowel preparation Sedation No. of colonoscopies where quality is documented No. of colonoscopies repeated over 60 days because of an initial inadequate intervention No. of colonoscopies: with sedation without sedation Cæcal intubation No. of colonoscopies where the cæcum is : visualized visualized + documented, visualized + documented with 2 of 3 landmarks Withdrawal times QUALITY INDICATORS IN COLONOSCOPY No. of colonoscopies where withdrawal times is documented 90% with excellent/good quality 100% of all initially inadequate colonoscopies 100% conforming to provincial standards 95% (asymptomatic), 90%(symptomatic) 100% of completed colonoscopy 100% of completed colonoscopy 100% of all completed colonoscopy without intervention P7 QUALITY INDICATORS IN COLONOSCOPY P8 STANDARDS INDICATORS SPECIFIC TARGETS Removal of the polyps Average number of polyps: removed removed + collected for histopathological analysis 95% of polyps collected P9 Colonoscopy report No. of colonoscopies where a report as been approved and signed by a colonoscopist Management of patient with risks Antithrombotic Therapy Adverse events Colonoscopists should provide appropriate followup to their patients without overuse of resources Assess the risk related to the colonoscopy for patients on antithrombotic therapy No. of adverse events over 30 day after colonoscopy Perforation: <1/1000 (all colonoscopies) <1/2000 (asymptomatic) <1/500 (symptomatic) Bleeding: <1/100 after a polypectomy <1/100 minor AEs <1/1000 major AEs 0 deaths Antibiotic prophylaxis Histopathology Antibiotic should be given on admission for patients with cirrhosis and colorectal bleeding All tissue must be sent to pathology (< 48 hrs), analyze ( 5 days) received ( 10 days) 100% of samples P10 P11 8
Slide 15 P7 Not the good word but I know someoneat work how can tell me. I will check tomorow (15/09/2011) Pascale, 14/09/2011 P8 P9 I know that this word dont have a - but in this case I but one because the word took to much place, that ok with you? Pascale, 15/09/2011 Peut-on employer ce mot en anglais ou il s'agit de jargon Pascale, 15/09/2011 Slide 16 P10 Not the good word but I know someoneat work how can tell me. I will check tomorow (15/09/2011) Pascale, 14/09/2011 P11 P12 I know that this word dont have a - but in this case I but one because the word took to much place, that ok with you? Pascale, 15/09/2011 Peut-on employer ce mot en anglais ou il s'agit de jargon Pascale, 15/09/2011
Management algorithms WHAT IS THE PQDCCR TRACKING WITH REGARDS TO ENDOSCOPIC PERFORMANCE? 9
Le plan d action Endoscopist scorecard Nom Prénom Hôpital/Institution Période de Q4 2013 à Q2 2014 Coloscopies (N) Taux d'intubation caecale (%) Dépistage Prép. Colique Sédation Analgésique Polypes Taux de complications Échelle de confort Patients Hors (n) Dépistage dépistage Numéro d'indentification du coloscopiste #1 Numéro d'indentification du coloscopiste # 2 % excellente, Dose de Dose de bonne, vs Sans Midazolam Fentanyl Nonajusté ajusté* ajusté inadéquate * (%) procédure procédure correcte, sedation - moyenne mg/ - moyenne mg/ Propofol (%) % de polypes récupérés nombre et moyen nombre % de % de envoyés de moyen procédure polypes en polypes de avec au récupérés pathologi par polypes Intraprocédprocéd d'agent Post- Utilisation moins 1 par e par procédur par polype procédure procédure e patient rales urales antagoniste 10
21 Continual Professional Development Program IN COLONOSCOPY ENDOSCOPIST Quebec colorectal cancer screening program Traditional Clinical Practice 1. Endoscopist starting point assessment: basic knowledge (knowledge, know how, skills) based on the score card Endoscopist Profile: 2. Website incorporating training tools (E learning modules) and individual endoscopist s results with respect to meeting clinical standards of practice 3. Direct observation and training units to improve colonoscopy practice (experts in endoscopy and pedagogy) 4. Upskilling course in colonoscopy techniques (Skills Enhancement for Endoscopy) (experts en endoscopie et en pédagogie) Personal portfolio indicating acquired training, experiences and goals to achieve 5. Certificate of attendance in the program and attainment of objectives 6. In case of uncertainty about the quality and safety of practice of an endoscopist, modalities of intervention to be agreed upon with the Collège des médecins du Québec 11
E-learning modules Module 0: Introduction to the quality program Module 1: Pre-procedure preparation administrative framework Module 2: Clinical preparation informed consent process, bowel preparation and antithrombotic therapy Module 3: Intra-procedure conscious sedation, ASA Physical Status Classification System Module 4: Endoscopy report and quality of bowel preparation Module 5: Colonoscopy techniques looping, torque, etc. Module 6: Polypectomy Module 7: Adverse events Module 8: Patient management and follow-up care 3 hours 12
Global Rating Scale Data entry screen Each item has a series of statements that have to be answered yes or no 13
Additional Challenges to be addressed Dissemination plan (Endoscopists Gen Surg GI Int Med + College) Validation of the modules evaluations Informatics Infrastructure Mid-long-term financing Tracking of performance and navigation of an endoscopist amidst the UK National Bowel Screening Program Apr 07- Apr 08, independent Colonoscopies. 14
INDICATEURS RELIÉS AU FINANCEMENT DE LA MISE À NIVEAU DES UNITÉS D ENDOSCOPIE Embedding quality/outcomes research in the PQDCCR Evaluation of the optimal FIT threshold value Validation of the Canadian GRS Validation of the colonoscopy referral sheet and the hierarchal triage priority scheme Development and validation of a new colonoscopy preparation assessment scale 15
Kolber, PLoSOne,2013 16
Kolber, PLoSOne,2013 Features of the CQI program 1. Features of the CQI program Endoscopists Nurses Technicians/ PABs Clerical/ Management Patients 1.01 Voluntary participation X 1.02 Summative and formative evaluation X X 1.03 Disclosure of results X X X X 1.04 Quality indicators X X X X 1.05 Training and education X X X X X 1.06 Patient centred X X X X X 1.07 Clinical quality centred X X X X 1.08 Feasibility and adaptability X X X X 1.09 Clarity of the intervention +/ +/ +/ +/ 1.10 Cost and Cost effectiveness X X 1.11 Maintaining of compliance X X X X 17
Features of the CQI program Endoscopists Nurses Technicians /PABs Clerical/ Management Patients 2. Attitudes and perceptions 2.01 Attitude towards intervention or the action plan -- ++ + --- 2.02 Sense of ownership as regards the intervention +/ + ++ 2.03 Perception of impact + + + + + Features of the CQI program Endoscopists Nurses Technicians/ PABs Clerical/ management Patients 3. Organizational characteristics 3.01 Involving all in the planning and implementation +/- + + + 3.02 Support from hospital administration - + + +/- 3.03 Dedicating staff to perform new roles - + + + 3.04 Access to human resources - + - + 3.05 Access to material + - - - 3.06 Access to training + + + + 18
Conlusion Endoscopy is a perfect paradigm for a team approach to quality improvement Colonoscopy has ignited and accelerated all endoscopy quality development Numerous quality initiatives under way across the country to achieve common quality standards Nurses are key to facilitating quality improvement initiatives and need to remain an integral part of both development and implementation processes 19