Canadian Association of Gastroenterology Consensus Guidelines on Safety and Quality Indicators in Endoscopy

Several organizations worldwide have developed procedure-based guidelines and/or position statements regarding various aspects of quality and safety indicators, and credentialing for endoscopy. Although important, they do not specifically address patient needs or provide a framework for their adoption in the context of endoscopy services. The consensus guidelines reported in this article, however, aimed to identify processes and indicators relevant to the provision of high-quality endoscopy services that will support ongoing quality improvement across many jurisdictions, specifically in the areas of ethics, facility standards and policies, quality assurance, training and education, reporting standards and patient perceptions.BACKGROUND: Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy.OBJECTIVE: To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery.METHODS: A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants.RESULTS: Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), qual: 97% to 100%) and patient perceptions ( statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified.DISCUSSION: The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services.CONCLUSIONS: The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy.

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An Environmental Scan and Evaluation of Home Dialysis Quality Indicators Currently Used in Canada

Canadian Journal of Kidney Health and Disease ◽

10.1177/2054358120977391 ◽

2020 ◽

Vol 7 ◽

pp. 205435812097739

Author(s):

Lisa Dubrofsky ◽

Ali Ibrahim ◽

Karthik Tennankore ◽

Krishna Poinen ◽

Sachin Shah ◽

...

Keyword(s):

Quality Improvement ◽

Quality Of Care ◽

Peritoneal Dialysis ◽

Quality Indicators ◽

Patient Centered ◽

High Quality ◽

Home Dialysis ◽

Environmental Scan ◽

Starting Point

Background: Quality indicators are important tools to measure and ultimately improve the quality of care provided. Performance measurement may be particularly helpful to grow disciplines that are underutilized and cost-effective, such as home dialysis (peritoneal dialysis and home hemodialysis). Objective: To identify and catalog home dialysis quality indicators currently used in Canada, as well as to evaluate these indicators as a starting point for future collaboration and standardization of quality indicators across Canada. Design: An environmental scan of quality indicators from provincial organizations, quality organizations, and stakeholders. Setting: Sixteen-member pan-Canadian panel with expertise in both nephrology and quality improvement. Patients: Our environmental scan included indicators relevant to patients on home dialysis. Measurements: We classified existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks. Methods: To evaluate the indicators, a 6-person subcommittee conducted a modified version of the Delphi consensus technique based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for further examination. We rated items from 1 to 9 on 6 domains (1-3 does not meet criteria to 7-9 meets criteria) as well as a global final rating (1-3 unnecessary to 7-9 necessary) to distinguish high-quality from low-quality indicators. Results: Overall, we identified 40 quality indicators across 7 provinces, with 22 (55%) rated as “necessary” to distinguish high quality from poor quality care. Ten indicators were measured by more than 1 province, and 5 of these indicators were rated as necessary (home dialysis prevalence, home dialysis incidence, anemia target achievement, rates of peritonitis associated with peritoneal dialysis, and home dialysis attrition). None of these indicators captured the IOM domains of timely, patient-centered, or equitable care. Limitations: The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals. Conclusions: These results provide Canadian home dialysis programs with a starting point on how to measure quality of care along with the current gaps. This work is an initial and necessary step toward future collaboration and standardization of quality indicators across Canada, so that home dialysis programs can access a smaller number of highly rated balanced indicators to motivate and support patient-centered quality improvement initiatives.

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Indicators of Safety Compromise in Gastrointestinal Endoscopy

Canadian Journal of Gastroenterology ◽

10.1155/2012/782790 ◽

2012 ◽

Vol 26 (2) ◽

pp. 71-78 ◽

Cited By ~ 6

Author(s):

Mark R Borgaonkar ◽

Lawrence Hookey ◽

Roger Hollingworth ◽

Ernst J Kuipers ◽

Alan Forster ◽

...

Keyword(s):

Patient Safety ◽

Quality Improvement ◽

Quality Indicators ◽

Gastrointestinal Endoscopy ◽

Metabolic Complications ◽

Screening Programs ◽

Consensus Group ◽

Canadian Association ◽

Improvement Programs ◽

Quality Improvement Programs

The growth in the use of endoscopy to diagnose and treat many gastointestinal disorders, and its central role in cancer screening programs, has led to a significant increase in the number of procedures performed. This growth, however, has also led to many variations in, among others, the provision of services, the choice of sedative medications and the training of providers. The recognition of the significance of quality in endoscopy has prompted several countries, including Canada, to initiate efforts to adopt nationwide quality improvement programs. The Canadian Association of Gastroenterology formed a committee to review endoscopy and quality with the aim of stimulating improvement. This article focuses specifically on patient safety indicators that were developed at a consensus conference aimed at generating a broad range of recommendations for selected endoscopic procedures, which if adopted, could lead to significant changes in how endoscopy services are provided.INTRODUCTION: The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs.OBJECTIVE: To identify key indicators of safety compromise in gastrointestinal endoscopy.METHODS: The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance.RESULTS: A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related – the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm/bronchospasm; procedure-related early – perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed – death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider, gastrointestinal bleeding within 14 days of procedure, infection or symptomatic metabolic complications.CONCLUSIONS: The 19 indicators of safety compromise in endoscopy, identified by a rigorous, evidence-based consensus process, provide clear outcomes to be recorded by all facilities as part of their continuing quality improvement programs.

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An Environmental Scan of Canadian Quality Metrics for Patients on In-Center Hemodialysis

Canadian Journal of Kidney Health and Disease ◽

10.1177/2054358120975314 ◽

2020 ◽

Vol 7 ◽

pp. 205435812097531

Author(s):

Daniel Blum ◽

Alison Thomas ◽

Claire Harris ◽

Jay Hingwala ◽

William Beaubien-Souligny ◽

...

Keyword(s):

Health Care ◽

Quality Improvement ◽

Quality Indicators ◽

Quality Metrics ◽

Care Quality ◽

Environmental Scan ◽

Modified Delphi ◽

Delphi Approach ◽

Effective Care ◽

Starting Point

Background: Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality. Objectives: To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada. Design: Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach. Setting: Canadian ICHD units. Participants: Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement. Measurements: We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks. Methods: Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments. Results: We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as “necessary” to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the “necessary” indicators measured the IOM domains of timely, patient-centered, or equitable care. Limitations: The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites. Conclusions: Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care. Trial Registration: not applicable.

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Complexity Science as a Frame for Understanding the Management and Delivery of High Quality and Safer Care

Textbook of Patient Safety and Clinical Risk Management ◽

10.1007/978-3-030-59403-9_27 ◽

2020 ◽

pp. 375-391

Author(s):

Jeffrey Braithwaite ◽

Louise A. Ellis ◽

Kate Churruca ◽

Janet C. Long ◽

Peter Hibbert ◽

...

Keyword(s):

Service Delivery ◽

Complexity Theory ◽

Wicked Problems ◽

Healthcare Services ◽

Complexity Science ◽

Healthcare Organisation ◽

Quality And Safety ◽

High Quality ◽

The Past ◽

Multi Agent

AbstractOver the past two decades, prominent researchers such as Greenhalgh [1], Plsek [2], Leykum [3], Lanham [4], Petticrew [5] and Hawe [6, 7] and their colleagues and teams have promoted using complexity theory to describe and analyse the various dimensions of healthcare organisation [8–12]. Internationally, in parallel, governments have recognised the need to ‘think differently’ about healthcare policy and service delivery, but without much traction on how that might be done and what it might mean. Nevertheless, it has now become more common—but by no means universal—to apply a complexity lens to understanding healthcare services and to improving them. This involves greater appreciation of elaborate, intricate, multi-faceted care networks, healthcare ecosystems, layered parts in composite settings, contextual differences across care settings, clinical cultures, multi-agent environments, and the convoluted, challenging, wicked problems [13] these systems throw up. However, with some relatively limited exceptions, the quality and safety fields’ interest in complexity has, to date, been largely superficial, both theoretically and empirically [1].

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Development of Quality Indicators for an Integrated Approach of Knee Osteoarthritis

The Journal of Rheumatology ◽

10.3899/jrheum.130680 ◽

2014 ◽

Vol 41 (6) ◽

pp. 1155-1162 ◽

Cited By ~ 20

Author(s):

Lies Grypdonck ◽

Bert Aertgeerts ◽

Frank Luyten ◽

Hub Wollersheim ◽

Johan Bellemans ◽

...

Keyword(s):

Quality Improvement ◽

Clinical Practice ◽

Usual Care ◽

Quality Indicators ◽

Integrated Approach ◽

High Quality ◽

Knee Oa ◽

Process Indicators ◽

Modified Delphi ◽

Core Set

Objective.Osteoarthritis (OA) is a common cause of disability worldwide. Knee OA care is often suboptimal. A first necessary step in quality improvement is to gain a clear insight into usual care. We developed a set of evidence-based quality indicators for multidisciplinary high-quality knee OA care.Methods.A Rand-modified Delphi method was used to develop quality indicators for knee OA diagnosis, therapy, and followup. Recommendations were extracted from international guidelines as well as existing sets of quality indicators and scored by a multidisciplinary expert panel. Based on median score, prioritization, and agreement, recommendations were labeled as having a high, uncertain, or low potential to measure quality of care and were discussed in a consensus meeting for inclusion or exclusion. Two final validation rounds yielded a core set of recommendations, which were translated into quality indicators.Results.From a total of 86 recommendations and existing indicators, a core set of 29 recommendations was derived that allowed us to define high-quality knee OA care. From this core set, 22 recommendations were considered to be measurable in clinical practice and were transformed into a final set of 21 quality indicators regarding diagnosis, lifestyle/education/devices, therapy, and followup.Conclusion.Our study provides a robust set of 21 quality indicators for high-quality knee OA care, measurable in clinical practice. These process indicators may be used to measure usual care and evaluate quality improvement interventions across the entire spectrum of disciplines involved in knee OA care.

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Quality improvement methodology to improve patient experience and transforming transplant service delivery

10.26226/morressier.5a38ffa4d462b8029238b4e7 ◽

2018 ◽

Author(s):

Roshni Rathore

Keyword(s):

Quality Improvement ◽

Service Delivery ◽

Patient Experience ◽

Improve Patient

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Hospital managers’ perspectives with implementing quality improvement measures and a new regulatory framework: a qualitative case study

BMJ Open ◽

10.1136/bmjopen-2020-042847 ◽

2020 ◽

Vol 10 (12) ◽

pp. e042847 ◽

Cited By ~ 1

Author(s):

Sina Furnes Øyri ◽

Geir Sverre Braut ◽

Carl Macrae ◽

Siri Wiig

Keyword(s):

Quality Improvement ◽

Adaptive Capacity ◽

Qualitative Content Analysis ◽

Regulatory Framework ◽

Local Context ◽

Quality And Safety ◽

Hospital Practice ◽

Hospital Managers ◽

Safety Improvement

A new regulatory framework to support local quality and safety efforts in hospitals was introduced to the Norwegian healthcare system in 2017. This study aimed to investigate hospital managers’ perspectives on implementation efforts and the resulting work practices, to understand if, and how, the new Quality Improvement Regulation influenced quality and safety improvement activities.DesignThis article reports one study level (the perspectives of hospital managers), as part of a multilevel case study. Data were collected by interviews and analysed according to qualitative content analysis.SettingThree hospitals retrieved from two regional health trusts in Norway.Participants20 hospital managers or quality advisers selected from different levels of hospital organisations.ResultsFour themes were identified in response to the study aim: (1) adaptive capacity in hospital management and practice, (2) implementation efforts and challenges with quality improvement, (3) systemic changes and (4) the potential to learn. Recent structural and cultural changes to, and development of, quality improvement systems in hospitals were discovered (3). Participants however, revealed no change in their practice solely due to the new Quality Improvement Regulation (2). Findings indicated that hospital managers are legally responsible for quality improvement implementation and participants described several benefits with the new Quality Improvement Regulation (2). This related to adaptation and flexibility to local context, and clinical autonomy as an inevitable element in hospital practice (1). Trust and a safe work environment were described as key factors to achieve adverse event reporting and support learning processes (4).ConclusionsThis study suggests that a lack of time, competence and/or motivation, impacted hospitals’ implementation of quality improvement efforts. Hospital managers’ autonomy and adaptive capacity to tailor quality improvement efforts were key for the new Quality Improvement Regulation to have any relevant impact on hospital practice and for it to influence quality and safety improvement activities.

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Nursing preceptorship, a supportive and reflective approach for promoting a healthy working environment: a multi-methods design

Nordic Journal of Nursing Research ◽

10.1177/20571585211025207 ◽

2021 ◽

pp. 205715852110252

Author(s):

Verena Jochim ◽

Kristina Rosengren

Keyword(s):

Quality Improvement ◽

Quality Indicators ◽

Role Models ◽

Qualitative Content Analysis ◽

Working Environment ◽

Eastern Region ◽

Staff Turnover ◽

Short Term ◽

Annual Survey ◽

Healthy Working

Shortage of nurses negatively influences the working environment in hospitals, by placing extra burden on newly graduated nurses. Thus, it is important to improve the knowledge and skills of nurses to increase their confidence levels. Experienced nurses serve as role models for junior nurses. This study aimed to describe and analyze a project with a nursing preceptorship in an internal medicine ward in the eastern region of Sweden. Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) were used in the multi-method approach. Quality indicators, staff turnover, short-term absence, and annual survey were analyzed using descriptive statistics. Moreover, two focus group interviews were analyzed using qualitative content analysis. The results showed marginal improvements due to quality indicators and working environment, and decreased staff turnover and short-term absenteeism. Two factors, ‘supportive working environment’ and ‘improvement in nursing’, were identified. The study concluded that selection of nurse preceptors with expertise and interest in supportive and reflective approaches is significant for promoting a healthy working environment. Moreover, interventions such as nursing preceptorship facilitate implementation (<one year) and evaluation using a multi-method design to describe, explain, and understand the possible considerations and consequences of quality improvement in healthcare.

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