Quality Improvement in the Endoscopy Center

by Justin Coile November 8, 2011

ABSTRACT

Quality improvement in the endoscopy center suggests a wide variety of techniques and approaches to improve the experience and outcomes of the patients receiving endoscopic services. The purpose of this paper is to review some of the popular processes and tools used to improve quality as well as delve into some of the policies, challenges and other realities that affect quality in the endoscopy center. Some of the processes we will explore are the PDSA cycle, RCA, Lean, and Six Sigma. Information technology, patient satisfaction, data and statistics will be discussed. The Patient Protection and Affordable Care Act and what it means for quality care will be reviewed as well as accreditation, certifications, and licensure.

Though high in number and occasionally complexity, the many and varied efforts made to improve quality are important to understand for leaders and practitioners in healthcare. Quality is of utmost importance when the product you are providing has such a great impact on its consumer. High quality health care translates to quality health, but a lack of quality can result in tragedy. This is what makes the efforts spent to improve quality worth it.

INTRODUCTION

Endoscopy centers are a high-risk setting that demand high quality standards to protect the safety of the patients. Shortfalls in quality in this setting can easily result in death or serious injury to the patient. The findings of the endoscopy procedures often determine the treatment a patient receives for serious diseases like cancer. The treatments are specific and life saving, but also potentially harmful; so it is important that quality is ensured during the endoscopic procedure. The diagnosis is often determined or influenced by what is discovered during the patient’s time in an endoscopy center.

The endoscopy center communicates and works with many other healthcare providers to coordinate the care and treatment of their patients. Referrals come from a variety of providers with a variety of objectives that need to be understood by the endoscopist to achieve the intended results. This communication is crucial to protect the patient from unnecessary of ineffective procedures. A demonstration of the need for effective communication is illustrated in the flowchart at the bottom of this section. This flowchart describes the phases a patient receiving an endoscopy goes through during their time in the endoscopy center.

Many endoscopy centers are located within full service hospitals and treat the inpatient and outpatient population alongside one another. There are many other departments in the hospital that are relied upon and affect the outcome of the endoscopist’s work. In order for high quality care to be provided in the endoscopy center, the departments that the center relies upon and works with must also be committed to high quality standards.

RESEARCH OBJECTIVES AND METHODS

The purpose of this study is to identify methods that have been used in endoscopy centers to improve quality. These methods will be evaluated and the results of the performance improvement objectives will be analyzed. Peer reviewed journal articles are the preferred source of information on quality improvements made in endoscopy centers and closely related areas such as in the operating room and perioperative services.

I utilized the USF library’s online database search to find the majority of the relevant articles. The databases I focused on were; PubMed, Health reference center-academic, MEDLINE (CSA), CINAHL, and Annual Reviews. Searches were conducted including key words such as “endoscopy”, and “surgery” as well as specific terms to narrow down specific techniques used including “PDSA”, “root cause analysis/RCA” and “PERT chart”, et cetera. Specific journals that focus on the field of endoscopy were searched to find relevant articles as well. The American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates provided some insight into the field.

Websites were also reviewed that were appropriate to the topic being studied. These websites included; IOM, IHI, National Quality Forum, AHRQ, National Guideline Clearinghouse, CAHPS, and Joint Commission. Parts of the Patient Protection and Affordability Act of 2010 were also reviewed in preparation for this paper.

FINDINGS

Much of the quality improvement objectives are focused on intra-operative improvements. Some of the important steps in the process involve the organization and labeling of specimens collected during the procedure. This has been an area where I have personally seen many mistakes made, and this type of mistake can influence the treatment of a patient. An incidence of cancer can be missed or someone without cancer could be treated for it if specimens are misplaced or mislabeled.

Other areas where improvement can be realized are the preoperative and postoperative areas within the endoscopy center. It is in these areas that the patient and their family will notice inferior quality. The quality of care received in these areas, while sometimes viewed as less critical than in the procedure room, affects the safety and outcome of the procedure itself. Deficiencies in these areas are what the patient and family members will remember, only the patient will be in the procedure room and then briefly until anesthesia is administered.

Various techniques are used to improve quality in specific areas and many times a combination of techniques are used to improve upon a problem area. Many of the studies conducted were by clinical faculty and staff, resulting in non-standard processes and tools being used to facilitate improving quality.

PDSA/RCA

There have been many performance improvement projects done that are initiated with a root cause analysis. The medical field is being constantly bombarded by malpractice lawsuits. These often trigger a root cause analysis to determine the cause of the problem. These are done partly to determine what the next step should be to deal with the legal problems, and partly to prevent the problem from occurring in the future. A problem with root cause analysis is that it is often conducted after something undesirable has occurred. Root cause analysis is an entirely reactive way to improve quality, while it is much better to improve a process before an adverse event occurs. Taking a more proactive approach, such as Failure Mode and Effects Analysis, could prevent expensive lawsuits and, more importantly, the events that trigger the lawsuits. Malpractice lawsuits do provide thorough and available information that can be useful when taking a more proactive stance when looking to improving quality. (Rogers, et al, 2006)

PDSA was discussed in “The interface of primary and oncology specialty care: from symptoms to diagnosis”. (Nekhlyudov & Latosinsky, 2010) This article states that the PDSA method is very useful in discovering whether or not a change made actually leads to improvement.

LEAN

The lean process was examined in an article in Gastroenterology Nursing, written by Karen Laing and Katherine Baumgartner. This article presented a case study from an endoscopy center at Fairview Southdale Hospital. The endoscopy department in this hospital faced a spike in demand and could not efficiently accommodate the increased demand with the resources it had. Some thought there needed to be increased staffing to take on the increased workload, but the leadership did not see that as the best solution. A quality improvement team of endoscopy nurses and technicians was formed, facilitated by a performance excellence consultant and the endoscopy unit manager, to implement change consistent with lean thinking.

One of the main goals of the team was to reduce “muda”, a Japanese term for wasteful activities. This would reduce the total time a patient spends in the endoscopy center (admission to discharge) and allow the staff to focus on productive tasks rather than waste time searching for patients or supplies, or other time wasting activities. The team also focused on decreasing room turnover time and improving patient flow.

The team met several times a week for two months, and met with the entire endoscopy staff, usually weekly, during the implementation of the lean improvement process. These staff meetings provided suggestions and increased staff buy in and ultimately decreased resistance to the changes implemented through the project. The changes in how the department operated were significant, but ultimately accepted without excessive resistance.

The results of the project were very positive. Inventory levels dropped and resulted in lower inventory costs and extra space, which was utilized for a staff break room. The total time a patient spent at the endoscopy center was decreased substantially. Staff roles became more clearly defined. Five S was used and resulted in the workspace becoming more organized. Inventory is now controlled using KANBAN, which has helped organize the supply and decrease excess while assuring all the supplies are kept at an adequate level. The whiteboard used to keep track of patients was simplified to where it is now actually functional, which allows the physicians and nurses to locate their patients. This process was such a success that when one of the nurses in the unit moved out of town, the team worked so efficiently that she did not need to be replaced; Whereas before this process the staff was in want of additional nurses to keep up with the increased workload. (Laing & Baumgartner, 2005)

Process Tools

The literature is full of useful charts and diagrams that help the reader visualize what the words in the study are explaining. These tools are also useful to the researcher, or anyone looking to improve quality, to quantify which areas need to be focused on to provide the greatest increase in quality for the resources invested in the improvement process.

One particular study used such process tools extensively. Flowcharts, although not exactly conforming to the recipes offered in the textbooks, littered the pages of “The interface of primary and oncology specialty care: from symptoms to diagnosis” (Nekhlyudov & Latosinsky, 2010). The process of constructing a flowchart forces a person to consider each step in a process, this purposeful consideration can and should lead to changes being considered to improve efficiency and reduce the opportunity for error. A visualization of a process, such as a flowchart, also helps those who are on a quality improvement team who are not familiar with a process to understand what the discussion is about and provide constructive feedback.

Types of Data/Statistical Methods

Data in the studies examined thus far has been collected in a variety of ways. Most of the data seems to be collected from the medical record, specifically the procedure notes of the nurse and the reports of the endoscopy physicians. Figures such as endoscopic retrograde cholangiopancreatography (ERCP) time, which is important because of exposure to fluoroscopy radiation, are collected from many cases done by many physicians and organized into graphs, diagrams and charts. (Cotton, 2011) Visual displays of information are included in the reports and provide quick and straightforward representation of the data.

Patient Satisfaction

Patient satisfaction has been used in endoscopy to focus on which areas to improve and to gauge the center’s performance. In the case study in lean performance improvement by Karen Laing and Katherine Baumgartner, patient satisfaction scores provided them with an idea on which areas in which their unit was lacking and which areas they needed to focus on for improvement. A specific telephone questionnaire was developed for this purpose, and the information gathered clarified what was important to the patient and which areas that had the greatest impact on their satisfaction with the treatment they received in the endoscopy department. (Laing & Baumgartner, 2005)

The Agency for Healthcare Research and Quality has developed CAHPS guidelines that are helpful in creating a patient satisfaction survey. It includes questions such as how well information is communicated, timeliness and customer service; all of which are important aspects to the care received in the endoscopy center. (CAHPS pocket reference, 2010)

Information Technology

Technology is an essential tool that can be used to improve quality in the endoscopy department. Many of the articles reviewed here collected their data through technology, which greatly expedited the process and resulted in higher quality, more standardized data. The use of electronic health records and information technology in endoscopy centers is sporadic, however. Small independent endoscopy practices have a hard time developing their technology compared to larger centers and those integrated within hospitals.

There is plenty of criticism regarding the implementation of electronic health records into endoscopy, particularly by physicians and other clinical staff (Littenberg, 2010). The staff that uses the software may not realize the real benefit of using this technology; there are many reasons for this, but there is a faction of practitioners who fear change and will not embrace this new technology based on that fear. Adequate training is often not provided and older healthcare providers do not intuitively understand how to use these programs. I was shocked at the hatred displayed in an article on health reform when discussing EHR implementation. (Littenberg, 2010)

Despite the perceived drawbacks, many endoscopy units and the hospitals they are located in are converting to an electronic medical record. Based on several news articles read for this paper, a popular system for endoscopy is ProVation. (“Rochester Endoscopy”, 2010) One of the driving forces behind the acceptance and desire for increased information technology is the “meaningful use” financial incentives from the Center for Medicare and Medicaid. The government has realized the benefits that could be had with increased, meaningful use of electronic health records. As a way of coercing those who may not see those benefits, the Center for Medicare and Medicaid has decided to compensate healthcare providers who implement these systems. (Littenberg, 2010)

Accreditation, Licensure & Certification

The Joint Commission and the Agency for Health Care Administration accredit all endoscopy units, but up until recently there has not been a specific designation for recognizing quality endoscopy units. The American Society for Gastrointestinal Endoscopy has recently begun recognizing endoscopy clinics that have a focus on providing quality care. There are specific criteria for the practitioners in the facility to meet and a department representative must go to a two-day training and agree in writing to comply with ASGE guidelines on key quality topics. (Cotton, 2011)

Patient Protection and Affordable Care Act of 2010

It is without doubt that the Patient Protection and Affordable Care Act will have a lot to do with the changes in the way endoscopy centers and all health care providers will approach quality improvement. The act includes financial implications for taking steps to improve quality by showing meaningful use of electronic health records. (PPACA, 2010) There is much concern among practitioners about the unknown implications of the recent health care reform legislation. New payment structures may have an impact on the utilization of endoscopic procedures and the reimbursement received from these procedures. Concerns about rationing and lower reimbursement contrast fears of longer waiting periods for an increased number of insured and a shortage of trained gastroenterologists to meet this demand. (Littenberg, 2010)

The CMS has also begun the Physician Quality Reporting Initiative that provides an incentive for physicians reporting certain quality metrics to CMS. Studies have found that the participation of gastroenterologists in this program is very low. (Pike, 2008)

DISCUSSION

As can clearly be seen from this assortment of data, there are many approaches and methods to managing quality. Each of these methods can be used in an infinite number of ways to produce the desired affect in any setting. It seems that much of the focus on improving quality in the endoscopy unit has focused on patient care issues. These relate to the safety and effectiveness of the procedures that are performed in the endoscopy center. There were some cases where efforts were focused on improving efficiency, but even these efforts were aimed at improving the experience of the patient. Regardless which dimension of health care an effort is focused on improving, if the effort is successful there will be improvements made across the board. An example of this would show that improving the effectiveness of a procedure will also improve efficiency by reducing repeat procedures, freeing those resources to treat more patients, and aiding in faster recovery times which helps with patient flow.

A weakness I found regarding quality improvement in endoscopy was the lack of widespread acceptance and adoption of many of the programs designed to standardize and improve the care of patients. Many of the self reported data in these studies were flawed by very low participation by gastroenterologists. Elective reporting does not seem to be an effective method of collecting reliable data on performance and quality metrics. This hints to a lack of commitment by endoscopy practitioners on improving their profession. Even with the low participation rates in quality improvement initiatives, there are still plenty of practitioners with a commitment to continuously improve the quality, effectiveness and efficiency of the care they provide.

CONCLUSIONS AND RECOMMENDATIONS

The quality improvement efforts highlighted in this article all had one thing in common; they were focused improving a specific area and were purposefully managed. In an endoscopy unit there are many different things going on and all of these things could use improvements and need to be done in a high quality setting. For the process to be effective, a specific area of improvement needs to be identified and focused on. Once the problem is clear, work can begin on finding and ultimately implementing the solutions. None of this will ever occur on accident, there must be a clear way forward and commitment by those involved in the process for a successful outcome. Far too often healthcare leaders and staff talk about “CQI” and improving quality, but do not back up that talk with substantive action.

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