Quality Improvement of Gastrointestinal Endoscopy in Korea: Past, Present, and Future

Jae Myung Cha

doi:10.4166/kjg.2014.64.6.320

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Cha: Quality Improvement of Gastrointestinal Endoscopy in Korea: Past, Present, and Future

Review Article

Korean J Gastroenterol 2014;64(6):320-332.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.64.6.320

Quality Improvement of Gastrointestinal Endoscopy in Korea: Past, Present, and Future

Jae Myung Cha

Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Korea

Correspondence to: Jae Myung Cha, Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, 892 Dongnam-ro, Gangdong-gu, Seoul 134-727, Korea. Tel: +82-2-440-6113, Fax: +82-2-440-6295, E-mail: drcha@khu.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The motivation for improving quality of gastrointestinal endoscopy begins with the desire to provide patients with the best possible care. Gastrointestinal endoscopy is an excellent area for quality improvement because of its high volume, significant associated risk and expense, and variability in its performance affecting outcomes. Therefore, the assurance that high-quality endoscopic procedures are performed has taken increased importance. The ‘Korean Gastrointestinal Endoscopy Research Foundation’ and ‘Korean Society of Gastrointestinal Endoscopy’, as ladders in promoting the highest quality patient care, formed endoscopy quality evaluation in ‘National Cancer Screening Program’ and ‘Endoscopy Unit Accreditation’ in Korea. However, both new systems have not settled down despite efforts of many years and support by the government. In this article, the past and present of quality improvement of gastrointestinal endoscopy will be reviewed, and the future of quality improvement of gastrointestinal endoscopy will be illuminated.

Keywords: Endoscopy, Endoscopy, digestive system, Colonoscopy, Quality improvement, Accreditation

References

1. National Research Council. America's health in transition: pro-tecting and improving quality. Washington: National Academies Press;1994.

2. Wennberg J. Small area variations in health care delivery. Science. 1973; 182:1102–1108.

3. Kohn LT, Corrigan J, Donaldson MS. Institute of Medicine (U.S.); Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington: National Academy Press;1999.

4. Institute of Medicine, Committee on Quality of Healthcare in America. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press;2001.

5. Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol. 2007; 102:856–861.

6. Leyden JE, Doherty GA, Hanley A, et al. Quality of colonoscopy performance among gastroenterology and surgical trainees: a need for common training standards for all trainees? Endoscopy. 2011; 43:935–940.

7. de Jonge V, Sint Nicolaas J, Cahen DL, et al. SCoPE Consortium. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointest Endosc. 2012; 75:98–106.

8. Mehrotra A, Dellon ES, Schoen RE, et al. Applying a natural lan-guage processing tool to electronic health records to assess performance on colonoscopy quality measures. Gastrointest Endosc. 2012; 75:1233–1239.

9. National cancer control programs. [Internet]. Goyang: National Cancer Center [cited 2014 Sep 29]. Available from:. http://ncc.re.kr/english/programs/intro.jsp.

10. Jung M. National cancer screening programs and evidence- based healthcare policy in South Korea. Health Policy. 2014. doi: 10.1016/j.healthpol.2014.08.012. [Epub ahead of print].

11. Endoscopy unit accreditation. [Internet]. Seoul: Korean Gastrointestinal Endoscopy Research Foundation [cited 2014 Sep 29]. Available from:. http://www.goodendoscopy.or.kr/program.

12. Jung KW, Won YJ, Kong HJ, Oh CM, Lee DH, Lee JS. Cancer statistics in Korea: incidence, mortality, survival, and prevalence in 2011. Cancer Res Treat. 2014; 46:109–123.

13. National cancer screening information system. [Internet]. Goyang: National Cancer Center [cited 2014 Sep 29]. Available from:. https://ncs.ncc.re.kr/ncsapps/Index_SSL.jsp.

14. Wickström G, Bendix T. The “Hawthorne effect”–what did the original Hawthorne studies actually show? Scand J Work Environ Health. 2000; 26:363–367.

15. Cohen J, Safdi MA, Deal SE, et al. ASGE/ACG Taskforce on Quality in Endoscopy. Quality indicators for esophagogastroduodenoscopy. Am J Gastroenterol. 2006; 101:886–891.

16. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2006; 63(4 Suppl):S16–S28.

17. Rembacken B, Hassan C, Riemann JF, et al. Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy. 2012; 44:957–968.

18. Jover R, Herráiz M, Alarcón O, et al. Spanish Society of Gastroenterology; Spanish Society of Gastrointestinal Endoscopy Working Group. Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening. Endoscopy. 2012; 44:444–451.

19. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966; 44(Suppl):166–206.

20. Aiken LH, Sermeus W, Van den Heede K, et al. Patient safety, sat-isfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012; 344:e1717.

21. Yanai H, Schushan-Eisen I, Neuman S, Novis B. Patient sat-isfaction with endoscopy measurement and assessment. Dig Dis. 2008; 26:75–79.

22. ASGE endoscopy unit recognition program. [Internet]. Downers Grove (IL): American Society for Gastrointestinal Endoscopy [cited 2014 Sep 29]. Available from:. http://www.asge.org/practice/practice-management.aspx?id=13576.

23. Global rating scale. [Internet]. [place unknown]: Global Rating Scale [cited 2014 Sep 29]. Available from:. http://www.globalratingscale.com.

24. Sint Nicolaas J, de Jonge V, Korfage IJ, et al. Benchmarking patient experiences in colonoscopy using the Global Rating Scale. Endoscopy. 2012; 44:462–472.

25. Cha JM, Han DS, Lee HL, et al. Endoscopist specialty is associated with high-quality endoscopy in Korea. Yonsei Med J. 2012; 53:310–317.

26. Physician quality reporting system. [Internet]. Baltimore (MD): Center for Medicare and Medicaid Services [cited 2014 Sep 29]. Available from:. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?re-direct=/PQRS.

Table 1.

Quality Evaluation Criteria of Esophagogastroduodenoscopy (EGD) in the National Cancer Screening Program

Criteria for ‘Manpower’
1. Qualification of endoscopists performing EGD
1) Is the endoscopist a specialist who is able to perform EGD?
2) Did the endoscopist receive endoscopy training for more than 1 one year after becoming a medical specialist?
2. Continuous medical education for EGD (one point per one hour education)
Criteria for ‘Process’
1. Are fasting state, general health status, and past medical and medication history of the patients checked before the EGD?
2. Has the patient received explanations for the necessity, notabilia, and any complications of EGD? Or have they been asked to sign informed consent?
3. Is the patient's status monitored and recorded during the EGD?
4. Is endoscopic biopsy performed in order to verify any suspicious lesions?
5. Are retroflexed or close observations of the EGD made in order to have more precise observation for the suspicious lesion?
6. Is the EGD inserted thoroughly into the duodenum and photo documentation of the second part of the duodenum obtained at all times?
7. Are the instruments for emergency resuscitation or therapeutic endoscopy available in case of any complications?
8. Does the EGD report include information about the location, shape, and size of sighted polyps/cancerous lesions?
9. Are the results of the EGD preserved as digital files or photo documents?
10. Is informed consent for conscious sedative endoscopy obtained?
11. Are SaO₂ and heart rate monitored during conscious sedative endoscopy?
12. Is the patient managed based on discharge criteria when leaving the endoscopy unit after conscious sedative endoscopy?
Criteria for ‘Facility and Equipment’
13. Are the cardia and fundus observed clearly with the retroflexed vision of the EGD from the gastric angle?
14. Are there endoscopy examination rooms for EGDs separate from those at the outpatient clinic?
15. Do you maintain a specimen reception registry for EGD?
16. Do you maintain a medication administration registry for EGD?
Criteria for ‘Outcome’
17. Is the date of examination precisely recorded in the EGD report?
18. Is the registration number precisely recorded in the EGD report?
19. Is the name of the endoscopist precisely recorded in the EGD report?
20. Is the presence of medication usage (e.g., anesthetics, analgesics, and sedatives) precisely recorded in the EGD report?
21. Is the presence of biopsy tests precisely recorded in the EGD report?
22. Are the EGD findings precisely recorded in the EGD report?
23. Is the endoscopic diagnosis precisely recorded in the EGD report?
24. Is the Helicobacter pylori infection test performed in cases of gastric or duodenal ulcer?
25. Do endoscopists attend endoscopy quality education or does your hospital have such a program?
Criteria for ‘Reprocessing’
Is the reprocessing process followed by the ‘Endoscopy cleansing and disinfection guidelines of Korean Society of Gastrointestinal Endoscopy’?
26. Is the precleaning and cleaning process completely performed?
27. Is the endoscopy channel brushed repeatedly during the reprocessing process?
28. Are all detachable parts including valves and rubber cap separated from the endoscope and exchanged for every examination?
29. Are the disinfectant solutions changed optimally according to recommended cycles of the disinfectant solution manufacturer?
30. Is the soaking time obeyed according to the guidelines of the disinfectant solution manufacturer?
31. Are the reusable components and accessories disinfected?
32. Do the clinicians, nurses, and cleansing staff attend the endoscopy cleansing and disinfection education of the ‘Korean Society of Gastrointestinal Endoscopy’?
33. Is the reprocessing room and equipment available?
34. Optimal keeping of the endoscope after the reprocessing process
1) Is the endoscope hung vertically after the reprocessing process?
2) Is the endoscope reprocessed just before the first examination of the next day?

Table 2.

Quality Evaluation Criteria of Colonoscopy in the National Cancer Screening Program

Criteria for ‘Manpower’
1. Qualification of endoscopist performing colonoscopy
1) Is the endoscopist a specialist who is able to perform colonoscopy?
2) Did the endoscopist receive endoscopy training for more than one year after becoming a medical specialist?
2. Continuous medical education for colonoscopy (one point per one hour education)
Criteria for ‘Process’
1. Are fasting state, general health status, past medical/medication history, and the bowel preparation of the patient checked before the colonoscopy?
2. Are written instructions about bowel preparation and colonoscopy including bowel preparation provided to the patient before colonoscopy?
3. Is the patient asked to sign informed consent stating the necessity, notabilia, and any complications of the colonoscopy?
4. Is the patient's status monitored and recorded during the colonoscopy?
5. Is endoscopic biopsy performed in order to verify any polyps or suspicious lesions?
6. Is withdrawal time at least 6 minutes on average in order to have a thorough look at the lesion during colonoscopy?
7. Does the colonoscopy report include information about the location, shape, and size of sighted polyps/cancerous lesions?
8. Are the results of the colonoscopy preserved as digital files or photo-documents?
9. Are the instruments for emergency resuscitation or therapeutic endoscopy available in case of any complications?
10. Is the intubation into the cecum photo-documented and recorded?
11. Is informed consent for conscious sedative endoscopy obtained?
12. Are SaO₂ and heart rate monitored during conscious sedative endoscopy?
13. Is the patient managed based on discharge criteria when leaving the endoscopy unit after conscious sedative endoscopy?
Criteria for ‘Facility and Equipment’
14. Are the appendiceal orifice, ileocecal valve, or more than three series of haustrations observed clearly with a single viewing?
15. Are there endoscopy examination rooms for colonoscopy separate from those at the outpatient clinic?
16. Do you maintain a specimen reception registry for colonoscopy?
17. Do you maintain a medication administration registry for colonoscopy?
Criteria for ‘Outcome’
18. Is the date of examination precisely recorded in the colonoscopy report?
19. Is the registration number precisely recorded in the colonoscopy report?
20. Is the name of the endoscopist precisely recorded in the colonoscopy report?
21. Is the state of bowel preparation precisely recorded in the colonoscopy report?
22. Is the presence of medication usage (e.g., anesthetics, analgesics, and sedatives) precisely recorded in the colonoscopy report?
23. Is the presence of cecal intubation precisely recorded in the report?
24. Is the presence of biopsy tests precisely recorded in the colonoscopy report?
25. Are the findings and diagnosis of colonoscopy precisely recorded in the colonoscopy report?
26. Is the average cecal intubation rate more than 90%?
27. Do the endoscopists attend endoscopy quality improvement education or does your hospital have such a program?
Criteria for ‘Reprocessing’
Is the reprocessing process followed by the ‘Endoscopy cleansing and disinfection guidelines of the Korean Society of Gastrointestinal Endoscopy’?
28. Are the precleaning and cleaning processes completely performed?
29. Is the endoscopy channel brushed repeatedly during the reprocessing process?
30. Are all detachable parts including valves and rubber cap separated from the endoscope and exchanged for every examination?
31. Are the disinfectant solutions changed optimally according to recommended cycles of the disinfectant solution manufacturer?
32. Is the soaking time obeyed according to the guidelines of the disinfectant solution manufacturer?
33. Are the reusable components and accessories disinfected?
34. Do the clinicians, nurses, and cleansing staff attend the endoscopy cleansing and disinfection education of the ‘Korean Society of Gastrointestinal Endoscopy’?
35. Is the reprocessing room and equipment available?
36. Optimal keeping of the endoscope after the reprocessing process
1) Is the endoscope hung vertically after the reprocessing process?
2) Is the endoscope reprocessed just before the first examination of the next day?

Table 3.

Accreditation Quality Rating Scale of Endoscopy Unit Accreditation (EUA) in Korea

Classification	EUA evaluation criteria	Grade
Criteria for ‘Manpower	(2 items of Regular A, 4 items of Demonstration)
Qualification (first accreditation)	At least half of endoscopists performing endoscopy should have a subspeciality qualification of the	Regular A
	‘Korean Society of Gastrointestinal Endoscopy’ or qualification equal to its subspecialty. In addition, remaining endoscopists should have a specialty board related to endoscopy.
	When only one endoscopist is working in the endoscopy unit, the endoscopist should have a specialty board related to endoscopy and complete at least six grade of continuous endoscopy education per year.
Continuous education	All endoscopists of the endoscopy unit should complete at least six grade of continuous endoscopy education per year. When manpower is to be changed at re-accreditation, criteria of manpower should satisfy the initial criteria of first accreditation.	Regular A
Endoscopy education	Endoscopy education program for new staff should be available.	Demo.
	Endoscopy education program should include the period of orientation course and be followed for this period.	Demo.
	Endoscopy unit should have its own continuous education course for endoscopy.	Demo.
Criteria for ‘Facility and equipment’	(9 items of Regular A, 2 items of Regular B, 4 items of Demonstration)
Endoscope	The cardia and fundus are observed clearly with the retroflexed vision of the EGD from the gastric angle.	Regular A
	The appendiceal orifice, ileocecal valve, or more than three series of haustrations are observed clearly with a single viewing of the colonoscope.	Regular A
	Endoscopy schedule should be maintained for a sufficient time interval (for example, at least 10 min for EGD and 15 min colonoscopy) for each examination in order to provide optimal time for reprocessing, preparation for examination, and procedure.	Regular A
Space	There are endoscopy examination rooms aside from those at the outpatient clinic.	Regular A
	There are recovery rooms for conscious sedative endoscopy.
Registry	A specimen reception registry is maintained for endoscopy.	Regular A
	Registries for medication and accessories are used for endoscopy.
Emergency resuscitation and monitoring	Pulse oximeter and O₂ supplementation are maintained for conscious sedative endoscopy.	Regular A
	Emergency cart including medications and devices for emergency resuscitation should be equipped and checked regularly for conscious sedative endoscopy.	Regular A
Environment	Endoscopy examination room and reprocessing room should be ventilated properly.	Regular B
Equipment	Endoscopy examination room is equipped with intensive monitoring devices for blood pressure and electrocardiography.	Regular B
Endoscope	Endoscope should be checked regularly and managed for damage or injury (such as, injury of lens, working channel and suction valve or flexion function).	Demo.
Environment	For colonoscopy, a dressing room and closet are maintained for both genders.	Demo.
Equipment	The recovery room of the endoscopy unit is equipped with patient monitoring devices for recovery of patients from sedation.	Demo.
	Portable O₂ tank is equipped for emergency situations (for transferring of emergency patients).	Demo.
Criteria for ‘Process’	(20 items of Regular A, 4 items of Regular B, 1 item of Demonstration)
Explanation	The patient is identified using name, birthdate, and hospital registration number before starting endoscopy.	Regular A
	Each endoscopic examinations is explained before starting endoscopy.
	For colonoscopy, the patient is asked to sign informed consent stating the necessity, notabilia, and any complications.	Regular A
	Informed consent should include signatures of physician and patient.
	Fasting state, general health status, past medical and medication history, and teeth state (for EGD) and bowel preparation state (for colonoscopy) of the patients are checked before the endoscopy.	Regular A
Sedation	Informed consent is obtained for conscious sedative endoscopy.	Regular A
	Sedative medications for sedative endoscopy are administered according to guidelines of ‘sedation and anesthesia in gastrointestinal endoscopy’.	Regular A
	Sedative medications should be kept in an inaccessible area with a locking device.	Regular A
	Patients’ level of consciousness is evaluated before starting conscious sedative endoscopy. Respiration, SaO₂, and pulse rate are monitored during the procedure of conscious sedative endoscopy.	Regular A
	The patients are managed based on discharge criteria when leaving the endoscopy unit after conscious sedative endoscopy.	Regular A
Process of examination	The patient's status is monitored and recorded during endoscopy.	Regular A
	The results of the endoscopy procedure are preserved as digital files or photo documents.
	Endoscope is retroflexed or closely observed in order to have more precise observation for the suspicious lesion.	Regular A
	Endoscopic biopsy is performed in order to verify any suspicious lesions.	Regular A
	Endoscopists should know the management plan for possible complications developed during endoscopy.	Regular A
	EGD is inserted thoroughly into the duodenum and photo documentation of the second part of the duodenum is obtained at all times.	Regular A
	Testing for Helicobacter pylori infection is performed in cases of gastric or duodenal ulcer.	Regular A
	Colonoscope should be inserted into cecum and photo-documentation of the cecum should be obtained.	Regular A
Explanation	Instructions regarding endoscopic biopsy should be explained to patients undergoing biopsy and how to obtain histopathological information should also be explained.	Regular A
	Instructions about precautions after endoscopy should be explained to all patients.	Regular A
Safety	Guidelines for handling toxic agents such as formalin should be available and obeyed.	Regular B
	Guidelines for a fall down injury should be available and obeyed.
Explanation	The patient is asked to sign informed consent stating the necessity, notabilia, and any complications of the EGD.	Regular B
Process	Withdrawal time is maintained at least 6 minutes on average in order to have a thorough look at the lesion during colonoscopy.	Regular B
Safety	Guidelines for renewal of endoscopy report should be available.	Demo.
Criteria for ‘Outcome’	(3 items of Regular A, 4 items of Regular B)
EGD	EGD report should include the following items: 1) the date of EGD; 2) name, sex and age of patients; 3) the registration number; 4) the name of endoscopist; 5) medication usage (e.g., anesthetics, analgesics, and sedatives); 6) biopsy; 7) findings; and 8) endoscopic diagnosis.	Regular A
Colonoscopy	Colonoscopy report should include the following items: 1) the date of EGD; 2) name, sex and age of patients; 3) the registration number; 4) the name of endoscopist; 5) bowel preparation state; 6) medication usage (e.g., anesthetics, analgesics, and sedatives); 7) cecal intubation; 8) biopsy; 9) findings; and 10) endoscopic diagnosis.	Regular A
Longitudinal data	Monthly registry for a number of endoscopic examinations should be maintained.	Regular A
Common item	Endoscopy report should include the descriptions for the 1) number, 2) location, 3) shape, and 4) size of polyps/cancerous lesions.	Regular B
	Therapeutic endoscopy report should include 1) method of endoscopic therapy and 2) retrieval of resected specimen.	Regular B
	Endoscopy report should include appropriate indication.	Regular B
Horizontal data	Monthly registry for complications (such as transfusion, hospitalization or surgery cases) of endoscopic examinations should be maintained.	Regular B
Criteria for Guideline ‘Reprocessing and Infection’	(13 items of Regular A, 4 items of Regular B and 2 items of Demonstration) Documented guidelines for endoscopy reprocessing should be available and followed in the endoscopy unit.	Regular A
Education Cleaning	Endoscopists, nurses, and cleaning staff must attend education on endoscopy reprocessing. Immediately after the endoscopic examination, the contaminants of the surface of the endoscope should be removed and the contaminants that remained in the biopsy channel are sucked out.	Regular A Regular A
	The endoscopy channel should be brushed repeatedly during the reprocessing process.	Regular A
	All detachable parts including valves and rubber cap should be separated from the endoscope and exchanged for every examination.	Regular A
Disinfection	High level disinfectants should be used in the reprocessing of the endoscope.	Regular A
	Each biopsy and working channel is filled with the disinfectant solution.
	Are the disinfectant solutions changed optimally according to recommended cycles of the disinfectant solution manufacturer?	Regular A
	The soaking time should be followed according to the guidelines of the disinfectant solution manufacturer.	Regular A
Rinsing	Using drinkable clean water, the endoscope and channels are sufficiently washed.	Regular A
Dry	Remaining water in each channel and surface of the endoscope should be removed and the endoscope should be hung vertically.	Regular A
Reprocessing	Precleaning, cleaning, disinfection, and rinsing are performed after every examination.	Regular A
Accessory	According to the manufacturer's guidelines, the endoscopic accessories that pass the mucous membrane should be sterilized.	Regular A
Drying	The endoscope is hung vertically in a cabinet after the reprocessing process.	Regular B
Space	The reprocessing room should be available and kept clean.	Regular B
	Endoscopy unit should be kept clean.
Etc.	For reprocessing, clinicians, nurses, and cleaning staff must use individual protection equipment (such as gloves, masks, and waterproof gowns) to protect themselves.	Regular B
Etc.	Enzymatic detergents or neutral detergents for medical use are recommended as cleansing solutions.	Demo.
	Quality control of the reprocessing process should be performed at least once a year.	Demo.

Demo., demonstration; EGD, esophagogastroduodenoscopy.

Table 4.

Comparative Analysis between Endoscopy Quality Evaluation Criteria in the ‘National Cancer Screening Program (NCSP)’ and Accreditation Quality Rating Scale of ‘Endoscopy Unit Accreditation (EUA)’

Characteristics	NCSP		EUA
Voluntariness	Involuntary program by government		Voluntary program by endoscopy society
Target unit	Endoscopy unit for NCSP		All endoscopy unit
Grade	2 Grade (pass/fail)		5 Grade (A, B, C, D, E)
Interval	2 Years		3 Years
Payment	None		Voluntary payment
Goal	Minimal requirement for endoscopy quality		Optimal requirement for endoscopy quality
Evaluation criteria	EGD (point)	Colonoscopy (point)	Regular A (item)	Regular B (item)	Demonstration (item)
Manpower	30	30	2	-	4
Facility/equipment	10	10	9	2	4
Process	30	30	22	2	1
Outcome	10	10	4	3	-
Reprocessing	20	20	17	-	2
Total	100	100	54	7	11
Requirement			100%	50%	Recommendation

EGD, esophagogastroduodenoscopy.

Table 5.

Summary of Proposed Quality Indicators for Esophagogastroduodenoscopy (EGD)¹⁵

Quality indicator	Recommendation grade
1. Accepted indication(s) is provided before performance of EGD	1C+
2. Informed consent is obtained, including specific discussion of risks associated with EGD	3
3. Prophylactic antibiotics are given in patients with cirrhosis with acute upper GI bleeding who undergo EGD	1A
4. Prophylactic antibiotics are given before placement of a PEG	1A
5. Complete examination of the esophagus, stomach, and duodenum, including retroflexion in the stomach	2C
6. Biopsy specimens are taken of gastric ulcers	1C
7. Barrett's esophagus is measured when present, with the location of the gastroesophageal junction and squamocolumnar junction in centimeters from the incisors being documented	3
8. Biopsy specimens are obtained in all cases of suspected Barrett's esophagus	3
9. Type of upper GI bleeding lesion is described and location is documented. For peptic ulcers, at least one of the following stigmata is noted: active bleeding, nonbleeding, nonbleeding visible vessels (pigmented protuberance), adherent clot, flat spot, cleaned based	3
10. Unless contraindicated, endoscopic treatment is given to ulcers with active bleeding or with visible nonbleeding vessels	1A
11. In cases of attempted hemostasis of upper GI bleeding lesions, whether hemostasis has been achieved is clearly documented	3
12. When epinephrine injection is used to treat nonvariceal upper GI bleeding or nonbleeding visible vessels, a second treatment modality is used (e.g., coagulation or clipping)	1A
13. Variceal ligation is used for endoscopic treatment of esophageal varices	1A
14. Written instructions, which include particular signs and symptoms to watch for after EGD, are provided to the patient on discharge	3
15. In patients undergoing dilation for peptic esophageal strictures, PPI therapy is recommended	1A
16. Patients diagnosed with gastric or duodenal ulcers are instructed to take PPI medication or an H₂ antagonist	1A
17. Patients diagnosed with gastric or duodenal ulcers have documented plans to test for the presence of Helicobacter pylori infection	1A
18. Rebleeding rates after endoscopic hemostasis are measured	1C+

GI, gastrointestinal; PEG, percutaneous endoscopic gastrostomy; PPI, proton pump inhibitor.

Adapted from Cohen J, Safdi MA, Deal SE, et al; ASGE/ACG Taskforce on Quality in Endoscopy. Quality indicators for esophagogastroduodenoscopy (Am J Gastroenterol 2006;101:886-891).

Table 6.

Summary of Proposed Quality Indicators for Colonoscopy¹⁶

Quality indicator	Recommendation grade
1. Appropriate indication	1C+
2. Informed consent is obtained, including specific discussion of risks associated with colonoscopy	3
3. Use of recommended postpolypectomy and postcancer resection surveillance intervals	1A
4. Use of recommended ulcerative colitis/Crohn's disease surveillance intervals	2C
5. Documentation in the procedure note of the quality of the preparation	2C
6. Cecal intubation rates (visualization of the cecum by notation of landmarks and photo documentation of landmarks should be present in every procedure)	1C
7. Detection of adenomas in asymptomatic individuals (screening)	1C
8. Withdrawal time: mean withdrawal time should be R6 minutes in colonoscopies with normal results performed in patients with intact anatomy	2C
9. Biopsy specimens obtained in patients with chronic diarrhea	2C
10. Number and distribution of biopsy samples in ulcerative colitis and Crohn's colitis surveillance. Goal: 4 per 10-cm section of involved colon or approximately 32 specimens per case of pancolitis	1C
11. Mucosally based pedunculated polyps and sessile polyps 2 cm in size should be endoscopically resected or documentation of unresectabiltiy obtained	3
12. Incidence of perforation by procedure type (all indications vs. screening) is measured	2C
13. Incidence of postpolypectomy bleeding is measured	2C
14. Postpolypectomy bleeding managed nonoperatively	1C

Adapted from Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy (Gastrointest Endosc 2006;63[4 Suppl]:S16-S28).

Table 7.

Quality Assurance in Screening Colonoscopy in the Position Statement of the European Society of Gastrointestinal Endoscopy¹⁷

Quality assurance item	Proposed standard by the European Society of Gastrointestinal Endoscopy
Consent and withdrawal of consent	Audit the number of patients who decline colonoscopy on the day of the procedure and the number of intraprocedural withdrawals of consent.
	Proposed standard: fewer than 5% of cases to withdraw consent on the day of the procedure and fewer than 1% during the procedure
Experience of the screening colonoscopist	We recommend that a minimum lifetime colonoscopy experience together with a minimum number of annual screening colonoscopies should be agreed.
	Proposed standard: to be agreed by screening boards
Bowel cleansing	The state of bowel cleansing should be audited.
	Proposed standard: at least 90% of examinations should be rated as “adequate” bowel cleansing or better
Sedation, analgesia, and comfort	Audit of sedation practices, including average doses used of medication together with comfort scores.
	Proposed standard: no more than 1% of patients should become hypoxic (saturation below 85% for more than 30 seconds) or for other reasons requiring administration of a reversal agent
Unadjusted cecal intubation rate	Audit the completion rate for all colonoscopies.
	Proposed standard: unadjusted cecal intubation rate of at least 90%
Adenoma and cancer detection rates	The number of detected adenomas and cancers should be audited.
	Proposed standard: to be agreed by screening boards
Colonoscope withdrawal time	Average withdrawal times should be audited.
	Proposed standard: a minimum of 6 minutes in at least 90% of purely diagnostic examinations
Polyp retrieval rate	Screening programs anticipate that all resected polyps are retrieved for histological analysis.
	Proposed standard: ≥90% of resected polyps should be retrieved for histological analysis
Significant interval lesions	We recommend that screening programs monitor size, appearance, location, and histology of all polyps larger than 1 cm and cancers found between screening examinations as well as after the patient has been discharged from a screening program.
	Proposed standard: to be agreed by screening boards
Specialist referral for removal of larger polyps	We anticipate that the removal of larger polyps will be deferred to a dedicated clinical session, perhaps at a separate tertiary referral left. Screening programs should record how larger polyps detected at screening are managed, together with details of outcomes.
	Proposed standard: to be agreed by screening boards
Cleaning and disinfection	Adoption of manufacturers’, national, and European standards for disinfection.
	Proposed standard: routine microbiological testing at intervals not exceeding 3 months
Tattooing sites of larger polyps and cancers	We recommend that screening programs set standards regarding which polyp sites should be tattooed.
	Proposed standard: the placement of tattoos following the removal of all polyps 2 cm or larger outside of fixed colonic landmarks such as the cecum and rectum
Unscheduled readmissions	We recommend that screening programs record details of all emergency admissions within 30 days of the screening colonoscopy.
	Proposed standard: to be agreed by screening boards
Perforation rate	We recommend that details should be recorded of all perforations complicating diagnostic and therapeutic procedures that require surgical repair and that occur up to 2 weeks after endoscopy.
	Proposed standard: fewer than 1 : 1,000 diagnostic or therapeutic examinations should result in a perforation requiring surgical repair.
Bleeding rate	All cases of immediate and late bleeding following polypectomy should be recorded.
	Proposed standard: fewer than 1 : 20 cases of bleeding should ultimately require surgical intervention

Adapted from Rembacken B, Hassan C, Riemann JF, et al. Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE) (Endoscopy 2012;44:957-968).

Table 8.

Quality Indicators (QI) and Auditable Outcomes (AO) by Spanish Society of Gastroenterology and Spanish Society of Gastrointestinal Endoscopy Working Group¹⁸

Quality indicators and auditable outcomes	QI/AO	Mandatory	Desirable
1. Age and sex of patient	QI/AO	+
2. Cancer detection rate (all cancers)	QI/AO	+
3. Cancer detection rate (endoscopically removed cancers)	QI/AO	+
4. Referral rate into surveillance programs (total and by risk category)	QI	+
5. Adenoma excision and retrieval rate±withdrawal times	QI	+
6.1. Numbers and detection rates of colorectal lesions, in total and broken down by: polypoid and non-polypoid	QI/AO	+
6.2 Numbers and detection rates in 6.1 broken down by sector of the colon	AO	+
7.1. Numbers and detection rates of colorectal lesions, in total, and by predicted histology:	QI/AO	+
1) non-neoplastic, 2) neoplastic, and 3) uncommon lesions
7.2. Numbers and rates in 7.1 broken down by sector of the colon	AO	+
8.1. Numbers and detection rates of colorectal lesions, in total, and by confirmed histology:	AO	+
1) non-neoplastic, 2) neoplastic, and 3) uncommon lesions
8.2. Numbers and rates in 8.1 broken down by sector of the colon	AO	+
9.1. Numbers and rates of discrepant lesions broken down by categories in 7.1 and 8.1	AO	+
9.2. Numbers and rates of discrepant lesions broken down by categories in 7.2 and 8.2	AO	+
10. Withdrawal times from caecum to anus (in patients who have not had biopsy or therapy)	QI/AO	+
11. Colonoscopy completion rate	QI	+
12. Wait time: Fecal occult blood test to colonoscopy	QI	+
13. Wait time: Flexible sigmoidoscopy	QI	+
14. Wait time: colonoscopy to pathology results	QI	+
15. Wait time: Flexible sigmoidoscopy to pathology results	QI	+
16. Wait time: pathology results to definitive treatment	QI	+
17. Unplanned admission on day of procedure: four options	AO	+
18. Type of insufflation gas (air or CO₂)	AO	+
19. Type of sedation used: three options	AO	+
20. Comfort: only if conscious or no sedation used	AO	+	+
21. Adequacy of preparation	AO	+
22. Delayed adverse outcomes: two options	AO	+
23. Key endoscopic characteristics of polyps written on pathology request form: five key characteristics: number, site, size, completeness of excision, separate pots used for different sites (see also 6–9)	QI	+
24. Lesions referred elsewhere for excision	AO	+
25. Patient feedback on information and consent, booking, environment, comfort and aftercare	AO	+	+
26. Adverse incidents related to incomplete pre-assessment	AO	+
27. Decontamination indicators	AO	+

Adapted from Jover R, Herráiz M, Alarcón O, et al; Spanish Society of Gastroenterology; Spanish Society of Gastrointestinal Endoscopy Working Group. Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening (Endoscopy 2012;44:444-451).

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