Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea

Jun Ki Min; Jae Myung Cha; Yu Kyung Cho; Jie-Hyun Kim; Soon Man Yoon; Jong Pil Im; Yunho Jung; Jeong Seop Moon; Jin-Oh Kim; Yoon Tae Jeen

doi:10.4166/kjg.2018.71.5.269

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Min, Cha, Cho, Kim, Yoon, Im, Jung, Moon, Kim, and Jeen: Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea

Review Article

Korean J Gastroenterol 2018;71(5):269-281.

Published online: 4 October 2018

DOI: https://doi.org/10.4166/kjg.2018.71.5.269

Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea

Jun Ki Min¹, Jae Myung Cha¹, Yu Kyung Cho², Jie-Hyun Kim³, Soon Man Yoon⁴, Jong Pil Im⁵, Yunho Jung⁶, Jeong Seop Moon⁷, Jin-Oh Kim⁶, Yoon Tae Jeen⁸

¹Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea

²Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea

³Department of Internal Medicine, Yonsei University School of Medicine, Seoul Korea

⁴Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju Korea

⁵Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea

⁶Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea

⁷Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea

⁸Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea

Correspondence to: Jae Myung Cha, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea. Tel: +82-2-440-6113, Fax: +82-2-440-6295, E-mail: drcha@khu.ac.kr

Received 9 April 2018 Revised 3 May 2018 Accepted 3 May 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Gastroscopy and colonoscopy are widely used for the early diagnosis of stomach and colorectal cancer. The present revision in-tegrates recent data regarding previous quality indicators and novel indicators suggested for gastroscopy and colonoscopy procedures for the National Cancer Screening Program in Korea. The new indicators, developed by the Quality Improvement Committee of the Korean Society for Gastrointestinal Endoscopy, vary in the level of supporting evidence, and most are based solely on expert opinion. Updated indicators validated by clinical research were prioritized, but were chosen by expert consensus when such studies were absent. The resultant quality indicators were graded according to the levels of consensus and recommendations. The updated indicators will provide a relevant guideline for high-quality endoscopy. The future direction of quality indicator development should include relevant outcome measures and an evidencebased approach to support proposed performance targets.

Keywords: Gastroscopy, Colonoscopy, Quality improvement, Safety, Mass screening

References

1. Ahn C, Hwang Y, Park SK. Predictors of all-cause motality among 514,866 participants from the Korean National Health Screening Cohort. PLoS One. 2017; 12:e0185458.

2. Jung M. National cancer screening programs and evidencebased healthcare policy in South Korea. Health Policy. 2015; 119:26–32.

3. Lee S, Jun JK, Suh M, et al. Gastric cancer screening uptake trends in Korea: results for the National Cancer Screening Program from 2002 to 2011: a prospective cross-sectional study. Medicine (Baltimore). 2015; 94:e533.

4. Yoo KY. Cancer control activities in the Republic of Korea. Jpn J Clin Oncol. 2008; 38:327–333.

5. National Cancer Center, Education for National Cancer Screening Program [Internet]. Goyang: National Cancer Center;c2017; [cited 2018 Feb 19]. Available from:. http://education.ncc.re.kr/main.do.

6. Shin A, Choi KS, Jun JK, et al. Validity of fecal occult blood test in the national cancer screening program, Korea. PLoS One. 2013; 8:e79292.

7. Cha JM. Quality improvement of gastrointestinal endoscopy in Korea: past, present, and future. Korean J Gastroenterol. 2014; 64:320–332.

8. 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.

9. Cha JM, Moon JS, Chung IK, et al. National endoscopy quality improvement program remains suboptimal in Korea. Gut Liver. 2016; 10:699–705.

10. Park WG, Shaheen NJ, Cohen J, et al. Quality indicators for EGD. Am J Gastroenterol. 2015; 110:60–71.

11. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2015; 110:72–90.

12. Ministry of Health and Welfare, National Cancer Center. Quality guidelines of gastric cancer screening. 2nd ed.Seoul: National Cancer Center;2017.

13. Ministry of Health and Welfare, National Cancer Center. Quality guidelines of colorectal cancer screening. 2nd ed.Seoul: National Cancer Center;2017.

14. Principles of training in gastrointestinal endoscopy. From the ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1999; 49:845–853.

15. Lee SH, Chung IK, Kim SJ, et al. An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve. Gastrointest Endosc. 2008; 67:683–689.

16. 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.

17. Jover R, Herráiz M, Alarcón O, et al. Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening. Endoscopy. 2012; 44:444–451.

18. Yalamarthi S, Witherspoon P, McCole D, Auld CD. Missed diagnoses in patients with upper gastrointestinal cancers. Endoscopy. 2004; 36:874–879.

19. Ren W, Yu J, Zhang ZM, Song YK, Li YH, Wang L. Missed diagnosis of early gastric cancer or high-grade intraepithelial neoplasia. World J Gastroenterol. 2013; 19:2092–2096.

20. Choi KS, Jun JK, Park EC, et al. Performance of different gastric cancer screening methods in Korea: a population-based study. PLoS One. 2012; 7:e50041.

21. Yamazato T, Oyama T, Yoshida T, et al. Two years'intensive training in endoscopic diagnosis facilities detection of early gastric cancer. Intern Med. 2012; 51:1461–1465.

22. 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.

23. Hetzel JT, Huang CS, Coukos JA, et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol. 2010; 105:2656–2664.

24. Kahi CJ, Hewett DG, Norton DL, Eckert GJ, Rex DK. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol. 2011; 9:42–46.

25. Pohl H, Srivastava A, Bensen SP, et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology. 2013; 144:74–80.

26. Wexner SD, Litwin D, Cohen J, et al. Principles of privileging and credentialing for endoscopy and colonoscopy. Gastrointest Endosc. 2002; 55:145–148.

27. ASGE Standards of Practice Committee. Jain R, Ikenberry SO, et al. Minimum staffing requirements for the performance of GI endoscopy. Gastrointest Endosc. 2010; 72:469–470.

28. Quality improvement of gastrointestinal endoscopy: guidelines for clinical application. From the ASGE, American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1999; 49:842–844.

29. Standards of Practice Committee. Lichtenstein DR, Jagannath S, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008; 68:815–826.

30. ASGE Standards of Practice Committee. Anderson MA, BenMenachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009; 70:1060–1070.

31. Hassan C, Bretthauer M, Kaminski MF, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy. 2013; 45:142–150.

32. Froehlich F, Wietlisbach V, Gonvers JJ, Burnand B, Vader JP. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc. 2005; 61:378–384.

33. Rex DK, Imperiale TF, Latinovich DR, Bratcher LL. Impact of bowel preparation on efficiency and cost of colonoscopy. Am J Gastroenterol. 2002; 97:1696–1700.

34. Schoenfeld PS, Cohen J. Quality indicators for colorectal cancer screening for colonoscopy. Tech Gastrointest Endosc. 2013; 15:59–68.

35. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedure: an updated report by the American Society of Anesthesiologists Committee on standards and practice parameters. Anesthesiology. 2011; 114:495–511.

36. Rizk MK, Sawhney MS, Cohen J, et al. Quality indicators common to all GI endoscopic procedures. Gastrointest Endosc. 2015; 81:3–16.

37. Bisschops R, Areia M, Coron E, et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gas- trointestsinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy. 2016; 48:843–864.

38. ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force. Calderwood AH, Chapman FJ, et al. Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointest Endosc. 2014; 79:363–372.

39. Rey JF, Lambert R. ESGE Quality Assurance Committee. ESGE recommendations for quality control in gastrointestinal endoscopy: guidelines for image documentation in upper and lower GI endoscopy. Endoscopy. 2001; 33:901–903.

40. Rex DK, Lewis BS, Waye JD. Colonoscopy and endoscopic therapy for delayed postpolypectomy hemorrhage. Gastrointest Endosc. 1992; 38:127–129.

41. Binmoeller KF, Thonke F, Soehendra N. Endoscopic hemoclip treatment for gastrointestinal bleeding. Endoscopy. 1993; 25:167–170.

42. Bretthauer M, Aabakken L, Dekker E, et al. Requirements and standards facilitating quality improvement for reporting systems in gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) position statement. Endoscopy. 2016; 48:291–294.

43. Kaminskin MF, Thomas-Gibson S, Bugajski M, et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. Endoscopy. 2017; 49:378–397.

44. Ford AC, Gurusamy KS, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori-positive people. Cochrane Database Syst Rev. 2016; 4:CD003840.

45. ASGE Standards of Practice Committee. Banerjee S, Cash BD, et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010; 71:663–668.

46. Reprocessing Guideline Task Force. Petersen BT, Cohen J, et al. Multisociety guideline on reprocessing flexible GI endoscopes:2016 update. Gastrointest Endosc. 2017; 85:282–294.

47. Herrin A, Loyola M, Bocian S, et al. Standards of infection prevention in reprocessing flexible gastrointestinal endoscopes. Gastroenterol Nurs. 2016; 39:404–418.

48. Oh HJ, Kim JS. Clinical practice guidelines for endoscope reprocessing. Clin Endosc. 2015; 48:364–368.

49. Enestvedt BK, Eisen GM, Holub J, Lieberman DA. Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures? Gastrointest Endosc. 2013; 77:464–471.

50. Charles RJ, Chak A, Cooper GS, Wong RC, Sivak MV Jr. Use of open access in GI endoscopy at an academic medical center. Gastrointest Endosc. 1999; 50:480–485.

Table 1.

Levels of Agreement and Recommendation

Definition
Level of agreement
A: Strongly agree with the statement and quality indicators
B: Agree with the statement and quality indicators
C: Uncertain of the statement and quality indicators
D: Disagree with the statement and quality indicators
E: Strongly disagree with the statement and quality indicators
Level of recommendation
Strong: Recommendation likely to apply to most National Cancer Screening Program endoscopy settings.
Intermediate: Recommendation, best action may differ according to particular circumstances or patients in National Cancer Screening Program endoscopy settings
Weak: Recommendation, alternative approaches likely to be better under some circumstances in National Cancer Screening Program endoscopy settings

Table 2.

Final Statements and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in the National Cancer Screening Program: Workforce, Process, Facilities and Equipment, and Outcome

	Statements
Workforce	An experienced endoscopist with sufficient training in EGD should perform EGD. (EGD)
	[Level of agreement: strongly agree 95.2%, agree 4.8%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	An experienced endoscopist with sufficient training in colonoscopy should perform colonoscopy. (CS)
	[Level of agreement: strongly agree 96.0%, agree 4.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	An endoscopist who performs endoscopies is required to receive continuous endoscopy education. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Endoscopy nursing staff is required to receive training for endoscopy quality improvement. (EGD/CS)
	[Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
Process	Clinicians should verify the overall condition of the patient before EGD. (EGD)
	[Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Clinicians should verify the fasting state, general health status, previous medical history, current medication history including anti-platelets or anticoagulants (antithrombotics), and quality of bowel preparation before colonoscopy. (CS)
	[Level of agreement: strongly agree 95.7%, agree 4.4%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Clinicians should provide bowel preparation education to examinees before colonoscopy. (CS)
	[Level of agreement: strongly agree 95.7%, agree 4.4%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Clinicians should provide a sufficient explanation of the procedure and obtain informed consent before colonoscopy. (CS)
	[Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	All of the standard imaging sites of EGD should be clearly photographed and stored as image records. (EGD)
	[Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	All of the standard imaging sites of colonoscopy should be clearly photographed and stored as image records. (CS)
	[Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
	Average withdrawal time in negative-result colonoscopies should be measured and should not be ≥ 6 min. (CS)
	[Level of agreement: strongly agree 70.8%, agree 29.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 72.7%, intermediate 27.3%, weak 0%]
	After EGD, the clinician should instruct the examinee as to the post-procedure precautions and how to obtain exam results. (EGD)
	[Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
	After colonoscopy, the clinician should instruct the examinee as to the post-procedure precautions and how to obtain exam results. (CS)
	[Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	The tissue sample obtained during endoscopy should be managed properly according to specific protocols. (EGD/CS)
	[Level of agreement: strongly agree 91.7%, agree 8.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Facilities and equipment	The endoscopy unit should be an independent facility from the outpatient clinic. (EGD/CS)
	[Level of agreement: strongly agree 92.3%, agree 3.9%, uncertain 3.9%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
	Clinicians should be prepared for complications and emergency situations during endoscopy. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Outcome	Endoscopy reports should be recorded with high accuracy. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Pathologic findings identified during endoscopy should be precisely described. (EGD/CS)
	[Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
	Helicobacter pylori infection should be assessed in patients diagnosed with peptic ulcers. (EGD)
	[Level of agreement: strongly agree 78.3%, agree 21.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 63.6%, intermediate 36.4%, weak 0%]
	Bowel preparation should be adequate for a thorough colonoscopy. (CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy.

Table 3.

Final Statements and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in the National Cancer Screening Program: Reprocessing and Sedation

	Statements
Reprocessing	Endoscopy reprocessing and disinfection guidelines approved by the Endoscopy Professional Association should be available in each endoscopy unit. (EGD/CS)
	[Level of agreement: strongly agree 94.1%, agree 5.9%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Endoscopic reprocessing procedures should be performed as directed by established protocols and guidelines. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Endoscopic accessories that pass through the mucosa, such as biopsy forceps or incision instruments, must be sterilized. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Personnel performing endoscopic reprocessing and disinfection should wear personal protective equipment. (EGD/CS)
	[Level of agreement: strongly agree 72.7%, agree 22.7%, uncertain 4.6%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 54.6%, intermediate 45.4%, weak 0%]
	Endoscopic reprocessing equipment and storage methods should be appropriate as directed by guidelines. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
	Endoscopists and reprocessing workers should complete endoscopic reprocessing education programs approved by the Endoscopy Professional Association. (EGD/CS)
	[Level of agreement: strongly agree 95.0%, agree 5.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Sedation	Pre-sedation history, risk assessment, and sedation-specific informed consent should be obtained for sedative endoscopy. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	During sedative endoscopy, the patient's vital signs should be monitored and documented. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
	Patients should be monitored with discharge assessment scales after sedative endoscopy. (EGD/CS)
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy.

Table 4.

Final Quality Indicators and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in the National Cancer Screening Program: Workforce, Process, Facilities and Equipment, and Outcome

Quality indicators
Workforce	Is the EGD for the NCSP performed by specialists with at least one year of supervised endoscopy training or endoscopists with experience of at least 500 or more EGD procedures? (EGD)
	□ Specialists with at least one year of supervised endoscopy training □ Endoscopist with experience of at least 500 or more EGDs
	□ Endoscopist without one year of supervised endoscopy training or experience of less than 500 EGDs
	[Level of agreement: strongly agree 61.9%, agree 38.1%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
	Is the colonoscopy of the NCSP performed by a specialist with at least one year of supervised colonoscopy training in more than 150 cases or an endoscopist with experience of at least 300 or more successful colonoscopies? (CS)
	□ Specialist with one year of supervised colonoscopy training with over 150 cases
	□ Endoscopist with experience of 300 or more successful colonoscopies
	□ Endoscopist without one year of supervised endoscopy training or experience of less than 300 successful colonoscopies
	[Level of agreement: strongly agree 66.7%, agree 33.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
	Did the endoscopist perform at least 300 EGDs during the 3-year ‘National Endoscopy Quality Improvement Program'? (EGD)
	□ Yes	□ No
	[Level of agreement: strongly agree 13.6%, agree 50.0%, uncertain 36.4%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 59.1%, intermediate 31.8%, weak 9.1%]
	Did the endoscopist perform at least 150 colonoscopies during the 3-year ‘National Endoscopy Quality Improvement Program'? (CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 37.5%, agree 54.2%, uncertain 4.2%, disagree 4.2%, strongly disagree 0%]
	[Level of recommendation: strong 54.6%, intermediate 40.9%, weak 4.5%]
	Did the endoscopist the complete at least 12 hours of endoscopy-related education courses during the 3-year ‘National Endoscopy Quality Improvement Program'? (EGD/CS)
	□ Yes	□ No
	How many hours of endoscopy-related education courses did the endoscopist attend over the past 3 years? (EGD/CS) () Hours
	[Level of agreement: strongly agree 36.7%, agree 33.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
	How often did endoscopic nursing staff participate in training for endoscopy quality improvement over the past 3 years? (EGD/CS)
	□ More	than 3 times	□ More than 1 time	□ None
	[Level of agreement: strongly agree 66.7%, agree 33.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 54.6%, intermediate 40.9%, weak 4.5%]
Process	Does the clinician verify the fasting state, general health status, past medical history, and medication history including anti-platelets or anticoagulants (antithrombotics) using a preprocedure checklist before endoscopy? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 96.0%, agree 4.0%, uncertain 36.4%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
	Does the clinician educate examinees on bowel preparation and provide colonoscopy information before examination? (CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 54.6%, agree 31.8%, uncertain 9.1%, disagree 4.6%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Does the endoscopist obtain written informed consent for the risks and benefits associated with colonoscopy? (CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Does the endoscopist photograph and record at least 8 clear standard EGD images? (EGD)
	□ Excellent	□ Fair	□ Poor
	[Level of agreement: strongly agree 73.9%, agree 21.7%, uncertain 4.4%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Does the endoscopist photograph and record at least 8 clear standard colonoscopy images including the maximal insertion site (e.g., the cecum)? (CS)
	□ Excellent	□ Fair	□ Poor
	[Level of agreement: strongly agree 77.3%, agree 22.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Does the endoscopist maintain an average withdrawal time of ≥ 6 min in negative-result colonoscopies in order to inspect the colon mucosa sufficiently? (CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 87.5%, agree 12.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
	Does the clinician instruct the examinee as to the precautions and how to check the results after EGD? (EGD)
	□ Yes	□ No
	[Level of agreement: strongly agree 85.7%, agree 14.3%, uncertain 4.4%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 81.8%, intermediate 18.9%, weak 0%]
	Does the clinician instruct the examinee as to the post-procedure precautions and how to obtain examination results after colonoscopy? (CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 91.7%, agree 8.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 81.8%, intermediate 18.9%, weak 0%]
	Does the clinician label the tissue sample obtained during endoscopy? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Facilities and equipment	Is the endoscopy unit separate from the outpatient clinic? (EGD/CS)
	□ Excellent	□ Fair	□ Poor
	[Level of agreement: strongly agree 92.3%, agree 3.9%, uncertain 3.9%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Are endoscopic treatment devices (① injection catheter, ② hemoclips) and resuscitation equipment available for the management of adverse events during endoscopy? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 84.0%, agree 16.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Outcome	Does the EGD report include all of the following items? (EGD)
	1) date of examination
	2) patient information: name, sex and age
	3) name of endoscopist
	4) medications
	5) diagnosis
	6) findings
	7) biopsy details
	8) complications, if any.
	[Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
	Does the colonoscopy report include all of the following items? (CS)
	1) date of examination
	2) patient information: name, sex, and age
	3) name of endoscopist
	4) medications
	5) diagnosis
	6) findings
	7) biopsy details
	8) quality of bowel preparation (or maximum insertion site)
	9) cecal intubation
	10) withdrawal time
	11) complications, if any.
	[Level of agreement: strongly agree 66.7%, agree 25.0%, uncertain 8.3%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 77.3%, intermediate 18.2%, weak 4.5%]
	When a pathologic finding is observed, how well are the location, size, and shape of the lesion documented? (EGD/CS)
	□ Excellent		□ Fair	□ Poor
	[Level of agreement: strongly agree 87.5%, agree 12.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 95.6%, intermediate 4.4%, weak 0%]
	Do you test the H. pylori infection status of patients diagnosed with peptic ulcers? (EGD)
	□ Yes	□ No
	Does the endoscopist test for H. pylori infection status of patients diagnosed with peptic ulcers? (EGD)
	□ Yes	□ No
	[Level of agreement: strongly agree 66.7%, agree 20.8%, uncertain 12.5%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 63.6%, intermediate 36.4%, weak 0%]
	Is the proportion of patients who achieved adequate bowel preparation higher than 85%?
	□ Yes	□ No
	[Level of agreement: strongly agree 41.7%, agree 54.2%, uncertain 4.2%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 40.9%, intermediate 59.1%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy; NCSP, National Cancer Screening Program.

Table 5.

Final Quality Indicators and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in National Cancer Screening Program: Reprocessing and Sedation

	Quality indicators
Reprocessing	Does the Endoscopy unit have ‘Endoscopy reprocessing and disinfection protocols' approved by the Endoscopy Professional Association? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 95.2%, agree 4.8%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Are the endoscopic reprocessing procedures performed properly as directed by specific protocols? (EGD/CS)
	□ Excellent		□ Fair	□ Poor
	[Level of agreement: strongly agree 95.7%, agree 4.4%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Are high-level disinfectants used during endoscopy reprocessing? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
	Do reprocessing personnel follow the disinfectant procedures during endoscopy reprocessing? (EGD/CS)
	□ Check both the disinfectant instructions and protocols regarding disinfectant management
	□ Check only disinfectant instructions
	□ Check only procedures of disinfectant management
	[Level of agreement: strongly agree 90.5%, agree 9.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
	Are the endoscopic accessories that pass through the mucosa, such as biopsy forceps or incision instruments, disposable or sterilized for reuse in the case of reusable products? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 90.5%, agree 9.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 100%, intermediate 0%, weak 0%]
	Do reprocessing personnel wear personal protective equipment? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 80.0%, agree 20.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 50.0%, intermediate 50.0%, weak 0%]
	Is there an appropriate reprocessing area separate from the endoscopy examination room? (EGD/CS)
	□ Excellent	□ Fair	□ Poor
	Is there an appropriate reprocessing room separate from the endoscopy unit? (EGD/CS)
	□ Excellent	□ Fair	□ Poor
	[Level of agreement: strongly agree 90.0%, agree 10.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 72.3%, intermediate 22.7%, weak 0%]
	Are endoscopes kept in a dedicated endoscope storage cabinet where the tip of endoscope does not touch the bottom surface of the storage cabinet? (EGD/CS)
	□ Excellent	□ Fair	□ Poor
	[Level of agreement: strongly agree 85.0%, agree 15.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
	Do endoscopists and reprocessing personnel complete endoscopic reprocessing education programs approved by the Endoscopy Professional Association? (EGD/CS)
	□ Excellent	□ Fair	□ Poor
	[Level of agreement: strongly agree 83.3%, agree 16.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Sedation	Does the clinician document the pre-sedation history and risk assessment and obtain sedation-specific informed consent separately?
	□ Excellent	□ Fair	□ Poor
	[Level of agreement: strongly agree 95.0%, agree 5.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
	Does the clinician monitor and record patient status (oxygen saturation, blood pressure, pulse rate), type and dose of sedatives, and adverse events during sedative endoscopy? (EGD/CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 89.5%, agree 10.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
	Does the clinician monitor patients using a standardized discharge scoring system after sedative endoscopy? (EGD/ CS)
	□ Yes	□ No
	[Level of agreement: strongly agree 95.0%, agree 5.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
	[Level of recommendation: strong 83.4%, intermediate 13.6%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy.

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