Joe, thanks. And I disagree, you are very eloquent and appreciate you kicking us off this morning. Really, really helps us out in understanding how we want to approach this quality course today. I'm really excited. I'm especially excited for our faculty to bring a fresh sort of perspective to some of these talks that may have been given in the past that you've seen. So I'm really looking forward to hearing what everyone has to say and I'm thankful that I'm doing it with good friends from around the country. So I think the best way to get started always is starting with a polling question. So if we could pull up the polling question. A 50-year-old female presents at your center for her first screening colonoscopy. I'm going to update this slide and maybe TR can tell us whether we should update this to say a 45-year-old female. She asked to see this physician with the highest adenoma detection rate. What do you tell her? And your choices are going to be I know but I can't share it. I know I can share the information or I don't know. Sorry. So let's have everyone vote. Okay. This is a nice mix. So I think the majority, but just slim majority actually will tell the patient who is asking who has the highest ADR who that person is. A quarter of people don't calculate ADRs and simply can't tell the patient who's asking for what is a relatively critical and basic quality metric. So that really helps us and really cues up the first presentation nicely. So I'm excited to present our first talk of the day. What constitutes a high quality endoscopy unit? All right. So I have a pretty sort of broad overview mandate of this in this lecture, which is really just trying to tell you, you know, what does quality and endoscopy mean? So I have an outline for this to sort of focus on why should you care about quality in GI endoscopy? A beginner's guide to starting endoscopy quality program in your institution. And then just a plug that we talked so much about quality, but we should also remember safety and that can be a blind spot in some of our programs as well. So, you know, dating ourselves now, this has come out, you know, quite a while ago now, this is over a decade or almost a decade ago. This New York times article that came titled pain till it hurts. And I would never get over this sort of subheading that says colonoscopies, explain why us leads the world and health expenditures. And it's a very inflammatory statement, but I'm okay with that. I just think it's an interesting concept that says, you know, this price variation is really explaining how healthcare isn't necessarily working in the United States. And what do I mean by this price variation? This was the accompanying infographic that talks about how colonoscopy prices vary throughout the United States going from as low as $2,000 at the time and all the way up to $9,000 in New York. So that's obviously a huge variation. And when you see variation like that, you really want to assume that there's going to be some improvement in outcomes for that great, that increase in costs. But as we know, there's probably not a five times improvement in outcomes when you pay five times the cost for a colonoscopy. In fact, there may be no relationship at all. And, you know, this value question in endoscopy has come up with this issue with anesthesia utilization as well. And maybe we'll hear a little bit more about that later, which is that, you know, the cost of anesthesia continues to go up related to GI endoscopy throughout the United States. And that there's marked regional variation of anesthesia use. And why am I showing you these slides? Because I think it's very important for us to understand that when we see variation in practice, there's probably some associated variation in quality and value. And that comes to that value question. We talk a lot about quality, but we also talk about value. Value is this concept of health outcomes over dollar spent, right? So, you know, are we actually getting the most bang for our buck? And we talk about value so much and it's great in concept, but how do we measure the outcomes of endoscopy? Who's going to do that? And who, you know, who's going to really say, let's sit down, look at these numbers and actually give feedback on this. And this is imperative upon us as healthcare institutions to do. And so another thing that we sort of, we see a lot of is people talk about quality and they basically just think about procedural effectiveness when we're in gastroenterologists. And again, we'll hear some lectures on the importance of things like endometric detection but there's so much more to quality than just procedure effectiveness. The sort of the outline that was brought up in the crossing the quality chasm is the idea of effective care, safe care, timely care, efficient care, equitable care, and patient-centered care. These are all important components of procedural quality. So I think quality measurement and endoscopy can be considered to matter if we can show that quality varies between providers. And I think that that's something that we need to prove to our providers, right? We need to show them that there's variation. If you ask endoscopists how good they are at procedures, everyone will say they're a high performer, right? Most of us would not be in practice if we didn't think we were doing a good job. And so this sort of inability to assess ourselves is why we need to be able to have some sort of forum, some sort of metrics that we can give as feedback. Because in reality, we would assume the quality of medical care varies widely, that there'll be low performers, average performers, and high performers. So how do we get that data? You know, this was data from our institution 10 years ago when if I would have asked everyone, are you doing a good job of colonoscopy? Everyone would have said yes. And then we finally started measuring it. And there's a huge variation in adenomyotection rates. Again, this is a decade old now. But until you measure this, you won't know that you're potentially four to five fold lower in adenomyotection rates than some of the high performers at our institution at that time. So it's very clear now that the quality of diagnostic colonoscopy is variable among providers. But until you measure it, it's very difficult to tell and convince the providers that there may be that variation. It's not just colonoscopy. The quality of ERCP or other advanced procedures also clearly varies between providers. So the nice study out of Europe many years ago now that shows that, you know, if you look at higher volume performers, there's a pretty significant difference in ERCP success rates, ranging from low 70% to upper 90%. So procedural success varies between providers no matter the procedure type. So I think it's clear that quality varies between providers. But are those differences meaningful, right? Do they impact outcomes? So if it doesn't make a difference in outcomes, it's not a quality metric that's important to measure. And so I'd like to do this thought experiment for this when I talk about this with the fellows, right? So if you're a patient and you are diagnosed, unfortunately, with early stage pancreas cancer, right, which has a high, you know, even higher than this five-year mortality rate. If you go see an oncologist, they're going to potentially offer you two therapeutic regimens, right? We'll call it drug A versus drug B. And your natural question is going to be, you know, what is the safety profile and what is the efficacy profile of these medications? And if I tell you, actually, drug A is going to give you a better chance for five-year mortality than drug B, that's how you make the decision. This is what we expect from our healthcare. We go in to see providers, we get some information on outcomes and safety, and then we make a decision with our provider. But when it comes to endoscopists and someone calls the schedule a procedure, it's essentially not something we do. We don't say, how good are you at this? What's the, you know, what's your pancreatitis rate? What's your adenine protection rate? All these things seem like more black box or sort of taboo questions to ask for proceduralists, but these are the same issues that face patients. They want to get the best outcomes, and so it's imperative upon us as the sort of leaders in this field to be able to make sure that patients can get this information if they need it. And, you know, TR will show us nice data later. This is sort of early data that shows us how important adenine protection rate is important in terms of interval colon cancer death. And again, I'm not going to dwell on this because we'll get a much better talk on this, but it's the idea that quality impacts important outcomes like death. So we need to measure it because it has an importance. I would say the quality also matters if we can show that there are feasible metrics and we can actually measure these metrics, right? Some of them, you know, are aspirational metrics that we just have no way of measuring these days. And so if we can measure them, then it's an important quality metric. And then ideally, that measurement improves the quality of care delivered. So that if I can measure the quality of, you know, Dr. Munzer's ERCP, and I can give him some feedback on his quality metrics, it's going to allow him to become a better endoscopist. And we've seen this in all sorts of things. You'll see it with adenine protection rate. If you measure adenine protection rate and give people report cards, their quality of endoscopy will improve. You can see this here in colon cancer. Again, if you measure the quality of colonoscopy, give people feedback on their ADR, and then get them to be better endoscopists, their quality improved as well. So I think it's very clear that we can measure quality, give feedback, and those improvements in quality can actually improve important patient outcomes like colon cancer rates and colon cancer death. So an old school comic for those of you who are part of our generation in the audience. So I brought home my report card dad. Well, let's see it. Remember how you once told me it didn't matter what grades I got just so long as I tried my hardest, right? And then the dad said, of course, well, you could have certainly been trying harder than this. So you admit you're lying, right? So it's not enough for us just to measure. We actually need to now go beyond just getting grades. We need to actually figure out how, once we've measured variations in quality, how are we going to actually make improvements? So we all need to think about how we're going to start a quality program in our institution or how we're going to enhance it. And so this is the beginner's guide to starting an endoscopy quality program. What you want to do is you want to make sure you assemble the right team. Sounds obvious. Identify achievable QI goals, and then tie that quality improvement into academic productivity, which is very important for those of us who are at academic institutions. It's a really good way to get a QI project and turn it into an academic publication. So it's very difficult to measure quality in practice, and I'm fortunate to be able to give this talk later in the morning to sort of go through and navigate the real challenges of data abstraction. But I sympathize with everyone in the audience that it's really great to say I want to measure something, but it's very difficult to do it in practice. You have to be able to assemble a QI team, and that is very important to have a diverse team. So you want a dedicated physician leadership, ideally someone who's not just in it to improve the quality of their own specific interests, right? So you don't want someone who's just interested in improving the quality of pancreatitis care and ignores the rest of gastroenterology and hepatology. You need hospital or ASC resources, right? You need an analyst, someone who can pull data. You need a QI or performance improvement leader who can understand sort of the nuances of those data pulls and what to do. And then IT or EHR resources are really important because you're going to end up having some things that you want to improve, and you need EHR solutions to do it. And that's where you want to bring these people in up front so that they're not surprised at the end. And then definitely include nurses whenever possible. They bring such valuable, different insights and often more rational solutions than some of our physician leaders do. And then we try to have monthly or bimonthly QI meetings so that momentum is kept, right? So that we're always meeting and making sure that we're kept honest about the things we said we're going to improve. And it's really helpful to have a sanctioned QI committee that provides legal protection around data collection. So if you have a sanctioned QI committee, this really allows you to talk about things in a quote-unquote safe space. So, you know, as an example, what we do at Northwestern Medicine, you know, QI is a system approach, right? So we have nearly a dozen hospitals with over 100 gastroenterologists. And so now our goal is to improve quality through the system, not just one hospital. So something that someone suggests at one of our regional hospitals, we make sure that that can be implemented throughout the whole system. We have this concept of clinical collaboratives, and it's a really interesting concept you'll see all through practice in the United States now, both on an institutional level, but potentially also on a disease-based level, like there'll be bariatric surgery collaboratives or colorectal cancer collaboratives, things like that. And this is the idea of bringing together people from multiple disciplines and working on common problems, right? So our health system clinical collaborative is a Northwestern GI collaborative that uses IT resources, QI leaders, GI clinicians, informaticists, and EHR specialists from all the hospitals working collectively to improve care. And then I think it's important that each hospital has a local QI committee to address incident reports, local issues, and the proposed QI initiative for the system. You just don't want one person driving all efforts. And so it's really important to start at the beginning to identify a problem and create a request, then discuss and approve requests, make sure that one person is not just sort of bullying all their pet projects to the front, determine and develop the best solution. One of the problems that physicians have is we go straight to a solution. Our job is to sort of think about a problem and then develop multiple solutions and then figure out which one is the best one and then implement it. And then obviously continue with ongoing measurement to make sure that we are actually making the improvements we thought we were. So how do we choose our measures? A lot of different ways to do that. You can use this Donabedian model, which I'm sure many of you or all of you have heard about, which is that there's three different types of metrics, right? There's a structure metrics, process metrics, and outcomes metrics. So what's structure? Structure would be the idea that let's say we should be using high definition scopes, right? So that's a quality metric. And you can basically, that's essentially a purchasing capital issue, right? So structure metrics are very important, right? Do you have GI trained nurses? Do you have high definition scopes, et cetera? But that's a relatively easy quality metric to measure and make progress on. And then we have process metrics, right? So these are not tied to definitive healthcare outcomes in terms of, you know, the patient doesn't care how long your withdrawal time is. They only care how long your withdrawal time is because it impacts endometriosis rate and colon cancer rates. And so these are sort of intermediate metrics that are very important because sometimes the outcome metrics are very challenging to measure on an individual level, such as interval colon cancer rates or interval esophageal cancer rates, perforation rates, et cetera. So, you know, your metrics you choose as an institution are going to be a mix of the structure, process, and outcome metrics. And it's good to have the group think about what makes the most sense to work upon. And so there are some CMS core measures for GI and hepatology that may be helpful for you if you're trying to figure out what should our group work on, what should we be thinking about, you know, doing. And it'll be things like, obviously, endometriosis rate, age appropriate screening colonoscopy, some IBD metrics that, you know, are very important. So not moving beyond the endoscopy, but thinking about some of the cognitive metrics that are very important as well. So you can refer to these as well for ideas on what you should be working on with your team. And here's some other ones that also talk about hepatology metrics as well. So again, a nice set of what are considered the most important metrics for you and your team to work on. It's helpful to make sure that, you know, you can look at our societies and think about what they think are quality metrics that are important as well. The ASGE and ACG, as you know, put out this document now almost a decade ago for all of our procedures, colonoscopy, upper endoscopy, ERCP, EUS, in terms of which quality indicators are important. And it's really nice because it gives you performance targets and gives you the justification for why these metrics were developed. Unfortunately, they're a bit outdated now. So some of these metrics, as you know, some of our speakers will talk about, the targets have moved a little higher, and we'll talk more about that later. But it's still a very nice document to lean on because it gives you a framework to approach quality improvement. An example of how these things would go is that they also give you these priority measures, right? So it's not just that they have quality metrics, they have priority ERCP measures, which would be like rate of deep cannulation of the ducts of interest in patients of native papilla without surgically altered anatomy. And that would be a greater than 90% metric. And then you have to decide, is the measure meaningful and is the measure feasible, right? So when I look at these metrics, I go, is it meaningful to actually cannulate the bile duct when I want to during ERCP? That's clearly a meaningful measure. It's not the sole measure, but it's a meaningful measure. And then is it feasible? Yeah. Right now it's through manual abstraction, but it is a feasible measure to calculate. And so tying this back to the beginning, finding meaningful measures and feasible measures are really important for us. And so how do you decide once you figure it out that this is the metric I'm working on, how do you create a pathway for improvement? There's lots of different ways, and you can read lots of books, or you can come to things like courses like this. You can email Eden, and she'll be happy to give you some advice as well. But there's a couple of different ways that we think about how to improve the quality of care. One is this sort of DMAIC, which is a process which is much more statistical. It's the define, measure, analyze, improve, implement, improve, and control. So it basically says, let's figure out the problem. Let's figure out how good or bad we're doing at that issue. Why are we not doing better? And then let's make some improvements and figure out if it actually improves the quality of care we're delivering. And a lot of people do this PDSA, which is a plan, do, study, act. Again, similar concepts. Let's figure out what we want to work on. Let's do it. Let's see if it made any difference. And then once we see how our changes made things better or worse, let's make some more improvements again. And so this idea of rapid PDSA is just doing this over and over more quickly. I think there's a lot of different ways to improve care. We'll hear about some of these today. You can give report cards, they show how you're doing and how you can do better. And so we do that here. You can improve care, clinical decision support through a colonoscopy order set, ERCP order sets, paper tie disorder sets, all sorts of things. My dog is screaming at me, I'm sorry. And that'll allow us to improve the care delivered with colonoscopy. So this would be example for, you know, split dose bowel preparations in the hospital, giving structured diet orders, all these sorts of things. So clinical decision support is a really important way you can improve care delivered to the hospital. You can use checklists and structured workflow. This also allows us to improve care. This is an example from many years ago of a structured process to help us improve the quality of care delivered. You can use simulation training and team training, which is really exciting to do, especially when your issues might be things that are more about team leadership and how you want to make sure everyone communicates well. Maybe you feel like you have some issues with how a team responds during a code in the GI unit, and this is where simulation training can be really helpful. And then just, you know, idea of multidisciplinary management. How do you improve care? Maybe by bringing in other people who can help you, you know, dieticians, nurses, APPs, you know, developing more of a team-based approach to care, that can be very helpful to improve the quality of care as well. Obviously, there's lots of things the ASG offers to help us do this. The endoscopy unit recognition program is a really great framework to allow us to understand which metrics the ASG thinks are important and give you some outline of how you can potentially make improvements in that. And then finally, I just want to make a quick plug for safety, right? We talked so much about quality, but remember, safety is such a big deal in endoscopy, especially. Lots of different studies out there that show that we really have a blind spot to procedure safety. This is a study now, over a decade ago, that showed when you actually looked at self-reported adverse events, when physicians actually knew about the adverse events and reported it, it was a small minority of the total adverse events that occur after procedures. And this happens a lot because patients go to other hospitals, or they come to this hospital or they come to this hospital, and we're not even aware of the adverse event that happens. And so, we really have a blind spot to safety because we don't always know what the negative outcomes that are occurring are. We've looked at this as well, and we saw that there's really fragmented care after procedures. And patients who have a procedure at our hospital may end up at another ED with an adverse event and we'll never know about it. And you can sort of see that in a lot of different ways. I think that new technology is a real blind spot to us as well. Most of our hospitals don't have a great way of credentialing people in new technology. And so, thinking about that in your endoscopy QI committee, if someone says that they're going to come in and do a novel procedure called a jejunal poem, do we have any way to sort of say whether they should be doing this? And if they should be, are they actually competent in doing this? So, something else for our QI committees to work on as well. And then, we've seen this even with this idea that people who say they're doing procedures, do they actually know what they're doing? When we asked SG&A members in the past about procedures like ERCP, they basically said that a large proportion of the time, 30% of the time, a device representative has to be there to assist them in using an accessory because they simply don't know how to use them. And so, these procedural safety questions and competency questions really will come up today. Think about this and what you want to work on in your institution, because there's so many things to work on besides just measuring ADR. You know, there's teamwork climate endoscopy errors. It's another important thing that you need to think about that, you know, that there is this importance in creating this, a unit that works cohesively together. We don't want the idea that our teamwork, our teammates are afraid to report errors because they think that the environment isn't conducive to that. You know, we see that, you know, when your teamwork scores are high, that you're less likely to, you're more likely to report errors that can help improve the quality of care. When your teamwork scores are low, you might be afraid to actually report errors and actually give feedback that can help improve the care in the future. Oftentimes, we see that our colleagues, including our nurses, are afraid to report medical errors because they're afraid of how the hospital or the administration will deal with it, right? So, nurses might say, and this survey of nurses said basically that, you know, that they're less likely to report errors because they feel the hospitals may not be dealing constructively with these problem physicians employees. If you don't, if the nurses and techs and other physicians don't think you're taking their feedback seriously, they're not going to give you any of those useful feedback to help you improve care. So, again, create that culture of safety to help people improve. So, in summary, I think you'd agree that there's significant variability in endoscopy quality and that this variability impacts clinical outcomes. It's unclear whether this variability in quality is modifiable sometimes, but at least for some procedures, it certainly is modifiable and should be impacted. In contrast to colonoscopy, most therapeutic endoscopy metrics are challenging to collect, and it should be a priority for societies like ASG to work on that. And future work should emphasize this improvement in quality of care. Thank you.

endoscopy quality

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patient outcomes

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