So, let's start with a polling question. So, question number one, a 50-year-old woman presents for her first screening colonoscopy at your center. She has to see the physician with the highest ADR in the practice. You tell her and pick one choice, A, I don't know, sorry, I can't tell you, B, I know, and I can share the information with you, or C, I know, but unfortunately, I cannot share this information. All right, so we have a wide range of answers. About a quarter of people can't share that information, or they don't have that information, so they can't share it, but almost half know the information and can share ADRs with their patients, and a third have ADR info but can't share that information, so really a wide, wide range of answers there. So, this actually cues up my first presentation nicely, so let's go ahead and run that. So, I have the honor today of kicking off this course by presenting my broad overview of what constitutes a high-quality endoscopy unit. In this talk, I'll try to make the case for why you really should care about quality in your endoscopy unit, and then you'll hear our speakers throughout the course today really take a deep dive into multiple aspects of quality and safety in endoscopy. I have no relevant disclosures for this talk. I'm going to start off by broadly discussing the multiple components of quality which are relevant to endoscopy. Then I'll make the case for why you should care about quality in endoscopy, and I'm going to focus on one specific domain of quality and quality improvement in order to do that. As part of that process, I'll give a brief overview of how to perform quality improvement in your unit, and I'll close this talk by discussing diversity, equity, and inclusion, and the importance of DEI when we think about quality in endoscopy. Let's start by discussing the components that constitute quality in healthcare. When you ask people, especially physicians, what quality is, the first thing that comes to mind for many is effectiveness. How effective are the endoscopies that that unit or that individual are performing? I think this is natural, as most of us spend a lot of our time thinking about outcomes and quality measures relating to effectiveness in endoscopy. These outcomes are very important, and as a matter of fact, constitute much of what I'm going to spend the next few minutes talking about. But I do want to take a step back here and highlight that it's important that when you think about quality in your unit, you look beyond simply effectiveness. These are the six components of quality as defined by the Institute of Medicine about 20 years ago. Quality care is effective care, but it's also care that's delivered in a timely manner. It's efficient care, and very importantly, it's care that's delivered safely. Additionally, patient-centered care and care that is equitable are also key components of quality. So going back to the title of this talk, what constitutes a high-quality endoscopy unit? High-quality endoscopy units are those in which the emphasis is on delivering quality care from the standpoint of all of these principles. It's not enough for a unit or a provider just to perform effective endoscopy, although this is obviously important in and of itself. A high-quality endoscopy unit focuses on all domains of quality. All that said, I'm going to start off by making the case for why we should all care about quality in our endoscopy units with a salient example based on the principle of effectiveness. Endoscopy is no longer flying under the radar. This is a really splashy headline you probably all remember seeing when it came out in 2013, and you've probably seen it multiple times since. Headlines like this really make people start thinking about how much we spend in this country on colonoscopies. The headline is the $2.7 trillion medical bill. With the subheadline, colonoscopies explain why the U.S. leads the world in health expenditures. The concept is that our cost per colonoscopy is significantly higher than it is elsewhere in the world, and that this cost is driving the massive healthcare-related expenditures in this country. Well, obviously, this is a dramatic headline designed to pull readers in, but it does bring up an important point. In and of itself, colonoscopy being expensive may not be the most concerning issue here for us who work in GI endoscopy, as we don't set the costs. But the issue here is that there is variation in cost, and when you have cost variations, people immediately wonder why. Is a colonoscopy in the U.S. really better than it is in another country where the cost may be lower? Well, not only do costs for endoscopy vary between countries, they also vary within the U.S. itself. This graphic from the same article shows the variations in cost for a colonoscopy throughout the country. Whereas the average cost in Baltimore is under $2,000, it's close to $9,000 in New York. So the obvious question here is, is the value of a colonoscopy in New York four times greater than it is in Baltimore? We all know that the concept of value is crucial in medicine, both for patients and for payers. And one of the components that goes into determining value in healthcare is health outcomes. So in healthcare, we can't know what the value of anything we're doing is without being able to measure our effectiveness. We've all heard about the shift in healthcare from volume to the concept of value. Value in healthcare is defined as health outcomes divided by dollars spent. So if you charge twice as much for your colonoscopy, but you can measure the outcomes of your colonoscopy, and they're objectively twice as good as those of your benchmark competitor, then you've maintained value. Obviously, the ideal is that we improve our health outcomes while maintaining or even lowering costs, and in that way, we're able to increase value while not actually increasing cost itself. This is great in concept, but I'll put forth the idea that it's actually been challenging to measure quality in GI endoscopy, and this is for a multitude of reasons. But we've made a lot of progress in this over the last 10 to 15 years. Now, we can say in some areas of GI endoscopy, we can measure and know who is actually performing high-quality endoscopy. Another issue when we speak about quality in endoscopy is that there has been a lot of uncertainty over who actually should be responsible for measuring this quality. Unlike some other specialties in medicine, such as surgery with the NSQIP, in which most surgical centers are enrolled and obligated to collect broad outcomes data, I would argue that that's not the case in GI endoscopy for the most part. We really haven't had that same push in GI endoscopy for all centers to become part of health outcomes registries like the NSQIP in surgery. So it really is up to our sites on a more individual level to collect quality data. I would argue that quality measurement in GI endoscopy matters if there is variability in quality between providers. If you think about it, if everyone performed endoscopy with the exact same level of quality, we wouldn't need to measure it. I think it's natural to assume that most endoscopists feel that they do high-quality work when performing endoscopy, that they're high performers in the endoscopy unit. I would venture to say that very few of us would say that we're doing a below-average job in endoscopy, but I think we know that that actually is not true. So in reality, we would reasonably assume that the quality of medical care amongst endoscopists varies widely along a classic bell curve distribution, where the majority of endoscopists are average performers, and there are fewer outliers in both the low-performer and high-performer categories. Obviously, we would like to know where we fall along this performance curve. So how do we do that? Well, we do that with data. I actually don't want to steal too much thunder from Dr. Dominance's talk on quality indicators in colonoscopy, and that's coming up right after this one. But ADR, adenoma detection rate, is a great example to illustrate that the quality of GI endoscopy can vary widely amongst endoscopists, and we can measure these differences with data. These are recent data from my institution for the last academic year. I'm in there somewhere, showing that while we have an average institutional ADR of about 40%, which is well above the benchmark of 25%, there is what I would consider to be significant differences in ADR amongst our providers, ranging from a low of around 22% to a high of around 55%. And I'm sure if I asked any one of my colleagues how they thought they were doing before they actually saw these numbers, they would all answer that they were at least average in terms of their effectiveness in detecting and removing adenomatous polyps. So I think this really does drive home the point that data matters, and it's crucial that we measure the relevant data in order to know how we stack up from a quality standpoint, both as individual endoscopists and as endoscopy units or institutions as a whole. We can also look at a multitude of other quality measures in endoscopy and find differences among providers, although many of these measures are newer and still need to be validated, and many of these haven't been at least yet shown to have a striking impact on important health outcomes that ADR has. We can see this in EGD and advanced endoscopy metrics as well, and you'll hear about those in talks later today. If we stick to colonoscopy, I've always found that sessile serrated polyp detection rate, or SDR, to be fascinating, and that we always seem to find a large variation amongst our endoscopists in this metric. You can see that at my institution, while our average SDR is 10.7%, we have variation among providers from SDRs that are less than 1% to SDRs of nearly 17%. So that's a wide variation, and when we see gaps like that, we know that there's likely an opportunity for low performers to improve, and we can't know that we need to improve or how much we need to improve unless we know where we stand in terms of these quality metrics. But more than just demonstrating that quality does vary between providers, I would argue that it's crucial that we spend our time and effort measuring quality only if by doing so we can meaningfully impact patient outcomes. So let's go back to ADRs. Most of you are probably familiar with this study, and you're going to see it again later on in talks today, this is a landmark study from Doug Corley and colleagues which really drives home the importance of ADR. This study demonstrated that increases in ADRs actually decrease the risk of interval colorectal cancer, so that's really powerful, right? I don't have the data on this graph, but if, for example, you as an endoscopist have an ADR of greater than 33%, which puts you in the highest quintile, the patient on whom you performed a screening colonoscopy has approximately half the chance of developing an interval colorectal cancer than if they had had that colonoscopy performed by an endoscopist with an ADR in the lowest quintile or less than 19%. But probably even more eye-opening is the fact that this study showed that each 1% increase in ADR actually decreased the risk of patients dying from an interval colorectal cancer by 5%. So I like to show the example of ADR because it beautifully illustrates the point that measuring quality, in this case measuring ADR, really does have a direct impact in terms of highly meaningful health outcomes for our patients. ADR provides us with a great example of quality varying between providers, and also that differences in quality that we can measure meaningfully impact outcomes. Let's talk about two other important aspects of quality measurement. I think it's apparent that we need to focus on quality measures that are feasible to measure. There are aspects of quality that are actually not easy or even feasible at all to measure. But if we can measure an aspect of quality, we would also ideally want to see that measuring quality in that case has the potential to lead to improvement in the quality of care delivered. In other words, if it is feasible to measure quality, and if indicated implement strategies to improve a provider's quality, then that's an ideal scenario in which measuring quality ended up leading to improvement in outcomes. As an illustration of this, this is another study from a few years ago which demonstrated that if you can improve the ADR of endoscopists, you can actually reduce the risk of their patients developing colon cancer. So in this case, if you can take low-performing providers and make them better performers, there is a very meaningful improvement in health outcomes for their patients, and that's really powerful. So how do we do this? How do we do this type of quality measurement? So I'm going to talk briefly about how to implement a successful quality improvement program in your unit. I will say that this is a huge topic, and in past iterations of this course we have dedicated full talks to this very topic. So this is going to be just a brief overview. In order to make quality improvement happen in your unit, you need to keep a few things in mind. You need to assemble the right team of people to engage in quality improvement. You want to identify achievable quality improvement goals that are feasible given the available resources in your units, and if possible, and this will depend on your center, you want to try to tie quality improvement into academic productivity. If you're in an academic medical center where you have trainees, this last goal is relatively easy. The ACGME now mandates QI project requirements for all house staff. So your trainees, your residents and fellows are all working on QI anyway as part of their programs, and it makes sense to tie your unit's QI work into a project with trainee participation, which is a classic win-win scenario. Well, how do you assemble your quality improvement team? This is going to vary depending on your unit. Are you a standalone ASC, or are you part of an academic medical center, for instance? It's important to have dedicated physician leadership, and this ideally is a physician who is interested in improving quality throughout the unit, and in all aspects of GI endoscopy, and not just in their domain of clinical interest. So someone who looks holistically at the entire unit. It's very difficult to do quality improvement without hospital resources. The resources available to you will differ depending on your institution. If possible, you want to partner with an analyst who can pull data, analyze it, and then give that data back to you in a form in which it's useful to you. IT and EHR resources are also crucial. I know that at my institution, the single greatest barrier to QI is obtaining the data that you want from our EHR. And having EHR specialists can make all the difference in whether or not your QI project gets done. Manual data extraction is incredibly time-consuming. Some institutions may have QI or performance improvement leaders who can be very helpful in helping move your QI program forward. You do want to include nurses in your program whenever possible, as they are key stakeholders in terms of endoscopy unit quality. And finally, you want to create a regularly scheduled quality committee meeting. This will ensure that your QI goals are being met and that your quality improvement programs continue to have momentum. Additionally, a sanctioned quality committee importantly provides legal protection around data collection and discussion, which can be very helpful when it comes to discussion of sensitive matters, such as underperforming physicians. How do we choose measures to track? How do we identify measures that lend themselves well to measurement and improvement? Well, we have the structure-process-outcomes model, the so-called Donabedian model. In this model, you can focus on any of these aspects. Structural refers to the physical and organizational characteristics of healthcare. Process refers to what is actually done in the process of providing healthcare. And outcomes refers to the effect of the healthcare delivered. Sometimes it's easiest to start with a project focusing on structure or process, as these may be easier to do than outcomes measures. Structures measure could be something as simple as equipment, say high-definition colonoscopes. So we know that we should be using high-definition colonoscopes for our colonoscopies, and we're not doing that, so implementing the use of high-definition colonoscopes may be a structure measure to improve quality. It's an easier one, because it just involves equipment, although, of course, this is an expensive intervention, but it's still a good one to do. A process measure may be something such as measuring withdrawal time or rates of retroflexion in colonoscopy. These process measures are associated with outcomes that are of interest to us, but are not the actual outcomes themselves. So it's not that we care so much about withdrawal time in and of itself, it's that we think that increasing withdrawal time allows us to detect more adenomatous polyps, for instance. And then there are outcomes. These are ideal quality measures, because they directly reflect health outcomes of interest. These are the most useful for us, because they're the ones that we're going to be using These are the most useful things to measure, but also may be the hardest measure. But they're definitely the types of measures we ideally try to involve in our quality improvement programs. I will say that most, if not all, of you are already participating in quality measurement in your unit, so you do have some familiarity with this. We have the CMS core quality measures, which are used in value-based incentive payments, and those are quality measures you may already be tracking. These are the core quality measures for gastroenterology, which you see include four colonoscopy-based measures. And you don't need necessarily to come up with meaningful quality improvement measures and ideas on your own. The ASGE and ACG have jointly published documents on quality indicators for all types of endoscopic procedures. This is an example of the joint ASGE-ACG quality indicator on ADR. These documents outline very nicely the quality measure of interest, including the definition of that measure, the level of evidence behind that quality indicator, the performance target for that specific measure, and the type of measure it is. And you can utilize these nicely vetted and established quality indicators in the quality improvement programs in your units. How do you actually do this? What's the process? How do you implement quality improvement in your units? There are two main approaches to quality improvement, although there are others as well. Some institutions will use the process known as DMAIC, or the Six Sigma approach, which is a very analytical approach to quality improvement. But most of you probably utilize the PDSA approach, where you plan, do, study, act, which is a straightforward and iterative approach to quality improvement. In PDSA, you first plan. You first identify a quality issue that you want to improve and then come up with a plan to do so. Contributions from members of the team involved or a quality committee can be used to fully define the proposal. Secondly, you do, so the plans that you came up with are carried out. Thirdly, you study the effect of your intervention on the outcome or outcomes of interest are evaluated. And then finally, you act. So after the results of your intervention have been analyzed, you then use this analysis to refine your plan of action, and the process is repeated until the desired goal is achieved. So I recommend utilizing one of these established strategies in your quality improvement work, as this will really help make your quality improvement projects become successful. Here, I think it's appropriate to plug the ASG's endoscopy unit recognition program. The EURP. Being involved in a structured endoscopy unit program such as EURP is really useful, as this helps you focus on areas in quality pertinent to endoscopy. If you look at the EURP application, you see that it requires assessment of various quality measures such as ADR and adverse event tracking with demonstration that quality improvement plans are in place if the unit or individual endoscopist fall below targets for these performance measures. Additionally, it's useful in that it mandates attestation that your unit follows several important safety guidelines in endoscopy, including the multi-society guidelines for endoscope reprocessing. And as part of the application, each unit does need to submit a quality improvement project that has been completed by that unit. So among its multiple benefits, the EURP program is a great way to really push the emphasis on quality improvement within your unit. I want to close with some words about diversity, equity, and inclusion. I focused a lot of the last 20 minutes or so on effectiveness in endoscopy as an important component of quality. But I do want to take some time right now to highlight the importance of equitable care as a key domain of quality in endoscopy. DEI considerations have become increasingly recognized as vital components of the quality of care we offer our patients. I would challenge all of us to really push ourselves to do better with respect to DEI throughout our practices and in our endoscopy units. We really need to make DEI a point of focus. We want to promote culturally competent care because we know that this leads to improvement in the patient experience and in health outcomes. We need to promote the values of diversity and inclusion for our patients and within the staff and providers in our endoscopy units. Doing this can take numerous forms, and there are multiple opportunities to do this. Dr. Day has a talk dedicated to DEI coming up later in today's course. And you'll also be hearing about DEI and its importance in multiple facets of endoscopy unit quality in all of today's talks, so stay tuned. In closing, here are some take-home points from this talk. Remember that quality has multiple components, and each one of these is as important as the others. In order to have a high-quality endoscopy unit, we need to constantly work on improving in all of these domains of quality. When we think about endoscopy specifically, we know that there is significant variability in quality, and importantly, these differences may have a direct impact on important clinical outcomes. We all want to improve our quality, and this is easiest to do when we have outcomes that can be directly measured. And most importantly, when we can demonstrate that measuring these can lead to downstream improvement in health outcomes. Quality improvement requires commitment within the unit and a dedicated team of people with diverse skills. There are numerous opportunities to engage in quality improvement within your unit. These include quality measures and indicators proposed by government agencies and our GI societies, but every unit has its own unique opportunities to identify areas that lend themselves to meaningful quality improvement.

endoscopy units

quality

adenoma detection rate

healthcare

measuring quality

effectiveness