So, really, what I'll do is really set the stage for the day and really talk about from a big picture view of what really constitutes a high quality endoscopy unit and, you know, the stellar faculty that you have today really will drill down into various aspects of this. These are my disclosures. First, we'll talk about what is quality in health care, how do we define quality in health care, and then ask the why question. Why really should you care about quality? What's the big deal? And we'll finish off with some big picture overview of approach to quality improvement in endoscopy units, how we take a structured approach to quality interventions, and we'll talk about the endoscopic unit recognition program that the ASG hosts, and we'll talk also about equitable and patient-centered care, and hopefully what you get from this talk is that quality is a broad term that incorporates several domains. So, let's first tackle the why and how we define quality, but before that, let's sort of kind of get us all going to see where we are at. Let me kind of ask you the question, does your endoscopy unit have an ongoing quality improvement program? Let's see how many, how it pans out. Oh, that's outstanding. So, 85% do have some form of a quality improvement program, so that's great. I think that we have, you know, in some ways we are preaching to the choir here, and so we can all learn from each other. So, one of the important aspects that is, one needs to recognize is that if quality is a multi-domain sort of construct, effectiveness by itself, it does not equal quality, but it's a good starting point. So, quality care, as defined by the Institute of Medicine, is effective care that is safe, timely, efficient, equitable, and patient-centered. So, one needs to focus really on all of these domains, and we'll kind of touch on all of these. So, why the focus on quality? I think it's no surprise to any one of us that as a nation, we pay the highest costs for health care in the world, and that immediately begs the question, are we getting our bang for the buck? And I think the answer to that is a definite maybe, like, so because when you take colonoscopy, as you see the numbers popping up on this graph, you can see the variation in colonoscopy costs, and, you know, once all the numbers sort of show up, you can see that a colonoscopy in New York based on these numbers costs about $8,500, and a colonoscopy in Baltimore costs about $2,000. So, the question is, is a colonoscopy in New York, when Dr. Yang does it, four times as good as somebody who does it in Baltimore? So, I think that's an open question, and that's where it brings up the question of value and the shift from volume to value, and value is typically defined as the health care outcomes per the dollar spent, but then as you drill deep into it, it's a great concept, but how do we measure? When we apply this to endoscopy, how do we measure the outcomes of endoscopy, and who will measure the outcomes? So, let's try to kind of drill deep into this, and try to understand, especially as it relates to gastrointestinal endoscopy. So, another poll, I just wanted to kind of get a pulse for the audience. Does your endoscopy unit measure performance metrics for screening colonoscopy, which is obviously the most common procedure that we perform as gastroenterologists? Oh, wonderful, wonderful. So, again, it looks like I'm preaching to the choir here. So, 87% do measure some form of performance metrics, so that's excellent, and Dr. Dominance is going to go into great detail in terms of colonoscopy metrics and things like that. So, I'm really looking forward to this talk, but in this talk, I really want to focus on the why. So, if you take screening colonoscopy as a test case, if you ask the question of why, the question would be, you know, if we should care about the quality, let's say if the quality varies between the providers or the centers, and if the quality differences meaningfully impact the outcomes, the so what question, right? And then, if there is interval colorectal cancer, so it really impacts the outcome, and then you should be able to measure quality and give feedback so that you can improve. So, when all of these criteria are met and the data supports these interventions, then it makes a lot of sense, and then it addresses the so what or the why question. So, let's go into that. Let's talk about the first component of it. Does quality vary between providers? And I think the answer is a resounding yes. Now, this is a sort of an informal assessment, but when you let's say you ask physicians to assess themselves, I think more than likely this is the sort of the data you're going to get if you ask for self-reported quality. But as with everything in life, you know, it is a bell curve, and when you really look at the data, so there are going to be low performers, there are going to be average performers, and there are going to be high performers, and depending on how you draw these lines, the quality of medical care definitely varies. So, just to show you an example, this is de-identified data from our center. We look at every individual physician, the number of colonoscopies, and the adenoma detection rate. So, on the x-axis is a de-identified physician ID, and on the y-axis is the adenoma detection rate, and these numbers indicate that year how many colonoscopies that person performed. Now, ours is a very varied and sort of sub-specialized practice, but it just gives you a sense that there is variability in the adenoma detection rate and in terms of the number of procedures and things like that that physicians perform. So, I think it's important to look at this data. I think this data, both from our center but also multiple other places, do identify that there is a variability in terms of how we perform and, you know, what our adenoma detection rate or whatever other metric you choose. So, then the question is, we said 87 percent do some sort of quality improvement or quality metrics. So, do you, in your endoscopy unit, monitor the adenoma detection rate? Wow, that's 95 percent. I think Jason will be very happy. So, that's excellent. You know, people are measuring their adenoma detection rate. I think the same logic applies for more advanced procedures. I know Dr. Yang will kind of touch upon quality metrics for advanced endoscopy, but this is just data for ERCP. You can see that the two lines represent the 95 percent, the two red lines represent the 95 percent confidence intervals, and this is the y-axis represents the procedural success, and the x-axis represents the volume of ERCP. Now, we won't go into a lot of detail, but just as you zoom into the graph, you can see that there is a wide variability among providers, even when they're clustered together, in terms of the overall success rate. So, I think it's fairly clear, based on this data and multiple other studies, that there is variability in how we deliver our endoscopic procedures. Then the question is, do these quality differences meaningfully impact outcomes? Now, using the best data is obviously for colonoscopy, and if you look at the seminal landmark study from Doug Corley in 2014, and I'm sure people will touch upon this, I think if you look at the last bullet point here, every one percent increase in adenoma detection rate is associated with a three percent decrease risk of interval colorectal cancer and a five percent decrease death from colorectal cancer. So, this is really, really powerful data, and it really underlines the fact that what we do and how well we do it impacts the outcomes that we are able to give to our patients. So, then the question is, we've established that quality varies between providers. We've established, you know, just on a brief level that quality differences really impact outcomes, but can we measure this? Is it feasible to measure quality, especially in gastrointestinal endoscopy? And I think the answer is obviously very yes. And does measuring quality improve the overall quality of care that is delivered? So, this is data from Dr. Keswani, and what they did is essentially they gave these report cards to providers and measured and evaluated their adenoma detection rate. And as you can see that as you provide those quality metrics, as you provide the feedback to physicians, the quality of their quality metrics, adenoma detection rate here definitely improves over time. And when the adenoma detection rate improves, I think this is a very powerful study. The rate of colorectal cancer, interval colorectal cancer really improves. So, this is the flip of the Doug Corley study where it shows that improvement in the adenoma detection rate leads to a reduction in interval colorectal cancer. So, we've really, I think, I hope I've sort of given you a broad overview to really address the why question. And now I think if we shift to how and give you a brief overview of how we approach quality approaches to defining and improving quality in your unit, I think it's important to recognize that there are structured approaches to quality. And this is a classic sort of cartoon. I think this will resonate with both parents and endoscopists. The son comes and says, I brought my report card home, dad. Well, let's see it. And remember how you once told me it didn't matter what grades I got. I'm sure parents resonate with this, like what we tell our kids. And just so long, I try my hardest, right? Well, you certainly could be trying harder than this. And so, you were lying, dad. So, I think it's important to level set expectations. I think this is where this goes. When we approach quality, one of the most important or one of the well-established models is called the Donabedian model, which looks at the structure, process, and outcomes of the unit, of the healthcare structure, of the healthcare unit, and how we approach it. So, if we apply that to endoscopy, the structure of the unit could be what kind of endoscopes you're using, are using high-definition endoscopy. If you're doing endoscopic ultrasound, do you have on-site cytopathology? Do you have trained nurses, magnet status, et cetera? And then the process is how are you measuring the process outcomes or the process metrics in terms of withdrawal time and things like that? And then really the outcomes. What are your outcomes in terms of adenoma detection rate, interval colorectal cancer, et cetera, et cetera? So, this sort of gives you a framework for how to look at and how to establish quality and measure quality in your unit. Now, once you drill down into a quality improvement project, these are two of the most common approaches to this. One is called the Six Sigma, the DMAIC model, where you define a quality problem specifically, you measure it, you analyze why the problem is occurring, you implement or improve a process or methods that help you avoid the problem or minimize the problem. And then once you've achieved the effect of your intervention, then you really enable methods to ensure that the improvement is maintained. People are likely aware of the PDSA model also, which is the plan, do, study, and act, which is very sort of has the same structure. But the point I think with these models is that one needs to be objective. One needs to define a specific problem that we are trying to solve and how we are going to solve it and then how we are going to maintain, how we are going to measure the outcomes of our intervention and how we are going to maintain the effect of those interventions. So, I think if there's one thing that folks take away from today in general, but hopefully my talk is that quality in gastrointestinal endoscopy, but in medicine in general, is a team sport. We are all, medicine is a team effort and that quality has to percolate throughout the entire team. So, how do we ensure a successful program? I think it starts with the right team. I think having the right team really takes you far along the quality continuum. We need to identify achievable quality improvement goals. We need to tie quality improvement to tangible incentives. We are all human and I think that the incentives are not necessarily financial incentives, but it's an incentive. Incentives could be validation, could be recognition, could be a whole host of other incentives, but I think it's important to bring that human element into this and people like to be appreciated. People like to be recognized for the effort that they're making and that really will permeate a culture of quality and safety. When we look at quality and safety, I think it's important to look at it as a culture change, a culture improvement rather than a specific quality improvement project. So, how do we go about the team? I think that physician or nursing leadership who are, it's ideally agnostic to clinical domain, but it could be that people who are engaged in that. Then we look at, there are several other aspects that you need in terms of resources, analysts or QI or performance improvement leaders, information technology, EHR resources. I think going back to the team component, I think it's very important to have the entire team represented at the table. That would include obviously nurses, but also techs and other people who are members of your endoscopy team. And then create a defined monthly or bi-monthly quality committee meeting. And if you have a sanctioned quality committee meeting, in most states, it provides legal protection around data collection that's not discoverable. So, people can speak freely, can look into what happened and how to improve the process. But when you really get down to the brass tacks of it, it is hard, you know, how do you go about it? But, you know, there's several strategies that are becoming available. In the olden days, it used to be a manual chart review, but now we have excellent registries, GI Quick being one of those. And I know Dr. Dominitz will briefly touch upon that. We could use a data warehouse, natural language processing, and artificial intelligence, I think is going to make this much, much easier. But it really depends on your practice setting, what resources are available. But even if resources are limited, I think it's defining that culture of quality and even starting with as simple as manual chart review can really help. Now, when we look at the CMS core quality measures, the Center for Medicaid and Medicare Services, colonoscopy metrics are right up there. And the same with the ASG quality indicators, especially for colonoscopy, is the abnormal detection rate for, and it sets the benchmarks for male and female. So, this sort of provides some sort of benchmarks of where to establish and look at how your unit is performing. So, what kind of quality interventions, how can we go about it? I think establishing the right team is the first and the most important, getting buy-in and engagement is, I think, the most critical thing. Everything else sort of follows well from that. Using a structured approach, rather than just saying very broadly, we are going to really focus on quality, but instead, you know, really drilling down and saying we're going to focus on this one metric, or we're going to start with this one metric and then go to other things. And make it relevant and practical to your practice. It has to be, you know, it has to be applicable to the local practice. Use a defined, structured approach to measure, analyze results, and design specific interventions. It's not just measuring and analyzing, but when people see that a specific intervention has come out of all that measurement, of that analysis, then it really creates that virtuous cycle to really sustain quality and then redesign interventions and engage people, which will really help. So, what are some examples? If you use electronic medical records, such as Epic, you can use clinical decision support tools with pre-populated order sets for, let's say, for colonoscopy, which, you know, give you a list of preps or preferred preps, things like that. Algorithms, now with artificial intelligence, really coming into effect. Checklists, I'm a big, big fan of checklists. I think that checklists really help, and they're easy, they're simple. Structured workflows can be very helpful. The other thing is team-based exercises. If your team, going back to quality as a team sport, do things together with your team. Simulate and really understand. Do the exercises rather than just giving a handout. Get input from everyone, multidisciplinary input and management for complex cases, things like that. And then really participate in quality programs that are offered by national societies, either through the institution, nursing societies, or nursing leaderships. And this is a good segue into the ASG EURP program, which we'll also talk about. This is just a really good example of a quality recognition program that is offered by a national society and really shows that your commitment to high quality care. And as people and patients especially see this and recognize it, I think our patients expect a lot from us, and rightfully so. So finally, I want to end by focusing on going back to our construct of quality being a multi-domain thing, and really end by also focusing on equitable care and patient-centered care. When we look at quality, I think it's important to ask the questions of, are we delivering care in a manner that is equitable and patient-centered? Are we able to care for patients from diverse backgrounds? And this could be, you know, it could be socioeconomic status, it could be race, it could be access to care, it could be multiple aspects of it. But as we ask those questions, I think we'll recognize that how we are able to really tailor our care to the patient in front of us. So let me end by saying that hopefully I've shown you that there is variability in endoscopic quality, and this variability really impacts outcomes. Quality care has several domains that includes equitable and patient-centered care, and we'll, you know, hear more about this in the course of the day. The very well-established quality measures in endoscopy and quality improvement does lead to improved outcomes. And when you take an approach to quality improvement projects, a structured approach and a very objective approach leads to better outcomes. And then eventually quality, I think, is a team sport, and we should develop a culture of safety and high-quality care in our unit. So thank you for your attention. And let's really start drilling down into that, you know, I've provided a really broad overview, but really let's drill down into the components of care that that we talked about.

quality

healthcare

endoscopy units

measuring quality

structured approach

patient-centered care