All right. Thanks, Neil. Appreciate it. I'm also really excited for the day. I hear we have individuals at home. We have group Olympic-style watch parties. This is all really wonderful. I also will encourage you all to participate when we get to our group discussions. We have some cases that I'm excited to get to. To kick off our first talk here, I feel so very passionately about the domains of quality, so I'm really excited to talk with you guys about it today. Today, we're going to start off with talking about leveraging the Institute of Medicine domains of quality in decision-making. I'm sure you guys have heard some of the domains, and we really want to talk about all of them today. I have no disclosures. We're going to define these domains of quality. We're going to spend a little bit of time talking about some of the examples within each, and then we're going to discuss examples of how to use these domains to evaluate different scenarios and then think through how to negotiate between them when making decisions. Then we'll provide a couple of models for measuring quality and improving quality, which of course is the focus of many of the talks later in the day. The definition of quality, I want to throw this out to the audience as a question. The definition of quality as a concept in medicine in America started in the year... Oh, interesting. All right, great. I'm very curious why 1966, if people knew the reason for that. The 1776, maybe when the country was defined, but not necessarily quality as a concept. For most of you, it's maybe you thought of it a little bit, but not really defined back then. 1855 is a special year or time. That's when Florence Nightingale was known to really start thinking about quality when it came to the Crimean War. That is a big year in quality generally, trying to improve hygiene practices and things like that. 1960 year, there was a gentleman, Don Obedian, who's known as one of the fathers of quality in medicine. He had done a lot of his work in that year. I'll actually say the definition of quality as a concept in medicine in America started with a book written in 2001. This is where the journey was. In 1999, there's a first book written by the Institute of Medicine, which is really this group that defined where medicine put their priorities. They wrote this book called To Err is Human, Building a Safer Health System. This was almost a new concept of patient safety. We had people like Don Obedian and Florence Nightingale thinking about it in certain areas, but really to think about it more holistically. This is where they really started to talk about it. That same year, perhaps correlated, the Agency of Healthcare Policy and Research renamed the Agency for Healthcare Research and Quality. Really, you're beginning to see this become part of the infrastructure for thinking about medicine. 2001 is the second book, the one on the right, Crossing the Quality Chasm, a new health system for the 21st century. This defined the domains of quality that we're going to talk about. That's the framework that's been used since then to think about the negotiations that we're going to talk about later today. This pie, I want you to think to yourself and also welcome to put into the chat, what are the domains of quality? I'm going to reveal them in a moment. We've talked about a few. There's some that are more perhaps commonly spoken of than others. As you're thinking about it, I'll reveal. Effective, efficient, timely, equitable, patient-centered, safe. Then we throw a seventh one in there, sustainable, as a more recent one, but not the original six. That's the seventh that some have added. What I really want to point out here is I drew this as a pie, not a list, because they are interdependent. You'll see in some of the examples that we talk about in a little bit, something that you aim to make something more safe may make your care less efficient. Something that you aim to make yourself more effective, meaning better procedures, may make you less timely. It's really important to think about how a change in favor of one may impact others positively or negatively. It must account for how the change in one impacts others. Now, factors may not always fit into one wedge singularly. It might be something that you make as a change that makes something both more effective and more efficient, which is great, or a consideration that impacts more than one wedge. Very rarely are you able to grow the pie and make them all bigger wedges. We recognize that oftentimes there's negotiation between them. With that, I'll dive into each one individually, and we'll define them. The first one, I think the most commonly thought one, especially when we talk about quality and safety, it's even thought of as its own entity outside of the domains, avoiding harm to patients from the care intended to help them. That sounds pretty basic, back to our original do no harm. Some examples when it comes to monitoring, as well as thinking about quality, complication rates. We expect those to happen sometimes, but we want to minimize those as much as possible and think about why they may be happening more often than we would expect it to. Measure the proportion of post-colonoscopy perforations or clinical significant bleeding. That's a pretty common one that units do. Measure a portion of post-ERCP pancreatitis. Then there are unexpected or near never outcomes like IV-related infections. We have many protocols in place to try to avoid this, even if it's not something we think about day to day, and probably because we've done a good job trying to avoid them. Post-procedure outcomes from poor decisions after sedation. We'll talk about transportation later, but a lot of the drive for it is because there's a desire to provide safe care and prevent harm. Now, a lot of the policies that exist are with the goal to provide safe care and prevent harm. As I was mentioning, we have to think about how it impacts the other domains as well and make these decisions. Effective, providing services based on scientific knowledge to all who can benefit and refraining from providing services to those not likely to benefit. Really avoiding both underuse and misuse, respectively. Examples of effective, and of course, there's a talk focused on this later. High quality colonoscopies for screening when due for guidelines. That is one of the basic things that we think for effective colonoscopies. Adequate prep, reached cecum, appropriate evaluation for masses and polyps. All of those are components of providing effective care. I'll add in there the flip side, which is avoiding scheduling procedures when they're not indicated. Not doing colonoscopies before guideline-based intervals. Thinking about EGDs without indication before doing them and considering other plans. Those would also be part of providing effective care. Efficient, so this includes avoiding waste, including waste of equipment, supplies, ideas, and energy. Now, it usually is interpreted as regarding to time, but of course, rescheduling patients would be inefficient or re-asking questions during the pre-op process would be an inefficiency. We do think about other things when we're thinking about efficiency, although oftentimes, we talk about time, how much time it takes to do something. Examples, organizing the end of unit to pass patient from pre-procedure, post-procedure, and to post-procedure activities smoothly. Having all team members ready to start for the first case on time. That's one of the metrics that some units use. Minimizing no-shows and doing as many cases as reasonably possible and in allotted time. Patient-centered, providing care that is respectful of and responses to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Many examples in this, of course, a patient with a history of trauma may have a preference, sorry, for the sex of the endoscopist, and it would be patient-centered to consider that in providing care. Shared decision-making for colon cancer screening after age 75, that's actually baked into our guidelines. Offering gluten-free snacks or having them available for those who need it or prefer it, and providing language-aligned materials for those who do not speak English. These are examples of things that I think many units already do to try to be patient-centered. Timely, slightly different than the efficiency, but related, reducing waits and sometimes harmful delays for both those who receive and those who give care. Examples, minimizing delays for diagnostic indications of endoscopy. Ideally, we wouldn't have a backlog, but we know that most units now have a backlog of cases. Avoid split days, meaning morning endoscopist and afternoon endoscopist, if the morning endoscopist runs late into the afternoon endoscopist's time, because that's frustrating for the afternoon team. We'll talk about equitable, providing care that does not vary on quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status. Examples, this is a difficult one. Let's say if we were able to match the location of endoscopic centers to where the population was, to make sure that everyone has equal or equitable access to having procedures done when needed. Have language-concordant materials for non-English speakers. As mentioned, things can fit into multiple wedges of the pie, and I think this fits both. A bonus here as a seventh is sustainable, considering the environmental impact of care and system-level decisions when weighing benefits and harms. Some examples here would be choosing the decisions to choose between reusable versus disposable endoscopes and supplies, to sort trash to minimize red bin waste, purchase supplies with lower environmental impact. A lot of these, as you can see, overlap with efficiency or with sometimes even effectiveness, but it can be considered as well. All right, so now that we've defined our domains of quality, and hopefully there are a few that you hadn't thought of but now are part of your framework, we're going to discuss some scenarios in which you can use the domains to evaluate what to do and how to make some decisions. Let's talk about BMI. As we all know, the country, state by state, is getting more purple, meaning higher percentages of obese adults, and the right side highlights Massachusetts, where I'm from, but you can see over time in the years that are shown here from 1990 to 2016, the proportion of patients with obesity in adults just goes up in almost every line, and even Massachusetts, which is one of the lower proportions, you can see going up over time. This is clearly an evolving situation and a growing population that we want to make sure that we're able to accommodate. Now, BMI greater than 40 is unaccepted at many sites currently, and most recently it's now defined as ASA3, and this may restrict ability for endoscopy in many ambulatory endoscopy centers. So what are the considerations and how do we think through the different domains in deciding what our BMI cutoff should be or if there should be one at all? So here's an example of thinking through all our domains and making a decision and thinking about is it positive, does it make the wedge grow, or is it negative, does it make the wedge shrink? Safety is a really interesting one for this particular scenario. The question is does it reduce complications to have a limit on BMI, or does it actually increase complications? And I say that because there's really not a lot of studies. There are a few looking at BMI greater than 35 that show that there are no increased complications from having a greater BMI, and we also know that if your decision is MAC versus RN sedation because you're thinking about people with higher BMIs needing more support, for example, MAC is actually associated with increased anesthesia complications compared to conscious sedation, which is sometimes a cutoff between the ASAs 2s and 3s in some centers. So there's at least in our unit no suggestion of increased complications for increased BMI. That's semi-anecdotal. And in many centers, patients with bariatric units or bariatric surgeons routinely send their patients for upper endoscopies, and we have to think about where can they go and is it overall more safe to allow for the procedures so they can get their surgeries done versus put up barriers that might make it more difficult. Timeliness. We know that if there are fewer options, it means that there's a longer wait to get the procedure done. So if you're waiting for that bariatric surgery, it might get even more delayed because you're waiting for the endoscopy. Efficiency. So there could be an argument made that sites with the restrictions may run more efficiently. They don't need as many resources for the higher weight patients like a Hoyer lift or having the structures that accommodate for higher weight. So it's possible that for some it may improve efficiency. Effectiveness for the patient as an individual patient. A longer wait could just mean that it's not scheduled, so therefore it's ineffective care. When it comes to patient-centeredness, one can make the argument that if they go to a center that is defined for higher BMI patients, that maybe the appropriate resources are available when they're needed. But I think the negative impact on patient-centeredness would be that the BMI outweighs other criteria. So maybe they're otherwise very healthy, but the BMI by itself is limiting their options and therefore limiting their care. Equity comes into question if the impact from evaluating BMI is seen to impact care correlated to socioeconomic status and many of the other factors that we know are related to high BMI. So this is an example of kind of thinking through the positives and negatives of what it may mean to consider BMI in your sites. I'll add a different one. So simethicone to flush water routinely. I think in terms of safety that this has become a story maybe 10 years ago or so, where it's thought to be a negative safety aspect of adding simethicone because it increases the risk for contamination inside viewing scopes. And then there are statements put out to say to suggesting against using it routinely. But the other aspect is that we know from the safety perspective that it may reduce time for anesthesia because you're able to get rid of the bubbles quickly and do your quicker procedures. Timeliness, quicker case time equals you can do more cases, so you might get more patients in. Efficiency, you use less water overall, so that might mean that you're using less time. The negative would be, you know, if you're adding another pharmaceutical agent that may impact reprocessing techniques, you know, it's something to consider. Effectiveness, we do know there is data showing that it improves polyp detection rate. Sustainability depends on how impacts reprocessing. And equity, of course, you know, I think one thing is to consider if you're adding, having the patient pay for the simethicone and if that's a barrier or a difficulty, like a regressive task. So many aspects of considering how, if to add simethicone outside of just the risk for contamination that's often considered. All right, so another audience poll question. How many scheduled, how much scheduled time is allotted for colonoscopies in your unit? For the majority of cases, obviously there are always outliers here and there. Okay, useful to know. Okay, so 21 to 30 minutes usually, some with 31 to 45. Few places that do more than 45. Great. Now, I ask that because, you know, we all think about how much time is appropriate, you know, how do we keep cases moving, how do we get to our backlog, but do safe procedures? And so this is a, you know, more of a fun exercise thought, but like, let's say if you were to shorten cases by 10 minutes. So safety is reduced time for anesthesia, but I think we would all recognize that rushed care may overlook safety practices and everyone feels rushed and, you know, doesn't make for a good work environment and that can lead to unsafe things to happen. Timeliness is, you know, quicker case times can do more cases. And this might be what, you know, some of the bean counters may be looking at, but we worry about the efficiency, right? There's less buffer. The day may run late more often. You won't be able to predict when, you know, someone has a poor prep that you need to get through, things like that. Effectiveness, we know that decreased time for evaluation may impact polyp detection rate. Patient centeredness, less time to answer questions and be able to learn what people's preferences are, things like that. And equity, this may impact care for our sicker patients that we know that when there are centers that have short periods, they may also have higher restrictions for who's able to come to those sites. And so that can be a barrier. So again, more of a fun exercise than a real consideration, but just thinking about, you know, our barrier conditions when we're making decisions. All right. So quickly, we'll talk about some models for measuring quality. And of course, you're going to have a lot more of this throughout the day. So value depends on quality, value by an equation is quality over cost. As we move towards value-based care, both terms become important. So then we want to ask ourselves, how do we measure quality? I'll do this very quickly to think to yourself, perhaps. Does your endoscopy unit measure performance metrics for screening colonoscopies? Hopefully the answer is yes, but there may be some that are no's and we want to be able to help provide some resources. Wow, that's pretty darn great. Okay. So for the 10% who are no's and don't know's, well, don't know's, you know, they might still be there, but great. Some room for improvement is also always good to know. So to quickly go back to our father of quality, Donna Bedian, the model is to think about, you know, the different areas where you can make changes as well as how to monitor them. So for structure, it's like thinking about, do you have high definition endoscopes that are available? Do you have onsite cytology? Do you have GI trained nurses? And do you have electronic medical records? This is something that we take for advantage, but it's a huge part of the structure that's provided. Process, you know, before we used to think about evaluating minimal withdrawal time, that's no longer one of the things that people look for, but we know that that's a process measure, right? We're thinking about like, well, this we think is related to our outcome that we care about. Retroflexion, being able to provide photo documentation, not that seeing the CECA means that you did a broader colonoscopy, but it's a sign that you completed it, right? So that's a process measure. Then outcome measures are really looking at your, you know, the things that you care about in the very end, right? So did you detect adenomas? Were there interval colon cancers? How many perforations were there? Did the patient feel better from their dysphagia? So that's from some, you know, ways of measuring the quality. Of course, cost is something to consider. The cost of colonoscopy, this is showing the cost throughout the country from 2013 in the New York Times article, and you can see it really varies. That obviously impacts what the value is as well, but nothing, something that we don't have as much control over. I did have one last poll question here. So our endoscopy unit has a designated quality improvement team or program. Wow, that's also very high. And for the 13%, you know, again, this is something that's an opportunity for improvement, as we say in the quality improvement world. So when you're thinking about how to assemble a quality improvement team, we know having a dedicated team helps people, you know, reach their goals and set up their metrics and put up some more longer-standing, you know, systems in place. So having dedicated physician leadership is helpful. There are usually hospital resources, like an analyst or a performance leader that can help set up your systems. Having support from IT is key. You always want to have representatives from other role groups, so nurses, surgical techs, fellows, because they're going to tell you more about the process than, you know, anyone will be able to know by themselves, having the team. And it's also helpful to have some sort of monthly or bimonthly meeting to discuss some of these issues that come up, right? So, you know, usually a sanctioned quality committee provides a legal protection around data collection, and this is a safe place to discuss cases or trends. As many of you know, you know, quality takes time and attention and resources, so it's helpful to have those dedicated leaders and systems in place to support it. So being at URP can be helpful for, you know, providing some of that support. I'll mention here that one of the models that we talk about when doing quality improvement projects, oops, I think I went forward by one, see if I can go back forward, is called a MAIC, where you define your problem, you measure it, you set up ways to analyze the causes of your problem, you set up things, strategies to try to improve it, and then you work things out so you can maintain that solution over time. So that's just one model, but there are many ways to think about quality improvement projects, where you're not just jumping right into, you know, implementing something, but really thinking about how you're going to measure it and analyze it ahead of time, things like that. All right, so in summary, there are six domains of quality. These are to be, you know, I had joked once that if I were to get a quality or get a tattoo, it would be of these, because it's so important to think about all of this when you're thinking about care. Think about the impact on all domains when considering evaluating quality and the impact of any changes with the goal of improved quality. Again, like we often think about what's to improve safety and effectiveness, we also want to think about how it impacts the others and vice versa. Define quality metrics for your unit. It sounds like a lot of you have teams in place and metrics, so great, and just, you know, of course, we acknowledge meeting your goals requires resources and a team effort. Use the tools and frameworks and quality improvement to achieve your goals. There are many out there, and, you know, some are supported by the URP program, as well as other things. All right, that's it for this talk. Thank you.

Institute of Medicine

healthcare quality

decision-making

quality improvement

interdisciplinary teams

DMAIC model