Quality assurance and credentialing in endoscopy: the standard of care for the future?

 

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The London OMED position statement on credentialing and quality assurance in digestive endoscopy is published in this issue of Endoscopy [1]. Both of the issues addressed in the statement are important. The increasing number of digestive endoscopy procedures performed and the widening range of diagnostic and therapeutic interventions have implications both for those who provide these services and those responsible for endoscopy training.

Digestive endoscopy began as a diagnostic tool 40 years ago but was not incorporated into any of the major medical subspecialties such as internal medicine, radiology, or general surgery. Most endoscopy units were set up in an ad hoc manner by enthusiastic gastroenterologists or surgeons assisted by an interested nurse or technician. As endoscopy expanded to include therapy it became an essential part of gastroenterology but no single medical specialty has been able to claim its ownership.

Today gastroenterologists perform the majority of endoscopic procedures but other specialties remain involved. With the introduction of natural orifice transluminal endoscopic surgery (NOTES) and other complex surgical interventions, surgeons will continue to play an important endoscopy role as will pediatricians, radiologists and general practitioners (and in many countries paramedical staff too). Digestive endoscopy needs a generally accepted, independent, and informed guideline to address both the quality of the endoscopic services provided for patients and the standard of training and assessment that prospective endoscopists should receive before being allowed to practice on members of the public.

The London OMED position statement has been prepared for use by the organizations that provide digestive endoscopy services and for the authorities responsible for endoscopy training and credentialing. It proposes international standards that if followed will ensure that patients receive a safe, high quality endoscopy service and that the clinician performing their examination has undergone appropriate training and has been judged competent to practice.

Concerns may be expressed as to the provenance of the position statement and the applicability of its proposals to the whole of the world community (taking account of differences in the epidemiology of disease and variations in clinical practice throughout the world). Others may consider such guidelines a threat to individual practitioners’ clinical freedom or believe that they usurp the responsibilities of national, regional, or local medical authorities. It must be emphasized therefore that the proposed guidelines are advisory and the working group makes it clear that national guidelines where present must be followed. The initiative came from the World Organisation of Digestive Endoscopy, OMED (Organisation Mondiale d’Endoscopie Digestive). The working party chairmen are distinguished senior endoscopists who have a particular interest in this area and the working party itself comprised recognized leaders from representative areas of the globe. The report sets out authoritative international recommendations aimed at promoting high quality digestive endoscopy services that are applicable across all specialties and communities.

The main recommendations concerning credentialing are that each trainee should undertake the same endoscopy training program whatever their specialty background. Whilst the process should take account of the number and variety of procedures the trainee has performed, he or she should also be observed in practice and be assessed by an independent expert before being credentialed. Separate credentialing is required for upper digestive endoscopy, colonoscopy, ERCP, EUS, enteroscopy, and capsule endoscopy. The trainee should be able to perform the therapeutic interventions commonly undertaken with each procedure. The health care institution has the responsibility of ensuring that the endoscopists employed are appropriately trained, credentialed and are competent to practice. Practice privileges should be time-limited with renewal dependent upon continued competency.

Health care institutions and individual endoscopy units must maintain a quality improvement programme based on quality indicators. These include general ones such as the indication for the endoscopic examination, informed consent, patient risk stratification, and sedation practice. Specific quality indicators are suggested for each of the endoscopic procedures, such as cecal intubation rate in colonoscopy and biopsy practice in EGD. This implies that quality indicators should be recorded so that the performance of the unit and their staff can be audited to enable improvements to be instituted and underperformance corrected. The working group conclude by recommending ”benchmarking“ which they define as ”the ability to compare performance across practitioners and units.”

The recommendations made by the working party are to be welcomed because the endoscopic community has to ensure that it is providing a service for patients that is safe and effective and that objective measures are in place to confirm this. The proposed guidelines are generally in line with those that have been suggested by other professional organizations. They do have implications for health providers and for individual endoscopists, both those in training and others who have been in practice for a number of years. The major concerns will be the extra time and expense involved in applying them, the ability of small independent units to comply, and that endoscopists already in practice may baulk at the prospect of having to maintain a personal quality assurance profile if benchmarking goes ahead. They may also have reservations about recredentialing.

Most of the quality indicators recommended are those that are normally included in the endoscopy report so the additional work required to collect them is limited. More time and energy will be required to analyze the data for auditing purposes. Computer-based endoscopy reports are particularly desirable in this context. They can be designed to ensure that all of the compulsory fields that relate to quality are completed and that the software enables each endoscopist to receive his or her individual quality results for comparison with the unit average and with national standards.

Computers are less expensive than they were and continue to improve in speed and memory; software companies, however, have not as yet taken on the challenge of the endoscopy unit in an effective way. Most of the packages available that provide a computerized report have not tackled the issues relating to audit and quality. None provide a comprehensive approach to endoscopy management that includes appointment making, reports, equipment inventories and tracking, pre- and post-procedure management, and patient onward referral. Most endoscopists still write their reports longhand or dictate them. Those who do employ a computer-generated report often type their findings in the free-text area at the bottom of the report rather than click the pre-designed fields. Software is needed that is more user-friendly and comprehensive; this would help endoscopy management in large units. A ready-made computerized quality assurance system would enable small departments to monitor the quality of their service and maintain it at a level comparable to that of larger ones.

From the point of view of the individual endoscopist, benchmarking by maintaining a personal quality assurance profile carries a number of advantages. It enables the endoscopist to determine whether he or she is achieving an appropriate standard of practice. If it becomes apparent to them that their performance has become suboptimal, the problem can be remedied in a timely fashion by personal education, attending a postgraduate course, or by seeking hands-on instruction.

The position statement published in this issue of Endoscopy is a challenge to the endoscopic community worldwide. It will take time for general application, but it is within the capacity of all endoscopists and endoscopy units to take account of the recommendations and to consider whether their practice can be improved.

Competing interests: None

References

• 1 Faigel D O, Cotton P B. The London OMED position statement for credentialing and quality assurance in digestive endoscopy.  Endoscopy. 2009;  41 1069-1074
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