Quality Assurance in Gastrointestinal Endoscopy

Introduction

“Quality” - whatever that means - has become a major priority for healthcare providers, patients, and funding agencies. In the UK, for example, the highly publicised investigations by the General Medical Council into mortality following heart surgery in children at Bristol led to serious public concerns about variation in standards of clinical care, and particularly about poor clinician performance. The British government responded in 1998 with the publication of a document: The New NHS: a First Class Service [1]. This document introduced the concept of “Clinical governance”, which is defined as “a framework through which National Health Service organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”. Clinical governance will be supported by a National Institute for Clinical Excellence (NICE), which will establish clinically defensible quality measures, and by the drawing up and dissemination of guidelines.

In the UK it is generally agreed that clinical audit has failed [2]. There are a number of reasons for this failure: a) audit tended to be ad hoc and sporadic; b) the audit “circle” was frequently unclosed, and c) management either did not see it as a priority or had a different agenda from clinicians. Much lip service was paid to clinical audit, but the reality was that doctors did not have the time, the resources, or the will to make it work.

Why should we apply quality assurance (QA) to endoscopy? There are a number of plausible reasons: a) to improve the overall quality of care; b) to limit inappropriate procedures; c) to limit morbidity and mortality; d) to improve training in endoscopy; e) to limit patient complaints and litigation, and e) to contain costs. The fundamental questions about QA for endoscopy which need to be adressed are: a) How can it be set up so that it works in everyday practice? b) What information do we need to collect, and how should we analyse it? c) How much will it cost, and who will pay for it? d) How do we set quality standards? e) How do we deal with underperforming doctors?

The challenge of European doctors is similar to that faced by their counterparts in the USA 30 years ago. The Americans reacted too slowly, and the result was the rise of third parties who measured healthcare quality and the consequent relinquishing of clinical autonomy [3].

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