Endoscopy 2000; 32(6): 483-488
DOI: 10.1055/s-2000-649
Review
Georg Thieme Verlag Stuttgart ·New York

Quality Assurance in Gastrointestinal Endoscopy

S. O'Mahony, G. Naylor, A. Axon
  • Centre for Digestive Diseases, Leeds General Infirmary, Leeds, UK
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
31. Dezember 2000 (online)

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].

References

  • 1 Department of Health (UK). The new NHS: a first class service.  London; Department of Health. Health Circular HSC, 1998: 113
  • 2 Berger A. Why doesn't audit work?.  BMJ. 1998;  316 875-876
  • 3 Shekelle P G, Roland M. Measuring quality in the NHS: lessions from across the Atlantic.  Lancet. 1998;  352 163-164
  • 4 Wexler R M. Quality assurance: an overview and outline for gastrointestinal endoscopy.  Am J Gastroenterol. 1989;  84 1482-1487
  • 5 Donabedian A. Evaluating the quality of medical care.  Millbank Mem Fund Q. 1966;  44 166-206
  • 6 Williamson J W. In: Williamson JW, et al (ed). Teaching quality assurance and cost containment in health care.  San Francisco; Jossey Bass, 1982: 352
  • 7 Department of Health (UK). Number of hospital episodes statistics, 1997 - 1998.  London; Department of Health, 1999
  • 8 Freeman M L, Nelson D B, Sherman S, et al. Complications of endoscopy biliary sphincterotomy and their prevention.  N Engl J Med. 1996;  335 909-917
  • 9 Froehlich F, Burnand B, Pache I, et al. Over-use of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care.  Gastrointest Endosc. 1997;  45 13-19
  • 10 Froehlich F, Pache I, Burnand B, et al. Underutilisation of upper gastrointestinal endoscopy.  Gastroenterology. 1997;  112 690-697
  • 11 Van Ackern K, Runck M, Striebel J P. Quality control in the European Union.  Acta Anaesthesiol Scand. 1996;  109 (Suppl) 10-13
  • 12 Mayer T A. Industrial models of continuous quality improvement. Implications for emergency medicine.  Emerg Med Clin N Am. 1992;  10 523-547
  • 13 The ASGE. Quality assurance of gastrointestinal endoscopy.  Manchester, MA; American Society for Gastrointestinal Endoscopy, 1988
  • 14 Joint Commission on Accreditation of Healthcare Organizations. Accreditation manual for hospitals. JCAHO, 1988
  • 15 The ASGE. Appropriate use of gastrointestinal endoscopy.  Manchester, MA; American Society for Gastrointestinal Endoscopy, 1992
  • 16 Fleischer D E, Al-Kawas F H, Benjamin S B, et al. Prospective evaluation of complications in an endoscopy unit: use of the ASGE quality care guidelines.  Gastrointest Endosc. 1992;  38 411-414
  • 17 Fleischer D E, Van de Mierop F, Eisen G M, et al. A new system for defining endoscopic complications emphasizing the measure of importance.  Gastrointest Endosc. 1997;  45 128-133
  • 18 The ASGE. Quality and outcomes assessment in endoscopy.  Manchester, MA; American Society for Gastrointestinal Endoscopy, 1998
  • 19 Johanson J F, Overholt B F, Frakes J T. Frequency of patient-centered outcomes measurement activities among private practice gastroenterologists.  New Med. 1998;  2 275-279
  • 20 Sapienza P, Levine G, Pomerantz S, et al. Impact of a quality assurance program on gastrointestinal endoscopy.  Gastroenterology. 1992;  102 387-393
  • 21 Mai H, Sanowski R, Waring J. Improved patient care using ASGE guidelines on quality assurance: a prospective comparative study.  Gastrointest Endosc. 1991;  37 597-599
  • 22 Naylor C D. What is appropriate care?.  N Engl J Med. 1998;  338 1918-1920
  • 23 Axon A TR, Bell G D, Jones R H, et al. Guidelines on appropriate indications for upper gastrointestinal endoscopy.  BMJ. 1995;  310 853-856
  • 24 European  Helicobacter pylori Study Group. Current concepts in the management of Helicobacter pylori infection. The Maastricht consensus report.  Gut. 1997;  41 8-13
  • 25  . NIH consensus development panel on Helicobacter pylori in peptic ulcer disease.  JAMA. 1994;  272 65-69
  • 26 Abboud P C, Malet P F, Berline J A, et al. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis.  Gastrointest Endosc. 1996;  43 450-452
  • 27 European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE). .  Endoscopy. 1999;  31 571-696
  • 28 Maratka Z. Terminology, definitions and diagnostic criteria in digestive endoscopy.  Englewood NJ; Normed Verlag, 1994
  • 29 ESGE Committee for Minimal Standards for Terminology and Documentation in Digestive Endoscopy. Minimal standard terminology for databases in digestive endoscopy. Preliminary presentation for testing.  Bad Homburg; Normed Verlag, 1995
  • 30 British Society of Gastroenterology. Guidelines for informed consent for endoscopic procedures.  London; British Society of Gastroenterology, 1999: January
  • 31 American Society for Gastrointestinal Endoscopy (ASGE). Methods of granting hospital privileges to perform gastrointestinal endoscopy.  Manchester, MA; ASGE publication, 1992: 1012
  • 32 European Board of Gastroenterology. Specialist training in gastroenterology in the European Community: the case for the European Boards.  Gut. 1994;  35 135-138
  • 33 Union Européenne des Médecins Specialistes (UEMS) Specialist Section, Gastroenterology/European Board of Gastroenterology. Charter on training of medical specialists in the EU: requirements for specialty of gastroenterology.  Brussels; UEMS, 1995
  • 34 Joint Advisory Group on Gastrointestinal Endoscopy. Recommendations for training in gastrointestinal endoscopy.  Joint Advisory Group on Gastrointestinal Endoscopy,. 1999; 
  • 35 Booth C C. What has technology done to gastroenterology?.  Gut. 1985;  26 1088-1094
  • 36 Neale G. Reducing risks in gastrointestinal practice.  Gut. 1998;  42 139-142
  • 37 Weller P C, Hiatt H H, Newhouse J P, et al. A measure of malpractice. Medical injury, malpractice litigation and patient compensation.  Cambridge, MA; Harvard University Press, 1993
  • 38 O'Mahony S, Axon A TR. Workshop on quality assurance in endoscopy. Manchester, UK: January 13, 1999: Summary report.  Endoscopy. 1999;  31 504-506

Seamus O'Mahony

Centre for Digestive Diseases Leeds General Infirmary

Great George Street Leeds LS1 3EX UK

Fax: Fax:+ 44-113-392-6968

eMail: E-mail:seamuso@ulth.northy.nhs.uk