Table 6.
Listed action plans.
| Proposed action plan (site) | Complete |
|---|---|
| Patient information pamphlet (1) | Yes |
| Implement comfort monitoring score (1) | No |
| Increase frequency of committee review of quality indicators to twice yearly (1) | Yes |
| Increase frequency of endoscopist feedback to twice yearly (1) | Yes |
| Implement annual appropriateness audits and communicate it to endoscopists (1) | Yes |
| Rereview direct to procedure guidelines yearly (1, 3) | No (site 1) Yes (site3) |
| Implement policy for ensuring that pathology results are communicated to patient by endoscopist (1) | No |
| Translate facility and procedure information to an additional prevalent community language (1, 2) | No (site 1) Yes (site 2) |
| Include equality of access question on existing patient survey (1) | No |
| Increase frequency of communication of wait times to endoscopy team (1) | No |
| Add contact number to patient discharge sheet (1) | No |
| Make information concerning biopsies and follow-up mandatory field on report | No |
| Designate an “adverse events review committee” (1) | Yes |
| Create and distribute yearly patient survey (2, 3) | Yes |
| Implement fax feature of electronic reporting to have reports sent directly to referring physician (3) | Yes |
| Admin assistants to track cancellation rates (2) | Yes |
| Front desk to notify referring physician when an appointment is missed (2) | Yes |
| Secure a locked space for patients to keep belongings (2) | No |
| Internal memo to remind endoscopists to send pathology reports to referring physicians (3) | No |