Table 2.
Survey results using the Delphi method to examine potential endoscopy unit quality indicators for the Patient Experience domain
| Patients' communication needs and performance | 1st round voting (n = 27), median (%), 1 = strongly disagree, 5 = strongly agree |
2nd round voting (n = 15), median (%) |
|||
|---|---|---|---|---|---|
| Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) | |
| Communication needs are recorded as part of the nursing assessment. | 5 | 5 (64.7) | 4.5 (50.0) | 4 (22.9) | 5 (80.0) |
| Language translation services are available when needed.∗ | 5 | 5 (71.4) | 5 (74.3) | 5 (58.8) | 5 (80.0) |
| The identity of the interpreter is documented. | 4 | 4 (31.4) | 5 (60.0) | 4 (28.6) | 5 (75.0) |
| Patient information is available on all endoscopic procedures performed in the endoscopy unit that conforms to literacy, language, and cultural appropriateness of the patient population cared for by the endoscopy unit. | 5 | 5 (56.3) | 5 (65.6) | 4 (31.3) | 5 (75.0) |
| The method of provision of information to the patient is documented. | 5 | 5 (51.5) | 5 (57.6) | 5 (56.3) | 5 (75.0) |
| Endoscopy unit has access to a quiet area that provides privacy for discussions with patients and care partner(s). | 5 | 5 (55.9) | 5 (58.8) | 4 (23.5) | 5 (55.0) |
| Unit policy discourages the use of family and friends as interpreters. | 4 | 4 (17.1) | 4 (28.6) | 4 (25.7) | 4 (15.8) |
| Scheduling and appointments | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Patients are informed of their appointment (ie, in person, by mail, phone, or email). | 5 | 5 (79.4) | 5 (79.4) | 5 (75.8) | 5 (85.0) |
| A preprocedure review is undertaken to screen patients for appropriateness and to communicate with patients about key elements of their procedure.∗ | 5 | 5 (88.2) | 5 (79.4) | 5 (73.5) | 5 (80.0) |
| Methods are in place for identifying appropriate surveillance appointment needs, and timely notification and scheduling of appointments is provided. | 5 | 5 (66.7) | 5 (57.6) | 5 (46.9) | 5 (60.0) |
| Patients and referring physicians are informed of their missed appointments, with commentary regarding the potential health consequences of missed appointments.∗ | 5 | 5 (54.6) | 5 (54.6) | 4 (18.2) | 4 (35.0) |
| Data on facility costs and quality are available and transparent to prospective patients, families, and referring physicians. | 4 | 4 (18.2) | 5 (51.5) | 3 (27.3) | 4 (10.0) |
| Informed consent | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Signatures are obtained on a consent form for all patients who are able to sign the form, and procedures are in place for those who cannot provide consent independently. | 5 | 5 (82.4) | 5 (91.2) | 5 (87.5) | 5 (95.0) |
| All patients are given an opportunity to ask questions about the procedure before the endoscopy by a professional trained in the consent process. | 5 | 5 (79.4) | 5 (76.5) | 5 (76.5) | 5 (90.0) |
| Informed consent is obtained and documented by the provider performing the procedure.∗ | 5 | 5 (79.4) | 5 (82.4) | 5 (72.7) | 5 (80.0) |
| Unit has a policy to review informed consent forms and process on a regular basis. | 5 | 5 (51.4) | 5 (51.5) | 4 (15.2) | 5 (70.0) |
| Published written patient information sheet that includes guidance on frequently asked questions for all procedures (both endoscopic and nonendoscopic) performed in the department is available to patients. | 5 | 5 (52.9) | 5 (57.7) | 5 (50.0) | 5 (65.0) |
| Endoscopy unit has a written policy for withdrawal of consent during an endoscopic procedure. | 4 | 4 (18.8) | 4 (25.0) | 3 (33.3) | 3 (70.0) |
| Procedural indications | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| The unit adopts standard indications for endoscopic procedures based upon current national guidelines.∗ | 5 | 5 (79.4) | 5 (75.8) | 5 (60.6) | 5 (84.2) |
| Unit policy exists to regularly review the indications for performed procedures according to published list of standard indications. | 5 | 5 (58.8) | 5 (52.9) | 4 (14.7) | 5 (60.0) |
| Use of an indication or time-to-procedure interval that is outside of accepted standards is clearly documented in the patient's health record. | 4 | 4 (18.2) | 4 (27.3) | 3 (28.1) | 4 (25.0) |
| Communication of results | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Procedure reports are communicated to referring providers.∗ | 5 | 5 (90.9) | 5 (87.9) | 5 (72.7) | 5 (95.0) |
| Pathology reports for patients with cancer are dispatched to referrers after the receipt of the report.∗ | 5 | 5 (78.8) | 5 (75.8) | 5 (64.5) | 5 (90.0) |
| Pathology reports are received by the endoscopist (or referrer) responsible for acting upon them within a timely manner.∗ | 5 | 5 (90.9) | 5 (87.9) | 5 (81.8) | 5 (87.9) |
| The unit uses a process for timely communication of results to referring providers that complies with HIPAA statutes and other state or federal privacy guidelines.∗ | 5 | 5 (78.1) | 5 (78.1) | 5 (64.5) | 5 (85.0) |
| Results (ie, from the endoscopy report) for all inpatients are available in the medical record before the patient leaves the department. | 5 | 5 (54.6) | 5 (51.5) | 5 (45.5) | 5 (72.2) |
| If the endoscopist has responsibility for taking action or making recommendations based on pathology reports, then the time it takes the endoscopist to act on the results or provide recommendations is tracked.∗ | 5 | 5 (60.6) | 5 (51.5) | 4 (18.2) | 5 (65.0) |
| Postprocedure communication/coordination of care | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Patients receive discharge instructions that include recommendations for follow-up, anticoagulation plan, need for antibiotics or other specific therapy (as indicated), and timing of resumption of prior medications.∗ | 5 | 5 (87.9) | 5 (84.9) | 5 (81.8) | 5 (90.0) |
| Process in place for patient to receive a copy of the endoscopy report. | 5 | 5 (69.7) | 5 (75.8) | 5 (66.7) | 5 (90.0) |
| Communication of results to the patient and/or family is complete and timely, including prompt acknowledgement of recognized adverse events and incomplete or neglected therapies, or sampling. | 5 | 5 (81.8) | 5 (78.8) | 5 (68.8) | 5 (85.0) |
| Upon discharge from the endoscopy unit, patients are given instructions, both written and verbal, that conforms to literacy and language appropriateness. Instructions document pertinent procedure findings, treatment, contact number in case of emergencies, and follow-up care.∗ | 5 | 5 (81.3) | 5 (78.8) | 5 (63.6) | 5 (85.0) |
| Disaster preparedness | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Endoscopy unit maintains a written disaster preparedness plan that provides for the emergency care of all persons in the facility in the event of fire, natural disaster, equipment failure, or other unexpected events or circumstances that are likely to threaten the health and safety, and they coordinate the plan with state and local authorities, as appropriate.∗ | 5 | 5 (78.8) | 5 (84.9) | 5 (87.9) | 5 (87.9) |
| Appropriate drills of disaster preparedness plan are performed and documented. | 5 | 5 (66.7) | 5 (74.2) | 5 (72.7) | 5 (87.9) |
| Ability to provide feedback | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Endoscopy unit has a person or committee responsible for reviewing patient complaints.∗ | 5 | 5 (78.1) | 5 (78.1) | 5 (64.5) | 5 (85.0) |
| Basic monitoring and recording of patient comfort and pain levels before, during, and after the procedure. | 5 | 5 (84.9) | 5 (84.4) | 5 (81.8) | 5 (85.0) |
| Endoscopy unit has a system for gathering patient feedback such as satisfaction surveys, focus groups, or invited comments. | 5 | 5 (84.4) | 5 (81.3) | 5 (74.2) | 5 (80.0) |
| Actions are planned in response to reported patient complaints.∗ | 5 | 5 (81.3) | 5 (78.1) | 5 (67.7) | 5 (80.0) |
| Documented process for adjudicating patient grievances exists on the unit, as required by state or federal law. | 5 | 5 (75.0) | 5 (75.0) | 5 (68.8) | 5 (80.0) |
| Patients can submit ad hoc patient concerns or positive comments about their care. | 5 | 5 (68.8) | 5 (63.6) | 5 (60.6) | 5 (75.0) |
| Patient is given realistic expectation that some discomfort may be experienced during the procedure. | 5 | 5 (71.9) | 5 (62.5) | 5 (62.5) | 5 (75.0) |
| Patient comfort and respect (surveys and nurse records) are reviewed. | 5 | 5 (56.3) | 5 (57.6) | 5 (56.3) | 5 (70.0) |
| Yield of return from patient satisfaction surveys is tracked and trended. | 5 | 5 (69.7) | 5 (75.0) | 5 (69.7) | 5 (70.0) |
| Patient comfort and respect results (from surveys and nurse records) are fed back to individual endoscopists and the endoscopy team and are acted upon to ensure issues have been effectively addressed. | 5 | 5 (70.0) | 5 (67.7) | 5 (54.8) | 5 (65.0) |
| Patient satisfaction surveys include questions regarding the quality of patient information provided. | 5 | 5 (66.7) | 5 (66.7) | 4.5 (50.0) | 5 (65.0) |
| Accessibility to facilities (ie, parking, way-finding). | 4 | 4 (30.4) | 5 (54.6) | 5 (51.5) | 4 (40.0) |
| Waiting room amenities are conducive to a positive patient experience (ie, ambiance, WiFi, seating, cleanliness, noise). | 4 | 4 (21.9) | 4 (24.2) | 4 (39.4) | 4 (35.0) |
Indicators that are shaded white had consensus reached on them (ie, median of “5” on the second round of voting for the relatedness parameter with ≥80% of respondents rating it a “5”) and were the 6 highest-rated indicators for this domain.
Note: Patients and payers did not participate in the voting process. Both groups were initially invited but opted not to participate.
HIPAA, Health Insurance Portability and Accountability Act of 1996.
∗
Mandated by national regulatory or accreditation standards.