Table 5.
Survey results using the Delphi method to examine potential endoscopy unit quality indicators for the Procedure-Related domain
| Preprocedure | 1st round voting (n = 30), median (%), 1 = strongly disagree, 5 = strongly agree |
2nd round voting (n = 22), median (%) |
|||
|---|---|---|---|---|---|
| Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) | |
| Endoscopy unit has a process to ensure that all elements of the preprocedure assessment are documented before the procedure begins. | 5 | 5 (86.7) | 5 (82.8) | 5 (83.9) | 5 (90.9) |
| Preprocedure process is reviewed by clinic leadership on a regular basis. | 5 | 5 (62.1) | 5 (62.1) | 5 (69.0) | 5 (71.4) |
| Preprocedure space is monitored to ensure that it meets patient and staff needs and is clean, functional, quiet, ensures patient privacy, and has amenities conducive to a positive patient experience. | 5 | 5 (66.7) | 4 (23.3) | 5 (67.7) | 5 (61.9) |
| Patients and families are kept informed about procedure-related wait to manage expectations. | 4 | 4 (22.6) | 5 (48.4) | 5 (46.9) | 4.5 (50.0) |
| Procedure | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Mechanism(s) are in place to detect, assess, and address concerns raised regarding physicians’ competence. | 5 | 5 (89.7) | 5 (75.9) | 4 (17.2) | 5 (86.4) |
| Endoscopy unit records, tracks, and monitors procedure quality indicators for both the endoscopy unit and individual endoscopists. | 5 | 5 (89.7) | 5 (75.9) | 5 (62.1) | 5 (86.4) |
| Unit has policy in place for patient pause/time-out that satisfies all key elements.∗ | 5 | 5 (90.0) | 5 (82.8) | 5 (93.3) | 5 (82.8) |
| Endoscopy unit has a privileging policy and committee to make decisions that a physician’s training and performance is in accordance with nationally accepted indicators.∗ | 5 | 5 (85.7) | 5 (82.1) | 5 (58.6) | 5 (81.8) |
| Data on quality indicators are communicated to staff and endoscopists. | 5 | 5 (89.7) | 5 (81.8) | 5 (53.6) | 5 (81.8) |
| Endoscope and accessories used in a procedure are identified in a procedure record.∗ | 5 | 5 (69.0) | 5 (69.0) | 5 (75.9) | 5 (81.8) |
| Endoscopy unit develops quality improvement projects that address indicators which are below targets. | 5 | 5 (78.6) | 5 (75.9) | 5 (60.0) | 5 (81.8) |
| Peer review of procedures by endoscopists is performed. | 5 | 5 (80.0) | 5 (82.8) | 4 (10.3) | 5 (77.3) |
| ERCP volume and sphincterotomy volume by physician and unit are tracked and considered for privileging. | 5 | 5 (41.3) | 5 (44.8) | 5 (13.3) | 5 (57.9) |
| Rate of scheduled procedures cancelled/rescheduled by provider. | 5 | 5 (51.7) | 5 (56.7) | 4 (20.7) | 5 (52.4) |
| Rate of scheduled procedures cancelled/rescheduled by patient. | 4 | 4 (10.3) | 5 (55.2) | 4 (20.7) | 4.5 (50.0) |
| Postprocedure | Related to quality | Meaningful to measure (%) | Feasible to measure (%) | Compliance in own endoscopy unit (%) | Related to quality (%) |
|---|---|---|---|---|---|
| Unit has a policy on reconciliation of specimen requisition to ensure physician and staff agree on specimen labeling.∗ | 5 | 5 (90.0) | 5 (82.8) | 5 (86.2) | 5 (95.5) |
| Patients are not discharged unless formal discharge criteria are met.∗ | 5 | 5 (89.3) | 5 (85.7) | 5 (86.2) | 5 (86.4) |
| Recovery space is clean, functional, quiet, ensures patient privacy, has adequate postprocedure monitoring for patients, and has amenities conducive to a positive patient experience. | 5 | 5 (75.9) | 5 (69.0) | 5 (79.3) | 5 (81.8) |
| Rate of hospital admissions after procedure. | 5 | 5 (79.3) | 5 (75.9) | 5 (66.7) | 5 (77.3) |
| Patient has an opportunity to speak with the provider who performed the procedure before discharge. | 5 | 5 (69.0) | 5 (55.2) | 5 (64.3) | 5 (77.3) |
| Unit has a policy in place for postprocedure follow-up call. | 5 | 5 (72.4) | 5 (75.9) | 5 (73.3) | 5 (77.3) |
| Rate of mislabeled/missing pathologic specimens. | 5 | 5 (82.8) | 5 (75.9) | 5 (69.0) | 5 (77.3) |
| Unit has a policy in place for lack of a responsible adult patient escort after procedure.∗ | 5 | 5 (69.0) | 5 (69.0) | 5 (83.3) | 5 (72.7) |
| Success rate of patient follow-up call after procedure. | 5 | 5 (58.6) | 5 (65.0) | 5 (53.3) | 5 (54.6) |
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.
∗
Mandated by national regulatory or accreditation standards.