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EDITORIAL
Getting the word out about quality measures
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Quality measures and quality indicators are buzzwordsthroughout medicine these days. The gastroenterologycommunity recognized at an early stage that procedure-related metrics would carry increasing importance withpayers, with the government, and ultimately with patientsdeciding where to go for their care. Anticipating the im-portance of this development, multiple societies steppedinto the arena of defining quality for endoscopic proce-dures, examining the available evidence, and proposingindicators for quality practice and reporting.1-4
How does a set of guidelines set forth by a group ofexperts and backed by the approval of professional soci-eties get disseminated and then adopted by practitioners?The first step in this case was the appearance of publica-tions, editorials, and seminars at postgraduate courses andnational society meetings that emphasized the rationalefor quality measures and the data supporting their use.5
With respect to colonoscopy, the ultimate justification formeasuring outcomes relating to quality indicators is evi-dence tying such effort to a decrease in the risk of intervalcolorectal cancer.6 Increasing recognition of the impor-ance of quality indicators by thought leaders and nationalocieties has led to growing adoption of collecting suchata in practice. Electronic data repositories have beeneveloped in conjunction with the electronic endoscopyeport generator manufacturers to greatly facilitate thisrocess. Although such calls have doubtless inspired earlydopters, demands on the part of accrediting bodies andventually payers and patients will clearly serve as theost compelling drivers to induce most endoscopists to
outinely track their performance in the not too distantuture.
Perhaps the best way to ensure that our professiondopts the practice of recognizing and striving to attainenchmark values for quality indicators is to fully incor-orate this routine into accredited training programs thateach endoscopy. This can be achieved in 2 ways: (1)each it as part of the formal curriculum and (2) requirerainees to record their performance and meet targets thatre based on achieving benchmarking goals for specificuality indicators. The latter method ensures that traineeseach objective levels of competency that are performanceased (technical competence) rather than related to num-
Copyright © 2012 by the American Society for Gastrointestinal Endoscopy0016-5107/$36.00
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ers of procedures performed with supervision (numericalompetence). It also fully prepares them to continue theractice of tracking their actual performance as they enterhe workforce. Of course, requiring fellows to measureuality indicators is an excellent way to teach them whathese indicators are. However, to convey the importancend evidence behind quality indicators, they should bencorporated into the didactic curriculum as well.
In this issue of Gastrointestinal Endoscopy, Thompsont al7 raise alarm bells that there is a very low currentnderstanding of colonoscopy quality measures amongastroenterology trainees. More didactic work within train-ng programs is proposed, but no specific details wereollected of how many lectures, how many hours, and inhat way endoscopy quality measures are currently
aught in programs across the country.
Thompson et al also describe an innovative way tontegrate this material into the gastroenterology fellowshipraining program. These authors examined the impact of a
eb-based tutorial on trainees’ knowledge of quality mea-ures in endoscopy. By using the American Society forastrointestinal Endoscopy membership database, the au-
hors identified trainee members who were then invited toarticipate. The authors administered an 18-question on-ine test before they randomized the participants to par-icipate in an online education tutorial or no further inter-ention. Six weeks later, both groups were invited toetake the same 18-question test. They showed that these of Web-based tutorial could improve trainee knowl-dge of endoscopy-related quality indicators.
In the current gastroenterology fellowship training en-ironment, it is necessary to teach fellows about quality ofare, objectively measure their acquisition of this knowl-dge, and assess, in an objective fashion, fellows’ overallognitive and procedural skills. Use of a Web-based tuto-
In the current gastroenterology fellowshiptraining environment, it is necessary to teachfellows about quality of care, objectively mea-sure their acquisition of this knowledge, and as-sess, in an objective fashion, fellows’ overall cog-nitive as well as procedural skills.
ial, such as that used by Thompson et al, is a novel
olume 76, No. 1 : 2012 GASTROINTESTINAL ENDOSCOPY 107
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Cohen & Poles Editorial
approach to satisfy these requirements. As such, it couldhelp training directors around the country by providing aready-made didactic program and free up limited instruc-tor time. To the extent that burdened directors can shareeducational resources over the Web and avail opportuni-ties for independent trainee learning, such tools may havewider application beyond teaching quality indicators. Still,it is not clear from the article by Thompson et al7 that this
ode of conveying the material is more effective than aocused inclusion of the same material into the local fel-owship didactic sessions.
The Web-based tutorial that they developed to teachbout quality measures for endoscopy appeared to objec-ively show that trainees significantly improved in theirnderstanding compared with those not provided the tu-orial. However, the “improved” group only achieved es-entially a “D” grade on the test. Further, this relativelyoor result was observed only 6 weeks after exposure tohe correct information on the tutorial. Although there maye responder bias among those fellows agreeing to par-icipate in the study over all fellows, it seems that thisould serve to select out the more motivated fellows and
hose more likely to respond to a questionnaire. Moreuestions remain about the test instrument and the opti-al structure of the didactic presentation of quality indi-
ator material. Although the questions were culled fromxisting Continuing Medical Education questions in largeart, there was no formal validation of this test. Were thenswers to the test questions reviewed with associatedvidence as part of the tutorial itself? Did the tutorialncorporate the interactive capacity for questions andnswers?
We have no doubt that it is possible to develop moreffective didactic instructions in endoscopy quality indica-ors. By making the material mandatory and not voluntarys in this study and by using local faculty to teach theaterial and grade their mastery of it, trainees will nooubt be more motivated to learn it. Further importantpen questions are whether the effects observed in thistudy will be durable and whether fellows who do under-tand quality indicators will reach competency bench-arks in colonoscopy more quickly than those who doot. Another significant obstacle for training directors wille integrating this instruction into a curriculum alreadyacked with numerous elements required by the Accred-
tation Council for Graduate Medical Education (ACGME)or inclusion without exceeding restrictions imposed onllowable work hours per week.8,9
In the latest iteration of the Gastroenterology CommonProgram Requirements, to be enacted in July 2012,ACGME proposes that gastroenterology fellows be botheducated and undergo evaluation for the 6 competencies.8
Under the practice-based learning and improvement com-petency, the ACGME states that fellows must demonstratethe ability to investigate and evaluate their care of patients,
to appraise and assimilate scientific evidence, and to con- c108 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 1 : 2012
inuously improve patient care based on constant self-valuation and lifelong learning. Among the requirements,ellows are expected to develop skills and habits, to beble to identify strengths, deficiencies, and limits in one’snowledge and expertise as well as set learning and im-rovement goals. Further, they are expected to systemat-cally analyze practice, by using quality improvementethods, and implement changes with the goal of practice
mprovement. The ACGME also requires that fellows usenformation technology to optimize learning. The study ofuality measures and the use of Web-based tutorials andesting to provide feedback appear to fall nicely in lineith many of these ACGME guidelines.Although the ACGME recommends that training pro-
rams use information technology to optimize learning, asas used in this study, there may be more robust ways to
each trainees about quality measures in endoscopy,hich would result in the more important outcome of
mproved patient care. To meet ACGME requirements andeach about quality measures, gastroenterology fellowshiprograms should consider collecting information to calcu-ate each fellow’s adenoma detection rate, cecal intubationate, and withdrawal time. In addition, it is useful to collectnformation on time to cecal intubation, withdrawal time,nd total procedural time, as well as medication dosessed for sedation and patients’ subjective pain scores.hese primarily objective measures of competence can beupplemented by use of the ASGE Diagnostic Upper En-oscopy Procedural Evaluation Form and Diagnosticolonoscopy Procedural Evaluation Form or Mayoolonoscopy Skills Assessment Tool. These data, derived
rom these tools and quality measures, can be relayed tohe fellows at their semiannual meetings with a specificiscussion on how their performance compares with na-ionally recognized quality measures, others in the fellow-hip as a whole, and their class averages for comparison.his process allows repetition of the educational element,ersonalizes the experience, and allows for testing thecquisition of the knowledge through improvement inndoscopy performance.
Data from our own institution last year when this pro-ram was initiated for the New York University School ofedicine Gastroenterology Fellowship Program demon-
trated improvement of the adenoma detection rate andithdrawal time by more than 6 minutes. It is our impres-
ion that this approach results in fellow education aboutolonoscopy quality measures, meets ACGME require-ents, and results in improvement in endoscopic perfor-ance. Clearly the Hawthorne effect, whereby simply
tudying an individual results in improved behavior, is aowerful tool to ensure that the trainees meet the desiredarks. It would be most interesting to know how partic-
pation in required benchmarking of quality indicatorsuring fellowship, as we have required at our program,orrelates with the score on a written test of quality indi-
ator knowledge, such as the one administered by Thomp-www.giejournal.org
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Editorial Cohen & Poles
son et al. Does the Web-based tutorial approach or somecomparable local incorporation of the topic into journalclubs and fellows’ conferences add anything to this sys-tematic performance tracking? If so, then we should find away to fit it into the training experience.
In summary, the article by Thompson et al makes a keyobservation, pointing out a present and easily remedieddeficiency in current gastroenterology training that oughtto affect future updates in core curriculum recommenda-tions as well as current training program behavior. Theimpact of the tutorial, although significant, is not particu-larly impressive. However, it does suggest that this mate-rial can be mastered by trainees if given sufficient empha-sis and exposure by their trainers and institutions.
DISCLOSURE
The authors disclosed no financial relationships rele-vant to this publication.
Jonathan Cohen, MD, FASGE, FACGMichael A. Poles, MD, PhD
New York University School of MedicineNew York, New York, USA
Abbreviation: ACGME, Accreditation Council for Graduate Medical Ed-
ucation.www.giejournal.org V
EFERENCES
. Rex DK, Petrini JL, Baron TH, et al. ASGE/ACG Taskforce on Quality inEndoscopy. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:886-91.
. AGA Task Force on Quality in Practice: a national overview and implica-tions for GI practice. Gastroenterology 2005;129:361-9.
. Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance ofcolonoscopy and the continuous quality improvement process forcolonoscopy: recommendations of the U.S. Multi-Society Task Force onColorectal Cancer. Am J Gastroenterol 2002;97:1296-308.
. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance forthe early detection of colorectal cancer and adenomatous polyps, 2008: ajoint guideline from the American Cancer Society, the US Multi-SocietyTask Force on Colorectal Cancer, and the American College of Radiology.Gastroenterology 2008;134:1570-95.
. Lieberman D. A call to action–measuring the quality of colonoscopy.N Engl J Med 2006;355:2588-9.
. Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colono-scopy and the risk of interval cancer. N Engl J Med 2010;362:1795-803.
. Thompson JS, Lebwohl B, Syngal S. Knowledge of quality performancemeasures associated with endoscopy among gastroenterology traineesand the impact of a web-based intervention. Gastrointest Endosc 2012;75:125-31.
. ACGME program requirements for graduate medical education in gastro-enterology (Internal Medicine). Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/144 gastroenterology_int_med_07012012.pdf. Accessed February 2, 2012.
. American Association for the Study of Liver Diseases, American Collegeof Gastroenterology, AGA Institute, and American Society for Gastroin-testinal Endoscopy. A journey towards excellence: training future gastro-enterologists the gastroenterology core curriculum, third edition. Am J
Gastroenterol 2007;102:921-7.GIE on Facebook
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