How quality assurance can help How quality assurance can help counter fraud in endoscopycounter fraud in endoscopy

Roland Valori

Gastroenterologist

National Clinical Director for Endoscopy

November 2010

Plan of presentation

• Describe: – what we do in endoscopy– what quality colonoscopy looks like– my perspective on fraud– our quality assurance framework

• Reflect – on what made an impact

• Speculate – on implications for HICFG– on how we can help each other

Today

White light

NBI

Dye application

Flat lesions and EMR

Colon cancer

Screening leads to a 15-18% reduction in death from cancer

Colonoscopy prevents cancer:

A 50% reduction in incidence is possible

Cumulative incidence distal cancer (%)Cumulative incidence distal cancer (%)- RCT of flexible sigmoidoscopy screening- RCT of flexible sigmoidoscopy screening

Smoothed yearly hazard rates for distal cancer (rectum and sigmoid colon)

£60 million for a national FS screening programme

Flexible sigmoidoscopy screening

Reductions in risk

CRC CRC deathLeft sided

CRCRight sided

CRC

ITT 23% 31% 36% 2%

Per-protocol 33% 43% 50% 3%

all cause mortality reduction of 3%

Colonoscopy screening

• Colonoscopy has no influence on right sided cancer

One reason why:

Would you be prepared tohave a colonoscopy done by a

colonoscopist selected at random?

Who would you choose?

Private colonoscopist

selected at random?

NHS colonoscopist

selected at random?

Who would you choose?

Because many private endoscopists:– don’t monitor their performance– decisions are influenced by reimbursement

Private colonoscopist

selected at random?

NHS colonoscopist

selected at random?

Why?

Colonoscopy activity: Australia/England

Australia 2007/8 England 2008/9

Total rate/1000/yr Total rate/1000/yr

Colon - private 402,203 36.5

Colon - public 118,111 10.7 350,875 7.0

Assuming an Australian population of 22 million and 50:50 private:public split

“Over servicing” – the million dollar colonoscopist

• Endoscopist has just done his tenth colonoscopy of the morning with deep sedation but, yet again, with incomplete mucosal visualisation:– Didn’t get to the caecum

– Poor prep

– Didn’t turn the patient

– Came out too fast

• But he found a couple of small polyps – so he is able to schedule another procedure

Feedback to the patient

“The good news for you is no cancer found, the bad news (good for me) is you will need another procedure…….

Now the guidelines say you don’t need another procedure, or at least not for 5 years, but then the guidelines are influenced by costs and I have seen cancer appear, even in so called low risk categories….”

“So we better repeat the procedure in a year”

Guess what?

Cancer found at splenic flexure

“Aren’t you pleased we paid no attention to those Government-sponsored money-saving guidelines?”

EU bowel cancer screening quality assurance guidelines - surveillance chapter 9

Recommendations:

9.19 Every screening programme should have a policy on surveillance. The policy may limit surveillance to the highest risk group if sufficient resources are not available to include people with lower risk (VI ‑ B)

9.21 Adherence to the guideline should be monitored (VI ‑ A)9.22 Surveillance histories should be documented and the results

should be available for quality assurance (VI ‑ A)

Validation of surveillance procedures

0

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40

60

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120

140

160

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200Measure 5.9 endoscopy Global Rating Scale:

“All surveillance procedures are validated clerically and clinically according to the latest guidance at least two months prior to the due date”

Yes No

April 2010 census

Colonoscopy: quality and safety

Expert Inexpert

Completion >95% <90%

Adenoma detection >20% <20%

Completeness of polyp excision complete often incomplete

Cancer miss rate 1% 10%

Perforation rate <1:5000 >1:1000

Serious polypectomy complications <1:500 >1:100

Patient experience usually good often bad

Appropriateness of repeats yes often no

Colonoscopy: quality and safety

Expert Inexpert

Completion >95% <90%

Adenoma detection >20% <20%

Completeness of polyp excision complete often incomplete

Cancer miss rate 1% 10%

Perforation rate <1:5000 >1:1000

Serious polypectomy complications <1:500 >1:100

Patient experience usually good often bad

Appropriateness of repeats yes often no

How should colonoscopists be monitored?

• Key performance indicators:– polyp detection rate– comfort– ‘completion’– non technical skills– use of sedation– appropriate surveillance

intervals

• Polypectomy KPIs– removal technique used– completeness of excision– retrieval rate– use of tattoo– complications– rates of cancer in

surveillance patients

Colonoscopists who monitor and, when necessary, act on these parameters are less

likely to be committing fraud

Who would you choose?

Surgeon colonoscopist

selected at random?

Physician colonoscopist

selected at random?

BCSP nurse colonoscopist

selected at random?

Australia 2010

Who would you choose?

Surgeon colonoscopist

selected at random?

Physician colonoscopist

selected at random?

BCSP nurse colonoscopist

selected at random?

what would the public think?

Australia 2010

What is fraud?

• Cheating the insurer and the insured• Knowingly not providing an acceptable standard of care• Not providing an acceptable standard of care

“Supplying faulty goods”

investment

output= net benefit

x

fraud

The patient’s view The patient’s view of endoscopy 2001of endoscopy 2001

Chaotic Long waits Poor communication Poor environment Poor experience

Thanks to Dr Bill GoddardNottingham University Hospitals

Modernisation agency (England)

2001 2002 2003 2004 2005 2006 2007 2008 2009

pilot work

National Endoscopy Programme

National Endoscopy Programme

2001 2002 2003 2004 2005 2006 2007 2008 2009

spread 28 regions

18 weeks

BC screening

endoscopist training programme

pilot work

Endoscopy units

Professionalbodies

Community services

Private sector

Regulatorybodies

Key relationships in 2009

JAG

Endoscopists

DH

Trainingcentres

policyquality

delivery

Professionalbodies

Quality assurance infrastructure 2010

JAGJoint Advisory Group on Gastrointestinal Endoscopy

PhysiciansSurgeonsNursesGPsRadiologistsPaediatricians

Professionalbodies

Regulatorybodies

Quality assurance infrastructure 2010

JAG

Department of Health

Quality assurance subgroups

Professionalbodies

Units

Regulatorybodies

Quality assurance infrastructure 2010

JAG

Individuals

Department of Health

Training

HICFG?

Quality assurance of units

• Endoscopy Global Rating Scale• Peer review accreditation

What would matter to you if you were having an endoscopy?

Endoscopy Global Rating Scale (GRS)

2004

Patient-centred standards Patient-centred standards - - endoscopy global rating scaleendoscopy global rating scale

· Clinical quality• appropriateness• information/consent• safety• comfort• quality • timely results

www.grs.nhs.uk

Quality of patient experience• equality • timeliness• choice• privacy and dignity• aftercare• ability to provide feedback

GRS - Levels for Safety item

Level D– Adverse events reviewed

Level C– Adverse events are acted upon

Level B– Action is monitored for effectiveness

Level A– Prospective monitoring of >5 known adverse events

www.grs.nhs.uk

GRS - Levels for Quality item

Level D– Quality and safety indicators are available

Level C– Indicators are monitored

Level B– Indicators are reviewed and action planned if

performance is below the standard

Level A– Indicators show that action taken to address

performance issues is successfulwww.grs.nhs.uk

D C B A

1 2 3 4 5 6+ Items

Each item has five levels A*- D

Each level is underpinned with 1-4 measures

1 2 3

Global Rating Scale (GRS) framework

The patient experience

Domains1 2

P

www.grs.nhs.uk

GRS measures – two questions

• Would I want this in place if I was a patient?• Do I have this in place in my service?

GRS item 11 – ‘Aftercare’ – levels C and B

Levels Measures

Af

t

ercare

Level C

Patients are discharged with procedure-specific aftercare information and knowing whether there is concern about malignancy.

Patients have a 24 hour contact number if they experience problems

There are procedure specific aftercare patient information sheets for all procedures performed in the department

There is a 24 hour contact number for patients who have questions and experience problems

All patients are told if they are suspected of having a malignancy on the same day as the procedure

If it is considered inappropriate to tell the patient malignancy is suspected, a note is made in the file of the reason

Level B

Patients are discharged knowing the outcome and future plans.

Not all patients leave with an appointment when one is required

All patients are discharged with verbal and written information about next steps appropriate for their care

All patients are told the outcome of the endoscopic procedure prior to discharge

All patients are told if further information from pathological specimens will be available, from whom and when

Patients’ views on aftercare processes are sought at least annually

Answer: yes or no

Responses define the level: all measures up to and including that level have to be achieved to score that level

www.grs.nhs.uk

Quality of the patient experience Web-based reporting

The GRS is an on-line check list of 149 measures: 12 items in two The GRS is an on-line check list of 149 measures: 12 items in two domains. Each item now has 5 levelsdomains. Each item now has 5 levels

Inadequate D Minimal achievement

Basic C Reactive

Good B Proactive

Excellent A Outward looking

Exemplary A* Able to support others

Level B is the current standard

There are two further domains: workforce and (registrar) training

% scoring A or B

GRS – National resultsGRS – National resultsone item -one item - nine censuses over 4.5 years (212 units)nine censuses over 4.5 years (212 units)

this slide is the key for the next two

level A or B is the current standard

0

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80

90

100

Consent and patient information

2005 2006 2007 2008 2009

OctOct OctApr AprAprApr Oct Apr

% scoringA or B

Completion rates of eleven censuses

Clinical quality

85% 94% 100% 97% 97% 98% 99% 99% 96%

2005

Apr Oct Apr Oct Apr Oct Apr Oct

2006 2007 2008 2009

97%

Apr Oct

99%

Apr

2010

GRS ResultsGRS Results: April 2005 – April 2010: April 2005 – April 2010

% scoringA or B

Quality of the patient experience

GRS ResultsGRS Results: April 2005 – April 2010: April 2005 – April 2010

85% 94% 100% 97% 97% 98% 99% 99% 96%

2005

Apr Oct Apr Oct Apr Oct Apr Oct

2006 2007 2008 2009

97%

Apr Oct

99%

2010

Apr

Completion rates of eleven censuses

Adopting the GRSAdopting the GRS

first awareness established practice

contemplation

preparation

actionmaintenance

awareness

Effective Health Care 1999;5(1)

doctors nurses

Clinical response to the GRSClinical response to the GRS

XXXX City Hospital“ When I first saw the GRS I have to be honest and say that I printed it, read it, ripped it up and chucked it in the bin I had no intentions of ever doing anything with it. Slowly I saw what was going on around me and I had another look. I now truly believe that its been the single most important thing that has helped us to improve our service. I feel somewhat embarrassed at my initial reaction.”

Endoscopy Unit Clinical Lead

The GRS in Canada

CAG Consensus Conference on Safety and Quality Indicators in Endoscopy, Toronto, June 2010

Endoscopy waits Jan 2007 – Dec 2008 Endoscopy waits Jan 2007 – Dec 2008

0

10,000

20,000

30,000

40,000

50,000

60,000

Jan-0

7

Feb-0

7

Mar

-07

Apr-07

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-07

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7

Jul-0

7

Aug-07

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7

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-08

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26 + Weeks

13 - 26 Weeks

7 - 13 Weeks

Median waiting times for endoscopy up to Feb 2010Median waiting times for endoscopy up to Feb 2010

Median waiting times for Endoscopy tests from April 2006

0.0

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B

07-0

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B

Me

dia

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ait

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tim

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wk

s)

COLONOSCOPY

FLEXI-SIGMOIDOSCOPY

CYSTOSCOPY

GASTROSCOPYMedian has dropped from 8.7 weeks in April 2006 to 2.1 weeks in February 2010 for colonoscopy; 6.5 weeks to 2 weeks for flexi sigmoidoscopy; 6.3 weeks to 2.2 weeks for cystoscopy; and 6.3 weeks to 2 weeks for gastroscopy

Final WavePennineLancashireBerkshireNorth StaffordshireSouth EssexSurreySussexBristol & WestonNorth EssexBath, Swindon & WiltshireBedfordshireCheshireCalderdale, Kirklees & WakefieldEast KentNorth & East DevonHarrogate, Leeds & YorkPeterborough & HuntingdonWest Kent & MedwayHereford & WorcesterBuckinghamshireCornwallShropshireManchesterLincolnshireOxford

Second Wave Heart of EnglandCoventry and WarwickshireBradford & AiredaleWest LondonCambridgeCounty Durham & DarlingtonLeicestershire, Northampton & RutlandSouth East LondonNorth of Tyne South YorkshireDorsetWest HertfordshireEast & North Hertfordshire NottinghamshireHampshireCumbria & WestmorlandSandwell & West BirminghamSomerset

First WaveWolverhamptonNorwichSouth DevonCheshire & MerseysideSt MarksSouth West LondonGloucestershireBoltonTeesSouth of TyneHumber & Yorkshire CoastDerbyshireNorth East LondonSolent and West SussexUniversity College London

58 Bowel Cancer Screening Centres

Bowel cancer screening programmeBowel cancer screening programme

SC

SC

SC

SC

SC

SC

SC

SC

SC

SC

Programme Hub:

(FOBT)

colonoscopy site

colonoscopy site

persons aged 60-75

screening centre

x58

x5

X100+

X100+

+ve test

accreditation visit

accreditation visit

76,434 colonoscopies done to date

process

What and who are assessed?What and who are assessed?

Pre-procedure- indications- consent- bowel prep, etc

Post-procedure- recovery- patient advice- follow-up, etc

Endoscopists’ performance data

staff

environment

kit

GRS

GRS

GRS

GRS

Accreditation visitsAccreditation visits

• Peer review process– Nurse: decontamination, workforce, environment– Endoscopist: training issues– Endoscopist: service issues

• Accreditation based on a validated GRS score for service, workforce and training domains:– A for timeliness (< 6 weeks)– B for all other items

• The process is supported by an on-line accreditation system designed to manage the process of accreditation, to upload evidence and to communicate with sites

GRS Measures Evidence required

Upload your evidence

Communicate with assessors

North Tyneside - JAG accreditation visit North Tyneside - JAG accreditation visit (provides secondary healthcare for population of 850,000)(provides secondary healthcare for population of 850,000)

I’ve written to the chair of the JAG separately about the exemplary quality of the process – if only all of the regulatory processes were this good.

The really striking (and humbling) thing though was the way yourself and the whole team have grasped the issue, driven massive improvements in a very short space of time and really transformed the service for patients.

Jim MackeyChief Executive

Targets for JAG visits All acute hospital sites (209)

- visited by April 2011  All private and community facilities (circa 250)

- testing of process completed by 31 Dec 2008- visits completed by 31 December 2012

Acute sector accreditation: service and trainingAcute sector accreditation: service and training- peer review visit- peer review visit

Total Visited Passed Deferred Fail

209 187 (89%) 148 37 2

6 have definite dates between now and December14 have agreed with the JAG to fix a date for the first half next year2  are being approached: little coming back

JAG accreditation of IS endoscopy Visit costs are currently £5,000 for a single site centre. Charges cover

administration, reimbursement of assessors and travel costs. Feedback (acute sites) indicates the cost of a visit is more than offset by the

benefits of going through the process Assessment is supportive and educational Accreditation will reassure a provider it is providing high standards of care

“Its really hardwork getting there but worth every second of it” Care UK

“Its really hardwork getting there but worth every second of it” Care UK

Traditional private hospitals

Require modified GRS Often gold standard patient pathway Often part of theatre Future of endoscopy in some providers is an issue Quality and safety audits a huge challenge Ideally need to see NHS and private data combined

Traditional private hospital – facilities and nursing issues

Often older facilities Decontamination issues as per NHS Mainly theatre nursing with endoscopy as sub specialty Generic workforce to cover patient journey No emergency care issues Pleasant, relaxed patient experience with one to one

consultations

What made the difference? What made the difference?

1. Having a clear goal2. Defining a good patient experience3. Aligning agendas4. Clinical engagement5. Support tools and knowledge6. Listening and responding to the service7. Using available levers8. Intensive support9. Support for the workforce10. Peer review accreditation

Speculate

Potential markers of fraudulent endoscopists

• High volume privately and low volume in NHS• High volume in a session (>6 in four hours)• Use of heavy sedation• Low completion rates • Does not follow guidelines on repeats• Short intervals between repeats• Resistance to participating in quality assurance• Fails to monitor performance• Resistance to responding to poor performance

CommissionerFamily doctor

Patient

CommissionerFamily doctor

Patient

Acute Hospital unitAcute Hospital unit

all providers measured against the same standards

all providers measured against the same standards

Using the market to sustain and improve quality

Community hospital unitCommunity hospital unit

Private hospital unitPrivate hospital unit

Training centre unitTraining centre unit

GRS + accreditation

Quality assurance subgroups

Professionalbodies

Units

Regulatorybodies

Quality assurance infrastructure 2010

JAG

Individuals

Department of Health

Training

HICFG

How can we help each other?

1. Having a clear goal2. Defining a good patient experience3. Aligning agendas4. Clinical engagement5. Support tools and knowledge6. Listening and responding to the service7. Using available levers8. Intensive support9. Support for the workforce10. Peer review accreditation