Post on 26-Mar-2015
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
20
40
60
80
100
120
140
160
180
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
10
20
30
40
50
60
70
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
May
-07
Jun-0
7
Jul-0
7
Aug-07
Sep-0
7
Oct-0
7
Nov-07
Dec-0
7
Jan-0
8
Feb-0
8
Mar
-08
Apr-08
May
-08
Jun-0
8
Jul-0
8
Aug-08
Sep-0
8
Oct-0
8
Nov-08
Dec-0
8
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
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
06-0
7 APR
06-0
7 JU
N
06-0
7 AUG
06-0
7 OCT
06-0
7 DEC
06-0
7 FE
B
07-0
8 APR
07-0
8 JU
N
07-0
8 AUG
07-0
8 OCT
07-0
8 DEC
07-0
8 FE
B
08-0
9 APR
08-0
9 JU
N
08-0
9 AUG
08-0
9 OCT
08-0
9 DEC
08-0
9 FE
B
09-1
0 APR
09-1
0 JU
N
09-1
0 AUG
09-1
0 OCT
09-1
0 DEC
09-1
0 FE
B
Me
dia
n w
ait
ing
tim
e (
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