Our Road to Achieve ASGE Endoscopy Unit Recognition Cynthia Mullin, ASN… · 2016-04-11 · Our...
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Our Road to Achieve ASGE Endoscopy Unit Recognition Cynthia Mullin, ASN, RN, CGRN 160 Allen Street, Rutland, Vermont www.RRMC.org | 802.775.7111 References: 1.) ASGE Web Site; 2.) Course Syllabus ASGE 2013 Improving Quality & Safety in Your Endoscopy Unit; 3.) Course Syllabus ASGE December 2011, Improving Quality & Safety in Your Endoscopy Unit Special thanks to our Endoscopy Chief and to all Endoscopy staff who contributed to the accomplishment of the certification. Without these efforts I would not be able to present this poster. 3 Month Study Patient Risk Assessment Documentation (ASA) Quality of Preparation Documentation (% of charts with prep documentation) Cecal Intubation Rate (% of documentation reaching cecum) Adenoma Detection Male Adenoma Rate Female Adenoma Rate # of Patients 74 411 288 264 265 MD #1 98% 96% 98% 39% 24% MD #2 99% 70% 97% 79% 54% MD #3 94% 97% 100% 23% 19% MD #4 100% 94% 97% 38% 20% MD #5 62% 97% 100% 46% 17% Unit Totals 94% 90% 98% 44% 28% Abstract Our Endoscopy Unit was recently recertified by ASGE (American Society for Gastrointestinal Endoscopy) in their EURP (Endoscopy Unit Recognition Program) . is program is designed to recognize safety and quality in the practice of GI Endoscopy. rough meeting rigorous criteria set fourth by the ASGE we have been honored for our high quality of safe patient care. e steps to obtain this recognition and the advantages to having this recognition will be outlined in this poster. Introduction In 2009, the Endoscopy Unit at Rutland Regional Medical Center applied for and obtained certification through the ASGE, a professional society for GI doctors. ASGE partnered with the CDC (Center for Disease Control) and SGNA (Society for Gastrointestinal Nurses and Associates) , a professional society for GI nurses, to certify Endoscopy Units who are committed to high standards of patient care and safety. rough this certification process we improved the quality of care by creating new policies, performing analysis of chart documentation, and adopting uniform standards of practice. is certification also provides marketability, and better reimbursement opportunities for the Endoscopy Unit at Rutland Regional.Certification requires renewal every three years. We received recertification in July 2015. is was a tremendous accomplishment and honor. It is my hope that by sharing our journey toward receiving ASGE recognition through EURP, I can encourage my fellow GI Nurses and associates to all pursue this certification. Aſter all, GI Nurses are constantly breaking the mold in the fields of Quality and Gastrointestinal-related policies and practice!!! The Application Process As we started down our road to recertification, we began with reviewing qualifying criteria from the ASGE website. We needed proof of successful and current accreditation by a recognized accrediting body. Units must remain accredited throughout the three years of recognition. Another requirement was that at least 50% of the Endoscopists needed to be members of ASGE. A representative of the unit needed to complete the ASGE Quality Course Improving Quality and Safety in our Endoscopy Unit within one year of the program application. We also needed to provide attestation that multi-society guidelines had been adopted in the areas of granting hospital privileges to perform gastrointestinal endoscopies, guidelines for reprocessing flexible gastrointestinal endoscopes, and guidelines for isolation precautions. Attestation was also necessary to prove all pertinent staff completed competency assessments for endoscope reprocessing, sterile medication administration and infection prevention in the year prior to application. We also needed to provide unit policies that had been developed and adopted for continuous and intermittent assessment depending on the quality measure. We studied the completeness of colonoscopy documentation by Endoscopists for prep quality, cecal landmark and appropriate assessment documentation. We also studied adverse events and adenoma detection rates. One cycle of data was required to be submitted pertaining to all studied quality measures. Submitted data needed to be anonymous of specific individual Endoscopists. Along with the data, areas of deficiencies were identified and a plan for improvement/remediation was formed by our Endoscopy Chief. Along with the above information an application fee was submitted. e application is reviewed by the Governing Board. ey can deny, request more information or approve applications. How We Did Our Data Collection • Data analyzed every four months on targeted QI indicators • Data collected daily by Endoscopy nurses and entered into computer program • Nursing leader compiles data, analyzing and putting into quality project report • Results communicated to physicians and Endoscopy Unit Our Team Members • Physician Leader/Endoscopy Chief • Nurse Director • Clinical Manager • Nurse Leader • Nursing team/data collection (all our nursing staff helped with some aspect of data collection) Advantages of Certification • Improved patient safety • Promotes quality patient care • Requires a continuous quality improvement process • Adoption of uniform standards • Marketability – Potential differentiator for the public • Recognition certificate & logo use for the unit • Patient Brochures on safety of endoscopy • Promote where ASGE physician members practice Criteria Studies for EURP We were required to write and adopt unit policies and establish guidelines for continuous or intermittent assessment of quality measures outlined by ASGE. We were also required to define the associated measurement targets for selected quality measures. • Cecal intubation rate by Endoscopists – (% of colonoscopy charts with documentation of the cecum is found) • Patient assessment for procedural risk (% of charts with documentation of codes ASA I, II, II, IV) • Quality of Prep during colonoscopy (% of documentation of prep adequate or better) Based on agreed scale: 1. Excellent – mucosal visibility excellent 2. Good/Adequate – colored liquid with small amount particulate matter/adequate to detect polyps > 6mm 3. Fair – mucosal staining, small amount of stool, limited visibility of mucosa 4. Poor/Inadequate – solid stool, poor visibility of mucosa • Adenoma detection rates by Endoscopists (number of screening or surveillance colonoscopies where at least one adenoma was detected) . Colonoscopies will include patients 50 years and older with no symptoms or previous history of colon polyps. (According to ASGE, the adenoma rate for the entire unit and for each Endoscopist should be > to 15% in women and should be > to 25% in men.) • Adverse event tracking (study is on-going) 1. Deaths attributed to procedure 2. Unplanned admission due to procedure 3. Unplanned anesthesia calls to intubate during moderate sedation 4. Perforation 5. Bleeds requiring transfusion • Use of Patient Satisfaction surveys in Endoscopy Unit Conclusion e rationale for the Endoscopy Unit Recognition Program being developed ( as stated on ASGE’s website) was to meet the need to “standardize and promulgate best practice, particularly with regard to infection control, to help its members ensure that the endoscopic services delivered were high in quality and safety” . It was also a way for “Gastroenterologists, Endoscopists, and units to distinguish themselves from lesser-quality services offered in varied environments by many types of practitioners.” We have found it to be a challenging but beneficial certification process. rough the analysis of data we have been able to improve our documentation and care, and to prove that the quality of care provided at our Endoscopy Unit is excellent. is process has not always been easy. Getting policies up to par and in place was a lot of work. e data collection process has been difficult at times for reasons such as incompatible computer programs and time issues. Working with physicians at times was challenging, but eventually positive. is was an opportunity for nurses and physicians to partner together in a quality improvement study. I would recommend that all Endoscopy units consider this program. ASGE provides information and courses to help with the process if you are lucky enough to be able to participate.
Transcript of Our Road to Achieve ASGE Endoscopy Unit Recognition Cynthia Mullin, ASN… · 2016-04-11 · Our...
Our Road to Achieve ASGE Endoscopy Unit Recognition Cynthia Mullin, ASN, RN, CGRN
160 Allen Street, Rutland, Vermontwww.RRMC.org | 802.775.7111
References: 1.) ASGE Web Site; 2.) Course Syllabus ASGE 2013 Improving Quality & Safety in Your Endoscopy Unit; 3.) Course Syllabus ASGE December 2011, Improving Quality & Safety in Your Endoscopy Unit
Special thanks to our Endoscopy Chief and to all Endoscopy staff who contributed to the accomplishment of the certification. Without these efforts I would not be able to present this poster.
3 Month Study
Patient Risk Assessment
Documentation (ASA)
Quality of Preparation
Documentation (% of charts with
prep documentation)
Cecal Intubation Rate (% of
documentation reaching cecum)
Adenoma Detection
Male Adenoma Rate
Female Adenoma Rate
# of Patients 74 411 288 264 265
MD #1 98% 96% 98% 39% 24%
MD #2 99% 70% 97% 79% 54%
MD #3 94% 97% 100% 23% 19%
MD #4 100% 94% 97% 38% 20%
MD #5 62% 97% 100% 46% 17%
Unit Totals 94% 90% 98% 44% 28%
AbstractOur Endoscopy Unit was recently recertified by ASGE (American Society for Gastrointestinal Endoscopy) in their EURP (Endoscopy Unit
Recognition Program). This program is designed to recognize safety and quality in the practice of GI Endoscopy. Through meeting rigorous criteria set fourth by the ASGE we have been honored for our high quality of safe patient care.
The steps to obtain this recognition and the advantages to having this recognition will be outlined in this poster.
IntroductionIn 2009, the Endoscopy Unit at Rutland Regional Medical Center applied for and obtained certification through the ASGE, a professional society for GI doctors. ASGE partnered with the CDC (Center for Disease Control) and SGNA (Society for Gastrointestinal Nurses and Associates), a professional society for GI nurses, to certify Endoscopy Units who are committed to high standards of patient care and safety. Through this certification process we improved the quality of care by creating new policies, performing analysis of chart documentation, and adopting uniform standards of practice. This certification also provides marketability, and better reimbursement opportunities for the Endoscopy Unit at Rutland Regional.Certification requires renewal every three years.
We received recertification in July 2015. This was a tremendous accomplishment and honor. It is my hope that by sharing our journey toward receiving ASGE recognition through EURP, I can encourage my fellow GI Nurses and associates to all pursue this certification. After all, GI Nurses are constantly breaking the mold in the fields of Quality and Gastrointestinal-related policies and practice!!!
The Application ProcessAs we started down our road to recertification, we began with reviewing qualifying criteria from the ASGE website. We needed proof of successful and current accreditation by a recognized accrediting body. Units must remain accredited throughout the three years of recognition. Another requirement was that at least 50% of the Endoscopists needed to be members of ASGE.
A representative of the unit needed to complete the ASGE Quality Course Improving Quality and Safety in our Endoscopy Unit within one year of the program application. We also needed to provide attestation that multi-society guidelines had been adopted in the areas of granting hospital privileges to perform gastrointestinal endoscopies, guidelines for reprocessing flexible gastrointestinal endoscopes, and guidelines for isolation precautions.
Attestation was also necessary to prove all pertinent staff completed competency assessments for endoscope reprocessing, sterile medication administration and infection prevention in the year prior to application. We also needed to provide unit policies that had been developed and adopted for continuous and intermittent assessment depending on the quality measure.
We studied the completeness of colonoscopy documentation by Endoscopists for prep quality, cecal landmark and appropriate assessment documentation. We also studied adverse events and adenoma detection rates.
One cycle of data was required to be submitted pertaining to all studied quality measures. Submitted data needed to be anonymous of specific individual Endoscopists. Along with the data, areas of deficiencies were identified and a plan for improvement/remediation was formed by our Endoscopy Chief.
Along with the above information an application fee was submitted. The application is reviewed by the Governing Board. They can deny, request more information or approve applications.
How We Did Our Data Collection• Data analyzed every four months on targeted QI indicators
• Data collected daily by Endoscopy nurses and entered into computer program
• Nursing leader compiles data, analyzing and putting into quality project report
• Results communicated to physicians and Endoscopy Unit
Our Team Members• Physician Leader/Endoscopy Chief
• Nurse Director
• Clinical Manager
• Nurse Leader
• Nursing team/data collection (all our nursing staff helped with some aspect of data collection)
Advantages of Certification• Improved patient safety
• Promotes quality patient care
• Requires a continuous quality improvement process
• Adoption of uniform standards
• Marketability – Potential differentiator for the public
• Recognition certificate & logo use for the unit
• Patient Brochures on safety of endoscopy
• Promote where ASGE physician members practice
Criteria Studies for EURPWe were required to write and adopt unit policies and establish guidelines for continuous or intermittent assessment of quality measures outlined by ASGE. We were also required to define the associated measurement targets for selected quality measures.
• Cecal intubation rate by Endoscopists – (% of colonoscopy charts with documentation of the cecum is found)
• Patient assessment for procedural risk (% of charts with documentation of codes ASA I, II, II, IV)
• Quality of Prep during colonoscopy (% of documentation of prep adequate or better) Based on agreed scale:
1. Excellent – mucosal visibility excellent2. Good/Adequate – colored liquid with small amount particulate matter/adequate to
detect polyps > 6mm3. Fair – mucosal staining, small amount of stool, limited visibility of mucosa4. Poor/Inadequate – solid stool, poor visibility of mucosa
• Adenoma detection rates by Endoscopists (number of screening or surveillance colonoscopies where at least one adenoma was detected). Colonoscopies will include patients 50 years and older with no symptoms or previous history of colon polyps. (According to ASGE, the adenoma rate for the entire unit and for each Endoscopist should be > to 15% in women and should be > to 25% in men.)
• Adverse event tracking (study is on-going)1. Deaths attributed to procedure2. Unplanned admission due to procedure3. Unplanned anesthesia calls to intubate during moderate sedation4. Perforation5. Bleeds requiring transfusion
• Use of Patient Satisfaction surveys in Endoscopy Unit
ConclusionThe rationale for the Endoscopy Unit Recognition Program being developed (as stated on ASGE’s website) was to meet the need to “standardize and promulgate best practice, particularly with regard to infection control, to help its members ensure that the endoscopic services delivered were high in quality and safety”. It was also a way for “Gastroenterologists, Endoscopists, and units to distinguish themselves from lesser-quality services offered in varied environments by many types of practitioners.”
We have found it to be a challenging but beneficial certification process. Through the analysis of data we have been able to improve our documentation and care, and to prove that the quality of care provided at our Endoscopy Unit is excellent. This process has not always been easy. Getting policies up to par and in place was a lot of work. The data collection process has been difficult at times for reasons such as incompatible computer programs and time issues. Working with physicians at times was challenging, but eventually positive. This was an opportunity for nurses and physicians to partner together in a quality improvement study.
I would recommend that all Endoscopy units consider this program. ASGE provides information and courses to help with the process if you are lucky enough to be able to participate.
