Departments of Gastroenterology, Quality and Risk Management, Rabin Medical Center, Tel Aviv University, Israel
Received date: November 19, 2012; Accepted date: November 20, 2012; Published date: November 22, 2012
Citation: Niv Y (2012) Quality Assurance and Risk Management in Gastroenterology. J Gastroint Dig Syst 2:e110. doi: 10.4172/2161-069X.1000e110
Copyright: © 2012 Niv Y. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Quality; Indicators; Risk
“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous” (Chantler) . Gastroenterology includes the consultation and endoscopy sections that could not be separated, and together exposed the patients to clinical errors and procedure complications, and the physician to law suits. In USA gastroenterology takes the 6th place in the number of claims, and the 16th place in the amount of money paid to the plaintiff . In a recent study from Japan, a significant increase in the number of claims for inappropriate treatments was found between the periods of 1990- 1999 and 2000-2009 . No significant change was demonstrated for treatment complications, delayed diagnosis, procedure complications or lack of informed consent. We looked at claims against the largest health insurance organization in Israel, Clalit Health Services, in the period of 2000-2006 and found 183 claims against gastroenterologists for a population base of 4 millions insured people [4-6]. Almost all the claims were about complications of endoscopic procedures, with 27 mortality cases. Quality of management and patient’s safety became the main goals of health strategy for prevention of adverse events as well as wasting lot of resources for claims. Quality indicators and risk management should be implanted in every gastroenterological unit and become an integral part of the daily work and good clinical practice.
The main problem in the gastroenterology clinic is missing the correct diagnosis, especially malignancy, wrong management and treatment that is not following guidelines and ineffective communication between the consultant, the patient and the family physician. There should be guidelines and clinical protocols to ensure good clinical practice and established communication lines with the primary care physician. Integrated internet system of the primary care physician and the consultant may overcome many obstacles. Pham et al. found that for 100 patients the family physician is in contact with 99 consultants . This burden of communication can be hazardous if not efficiently used. A clear and focused referral letter and comprehensive answer were reported by only 34.8% and 62.2% of the consultants and family physicians, respectively . Having integrated communication system may result in a change of referral pattern and new strategy. Instead of “I’m referring you to the specialist” the message may be: “I’m consulting with my specialist colleague to see what else we need to do, which may include sending you to the specialty clinic for a visit” . This approach may also reduce inappropriate referrals, and enables a better follow up after endoscopic procedures, including tracing potential adverse events and hospitalization which otherwise may skip the awareness of the endoscopist [10,11].
Quality indicators are efficient tools for following good clinical practice and avoiding mistakes and adverse events. In gastroenterology the first quality indicators were described and validated for performing colonoscopy . Since many colonoscopies are performed for screening and prevention of colorectal cancer it is frustrating to diagnose an interval cancer after a recent normal colonoscopy . Good preparation, complete examination, withdrawal time longer than 6 minutes, and adenoma detection rate became essential indicators for a good colonoscopy . Other endoscopic procedures and daily consultation are waiting for quality indicators to be established. A first trial in this direction was performed in our integrated gastroenterology service (Table 1).
|Bone densitometry for patients with IBD||Patients >20 years old with Crohn's disease or ulcerative colitis||Of those in the denominator, patients who underwent bone densitometry within the last 5 years|
|Preventive medications for high risk patients on aspirin / NSAIDs||High-risk patients (>70 years old, underlying comoborbidity or concomitant medications) on chronic aspirin / NSAIDs therapy||Of those in the denominator, patients who were prescribed proton pump inhibitors|
|Colonoscopy following positive FOBT||Patients with positive FOBT||Of those in the denominator, patients who underwent colonoscopy within 6 months|
|EGD in Barrett's esophagus||Patients with a diagnosis of Barrett's esophagus||Of those in the denominator, patients who underwent EGD within the last 3 years|
|Poor preparation for colonoscopy||Patients who underwent colonoscopy||Of those in the denominator, patients for whom the interpretation of the gastroenterologist was "medium preparation", "poor preparation", "no preparation" or "unable to perform colonoscopy",|
|EGD for GERD patients over 45 years||Patients over 45 years old with a diagnosis of GERD||Of those in the denominator, patients who underwent EGD within the last 3 years|
|Unplanned EGD / surgery following EGD||Patients who underwent EGD||Of those in the denominator, patients who underwent unplanned repeat EGD or surgery within 72 hours|
|Repeated colonoscopy for patients with CRC||Patients with CRC in colonoscopy||Of those in the denominator, patients who underwent follow-up colonoscopy within 12-18 months|
Table 1: Quality indicators developed for assessing the Integrated Gastroenterology Service.
Accountability of gastroenterology units in the community and hospital is depended on quality and risk management. Daily, routine work, endoscopy performance and patients’ management should be performed according to guidelines and clinical protocols, and followed persistently with quality indicators.