Text: Dr John T. Anderson, Gastroenterology Department, Cheltenham General Hospital, [email protected]
John Anderson
Endoscopic performance measures can be applied to many different aspects of an endoscopic service. Performance of individual endoscopists has often been the focus but for organisations, service efficiency, productivity, cost-effectiveness and impact on patient outcomes are key.
Improving individual endoscopic performance can result from the introduction of simple measurement tools and audit. For most individuals, performance improvements usually require formal training. Co-ordination of a structure training approach encourages efficient and effective utilisation of training resource.
Quality assurance (QA) of hospitals, departments and individuals is now demanded. QA improves patient safety, appropriate use of resource and most importantly, positive patient outcomes. Endoscopy is a valuable diagnostic and therapeutic service. Demand continues to increase in response to cancer screening programmes and new therapeutic techniques. Improving the performance of endoscopists requires robust performance data and standards to measure against. Several countries and organisations have now developed specific quality standards to assess performance of both the service and individuals.1,2,3
Historically, endoscopists have worked in isolation with a limited review of performance quality. Now measurement of key performance indicators (KPIs) is advocated in both screening programmes and routine practice to provide some indication of the quality of the service. 1,2,3
The current information technology (IT) systems used in endoscopy have focused on the user interface. This results in good quality endoscopy reports, but variable quality in data outputs. Data analysis is further impaired by poor integration with other IT systems. Automated good quality performance data is rare. Any endoscopic data produced tends to relate to inputs and outputs rather than outcomes. Double entry of data is often required for any meaningful analysis or comparisons. Analysis relies on all data being available, necessitating exclusive use of electronic reporting systems and mandating data submission. Improving data output enables training to be developed and targeted at those who require it. This will result in improving the effectiveness and efficiency of available training resources. Data will also inform whether acceptable standards of practice are reached and maintained. Smart IT systems may enable automated regulation, certification and revalidation of endoscopic practice.
Individuals are increasingly aware of their own performance data, often provided in comparison with others. This generates a demand from independent colonoscopists for technical skills training in endoscopy, not just trainees.
Endoscopists appear comfortable attending gastroenterology updates on IBD, hepatology, etc, but rarely consider endoscopy skills improvement courses. Individuals must recognise, accept and commit to lifelong endoscopy training and skills improvement. The expectations of patient, providers and purchasers continue to rise. Delivering an increasingly higher quality endoscopy service requires continued improvements in endoscopists performance. This can only be achieved supported by a cultural change and acceptance that endoscopy training is a core component of the service provision.
The majority of endoscopy training is provided by hospital departments alongside service provision. Internal motivation, external service pressures and variation in training may encourage trainees to rapidly progress to independent practice. This leads to a cohort of largely self-taught endoscopists. Once independent, individuals are regarded as a service provider and also expected to assist in training others.
There are departments where endoscopy training provision is regarded with irritation, frustration and impatience. Some trainers may express similar feelings when providing training. Service pressures can adversely challenge training provision, if erroneous equating high throughput and quick procedure time with quality. Training cannot flourish or develop in a environment under extreme service pressure.
Performance data for trainers’ performance should exceed the quality standards for the procedure they teach. Effective endoscopy skills training requires the ability to be able to deconstruct a complex technical challenge and precisely articulate in small steps, what is required for the trainee to succeed in a given task. The more novice the trainee the more basic the instructional steps. This requires conscious competence of the technical skill and how to teach it. Self-taught, independent endoscopists may well develop into trainers without conscious competence.
This can lead to challenges being solved by the trainer ‘taking over the scope’, rather than providing the instruction on technique for the individual to solve the problem themselves. Lack of trainer competence does not necessarily lead to a failure of the procedure, but is sub-optimal for training and can adversely affect the patient experience.
It is recognised that endoscopists with good personal performance data do not necessarily make good trainers. Organisations should be encouraged to identify those trainers who provide effective, trainee orientated training, supported by positive feedback.
An accepted structure of training in endoscopy skills provides a platform for future workforce development. Learning objectives should be aligned to a competency framework and focused on formative assessment. Endoscopy trainees should have a dedicated career pathway which includes provision of endoscopy services, preventing dilution of training resource.
Some countries have utilised non-medically trained individuals (e.g. nurses) to rapidly expand the endoscopic workforce. Training requirements for these individuals are more complex and can be more protracted. Issues include the lack of medical training and experience necessary for management decisions post-procedure. Whilst some non-medically trained endoscopists provide excellent service, others struggle with the patient responsibility and risk management integral with independent practice. Selection criteria for non-medically trained endoscopy trainees is critical and supportive mentorship essential.
For established and independent endoscopists, basic endoscopy training techniques are identical to those used for trainees although a modified teaching approach may be required. The increasing focus on endoscopic therapy has helped generate enthusiasm for more skills training. For many, previous endoscopy training will have included no formal therapeutic training. All endoscopists benefit from skills improvement training.
The creation of training centres, or specialist training units can help facilitate development of training expertise and endoscopy training techniques. Training units will help evolve minimum standards for training facilities. Ideally, networked training units can co-operate in producing training programmes to meet the requirements and demands of independent and trainee endoscopists, matching training with service requirements.
Development of a clear strategic vision for endoscopy training will help deliver a rapid improvement in endoscopy performance. For this to succeed, cultural change, political and financial support together with co-operative working will be required. Endoscopy skills training continues to evolve and meet the challenge to deliver high quality therapeutic and diagnostic endoscopic practice. IT should be encouraged to provide automated monitoring of the quality of units, individuals and the impact of the service provided. Improving the performance of individual endoscopists should result in improved patient outcomes.
