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Performance Management

Performance Management. Derek Gillen. Why?. To try to optimise outcomes for patients ↑ safety ↑ comfort ↓ missed pathology. How?. Sustainable audit: Symptomatic population: GRS Audits Screened population: GRS Audits + BCS Audits. For Whom?. Scottish BCSP NHS GGC QIS/JAG (GRS)

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Performance Management

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  1. Performance Management Derek Gillen

  2. Why? • To try to optimise outcomes for patients • ↑ safety • ↑ comfort • ↓ missed pathology

  3. How? • Sustainable audit: • Symptomatic population: GRS Audits • Screened population: GRS Audits + BCS Audits

  4. For Whom? • Scottish BCSP • NHS GGC • QIS/JAG (GRS) • GMC (Revalidation) • Ourselves • (Patients?)

  5. GRS Colonoscopy-related Audits • Level C: • Flumazenil usage* • No of procedures* • Completion rate* • Adenoma Detection Rate • Sedation/analgesia*

  6. GRS Colonoscopy-related Audits • Level B: • Colonic Polyp recovery • 8 day readmission • 30 day mortality

  7. GRS Colonoscopy-related Audits • Level A: • Comfort levels for colonoscopy • Diagnostic biopsies for diarrhoea*

  8. English v Scottish BCS Audits • English: BSG/BCSP/AUGIS/ACPGBI (ratified by JAG) • Scottish: SBCSP and NHS Scotland

  9. English BCS Audits • 1) Minimum no of colonoscopies • 2) Caecal Intubation rate • 3) Cancer detection rate • 4) Adenoma detection rate • 5) Withdrawal time • 6) Polyp retrieval • 7) Tattooing • 8)Sedation • 9) Complication rates

  10. English BCS Audits • 1) Minimum number of BCS Colonoscopies • ≥ 150 per annum

  11. English BCS Audits • 2) Caecal Intubation rate • American and Canadian Standards: • > 95% adjusted for poor prep/strictures • → 90% unadjusted in UK • How? • Photo evidence of ICV or appendix • NB ITT

  12. English BCS Audits • 3) Cancer Detection Rate • ≥ 11 per 100 screening colonoscopies • 4) Adenoma Detection rate • ≥ 35% (target ≥ 40%) • (NB ADR more important than cancer detection rate)

  13. Adenoma Detection Rate • Evidence is important? • Kaminski et al (NEJM 2010) • 186 endoscopists; 45000 screened patients • ADR correlates with interval cancer rate (P=0.008) • Rate < 20% has a hazard ratio of interval cancer of 12.8

  14. English BCS Audits • 5) Withdrawal time in –ve colonoscopies • ≥ 6 minutes (target ≥ 10 minutes) • Basis? • Barclay et al NEJM 2006 • 12 GI with 2053 screening colonoscopies • Minimum adequate time 6 minutes (expert opinion)

  15. Proportion of colonoscopies with adenomata found Withdrawal time (minutes)

  16. Withdrawal times • Barclay et al- Results: • Overall neoplasia rate: • 23.5% (range 9.4-32.7%) • Withdrawal range: • 3.1 to 16.8 minutes • < 6 minutes versus > 6 minutes: • Any neoplasia: 11.8 v 28.3% (P<0.001) • Advanced neoplasia: 2.6 v 6.4% (P<0.005)

  17. Withdrawal times • Further study: • ↑ to ≥ 8 minutes (2325 screening colonoscopies) • ADR ↑ • No. of adenomata per patient ↑ • No. of advanced adenomata ↑

  18. English BCS Audits • 6) Polyp retrieval • > 90% (target > 95%) • No. of polyps with tissue for histology/ no. of polyps recorded

  19. English BCS Audits • 7) Tattooing: • By local agreement between screeners and Colorectal MDT

  20. English BCS Audits • 8) Sedation: • In line with BSG Guidance • < 5mg < 70 • ≤ 2mg > 70 • Use of reversal agents

  21. English BCS Audits • 9) Complications: • Perforation rate: • <1 in a 1000 • Therapeutic Perforation rate: • <1 in 500 • Post-polypectomy bleeding: • transfusion in <1 in 100 (polyps >1 cm)

  22. Scottish BCS Audits • Completion rate • Complications • Admissions • Perforations • Bleeding • deaths • Cancer detection rate • Adenoma detection rate • PPV: • Cancer • Adenoma • High risk adenoma • For any neoplasm

  23. GGC BCS Audits • 1) Minimum no. of colonoscopies • 2) Caecal Intubation rate • 3)Cancer detection rate • 4) Adenoma detection rate • 5)Withdrawal time • 6)Polyp retrieval • 7)Tattooing • 8)Sedation • 9) Complication rates

  24. Performance management • Audits performed • → Local GRS Lead • → Local Resolution with action plan • → No resolution/safety issue • → Lead clinician • → No resolution/safety issue • → relevant CD/Clinical Governance pathways

  25. Completion rates • 85-90% • Review reasons for recent incompletes • Continue colonoscopy • > But further skills improvement training • 80-84.9% • Own measures to improve performance within 3/12 • Consider skills course • Reaudit next 100 colonoscopies (or 12 months)

  26. Completion rate • 75-79.9% (or 80-85% with unsatisfactory reaudit) • Action plan with endoscopy lead over 3/12: • JAG approved skills course • And/or mentoring by a TTT trainer • And/or masterclass session • > Reaudit next 100 (or 12 months) • > If rate still <80%, colonoscopy only under supervision until cusum >85%

  27. Completion rate • <75% • Independent colonoscopy suspended • Colonoscopy only with a TTT trainer • Attend JAG course • Independent practice only at cusum of 85

  28. Summary • We need to QA our performance • Necessary audits and standards defined • Sustainable audits available soon • Governance processes in place

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