John Lytle, administrator at Triangle Endoscopy Center in Durham, N.C., explains how the center has worked to create and maintain actionable quality improvement metrics according to standards set by the Accreditation Association of Ambulatory Health Care.
Q: How does Triangle Endoscopy Center create quality improvement metrics?
Mr. John Lytle: AAAHC and CMS' standards require that we have an organized, well-maintained and peer-based quality improvement program. The process of implementing QI metrics starts with proper documentation. The nurses do chart reviews to make sure proper documentation is being put into patients' charts. For example, they document vital signs throughout the procedure, whether patients experience pain and patients' reaction to the procedure, including non-verbal cues because they're sedated.
Physicians are also very methodical in making sure they get to the end of the colon. One thing they are making sure of is whether landmarks in the colon are documented during a colonoscopy. [They also take] pictures of [the colon] on a regular basis to make sure the end of the colon has been truly reached. That signals withdrawal, which is important because physicians are trying to withdraw the scope in a controlled process and looking carefully to locate polyps. At the end of the procedure, physicians make a note that requires certain details, such as how much medicine the physician gave, what was the extent of procedure, how much time the entire procedure took, how long it took to withdraw the scope, were there any polyps and whether he or she took them out.
These post-operation notes are reviewed on a quarterly basis. All the physicians' notes are passed around to their colleagues. During these peer reviews, the reviewer will look at the notes and any labs that came back from the pathologist and see if the pathology and recommendations match up. After the peer reviews, we try to find out if there were any [significant trends] that were missed. For example, adenomatous polyps can turn into cancerous tissue. That's something we track to make sure we maintain a high level of adenomatous polyp detection. The physicians are measured up against their peers and also on a national level. We also track withdrawal times of scopes and make sure colonoscopies are done correctly and within a maintained time of approximately eight to nine minutes. We want to make sure our physicians are conscious of that time window and looking carefully for polyps.
Learn more about Triangle Endoscopy Center.
Q: How does Triangle Endoscopy Center create quality improvement metrics?
Mr. John Lytle: AAAHC and CMS' standards require that we have an organized, well-maintained and peer-based quality improvement program. The process of implementing QI metrics starts with proper documentation. The nurses do chart reviews to make sure proper documentation is being put into patients' charts. For example, they document vital signs throughout the procedure, whether patients experience pain and patients' reaction to the procedure, including non-verbal cues because they're sedated.
Physicians are also very methodical in making sure they get to the end of the colon. One thing they are making sure of is whether landmarks in the colon are documented during a colonoscopy. [They also take] pictures of [the colon] on a regular basis to make sure the end of the colon has been truly reached. That signals withdrawal, which is important because physicians are trying to withdraw the scope in a controlled process and looking carefully to locate polyps. At the end of the procedure, physicians make a note that requires certain details, such as how much medicine the physician gave, what was the extent of procedure, how much time the entire procedure took, how long it took to withdraw the scope, were there any polyps and whether he or she took them out.
These post-operation notes are reviewed on a quarterly basis. All the physicians' notes are passed around to their colleagues. During these peer reviews, the reviewer will look at the notes and any labs that came back from the pathologist and see if the pathology and recommendations match up. After the peer reviews, we try to find out if there were any [significant trends] that were missed. For example, adenomatous polyps can turn into cancerous tissue. That's something we track to make sure we maintain a high level of adenomatous polyp detection. The physicians are measured up against their peers and also on a national level. We also track withdrawal times of scopes and make sure colonoscopies are done correctly and within a maintained time of approximately eight to nine minutes. We want to make sure our physicians are conscious of that time window and looking carefully for polyps.
Learn more about Triangle Endoscopy Center.