Commentary

Measuring quality in the NHS: lessons from across the Atlantic

The aim of this study was to assess the quality of colonoscopic procedures in our endoscopy unit with the goal of improving performance.

We prospectively audited 500 consecutive colonoscopic procedures and assessed sixty-two process or outcome indicators for each procedure.

Most of the measured indicators were within standard limits: cecal intubation rate (92%), inadequate bowel preparations (24%), inappropriate procedures (9.7%), normal procedures (54%), yield for neoplasia (32%), morbidity (0.4%), and overall patient satisfaction (95.8%). Some indicators were outside standard limits suggesting our practices should be modified: endoscopy withdrawal time less than 6 minutes (78%), forceps removal of polyps (31%), resected polyps not recovered for pathological examination (12%), adenomas with villous elements (22%), patients unsatisfied because of time spent waiting for the procedure (19%), patients unsatisfied because of inadequate explanations (10%). There was no standard for a few indicators: patient discomfort (6.9%), diagnostic success (89%), therapeutic success (92%). Three new indicators were proposed: proportion of patients aged < 50 years, number of normal colonoscopic procedures to perform to detect one advanced adenoma or cancer, and proportion of colonoscopic procedures causing discomfort. The diagnostic yield of colonoscopy was dependent on age, gender, indication and appropriateness of indication but not on the prescriber.

This audit allowed us to evaluate our endoscopic practices and to detect certain shortcomings and deviations from standards. It enabled us to change some of our practices with the goal of improving the quality of our colonoscopic procedures.

Le but de ce travail était d’évaluer la qualité des coloscopies réalisées dans notre unité hospitalière d’endoscopie digestive avec l’objectif de l’améliorer.

Audit interne prospectif de 500 coloscopies consécutives avec analyse de 62 critères de processus et de résultats par examen.

La plupart des critères évalués étaient conformes aux standards : 92 % de coloscopies completes ; 24 % de préparations coliques insuffisantes ; 9,7 % d’indications inappropriées ; 54 % de coloscopies normales et 32 % avec lésions néoplasiques ; 0,4 % de morbidité et 95,8 % des malades globalement satisfaits. Quelques critères s’écartaient des standards et rendaient nécessaire une modification des pratiques : 78 % d’explorations coliques de durée inférieure à 6 minutes au retrait ; 31 % de polypectomies à la pince ; 12 % de polypes non récupérés pour l’analyse histologique ; 22 % d’adénomes à contingent villeux ; 19 % des malades insatisfaits par l’attente le jour de l’examen et 10 % par la qualité des informations données. Il n’y avait pas de standard pour quelques critères : inconfort signalé par 6,9 % des malades ; succès diagnostique dans 89 % des cas et succès thérapeutique dans 92 %. Trois nouveaux critères d’évaluation étaient proposes : le taux de malades d’âge inférieur à 50 ans ; le nombre de coloscopies normales à faire pour chaque coloscopie avec lésion néoplasique significative et le taux de coloscopies sources d’inconfort. Le rendement diagnostique des coloscopies variait avec l’âge, le sexe, l’indication et la pertinence de l’indication mais ne variait pas avec le prescripteur.

Cet audit a permis de nous évaluer, de détecter certains écarts et dysfonctionnements et de modifier certaines de nos pratiques pour améliorer la qualité de nos coloscopies.

This paper defines quality of health care. We suggest that there are two principal dimensions of quality of care for individual patients; access and effectiveness. In essence, do users get the care they need, and is the care effective when they get it? Within effectiveness, we define two key components — effectiveness of clinical care and effectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system, processes of care, and outcomes resulting from care. The framework relates quality of care to individual patients and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care. However, care for individuals must placed in the context of providing health care for populations which introduces additional notions of equity and efficiency. We show how this framework can be of practical value by applying the concepts to a set of quality indicators contained within the UK National Performance Assessment Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the differences between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care shows which aspects of care any set of quality indicators actually includes and measures and, and which are not included.