Quality Improvement in Gastroenterology Clinical Practice

Rakhi Kheraj; Sumeet K. Tewani; Gyanprakash Ketwaroo; Daniel A. Leffler


Clin Gastroenterol Hepatol. 2012;10(12):1305-1314. 

In This Article

Abstract and Introduction


An emphasis on quality improvement (QI) is vital to the cost-effective provision of evidence-based health care. QI projects in gastroenterology have typically focused on endoscopy to minimize or eliminate procedure-related complications or errors. However, a significant component of gastroenterology care is based on the management of chronic disease. Patients with chronic diseases are seen in many different outpatient practices in the community and academia. In an attempt to ensure that every patient receives high-quality care, major gastrointestinal societies have published guidelines on the management of common gastrointestinal complaints. However, adherence to these guidelines varies. We discuss common outpatient gastrointestinal illnesses with established guidelines for management that could benefit from active QI projects; these would ensure a consistently high standard of care for every patient.


In recent years quality improvement (QI) and quality assurance (QA) have become catch phrases that are widely used throughout medicine. Although these terms are often used interchangeably, they differ in scope and relevance to day-to-day practice. QA is defined as planned, systematic activities that are implemented to ensure that a level of performance is attained. In medicine this has most often taken the form of compliance sessions and morbidity and mortality conferences, where adverse outcomes are discussed retrospectively in annual training.

Although salutary changes often derive from such peer review, this is by nature a reactive process suited more toward avoiding aberrant events than toward raising the overall level of care (Figure 1).[1] The recognition of the limitations of QA methodology in healthcare has led directly to the ascendance of QI as the accepted framework for healthcare initiatives. Exemplified by the Plan-Do-Study-Act cycle (Figure 2), QI is a measurement-driven process defined by continuous proactive efforts to improve care—not through avoidance of specific unwanted events as in QA but through manipulation of the processes of healthcare delivery.[2,3] Individuals engaged in QI seek to alter the processes through which healthcare is delivered and improve outcomes by reducing unintended variation, eliminating errors, streamlining care, and enhancing communication.

Figure 1.

Evolution of a culture of QI. Adapted from Hudson P. Applying the lessons of high risk industries to healthcare. Qual Saf Health Care 2003;12(Suppl 1):i7–12.

Figure 2.

Plan-Do-Study-Act cycle. Adapted from Langley GL, Nolan KM, Nolan TW, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers, 2009.

In gastroenterology, QI initiatives have largely centered on endoscopy. Endoscopy is an excellent area for QI work because of the high volume of a limited range of invasive procedures with standardized reporting and significant associated risks and expense. Efforts in the endoscopy realm have varied;[4] they include patient education[5–9] and recall,[10–12] optimization of preparation,[13] sedation monitoring,[14,15] adenoma detection,[16,17] biopsy obtainment,[18–20] reporting,[21] and adverse event recognition.[22,23] In contrast to endoscopy, QI work in gastroenterology clinical practice has been more limited, and measures of quality of care in the inpatient and outpatient settings are less well defined.[24] It is not the intent of this review to recommend guidelines discussed but to review the guidelines on specific outpatient conditions presented by major gastroenterology societies. However, QI is widely applicable to gastroenterologists as well as primary care physicians, as they try to streamline care while avoiding unwanted errors in managing a multitude of common gastrointestinal conditions.

With the growing emphasis on healthcare outcomes and accountability, it is in the interest of all groups to critically evaluate and refine delivery of care in the outpatient setting. Although the QI needs in endoscopy are relatively uniform, appropriate QI projects in outpatient clinical practice will become more dependent on specific practice characteristics. Although inpatient gastroenterology QI efforts are of great importance, because most patient care occurs in the outpatient setting, this review will focus on the most commonly encountered topics in outpatient gastroenterology, in which QI efforts can decrease practice variation and improve care. The goal of this review is to provide examples of common targets for QI work in outpatient clinical practice suitable for improvement of measurable patient outcomes as well as for accreditation and certification purposes. The QI projects we present will follow the Plan-Do-Study-Act cycle, emphasizing the iterative process and focusing on preidentified measurable outcomes.