Posted 19th Jul 2012 in Other Topics

A new tool is helping four District Health Board (DHB) trial sites re-focus their endoscopy services on the needs of patients and lift the overall quality of the service.

National Clinical Lead Gastrointestinal Endoscopy, Dr David Theobald, who has a sector-based appointment funded through the Ministry of Health, says the endoscopy Global Rating Scale (GRS) – developed in the UK – evolved from a desire to determine whether endoscopy units were providing a patient-centred service. The introduction of the GRS in the UK was prompted, as it has been in New Zealand, by discussions on a potential national bowel screening programme.

“A series of meetings took place throughout England and endoscopy staff were asked what they thought was important for a patient having an endoscopy. From their responses, the 12 patient-centred standards of the Endoscopy Global Rating Scale were created. These focus on clinical quality and quality of the patient experience. Other standards focusing on workforce and training were developed at a later stage.”

The GRS is a web-based tool that allows endoscopy units to assess themselves against theses standards.

Figure 1: Endoscopy Global Rating Scale Standards

Figure 1: Endoscopy Global Rating Scale Standards

Dr Theobald says prior to the introduction of the GRS in the UK endoscopy services were under-resourced with long waiting times and waiting lists. Quality measures were poor and not monitored and there was considerable variation between endoscopy units.

Dr Theobald and National Endoscopy Service Improvement Lead, Jenni Masters, have talked to health professionals in endoscopy units throughout New Zealand and found the issues here were very similar.

Following the introduction of the GRS in the UK there was a dramatic improvement in the performance of endoscopy units. Clinical quality measures improved for all of the quality standards. Feedback indicated that improvements in GRS scores reflected substantial improvement in the patient experience.

In New Zealand, a one-year development trial of the GRS is underway at four DHBs – Canterbury, Wairarapa, Lakes and Waitemata. It finishes in September 2012 and an independent evaluation of the first six months of the trial is now completed. The evaluation focuses on the use of the tool as a mechanism for quality improvement in endoscopy.

Dr Theobald says the GRS provides a framework for DHBs to work with, providing local solutions for local quality issues.

”There is a change of emphasis to making the patient experience the primary outcome quality measure. That doesn’t mean more traditional quality measures like caecal intubation rates are ignored, but they become part of an overall quality whole.”

Each hospital taking part in the trial has a web-based dashboard that shows where they are on the quality improvement path on all the standards. The dashboard shows how far they have to go and the next steps to take.

The GRS website also has a knowledge management system which enables knowledge to be shared across DHBs.

“There is a lot of good work going on in DHBs, but it often takes place in silos and isn’t shared,” says Jenni Masters. “The knowledge management system enables people to upload their good ideas so that they can be seen and used by others.”

Dr Theobald says the evaluation is showing there has already been quality improvement at the trial sites.

“It is important to remember quality improvement comes before quantitative results. In other words, you need to be delivering high-quality endoscopies before you focus on delivering more of them. There is no benefit to increasing the number of endoscopies carried out, if they are of poor quality.”

He says having an audit cycle is an important part of the use of the GRS and of continuous quality improvement. The audit cycle emphasises the need to continually assess performance against standards, and to implement required changes.

Figure 2: Audit cycle

Figure 2: Audit cycle


Each hospital using the GRS convenes an Endoscopy Users Group (EUG) made up of the endoscopy department, nurse, training and management leads.

The Endoscopy Users Group carries out the tasks on the left hand side of the audit cycle, says Dr Theobald.

“It is the EUG that drives the change, based on the data gathered on the right hand of the audit cycle. It conducts the audits and sets the clinical strategic approach for the hospital.”

With the trial of the GRS in four DHBs drawing to a close, focus is now turning to a national roll out of the tool. Dr Theobald says this can only be a good thing for patients.

“The GRS has raised the profile of endoscopy, improved teamwork and standards, identified service gaps, and provided evidence for investment in endoscopy for DHBs. But above all, it has improved the patient’s experience of endoscopy.

For further information about the GRS tool contact Dr David Theobald on 021 688 891; david_theobald@moh.govt.nz, or Jenni Masters on 04 816 4432, 021 247 1404, jenni_masters@moh.govt.nz

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